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Consultation Manual Part 1 - Interview Skills

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Contains bullet-point summary of questions to be asked in medical interview / consultation based on the presenting complaint or system. Contains additional information on clinical reasoning and developing a differential diagnosis

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Consultation Manual Part 1 - Interview Skills

  1. 1. Medical Consultation Manual: Part I Interview Skills Christiane Riedinger May 2014
  2. 2. TOC: Interview Skills ● General Interview Structure ● Pain ● Cardiovascular History ● Respiratory History ● Abdominal History ● Hepatobiliary History ● Neurological History ● Psychiatric History ● Alcohol Consumption History ● Elderly ● Genitourinary History ● Gynaecological History ● Varicose Veins History ( + DVT) ● Musculoskeletal/Rheumatic History ● Endocrinological History ● “Lumps and bumps” History ● Eye History ● ENT History ● Dermatological History ● Paediatric ○ General Paediatric History ○ Developmental Assessment ● CCS ○ Overview ○ Gathering information ○ Explanation and Planning ■ Breaking bad news, e.g. DVLA regulations, amputation ■ Explain risk ○ Special scenarios ■ Elderly patient ■ Diversity, using translators ■ Difficult patient ■ Psychiatric history ○ Specialised skills ■ Assessing capacity ■ Obtaining consent ○ Death and dying
  3. 3. General Statement This document lists the general points of a medical interview first. This is followed by more specific history questions depending on the presenting complaint and the affected system (e.g. CV, resp., abdo., etc.). Initially explore the presenting complaint, but also ask about related presenting complaints for the system in question. The main presenting complaints have been highlighted in blue. The lists of specific questions are meant to be asked within the framework of the general history, not in isolation! Incorporate the content of the History into the general clinical communication skills, e.g. according to the Calgary-Cambridge model. Red flag symptoms have been highlighted in red and have to be ruled out/in. Where possible, this document lists possible differential diagnoses depending on the presenting complaint (if not, look them up in the Oxford Handbook of Clinical Diagnosis), and tries to aid the process of clinical reasoning by outlining particular features of the history that allow narrowing down of the differential diagnosis.
  4. 4. Framework for Diagnostic Reasoning Initial DD based on surgical sieve Narrowed down DD and conditions to rule out Working Diagnosis and conditions to rule out Initial case features Each presenting symptom and patient’ s age, sex, and in some cases genetics. Hx Ex Diagnosis Ix Confirmation of diagnosis: A diagnosis becomes final when it explains all findings. Rx Useful resource: Obtain initial DD based on presenting complaint from “Oxford Handbook of Clinical Diagnosis”. Useful resource: Obtain particular questions to ask depending on presenting complaint from this document or “Masterpass, Focused History taking for OSCEs - A Comprehensive Guide for Medical Students”. So far, I haven’t found any better or more comprehensive books. Useful resource: “Oxford Handbook of Clinical and Laboratory Investigation”, also organised by presenting complaint. Useful resource: “Oxford Handbook of Clinical Medicine”. It is very important to choose the right/best/most appropriate diagnostic lead to enter the equation here. The better the lead, the smaller the DD. An initial lead may be replaced further down the line when particular signs are found or particular Ix are +ve. The working DD is used to formulate the draft management plan.
  5. 5. Diagnostic Timeframe ● Acute ○ Seconds Electrical: neural or heart ○ Seconds to minutes Embolus, trauma, rupture ● Subacute ○ Minutes to hours Thrombotic ○ Hours to days Acute infective ● Chronic ○ Days to weeks Chronic infective ○ Weeks to months Neoplastic ○ Months to years Degenerative Evidence-based DD and Mx ● Positive findings summary ● Relevant negative findings summary ● Assessment and plan ○ ?Condition 1: ■ outline evidence ■ outline management plan: Ix and/or Mx, Rx ○ ?Condition 2: ■ ... ○ Other active diagnoses ■ Outline evidence and plan for important comorbidities
  6. 6. General History ● PC ID presenting complaint ● HPC History of presenting complaint ○ Site ○ Onset ○ Timing ○ Associated symptoms ○ Has this occurred before? ● PMH Past medical history ● FH Family History ● SH Social History ○ Occupation ○ Housing ○ Smoking ○ Alcohol ○ Illicit drug use ● Contacts Travel History and sexual contacts ● Drugs ● Allergies ● Systems review / functional inquiry / checklist ○ General ○ CV ○ Resp ○ GI ○ GUS ○ Neuro ○ Endocrine ○ Locomotor ○ Psychiatric
  7. 7. Functional Enquiry ● General ○ Sleep ○ Fatigue ○ Malaise ○ Fever ○ Sweats ○ Snoring ○ Skin - rashes, bruising, colour ○ Hair - amount, distribution, quality ● CV SOB, chest pain, sputum, orthopnoea palpitations, oedema, syncope, PVD ● Resp Cough, sputum, haemoptysis, ● GI Pain, dysphagia, dyspepsia, acid reflux, n&v, change in bowel habit, diarrhoea, constipation, melaena, haematemesis, weight loss, anaemia, infection, travels ● Liver Jaundice, skin (pruritus, rashes, colour), haematemesis, haematological (clotting, bleeding, recent transfusions), drugs (incl. IVDU), alcohol, infection, travels, sexual contacts, leg swelling ● GUS Dysuria, haematuria, polyuria, hesitancy, urgency, terminal dribbling, continence ● CNS Fits, faints, funny turns, weakness, sensory ● Endocrine Weight loss/gain, polyuria ● Locomotor Joint swelling, morning stiffness, distribution, pain local v. diffuse ● Psychiatric Mood, depression, mania, ● ENT Hoarseness, vertigo
  8. 8. Pain History ● O SOCRATES+ ● Open questions ● Site ● Onset ● Character ● Radiation ● Attenuation ● Timing ● Exacerbation ● Severity ● +Associated features
  9. 9. Cardiovascular History ● Chest pain ○ Site, onset, character, radiation (left arm, jaw, neck, shoulder blade, abdomen/indigestion), attenuation (by rest, leaning forward => pericarditis), timing, exacerbation (on exercise, exertion, emotion), severity ○ Associated with nausea and vomiting, sweating? ○ Distinguish cardiac from pleuritic from other causes (pleuritic = sharp pain on deep inspiration) ● Shortness of Breath (SOB) ○ Onset ■ Timing: sudden implies vascular cause ■ Cause: Is onset predictable? Exertion/rest (=> severe) /lying down (=> orthopnoea, paroxysmal nocturnal dyspnoea) ? Exercise tolerance: how long can patient walk? Has this recently become worse? ■ How many pillows does patient sleep on at night? ○ Duration ■ Constant vs. intermittent ○ Associated wheeze ○ Precipitating, exacerbating and relieving factors ● Palpitations ○ Frequency ○ Duration ○ Onset, triggers ○ Rate and rhythm ○ Missed beats ○ Precipitating, exacerbating and relieving factors ○ Associated symptoms ● Oedema ○ Timing/Onset: end of day, after standing ○ Location: ankle, legs, lower back, face, arms, one vs both legs ○ Varicose veins ○ Pain ● Syncope ○ +/- dizziness/preceding symptoms and if so, what does patient mean by it? ○ +/- loss of consciousness ○ Length of recovery ○ On exertion, postural, sudden
  10. 10. Cardiovascular History: ctnd. ● Peripheral vascular disease (PVD) ○ Cold peripheries ○ Claudication: explore leg pain SOCRATES, especially relation to length of walking, time to onset, does patient have to hang leg out of bed to relieve pain at night, does pain occur at rest? ○ Associated ulcers? ○ Presence of varicose veins or joint swelling ● RISK FACTORS!!! ○ Smoking ○ Exercise ○ Weight ○ Diabetes ○ HTN ○ High cholesterol ○ Familial hyperlipidaemia ○ Exacerbation of heart failure by: anaemia, infection, thyroid disease ● Related systems ○ Respiratory ○ GI - Especially problems with gastro-oesophageal reflux? ○ Endocrine - many endocrinological conditions have a link to cardiac symptoms, especially the thyroid ○ Neuro - if syncope
  11. 11. CV: Distinguishing Features ● Chest pain triggered by exacerbation and relieved by rest => Angina ● Sudden onset crushing chest-pain radiating to shoulder or jaw, not relieved by test => Acute coronary syndrome ● Sudden onset chest-pain radiating to back between shoulder blades? +/- signs of shock. => Aortic dissection ● Chest-pain relieved by sitting forwards? Aggravated by lying down and inspiration? => Pericarditis ● Sudden-onset SOB => Pneumothorax ● Sudden onset chest-pain, may be pleuritic (worse on deep inspiration), sudden onset SOB and haemoptysis => PE ● Sudden onset chest-pain following vomiting => Boerhaave’s perforation of the oesophagus
  12. 12. Respiratory History ● Shortness of Breath (SOB) ○ Onset ■ Timing: sudden implies vascular cause ■ Cause: Is onset predictable? Exertion/rest (=> severe) /lying down (=> orthopnoea, paroxysmal nocturnal dyspnoea) ? Exercise tolerance: how long can patient walk? Has this recently become worse? ■ How many pillows does patient sleep on at night? ○ Duration ■ Constant vs. intermittent ○ Associated wheeze ○ Precipitating, exacerbating and relieving factors ● Chest pain ○ Site, onset, character, radiation (left arm, jaw, neck, shoulder blade, abdomen/indigestion), attenuation (by rest, leaning forward => pericarditis), timing, exacerbation (on exercise, exertion, emotion), severity ○ Associated with nausea and vomiting, sweating? ○ Distinguish cardiac from pleuritic from other causes (pleuritic = sharp pain on deep inspiration) ○ Associated symptoms of infection: fever, malaise, recent travel ● Cough ○ Duration ○ Onset ○ Precipitating/relieving factors ○ Associated features ○ Sputum ■ Amount ■ Colour ■ Viscidity ■ Postural drainage ○ Haemoptysis ■ Duration ■ Mixed with sputum or frank ■ Associated features
  13. 13. Respiratory History: ctnd. ● Risk factors for lung disease!!! ○ Smoking, including non-tobacco ○ Occupational Hx; farming (alveolitis), building (astbestosis), mining (pneumoconiosis, silicosis) ○ Pets and other allergen exposure ○ Medications ○ Nutritional status => anaemia ○ ets, occupational Hx, medications, nutritional status => anaemia ○ Signs of DVT ○ FH: A1AT deficiency ● Related systems review ○ Cardiac SOB, chest pain ○ GI Aspiration => pneumonia? ○ Musculoskeletal Neuromuscular diseases impairing breathing ○ General Weight loss, night sweats, paraneoplastic (Cushing’s, hyper- calcaemia, MG, LES) ○ Haematological Anaemia or blood loss, clotting disorders => PE
  14. 14. Resp: Distinguishing Features ● Persistent, productive cough >3d +/- fever (note presentation of atypical pneumonias) => suggests pneumonia ● Persistent, productive cough on most days of past 3 months and recurring during 2 consecutive years => chronic bronchitis ● Dry cough + SOB => asthma, LV failure, fibrosis ● Transient, reversible (+/- nocturnal) cough, wheeze, diurnal variation => asthma ● Blood-stained sputum => PE, lung CA, cavitating pneumonia ● Regarding SOB, it is useful to divide up potential DD based on the timescale in which the SOB develops, e.g. mins, hours-days, weeks-months ○ Sudden onset Pneumothorax, PE, flush pulmonary oedema in renal vascular disease, ARDS can be relatively sudden, too ○ Intermediate Infectious, heart failure ○ Slow Fibrosis, malignancy
  15. 15. Abdominal History ● Abdominal pain ○ Site (quadrants of the abdomen), onset (sudden and severe in ischaemia, colicky or constant, colicky on top of background pain), character (colicky vs constant, stabbing), radiation (to shoulder, loin to groin, migration from initial central to LIF pain => appendicitis), attenuation (with food => duodenal ulcer, relieved by defecation), timing, exacerbation (worse by food => stomach ulcer, after fatty food => biliary), associated symptoms ● Relating to Food Intake ○ Appetite, weight loss, signs of anaemia ○ Dysphagia ■ Type of food: liquid and solid => neuro, solid only => malignancy ■ Where does difficulty occur? high or low ■ Associated pain? => odynophagia, consider infection ■ Gurgling of food, halitosis => pharyngeal pouch ■ Globus sensation? ■ Associated chest infections? ■ Immunosuppression? => oral/oesophageal candidiasis ○ Heartburn ■ Association with food ■ Associated risk factors ● Smoking ● Coffee ● NSAIDS, steroids, SSRIs, bisphosphonates ● Blood group O ● Stress ● (H. pylori - keep in mind, not relevant for the Hx) ○ Dyspepsia/indigestion: bloating, belching, epigastric pain, heartburn ■ ALARMS symptoms: anaemia, loss of weight, anorexia, recent onset / progression, melaena/ haematemesis, swallowing difficulty, age>55 ○ Nausea ○ Vomiting ■ Distinguish from regurgitation ■ Haematemesis, coffee-ground vomiting, bile, undigested food ■ Relation to meals ■ Effortless, projectile, self-induced ■ Worse in the mornings
  16. 16. Abdominal History ● Regarding Bowels ○ Regularity, last bowel opening, passing of wind ○ Recent changes ○ Quality of stool: Bristol stool chart ○ Associated symptoms: straining, severe pain, haemorrhoids, urgency, incontinence ○ Diarrhoea, mucus, steatorrhoea (stool won’t flush) ○ Constipation, tenesmus, manual evacuation ○ Urgency, incontinence ○ Melaena and rectal bleeding, blood on paper, mixed in with stool (=> small bowel), filling the pan (diverticulosis) ● Regarding infection ○ Fever, rigors ○ Travel ● Extra-abdominal features ○ Skin reactions ■ Dermatitis herpetiformis => coeliac ■ Erythema nodosum => UC, Crohn’s, malignancy ■ Tan including gums and skin creases => Addison’s ○ Rheumatological ■ Uveitis, arthritis => UC, Crohn’s ○ Symptoms of hyper- or hypothyroidism ● Drugs, e.g. laxatives, opioids, antibiotics ● Toxins ● Related systems review ○ GYNAECOLOGICAL - always in female! possible pregnancy, endometriosis ○ CV if ischaemic bowel disease or epigastric pain (!MI) ○ Endocrine ○ Urological ○ Rheumatological ○ Dermatological
  17. 17. Hepatobiliary History ● Pain ○ SOCRATES ○ Radiating to shoulder? ○ Pain associated with ingestion of food? ● Alimentary symptoms ○ Nausea, vomiting ○ Change in bowel habits ○ Colour of stools and urine ○ Haemorrhoids (sign of portal hypertension?) ○ Haematemesis ● Haematological ○ Previous Transfusions ○ Tendency to bleed or bruise ● Skin ○ Pruritus (note: caused by bile salts in skin, not bilirubin!) Pruritus and fatigue, can think early liver disease, e.g. in PBC or PSC. ○ Rash ○ Colour change ● Jaundice ○ Onset ○ Duration ○ Associated features, e.g. pruritus, rash ● General systemic features, e.g. of infection (=> recent travel, sexual encounters, contact with infected), B-symptoms, weight loss ● Other associated symptoms: OEDEMA, ascites ● IVDU, piercings, tattoos ● Important aspects of general history ○ Social History Alcohol consumption, lifestyle, nutrition ○ Drug History Important. Drugs causing cholestasis? ○ Contact Travel and sexual ○ Family History Cancer, Gilbert’s, Haemochromatosis, Crigler-Najjar ● If concerned about alcohol abuse, use CAGE questionnaire ○ Have you ever felt you need to cut down on your drinking? ○ Have you ever been annoyed by people commenting on your drinking? ○ Have you ever felt guilty about your drinking ○ Have you ever had to have a drink in the morning to get going? = eye opener ● Related systems review: GI, rheumatological for autoimmune hepatitis, neuro, psych.
  18. 18. Abdo: Distinguishing Features DD Based on Intensity and Location of Pain ● Consider onset and progression of abdominal symptoms. ○ Fast = vascular ○ Migration from generalised to localised = peritonitis extending from visceral to parietal peritoneum, e.g. of appendicitis ● Mild ○ Constipation ○ Menstruation ○ UTI ○ IBS ○ Non-specific ● RUQ Green = typical location of the pain, but can also be in adjacent quadrant. ○ Liver Hepatitis ○ Gallbladder Acute and chronic cholecystitis, cholangitis ○ Lung Pneumonia ○ Kidney Renal colic, pyelonephritis, PCKD ○ Duodenum Peptic ulcer ○ Colon Ischaemic bowel, IBS, IBD, obstruction ○ Vascular Ruptured AAA ○ Back Musculoskeletal or related to nerve compression ○ Skin Herpes zoster, haematoma ● LUQ ○ Kidney Renal colic, pyelonephritis, PCKD ○ Spleen Abscess, rupture ○ Stomach Gastritis, peptic ulcer ○ Pancreas Pancreatitis, retroperitoneal fibrosis ○ Oesophagus GORD, perforated lower oesophagus ○ Vascular AAA, dissection ○ Colon Ischaemic bowel, IBS, IBD, obstruction ○ Back Musculoskeletal or related to nerve compression ○ Skin Herpes zoster, haematoma ● Epigastrium ○ Heart ACS ○ Stomach Gastritis, peptic ulcer ○ Oesophagus GORD, perforated lower oesophagus ○ Liver Hepatitis ○ Gallbladder Acute and chronic cholecystitis, cholangitis ○ Pancreas Pancreatitis, retroperitoneal fibrosis ○ Vascular AAA, dissection ○ Colon Ischaemic bowel, IBS, IBD, obstruction ● LLQ ○ Colon, including sigmoid Ischaemic bowel, IBS, IBD, obstruction, diverticulitis, strangulated hernia ○ Kidney Ureteric colic ○ Ovary Ectopic pregnancy, salpingitis, ovarian cyst rupture ● RLQ ○ Colon, including append Ischaemic bowel, IBS, IBD, obstruction, strangulated hernia, appendicitis ○ Kidney Ureteric colic ○ Ovary Ectopic pregnancy, salpingitis, ovarian cyst rupture ● Suprapubic ○ Bladder Cystitis, urinary retention ○ Uterus Endometriosis, PID ○ Ovaries Ectopic pregnancy, salpingitis, ovarian cyst rupture
  19. 19. Abdo: Distinguishing Featuresctnd. GENERAL ● Parietal pain Localised ● Visceral pain Poorly localised ● Referred pain Poorly localised pain of visceral origin is referred to the dermatome of somatic sensory information entering the spinal cord at the same level ○ Phrenic nerve and axillary n (?) Diaphragm to shoulder, liver and gallbladder to shoulder, spleen to shoulder, lung to shoulder ○ ? Pancreas to back ○ ? Abdominal aorta to back ○ ? Heart to jaw ○ ? Ureter to genitals RELATING TO FOOD ● Pain directly after eating => Stomach ulcer ● Pain with delay after eating, at night => Duodenal ulcer TYPES OF COLICS AND PERITONISM ● Sharp RUQ pain radiating to right shoulder, +/- n&v, after fatty meal, usually w/o jaundice unless Mirizzi syndrome where stone compresses the bile duct directly. Duration few h. => Gallstone/biliary “colic” ● Continuous (<6h) severe epigastric or RUQ pain, radiating to the back and around costal margins. Shoulder if diaphragm involved => Cholecystitis, can be preceded by stone ● Upper abdominal pain, indigestion, bloating, burping, nausea and occasional vomiting = “Flatulent dyspepsia” after fatty meals => Chronic cholecystitis ● RUQ pain, fever, jaundice = charcot’s triad, +/- choledocholithiasis => Ascending cholangitis ● Gradual onset obstructive jaundice => Cholangiocarcinoma, head of panc. CA ● RUQ pain, tender hepatomegaly, mild jaundice, +/- fever => Hepatitis ● Wave-like abdominal pain due to bowel contractions attempting to relieve obstruction. => Intestinal colic (true colic) ● Severe relapsing-remitting back/loin pain radiating to the groin. Potential scrotal/labial pain. Patient writhing, unable to get comfortable. Stone mid-ureter may mimic appendicitis on the R and diverticulitis on the L => Ureteric colic Note during examination: tenderness in the renal angle on percussion => Retroperitoneal inflammation ● Acute abdominal pain, (rebound) tenderness, guarding, rigidity. Initially generalised (visceral peritoneum), then localised (spread to parietal peritoneum). Potentially absent bowel sounds. Patient lies still => Peritonism ● Sudden onset R iliac fossa pain => Ovarian cyst torsion
  20. 20. Abdo: Distinguishing FeaturesDD of other presenting symptoms ● Dysphagia ○ A symptom without many associated signs ○ Fluids worse than solids implies neuromuscular cause ○ Solids worse than fluids implies obstructive cause ○ Acute on chronic: oe CA + food bolus, can’t even swallow saliva ○ Relating to the oesophagus ■ Intraluminal ● Foreign body ● Polypoid tumours ● Oesophagitis ● Infection: candidiasis, herpes simplex ■ Intramural ● Oesophageal spasm, diffuse oesophageal spasm ● Achalasia ● Oesophageal stricture: benign (GORD, irritants) or malignant, inflammatory 2* to reflux ● Carcinoma of the oesophagus: adeno or squamous ● Carcinoma of the cardia of stomach ● Oesophageal web (of desquamated epithelium) = Plummer Vinson syndrome, in middle aged females with iron deficiency anaemia ● Nutcracker oesophagus, high-pressure contractions with normal peristalsis on manometry ● Scleroderma ● Presbyoesophagus ● Schatzki ring (of mucosal tissue in distal oe) ■ Extramural ● External oesophageal compression: lymph nodes, LA enlargement, substernal thyroid, malignancy, retrosternal goitre, thoracic aortic aneurysm, congenitally abnormal vessels = dysphagia lusoria ● Pharyngeal pouch ● Rolling hiatus hernia ○ Systemic ■ Scleroderma ■ MG ■ MS ■ Parkinson’s ○ Neurological ■ Bulbar palsy, affecting the cranial nerves VII-XII and their muscular territories ■ Pseudobulbar palsy, UMN ■ Motor neurone disease ○ Musculoskeletal ■ Myasthenia gravis ○ Inflammatory/Drugs ■ Xerostomia ○ Psychological ■ Globus pharyngeus
  21. 21. Abdo: Distinguishing FeaturesDD of other presenting symptoms ● Odynophagia ○ Foreign body ○ Mainly infectious: pharyngitis, tonsillitis, mononucleosis, candidiasis, ... ○ Oropharyngeal ulceration ○ Agranulocytosis = Granulopenia ○ GORD ● Heartburn ○ GORD ○ Hiatus hernia ○ ACS ○ Pregnancy ○ Obesity ○ Smoking ○ Nutrition ○ NSAIDS, SSRIs, TCA, steroids ● Indigestion/Dyspepsia = Epigastric pain, bloating, heartburn ○ Inflammation: GORD, gastritis, PUD ○ Oesophageal, gastric GA ○ Non-ulcer dyspepsia ○ Gastric ulcer: pain worse on eating ○ Duodenal ulcer: pain improves on eating ● Nausea ● Vomiting ● Haematemesis ○ Trauma - have you been vomiting/retching? ■ Mallory-Weiss tear ■ Boerhaave syndrome ○ Inflammation - dyspepsia? ■ PUD: GU or DU ○ Neoplasia ■ Gastric or oesophageal CA - dysphagia? ○ Congenital - FH? ■ Angiodysplasia ○ Acquired - Liver Hx ■ Varices from portal hypertension ○ General - Drug Hx, FH ■ Bleeding diatheses and warfarin ○ Swallowed blood ■ Epistaxis - Nose bleeds? ■ Lung Ca - Haemoptysis?
  22. 22. Abdo: Distinguishing FeaturesDD of other presenting symptoms ● Diarrhoea ○ Acute vs chronic ○ Recent change of bowel habit >6w? +/- weight loss, anaemia => red flag for Ca? ○ Relieved by defecation? yes = large bowel, no => small bowels ○ Severity: nocturnal? (IBS vs IBD) ○ +/- blood => ischaemic colitis, IBD, C. diff colitis, dysentery ○ +/- mucus => Ca, UC ○ +/- pus => abscess, diverticulitis, IBD ○ +/- drugs => Abx, laxatives, lactulose, EtOH ○ +/- fat (floats) => pancreatic, biliary ○ +/- signs of hyperthyroidism ○ +/- signs of infection ○ +/- travel history ○ +/- chronic pain / neuropathic pain making IBS more likely ○ +/- extraintestinal features (dermatitis herpetiformis => coeliac; erythema nodosum, uveitis, arthritis => UC) ● Steatorrhoea - see diarrhoea ● Constipation ○ For diagnosis: ROME criteria, need >2 associated symptoms for >3w ■ Straining ■ Tenesmus ■ Hard, lumpy stools ■ Manual evacuation ■ Sensation of blockage ○ Timing: chronic / new onset, frequency of stools ○ “Benign” general contributors: dehydration, low fibre diet, lack of privacy, stress, immobility ○ Associated symptoms: ■ Pain, e.g. from haemorrhoids, anal fissure ■ Bleeding ■ Chronic/neuropathic pain (=> IBS, see also Manning/Rome criteria for diagnosis) ■ Presence of hernia ■ Red flags for bowel CA: change in bowel habit, weight loss, anaemia ■ Symptoms and signs of hypothyroidism ■ Symptoms and signs of hypokalaemia, porphyria, uraemia, Pb poisoning ■ Neuro Hx for MS, myelopathy, cauda equina syndrome ○ Related PMH: ■ Previous surgery (adhesions) ○ Drug History (e.g. opioid analgesics) ■ Opioids ■ Antimuscarinics ■ Diuretics ■ Laxative dependence!! ○ Cardinal signs of obstruction ■ Pain ■ Vomiting ■ Distension ■ Constipation (absolute = neither flatus nor faeces)
  23. 23. Abdo: Distinguishing FeaturesDD of other presenting symptoms ● Faecal incontinence ○ Overflow diarrhoea? ○ Obstetric history ○ Previous surgery ● Tenesmus - see constipation ● Rectal bleeding ○ Common: haemorroids ○ Infectious: dysentery (shigella, E.coli 0157) ○ Inflammatory: diverticulitis, IBD ○ Neoplastic: GI malignancy ○ Vascular: ischaemic colitis ○ Congenital: angiodysplasia, hereditary haemorrhagic telangiectasia ● Jaundice ○ See paragraph on colics and peritonism ○ Pre-hepatic: also think haemolysis, e.g. autoimmune, just jaundice no liver Sx ○ Hepatic: +/- hepatomegaly ○ Post-hepatic: stools light and urine dark ● DD of lump on IF ○ Kidney transplant ○ Horseshoe kidney (definitely don’t want to accidentally remove this!)
  24. 24. Neurological History ● Handedness ● Important parts of general history ○ (HPC, PMH) ○ Age ○ Occupation ○ Drug history ○ Family history ○ Social history ● Neurological screening questions ○ Headaches ○ Memory disturbances ○ Dizziness ○ Giddiness ○ Blackouts ○ Changes in taste or smell ○ Visual problems ○ Double vision ○ Difficulty with speech ○ Difficulty swallowing ○ Weakness ○ Numbness, tingling
  25. 25. Neurological History: Head Injury ● Aim: assess for potential admission for observation ● Falls from height? (Take seriously) ○ Onto grass or concrete? ● Road traffic accident ○ Seat-belts worn? ○ Speed at impact ○ What happened to other passengers ○ Has alcohol been consumed, or drugs? ● LOC? ○ Regaining of consciousness? ○ Lucid interval likely to deteriorate again? ○ Did baby cry immediately after the injury? (Good sign) ● Visual disturbances ● Dizziness ● Headache ● Amnesia (>30min retrograde is indication for imaging) ○ <1h anterograde amnesia => mild injury ○ 1-24h anterograde amnesia => moderate injury ○ >24h anterograde amnesia => severe injury
  26. 26. Psychiatric History ● Establishing a rapport is particularly important in this history. Mention to patient that environment safe. Encourage with open questions. Give plenty of time. ● Patient Details: ask for name, address, DOB ● Presenting Complaint ○ Reason for referral: voluntary or involuntary ○ Ask patient to state PC in his/her own words ● HPC ○ Open questions, this is when you do the main part of the mental state assessment ○ Onset and timing ○ Cause as presumed by patient ○ Alleviating/aggravating factors ○ Effect on life, relationships, work ● Exploration of psychiatric symptoms ○ Depending on the presenting psychiatric symptom ○ Symptoms of DEPRESSION ■ Low mood ■ Anhedonia ■ Self-denigration ■ Lack of interest ■ Early morning waking ■ Poor appetite ■ Loss if interest in sexual activities ■ Weight loss ■ Mania ○ ELEVATED MOOD ■ Changeability, sleeping, appetite, concentration, sexual relationships ■ Do you have any special talents? ○ ANXIETY - most common symptom in psychiatry! ■ Nature, severity, precipitants ■ Does patient consider themselves anxious in general? ■ Distinguish psychic vs somatic anxiety (palpitations, sweating, dyspnoea, pallor, abdominal discomfort) ■ Consider situations in which anxiety is a normal experience. Not normal: prolonged, level of anxiety out of keeping with the situation. ■ Is anxiety generalised (=> GAD) or specific? ○ PHOBIAS/PANIC ATTACKS ■ Triggers? Stimuli? (Trigger indicates specific phobia, more generalised trigger indicates social phobia or agoraphobia, no triggers suggest panic attacks) ■ Avoidance, development of obsessions and compulsions (= ritualised avoidance, sometimes initial trigger can even be forgotten) ● Do any thoughts or worries keep coming back to your mind even though you try to push them away? ● Do you ever find yourself spending a lot of time doing the same thing again and again, even though you’ve done it well before? ■ Determine if these thoughts are the patient’s own thoughts (otherwise psychotic)
  27. 27. Psychiatric History ● Exploration of psychiatric symptoms - continued ○ ABNORMAL PERCEPTIONS, HALLUCINATIONS ■ Distinguish distorted internal perception of external object from false perceptions (hallucinations or internal perceptions without external object, pseudo-hallucination is when the patient has insight in the hallucination) ■ Modalities of hallucinations: visual (e.g. Pick’s disease, more likely due to organic cause), auditory (e.g. psychosis), tactile (e.g. perception of small moving objects/insects in alcohol withdrawal), gustatory, olfactory (e.g. in epileptic auras), proprioceptive, vestibular, hypnagogic/hypnopompic (occurring when falling asleep) ■ Useful phrases: ● “You seem to be bothered at times by something and look away, is there something you are hearing?” ● “Do you have thoughts that you head out loud in your head?” ○ ABNORMAL BELIEFS, DELUSIONS ■ Useful phrases ● Now I’d like to ask you some routine questions about some experiences which some people have. ● Have you ever felt that you were unreal, or that the world had become unreal? ● Do you have any particular worries on your mind at the moment? ● Do you ever feel that people are watching yo? ● When you are reading the newspaper, do you ever feel that the stories refer to you directly? ● Do you ever feel that people are trying to harm you in any way? (=> persecutory beliefs) ● Do you ever feel you are to blame for anything or responsible for having done anything wrong? (=> delusions of guilt in psychotic depression) ○ FIRST RANK SYMPTOMS OF SCHIZOPHRENIA ■ Auditory hallucinations, delusional perceptions, delusions of control (passivity of affect and action), delusions of thought interference (thought insertion, withdrawal, broadcasting) ■ Useful phrases ● Do you ever hear voices that comment on what you are doing? (note: in the third person) ● Do you ever get the feeling someone is interfering with your thoughts? Or that your thoughts can be transmitted to others? ● Do you ever get the feeling you are being controlled or that your thoughts or actions are being forced on you? ○ THOUGHT DISORDERS ■ Acceleration (flight of ideas) and deceleration of thought (=> depression) ■ Observation of the form/structure/process of thought ○ EATING DISORDERS ● Previous Psychiatric History PPH ○ Including voluntary/compulsory hospitalisations ○ Success of previous treatments
  28. 28. Psychiatric Historyctnd. ● PMH ● General systems review ○ Mood ○ Sleep ○ Appetite ● Personal Hx ○ Early life and development abuse, bereavements, separations, developmental delays ○ Educational Hx including suspensions, being expelled ○ Occupational Hx including timing of previous employment, relationship with colleagues, satisfaction with work ○ Relationship Hx marriages, partners, children, sexual difficulties, pregnancy Hx, quality of relationships ● Premorbid personality ○ Patient’s self-description of time before illness ○ Coping mechanisms, things they enjoyed doing ● Risk assessment ○ To self suicidal thoughts, plans, intentions to carry out plans, actions ● How do you feel about the future? ● Have you ever thought that life was not worth living? ● Have you ever wished you could go to bed and not wake up in the morning? (=> passive thoughts of death) ● Have you had thoughts of ending your life? (if so, frequency, are thoughts fleeting and rapidly dismissed, or prolongued? Are they occurring more often?) ● Have you made any preparations? (Incl. suicide note) ● Have you previously tried to take your own life? ● Have you ever harmed yourself? Under what circumstances? What do you feel or think before harming yourself? ○ To others Violence, sexually inappropriate behaviour ○ By others Vulnerabilities, abuse ○ Self neglect Nutrition, hygiene, housing, drugs ● Forensic Hx ● FH ○ Mental health of family ○ Drug and alcohol abuse ○ Forensic encounters ○ Deaths in family and effect on patient ● SH ● DH ● ICE and effect on life!
  29. 29. Psychiatric HistorySummary ● PC ● HPC ● Exploration of psychiatric symptoms ○ Depression ○ Elevated mood ○ Anxiety ○ Phobias, panic attacks ○ Abnormal perceptions, hallucinations ○ Abnormal beliefs, delusions ○ First rank symptoms of schizophrenia ○ Thought disorders ○ Eating disorders ● Previous psychiatric Hx ● PMH ● General systems review ○ Mood ○ Sleep ○ Appetite ● Personal Hx ○ Early life and development ○ Educational Hx ○ Occupational Hx ○ Relationship Hx ● Premorbid personality ● Risk assessment ○ To self ○ To others ○ By others ○ Self neglect ● Forensic Hx ● FH ● SH ● DH ● ICE and effect on life!
  30. 30. Psychiatric HistoryCCS and Background ● Deal with emotional impact on patient ● Normalise statements of patient if appropriate “In stressful times, people may...” ● Is there a systematised delusional system of many different types of delusions? ● Floridly psychotic patients with obvious thought disorder, pressure of speech, paranoia, hallucinations and delusions ○ Non-threatening starting-questions ■ Start with name, address, DOB ■ Any physical discomfort? ■ Initially focus on “external” not “internal” problems ○ Behaviour and body language: Keep calm, sit still, appear relaxed, neutral, non- threatening, open posture ○ Time open and closed questions well, either can have bad effects ○ Building a rapport with the patient ■ Use patient’s own language ■ Lack of surprise reaction, appearing non-judgmental and respectful ■ Be flexible and adjust to emotional state and ability to concentrate/focus ○ Avoid: ■ Long and detailed introduction and explanation of why you are here ■ Sharing personal thoughts, confronting delusions ■ Staring, touching ● Less florid patient ○ Effect on life ○ Signposting and sequencing to provide structure in thought disorder ● Skills for Viva ○ DD, know diagnostic criteria (pick one) ○ Management ■ Structure according to low to high intervention ■ Conservative: removal of stressors ■ Include observation in low stimulus environment if appropriate ○ Mention to check with seniors
  31. 31. Suicide Assessment ● Consent for discussion and patient’s feelings ● HPC ○ What has happened ○ Reason for attempt: ■ Impulsive? ■ Extent of planning: will, suicide note, avoiding attention and discovery, research/preparation ○ Events preceding the attempt ○ Method chosen (and did they know / presume method was fatal) ○ Any other drugs or alcohol consumed prior to event ● Current feelings ○ How does patient feel now ○ Feelings regarding failed attempt: regret, relief ○ Stressors: money, relationships, mental illness, physical illness, substance abuse ○ Protective factors: dependents, interests ○ Future plans ■ Would they do it again ■ Other plans of self-harm ■ Access to guns, medications etc. ● Risk factors ○ FH, previous attempts, mental illness ● Assess symptoms of depression ○ Disturbance of mood ○ Feelings of hopelessness and helplessness ○ Self-esteem ○ Poor concentration ○ Anhedonia ○ Guilt ○ Agitation ○ Appetite, weight, sleep ○ Delusions or psychotic symptoms ● PMH ○ Previous suicide attempts: details and methods used ○ Psychiatric illness ● Social background ● Personal circumstances and employment ● Would they like treatment? Do they think it may help? ● Important CCS skills ○ Build relationship ○ Open questions, listening skills, use of silence ○ Picking up on verbal and non-verbal cues ○ Facilitation via repetition, interpretation and paraphrasing ○ Non-verbal communication of empathy, acceptance and support ○ No premature reassurance ● Viva questions: overdoses and antidotes, always include risk in presentation, prognoses/relapse risk
  32. 32. Abbreviated Mental Test ● AMTS 1. Age 2. DOB 3. Time (to nearest hour) 4. Address for later recall (42 West Street) 5. Year 6. Name of institution 7. Recognition of two persons, e.g recognise doctor and nurse’s profession, recognise another person visible to doctor and patient 8. Year of 1st world war 9. Name of present monarch 10. Cunt backwards from 20 to 1 Score out of ten, <9 (8-7) cognitive impairment => further testing ● Other tests include ● Orientation to time ○ Year ○ Season ○ Month ○ Date ○ Day of the week ● Orientation to space ○ Country ○ County ○ City ○ Hospital ○ Floor/ward ● Registration: ○ Say three words ○ Repeat them ○ Remember them for later ● Count backwards from 100 in 7’s (or from 20 to 1) ● Repeat three words from earlier ● Naming of 2 common objects ● Naming of 2 people ● Name date of birth ● Current monarch ● Beginning of 2nd world war ● Further possible tests (part of Mini Mental State Examination) ● Oral Instruction: ○ Take a paper, fold it in half and put it on the floor ● Carry out a written instruction ● Make up a sentence about anything and write it down ● Draw two intersecting pentagons (or copy them from a drawing)
  33. 33. Elderly ● May have multiple co-morbidities: no need to discuss all, ask what is on patient’s agenda ● Always also assess activities of daily living: ○ Remember 10 in order of daily routine ○ Toilet use ○ Bowel and bladder incontinence ○ Bathing ○ Dressing ○ Grooming ○ Stairs ○ Cooking ○ Feeding ○ Transfer ○ Mobility ● Address difficult areas, e.g. incontinence, with sensitivity ● Obtain information from family without excluding the patient ● Clarity and good signposting in case of mental impairment
  34. 34. Alcohol History ● Signs of alcohol abuse ○ Difficulty or failure of abstinence ○ Narrowing of drinking repertoire ○ Priority to maintain alcohol intake ○ Increased tolerance ○ Withdrawal symptoms ● CAGE questionnaire ○ Cut down - does patient feel like they should cut down their alcohol consumption? ○ Annoyed - does patient feel annoyed when others comment on their drinking? ○ Guilt - does patient sometimes feel guilty about their drinking? ○ Eye opener - does patient feel they need a drink in the morning? ● TWEAK - more sensitive than CAGE ○ Tolerance ○ Worry about drinking ○ Eye opener ○ Amnesia from alcohol use ○ Cutting down attempts ○ If >2 apply then TWEAK +ve ● Signs of withdrawal ○ Sweats ○ Nausea ○ Tremor ○ Fits ○ Hallucinations ● Side-effects of alcohol abuse ○ Liver hepatitis, cirrhosis, portal hypertension, varices ○ GI peptic ulcers, pancreatitis ○ Heart arrhythmias, hypertension, cardiomyopathies ○ CA GI, breast ○ Haemmegaloblastic anaemia ○ CNS memory loss ● Coexisting depression? ● Does patient want to quit drinking? Helps to plan treatment, either abstinence or controlled intake ● Perform Mini Mental test or Abbreviated Mental Test AMT
  35. 35. Genitourinary History ● Micturition ○ Volume ■ Polyuria ■ Oliguria <400mL/24h ○ Quality ■ Colour ■ Smell ○ Irritative symptoms ■ Frequency, day vs. night (nocturia, nocturnal enuresis/bedwetting) ● >every 2h/day ● >2x/night ■ Urgency and urge incontinence ■ Nocturia ○ Obstructive symptoms ■ Hesitancy ■ Poor Stream ■ Intermittent flow ■ Terminal dribbling ■ Incomplete voiding ○ Associated symptoms ■ Pain - dysuria (dysuria+frequency => UTI?) ● Painful vs. painless haematuria (red flag!!) ● Triad of kidney tumour symptoms: pain, haematuria, mass in flank! ■ Blood - haematuria ● Microscopic vs. macroscopic ● Beginning of stream = urethral/prostatic ● Throughout = lesion in bladder, ureter or kidneys ● End of stream = schistosomiasis ● + Clots? ■ Thirst - polydipsia ○ Incontinence ■ Stress Incontinence - 1st part of urethra no longer in abdominal cavity, ↑ abdo pressure causes leakage ■ Overactive bladder - Uncontrolled increases in detrusor activity ■ Overflow incontinence - Overfilling due to obstruction or neurogenic causes +/- weak muscles, previous surgery ■ Timing ■ Cause ■ Associated faecal incontinence ■ Previous trauma at delivery, dragging sensation indicating prolapse? ■ Impact on daily living
  36. 36. Genitourinary History ● Prostatism ○ Starting micturition ○ Stream ○ Terminal dribbling ○ Nocturia ● Gynaecological History ○ Menstrual Hx ○ Contraceptive usage ○ Prior genital or pelvic infections ○ Sexual Hx ● Renal pain ○ Dull pain below 12th rib? ○ Ureteric colics? (sudden onset, severe loin pain, e.g. from costovertebral angle and flank towards groin radiating to the groin +/- haematuria) ● Associated endocrine effects of chronic kidney disease ○ Anaemia ○ Renal osteodystrophy ● Drug History ○ Diuretics, drugs that affect the bladder ● Social History ○ SMOKING ○ OCCUPATION! ● FH ○ Urological cancer ● Systems review ○ Constitutional ○ GI ○ Neurological (e.g. MS) ○ Endocrine ○ Psychiatric
  37. 37. Gynaecological History ● Menstrual Hx ○ Menarche ○ Menopause, if near ■ Hot flushes ■ Night sweats ■ Urinary Hx ■ Vaginal dryness ■ Loss of libido ■ Insomnia ■ Lethargy ■ Irritability ■ Loss of confidence ■ Depression ■ Post-menopausal bleeding ○ Frequency and duration, e.g. 3-5d/28 oligo/amenorrhoea ○ Regularity ○ Flow ■ Excessive bleeding - menorrhagia (>80mL when 35mL normal) ■ Flooding ■ Clots ■ Frequency of changing protection ■ Interference with lifestyle ■ Associated features of anaemia ○ Associated symptoms ■ Pain - dysmenorrhoea ■ PMS ● Other bleeding from the genital tract ○ In-between periods ○ After intercourse ● Gynaecological Hx ○ Vaginal discharge ○ Galactorrhoea ○ Previous STIs or PID ○ Cervical smear Hx, results and potential treatment ● Sexual Hx ○ Dyspareunia ○ Post-coital ache ● Obstetric Hx ● Contraceptive Hx ● Drug Hx ● If amenorrhoea associated visual disturbance (pituitary adenoma?) ● If inquiring about infertility ○ Length and method of previous attempts at conception ○ Is ejaculation achieved ○ Previous pregnancies and children of partner ○ Lifestyle of couple ■ Weight ■ Exercise ■ Smoking ■ Occupation, stress ○ Partner: crypto-orchidism, mumps ○ Endocrinological disorders: thyroid, pituitary, PCOS
  38. 38. Sexual History ● Relating to Presenting Symptoms ● Vaginal Discharge ■ Normal ■ Onset, duration ■ Improving/worsening ■ Colour ● Yellow => chlamydia, gonococcus, trichonomas vaginalis ● White => bacterial vaginosis, candida, physiological ■ Associated malodour ● Bacterial vaginosis ● Trichonomiasis ■ Irritation ● => candida ● Trichonomiasis ■ Pelvic pain ● => PID due to chlamydia or gonococcus ■ Dyspareunia ■ Associated sores or ulcers ■ Abnormal vaginal bleeding ■ Hx of genital infections ■ Drug Hx ■ LMP / pregnancy ■ Last smear ○ Dyspareunia ■ Distinguish deep from superficial (deep => endometriosis) ○ Urethral pain ■ Onset and duration ■ Socrates ● Severity. If >moderate => gonococcus or herpes ■ Discharge ● Profuse yellow => gonococcus ■ Scrotal discomfort => epididymo-orchitis ■ Associated ulcers => herpes ■ Hx of genital infections ■ Drug Hx ● Sexual Hx ○ Last intercourse ■ Contraception used? ■ Which method? ○ Partners: ■ Single partner ■ Multiple partners ■ Gender of partners ■ Number of sexual partners in last three months (address infidelities sensitively) ■ Previously known or new acquaintance, have they mentioned symptoms? ■ HIV exposure concern XX XY
  39. 39. Sexual History: ctnd. ● Sexual Hx - ctnd ○ Partners ctnd ■ HIV exposure concern ● Any previous partners HIV positive ● High risk group ● Previous HIV test ● Hep B vaccination ● Sexual orientation: heterosexual, bisexual, homosexual, MSM, … ● Any sexual contacts abroad? ● Sexual Practice ○ Vaginal ○ Anal ○ Oral ○ Which way around ○ Use of barrier methods ● Key CCS skills ○ Eye contact ○ Use of language ○ Timing of open vs closed questions ○ Signposting of difficult questions ○ Non-judgmental attitude ○ Refraining from assumptions XX XY
  40. 40. Varicose Vein History ● Presenting symptom regarding vein ○ Cosmetic ○ Pain, specific, non-specific ○ Swelling ○ Cramps ● Family Hx of varicose veins ● Risk factors for DVT and PE ○ FH ○ OCP ● Number of past pregnancies ● If suspect a DVT, ask ○ Symptoms in both legs? ○ Current pregnancy ○ Mobility, recent travel ○ Pain ○ Trauma ○ Pitting oedema, incl. elsewhere on body ○ Associated skin changes ○ Past illnesses, DVTs
  41. 41. Musculoskeletal/Rheum. History ● Pain ○ LOCAL vs DIFFUSE ○ Exacerbating/relieving factors, e.g. with movement? ○ Periarticular vs. articular? ● Stiffness ○ EARLY MORNING vs NO EARLY MORNING ● JOINT SWELLING ● DISTRIBUTION/PATTERN of joints ● ASSOCIATED FEATURES ○ Rash ○ Raynaud’s ○ Mucosal dryness ○ Eye symptoms ○ GI symptoms ○ Weight loss ○ Previous bacterial infections ● Loss of function ○ e.g. Limb weakness ● Assess FUNCTIONAL CAPACITY ○ Can you dress yourself without much difficulty? ○ Can you manage walking up and down the stairs? ○ Pain => if all three yes then unlikely to be severe ● Important parts of general Hx ○ FH ○ Drug Hx, e.g. warfarin => haemarthrosis ○ Social Hx ○ Systems review ■ Depression ■ Constitutional symptoms
  42. 42. Endocrine Hx ● General ○ Weight loss or gain Thyroid, Cushing’s etc. ○ Wasting Malignancy ○ Overgrowth Acromegaly ○ Fatigue Hypothyroidism, DM, Addison’s, acromegaly ● GI ○ Appetite Loss in Addison’s, inc. in thyrotoxicosis ○ Polydipsia DM, renal, hypercalcaemia, diabetes insipidus ○ Diarrhoea Addison’s, hyperthyroidism ○ Constipation Hypothyroidism, hypercalcaemia ● Urogenital system ○ Polyuria DM, DI ○ Menstrual changes PCOD, pituitary disease ○ Impotence Hyperprolactinaemia, hypogonadism, acromegaly ● Skin ○ Pigmentation Addison’s, hypopituitarism, Cushing’s, acromegaly ○ Dryness Hypothyroidism, hypoparathyroidism ○ Sweating Hyperthyroidism, phaeo, acromegaly ● Nervous system ○ Irritability, restlessness Thyrotoxicosis ○ Headaches Hypoglycaemia ○ Seizures Hypoglycaemia ○ Visual loss Acromegaly, DM ● Cardiovascular ○ Postural hypotension Addison’s ● ENT ○ Hoarseness Malignant thyroid CA ○ Neck lump Thyroid ○ General thyroid screening ● Relevant parts of general HX ○ FH ○ SH ○ DH, esp. steroids
  43. 43. “Lumps and Bumps” History ● Properties of lump ○ Site ○ Number ○ Shape ○ Colour ○ Swelling ○ (Further details during examination) ○ If lump in breast: does it vary with the cycle? ● Timing ○ Onset ○ Changes over time (<3w most likely to be due to infection) ○ Previous similar symptoms ● Associated symptoms ○ Pain ○ Itching ○ Bleeding ● Skin type ● Menstrual Hx if breast lump ○ Menarche, menopause ○ Cycle and regularity ○ Parity ○ Age at birth of children ○ OCP, HRT ● Relevant parts of normal Hx ○ FH => congenital syndromes, cancer, especially if breast lump (1st degree relative with breast cancer with CA < 40 or bilateral breast CA => doubles risk) ○ Systems review => general ○ Travel history
  44. 44. “Lumps and Bumps” DD ● This DD should be a combination of DD of neck, skin and groin lumps. ● CONSIDER NO MATTER WHERE THE LUMP IS ○ Superficial lumps ○ Sebaceous cyst Central punctum, round, soft, fluctuant ○ Lipoma Soft, mobile, painless, smooth, demarcated in layer where you would expect fat, may be fixed to muscle, especially over scapula, may be fluctuant if fat liquid in warm skin, Dercum’s if many ○ Abscess Pain, swelling, erythema ○ Dermoid cyst At sites of embryological fusion, e.g.near eyebrow of child, under tongue, at midline. ○ Lymph node Firm, mobile, can be tender ● CONSIDER IF PIGMENTED SKIN LESION ○ See skin examination appendix! ● CONSIDER IN GROIN AND ABDOMEN ○ Incisional hernia Below scar of abdominal incision ○ Paraumbilical hernia Adjacent to umbilicus ○ Congenital umbilical hernia In infant ○ Spigelian hernia At semilunar line below arcuate line ○ Inguinal hernia Superomedial to pubic tubercle ○ Femoral hernia Inferolateral to pubic tubercle ● CONSIDER IN NECK, distinguish based on triangles of the neck ○ Thyroid Moves on swallowing ○ Thyroglossal cyst Moves on swallowing, MIDLINE! ○ Salivary gland Submandibular, does not move on sw. ○ Branchial cyst(s)* Ant. to upper sternocleidomastoid ○ Carotid aneurysm In sup. or inferior carotid triangles ○ Cystic hygroma Base of post. triangle on L, transilluminates Examine mouth, larynx and trachea and hypopharynx as can obstruct! ○ Laryngocele Made worse by blowing ○ Pharyngeal pouch Post. triangle ○ Cervical rib Post. triangle ○ Subclavian artery aneurysm Supraclavicular triangle ○ Sternocleidomastoid tumour In infant after birth injury ○ Parotid tumour ○ Parotiditis ○ Salivary calculi causing swelling in gland ○ Salivary gland neoplasms: pleomorphic/mixed salivary adenoma, adenolymphoma/Warthin’s tumour, adenoid cystic carcinoma = malignant +/- VII palsy ○ VERY rare in neck: parathyroid lump
  45. 45. Eye History ● PC ○ Reason for consultation: ■ Main presenting symptom ● If pain distinguish from irritation ● If pain also includes eye movements? => neuritis ■ Reason for referral, e.g. abnormal finding on eye test ○ Which side or bilateral? ○ Timeframe ■ Acute/sudden loss of vision ■ Chronic loss of vision ○ Important questions regarding sudden loss of vision HELLP ■ Headache associated? +>50 => Temporal arteritis! ■ Eye movements hurt? => Optic neuritis ■ Lights or flashes preceded loss? => Detached retina ■ Like a curtain descending? => Amaurosis fugax ■ Poorly controlled DM? ● HPC ○ Timeframe, acute or chronic ○ Precipitating, exacerbating, alleviating factors ○ Associated symptoms: ■ Headache ■ Jaw claudication ■ Temporal tenderness ● Past ocular history ● Particularly important ○ FH: squints, glasses, glaucoma, childhood cataract, ocular tumours or any other “eye disease” ● Associated conditions in PHM ○ Diabetes ○ Hypertension ○ Arrhythmias ○ Asthma ○ COAD (airway disease) ○ MS ○ Sarcoid ○ Collagen disorders ○ IBD ○ Nasal disease ■ Sinusitis ■ Hay fever
  46. 46. ENT History ● Ear - cardinal symptoms ○ Otalgia ■ Referred from teeth or throat or not referred ○ Otorrhoea ■ Watery (=> external as no mucinous glands) ■ Mucous (=> middle) ■ Seroganuinous (=> middle) ■ Offensive ■ Suppurative ■ CSF ○ Hearing loss ■ Acquired vs. congenital (syndromic vs. non-syndromic) ○ Tinnitus ■ Character ● Constant vs pulsatile ● Tonal vs popping/clicking vs. gushing ● Bilateral vs unilateral (for MRI ?vestibular schwannoma?) ■ Alleviating/exacerbating factors ■ Impact on life ○ Vertigo ■ Duration (s-benign, h-migraine, d-central) ■ Associated symptoms ● Panic ● Loss of memory ● Feeling unreal ● Nausea ● Hearing loss, tinnitus ● Nystagmus ● Nose - cardinal symptoms ○ Rhinorrhoea ■ Pain ■ Discharge ■ Anosmia ■ Systemic symptoms, e.g. fever ○ Nasal obstruction ■ Unilateral vs. bilateral ■ Intermittent vs. persistent ■ Affecting speech, eating, smell, sleep ○ Epistaxis ■ Drugs affecting clotting ○ History of trauma ● Throat - cardinal symptoms ○ Hoarseness ○ Dysphagia ○ Neck lumps
  47. 47. Dermatology History ● PC ● HPC ○ Timing ○ Pattern of recurrence, recent change, e.g. in mole ○ Course ○ Symptoms: ■ Itching ● Severe at night interfering with sleep Scabies Dermatitis herpetif. ■ Pain ○ Areas affected ○ Alleviating/Exacerbating factors ○ If presuming infection ■ Contact with patient with skin infection ■ Insect bites ■ Recent skin injury ■ Recent live immunisation ■ Immunocompromise ● PMH ○ Previous skin disease ■ Infantile eczema ■ Also + asthma or hay fever => atopic eczema ○ Common skin diseases ■ Eczema ■ Psoriasis ■ Acne ○ Common systemic diseases with skin manifestations ■ Diabetes ■ TB ■ Immunosuppression ■ HIV ○ Treatments so far and if they worked ○ Any immunosuppression as predisposes to skin cancer
  48. 48. Dermatology History ● Relating to the sun ○ History of high sun exposure or sunbed use? ○ Skin response to sun: ■ How fast does rash occur? ● Sun urticaria: within 5min and lasting 1h ● Polymorphic light eruption (rxn to UV light): very itchy and within several hours and lasting days ● Porphyria*: within minutes and lasting several days, blisters and erosions ● Also possible DD: SLE and drug-induced photosensitivity ○ How well does patient tan ● Allergies ○ Contact allergies (e.g. nickel, perfume) ○ Systemic allergies to drugs ● Drug Hx ○ Topical and systemic drugs ○ For topical drugs ask if ointment or cream ○ Consider possibility of drug-induced rash! (If taken <2m) ○ Current and in the past ○ Treatments so far and if they worked ● Travel Hx ● Sexual Hx ● Social Hx ○ Impact of any activities on the skin ■ Work ■ Hobbies ■ Are gloves worn? ■ Does condition improve or worsen at week-ends or holidays? ○ Alcohol intake (worsens psoriasis) ○ Smoking ● Family Hx ○ Are skin conditions present and are they the same as the patient’s? ○ Atopy: eczema, asthma, hay fever ○ Psoriasis ○ Genetic disease ○ Skin cancer
  49. 49. Appendix: DD of Skin Lesion ● Pigmented lesions ○ Benign naevus ○ Malignant melanoma ○ Basal cell carcinoma ○ Squamous cell carcinoma ○ Bowen’s disease (SCC in situ) ○ Kaposi sarcoma ● Benign skin lumps ○ Keloid scars ○ Lipoma ○ Neurofibroma ○ Sebaceous cyst ○ Carbuncle ○ Hydratenitis suppurativa ○ Papillomas ○ Vascular malformations ■ Cherry angiomas ■ Port wine stains ■ Strawberry naevi ■ Cavernous haemangiomas ■ Venous lakes ■ Glomus tumours ■ Pyogenic granulomas ● Always consider in skin lumps ○ Superficial lumps ■ Sebaceous cyst Central punctum, round, soft, fluctuant ■ Lipoma Soft, mobile, painless, smooth, demarcated in layer where you would expect fat, may be fixed to muscle, especially over scapula, may be fluctuant if fat liquid in warm skin, Dercum’s if many ■ Abscess Pain, swelling, erythema ■ Dermoid cyst At sites of embryological fusion, e.g.near eyebrow of child, under tongue, at midline. ○ Lymph node Firm, mobile, can be tender
  50. 50. Paediatric History ● Always ask for the child’s age ● PC ● HPC ● PMH including ○ Past illnesses, admissions, operations, accidents, injuries ○ Maternal obstetric history ○ Birthweight and gestation ○ Perinatal problems ● General inquiry ○ General health ○ Normal growth ○ Pubertal development ○ Feeding/drinking/appetite ○ Any recent change in behaviour or personality ● Developmental Hx ● Family Hx ○ Possibly family tree ○ Cosanguinity? ● Immunisations ● Drugs ● Allergies ● Systems enquiry ○ Rashes ○ Fever ○ Respiratory: Cough wheeze, breathing problems ○ ENT: Throat infections, snoring, stridor ○ CV: Murmur, cyanosis, exercise tolerance ○ GI: Vomiting, diarrhoea/constipation, abdo p ○ GU: Dysuria, frequency, wetting, toilet training ○ Neuro: Seizures, headaches, abnormal movements ○ Musculoskeletal: Gait, limp, pain or swelling, functional abnormalities
  51. 51. Developmental Assessment ● Consider groups of development separately: ○ Gross motor ○ Fine motor (basically HANDS!) and vision ○ Speech, language and hearing ○ Social, emotional and behavioural ● Assess different milestones, median and limit age by observing and asking the parents ● Think about the sequence, what comes before what to anticipate next steps ● Assess stage for each field ● Compare the stages in each group and relate to age ● If all fields affected: global developmental delay, otherwise specific developmental delay ● Knowing when times of greatest acceleration take place (see blue times on next page) helps which group of skills to start with depending on the age ○ >18m focus on gross motor, fine motor, hearing, vision ○ 18m-2.5y focus on acquisition of speech, language and fine motor skills, gross less important ○ 2.5-3.5y speech, language and social, emotional, behavioural ● Equipment needed ○ Cubes ○ Ball ○ Picture book ○ Doll ○ Miniature toys (e.g. tea set) ○ Crayons ○ Paper ● Problems ○ Subjective ○ Child may not want to cooperate ○ Early motor development is a poor predictor of cognitive development, speech is better but takes longer to assess ● Clinical signs that may aid diagnosis ○ Growth charts ○ Dysmorphic features ○ CNS, CV, sensory examination ○ General mobility, behaviour, dexterity, communication, cognition ● Some standardised screening tests ○ Schedule of growing skills ○ Denver developmental screening tests ○ Griffiths and bailey infant development scales ○ Reynell language scale ○ Gross motor function measure ○ Autism diagnostic interview ○ IQ tests
  52. 52. Developmental Milestones Gross motor development milestones (median ages, limit age) most change 0-1y ● -newborn: limbs flexed symmetrically ● newborn: head lag on pulling up limit age for head control 4m ● 6-8w: raises head to 45* when prone ● 6-8m: sits without support (6 = round, 8= straight back) 9 months ● 8-9m: crawls ● 10m: walks around furniture stands 12m ● 12m: walks unsteadily with broad gait and hands apart 18m ● 15m: walks along steadily Vision and fine motor milestones (median ages) most change 0.5-1.5y ● 6w: follows face/object in midline and follows it 3m ● 4m: reaches for to 6m ● 6m: palmar grasp ● 7m: transfers toy from one hand to the other 8m ● 10m: pincer grip 12m ● 16-18m: makes marks with crayon ● 14m-4y: towers ○ 18m: 3 ○ 2y: 6 ○ 2.5y: 8 or train ○ 3y: bridge ○ 4y: steps ● 2-5y: drawing: ○ 2y: line ○ 3y: circle ○ 4y: cross ○ 4.5y: square ○ 5y: triangle ○ can copy 6 months earlier though, so draw without demonstration, need to point to the desired result Hearing, speech and language most change most change 1.5-2.5y ● newborn: startles to noise ● 3-4m: vocalises ● 7m: turns head to sounds ● 7m: uses sounds indiscriminately ● 10m: uses sounds discriminately ● 12m: 2-3 words other than dada or mama ● 18m: 6-10words, shows parts of the body ● 20-24m: >2 words in a phrase ● 2.5-3y: talks constantly in 3-4 word sentences Social, emotional and behavioural most change 2-4y ● 6w: smiles responsively 8w ● 6-8m: puts food in mouth ● 10-12m: waves bye bye, plays peek-a-boo 10m fear of strangers ● 12m: drinks from a cup with two hands ● 18m: holds spoon and gets food into mouth ● 18-24m: symbolic play (feed teddy etc) ● 2y: dry by day, can pull off clothing ● 3y: parallel interactive play with other children
  53. 53. ?Malignancy History
  54. 54. Communication Skills

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