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Explaining a Diagnosis of Asthma – OSCE Guide

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Being able to share information in a clear and concise way is an essential skill in all fields of medicine. This can range from simple explanations, such as why a blood test may be needed, to more complex situations, such as explaining a new diagnosis. Often, sharing information with a patient occurs naturally during a consultation. However, providing clinical information may also be the primary focus of an appointment, and in these situations, it is crucial to have a structured format in order to communicate more effectively.

This guide provides a step-by-step approach to explaining a diagnosis of asthma. You should also read our overview of how to effectively communicate information to patients.


Structuring your explanation

Explaining a diagnosis requires structure and adequate background knowledge of the disease. Whether the information being shared is about a procedure, a new drug or a disease, the BUCES structure (shown below) can be used.

Explaining a diagnosis of diabetes
BUCES structure for explaining a diagnosis

 


Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient’s name and date of birth.

BUCES can be used to remember how to structure a consultation in which providing information is the primary focus. Before explaining the various aspects of a disease, it is fundamental to have a common starting point with your patient. This helps to establish rapport and creates an open environment in which the patient can raise concerns, ask questions and gain a better understanding of their problem. After introducing yourself, it is important to take a brief history (this is the first part of the BUCES structure):

  • What has brought the patient in to see you today?
  • What are their symptoms?
  • Are there any risk factors that can be identified? (e.g. lifestyle/family history)

For example, an asthmatic patient may describe episodes of shortness of breath, wheezing and nocturnal cough. They may have risk factors such as pre-existing atopy (e.g. eczema, hay fever) and a family history of asthma.

Tip: Practice taking concise histories to get the timing right. In OSCE stations, timing is crucial and you do not want to spend all your time taking a history when you are meant to be explaining a diagnosis! A rough guide would be to keep the introduction and brief history between 1-2 minutes maximum.

You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.

What does the patient understand?

Following a brief history, it is important to gauge the patient’s knowledge of their condition. Some patients may have a family member with asthma and therefore have a fairly good understanding of what the condition entails. Other patients may have heard of asthma but only have a vague understanding of the important details. The patient sitting before you may not even know at this point that they have asthma – you may be the first person to inform them of the diagnosis.

Due to these reasons, it is important to start with open questioning. Good examples include:

  • “What do you think is causing your symptoms?”
  • “What do you know about asthma?”
  • “What has been explained to you about asthma so far?”

Open questioning should help you to determine what the patient currently understands, allowing you to tailor your explanation at an appropriate level.

At this stage, primarily focus on listening to the patient. It may also be helpful to give positive feedback as the patient talks (i.e. should a patient demonstrate some understanding, reinforce this knowledge with encouraging words and non-verbal communication such as nodding).

Checking the patient’s understanding should not be solely confined to this point of the consultation but should be done throughout by repeatedly ‘chunking and checking’.

Tip: Try using phrases such as: “Just to check that I am explaining asthma clearly, can you repeat back to me what you understand so far?”. This is far better than only saying “What do you understand so far?” as the onus is placed upon the quality of your explanation rather than there being an issue with the patient’s ability to understand.


What are the patient’s concerns?

The patient’s concerns should never be overlooked. A diagnosis of asthma can be a significant life event and provoke a variety of worries. Asking the patient if they have any concerns before beginning your explanation allows you to specifically tailor what is most relevant to the patient, placing them at the centre of the explanation. The “ICE” (ideas, concerns and expectations) format, can provide a useful structure for exploring this area further.

ICE

Ideas:

  • What does the patient think is causing their symptoms?
  • What is their understanding of the diagnosis?

Concerns:

  • What are the patient’s concerns regarding their symptoms and diagnosis?

Expectations:

  • What is the patient hoping to get out of the consultation today?

Explanation

After determining the patient’s current level of understanding and concerns, you should be able to explain their condition clearly. Asthma can be confusing to medical students and doctors, let alone patients. Avoid medical jargon so as not to confuse your patient.

You should begin by signposting what you are going to explain to give the patient an idea of what to expect.

“I’m going to begin by talking about how the lungs work and then move on to discuss what asthma is, what causes it and how we can manage it together.”

Tip: Use the mnemonic “Normally We Can Probably Manage” to help you remember the structure of explaining a disease.

Normal anatomy and physiology

“When you breathe in, air travels from your mouth down deep into your lungs through a sequence of smaller and smaller tubes that resemble the branches of a tree. When the air reaches the smallest of these tubes, your body absorbs the oxygen from the air into your blood. Oxygen is then used to power all of the cells in your body.”

What is asthma?

“Asthma is one of the most common lung conditions. People with asthma have sensitive and inflamed airways that can become narrower than normal.”

“The most common symptoms include coughing, wheezing, chest tightness and shortness of breath. You may not have all of these symptoms at the same time.”

“The symptoms of asthma tend to come and go, often in response to specific things known as triggers.”

“It is important to take asthma medication every day, even if you are feeling well, as this reduces the chance of you getting symptoms or becoming unwell.”

What is the cause of asthma?

“We don’t know the exact cause of asthma, although some things make people more likely to get asthma, such as having other allergies or having a family history of asthma.”

“Most people tend to develop asthma as a child, but it can start in adulthood too.”

“The symptoms of asthma are caused by intermittent narrowing of the small tubes within the lungs. This makes it harder for air to move in and out of your lungs, causing you to feel tight chested and short of breath. Sometimes the narrowed tubes cause the air to whistle as it moves through them, like the wind in a tunnel – this is called a wheeze. The narrowing of your airways can also cause irritation, leading to a cough.”

“These symptoms tend to occur in response to specific triggers. Asthma can have many triggers, but some common ones include allergies (e.g. to pollen, pets or food), infections, stress, smoking and sudden temperature changes. It is important to try and work out what triggers your asthma, as it will be different for different people. Avoiding your triggers is a key part of managing asthma.”

Problems/complications of asthma

Asthma has the potential to be fatal, so outlining the potential complications is necessary so that the patient can recognise problems early and take appropriate action. This information needs to be delivered in a sensitive manner, whilst ensuring the patient is aware of the importance of treatment adherence and red flags that indicate the need for urgent medical attention.

Acute asthma

“Sometimes people with asthma experience a worsening of their symptoms that may not improve when they use their inhalers, this is commonly called an “asthma attack” or “asthma exacerbation”. It is important to manage this appropriately as they can potentially be life-threatening.”

“Signs of an asthma attack include: wheezing a lot, having a very tight chest, coughing a lot, finding it difficult to walk or talk due to breathlessness, breathing quickly or your reliever inhaler not helping your symptoms. You may have all of these or just some of them, for example, you may not have a wheeze.”

“If you are experiencing worsening symptoms and find that your reliever inhaler isn’t helping you should call 999. If your reliever inhaler helps your symptoms, you should contact your GP for an urgent review of your asthma. You may need extra medication to treat this worsening of symptoms, for example, a short course of steroid tablets to help settle the inflammation.”

Persistent symptoms

“It is important to take your asthma medication every day, no matter how well you feel. This is because the protection builds up in your airways and helps to prevent you from experiencing symptoms or asthma attacks in response to triggers.”

“If you experience symptoms frequently despite following your treatment plan you should seek a review from your GP or asthma nurse, who may alter your medications to try and improve your symptoms. You should also make sure to seek a review if your daily activities are being affected by symptoms, you find that you are waking up in the night with asthma symptoms or your peak flow readings are lower than normal.”

“A small number of people with asthma will have severe asthma and may experience frequent symptoms that are hard to control, but the majority of people will find their asthma is well managed with a preventer inhaler and reliever inhaler.”

Management

Aims of asthma management

The aims of asthma management include:

  • No daytime symptoms
  • No night-time waking due to asthma
  • No asthma attacks
  • No limitations on activity including exercise
  • Minimal side effects from medication

Example

“The primary aim of treating your asthma is to minimise the impact of the condition on your day to day life. If asthma is managed appropriately, we would expect you to have no symptoms during the day or at night. We would also expect you to not feel limited when exerting yourself during exercise. Finally, we would want to minimise any side effects from any treatment you receive.”

Overview of asthma management

  • Provide information about asthma triggers
  • Initiate treatment at a step which is appropriate for the severity of the patient’s symptoms
  • Provide the patient with a personalised asthma plan and appropriate education to ensure good compliance
  • Ensure the patient is up to date with all necessary immunisations
  • Provide advice about weight loss and smoking cessation if relevant

Inhalers

Reliever (e.g. salbutamol inhaler)

Explain what a reliever inhaler is and when it should be used:

“You will be given a reliever inhaler, the most common one is salbutamol and it is typically blue. This is used to help relieve asthma symptoms and asthma attacks. It works by helping to relax the airways when they become narrow.”

“If your asthma is well-controlled you shouldn’t need to use this more than three times a week. If you are needing to use it more than this you should request a review of your asthma with your GP.”

“You should take two puffs of this, with 30 seconds in between, when you feel short of breath.”

Preventer (e.g. beclomethasone inhaler)

Explain what a preventer inhaler is and when it should be used:

“You will also be prescribed a preventer inhaler. This helps in the long-term to reduce the inflammation in your airways and makes them less likely to narrow in response to triggers.”

“You should inhale…(x puffs…x times a day) every day. It is really important to try not to miss any doses.”

“You should also make sure to rinse out your mouth after using this as you can sometimes develop a sore, inflamed mouth when taking it.”

For more information, see the Geeky Medics guide to inhaler technique.

Other treatment

Explain that sometimes people may require other medications or referrals to specialists:

“Most people find that a preventer and reliever inhaler control their asthma well, however, some people require more treatment.”

“If you continue to have regular symptoms you should request a review of your asthma with your GP as you may require more medications, for example, there are tablets that can also be used to treat asthma. Or you may be referred to a lung specialist who can run more detailed tests and may use different medications to help your symptoms.”

Peak flow meters

Explain what a peak flow meter is, when it should be used and how to carry out a peak flow measurement:

“We will also give you a device called a peak flow meter. This is a tube that you blow into which measures how fast you can blow air out of your lungs.”

“As asthma causes narrowed airways it can make it harder to blow air out of your lungs, so when people are having asthma symptoms or their asthma is poorly controlled their peak flow readings will be reduced.”

“You can work out a predicted peak flow based on your height, sex and age but it is important to monitor it over time to find out what your personal best is, this is because some people may have peak flows that are very different to their predicted values. Your personal best peak flow can then be used to help develop a personalised asthma management plan based on your numbers and symptoms.”

“When starting or changing treatment you should check your peak flow twice a day, generally in the morning and evening. When your readings have stabilised you should check it if you feel your symptoms are getting worse or if you are concerned about your asthma.”

For more information, see the Geeky Medics guide to recording a peak expiratory flow rate measurement.

Personalised asthma management plans

Explain why a personal asthma management plan is beneficial and how it can be completed:

“It is recommended that anyone with asthma has a personal management plan. It tells you and other people what your normal asthma medicines are, what to do if your symptoms are getting worse and what to do in an emergency situation.”

“A management plan is helpful because it gives you more control over the management of your asthma and can help to prevent asthma attacks from happening.”

“You should book a review appointment with your GP or asthma nurse in a couple of weeks to complete your management plan. You can find examples online, such as on the asthma UK website.”

Other aspects of asthma management

Explain the other aspects of asthma management that are important, such as annual reviews and vaccinations:

“You should aim to have a review of your asthma with your GP at least once a year, even if you are completely well. This will make sure that your asthma is well controlled, and you know what to do if your symptoms get worse. If you are having problems with your asthma, you may need reviewing more regularly than this.”

“It is also really important to make sure you are up to date on your vaccinations and that you get your flu jab each year. As a patient with asthma, you are entitled to this for free. This is important as the flu virus is a very common trigger for asthma symptoms and people with asthma can become very unwell with flu.”

If the patient is a smoker then you should also offer smoking cessation advice. For more information, see the Geeky Medics guide to smoking cessation counselling.


Closing the consultation

Summarise the key points back to the patient.

“We have discussed quite a lot today, including what asthma is, the symptoms you might experience and how the condition is managed. I realise this is a lot of information to take in and therefore I have a leaflet which summarises everything we’ve discussed. You will require regular checks to ensure your asthma continues to be well controlled. It is also important that you seek a review if you notice your symptoms worsening. If you begin to feel very short of breath, despite using your treatments, you should call an ambulance.”

“Going forward, it is important that following this appointment you attend an inhaler check appointment with a specialist asthma nurse to make sure your inhaler technique is correct. You will also need an appointment to complete an asthma management plan. It is very important that you stick to the asthma plan and use your preventer inhaler even when you are feeling well in order to get the full benefit of treatment.”

Ask the patient if they have any questions or concerns that have not been addressed.

“Is there anything I have explained that you’d like me to go over again?”

“Do you have any other questions before we finish?”

Direct the patient to further information about the condition using websites and leaflets.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.


Editor

Dr Chris Jefferies


References

  • NHS.uk. Asthma overview. Available from [LINK].
  • NICE Clinical Knowledge Summaries (CKS). Asthma-newly diagnosed. Available from [LINK].
  • Asthma + Lung UK. Health advice. Available from [LINK].

 

 

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