RED FLAGs in Respiratory

Red Flags in Respiratory cases

Hello fellow medics,

I hope you are all well.

Below is a summary of a few red flags one should be aware of when taking a respiratory history from a patient. These questions will allow you to rule out any sinister causes of their symptoms (ie cancer) or emergency reasons (ie Pulmonary embolism)

1) Chest pain

Chest pain in any context is not good. In the case of a respiratory station it could mean: Pulmonary Embolism. Also if they have chest pain, it is also a good idea to rule out cardiac cause (ie worsens with exercise, cardiac background, radiation to arm/chin)

“Do you have any chest pain when you take a deep breath in?” (pleuritic chest pain)

“Are you able to replicate the chest pain by pressing down on the chest wall?” (which may indicate MSK related pain)

2) Leg swelling

You can get leg swelling unilaterally which may indicate a DVT or bilateral which may mean cardiac failure. It is best to elicit WHEN they noticed the leg swelling (a short history is more worrying than a longer history) and if it is one or both legs. Leg pain and swelling also together is more worrying.

“Have you noticed any sudden swelling of your legs? If so, is it both or the one leg”.

Also work out where the swelling is- Is it the whole leg or just the ankle/foot.

3) Haemoptysis

A patient with haemotypsis should cause concern and always lead to further questions. You want to know how many times it has occured, for how long and if they have any associated symptoms ie shortness of breath. It is vital to do a smoking history (pack-years) and work history.

There are many causes of haemoptysis, but the main worrying reasons are: cancer, PE, TB. So having these in your mind will allow you to ask further questions to differentiate.

“Have you noticed any blood when you cough? If so, how much approximately and how many times has it occurred?”

4) Night sweats and weight loss

As I have explained in my blog about “Red flags: history taking” this a universal red flag for all cancers. In the context of respiratory causes, you need to think about TB, pneumonia and cancer. There are also rheumatological causes that can lead to this too.

“Have you noticed any night sweats, so much so you have had to change your clothes?”

“Have you noticed any sudden weight loss, if so, how much and over what period of time?”

5) Persistent new cough

A very vague symptom, as can occur in non life threatening conditions but in addition to the other red flag can be worrying. Also for how long have they had this persistent cough.

“So do you have a new cough, how long has it been bothering you for?”

6) Any new respiratory symptom + smoker

Smoking increases risk of all cancers, and so is an important question to ask in the social history. This cannot be ignored when doing your risk assessment for someone you suspect to have cancer.

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I hope this was a refresher/reminder of questions and ideas to think about when doing a respiratory history.

The aim is not to teach you the above, but to remind you.

For more details regarding 2 week wait/urgent lung referrals, the best resource for this is: cks.nice.org.uk - which has all the up to date, evidence based guidelines (as it all depends on age and length of symptoms).

Please do follow me on instagram, facebook or twitter for quick reminders and to join the community!

Please feel free to email me if you have any questions or suggestions.

Happy revision :)

History Taking: Patient with low mood (depression)

History taking: psychiatry case

Mental health station is commonly tested in the OSCE as it makes up a large proportion of consultations in both primary care and also influences decisions in secondary care. The examiners want to ensure that the candidate has a sound understanding of the questions to ask, the red flags to rule out and the communication skills for a smooth consultation.

Important factors:

• listening is far more important than talking.

• show empathy with verbal and non verbal communication, whether that is with head nodding or saying “OK, I see”. Listening skills are important in ALL stations, but this one in particular!

• if the patient cries, be silent and to break the silence say something empathetic “I can see that you are very upset”

• ask about suicide, do not be afraid to ask this. Ask sensitively.

• use the patients own words when reflecting what they have said. This shows you are listening and not making your own interpretation

  • “tell me more about ‘feeling alone and desperate’?”

• Social history is just as important as all other components. Candidates often feel this doesn’t require as much attention, but this is not true. Knowing who the patient lives with, their support network, if they go to university/work will firstly allow safety netting (if they were suicidal) and also builds rapport.

Below is a summary of the questions to ask and why (as knowing the ‘why’ makes it a whole lot easier to remember!) I have focused the history on low mood to make it easier to discuss.

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PRESENTING COMPLIANT

“How can I help you today?’

Let the patient talk and express themselves. The first 1 minute (‘golden minute”) will tell you mostly what you need to know. Listen to them, make a mental note/physical note of the important statements they used

HISTORY OF PRESENTING COMPLIANT

Core symptoms

This is where you want to know if they have the specific “core symptoms” of depression.

"Have you in the last month felt persistently low in mood?”

“Have you in the last 1 month lost interest in things that used to interest you?”

“Have you in the last 1 month felt low in energy?”

Biological symptoms

With depression, patients also have other ‘biological symptoms” along with the core symptoms.

“Are you sleeping?” “Have you had issues with your sleep?”

This may be OVER sleeping or UNDER sleeping.

“How is your appetite?” “Are you eating less/more”

They may over eat/under eat. Remember depression can go hand in hand with an eating disorder. Of course this is something you will not be able to cover in a 10 minute station.

“Have you noticed a change in your libido?”

Remember low mood doesn’t just affect the patient, but also loved ones. It has a significant impact on relationships.

Cognitive symptoms

• change in concentration

• how they feel about themselves and the world around them

Associated psychiatric conditions

With depression, patients can suffer from associated psychiatric conditions ie eating disorder or psychosis. Here you need to ask questions to rule this out:

“Have you ever worried about your weight?” - eating disorder

“Have you ever felt euphoric?” - Mania (bipolar)

“Have you ever heard voices when no one is ever around?” psychosis (auditory hallucinations)

“ Have you ever seen something that you couldn't explain?” psychosis (visual hallucinations)

“Do you ever feel like people are talking about you behind your back?” psychosis

Candidates find it odd asking the above questions, so you can always start with

“these questions may sound odd, but it is important we discuss them” This also gives a warning shot to the patient.

The above questions may need examples if the patient is not understanding you ie “Do you feel like like people are speaking about you negatively, ie you feel like people are out to get you?”

RISK ASSESSMENT

Vital questions that have to be asked in a patient presenting with suicidal thoughts/deliberate self harm:

1. ask about suicide, do not be afraid to ask this. Ask sensitively. There are lots of different ways ie

   • “have you ever thought life was not worth living"?”

   • “do you ever wish you weren’t here"?”

   • “do you feel the world would be better without you”

2. Ask about self harm

   • “Do you have thoughts about harming yourself?

   • “Have you ever harmed yourself”

If they say they DO have thoughts of harming themselves or DO have thoughts of wanting to end their lives, the next best step is to ask about protective factors: essentially what would STOP them from hurting/killing themselves. Working as a GP, this question is essential for me to evaluate “risk” and my next step. Also, having an idea of the patients social set up will help me, ie do they live alone, do they have lots of friends around them.

“I really appreciate you being open with me about these thoughts you are having, it must have been so difficult to say this” “What stops you from actually ending your life"?”

Most patients will say ‘oh i don’t actually want to, its just fleeting thoughts” some say “my family, my children, my dog, religion”.

PAST PSYCHIATRIC HISTORY

You want to find out if they have 1) seen their GP for their mental health in the past 2) Been on medications for mental health issues 3) been admitted into hospital for mental health issues

This will put the above information into context. Is this is a patient who has been sectioned for mental health problems? - this is more worrying than a patient who has never been on any medications.

PAST MEDICAL HISTORY

The same questions as other history taking stations

DRUG HISTORY

Same as other history taking stations

additional factors:

If they have taken antidepressants/anti psychotics in the past /currently, you need to know 1) what medications 2) the dose 3) for how long.

FAMILY HISTORY

Same questions as other stations but with additional questions around mental health issues in the family. Many mental health problems run in the family. Also you want to know if the patient grew up around a parent with depression, or a parent who committed suicide.

SOCIAL HISTORY

• alcohol, drugs, smoking

• forensic- have they ever been in trouble with the police

• student/working - how has their mood impacted this

• relationship - are they single? do they find it difficult to form relationships

• who do they live with?

• Do they speak to their friends and family? (support network)

INSIGHT

You may want to ask this if the patient has come with a relative who is worried. Does the patient actually see that they may have depression? Having insight makes the management different to someone who is not aware they they have a mental health problem.

ICE

Same questions as other history taking station

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I hope you found this information useful. It is not a comprehensive guide and there to just get you thinking and reflecting on your own style of history taking.

Please feel free to send me an email if you have any question, queries or corrections!

Also if you would like to have one-to-one revision, again either send me an email and we can arrange one hour (free!) of discussing your needs and how i can be of help with your revision. Or you can sign up via the website.

Please follow my twitter/instagram/facebook for further quick bites of information.

Happy revision :)

OSCE revision - Recognition/management of unwell patient : A-E

OSCE revision - the recognition and management of an unwell patient using the A-E approach

Welcome fellow medics!

I hope we are all well and revision is going to plan..

Here I have put a summary together of the basic approach to an “unwell patient” which will be a station in the OSCE exam/clinical skills exam.

KEY POINTS:

This station is to check you can RECOGNISE AN UNWELL PATIENT and also MANAGE AN UNWELL patient

The approach used is the “A-E” approach- which stands for Airway, Breathing, Circulation, Disability and Exposure.

This is a quick guide- for more in depth info please refer to: https://www.resus.org.uk/resuscitation-guidelines/abcde-approach/ (which is amazing trustworthy information).

This is in no shape or form comprehensive. It is a quick summary to get you thinking.

The process is simple but can catch candidates out due to a few simple errors, which can be amended by:

1) if something is wrong in the “A-airway: - you fix it and THEN move on to “B-breathing” etc. A-E is in order of saving the patients life. DO NOT move on until you have fixed the section.

2) Vocalise what you are looking for, ask for the answer “I would like the blood oxygen levels” and then place the sats probe on the mannikin.

3) USE THE EQUIPMENT! If you want a blood pressure, pick up the BP machine, if the examiner is not looking to mark this, they will give you the answer, STOP and MOVE on.

4) Although you feel you have to be quick on this station because it is an “emergency” the best candidates are those who are calm, relaxed and clear. So ironically, slow down!

5) Vocalise what is on your mind. The examiner cannot and will not read your mind. Aim your discussion at the examiner. Speak to the mannikin, make it real and natural.

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You will be given an information card ie “you are a FY1 and have been asked by the nurse to come see Mr Smith, whom they are worried about”

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AIRWAY

The one and simple question to check airway - talk to the patient. literally.

“Hello Mr Smith, how are you feeling?”

This can then go a few ways:

He responds - AIRWAY PATENT MOVE ON…(most likely as this is checking your A-E approach)

He is gargling- you need to sort the airway - ie suction

He IS NOT RESPONDING - that is another station..this will then become BLS/CPR etc

BREATHING

So Mr Smith is chatting to you, so you can now move onto his breathing. This is everything to do with the lungs essentially.

You want the following information : LOOK LISTEN FEEL

• SAY you are checking the colour of the patient

• CHECK blood saturations - find that probe

• CHECK (auscultate) lungs - physically examine the patient/mannakin. The examiner will stop you to give findings

• ASK for respiratory rate

React to what is being said to you - listen to the examiner (some examples)

• Blood saturations low- place oxygen mask on mannikin

• Chest findings ie “crackles on left side” ACKNOWLEDGE + INTERPRET “I am considering this may be a chest infection”. Now you might think, why would i say it now…well you might forget/run out of time at the end, so say it when you realise it.

• Raised respiratory rate - may indicate infection, etc. Again ACKNOWLEDGE.

• He looks blue around the lips, well hopefully some O2 will help him out.

CIRCULATION

So you have sorted out his breathing, you have put some oxygen on him, he is looking OK, he is talking to you, and his colour has improved. Now you want to check his circulation, this being the next important factor.

• LOOK/FEEL fingers - are they warm and well perfused? good.

• CHECK CAPILLARY REFILL

• CHECK blood pressure - LOOK for BP cuff

• CHECK pulse

• CHECK JVP - for cardiac failure

• CHECK for bleeding

• LISTEN to heart sounds

• GET IV ACCESS- whilst there - take full set of bloods

• GET an ECG/attach patient to a cardiac monitor (remember you are vocalising all of this)

React to what is being said to you:

• Low BP - GIVE fluids- ie a fluid bolus of 500ml

• Cap refill time increased - again this may indicate low BP due to ? sepsis. ACKNOWLEDGE and vocalise and react with ie fluids.

• Raised pulse - ? septic, infection.

• Has chest pain/ an odd ECG- ? MI. State you would consider treatment for this/alerting your cardiac colleagues.

• raised JVP- state you feel this may be cardiac failure, and therefore would consider “furosemide”

DISABILITY

So Mr Smith’s blood saturations are improving, he has had his ECG (no acute findings), his BP and pulse are much better with some fluids and you are happy to move on.

• CHECK drug chart - ? drug reaction, any drugs on there of concern/culprits

• CHECK pupils - PEARL?

• CHECK AVPU- conscious level

• CHECK BM- ? hypogylcaemic

React to what is being said to you:

• if a drug is the issue - take drug off drug chart

• Pupils - pinpoint ? opiate overdose. You would reverse this.

• BM- low - is this a insulin OD, fix it with glugogel etc

EXPOSURE

• ASK the patient if they are happy to be exposed. Remember to cover the patient after. You don’t want to lose an easy mark for “patient dignity”

• uncover the patient/manakin and check for any rashes/bleeding etc

• I would do an abdominal examination if the complaint was GI related etc

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I hope the above summary gave some clarification on this type of station.

Remember to speak out loud, speak to the mannikin as if a real patient, speak to the examiner with what your thoughts are…“I am checking the blood pressure” “I am looking for bleeding”.

You are summarising/explaining your findings to the examiner “I am worried about his low BM and therefore would consider safely administering glucose”.

Practice makes perfect. It may feel odd initially as it feels unnatural BUT with practice you will feel more confident in just doing it without worrying.

Best of luck with revision, be safe, be confident and say what is on your mind - otherwise you wont get the mark..

Happy revision and happy vibes!

History Taking: Ideas, Concerns and Expectations

History take: ideas, concerns and expectations

Welcome to my blog page, thank you for taking the time to read this, I hope you are all well during these odd times.

“Ideas, concerns and expectations” commonly referred to as "‘ICE’ can be questions that make you feel uncomfortable. It can feel like it stops the flow, feels out of place and repetitive.

This blog will outline WHY it is important and HOW to integrate it into your history, so it flows better. As without the KNOW- it’s difficult to truly remember to the ask the questions with conviction.

The example questions are just examples, you should find what is comfortable for you!

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IDEAS

“What do you think is going on?”

“What are your ideas on what might be causing these symptoms?”

Why are we asking this?

Essentially you want to know what is on the patients mind. You want them to say what they think might be going on, which could be completely irrelevant. Getting their prospective on what they think the cause of their symptoms are, will introduce a starting point for when you are telling them what YOU think their diagnosis is.

Putting it into context:

“Mrs Smith, you suggested you thought you may have asthma, well taking your shortness of breath and noisy breathing into account, this does seem very likely”

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CONCERNS:

“Was there anything you were particularly worried about?”

“You did say you were worried about cancer, do you have any other worries?”

Why are we asking this?

We want to know what worries the patient the most, which might NOT always be their “ideas”! They might think they have asthma (ideas), but worried it could be lung cancer (concerns). Patients/actors are complex, they have many worries and anxieties, which they don’t always discuss, so it is our job as doctors to bring this out.

Putting it into context:

“Sheila, you said you were worried you might have cancer like your brother, tell me more about this”

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EXPECTATIONS:

“What were you hoping for from todays consultation?”

“How can I best help you today?”

Why are we asking this?

You want to get an idea of what the patient wants from today, do they want a blood test? Do they want you to reassure them, the list is endless. Knowing the “expectations” can be nicely linked to the diagnosis/management of the patient. Again, we feel this is an odd question- they are worried about cancer and they OBVIOUSLY want me to rule this out? This is not always the case.

Putting it into context:

“George, you said that you would like a chest X-ray for this persistent cough, well I agree that would be a good next step”

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I hope you found the information useful and easy to follow. I do believe that practice makes perfect, so whether that is practicing with friends or signing up for one-to-one revision with myself- keep focused :)

Remember this exam is like a driving test- everything has to be obvious and exaggerated for the marks. Make the examiner’s life easy and SHOW them the marks!

Happy revision :)