Critical analysis of history taking and comprehensive physical examination from practice
Introduction
This essay aims to critically analyse and reflect upon the history taking model, clinical assessment, and communication/skills, used to direct the interview of a patient diagnosed with a sore throat. This will be achieved via, critiquing the positives and the negatives of the current consultation models used in clinical practice. The clinician is currently employed in an Urgent Treatment Centre setting, as a trainee Advanced Clinical Practioner. This setting is an excellent place to facilitate and implement the assessment tools needed to assess, plan treat and discharge safely.
Within the training module of Advanced Physical Assessment and Consultation Skills, it requires evaluation of patients with minor illnesses only. Indeed, this follows the NMC (2016) guidance of capability and competency. This enables clinicians to practice only within their scope of practice.
Refection will be made on the history taking model used against others currently used by nurses and healthcare professionals. This essay also examines how information was extracted from the patient and whether data gathering was sufficient to determine the diagnosis. An exploration on the prescription given and the guidance supporting the decision will also be presented. Current guidelines, studies from published journals and policies will be used to underpin the discussions throughout. A conclusion will then summarise key issues presented, which include the relevance of the history taking model used and the prescribing decision made for the patient. As outlined in the Nursing and Midwifery Council’s (NMC) (2018) Code, the patient will be anonymised, and a pseudonym will be used to protect her real identity. All other identifying information will also be removed to ensure patient confidentiality.
History Taking
Anna (pseudonym) is an 18-year-old university student who presented to the Urgent Treatment Centre (UTC) with a red, swollen throat, and both tonsils showing lesions with exudate/pus. She complained that she had a sore throat for four days and was taking regular Paracetamol to ease the pain. While experiencing odynophagia only, she had no other remarkable past medical history.
Her pulse rate was 100 and respiratory rate of 18. Her blood pressure was 110/80 while oxygen saturation was 97%. She was febrile during presentation with a temperature of 38.2 degrees Celsius (normal range of body temperature is 36-37.5 degrees Celsius) (Nair & Peate, 2015). Her National Early Warning Score (NEWS2) was 2. (RCOP). The scoring system was identified as an excellent tool to isolation and escalate the acutely unwell patient. It provides a quick risk assessment for clinicians to exclude red flag diseases such as sepsis immediately and identify when a patient needs other clinical in put via specialist services. Before this tool existed, there was a lacuna, in identifying these patients that needed a quick emergency response to their symptoms. This is a universally recognised, standardised, and validated assessment tool, that is utilised nationally and throughout the world. Therefore, within this patients’ parameters the main indication of a red flag sepsis was excluded. The presentation of a red flag sepsis would include the following deranged pathology, a very high or low temperature, tachycardia, tachapnoea, low peripheral oxygen saturations in combination with a reduced capillary refill time. Red flag sepsis was definitely excluded on this occasion.
She did however have posterior cervical Lymphadenopathy, which was palpable to the right jaw line. Her medical history showed she had no allergies, was not taking any drugs, no history of smoking and drinks alcohol socially. She was taking oral contraceptives. Another salient red flag to screen for in acute sore throats is a peritonsillar abscess. This would present with trismus, drooling, muffled voice and a deviated uvulae. These were not clinical features in this assessment and therefore this differential was excluded.
The clinical findings that did however suggest a streptococcal throat in above of the findings. The centor score was applied as a clinical predictive tool. To stratify risk and direct treatment algorhythyms.
Centor scores of less than 3 have a reasonable specificity rate of 95% (Albers et al 2011). The strengths of this review are in the number of all randomised controlled trials reviewed. There were 21 studies, population of 4839, however this information is 10 Years old
During patient assessment in the UTC, history taking takes place to ensure that high, quality care is delivered for Anna. According to Fawcett and Rhynas (2012), history taking remains a crucial component of patient assessment and enables nurses to provide high quality nursing care. It is during history taking that the patient’s problems are identified, and care priorities are presented (Eriksson et al., 2017). Following establishment of care priorities, nurses can then commence nursing intervention designed to optimise patient outcomes (Denness, 2013). However, it is argued that not all healthcare practitioners have the natural aptitude for communication and listening skills necessary in obtaining an effective history of the patient (Lowth, 2015). During Anna’s care, the Enhanced Calgary Cambridge Model with assets of the Medical Model were used over Pendleton and other more commonly used models for history taking such as the Neighbourhood Model. The Calgary Cambridge Model (CCM) (Munson, 2007) is described as a five-step process that begins with initiating the session, gathering information, physical examination, explanation and planning and closing the session. The Medical Model also allows for disease detection and a differentiation that supports the latter. In contrast, Pendleton’s model has 7 questions, which the author finds too long and tedious for patient assessment in an UTC setting. While both models and other recent models are patient-centred, the length of the models was taken into consideration to ensure that only relevant information was extracted during history taking. Sometimes depending on the patient gender, age and mental status, there can be a mixture of models, which ensures the best information is extracted to lead to an ultimate decision and best practice.
The use of a structured model is important since this ensures that no important information is missed during patient consultation and history taking (Moulton, 2007). However, patients have to complete all questions before the session is closed. This is necessary since this is believed to inform healthcare practitioners relevant information that would help the nurse establish an initial diagnosis (Munson, 2007). Effective history taking is important as 80% of the information shared by a patient often leads nurses to develop a formative diagnosis and rule out other diseases that share the same signs and symptoms (Lloyd & Craig, 2007). While a structured model ensures extraction of all relevant information and is considered as a thorough approach, is criticised as time consuming since this asks patients a series of full questions (Lowth, 2015). In the NHS, particularly in the UTC setting, nurses may not have sufficient time to draw out all information and ask all the questions found in the structured history taking model. Further, it is also difficult to extract
information that is not relevant to the patient’s current condition (Lowth, 2015). For inexperienced nurses or newly hired nurses, this means concentrating on the questions rather than on the answers of the patients (Ali, 2018). This may disengage patients, especially if they are asked about other symptoms of diseases that are not relevant to their presenting question. Since the Calgary Cambridge model posits questions that ask patients about their past medications and diagnosis, patients may wonder why they are being asked about prior diseases when they are presenting with a new condition (Munson, 2007). The patient is only interested in conversing their symptom descriptions as in the Medical Model and because of this a mixture as discussed earlier is needed.
Since nurses tend to only have limited time in the UTC, it is important for the nurses to be well acquainted with the questions used in the Enhanced Calgary Cambridge model.
On evaluation, the author first established an environment where the patient would feel that they are important, and the consultation was unhurried. While this was difficult to maintain in a highly fast-paced environment, the author ensured that the assessment was done in a quiet place where privacy is maintained, and any information could not be overheard by other nurses or patients. The author also ensured that Anna was seated comfortably while the nurse maintained an open posture (i.e. arms uncrossed). According to Kourkouta and Papathanasiou (2014), nonverbal cues and messages are crucial during communication since this would help the patients feel that they are highly valued and important to the nursing team. The same study also found out that patients perceive healthcare practitioners as compassionate whey they listen actively to them, do not stand above them during the consultation and maintain an open posture. Maintaining an open posture and positive nonverbal cues during the history taking is important since how the nurses present themselves to the patient is seen to be more important than the words actually said during the consultation (Casey & Wallis, 2011).
On evaluation, Anna was asked open-ended questions one at a time with negative questions avoided. The latter are considered as potentially confusing and may alarm patients (Lloyd & Craig,
2007). In some cases, patients may agree to the nurses’ questions without listening properly. Open questions were also used during history taking. This is necessary since this allows the patients to
answer freely and describe their symptoms according to their own understanding and how they perceive their condition or status, such as pain. During history taking, Anna was asked to describe the pain accompanying her sore throat. She explained the level of pain using the visual analogue scale (VAS), which helped inform the team on the level of pain she was experiencing. She was also asked if this was intermittent or continuous. Asking patients to describe pain is important for those with symptoms associated with tonsilitis. It is suggested that pain assessment is often missed, especially in a busy ward environment or in an A&E (Thim et al., 2012). Therefore, pain assessment is critical as unmanaged pain could lead to worsening of health outcomes, poor patient satisfaction and poor quality of care (Thim et al., 2012). The attending nurse ensured that the patient’s pain description was taken into account. This was regarded also as accurate as it would be difficult to verify the patient’s self-report of pain since pain is highly subjective (Kaufman, 2008). The subjectivity of pain may be associated with the patient’s gender, culture, tradition, beliefs and level of education or socioeconomic status (Kaufman, 2008). Hence, relying on self-reports of pain is essential during management as this would present an accurate description of pain for the patient. Further, continuous assessment of pain would also determine if the patient responds to nursing interventions and medications.
During initiating the session and gathering of information, the attending nurse ensured that Anna would feel comfortable. Effective communication was also practiced as assurance to Anna that we would be addressing her presenting symptoms. For instance, the attending nurse looked at Anna in the eyes to help her feel that the nurse was actively listening. However, in some cultures, directly looking a person in the eye is often perceived as challenging authority, especially between a patient and nurse or healthcare practitioner (Ali, 2018). In contrast, in NHS setting, directly looking the patient in the eye is often perceived by patients as a sign of compassion and concern (Kourkouta and Papathanasiou, 2014). The attending nurse also tried to reassure the patient through a
therapeutic touch. Although this is also acceptable in UK’s healthcare culture, some other patients would find this uncomfortable, especially when therapeutic communication and rapport has not been established (Ali, 2018).
In the next stage of the CCM, physical examination was done using the ABCDE framework (Airway, Breathing, Circulation, Disability, and Exposure) (Resuscitation Council UK, 2020). This model offers a structured approach to physical assessment and is used by nurses and other healthcare practitioners in the UTC and in the ward environment. The use of a structured assessment tool during history taking is essential since this would ensure that all important information on the physical health status of the patient is recorded. Further, this model also helps healthcare practitioners identify early signs of clinical deterioration (Resuscitation Council UK, 2020) or whether the patient’s care should be escalated to a critical care response team. Results of the ABCDE assessment showed that Anna had a NEWS score of 2, which means that she has low risk of clinically deteriorating during care (Royal College of Physicians, 2019). Results also revealed that the immediate care priorities include reducing her body temperature to normal levels as she was febrile, management of pain due to acute sore throat and presence of pus or exudates in her tonsils. In the fourth stage of the CCM, the attending nurse and healthcare practitioners explained to her the need to monitor her and implement nursing interventions and care plans that are acceptable to her. This stage was important to ensure the patient understood the rationale behind the proposed nursing interventions (Schultz & Doty, 2016). Further, she was involved in care decisions, which is an integral part of patient-centred care (Rathert et al., 2012). However, it is also acknowledged that some patients prefer nurses and other healthcare practitioners to make decisions for them during care (Rathert et al., 2012). While this is true in some patients, it was not applicable to Anna who was highly involved in the care process. She asked relevant questions such as whether she needed to take antibiotics or should she continue her pain medications to relieve
pain. This is not unusual as patients with high levels of education (i.e. university education) are found to more likely to participate in care planning and be involved in decision-making regarding
their care (NHS Education for Scotland, 2013). Following planning of her care, the history taking session was closed with the attending nurse and healthcare practitioners asking Anna if she had any questions about her care and to repeat the care plan to her. The latter was done to ensure that the right information was received by the patient (Munson, 2007). It is observed that in some cases, due to the high volume of patients in acute care settings, patient understanding about their care plan is no longer examined (Moulton, 2007). In turn, this can have a negative impact on patient
adherence to a care plan since poor understanding on the nursing interventions would likely lead to low uptake of medications and self-management strategies (Lloyd & Craig, 2007).
Prescribing Decision
Results of the physical assessment and information from Anna’s history and presenting symptoms led to the nursing diagnosis of acute sore throat and tonsilitis. Following this information, the attending nurse informed Anna of potential nursing interventions, which include prescription of antibiotic regimen. However, the attending nurse also informed Anna that acute sore throat, including tonsilitis, is self-limiting and is often triggered by a viral infection (Pelucchi et al., 2012). It has been shown that symptoms can last for at least one week (NICE, 2015). However, most individuals will experience relief of symptoms within this period without antibiotics, regardless if the infection is viral or bacterial (Pelucchi et al., 2012). In Anna’s case, she was prescribed with an antibiotic based on the Centor criteria (Scottish Intercollegiate Guidelines Network [SIGN], 2010).
A patient is most likely to have Group A beta-haemolytic streptococcus (GABS) infection, which is the most common cause of streptococcal infection, when the following criteria are present: no cough, tonsillar exudates, history of fever, tender anterior cervical lymphadenopathy (SIGN, 2010). Since Anna presented with all four criteria, she was informed that an antibiotic regimen would likely result in earlier resolution of her acute sore throat and tonsillitis. However, she was also informed of potential side effects of antibiotic regimen and the risk of antimicrobial resistance (National Institute for Health and Care Excellence [NICE], 2015, 2018). As part of antimicrobial stewardship, the attending nurse informed Anna of the need to take the prescribed
medication as indicated to avoid resistance to penicillin in the future (Royal Pharmaceutical Society, 2016). It was also important for the nurse to ensure that antibiotic prescribing was appropriate for the patient. Although acute sore throat and tonsilitis can resolve on its own, presence of exudates on the tonsils, lymphadenopathy and fever can increase the risk of prolonged infection and even sepsis in those with weakened immune system (Pelucchi et al., 2012, NICE, 2015). The attending nurse informed Anna of the potential risk of not receiving and receiving antibiotics. This was necessary to ensure that Anna understood the risks and benefits of
antimicrobial prescribing, which in turn helped her make a decision to receive an antibiotic prescription of penicillin.
The National Institute for Health and Care Excellence (NICE) (2015) guideline for acute sore throat recommends the use of penicillin as the first line of treatment for patients with a Centor score of 3-4. To prevent any anaphylactic reaction, the nurse ensured that Anna was not allergic to penicillin. Since her medical history showed that she had no allergies to penicillin, a decision was made to prescribe Phenoxymethylpenicillin 1000 mg twice a day or 500 mg four times a day for 10 days (NICE, 2018. British National Formulary, 2021). This was done since a 10-day course increases the chance of microbiological cure while a 5-day course may be sufficient for symptomatic cure only (NICE, 2018). A review of Anna’s medical history also revealed that she has been taking contraceptive pills. As part of patient management, the nursing team informed Anna that concurrent medication of penicillin with contraceptive pills may reduce the effectiveness of the latter. A large, observational study (Aronson and Ferner, 2020) reported an increased risk of pregnancy when contraceptives and antibiotics are taken together. However, the study could not provide a causal relationship between pregnancy and combination of antibiotics and birth control pills due to the retrospective study design used and limitations of this type of research. In Anna’s case, she was informed that the study was not able to establish a causal relationship. Despite this lack of causal relationship, the evidence on the association between pregnancy and combined used of oral contraceptives and antibiotics was strong. Hence, advice was given to Anna to use
additional extra precautions to prevent unintended pregnancy. She was advised to use other forms of contraceptives, such as condoms, to prevent unwanted pregnancy. DO NO HARM 7 steps to px
Apart from informing Anna on the interactions of penicillin with birth control pills, she was also informed to manage her pain levels through administration of analgesics. Since she was taking paracetamol with no immediate relief, a consideration was made to use Ibuprofen. However, a meta-analysis of randomised controlled trials (Choi et al., 2013) nos grade b research oldshowed that there was no significant difference between Ibuprofen and Pracetamol in terms of pain relief in patients experiencing colds or sore throat. Although both Ibuprofen and Paracetamol are more effective
than placebo in reducing pain in acute sore throat, both Diclofenac and Ibuprofen are slightly more effective than paracetamol in relief of pain (Gehanno et al., 2003; Burnett et al., 2006). Since large, sufficiently powered randomised controlled trials support the effectiveness of Ibuprofen in symptom relief over paracetamol, although the difference is only slightly significant, the team advised Anna to take Ibuprofen instead of Paracetamol. After weighing information received, Anna decided to take Ibuprofen 400 mg every 6 hours for symptom relief of pain.
Anna was advised to take adequate fluids to relieve symptoms and to get adequate rest to promote recovery. As part of safety netting, Anna was informed to immediately visit A&E or call for ambulance service should her symptoms worsen, such as inability to swallow, having a hoarse voice, cough, signs of sepsis such as increasing confusion, high fever, increased respiratory rate and rigors. Safety netting is necessary to ensure Anna’s safety and to prevent any complications or clinical deterioration (Pelucchi et al., 2012).
Conclusion
Patient involvement in care decision-making is crucial in ensuring that health outcomes are optimised. An appropriate history taking model such as the CCM, is necessary to ensure that
patient-centred care is practiced. As demonstrated in Anna’s case, she was involved in all stages of history taking, which in turn offered relevant information that allowed the attending nurse to make an appropriate diagnosis. The nursing interventions, medication and management strategies presented to Anna were all evidence-based and supported by current guidelines. This is critical when providing care since this ensures that interventions are supported by robust evidence from published literature. The prescription of an antibiotic was only decided after careful evaluation of Anna’s symptoms and use of the Centor criteria. Finally, interaction of Penicillin with current oral contraceptive use was also explained to Anna. This is important in helping her make a decision and take precautions to avoid unintended pregnancy. Finally, appropriate safety netting was performed to prevent complications or to protect Anna’s safety while undergoing medication.
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