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Chronic Breathlessness Alina Malgina / 8 October ‘24Use code CBOSCECREW24 at checkout on geekyquiz.com for 10% off OSCE flashcards, OSCE stations and knowledge bundles. Learning Objectives ● Aim to take focused history surrounding chronic breathlessness ● Explore specific signs and symptoms that can help reach diagnosis in patients presenting with chronic breathlessness ● Taking a smoking history ● Overview of sharing information CCA/OSCE stations and smoking cessation adviceWhat is considered chronic?Chronic Breathlessness ● Acute – minutes ● Subacute – hours to days ● Chronic – usually > 4 weeksChronic Breathlessness ● Acute – minutes ● Subacute – hours to days ● Chronic – usually > 4 weeks 65-year-old male presenting with a 2-year history of increasing shortness of breath HPC: Used to be an avid walker, now struggles to walk to the shopCauses of Chronic Breathlessness ● Cardiac ● Pulmonary (respiratory) ○ COPD/Asthma/Bronchiectasis ○ Arrhythmia ○ Cardiomyopathy ○ Cystic fibrosis ○ Congenital Heart Disease ○ Interstitial lung disease ○ Hypertension ○ Ischemic heart disease ○ Lung cancer ○ Valvular heart disease ○ Occupational lung disease ● Other causes ○ Pulmonary Vascular Disease ○ Anemia (hypertension) ○ Chest wall disease ○ Deconditioning/obesity ○ Pleural Infiltration by Mesothelioma ○ Diaphragmatic splinting ○ Hypothyroidism ○ HypoventilationHistory akingPC and HPC ● Start with the open questions – ‘what brought you in today?’ ● Then get to the nitty and gritty ■ Timing – How it has changed over time ○ Use SOCRATES to help where applicable ● Diurnal variation ■ Site – N/A ● PND? ■ Onset – Clarify when this stated, helps to ■ Exacerbating or relieving factors identify whether chronic or not ■ Character/Radiation – N/A ● Exercise/medication/laying flat/environmental triggers ■ Associated symptoms ■ Severity ● What symptoms can you think of? ● MRC Dyspnea Scale ● Red FlagsAssociated Symptoms ● Progressively reduced exercise tolerance ● Weight loss & appetite loss ● Chronic, non-productive cough ● Fatigue ● Hemoptysis ● Night sweats ● Hoarseness ● Wheezing ● Pain in shoulder and arm ● Chest tightness or pain ● Headache ● Enlarged lumps or bumps anywhere (lymphadenopathy) ● Finger clubbing ● Orthopnea ● Frequent respiratory infections ● Leg oedemaAssociated Symptoms ● Progressively reduced exercise tolerance ● Weight loss & appetite loss ● Chronic, non-productive cough ● Fatigue ● Hemoptysis ● Night sweats ● Hoarseness ● Wheezing ● Pain in shoulder and arm ● Chest tightness or pain ● Headache ● Enlarged lumps or bumps anywhere (lymphadenopathy) ● Finger clubbing ● Orthopnea ● Frequent respiratory infections ● Leg oedemaMRC Scale ICE and Summary ● After PC and HPC, ask patient for their ideas, concerns and expectations. ○ Can reveal some important details ‘I worked in construction my whole life and heard that my line of work can cause cancer. Is that possible’ ■ ‘My father died of lung cancer, I am worried I might have it too’ ● Summarize – helps to organize your thoughts and helps to make sure you haven’t missed anything in your consultation!PMHx and Mx ● Ask about specific conditions first 🡪 then ● Ask about specific medication 🡪 then general general ○ COPD ● Medication that can increase risk of lung ○ Interstitial Lung Disease fibrosis ○ Bronchiectasis ○ Amiodarone ■ Recurrent chest infections when young ○ Bleomycin ○ Autoimmune e.g., SLE, Rheumatoid arthritis, ○ Cyclophosphamide alpha-1 antitrypsin ○ Methotrexate ○ Metastasis e.g., colon, breast, kidney, testicle, melanoma, thyroid, esophageal and sarcoma ○ Nitrofurantoin Family History Important to cover any history of lung disease, cardiovascular disease, autoimmune conditions and malignancy ● Clarify at what age the disease developed for people ○ E.g., early onset COPD due to alpha-1 antitrypsin disorder ● If family members are deceased asked at what age and the cause of death Social History: general, smoking, alcohol, drug use and occupation ● General ● Occupation – ESSENTIAL! ○ Ask about where they live ○ Farmers – hay dust and Asperigullus ○ Pets or hobbies like bird-keeping mould ○ Mould at home ○ Bakers – flour dust and enzyme additives ○ Travel history? ○ Plumbers/construction workers - ● Smoking History asbestos ○ Primary cause of early exertional dyspnea ○ Type and amount of tobacco used ○ Calculate the number of pack years Don’t forget allergies and systemic review! Systemic symptoms Respiratory System Gastrointestinal symptoms ENT Symptoms - Fever - Dyspnea - Appetite change - Hearing loss/tinnitus Dermatological symptoms - Night sweats - Cough - Nausea - Otalgia - Weight change - Sputum - Vomiting - Facial pain - Rashes - Fatigue - Wheeze - Dyspepsia - Persistent nasal discharge - Skin lesions Cardiovascular symptoms - Hemoptysis - Dysphagia - Epistaxis - Skin color changes - Chest pain - Pleuritic chest pain - Abdominal pain - Dysphonia - Ulcers - Palpitations Genitourinary System - Abdominal distention - Dysphagia - Dyspnea - Changes in urine output or color - Jaundice - Odynophagia - Pre-syncope - Pain around flanks or bladder area - Change in bowel habits Musculoskeletal System - Syncope - Bladder control symptoms Neurological symptoms - Bone and joint pain - Orthopnea - Obstructive symptoms - Visual symptoms - Muscular pain - Peripheral oedema - Uremic symptoms - Headache - Trauma - Motor or sensory disturbances - Loss of consciousness/confusionPractise CasesPC: 65-year-old male presenting with a 2-year history of increasing shortness of breath HPC: Used to be an avid walker, now struggles to walk to the shop ● No weight loss/haemoptysis/night sweats ● Has had increased fatigue recently and a dry cough PMHx – Crohn's Disease Mx - methotrexate: 15mg injections weekly Fx – none to note Sx – worked as a business consultant, 25-pack year history, doesn’t drink alcohol or take recreational drugs, does live in a house with a large mould issuePC: 65-year-old male presenting with a 2-year history of increasing shortness of breath HPC: Used to be an avid walker, now struggles to walk to the shop ● No weight loss/haemoptysis/night sweats ● Has had increased fatigue recently and a dry cough PMHx – Crohn's Disease Mx - methotrexate: 15mg injections weekly Fx – none to note Sx – worked as a business consultant, 25-pack year history, doesn’t drink alcohol or take recreational drugs, does live in a house with a large mould issuePC: 72-year-old male presenting with a 6-month history of increasing shortness of breath HPC: Noticed that he can get short of breath when walking up the stairs now and used to be a very active individual, it recently started to be painful to take deep breaths ● Has noticed that his trousers are all loose on him and that he regularly has to change bed sheets as he sweats profusely at night ● He feels like he has had the flu-like symptoms for nearly 6 months PMHx – Hypertension Mx - Amlodipine Fx – none to note Sx – 25 years work as a plumber, lives with wife at home, 40-year pack history, doesn’t drink or take recreational drugsPC: 72-year-old male presenting with a 6-month history of increasing shortness of breath HPC: Noticed that he can get short of breath when walking up the stairs now and used to be a very active individual, it recently started to be painful to take deep breaths ● Has noticed that his trousers are all loose on him and that he regularly has to change bed sheets as he sweats profusely at night ● He feels like he has had the flu-like symptoms for nearly 6 months PMHx – Hypertension Mx - Amlodipine Fx – none to note Sx – 25 years work as a plumber, lives with wife at home, 40-year pack history, doesn’t drink or take recreational drugsSmoking Cessation Consultation Sharing Information Station Use the BUCES structure to help guide you through these type of stations Brief History – in this case it would be a smoking history Understanding – what does the patient know about the health impacts of smoking? Concerns – about smoking and quitting Explanation – provide information about the type of support and some ways to help quit Summarize – plans for support and next steps Appropriate Timing ● Always! Every consultation counts! ● Most of the time delivered in GP settings, can sometimes have specific appointments for these conversations ● For CCA/OSCE stations start as you would every other consultation ○ Wash your hands etc. ○ Introduce yourself ○ Confirm patient’s name and date of birth ○ Explore the REASON for patient’s visit ● Don’t forget your OARS! (Open questions, affirmations, reflections, summaries) ICE and DARN CAT By using ICE you can try and explore the patient’s views on smoking ● This can help determine their motivation for smoking and the barriers to quitting Use DARN CAT to help identify cues in the patient’s script that may indicate a desire to change or an interest to further discuss Desire Ability Reasons Need Commitment Activation Taking Steps Important Aspects to Cover As with any history, start with the history of presenting complaint ● How long has the patient been smoking and how much does the patient smoke? ● What type of tobacco or nicotine does the patient smoke? ● In what situations does the patient smoke? ● How does the smoking make the patient feel? ● How does it affect the patient’s life and relationships? ● How does the patient finance their smoking and how much would they save if they quit? ● Previous quit attempts, and why they didn’t work? Explore any withdrawal symptoms patient might experience PMHx and Mx Remember the physiology about the type of conditions that may be affected by smoking and ask about them specifically ● Pre-existing lung disease ● Cardiovascular disease and cardiovascular risk factors ● Previous hospital admissions and surgery Ask patient if they have ever tried any medication/treatment to help quit e.g., Nicotine Replacement Therapy Fx and Sx ● Explore patient’s family history ● Explore patient’s social history ● Ask about if any other family members ● Ask about alcohol intake and smoked recreational drug use ● Ask if there has been any history of ● Ask about who lives at home and do malignancy within the family they live with anyone who is a smoker? ● Not only to help understand rationale for ● Explore psychosocial aspects of patient’s smoking but may be clinically relevant! health – work/family/stress – are these factors that could be contributing? Counselling 5 A’s Approach Ask – History/smoking status Advise – Risks and long-term effects/commend patient for coming to to speak to you. Reassure support. Assess – Understanding of the consequences, patients view/motivation Assist – Provide information and therapies to help the process Arrange – follow up visit! (ideally within 1-2 wks) Advice to Give ● Agree a quit date with a patient ○ Usually within 2-4 weeks, the more abrupt the better! ● Encourage to tell friends and family ○ Helps accountability and support ● Anticipate challenges that they may face and work through them ● Remove all tobacco products with the help of counselling and pharmacological therapies Pharmacological Therapies Nicotine Replacement therapy Varenicline 1 line – available as patches, sprays, gum Most effective treatment, increases cessation Caution in patient with CVD or ACS by more x2 Increases successful cessation by 1.5x Advise to start 1 week before quit date and complete 12-week course Bupropion Advise to start 1-2 weeks before quit date and complete 12-week course Increases successful cessation by x2 Counselling for Smoking Cessation Explain to patients that some may benefit from more than one option ● Brief intervention ○ Short discussions in a face-to-face behavioural therapy e.g., GP ● Individual counselling ○ Formal sessions with a trained therapist ● Group counselling ○ Prescence of other people can help motivate to quit ● Telephone counselling ○ Proactive approach involving pre-arranged telephone calls