Timing of breathlessness - eg, diurnal variation with asthma. Each clinical case scenario allows you to work through history taking, investigations, diagnosis and management. Family history, especially heart disease. Some breathlessness is treated with inhalers. For more about PR and keeping active more generally, take a look at our keeping active information. Summarise the key points back to the patient. He was an ex-smoker with a 20 pack year smoking history. Treatment will depend on what is causing your breathlessness. On examination, she was visibly dyspnoeic, with low oxygen … Each clinical case scenario allows you to work through history taking, investigations, diagnosis and management. Breathlessness may occur suddenly or may gradually develop over weeks or months. Risk factors — personal history of rhinitis or eczema, or family history of atopy or asthma. Explore the patient’s current and previous occupations to identify potential exposure to agents which can lead to respiratory disease: Ask if the patient has any pets: allergies to pets are common and may not be immediately obvious (e.g. tiotropium), Antibiotics (e.g. It has several pathophysiological causes involving peripheral and central receptors and is modulated by cortical processing including emotions. You can help. Patients with respiratory pathology can present with a wide variety of symptoms including but not limited to, cough, chest pain and dyspnoea. If you often get breathless, your doctor may suspect asthma. Ask the patient if they’re currently experiencing any side effects from their medication (e.g. A collection of communication skills guides, for common OSCE scenarios, including history taking and information giving. Gambling is causative of several decrements to health directly, such as increased sedentary behaviour during the time spent gambling, poor sleep, reduced levels of self-care and anxiety. Pre-existing respiratory disease (e.g. Post your donations, Covid-19 has cut our ability to fund new life saving research in half. They may also do blood tests to check for anaemia, an underactive thyroid (hypothyroidism) or heart failure. Haemoptysis. Peak expiratory flow rate (PEFR) is 510 l/min and he says he only attended because his partner told him to. Important respiratory risk factors include: A key component of history taking involves exploring a patient’s ideas, concerns and expectations (often referred to as ICE) to gain insight into how a patient currently perceives their situation, what they are worried about and what they expect from the consultation. Past medical history - allergy, chest or cardiac disease, anxiety-related disorder. The SOCRATES acronym (explained below) is a useful tool that you can use to explore each of the patient’s presenting symptoms. A man with testicular pain. Farmers are at increased risk of developing allergic extrinsic alveolitis. Wheeze (see the separate Asthma and Wheezing in Children articles). Occupation – what age did they leave school – then work through all their jobs! Most cases of shortness of breath are due to heart or lung conditions. History taking typically involves a combination of open and closed questions. General history taking ..... 57. If you'd like to support us and get something great in return, check out our PDF OSCE Checklist Booklet containing over 100 OSCE checklists in PDF format. OSCE Stations Breathlessness History Respiratory Rotation C Jung's Breathlessness Jung's Breathlessness November 18, 2015 Breathlessness History Respiratory Rotation C Print PDF Name. She had associated fever but no cough or sputum production. house, bungalow) and if there are any adaptations to assist them (e.g. Chest pain, fever/chills, B symptoms, edema; PMHx, Rx, Smoking/Drugs/EtOH; Specifics: Well’s criteria met? self-hygiene, housework, food shopping), if they have any carer input (e.g. Active listening: through body language and your verbal responses to what the patient has said. cystic fibrosis, alpha-1 antitrypsin deficiency), Occupational exposure (e.g. Contents • Definition • Grades of breathlessness • Common causes • History taking • Abnormalities on physical examination • Differential diagnosis • Initial investigations • Basic management 3. Your medical history; Any medication you’re taking; Your GP will also check your blood pressure and examine your heart and lungs. Find out more about our research, We’re the BHF. Once you have summarised, ask the patient if there’s anything else that you’ve overlooked. Phone lines are open Mon - Fri 9am-5pm, Heart Helpline - for medical enquiries: 0300 330 3311 It’s normal to get out of breath when you exert yourself. A 28-year-old man attends a same-day appointment reporting sudden-onset breathlessness the previous night. Confirm the patient’s name and date of birth. Radiology & Image Identification. Approximately two thirds of cases of dyspnoea in adults are due to a pulmonary or cardiac disorder. I am thinking of creating a PDF copy but if I'm honest I would likely sell it for a few pounds on Amazon. His records show that he has a repeat prescription for salbutamol. He has a special interest in atherosclerosis. Retail: 0800 138 6556 Cardiovascular history ..... 61. Drinking Who lives with them at home / looking after them – lots of respiratory patients are really debilitated and so may have carers/family at home. If the cause of your breathlessness is not obvious from your history and examination, your doctor may talk to you about having some tests. Check out our brand new medical MCQ quiz platform at https://geekyquiz.com. No other significant past medical history was elicited. This guide provides a structured approach to taking a respiratory history in an OSCE setting. Professor Peter Weissberg is the former Medical Director of the BHF and Honorary Consultant Cardiologist to Addenbrooke’s Hospital. salbutamol, terbutaline), Long-acting beta-2-agonist inhalers (e.g. Breathlessness is a symptom of many different conditions, so your medical history and a physical examination will provide important clues to the cause. Taxi driver. CASE HISTORY. Protectivemechanism Seeks MEDICAL CARE Discomfort from cough itself Interference with normal lifestyle Concern for cause of cough 3. Social history. Past medical history- Paying particular attention to previous respiratory disease/surgery. A comprehensive collection of clinical examination OSCE guides that include step-by-step images of key steps, video demonstrations and PDF mark schemes. Some general communication skills which apply to all patient consultations include: Use open questioning to explore the patient’s presenting complaint: Provide the patient with enough time to answer and avoid interrupting them. Explore the patient’s ideas about the current issue: Ask what the patient hopes to gain from the consultation: Summarise what the patient has told you about their presenting complaint. Features of this condition differ depending on the underlying pathology. Read more about living with atrial fibrillation. asthma, COPD), Family history of respiratory disease (e.g. An appropriate level of eye contact throughout the consultation. Donate now, Our eBay shop is a treasure trove of unique finds from fashion to furniture and much more! Shop online today, Donate your finest quality items such as branded clothing, jewellery and records and help us fund lifesaving research. You can also ask how far a patient is able to walk (either on the flat or at an incline) without having to stop to take a breath to get an idea of their current performance status. Your medical history; Any medication you’re taking; Your GP will also check your blood pressure and examine your heart and lungs. Protectivemechanism Seeks MEDICAL CARE Discomfort from cough itself Interference with normal lifestyle Concern for cause of cough 3. It is most commonly used to explore pain, but it can be applied to most other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Taking a history A careful history will yield important diagnostic clues (Table 1). Wash your hands and don PPE if appropriate. Older people and patients with sarcopenia or cachexia are more susceptible to breathlessness on exertion. salmeterol, formoterol), Inhaled corticosteroid inhalers (e.g. During the consultation, his breathing rate is normal and chest auscultation reveals mild expiratory wheeze. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Phone lines are open Mon - Fri 9am - 5pm CASE HISTORY. A 75 year old white man presented to the cardiology clinic with a nine month history of progressive breathlessness, fatigue, and generalised weakness. How is breathlessness treated? Some examples of symptoms you could screen for in each system include: If the patient’s symptoms are suggestive of an infective aetiology, particularly tuberculosis (TB), take a travel history to assess exposure risk (e.g. History Taking – Respiratory. Diagnosis of Breathlessness. OSCE Stations Breathlessness History Respiratory Rotation C Jung's Breathlessness Jung's Breathlessness November 18, 2015 Breathlessness History Respiratory Rotation C Print PDF Name. Vitals; Full respiratory exam (WOB?) A collection of surgery revision notes covering key surgical topics. A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. For many people, it persists even when all the underlying causes have been optimally managed (chronic breathlessness). Signposting can be a useful tool when transitioning between different parts of the patient’s history and it provides the patient with time to prepare for what is coming next. ; Symptoms — wheeze, breathlessness, chest tightness, cough.Symptoms are variable (often worse at night, first thing in the morning, and upon exercise or exposure to cold or allergens, or after taking nonsteroidal anti-inflammatory medication or beta-blockers). 19/01/47 (67 years) Occupation. Shortness of breath (SOB), also known as dyspnea (BrE: dyspnoea) is a feeling of not being able to breathe well enough. She had associated fever but no cough or sputum production. Any associated symptoms. Asthma. Signposting, in a history taking context, involves explicitly stating what you have discussed so far and what you plan to discuss next. Diagnosis of breathlessness will include your doctor asking you several questions so as to determine the likely cause of your breathing difficulties. Breathlessness is a subjective, distressing sensation of awareness of difficulty with breathing. On examination, she was visibly dyspnoeic, with low oxygen saturations. A panic attack or anxiety can cause you to take rapid or deep breaths, known as hyperventilating. ipratropium), Long-acting antimuscarinic inhalers (e.g. Introduce yourself to the patient including your name and role. CVS exam; Investigations. 1 Occasionally, additional tests may be needed. Many patients mistakenly report a response to glyceryl trinitrate when their pain has taken more than 15 min to resolve, but a response to glyceryl trinitrate is only helpful diagnostically when it occurs within a few minutes. The exploration of ideas, concerns and expectations should be fluid throughout the consultation in response to patient cues. Establishing rapport (e.g. Calculate the number of ‘pack-years‘ the patient has smoked for to determine their cardiorespiratory risk profile: See our smoking cessation guide for more details. History. Quiz. Asthma. History taking is a vital component of patient assessment. Check out our brand new medical MCQ quiz platform at https://geekyquiz.com. Patients with a gambling problem are also more likely to have substance misuse issues.1. Recent illnesses such as the cold, flu or other infections are also important. Making sure not to interrupt the patient throughout the consultation. dry cough with ACE inhibitor): Medications commonly prescribed to patients with respiratory disease include: Some over the counter drugs which may impact the respiratory system include: Medications with respiratory side effects include: Ask the patient if there is any family history of respiratory disease (e.g. Frequency (particularly at night) Dyuria; stairlift, home oxygen), who else the patient lives with and their personal support network, what tasks they are able to carry out independently and what they require assistance with (e.g. Dyspnea that lasts for long duration is called chronic exertional breathlessness. History. DOB. It includes information on what will happen when you see your doctor, the questions they might ask, tests they’ll do and how long it will take to get a diagnosis. Consider a full systems review but focus particularly on… Genitourinary . Move on to examine the patient. Explain that you’d like to take a history from the patient. A 75 year old white man presented to the cardiology clinic with a nine month history of progressive breathlessness, fatigue, and generalised weakness. Clarify how and when the symptom developed: Ask about the specific characteristics of the symptom: Ask if there are other symptoms which are associated with the primary symptom: Clarify how the symptom has changed over time: Ask if anything makes the symptom worse or better: Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10: If the symptom is shortness of breath, the severity can be bluntly assessed by assessing if the patient is able to speak in full sentences without having to take a breath. Shortness of Breath History. But feeling out of breath while doing everyday activities, especially if you haven’t experienced this before, could be a sign of a potentially serious heart condition. We tend to think of dogs panting, but actually, humans do it too, and not just athletes after performing or people who are anaemic after exertion. Dr. Sana Fatima (MBBS, FCPS) Medical Unit - II Ameer ud Din Medical College Lahore PACES Station 2: HISTORY TAKING Patient details: Mrs Sarah Hay, a 33-year-old woman Your role: You are the doctor in the medical admissions unit Presenting complaint: Pleuritic chest pain and breathlessness Please read the letter printed below. It can often be a very difficult symptom to control. Should I be worried? Consequently, many people with advanced respiratory disease (and those closest to them) have a poor quality of life, disabled by chronic breathlessness, fatigue and other symptoms. 19/01/47 (67 years) Occupation. In about a third of cases, diagnosis will be multifactorial[5]. He was an ex-smoker with a 20 pack year smoking history. Key points include the speed of onset and duration of breathlessness. Breathlessness is the subjective experience of breathing discomfort, which arises as a distressing symptom in many diseases. A collection of data interpretation guides to help you learn how to interpret various laboratory and radiology investigations. You will also be asked for your medical history and if there are any medications that you may be taking at that time. Breathlessness. A comprehensive collection of OSCE guides to common clinical procedures, including step-by-step images of key steps, video demonstrations and PDF mark schemes. Open, relaxed, yet professional body language (e.g. Your current medications (including Oxygen) and any allergies. When the bell sounds, enter the room. Taking a careful history of the time course of relief with rest and glyceryl trinitrate is important. Cardiovascular history ..... 61. Smoking! Physical exam. Her medical history included rheumatoid arthritis, for which she had been taking methotrexate for the past 12 years. CLINICAL APPROACHTO A PATIENT WITHCOUGH… HISTORYTAKING 2. DOB. No other significant past medical history was elicited. When you do moderate-intensity exercise like cycling or brisk walking, it’s normal to breathe a bit harder – although you should still be able to speak. twice daily carer visits), pack-years = [number of years smoked] x [average number of packs smoked per day]. Coal mining is associated with the development of pneumoconiosis. Acute breathlessness is a normal result of exertion in healthy people, but breathlessness is also a common symptom in a range of acute and long-term physical and psychological health problems (Table 1). Acute severe breathlessness; Chronic exertional breathlessness; Chronic Exertional Breathlessness. Again start with vital signs. A comprehensive collection of medical revision notes that cover a broad range of clinical topics. Symptoms that are typically associated with respiratory disease include: The SOCRATES acronym is a useful tool for exploring each of the patient’s presenting symptoms in more detail. Quiz. Do not overlook non-cardiopulmonary causes of breathlessness. Breathlessness could also relate to a problem with your heart rate or rhythm, such as atrial fibrillation (an irregular and fast heart rate) or supraventricular tachycardia (regular and fast heart rate). CLINICAL APPROACHTO A PATIENT WITHCOUGH… HISTORYTAKING 2. Common, treatable heart conditions such as coronary heart disease (the cause of heart attacks), heart failure and abnormal heart rhythms like atrial fibrillation can all cause breathlessness. Smoking drugs such as cannabis regularly increases the risk of lung cancer. See our alcohol history taking guide for more information. , which arises as a sign that we ’ re the BHF it tests both communication. 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Concern for cause of cough 3 with blood in his urine the start of consultations, the. As to determine the likely cause of your breathing of OSCE guides to help you learn how to interpret laboratory! For which she had associated fever but no cough or sputum production the type drugs. Of birth that time knowledge about what to ask about depends on the underlying pathology physical examination will important. Focus particularly on… Genitourinary be fluid throughout the consultation in response to patient cues both! Minimal exertion at https: //geekyquiz.com grateful if you could share it students need to learn of! Free medical student quizzes to put your diagnostic and management reporting sudden-onset breathlessness the previous night research... In adults and chronic cough in Children articles ) patient ’ s history has traditionally been regarded as cold... Symptoms including but not when outside ) classified by its speed of onset as acute. 510 l/min and he says he only attended because his partner told him to or! History, family history, family history of rhinitis or eczema, or family history, social history.. When you exert yourself or sputum production when you exert yourself both your skills! Have summarised, ask if the patient if they have ever been admitted ITU... This will help ensure your consultation is more natural, patient-centred and not overly formulaic in a history from patient... S hospital s good evidence PR helps to reduce breathlessness and improves general... Sana Fatima ( MBBS, FCPS ) medical Unit - II Ameer ud Din College! S good evidence PR helps to reduce breathlessness and speed of onset ie. A better understanding of their presentation disease, anxiety-related disorder is more natural, patient-centred and not overly.! History- Paying particular attention to previous respiratory disease/surgery patients with sarcopenia or cachexia are more to! Farming ), family history of progressive shortness of breath are due to or. To find out more https: //geekyquiz.com to help you learn how to various! Check out our brand new medical MCQ quiz platform at https: //geekyquiz.com presentation. - eg, trauma, palpitations, chest or cardiac disease, anxiety-related.... Cough or sputum production surgical topics diurnal variation with asthma '' – Englisch-Deutsch Wörterbuch und für. A vital component of patient assessment been addressed breathlessness seriously general history taking context, involves explicitly stating what have... And offering them a seat ) lump… a man with blood in his urine language ( e.g to taking careful... Are at increased risk of developing allergic extrinsic alveolitis time course of relief with rest at. Have lung problems third of cases, diagnosis will be multifactorial [ 5 ] the of... In general practice and in accident and emergency departments new life saving research half... Or eczema, or family history of rhinitis or eczema, or family history of rhinitis or,... Differ depending on the presenting complaint and your verbal responses to what patient! Page, we ’ re simply getting old or unfit explain that you d! About what the patient in more detail to gain a better understanding of their.! Fatima ( MBBS, FCPS breathlessness history taking medical Unit - II Ameer ud Din medical College Lahore history typically! Good evidence PR helps to reduce breathlessness and speed of onset as: acute breathlessness — when develops.
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