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Clinical conditions fall into one of four categories.???? A clinical condition can be….Serious and an emergency?? (e.g. a PE, acute asthma, acute MI, acute Heart Failure)Serious but not an emergency?? (suspicions of a new cancer)Not sure if serious or not but need to keep any eye on? (e.g. feeling short of breath for 4 weeks probably post viral infection, but need to make sure nothing else kicking off)Not serious, no need to keep an eye on.?? (acute viral sore throat)In triage, we are trying to work out which of these categories the patient you are talking to falls into because this will determine THE NEXT STEP.Serious & Emergency à needs on-call GP/Hospital admissionSerious but not an emergency à Needs further Ix or Referral by GPNot sure if serious but need to keep an eye on à safety net, put follow up in place and review.Not serious, no need to keep an eye?on à Reassure, provide self-help & safety net.A few other Important Things in Respiratory TriageWhen patients tell you about their physical features, we call those specific difficulties symptoms.? So, when a patient says they have chest pain, chest pain is a symptom.When you examine a patient, the things you find are called signs.? So, a respiratory rate over 21 is a sign that someone is struggling to breath.The problem is that some of the symptoms AND signs of the respiratory system can also be signs and symptoms of a cardiac cause.? The two main ones are Shortness of Breath (SOB) and Chest Pain – both can be a sign of a respiratory problem or a cardiac one or both!?? It is our job to figure out which by trying to work out the clinical story of what is going on.Remember; work out the patient’s story (or narrative).?? Don’t rely on individual bits of clinical data on their own.?? You need to put all the bits of data together and make a story – because it is that story which tells you what is going on.?? ?As an analogy, if your partner was late from home one day this week, you would be silly to think they were having an affair.? The bus could have been late.?? They might have had extra to do at work.? They might have popped into the supermarket and so on.????? However, if your partner was late several days a week for the last 3 months, wearing new cologne, taking more interest in their appearance and dress sense, your suspicions are more likely to be right.??? Doctors work in a similar way? They don’t rely on one or two bits of clinical information.? They try to gather SEVERAL BITS of the RIGHT CLINICAL INFORMATION to help them build a more ACCURATE STORY or PICTURE of what is going on and in so doing are more likely to come to the RIGHT DIAGNOSIS and hence APPROPRIATE MANAGEMENT PLAN, with LESS LIKELIHOOD OF MISTAKES.???You need to do the same Respiratory EmergenciesOther Serious Respiratory ConditionsAcute infective exacerbation of COPDAcute AsthmaPulmonary Embolus (PE)Foreign bodyAcute epiglottitis (drooling mouth in a child – never examine)Pneumothorax (young tall thin blokes or those with COPD)AsthmaCOPDLung CancerPulmonary FibrosisCardiac EmergenciesOther Serious Cardiac ConditionsAngina (unstable)Acute MIAcute Left Ventricular Failure (Acute LVF) – usually with fast Atrial Fibrillation (AF)Chronic Heart FailureHOCM (cardiomyopathy)ASD (atrial septal defect)VSD (ventricular septal defect)The HistoryThe Open Question“Would you mind telling me what’s been going on”Start of by asking the patient to tell you in their own words what has been going on.?? Don’t interrupt them.??They will probably run out of things to say after a minute or so but in so doing will have laid down the platform of their story.?? Once you listen to their story, you will then have an idea of what questions are more important to ask over others.You may for instance want to clarify one or two things that aren’t clear to you or seem a bit odd or don’t make sense.? If so, ask away.?? Always ask in a way to show that you are trying to truly listen and understand.Don’t be confrontational? confrontation makes it more likely the patient will be on the defensive and a less accurate story will evolve.? Accurate stories emerge when both parties in the conversation get on.? The 6 Respiratory Symptom AreasThe one and only rule: Do NOT just explore one area; explore all 6 areas. Then review the 6 areas together because that will tell you what to do next – whether to reassure, book an appointment with a GP, get the on-call Dr to see and so on. Once you become familiar with going through the 6 areas, eventually you will be able to cover each area in less than a minute!Duration: “How long have you had it?”“Did it come on gradually or suddenly?”Short & Sudden -? could be something not serious like a viral sore throat. But don’t be fooled - need to make sure not an emergency like a PE or acute HF. The other 5 symptom areas below will help you work out if it’s an emergency or not. If serious GP review same day ASAP.Long & Gradual?– symptoms that have been going on a while are usually a sign of something brewing up.?? Therefore, they need looking into further, perhaps with more tests and follow up with the GP.? For example, someone who is gradually getting more and more SOB over the last 6 months could be COPD, Pulmonary Fibrosis, Lung cancer etc. So, the patient should be reviewed by the GP within 2 weeks.Cough & Sputum “Are you bringing up any phlegm with your cough or is it dry?”“What colour is the stuff that you are bringing up?”“Is there any blood in that?”??? “Is that blood streaky in your spit or does it look like clumps?”“Do you bring up any white frothy stuff?” (à Heart Failure, needs seeing by GP ASAPDirty or green sputum usually means an infection (viral or bacterial). White frothy sputum is more of an indication of Heart Failure and needs a GP to review (same day if marked SOB, otherwise a week will do). Blood streaking the sputum is not serious, means someone has just coughed a bit to hard and a small blood vessel has burst and will self-heal.? HOWEVER, non-streaky blood could mean Infection, Cancer, TB, PE needs seeing by GP ASAP same day)Chest Pain? “Have you been experiencing any chest pain lately?”Duration: “How long does that pain last?”Nature of the pain: “What is that chest pain like?? Is it sharp like a needle or knife, tight like someone is squeezing you or dull like a toothache in your chest?”“Do you have a sharp pain when you breath in, or laugh or cough?”.? Can you take a deep breath in for me now?? Does that hurt??? Is it sharp or dull?”If dull or tight pain, ask: “Is that pain going anywhere else like your neck or arm??? Are you feeling sick or sweating or short of breath?”Duration of the painIf <5 second twinges à nothing to worry about.? Most likely muscle/nerve twinges. (providing other 5 respiratory symptom areas are ok).If < 15 minutes à can be angina à need to see Dr same dayIf >15 minutes à could be a heart attack à call 999Nature of the pain:Pleuritic pain is sharp pain on?inspiration, cough, laughing.???? Can be caused by serious things like lung infection, PE, pleurisy.??If patient has fallen – think about a broken rib. Or coughing hard – intercostal muscle pin.? If present, review other 5 respiratory symptom areas and probably needs urgent assessment by GP.? If dull or tight pain (whether it is radiating to the neck/arm or not) could be a heart attack or something similar à ask them to call 999SOB?(Shortness of Breath = medical name = dyspnoea)“Are you short of breath?”?? “Has that come on suddenly or gradually?”“When are you short of breath. Is it when at rest or when you are doing things?” “Can you get dressed without getting short of breath? What about the stairs?”“Is there any wheeze or noises you can hear when you breathe in or out?”Remember SOB can be a symptom of either a respiratory or cardiac problem (or both!).? New shortness of breath is always worrying.? Sudden shortness of breath needs urgent assessment by a GP.??? Gradual shortness of breath also needs assessment by the GP but how quickly depends on how bad the shortness of breath is for the patient.????? If mild – see GP in the week.? If quite bad now, see GP same day. But don’t forget to do assessment of all 6 respiratory symptom areas.Wheezy noises (especially on breathing out) indicate asthma. A wheezy on inspiration (the in breath) can be a sign of an obstruction (foreign body or tumour).If the patient is known to have a shortness of breath problem like COPD, then the question to ask instead of “Are you short of breath?” is…“What is your breathing like at the moment compared to what is normal for you?”.Temperature “Have you been feeling hot and cold or getting any shivering attacks?” “Do you have a thermometer in the house?”?? “Would you mind taking it for me and telling me what it is?”“Would you mind touching the front of your chest.? Does it feel hot?”?? (not a very good test!?? Above two are better.)Patients can’t tell if they have a fever just by touching themselves. Many don’t even realise that rigors and chills are a feature of fever. And many don’t even know what the words rigors and chills mean. So, it is best to ask about hot-cold episodes and the shivers. If a patient has rigors and chills (i.e. shivering attacks) it usually means they have a bad fever.??? That means they need to be reviewed by a GP same day.? Unless it is something infectious like the Corona virus, in which case, advise on taking paracetamol to get it down and ring 111 for further advice. Blackouts “Have you had any fits, faints, blackouts or other funny turns?” If yes, then it is worrying à see GP ASAP for assessment the same day.Additional Cardiac Questions If you Thing the Patient has SOB OR Chest pain which is Cardiac in origin…Palpitations“Do you notice your heart racing in your chest?”“Are those palpitations there all the time or do they come and go?”“And are those palpitations triggered by exertion like exercise or can they happen at any time?”Any palpitations need further evaluation by a GP. Palpitations during exercise can be serious. Same day assessment by GP.Oedema“Have you noticed any ankle swelling? How bad is it? Can you get your normal shoes on?”Ankle oedema (oedema is a medical term for fluid), usually indicates heart failure. But it can also be gravitational oedema (just caused by gravity and ageing circulation in older people). On it’s own doesn’t mean much – can only conclude when you have explore all 6 areas above.More on BreathlessnessOrthopnoea“Are you breathless when you lie down flat? How many pillows do you normally sleep on then?”Breathless on lying down is called orthopnoea and is a sign of Chronic Heart Failure. Some patients have it so bad that they sleep in a chair! On it’s own, it indicated chronic heart failure and needs review GP review within a week – esp if it has been like that for a while - but if the patient is more short of breath than usual, needs to see a GP ASAP same day. Examination over the Phone…Listen to their breathing?? - do you hear any wheezing?? Do not ask “let me listen to your breathing”. Try and listen to it naturally as they speak. Are they coughing while they speak to you.? (Again, do not ask them to cough!)Are they able to speak in sentences without stopping for air? If they have to pause after a few words to take a breath, they are significantly short of breath!Ask them to count from 1 to 30 as quickly as possible and time them. Roth Score says anyone under 8 seconds is probably doing okay. Any one over 8 seconds – interpret in light of symptoms above. (Not worth doing in the bad chronic COPD).Scenarios CHILDREN à doctor not nurse. Anything to do with breathing problems in children to be assessed by doctor, not nurse. ADULTS nurses will only be involved in adult triage.I think I have coronaI have a new coughI have a feverI am Short of BreathRefer to 111 “Have I got Corona” Internet Web Tool111 said talk to my GP practiceLook at the discharge note. Double check that the discharge note says 111 is generally happy with the patient to simply self-isolate (PS otherwise they would have admitted). Don’t argue with the patient if the patient said “111 asked me to ring you” but on the 111 sheet they clearly didn’t. Instead just say:Can you just summarise for me the symptoms you were getting that made you ring 111Are those symptoms better, worse or pretty much the same?Is there any shortness of breath? If there is no shortness of breath….Thanks for that information. It looks like that you don’t have too much to worry about at this stage. We know the virus can last around 7 days but gradually it should get better and I am hoping that is what will happen to you. Make sure you take 2 paracetamol four times a day to bring any fever down (check no liver problems, if they do, pass onto GP). Also, make sure you drink plenty – at least 6 glasses of water a day. Hopefully you will be better by around XXXday. What you need to watch out for is Shortness of Breath. If you get any of that, you must call 111 again. Is that okay?”If patient has shortness of breath which is new since ringing 111 ask them to rang 111 again for adviceIf the patient has shortness of breath that WAS mentioned to 111Ask if the shortness of breath is better, worse or about the same. If shortness of breath worse ask them to ring 111 back ASAP.If getting better or much the same say “Thanks for that information. It looks like that you don’t have too much to worry about at this stage. We know the virus can last around 7 days but gradually it should get better and I am hoping that is what will happen to you. Make sure you take 2 paracetamol four times a day to bring any fever down (check no liver problems, if they do, pass onto GP). Also, make sure you drink plenty – at least 6 glasses of water a day. Hopefully you will be better by around XXXday. What you need to watch out for is Shortness of Breath. I know you already have a bit of it, but if it starts getting worse, you must call 111 again. Is that okay?”I need a rescue pack/extra inhalersCheck the notes that they are asthmatic or COPD.For asthmatics say…Can I just double check that you feel your asthma is stable at the moment? (If not, same day appt with nurse)That’s great. The current official advice is good news for you. It says that you do not need extra inhalers/rescue pack and that you should simply continue with what you have and re-order at the right time like you normally do. Keeping on top of your asthma is clearly important. But having extra inhalers is unlikely to protect you from the corona virus. And besides, if you did end up catching the corona virus and you started to feel unwell with it, especially with your breathing, the doctors would much rather you spoke to them so they can do a proper medical assessment than you relying on inhalers which may not help. For COPDs who are not severe and did not receive a letter…Can I just double check that you feel your COPD is stable at the moment? (If not, same day appt with nurse)That’s great. The current official advice is good news for you. It says that you do not need extra inhalers/rescue pack and that you should simply continue with what you have and re-order at the right time like you normally do. Keeping on top of your COPD is clearly important. But having extra inhalers is unlikely to protect you from the corona virus. And besides, if you did get it, and you started to feel unwell with it, especially with your breathing, the doctors would much rather you spoke to them so they can do a proper medical assessment than you relying on inhalers which may not help. For COPDs who are severe or received a letter…Can I just double check that you feel your COPD is stable at the moment? (If not, same day appt with nurse)That’s great. I’m going to give you a rescue pack/extra inhalers to keep at home. But remember this important message. If you think you have caught the Corona virus and you started to feel unwell with it, especially with your breathing, the doctors would much rather you spoke to them so they can do a proper medical assessment than you relying on inhalers which may not help. Is that clear?The History (Your Desktop Version)The Open Question“Would you mind telling me what’s been going on” (let them talk)The 6 Respiratory Symptom AreasThe one and only rule: Explore all 6 areas. Then review the 6 areas to make a conclusion. Duration: “How long have you had it?”“Did it come on gradually or suddenly?”Cough & Sputum “Are you bringing up any phlegm with your cough or is it dry?”“What colour is the stuff that you are bringing up?”“Is there any blood in that?”??? “Is that blood streaky in your spit or does it look like clumps?”“Do you bring up any white frothy stuff?” (à Heart Failure, needs seeing by GP ASAPChest Pain? “Have you been experiencing any chest pain lately?”Duration: “How long does that pain last?”Nature of the pain: “What is that chest pain like?? Is it sharp like a needle or knife, tight like someone is squeezing you or dull like a toothache in your chest?”“Do you have a sharp pain when you breath in, or laugh or cough?”.? Can you take a deep breath in for me now?? Does that hurt??? Is it sharp or dull?”If dull or tight pain, ask: “Is that pain going anywhere else like your neck or arm??? Are you feeling sick or sweating or short of breath?”SOB?(Shortness of Breath = medical name = dyspnoea)“Are you short of breath?”?? “Has that come on suddenly or gradually?”“When are you short of breath. Is it when at rest or when you are doing things?” “Can you get dressed without getting short of breath? What about the stairs?”“Is there any wheeze or noises you can hear when you breathe in or out?”If the patient is known to have a shortness of breath problem like COPD, then the question to ask instead of “Are you short of breath?” is… “What is your breathing like at the moment compared to what is normal for you?”.Temperature “Have you been feeling hot and cold or getting any shivering attacks?” “Do you have a thermometer in the house?”?? “Would you mind taking it for me & telling me what it is?”“Would you mind touching the front of your chest.? Does it feel hot?”?? (not a very good test!?? Above two are better.)Blackouts “Have you had any fits, faints, blackouts or other funny turns?” Examination over the Phone…Listen to their breathing?? - do you hear any wheezing?? Are they coughing while they speak to you.? Are they able to speak in sentences without stopping for air? Ask them to count from 1 to 30 as quickly as possible and time them. Roth Score cut off is 8s.Additional Cardiac Questions If you Thing the Patient has SOB OR Chest pain which is Cardiac in origin…Palpitations“Do you notice your heart racing in your chest?”“Are those palpitations there all the time or do they come and go?”“And are those palpitations triggered by exertion like exercise or can they happen at any time?”Oedema“Have you noticed any ankle swelling? How bad is it? Can you get your normal shoes on?”Orthopnoea“Are you breathless when you lie down flat? How many pillows do you normally sleep on then?” ................
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