Respiratory and Drug History Taking PDF

Respiratory and Drug History Taking Rebecca Walmsley Clinical Programme Lead, Course Director ram29 Lynsay Moyes Medical Education Pharmacist lm380 Learning Outcomes • Understand the role of a medical history in making a clinical diagnosis • To demonstrate an understanding of specific respiratory...

Respiratory and Drug History Taking Rebecca Walmsley Clinical Programme Lead, Course Director ram29 Lynsay Moyes Medical Education Pharmacist lm380 Learning Outcomes • 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 interrelate • To understand how to take a detailed drug history The importance of a medical history  Form a differential diagnosis and put health in context  Identify risk factors for conditions  Red flags  Direct further clinical examination  Direct investigation and management  Develop a rapport between patient and health care worker The Structure  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) Presenting Complaint • Description of symptoms in patient’s own words • One sentence • Example: “I am feeling breathless” History of Presenting Complaint  Allow the patient the opportunity to speak  Remember initial open questions  Try to establish time-lines; interventions and impact  Be constantly thinking - What are the possible diagnoses? - What else do I need to know to help decide which diagnosis is the correct one? • Consider impact on ADLs and QOL  Summarising at this stage may be helpful Respiratory Questions: HPC  Respiratory system: - 1. Chest pain 2. Dyspnoea 3. Cough 4. Sputum 5. Haemoptysis - 6. Wheeze - 7. Systemic upset Explore each symptom 1. Chest Pain – questions to ask • 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) Chest pain - causes Site of pain Causes Central Tracheitis Angina/ MI Aortic dissection Massive PE Oesophagitis Lung tumour / metastases Mediastinal tumour/ mediastinitis SSSShinles Non central Shingles Rib fracture Lung tumour Pneumonia PE Pleural Pneumonia / Bronchiectasis / TB Lung tumour/ metastases/ mesothelioma PE Pneumothorax Chest wall Muscular / rib injury Costochondritis Lung tumour / bony metastases/ mesothelioma Shingles (herpes zoster) 2. Dyspnoea–questions to ask  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 Dyspnoea- onset Speed of onset Conditions Minutes PE Pneumothorax Acute LVF Acute asthma Inhaled foreign body Hours to days Pneumonia Asthma Exacerbation of COPD Weeks to months Anaemia Pleural effusion Respiratory neuromuscular disorders Months to years COPD Pulmonary fibrosis Pulmonary TB Dyspnoea  Respiratory causes – 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 Dyspnoea  Cardiovascular causes – E.g. cardiac failure (LVF), associated with angina or MI  Non cardio-respiratory causes – E.g. anaemia, obesity, hyperventilation, anxiety, metabolic acidosis 3. Cough- questions to ask         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 Cough  Acute cough – Viral or bacterial infection / pneumonia / inhalation of foreign body/ irritants  Chronic cough – Common - gastro-oesophageal reflux / asthma/ COPD / smoking / post-nasal drip / occupational or other irritants / medication (ACEI) – Less common – lung tumour / bronchiectasis / interstitial lung disease  Red flags – Haemoptysis, breathlessness, weight loss, chest pain, smoker Characteristics Common causes Productive Infection Bronchiectasis Persistent ‘moist’ cough worst in morning COPD Associated with wheeze Painful Asthma / COPD Tracheitis Harsh/ barking Laryngitis/ laryngeal tumour Chronic, dry cough Persistent with haemoptysis Interstitial lung disease Bronchial carcinoma ‘Bovine’ cough (non-explosive cough) Left recurrent laryngeal nerve invasion (secondary to malignancy) Neuromuscular disorders 4. Sputum- questions to ask        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 Sputum Type Appearance Cause Serous Clear, watery Frothy, pink Acute pulmonary oedema Mucoid Clear, grey White, viscid COPD/ asthma Purulent Yellow, green, brown Infection Rusty Rusty red Pneumococcal pneumonia 5. Haemoptysis- questions to ask     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) Haemoptysis Cause Example Malignant Bronchial carcinoma Metastatic lung disease Infective Acute infection Bronchiectasis TB Vascular Pulmonary infarction or pulmonary embolus Cardiac Mitral valve disease Acute LVF Vasculitis Wegener’s granulomatosis Good pasture’s syndrome Other Trauma Anticoagulation (consider warfarin) Clotting disorder 6. Wheeze - questions to ask  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 7. Systemic upset - questions to ask  Change in appetite  Weight loss  Fever  Tiredness / lethargy Past Medical History  Medical conditions  Visits to the doctor – Hospital / GP  Investigations / procedures  Operations  Establish if problems on-going / resolved fully / managed  Time-line of events; try to document chronologically Taking an accurate medication history – generalisable principles Why ensure accurate medication history? • Improves patient safety • Reduces medication errors / near misses • Reduces missed doses in hospital • Reduces delays to treatment • Savings to NHS from prevented errors • Improves therapeutic outcomes The Golden Rules of medication history taking • 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? 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 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 • • • • • • • Starting the history taking…. “Which medicines are currently prescribed for you to take?” For each drug, in turn:• • • • • • • • • 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? Non-prescribed medicines • • • • Over the counter medicines? Complementary and alternative medicines? Smoking? Recreational drug use? Allergies • 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? • Check other sources of information Previous adverse effects 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? Check other sources of information Concordance / Adherence - Is patient taking their medicines? • Intentional non-adherence– definite decision to not take medicine(s) • Unintentional non-adherence For example due to….. 1. Physical dexterity 2. Reduced vision 3. Cognitive impairment 4. Poor understanding Inhaled respiratory medicines Citation: The Pharmaceutical Journal, Vol 297, No 7892, online | DOI: 10.1211/PJ.2016.20201602 33 The colourful world of inhalers • Blue – “reliever” e.g. salbutamol (short acting beta 2 agonist) • Brown – “preventer” e.g. beclomethasone (corticosteroid) Nowadays - colours of the rainbow…..ask patient! Many inhaler device types: e.g. Mdi = metered dose inhaler, Accuhaler, Autohaler, Easibreathe, Handihaler, Via spacer / aerochamber Videos on inhaler devices and technique https://www.youtube.com/user/MedicinesOrgUk/videos Support groups: 35 Family History  Family members – Ask about first degree relatives  Alive / deceased?  Cause / age at death  (Be sensitive and think!) – Ask about any health problems – Ask about conditions that run in the family Social history  Occupation / hobbies – Occupational asthma – Asbestos exposure – Coal worker's pneumoconiosis – Extrinsic allergic alveolitis (hypersensitivity pneumonitis)  E.g. ‘farmer’s lung’ / ‘bird- fanciers lung’     Pets Housing Smoking – pack years helpful Support / help required (ADLs) Systems Enquiry / Review Couple of questions (approx.) for each remaining system – quick screening tool For example: • CVS – palpitations, syncope • GI – change in bowels, abdominal pain • GU – urinary symptoms, LMP • Endocrine – lumps in neck, temp intolerance • MS – aches/stiffness joints/muscles/back • CNS – headaches, fits Hints  Don’t think in isolated systems  Symptoms may be caused by problems in other areas  Apply your science knowledge  Use your abilities of logic and problem solving to put it together Putting it together • A 60 year old gentleman is having chemotherapy for a GI malignancy, he develops pleuritic chest pain, shortness of breath and haemoptysis • A 70 year old smoker develops a fever, wheeze and a cough with mucky sputum • A 15 year old girl who is otherwise fit and well develops a nocturnal cough and wheeze exacerbated by exercise Learning Outcomes • 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 interrelate • To understand how to take a detailed drug history