Respiratory and Drug History Flashcards
What is the importance of a medical history ?
- Form a differential diagnosis
- Identify risk factors for conditions
- Identify red flags
- Direct further clinical exams
- Direct investigation and management
- Develop a rapport between patient and health care worker
Identify the structure of history taking.
- Presenting complaint (PC)
- History of presenting complaint (HPC)
- Past medical history (PMH)
- Medication/ allergies(DH)
- Family history (FH)
- Social history (SH)
- Systems enquiry/ review (SE)
Define presenting complaint.
Description of symptoms in patient’s own words
What are symptoms to ask about in a respiratory system enquiry ?
- Chest pain
- Dyspnoea
- Cough
- Sputum
- Haemoptysis
- Wheeze
- Systemic upset
What are the main indicators of pleuritic pain ?
Chest pain that is sharp on coughing and inspiration
What are possible sites of chest pain ?
Central, non central, pleural, chest wall
What are possible causes of central chest pain ?
- Tracheitis
- Angina/ MI
- Aortic dissection
- Massive PE
- Oesophagitis
- Lung tumour/ metastases
- Mediastinal tumour/ mediastinitis
What are possible causes of non-central chest pain ?
- Shingles
- Lung tumour
- PE
- Rib fracture
- Pneumonia
What are possible causes of pleural chest pain ?
- Pneumonia / Bronchiectasis / TB
- Lung tumour/ metastases/ mesothelioma
- PE
- Pneumothorax
What are possible causes of chest wall pain ?
- Muscular / rib injury
- Costochondritis
- Lung tumour / bony metastases/ mesothelioma
- Shingles (herpes zoster)
What are possible questions to ask about dyspnoea ?
- Is there anything that brings it on?
- Does anything make it better or worse?
- Are you always breathless? Is it when you walk/ exercise?
- Do you get breathless lying down?
– Orthopnoea/ PND (cardiac causes) - How far can you walk normally? How far can you walk now? i.e. exercise tolerance
- How do you manage walking uphill / up stairs?
- Is there anything it stops you from doing?
- Have you noticed any other symptoms?
– Consider – cough, sputum, chest pain, palpitations, wheeze, stridor
What could dyspnoea with onset of minutes be due to ?
- PE
- Pneumothorax
- Acute LVF
- Acute asthma
- Inhaled foreign body
What could dyspnoea with onset of hours to days be due to ?
- Pneumonia
- Asthma
- Exacerbation of COPD
What could dyspnoea with onset of weeks to months be due to ?
- Anaemia
- Pleural effusion
- Respiratory neuromuscular disorders
What could dyspnoea with onset of months to years be due to ?
- COPD
- Pulmonary fibrosis
- Pulmonary TB
What are possible respiratory causes of dyspnoea ?
– Airways e.g. asthma, COPD, bronchiectasis, cystic fibrosis, laryngeal tumour, foreign body, lung tumour
– Parenchyma e.g. pneumonia, pulmonary fibrosis, sarcoidosis, TB – Pulmonary circulation e.g. PE
– Pleural e.g. pneumothorax , pleural effusion
– Chest wall e.g. kyphoscoliosis, ankylosing spondylitis
– Neuromuscular e.g. myasthenia gravis, Guillain-Barre syndrome
What are possible CV causes of dyspnoea ?
- LVF
- Angina or MI
What are non-CV causes of dyspnoea ?
- Anaemia
- Obesity
- Hyperventilation
- Anxiety
- Metabolic acidosis
What are questions to ask about the symptom of cough ?
- How long have you had it? (i.e. is it a new problem?)
- When does it occur?
- Is there anything that makes it better or worse?
- Is it a dry cough? Do you cough anything up?
- Do you smoke?
- Has your medication changed recently?
- Do you experience any other symptoms?(consider dyspnoea, weight loss, stridor, pain, syncope, vomiting)
What are the most common causes of acute cough ?
- Viral or bacterial infection
- Pneumonia
- Inhalation of foreign body
- Irritation
What are the most common causes of chronic cough ?
MORE COMMON
- Gastro-oesophageal reflux
- Asthma/ COPD / smoking
- Post-nasal drip
- Occupational or other irritants
- Medication (ACEI)
LESS COMMON
- Lung tumour
- Bronchiectasis
- Interstitial lung disease
What are red flags in a patient with coughing ?
- Haemoptysis
- Breathlessness / chest pain
- Weight loss
- Smoking
What are possible characteristics of cough ?
- Productive
- Persistent ‘moist’ cough worst in morning
- Associated with wheeze
- Painful
- Harsh/ barking
- Chronic, dry cough
- Persistent with haemoptysis
- ‘Bovine’ cough (non-explosive cough)
What are the most common causes of productive cough ?
- Infection
- Bronchiectasis
What are the most common causes of persistent ‘moist’ cough worst in morning ?
-COPD
What are the most common causes of cough associated with wheeze ?
- Asthma
- COPD
What are the most common causes of painful cough ?
-Tracheaitis
What are the most common causes of harsh/barking cough ?
-Laryngitis/laryngeal tumour
What are the most common causes of chronic, dry cough ?
-Interstitial lung disease
What are the most common causes of persistent cough with haemoptysis ?
-Bronchial carcinoma
What are the most common causes of bovine cough (non-explosive cough) ?
- Left recurrent laryngeal nerve invasion (secondary to malignancy)
- Neuromuscular disorders
What are the questions to ask concerning sputum ?
- How often do you produce sputum when you cough ?
- How much sputum do you cough ? Has this changed ?
- What color ? Has the color changed ?
- Is there any blood ?
- Is it frothy or thick ?
- Is there any abnormal smell or taste
- Have you been experiencing any other symptoms ? (e.g. fever, dyspnoea, pain)
What are the main types of sputum ?
Serous, mucoid, purulent, rusty
What is the appearance of serous sputum ?
Clear, watery
OR pink , frothy
What is the appearance of mucoid sputum ?
Clear, grey
OR white, viscid
What is the appearance of purulent sputum ?
Yellow, green, brown
What is the appearance of rusty sputum ?
Rusty red
What are the most common causes of serous sputum ?
Acute pulmonary oedema
What are the most common causes of mucoid sputum ?
COPD/Asthma
What are the most common causes of purulent sputum ?
Infection
What are the most common causes of rusty sputum ?
Pneumococcal pneumonia
What are questions to ask concerning haemoptysis ?
- When did you first notice blood in your sputum?
- How many times has it happened?
- How much blood is there?
- Are there any other colours in the sputum apart from the blood?
- Have you noticed bleeding or bruising anywhere else?
- Are you taking any medication to thin the blood?
- Have you noticed any other symptoms?
(consider breathlessness / chest pain / cough / weight loss (pleuritic chest pain and hemoptysis is a red flag))
What are the different kinds of haemoptysis ?
Malignant, infective, vascular, cardiac, vasculitis
What are common causes of malignant haemoptysis ?
- Bronchial carcinoma
- Metastatic lung disease
What are common causes of infective haemoptysis ?
- Acute infection
- Bronchiectasis
- TB
What are common causes of vascular haemoptysis ?
- Pulmonary infarction
- Pulmonary embolus
What are common causes of cardiac haemoptysis ?
- Mitral valve disease
- LVF
What are common causes of vasculitis haemoptysis ?
- Wegener’s granulomatosis
- Good pasture’s syndrome
What are common causes of other haemoptysis ?
- Trauma
- Anticoagulation (consider warfarin)
- Clotting disorder
What are questions to ask about wheezing ?
- When does it occur; timing and frequency
- Exacerbators / relievers
- Do they have an inhaler for wheeze – how often do they need to use it?
- Exercise tolerance
- Severity
What are questions to ask about systemic effect ?
- Change in appetite
- Weight loss
- Fever
- Tiredness / lethargy
Why is it important to take an accurate medication history ?
GENERAL
- Improves patient safety
- Savings to NHS from prevented errors
SPECIFIC
- Reduces medication errors/near misses
- Reduces missed doses in hospital
- Reduces delays to treatment
- Improves therapeutic outcomes
Identify the golden rules of medication history taking.
- Use more than one source of info to confirm patient’s medication history (e.g. carer)
- Be alert to use of high risk medicines (e.g. warfarin, insulin, methotrexate) as accuracy critical in these cases.
- Women of child bearing age – ask about prescribed contraception
- Taking part in any clinical trials ?
Identify examples of sources of information about a patient’s medicines.
- Patient or family/friends/carers
- Patient’s own medicines
- Repeat prescription slips/other lists
- GP surgery staff / letter/ printout
- Substance misuse services – e.g. for methadone doses
What are specific questions to ask about each drug listed by the patient ?
- Name of medicine?
- Do you know what it is for?
- What is the dose/strength?
- What is the route?
- Number of tablets or puffs or dose units taken?
- Type/Form – device type?
- How often do you take this?
- Any recent changes to dose / frequency?
- Do you think you have any side effects with any of these medications?
What are questions to ask about non-prescribed medication ?
- Over the counter medicines ?
- Complementary and alternative medicines ?
- Smoking ?
- Recreational drug use ?
What are possible questions to ask about allergies to medication ?
- Are you allergic to any medicines ?
- What happened when you had these medicines ?
- Have any medicines caused a rash or difficulty breathing in the past?
What are different questions to ask to find out whether a patient has ever developed an adverse reaction to a medication ?
- Have any medicines recently been stopped and if so why?
- Have you ever had a medicine stopped because the Dr thought it was making you worse?
- Have you ever stopped a medicine because you felt unwell?
Define concordance.
A negotiated, shared agreement between clinician and patient concerning treatment regimen(s), outcomes, and behavior
Define adherence.
Is patient taking their medicines?
What are the main types of non-adherence ?
Intentional non-adherence (definite decision to not take medicine(s))
Unintentional non-adherence
What are possible reasons for unintentional non-adherence ?
- Physical dexterity
- Reduced vision
- Cognitive impairment
- Poor understanding
How can occupations/hobbies be relevant to respiratory history ?
Because – Occupational asthma – Asbestos exposure – Coal worker's pneumoconiosis – Extrinsic allergic alveolitis aka hypersensitivity pneumonitis (e.g. ‘farmer’s lung’ / ‘bird- fanciers lung’)
Define ADLs.
(=Activities of daily living) Activities that are necessary for daily care of oneself and independent community living.
Give examples of ADLs.
Using the toilet and grooming, dressing, and feeding oneself
What are things to ask about in a GI system enquiry ?
Change in bowels, abdominal pain
What are things to ask about in a GU system enquiry ?
Urinary symptoms, LMP
What are things to ask about in an endocrine system enquiry ?
Lumps in neck, temp intolerance
What are things to ask about in an MS system enquiry ?
Aches/stiffness joints/muscles/back
What are things to ask about in a CNS system enquiry ?
Headaches, fits
What are aspects of social history to ask about in a respiratory systems enquiry ?
- Occupation/Hobbies
- Pets
- Housing
- Smoking
- Support / help required (ADLs)
