Respiratory System Focused history taking Ishraq Elshamli Respiratory Unit Tripoli Medical Center

History Taking A history is the story of the patients illness. It is the first step in determining the etiology of a patient’s problem Let the patient describe his or her problem. Be a medical detective to establish the diagnosis.

History Taking > 80% of diagnosis may be made from history alone. Examination and investigations would either confirm or refute the history based diagnosis.

Skills Needed for history taking The ability to : Understand and be understood. Obtain relevant information. Interview logically Interrupt when necessary without inhibiting patient. Look for non verbal clues. Establish good relationship with patients. Be able to summarize the information.

The patient initiates this by describing a particular symptom which you would use for additional questioning that will help identify the cause of the problem.

Understanding the Pathophysiology of disease ( Medical Knowledge) as well as Increased ExposureTo Patients and disease will improve the skill of taking a good history.

The Most Important Symptoms are: Cough. Sputum. Haemoptysis. Breathlessness. Wheeze. Chest pain.

1. Cough Origin cause charactiristic Pharynx Post. Nasal drip Usualy persistent Larynx Laryngitis, tumour, whooping cough Harsh barking painful persistent Trachea Tracheitis Painful Asthma Dry or productive,worse at night, cold exp, or allergen COPD Worse in the morning , often productive Bronchial carcinoma Persistent, associated with hemoptysis Pneumonia Initialy dry the productive Bronchiectasis Productive, positional changes Pulmonary edema Often at night, frothy sputum Pulmonary tuberculosis Productive, wt. Loss, fever Interstitial lung disease Dry, irritant, distressing Other Drug induced ACE, B- Blocker

How To Assess Cough ? It is important to ask about : Frequency: Intermittent OR Persistent Severity : Diurnal variation Character dry or productive Associated symptoms e.g chest pain What is responsible or Triggered by : Sputum in the respiratory tract e.g. in acute infections or Bronchiectasis. Cigarette smoke . Pungent smell. Cold air.

2.SPUTUM TYPES: Mucoid as in Chronic Bronchitis. Green or Yellow in Infection. Bloody in bronchogenic carcinoma, T.B Rusty colour in Pneumonia. Pink and frothy in Pulmonary oedema. Foul smelling suggest anaerobic infection. Clear watery, large volume (Bronchorrhea ) in alveolar cell carcinoma.

How To Assess Sputum ? It is important to ask about: Colour. Amount OR Volume, fill a teaspoon, tablespoon, eggcup, a sputum cup. positional changes. Taste or Smell. Viscosity Blood stained.

3. HAEMOPTYSIS CAUSES : Common: Bronchial Carcinoma. Pulmonary Infarction. TB. Bronchiectasis. Lung Abscess. Acute/chronis bronchitis. Other: Mitral stenosis. Aspergilloma. Connective tissue disease. Goodpasteurs disease. Forign body. Anticoagulation Chest trauma.

How to assess HAEMOPTYSIS? It Is Important To Ask About: Is it frank blood or associated with purulent sputum. Is it frank blood or streaks of blood. Amount ? Is it coughed up or vomited. Previous respiratory illnesses e.g.Tuberculosis, Bronchiectasis. D.V.T, connective tissue disease.

4. BREATHLESSNESS Undue awareness of breathing. Shortness of breath. Unable to get enough air.

BREATHLESSNESS Pulmonary causes: COPD Pulmonary fibrosis. Days- Weeks Hours Minutes Pulmonary causes: COPD Pulmonary fibrosis. Pulmonary collapse due to obstructing bronchial carcinoma Pneumonia Asthma Airway occlusion by FB, laryng. Edema Sp. Pneumothorax. Acute pulmonary embolism Other: Psychogenic. Anemia Pleural effusion Pulmonary embolism Acute pulmonary edema due to left heart failure, MI, arrhythmia.

How To Assess A Patient With Breathlessness? Onset & progession: ACUTE , sudden OR Gradual over a prolonged period or time. Progression the time period over which breathlessness developed. Timing Early morning→ severe asthma and LVF During the week→ occupational asthma Winter→ bronchitis Spring→ atopic asthma

3.Severity or Grade: How far the patient can walk on the flat without stopping. How many steps can be climbed without stopping. Do you feel breathless when washing or dressing. Do you feel breathless at rest. Variability: Episodic ( intermittent) or persistent. worse at night and early morning (morning dippers in asthma) lying flat (orthopnea) in heart failure and severe airway obstruction. AGGREVATING&RELIEVING FACTORS Exercise, cold exposure, Excitement, Drugs.

SEVERE LEFT HEART FAILURE 5. WHEEZE Musical sound best heard on expiration A common in patients with airways obstruction caused by Asthma or COPD. May be present only: At night or early morning, On exposure to cold air or Allergen and On Exercise. Diffuse expiratory wheezes may occur in SEVERE LEFT HEART FAILURE

STRIDOR Noisy respiration, always inspiratory. Indicates central large airway obstruction. Causes: Carcinoma Larynx Tracheal stenosis extrinsic compression

6. CHEST PAIN Causes Of Central Chest Pain Tracheitis and bronchitis. Angina. Massive pulmonary embolism. Pericarditis. Acute aortic dissection. Oesophagitis. Large central tumour.

Causes Of Lateral Chest Pain Pleural Pain: Sharp and stabbing in character. Localized or referred to shoulder tip if diaphragmatic pleura is involved. Worse on deep inspiration or cough, if severe, shallow breathing, avoidance of movement, and cough suppression. Results from inflammatory or malignant involvement of the parietal pleura. e.g. Pneumonia, Pulmonary infarction, Malignancy, Lung abscess, Rheumatoid arthritis

SUMMARY CAUSES OF CHEST PAIN STRUCTURE Possible CAUSE of pain Pleura Inflammation, infarction Muscle Strain from coughing Bone Rib fracture or Tumour Costochondral junction Tietze’s syndrome nerves Herp. zoster,Pancoast tumour Heart and great vessels Cardiac ischemia, Infarction, aortic dissection, aneurysm Oesophagus Spasm reflux

How To Assess A Patient With Chest Pain Enquire about: Site. Mode of onset. Character. Radiation. Intensity. Precipitating Aggravating and relieving factors. Relationship to breathing, coughing or movement

Co-existing Symptoms Fever. Hoarseness of voice. Ankle swelling. Poor appetite and weight loss. Snoring and day time sleepiness.

OSCE Objective Structured Clinical Examination The curriculum tells the staff what to teach....  The OSCEs tells the students what to learn

But you will make it if you prepare for it and It is a stressful exam?!.. But you will make it if you prepare for it and practice, practice, practice..!

WHAT IS OSCE OSCE is objective structured clinical examinations It is standards in clinical exam in Europe and states

The OSCE increase the fairness by: 1.Increase the range of skills that the students are tested for 2. Increase the numbers of examiners by whom the students are assessed 3. asking the students the same questions over the same period of time

Most of exam will get the patients with abnormal finding But we can get normal .. We can get volunteers…

It consist of 6 stations over (80 ) minutes 4 Physical examination skills station. History taking skills station. Oral exam station ( Management of common cases, Emergency, Radiology, Instruments). All are patients oriented

Physical examination skills General History taking skills station Physical examination skills Dermatology Physical examination skills Cardio/Neur Oral exam station Physical examination skills Resp/Abd

What are examiners looking for ? 1. A confident approach 2. A good skill performance 3. Good applied knowledge 4. Clear answers 5. Good communications

1. History taking Skills Introduction: Good morning Miss. N.J I am Dr. XYZ, senior house officer in the department of (?) I would like to have a small chat with you regarding your (---------) is that all right with you? Introduce yourself Reason Permission

Focused history taking OSCEs (Data gathering station) Here you will show your medical knowledge concerning the current specific patient and case. Include: The chief complaint. History of present illness. Past medical and surgical history. Medications and allergies. Family history and social history. Occupational history.

The examiner will ask you 2-4 standard questions which are usually: What is your Provisional diagnosis for this patient? What is your three most relevant differential diagnosis? What are the risk factors of this patient? What is your only / three investigation you are going to order for this patient and why?

What is your initial / short term plan of management? What is your long term plan of management? Interpret this lab findings / imaging...etc. Prognosis? If this patient came back in .. days / weeks with .. what will be your explanation.

1. History taking Skills N 1. History taking Skills N.J is a 29 year old woman who has been diagnosed with asthma recently Introduction: Good morning Miss. N.J I am Dr. XYZ, senior house officer in the department of (?) I would like to have a small chat with you regarding your asthma, is that all right with you?

Questions to be asked in history taking Wheeze, dyspnoea or cough? Disturbed sleep? Exercise (quantify distance to breathlessness). Days per week off work or school. Diurnal variation? Precipitating factors: emotion, exercise, infection, allergens and drugs. Any other atopic diseases like eczema, hay fever, allergy. Any Family history of asthma?

Any Acid reflux? Occupational history? Drugs , inhalers, NSAID, Corticosteroids. Past medical history: Hospitalizations, emergency Rx, ICU admissions, intubation. Social history Smoking duration and amount, alcohol, living conditions, number of children, animals.

Questions: Investigations Management

2. History taking Skills N 2. History taking Skills N.S is a 50 ys old employee presented to the Medical OPD complaining of Chest pain, take a focused history. timing

Introduce yourself and make the patient comfortable in the bed. Onset: when did the pain start? Sudden, gradual? Is this the first time? Have you felt similar symptoms before? Site& Radiation of pain to the jaw, arm or to the back ? Precipitating .What were you doing when pain came on? Palliation .What make pain less? antacids, rest, positional

Cont’ Chest Pain Provocation: What make pain worse? Exercise, food, emotion, deep breaths Character : sharp, dull, heavy, squeezing, tearing Duration of the pain? Describe the course of the pain. (Worsening, intermittent, better),timing of day. Associated features like nausea, vomiting,sweating and breathlessness?

Objective -PMHx- Previous similar episodes? (past therapy, investigations) Hx: MI, documented CAD, angioplasty, CABG Important historical risk factors Smoking Hypertension Diabetes mellitus hypercholesterolemia positive family history

D/D Acute myocardial infarction, angina, pericarditis, myocarditis, aortic dissection. PE, pleurisy, pneumothorax. Oesophagitis + spasm, acid peptic disease, cholecystitis and pancreatitis. Costochondritis, rib fracture. Herpes zoster.

Hemoptysis J.T is a 66 year old man who comes to your office complaining of coughing up blood. In the next 10 minutes take focused history.

COPD exacerbation N.C is  65 year old man known case of COPD who comes to the emergency complaining of shortness of breath for two days. In the next 10 minutes, take a focused history.

Cough A.H is a 62 year old man who comes to your office with cough for three months. In the next 10 minutes take focused history.

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