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Flashcards in Histories Deck (68):
1

Chest pain

SOB (orthopnoea, PND, excercise tolerance)
Nausea, vomiting, sweating
Palpitations (regular, irregular)
Syncope (LOC, dizziness, light headed)
Ankle swelling (unilateral/bilateral)
Calf swelling (pain, redness)
Haemoptysis (PE, pneumonia, mitral stenosis, lung cancer, TB)

Modifiable risk factors: smoking, alcohol, hypercholesterolemia, obesity (central), hypertension, diabetes mellitus, sedentary lifestyle, poor compliance with medication, stress.

Non-modifiable risk factors: age, male, family history, previous CVD.

2

Productive cough

Chest pain (unilateral, worse on deep inspiration)
SOB (acute/intermediate/chronic onset)
Previous breathing problems
PND/orthopnoea
Stridor (inspiratory, upper airway obstruction by foreign body or tumour)
Wheeze (expiratory, obstruction of small airways, cardiac wheeze in pulmonary oedema, ?when: night, cold, exercise, monophonic/polyphonic)
Cough
Sputum
Haemoptysis

Ask about previous respiratory investigations (lung function test, CT scan, allergen testing)

3

Abdominal pain

SOCRATES
Nausea, vomiting (haematemisis, relationship with food)
Abdominal distension (bowel obstruction, ascites)
Anorexia, weight loss
Dysphagia (solids or liquids?)
Dyspepsia (OTC antacids?)
Diarrhoea (increased frequency? loose consistency?)
Constipation (last bowel movement, flatus)
Blood or mucus PR (mixed with stool, coating stool, on toilet paper, fresh blood, melena)

Urological: frequency, dysuria, haematuria, hesitency, terminal dribbling

Gynaecological: discharge, bleeding, dyspareunia, LMP

Smoking (GI malignancy, Crohn's, protective in UC), alcohol (pancreatitis), recent travel (enterotoxogenic E.coli)

4

DDx for umbilical pain

Early appendicitis
Intestinal obstruction
Acute gastritis
Peptic ulcer disease
Acute pancreatitis
Ruptured abdominal aortic anneurysm
Gastroenteritis
IBS
IBD
Constipation
Perforated viscus

5

DDx for RIF pain

GI: appendicitis, diverticulitis, IBD, intestinal obstruction, Meckel's diverticulitis, perforated viscera, obstructed/incarcerated inguinal or femoral hernia.

Gynaecological: ruptured ovarian cyst, torsion of ovarian cyst, PID, ectopic pregnancy

Urinary: UTI, renal calculi

Other: testicular torsion, musculoskeletal

6

Diarrhoea

Stool description (volume, consistency, colour, blood, mucus, tarry, floating)
Timing (frequency, nocturnal, duration)
Previous bowel habit
Tenasmus

Medications: ABX (C. difficile), laxatives, cytotoxics, PPIs, NSAIDs
Recent travel: food, activities, vaccinations
Contact: animals, individuals suffering with diarrhoea
Diet: meat, eggs, seafood, dairy, wheat, unusual
PMH: diabetes, IBD, abdo surgery, HIV, organ transplant, malignancy, chemo, radiotherapy, constipation
Occupation: vetinary surgeon, NHS staff symptom-free for 48h before return to work
Family Hx: IBD, coeliac's disease

7

Causes of diarrhoea without blood

Enterotoxigenic E.coli (traveller's diarrhoea)
Malaria (P. falciparium)
Giardiasis
Enterotoxin producing strains of Staph aureus
Cholera

8

Causes of diarrhoea with blood

Enterohaemorrhagic E.coli
Shingella, salmonella, campylobacter
Clostridium difficile
Schistosomiasis

9

Extra intestinal manifestations of IBD

Eye: uveitis, iritis, episcleritis

Musculoskeletal: seronegative arthritis*, osteoporosis

Dermatological: erethema nodosum, pyoderma gangrenosum. aphthous mouth ulcers

Other: AI haemolytic anaemia, finger clubbing, growth failure, primary sclerosing cholangitis~, interstitial lung disease (rare)

*More common with Crohn's
~More common with UC

10

Headache

1. New acute onset? Headache part of chronic/recurrent headache history?
2. Exclusion of intracranial haemorrhage (SAH), intracranial infection (meningitis, encephalitis)

SOCRATES
Neurological (LOC, motor/sensory deficit, gait, disturbances in vision, speech, hearing, incontinence)
Meningism (neck stiffness, photophobia, headache)
Infection: Fever, diarrhoea, malaise
Rashes
Scalp tenderness when brushing hair/pain on chewing gum (temporal arteritis)
Nausea and vomiting
Visual disturbance/ aura
Watering of eyes/nasal congestion (cluster headaches)
Wears glasses?

PMH: kidney disease (damage kidney->hypertension->PKD->berry anneurysm-> SAH), TIA/stroke, migrain/tension headache

11

Subdural haemorrhage features

Recent head injury
Gradual onset headache, constant/fluctuating
Fluctuating levels of conciousness: loss at time of injury, lucid interval, deterioration as haematoma forms

More common in ELDERLY and ALCOHOLICS

12

Extradural haemorrhage features

Recent head injury
Gradual onset headache, constant/fluctuating
Fluctuating levels of conciousness: loss at time of injury, lucid interval, deterioration as haematoma forms

More common in YOUNG (dura mater less fixed to skull) and ALCOHOLICS

13

Intracranial haemorrhage features

Sudden onset, severe headache
Symptoms of raised ICP (waking up with headache, vomiting without nausea)
Focal neurology (corresponds to area of brain damaged)

14

Subarachnoid haemorrhage features

Sudden onset, severe headache
Meningism (neck stiffness, photophobia, headache)
Drowsiness/ LOC
Focal neurology

15

Meningitis/encephalitis features

Fever
Rash (non-blanching, meningococcal septicaemia)
Meningism (neck stiffness, photophobia, headache)
Infective symptoms: flu-like, sweating, malaise, joint pain, diarrhoea
Nausea and vomiting
Drowsiness/ LOC

NOTIFY PUBLIC HEALTH AUTHORITIES OF MENINGOCOCCAL INFECTION (immunisation and prophylaxis for contacts, rifampicin for 'kissing' contacts)

16

Space occupying lesion features

Absence of other clear diagnosis for headache
Old age at onset
Focal neurological symptoms and signs
Headache on walking (more commonly caused by migraine)
Vomiting without nausea

17

Temporal arteritis features

Usually in patients >60years
Frontal or occipital
Jaw pain (whilst eating or talking)
Scalp tenderness
Visual disturbances
Malaise and proximal muscle weakness

18

Cluster headache features

Localised around one eye, associated with anatomical features such as lacrimation and nasal congestion
Occurs for 15 mins- 2 hours for 6-8 weeks, then subsiding for months

19

Cervical spondylosis features

Headache associated with neck pain
Worsens with neck movements

20

Migraine features

Chronic or recurrent headache
May have a prodrome or aura (only ~10% of those with migraines will have neurological aura)
Non- specific triggers (cheese, chocolate, stress)
Related to OCP
Photophobia or other visual disturbances such as zigzag lines
Nausea and vomiting
Family Hx

21

Tension headache features

Band-like dull ache, sometimes with sharp exacerbations
In scalp rather than cranium
Can last throughout the day, worsening in evening
May get tired or dizzy

22

Intermittent claudication

SOCRATES
Sudden pain: embolic>thrombotic
Radiation: dermal distribution consider nerve compression
Worse when bending/twisting: musculoskeletal pain/ spinal stenosis
Worse at night: in PVD patients hang leg off side of bed to reduce pain, improves circulation with assistance from gravity
Foot ulcers
Feet feel numb or cold? (warm if collateral vessels have developed)
Impotence (phrase sensitively)
Muscle weakness
Angina
Palpitations in context of AF
Malignancy (increased risk of thrombotic disease)
CVS risk factors

23

Buttock/thigh pain indicates?

Arterio-iliac disease

24

Calf pain indicates?

Femero-popliteal disease

25

Acute embolism symptoms

Sudden onset
AF/mural thrombus/post MI
No other symptoms of intermittent claudication
Cold leg (no time for collateral supply formation)
Normal vasc exam in other leg

26

Ix for intermittent claudication

Doppler, MRA, CTA
Urinalysis, BP, ECG
Bloods : FBC, U&E, lipid profile, fasting glucose
Exercise testing
Electrocardiography

27

Management for intermittent claudication

Risk factor management (stop smoking, weight loss, diet changes)
Exercise (develop collateral circulation)
Careful not to injure leg
Aspirin, statins, ACEi
Treat risk factors: hypertension, diabetes

28

Breast history

Breast lump:
-Site, size, consistency, painful
-Onset
-Preceding trauma
-Breast/nipple changes
-Nipple discharge (bloody?)
-Changes throughout menstrual cycle
-Similar lump in past?
-Parity, LMP
-Breastfeeding (protective)? Duration?
-SOB
-Skin changes elsewhere
-Weight loss
-Swelling (especially arm on affected side)
-Malaise
-Backache

Ask about OCP, HRT

Risk factors: previous breast cancer, smoking, early menarche, late menopause, nulliparity, family Hx of breast or ovarian cancer (age, 1st degree)

29

Breast cancer management

Medical:
-CMF chemo (cyclophosphamide, methotrexate, 5-flurouracil)
-Hereceptin
-Tamoxifen
-Aromatase inhibitor (letrozole, anastrozole, exemestane)

Surgical:
-Wide local excision of lump (sentinel lymph node biopsy)
-Simple mastectomy

Axilliary node clearance additionally done:
-USS/FNAC/core needle biopsy positive for metastasis
- Sentinel node biopsy positive for mets
(morbodities: lymphoedema, bruising, shoulder stiffness, reduced movement)

Cosmetic:
nipple tattoo, abdominal sheath flap, latissimus dorsi flap.

30

DDx for breast lump

Fibroadenoma (20-35 yrs)
Fibrocystic change (20-40 yrs)
Abscess (20-30 yrs, child bearing age)
Cyst (40-50 yrs, perimenopausal)
Malignancy (40-70)

31

Back pain

SOCRATES
Bone pain?
Constant or progressive?
Nocturnal pain?
Does pain radiate to foot? (Sciatic pain)
Problems walking?
Cancer Hx (ask about type and Tx)
Incontinence (fecal/urinary)
Difficulty passing urine
Bowel/bladder symptoms
Numbness, tingling, leg weakness (peri-anal numbness =saddle anaesthesia
Fever, unexplained weight loss, night sweats
Morning stiffness
Leg claudication

32

Back pain causes in 15-30 years

Trauma, fracture, prolapsed disc, ankylosing spondylitis

33

Back pain causes in 30-50 years

Degenerative disease, prolapse disc, malignancy (mets e.g. breast, lung, prostate, kidney, thyroid cancer)

34

Back pain causes in 50 years+

Degenerative disease, osteoporosis (wedge fracture), malignancy, myeloma

35

Mechanical back pain:

1. Low back pain arising from an anatomical structure e.g. muscle, ligament or intervertebral disc due to trauma, deformity, degenerative change

2. Osteoporotic fracture

Clinical presentation:
Sudden onset
Eased by rest
Unilateral
Increased by coughing/sneezing
Heavy lifting...

Muscular pain, not central (paraspinal muscles)

36

Inflammatory back pain:

1. Inflammatory spondylitis

2. Epidural abscess

3. Malignancy

4. Paget's disease

Clinical presentation:
Predominant stiffness (>30mins in the morning)
Gradual onset and progressive
Increased pain with rest
Disturbs sleep
Stiff/rigid spine on examination, symmetrical restriction +/- joint tenderness

37

Cauda equina syndrome

Compression of the cauda equina e.g. posterior disc herniation, metastatic deposits

Urinary and fecal incontinence
Urinary retention
Persistant, progressive
Bilateral leg pain
Normal leg pulses
Pain eased by leaning forward
Stiff spine on examination
Bladder/bowel disfunction

URGENT ASSESSMENT AND MANAGEMENT: MRI and consideration for surgery, radiotherapy

38

Sciatica

Compression of a lumbosacral nerve root by a protruding disc

Pain radiates from buttock down back of leg and into foot
often accompanied by paraesthesia with same distribution

Conservative management (analgaesia + physio). ?Surgery

39

Discitis

Fever, systemic upset
Risk factors: injecting drug user

40

Joint pain/stiffness/swelling

SOCRATES
Morning stiffness (30mins=inflammation, 5 mins=OA)
Better or worse after exercise?
Sleep disturbance
Loss of function

41

Rheumatoid arthritis

Slowly progressive
Symmetrical polyarthritis
Small joints (commonly hand)
Deforming
Early morning stiffness

42

Gout

First MTP joint most commonly affected
Isolated swollen, hot painful joint
Hyperuricaemia risk factors e.g. diuretics, excess alcohol (esp. beer), renal disease

43

Psoriatic arthritis

Associated skin plaques, nail changes
Early morning stiffness
Many patterns of joint involvement

44

SLE

Systemic illness, intermittent fevers
Photosensitive rash
Generalised myalgia and arthralgia
Other systemic (psychological disturbance, pleuricy, ulcers)

45

Enteropathic arthritis

Symmetrical arthritis of lower limb joints and sacroiliac joints
Early morning stiffness
Symptoms/diagnosis of Crohn's or UC

46

Osteoarthritis

Elderly
Worse on movement (rest helps) and at end of day

47

Septic arthritis

Isolated, hot, red swollen joint
Agonisingly painful
Systemically unwell with fever

48

Drug Hx

Current and recently prescribed drugs (GP, specialists, privately)
-Ask specifically about: contraceptives, ear/eye drops, inhalers, creams/ointments, injections, patches, vitamins, food, dietary supplements.
-Smoking and alcohol
-Ask about name, strength, formulation, frequency, dose, duration
-Indications (incl. patient's perception)

Current and recent non-prescribed drugs (OTCs, complementary and herbal/homeopathic remedies, borderline substances, recreational drugs incl. illicit substances)

Any drug related problems (ADRs)

Allergies (non drug=eggs, nuts, drug allergies) and hypersensitivities (signs, symptoms, severity and duration)

Response to treatment

Treatment failure

Adherence to treatment regimens.

49

Alcohol Hx

CAGE questionnaire (>2, alcohol abuse/dependence)

How much in a week?
How often?
Binge or steady?
What time?
What makes you start drinking? (e.g. stress, alcohol availability)
Where? (alone, with company)
What do you drink (beer, wine, spirits)
How much on a typical day?

Past alcohol Hx:
When did you start?
Longest period without drinking?
Family Hx of alcoholism?

Health problems associated with alcohol?
Anaemia
Cirrhosis, pancreatitis
GORD, peptic ulcer disease
Epilepsy, ataxia, peripheral neuropathy, amnesia
Depression (assess mood), hallucinations, Wernicke's encephalopathy, Korsakoffe's syndrome (assess cognition)
IHD, cardiomyopathy, hypertension

Screen for alcohol dependence syndrome

Social complications:
Absenteeism, loss of job, divorce, driving convictions, decreased job productivity, relationships trouble, police encounter

Prev. Tx:
Detox programmes, AA

Maintaining factors:
Access to alcohol? Social isolation? Avoidance of withdrawal symptoms

Assess motivation to change...

50

Alcohol dependence syndrome features

ICD-10, 3 of 6 criteria below (over 12 months):
-Strong desire, sense of compulsion to take substance

-Difficulties controlling intake of the substance (either its onset, termination or levels of use)

-Physiological withdrawal state or use of the same/similar substance to prevent such a withdrawal state- What happens when you stop drinking?

-Tolerance- Are you finding yourself drinking more to get drunk?

-Lack of other activities and interests

-Ongoing substance misuse despite clear evidence of harmful consequences.

51

Urological Hx

Dysuria
Polyuria (fluid intake)
Frequency, volume
Urgency
Nocturia
Haematuria (how much? tiredness, breathlessness on exertion)
Hesitency/terminal dribbling
Poor urinary stream
Urinary incontinence
Fevers, rigors
Nausea, vomiting
?Catheter

52

Cystitis

Dysuria, burning pain on urination
Frequency and urgency

53

Urethritis

Dysuria
Purulent urethral discharge

54

Pyelonephritis

Dysuria
Loin pain
Fever/chills/rigors
Vomiting

55

Benign prostatic hyperplasia

Poor flow, terminal dribbling
Hesitancy
Overflow incontinence
Elderly male

56

Bladder transitional cell carcinoma

Painless haematuria
History of aromatic amine exposure e.g. dye washers, painters, decorators

57

Urethral trauma (e.g. catheter)

History of catheter use or trauma

58

UTI

Frequency/urgency/dysuria

59

Calculi

Loin to groin pain

60

Diabetes mellitus

Polydipsia/thirst
Polyuria
Weight loss
Tiredness
Visual disturbance

61

Diabetes insipidus

Polydipsia/thirst
Polyuria

62

Chronic kidney disease

Non-specific symptoms e.g. fatigue, weakness, puritis, dyspnoea

63

Stress incontinence (incompetent sphincter)

Small losses with effort e.g. coughing, bending, exertion

Risk factors: multiple pregnancies, post-menopause

64

Urge incontinence (Detrusor instability in idiopathic cystitis or stone. Hhyperreflexia such as in MS, CVA, spinal cord injury)

Urge to pass urine followed by uncontrollable bladder emptying

65

Overflow incontinence (prostatic hypertrophy, stricture or stone)

Dribbling and poor stream
Hesitency
Elderly male or history of obstruction

66

Fistula between bladder and vagina or urethra

Continuous urine leak

67

Urethral stricture

Retention
History of trauma or recurrent catheter use

68

Bladder neck obstruction (e.g. tumour, calculus)

Retention
Haematuria