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Shortness of Breath History Taking

Shortness of Breath History Taking. By Ben Ryan Final Year Medical Student. Why am I doing this?. Easy to go through 3 rd year without fully developing history taking skills

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Shortness of Breath History Taking

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  1. Shortness of Breath History Taking By Ben RyanFinal Year Medical Student

  2. Why am I doing this? • Easy to go through 3rd year without fully developing history taking skills • Important take home points:It is good practice to know the differential diagnoses for each of your presenting complaintsYou should know at least one associated feature for each differential (if possible), and show to the examiner that you know thesePlanning a structure that works for you is extremely important for taking good histories

  3. History Taking (General) • SOCRATES is helpful, but I have some criticisms: • A (associated symptoms) – should really be asked in a separate area as a ‘systems review’ after you have taken the important information from the HPC. Consultation will feel much smoother. • Timeline and Onset – should really be asked together, and be fully explored early on in the consultation. • Always follow up on patient cues • ‘It’s really affected my work’ – ask them about their work. As you need to keep a structure, after you have asked this you can say ‘I might ask you more about your work later on.’, then continue with the rest of your history • Demonstrate empathy as early on as possible • ‘It sounds like you’ve been through quite an ordeal, I’m sorry you’ve had all this to deal with.’

  4. My Approach • When starting any history: • Open question to get started • ‘How long has this been going on for?’ • ‘How did it come on?’ (gradually/suddenly) • ‘How has it changed since then?’ • ‘Was there anything that happened around then that you felt could have triggered it?’ • ‘Have you ever had this before?’ • ‘How were you before this came on?’ (for example, how much could you do previously before you would get short of breath?) • ‘Are there any particular times you get this symptom?’ • This can be applied to any history, and once you have asked these you won’t be far off having a diagnosis.

  5. History Taking (General) – My approach • Introduction • HPC • Onset, timeline, triggers • More detail on presenting symptom: the rest of SOCRTES, further description of symptom • ICE • ‘Sometimes when people come to see the doctor, they already have an idea of what they think the problem could be. Is that something you can relate to?’ • ‘Is there anything in particular that you have been worried about?’ • ‘How exactly are you hoping we can help?’

  6. continued • Associated Symptoms (Extremely important! Need to learn the differentials for your presenting complaints, and accompanying symptoms) • Warn the patient that you have a couple of quick questions for them, just to get a better idea of what’s going on • Quickly ask symptoms that relate to possible diagnoses • This is where your revision is important. Also important in the future as a safe doctor!

  7. continued • PMH • ‘Do you have any other medical conditions?’ ask specifically about relevant medical conditions • ‘Have you ever had to spend time in hospital for anything?’ • FH • Easy to follow on after PMH • Any conditions run in the family? Ask specifically about relevant medical conditions, and clarify details if needed • DH • ‘Do you take any medications?’ ‘What about inhalers, creams or eye drops?’ • ‘Do you take anything over the counter?’ • ‘Do you have any allergies?’ • SH • Work, family and personal life • Alcohol, smoking and recreational drug use. Ask this early if it is necessary for your history and you are short on time.

  8. Shortness of Breath Histories

  9. Differential Diagnoses – Acute causes • Asthma attack - likely young, history of asthma/atopy, wheeze, chest tightness • Exacerbation of COPD – Smoking history, hx of COPD, previous respiratory symptoms that have worsened, possibly signs of infection • Pulmonary Embolism - likely chest pain, recent leg swelling, possibly recent surgery or long flight • Acute coronary syndrome - really important! Likely to have chest pain, but not necessarily. May have nausea/vomiting/sweating. May have history of coronary heart disease. • Pneumonia – likely to have cough/fever/sputum production and feeling unwell. • Pneumothorax - unlikely in an OSCE? Little to go off, but possibly recent chest trauma or lung disease • Pulmonary oedema – unlikely in an OSCE? shortness of breath worse on lying down, history of heart disease • Anxiety attack – unlikely in an OSCE? tingling in lips and fingers. • Arrhythmias – unlikely in an OSCE? Palpitations, possibly irregular with other cardiac features

  10. Differential Diagnoses - Chronic • COPD – progressive worsening breathless in a smoker. Possibly chronic cough, wheeze and sputum production. • Chronic Heart Failure – progressive worsening breathlessness. Possibly history of heart disease. Can still have cough and sputum production. • Lung Cancer – Weight loss, haemoptysis, smoking history. Possibly hoarse voice/dysphagia. • Pulmonary fibrosis – Unlikely in OSCE. progressive worsening breathlessness. Few other symptoms. Possibly medication and occupational risk factors? • Tuberculosis – unlikely in an OSCE. Weight loss, feeling generally unwell, travel history or close contact with people with TB. • Anaemias – Unlikely in an OSCE. Many causes of anaemias, including cancers! Ask about blood loss? Frequent infections?

  11. Priorities for SOB • Clarification of SOB:how long has it been going on for? How did it come on?How has it changed since then? Any triggers?Any particular times you get SOB? • Importantly:When do you get SOB now? How much exercise/movement can you do? Breathless at rest? Dressing yourself? Walking on the flat? Walking up stairs?How were you before this? (basically, how much could they do previously without getting SOB, to compare how bad this episode is compared to their baseline).

  12. Associated Symptoms to think about in SOB (by systems) • Respiratory symptoms – cough, wheeze, sputum production, haemoptysis • Cardio symptoms – chest pain, ankle swelling, palpitations, syncope • Systemic symptoms – Fever, weight loss

  13. Particular symptoms for differentials (acute) • Asthma:history of atopy. Made worse by pets, or changes in house? Cold air? Exercise? Emotion? Recent medications (beta-blockers/NSAIDs) • COPD:Smoking history • Pulmonary Embolism:Recent leg swelling? Chest pain? Recent surgery, immobility or long journey? • Acute Coronary syndrome:Chest pain, radiating anywhere? Past history of Coronary heart Disease? • Infectious:Fever? Feeling generally unwell? • Anxiety:Tingling in lips and fingers? (may also have other symptoms like palpitations)

  14. Particular symptoms for differentials (chronic) • Chronic Heart Failure:Orthopnoea – SOB on lying down, how many pillows do you sleep on at night? PND – paroxysmal nocturnal dyspnoea – walking up at night out of breath? Ankle swelling. Recent heart attack? • COPD:Smoking history. Cough, wheeze, sputum production. • Lung cancer:Weight loss, haemoptysis, chronic cough and chest pain • Tuberculosis:weight loss, feeling generally unwell, travel history, ever been vaccinated against, recent contact with TB?

  15. My favourite book for History Taking

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