History and presenting symptoms Flashcards
What are important factors in making a diagnosis?
- History (most important)
- Examination
- Investigation
What is the Calgary Cambridge guide to consultation?
- Initiating the session
- Gathering information
- Physical examination
- Explanation and planning
- Closing the session
What is the presenting complaint (PC)?
What the patient tells you is wrong with them
Is the presenting complaint the diagnosis?
No, people do not present with pneumonia for example. They present with fever, pleuritic chest pain, productive or non-productive cough, etc
What is the history of the presenting complaint?
Taking the PC and expanding on the history to work out the diagnosis
What sort of questions are asked in HPC?
- “When did it start?”
- “What was the first thing you noticed?”
- “Ever had it before?”
What is the SOCRATES method of taking a history of pain?
S - site of pain
O - onset (gradual or sudden)
C - character (sharp, dull, burning)
R - radiation (does the pain move anywhere else?)
A - associations with pain (e.g nausea, vomiting)
T - Timing of pain (duration, worsening, improving)
E - Exacerbating and alleviating factors
S - severity (1-10 or compare to child birth)
What places could chest pain be coming from?
- Lungs
- Heart
- Parietal pleura
- Bones, muscle, skin
- GI tract
What are the features of cardiac pain?
- Referred pain
- Central, crushing, “tight band”
- Usually left-sided
- Can be epigastric
- Often radiates (left arm, neck, jaw/teeth)
- Autonomic symptoms (pallor, nausea, SOB)
- Usually worse on exertion
What are features of pleuritic pain?
- Sharp
- Worse on inspiration - patient will normally breathe shallowly as deep breathing causes intense pain
- Usually easily locatable
- Non-specific (not attributable to a specific pathology)
What are features of lung pain?
- Contain no pain receptors (insensate)
* Do contain J receptos, which cause cough
What is pleurisy?
If pathology in lungs reaches the pleura
What can cause GI pain?
- Oesophageal spasm
- Trapped wind
- Reflux oesophagitis
(Oesophageal spasm and trapped wind can mimic angina)
What are the features of musculoskeletal pain?
- Usually worse on movement
* Reproducible i.e. can bring it on by pressing on the chest
List reasons why people get breathless
- Demand put on cardiorespiratory system i.e. exercise, weight
- Capacity i.e. fitness, cardiac function, respiratory function
What are history questions associated with breathlessness?
- What do you mean by breathless?
- Can’t breathe in? Or Out?
- When?
- Doing what?
- Orthopnoea? - out of breath when laying flat
- Paroxysmal Nocturnal Dyspnoea (PND)? - attacks of severe shortness of breath and coughing that generally occur at night (usually indication of cardiac problems)
- Associated symptoms? - wheeze, stridor, cough
- Time frame? - acute, subacute, chronic
What are the 3 time frames associated with respiratory disease?
- Acute - very suddenly
- Subacute
- Chronic - persisting for a long time
What are examples of acute respiratory diseases?
- Pulmonary embolism
- Pneumothorax
- Pulmonary oedema
What are examples of subacute respiratory diseases?
- Pneumonia
- Pulmonary oedema
- Pleural effusion
- Asthma/COPD
What are examples of chronic respiratory diseases?
- COPD
- Pulmonary fibrosis
- Pulmonary embolism - multiple small pulmonary emboli, breathlessness gets worse as time goes on
What are 3 classifications of cough?
- Dry
- Productive
- Blood (haemoptysis)
What does an acute, dry cough lasting for less than 8 weeks indicate?
Viral infection - very common
However, can indicate something more nasty
What are nasty diseases associated with acute, dry cough?
- Lung cancer
- Mesothelioma
- Pulmonary metateses
- Pulmonary fibrosis
- Sarcoidosis
- Pneumonitis - inflammation of lung tissue
What 2 factors can cause a chronic dry cough?
- Reduction in cough threshold - GORD, ACE inhibitors, upper airway diseases
- Increase in stimulus - smoking, GORD, allergens, ACE - inhibitors
What is a productive cough?
Production of sputum
What does sputum contain?
- Neutrophils
- Eosinophils
- Bacteria/fungus/virus
- Airway secretions
What makes sputum green?
Neutrophils
What is the most useful tool in determining the nature of a COPD exacerbation (worsening of COPD symptoms)?
Sputum gazing - looking at sputum colour
Dark sputum = worst
What is massive haemoptysis?
> 500ml in 24 hours
What is non-massive haemoptysis?
<500ml in 24 hours
What are the 4 main causes of haemoptysis?
- Infection
- Carcinoma
- Pulmonary embolism
- Bronchiectasis - permanent enlargement of parts of the airway
What are other reasons for haemoptyisis (aside form the “big 4”)?
- Cardiac
- AVM
- Anticoagulation
What is a systemic enquiry?
Investigating other systems to make sure you aren’t missing something else
What are the 4 different types of medical history?
- Previous medical history (PMH)
- Family history (FH)
- Drug history (DH)
- Social history (SH)
What is previous medical history (PMH)?
- Childhood infection, etc
What is family history (FH)?
Genetic tendency to develop diseases like COPD
What is drug history?
Previously prescribed drugs - also includes drug allergies
What is social history?
- Occupation/hobbies e.g. asbestos, coal mining, smoking
