Respiratory and drug history taking

Question 1

Learning outcomes

Answer 1

• Understand the role of a medical history in making a clinical diagnosis
• To demonstrate an understanding of specific respiratory questions
• To demonstrate an awareness of the causes of common respiratory symptoms
• To understand how different body systems inter- relate
• To understand how to take a detailed drug history

Question 2

Discuss ‘the structure’

Answer 2

 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)

Question 3

What resp questions should you ask in HPC?

Answer 3

• 1. Chest pain - 2. Dyspnoea - 3. Cough
• 4. Sputum
• 5. Haemoptysis
• 6. Wheeze
• 7. Systemic upset Explore each symptom

Question 4

What questions should one ask in relation to chest pain

Answer 4

• SOCRATES is a useful mnemonic: Site
Onset
Character
Radiation
Associated symptoms Timing
Exacerbators / relievers Severity (1-10 rating scale)
• Consider structures pain might come from
• Consider pleuritic pain (sharp on coughing and inspiration)

Question 5

What questions should one ask in regards to dysnoea?

Answer 5

 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

Question 6

What questions should one ask in regards to cough?

Answer 6

 How long have you had it?
 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

Question 7

What questions should one ask in regards to sputum?

Answer 7

 How often do you produce sputum when you cough?
 How much sputum do you cough up? Has this changed?
 What colour is it? Has the colour 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

Question 8

What questions should one ask in regards to haemoptysis?

Answer 8

 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?
– E.g. breathlessness / chest pain / cough / weight loss (pleuritic chest pain and hemoptysis is a red flag)

Question 9

What questions should one ask in regards to wheeze?

Answer 9

 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

Question 10

What questions should one ask in regards to systemic upset?

Answer 10

 Change in appetite
 Weight loss
 Fever
 Tiredness / lethargy

Question 11

What are the golden rules of medication history taking

Answer 11

• Be structured – methodically collect current meds, allergies and previous adverse drug reactions
• Engage with the patient whenever possible but find out who knows best about meds - ?carer
• Use more than one source of information to accurately confirm a patient’s medication history.
• 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
• Are they taking part in any clinical trials?

Question 12

What are sources of information about a patients medicines

Answer 12

• Patient or family/friends/carers
• Patient’s own medicines
• Repeat prescription slips/other lists
• GP surgery staff / letter/ printout
• Previous hospital notes/letters
• Community pharmacy
• Emergency Care Summary (ECS) Scotland only. (called Summary Care Record in England)
• MAR chart – Medication Administration Records from care homes, prepared by Pharmacy
• Substance misuse services – e.g. for methadone doses

Question 13

What should you ask about each drug a ptx takes?

Answer 13

• 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?

Question 14

When discussing prescriptions what should you remember?

Answer 14

Non-prescribed medicines
• Overthecountermedicines?
• Complementary and alternative medicines? 
• Smoking?
• Recreational drug use?

Question 15

What questions should you ask when discussing drug allergies

Answer 15

• Areyouallergictoanymedicines?
• What happened when you had these medicines?
• Have any medicines caused a rash or difficulty breathing in the past?
• Check other sources of information

Ways of asking….
• 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?

Question 16

Discuss Concordance / Adherence - Is patient taking their medicines?

Answer 16

• Intentional non-adherence– definite decision to not take medicine(s)
• Unintentional non-adherence For example due to…..
1. Physicaldexterity
2. Reducedvision
3. Cognitive impairment
4. Poor understanding

Question 17

Discuss inhalers

Answer 17

• Blue – “reliever” e.g. salbutamol (short
acting beta 2 agonist)
• Brown – “preventer”
e.g. beclomethasone (corticosteroid)
Nowadays - colours of the rainbow…..ask patient!