Taking a respiratory history

used the ISCE guid + Geeky medics: https://geekymedics.com/respiratory-history-taking/

How do you start a history?

1. Introduce yourself

2. Check the patients info (Name, DOB)

3. Consent

What is the first question you should start with after the introduction?

An open question like "How can I help you today".
(Try to avoid how are you feeling today or what bought you in today because they may given other answers).

Examples of open questions.

What seems to be the problem?
Can you tell me some more?
Anything else?
Anything else you want to add or mention?

Make sure you start with open questions and then after you got all information you can ask closed questions.

After you ask the first open question and receive enough information, what do you ask afterwards?

SOCRATES- may not work for all conditions

What does SOCRATES stand for?

Site
Onset- how and when the symptoms develop
Character
Radiation
Associated symptoms
Time course- has the symptom changed over time?
Exacerbating or relieving factors
Severity

SOCRATES- how can you ask for site?

Where is the pain?
Can you point to where you experience the pain?

SOCRATES- how can you ask for onset? (SOB example)

“Did the shortness of breath come on suddenly or gradually?”
“When did the shortness of breath first start?”
“How long have you been experiencing the shortness of breath?”

SOCRATES- how can you ask for character?

Can you describe the (symptom)? (e.g. “tight chest”, “can’t take a deep breath”)
Is it constant, or does it come and go?

SOCRATES- how can you ask for radiation?

Does the (symptom) move anywhere?

SOCRATES- how can you ask for associated symptoms?

“Are there any other symptoms that seem associated with the pain?” (e.g. fever in pneumonia, shortness of breath and haemoptysis in pulmonary embolism)

SOCRATES- how can you ask for time course?

“How has the (symptom) changed over time?”

SOCRATES- how can you ask for exacerbating or relieving factors?

Does anything make the (symptom) worse? (e.g. exertion, exposure to an allergen, cold air)
Does anything make the pain better? (e.g. rest, inhaler)

SOCRATES- how can you ask for severity?

“On a scale of 0-10, how severe is the chest pain, if 0 is no pain and 10 is the worst pain you’ve ever experienced?”

For SOB it can be accessed by the ability of the patient to speak full sentences without having to take a breath. you can also ask how much they can walk before they need to take a break/ breath.

What comes after SOCRATES?

Past Medical History (PMH)

What questions can be asked for Past Medical History (PMH)?

Are you otherwise well?
Do you suffer form any other illnesses?
Have you had any serious illnesses in the past?
Have you had any operations?
Have you had diabetes?
Do you have rheumatoid arthritis (can cause pulmonary effusion , Interstitial lung disease)

What other topics do you have to ask for after Past Medical History (PMH)?

Medications

How do you ask for medication?

Are you prescribed any medication?
What medication do you take?
Do you take any over the counter medication?
Any over the counter remedies?
Do you take any contraceptives? (Can cause a clot/ pulmonary clot)
Methotrexate is an immunosuppressant which is given for rheumatoid arthritis. Can cause anaemia (in the elderly) and fibrosis of the lungs.

What other topics do you have to ask for after medication?

family history, social history, recreational drug history, allergies, (immunisation history - respiratory history)

How do ask for family history?

Has anyone in the family suffered with a similar illness? (or you can be more specific with the illness)
Do any of your parents or siblings have any lung problems?”

If one of the patient’s close relatives are deceased, sensitively determine the age at which they died and the cause of death:

“I’m really sorry to hear that, do you mind me asking how old your mother was when she died?”
“Do you remember what medical condition was felt to have caused her death?”

What should you do before asking for more personal information?

Give them a warning. " If you don't mind I will ask a couple of more personal questions"

How do ask for social history?

1. Elderly- are you living alone?

2. Uni student- are you living in shared housing?

3. Do you work/ used to work? What does your partner work? (e.g. husband comes home with clothes which has asbestos on them and wife cleans it- not both are exposed to the asbestos)

4. Do they have any pets or hobbies (e.g. bird keeping)?

5. Do you exercise regularly?

6. Do you smoke?

7. How much do you smoke?

8. Do you drink?

9. How much do you drink? Like around 4 bottles of wine? (exaggerate to increase the chance of them telling the truth)

10. When do you drink?

11. Do you gamble? (depends on the illness- anxiety related)

12. Do you have any issues with regard to gambling?

13. Have you travelled recently? (possible to develop pneumonia from aeroplanes) Ask this near the end when you have developed more rapport and trust.

How do ask for drug history ?

I ask this to all my patients but do you take drugs?
Do you take any drugs?
What types of drugs do you take?
How do you take them? injection, nasal?
How much do you take?
Ask this near the end when you have developed more rapport and trust.

How do you ask for allergies?

Do you have any allergies?
Can you explain what happened when you took X?

How do you ask immunisation history?

Have you taken a vaccine for:
Influenza
Pneumococcus
COVID-19
Tuberculosis

GP has immunisation records
Maybe ask for first time patient

What 3 topics do you end with?

1. Systemic enquiry

2. ICEE

3. Summary

What is a systemic enquiery?

Performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.

How do you ask for systemic enquiry?

Some of them can just be observed. The rest can be asked for.

Systemic: fevers, weight change, fatigue
Cardiovascular: chest pain, palpitations, oedema, syncope, orthopnoea
Gastrointestinal: nausea, vomiting, dysphagia, abdominal pain
Genitourinary: oliguria, polyuria
Neurological: visual changes, motor or sensory disturbances, headache, confusion
Musculoskeletal: chest wall pain, trauma
Dermatological: rashes

What is ICEE?

Ideas
Concerns
Expectations
Effects on life

ICEE- How do you ask for Ideas?

“What do you think the problem is?”
“What are your thoughts about what is happening?”
“It’s clear that you’ve given this a lot of thought and it would be helpful to hear what you think might be going on.”

ICEE- How do you ask for Concerns?

"Is there anything, in particular, that’s worrying you?”
“What’s your number one concern regarding this problem at the moment?”
“What’s the worst thing you were thinking it might be?”
"Is there anything your worried about?"

ICEE- How do you ask for Expectation?

“What were you hoping I’d be able to do for you today?”
“What would ideally need to happen for you to feel today’s consultation was a success?”
“What do you think might be the best plan of action?”
"Is there anything you had in mind about..."
"We will try our best to help you. But what would you like me to do?"

ICEE- How do you ask for Effect on life?

How has this illness effected you day to day life?

How do you do a summary?

You start by saying "I will do a quick summary of all that you have said. Please feel free to stop me if I have said anything that was wrong or if you would like to add anything"

Say the summary. This is all the important info the patient has given you.

You can then ask them if you have forgotten anything important or you may have remembered something you would like to ask them.

How do you end the consultation.

Thank them.
"I am going to report to my consultant and then she will come + see you with me"
Also, ask them if they have any Q

How to create rapport between you and the patient?

• Let them sit first

• Listen to the patient

• Don't interrupt the patient

• Maintain a good posture + good eye contact

• Be professional especially with the more sensitive topics

• Don't give any personal opinions

• If you don't know the answer be honest and say that you will ask and get back

• If they mention anything sad or difficult be empathetic and understanding. E.g "That must have been difficult for you"

• respect the patients wishes and lead the treatment they way they would like it

• Don't give any false hope or exclude a condition completely when it could be a possibility

• Be patient

How do you calculate pack-years for smoking?

pack-years = [number of years smoked] x [average number of packs smoked per day]
one pack is equal to 20 cigarettes

What does SOB indicate?

AF, palpitations, cardiomegaly

What can a nebuliser cause (side effect)?

tachycardia + fine tremor due to the high lactate levels

What is doxycycline given for?

Pneumonia, acne, malaria

What is a side effect of doxycycline?

yellow teeth

What disease cause blood in sputum (haemoptysis)?

TB, cancer

What can a steroid inhaler cause?

Thrush on the tongue ( tell them to rinse their mouth after using the inhaler)

What are some signs of malignancy?

Thin or lost a lot of weight, haemoptysis, no pain in lymph nodes when palpated.

Symptoms of marfan's syndrome?

1. tall + think

2. Loose + flexible joins

3. Pectus excavatum or Pectus carinatum

4. Scoliosis- curved spine

5. Spondylolisthesis is where one of the bones in your spine (a vertebra) slips forward over another vertebra.

6. Dural ectasia is a condition where the dura becomes weakened and expands outwards.

7. Eye problems (DVLA if driving)

8. aortic aneurysm

9. Left ventricle hypertrophy

10. Mitral/ tricuspid stenosis/regurgitation

11. Stretch marks

An issue with the connective tissue