WEEK. OSPAP Programme. Respiratory Examination & History. Slide 1 of 49 MPHM14 OSPAP Clinical Skills

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1 OSPAP Programme Respiratory Examination & History Slide 1 of 49 MPHM14 OSPAP Clinical Skills

2 The Beginning! Environment! Introduce yourself Ask permission to take the history Have you got the correct person!! Patients Demographics Name Age Occupation Background Slide 2 of 49 MPHM14 OSPAP Clinical Skills

3 Initiating the Session: Preparation Establishing initial rapport Identifying reason for the consultation Providing Structure: Making organisation overt Attending to flow Gathering Information: Exploration of the patient s problem to discover the: Biomedical perspective Patient perspective Background information (context) Physical Examination Explanation and planning: Providing the correct amount and type of information Aiding accurate recall and understanding Achieving a shared understanding: incorporating the patient s illness framework Planning, shared decision making Building the relation ship: Using appropriate non-verbal behaviour Developing rapport Involving the patient Closing the session: Ensuring appropriate point of closure Forward planning Kurtz S, Silverman J, Benson J, Draper J (2003) Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides. Academic Medicine;78(8): Slide 3 of 49 MPHM14 OSPAP Clinical Skills

4 Structure Presenting Complaint History of Presenting Complaint Past medical history Drugs (medications/allergies) Family history Social history System enquiry Polly (Peter) Has Pretty Damn Fine Sexy (smelly) Stockings (socks) Slide 4 of 49 MPHM14 OSPAP Clinical Skills

5 OPQRSTU O P Q R S T U Onset Pain, precipitating factors Quality, quantity Radiation, relieving factors Severity/score, symptoms Timing You (ICE) Slide 5 of 49 MPHM14 OSPAP Clinical Skills

6 I.C.E. Ideas Do you have any particular worries about this symptom? Concerns What is concerning you? Expectations What are you hoping for me to do for you today? (Moulton 2007) Slide 6 of 49 MPHM14 OSPAP Clinical Skills

7 Past Medical History Open questions What illnesses have you had? (include psychiatric conditions if appropriate) Slide 7 of 49 MPHM14 OSPAP Clinical Skills

8 History Taking Drug History Not just prescribed drugs - include over the counter remedies and alternative medicine Name each substance, dose and duration Compliance Drug allergies & sensitivities Slide 8 of 49 MPHM14 OSPAP Clinical Skills

9 Medication and Allergies Medication Generic name if possible Dose Route of administration Recent change Include OTC and homeopathic / herbal Recreational drugs Allergies & Sensitivities When? Diagnosed? How presented, symptoms Slide 9 of 49 MPHM14 OSPAP Clinical Skills

10 History Taking Family history Open question - tell me about any illness(es) which run in the family Ask specifically about immediate family including parents Diagnosis and age Cause of death Slide of 49 MPHM14 OSPAP Clinical Skills

11 Social History Family situation Relationships incl. Marital status Occupation Past and present Exposure Community Involvement & Network Hobbies Slide 11 of 49 MPHM14 OSPAP Clinical Skills

12 Social History Alcohol history Quantity and type Place of drinking Alone or accompanied Money spent Purpose Slide 12 of 49 MPHM14 OSPAP Clinical Skills

13 Social History Tobacco Duration Type - pipe, cigarettes, cigars Amount If stopped when Slide 13 of 49 MPHM14 OSPAP Clinical Skills

14 Systematic Inquiry General Well being Appetite Sleep Energy Weight change Slide 14 of 49 MPHM14 OSPAP Clinical Skills

15 Systemic Enquiry Direct questioning Organise symptoms by system Explore any positives with open ended questions and then clarify as per presenting complaint Use lay terms Summarise Anything else? Slide 15 of 49 MPHM14 OSPAP Clinical Skills

16 Systemic Enquiry C.V.S. Chest pain Breathlessness On exertion Lying flat Wake up at night Orthopnoea Palpitations Ankle swelling Exercise Tolerance Pain in legs when walking Slide 16 of 49 MPHM14 OSPAP Clinical Skills

17 Systemic Enquiry R.S. Shortness of breath Chest pain On inspiration Cough Sputum Blood Wheeze Slide 17 of 49 MPHM14 OSPAP Clinical Skills

18 Systemic Enquiry GI System Dental / Gum Problems Reduced appetite/weight loss Swallowing painful difficult Indigestion, heartburn Abdominal pain Vomiting Altered bowel habit Blood loss Slide 18 of 49 MPHM14 OSPAP Clinical Skills

19 Systemic Enquiry Urogenital Pain on passing urine Frequency - day, night Colour of urine Males: Females: (age), difficulty starting, poor stream, dribbling, discharge, libido menarche, menopause, frequency, regularity, urge or stress, incontinence, discharge, abnormal bleeding, libido Slide 19 of 49 MPHM14 OSPAP Clinical Skills

20 Systemic Enquiry CNS Weakness Disturbance of sensation Headaches Visual disturbance Dizziness, blackouts (clarify these) Fits Confusion Disturbance of speech Hearing Slide 20 of 49 MPHM14 OSPAP Clinical Skills

21 Systemic Enquiry Locomotor Joint Pain Joint Stiffness Swelling Mobility Gait Falls Redness and warmth Slide 21 of 49 MPHM14 OSPAP Clinical Skills

22 Systemic Enquiry Endocrine Heat intolerance (change) Cold intolerance (change) Change in sweating Thirst and Polyuria Prominence of eyes (change) Swelling in neck Energy Slide 22 of 49 MPHM14 OSPAP Clinical Skills

23 Systemic Enquiry The Skin Rash Spots Itching Ulcers Lumps/growths Slide 23 of 49 MPHM14 OSPAP Clinical Skills

24 Summary Salient features of Presenting history Relevant past history Background Differential diagnosis Slide 24 of 49 MPHM14 OSPAP Clinical Skills

25 History Taking Explanation Most important from the patients point of view Communication skills are vital Speak clearly and audibly Avoid jargon Avoid emotive words Most important information first Slide 25 of 49 MPHM14 OSPAP Clinical Skills

26 Examination Includes: General inspection Specific inspection (hands, face, chest) Palpation Percussion Auscultation Additional checks Slide 26 of 49 MPHM14 OSPAP Clinical Skills

27 Inspection General inspection Hands Face Eyes Mouth Anterior chest Posterior chest Slide 27 of 49 MPHM14 OSPAP Clinical Skills

28 Palpation Lymph nodes Trachea Anterior chest Posterior chest Slide 28 of 49 MPHM14 OSPAP Clinical Skills

29 Percussion Explain purpose of percussion Identifying areas of tympany & dullness Identify appropriate percussion points Use correct percussion technique Compare side to side, identifying percussion note Posterior chest As per anterior chest Slide 29 of 49 MPHM14 OSPAP Clinical Skills

30 Auscultation Explain purpose of auscultation- asks pt to breathe through mouth Identify normal /abnormal breath sounds and causes bronchial, vesicular, crepitations, wheeze, pleural rub Identify appropriate auscultation points Takes time to Listen thru full respiratory cycle at identified auscultation points Demonstrate correct auscultation technique with diaphragm placed firmly on chest wall Demonstrate vocal resonance Correct vocal resonance technique Posterior chest: As per anterior chest Slide 30 of 49 MPHM14 OSPAP Clinical Skills

31 Additional checks Sacral oedema (as in heart failure) Inspect both legs: Calf pain Leg swelling Palpate calves for tenderness DVT Increased temp of leg Inflammation Thank the pt Slide 31 of 49 MPHM14 OSPAP Clinical Skills

32 Recap Examination: General inspection Specific inspection (hands, face, chest) Palpation Percussion Auscultation Additional checks History: Presenting Complain Hx PC (OPQRSTU) Prev Med Hx Drug Hx Family Hx Social Hx Systems Review Slide 32 of 49 MPHM14 OSPAP Clinical Skills

33 Slide 33 of 49 MPHM14 OSPAP Clinical Skills

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