History TakingChapter 1

Curriculum code: CC1, CC5, CC6, CC11, CC12

History taking and communication stations are easy to fail if not prepared in advance. In the exam, it is essential to show that you can take an adequate and focused history in the short time available and make a shared management plan with your patient. Since time is of the essence, it is important to have a structure otherwise omissions can be made.

3Your vision has been fine all along, you don't feel sick or dizzy and your arms and legs feel completely normal.’ Use silence and body language appropriately to demonstrate you are listening and encourage the patient's responses. Actively establish the patient's ideas about the condition. What is it that they are concerned about and what do they expect out of the consultation?

While explaining and planning:

Many presentations involve the complaint of pain as either the primary problem or a related one. A detailed history of the characteristics of the pain is fundamental to help identify the likely cause, the severity of the problem and the impact on the patient. In addition to a standard history focused (SOCRATES) questions should include:

Curriculum code: CC1, CC6, CC12, CAP13, HAP13

Effective history taking requires the clinician not only to collect facts quickly, but also to try to find out what the patient is really thinking. Without exploring what is actually on a patient's mind, it is only possible to form a partial idea of how a problem affects an individual and it is certainly difficult to understand their point of view. There are many scenarios where patients may be embarrassed or feel inhibited about aspects of their problem and if a candidate fails to elicit these issues valuable marks will be lost.

With this in mind during every scenario the candidate must consider whether or not they have elicited the patient's ideas, concerns and expectations. Simple phrases may help get a much deeper understanding of what other factors are influencing the consultation:

It is by addressing this aspect of the consultation that a clinician will gain the information to make the exchange more effective for both parties. For example realising:

This is equally important in helping understand a patient's perspective on their situation. Areas to consider may include:

All these factors play a significant part in placing the patient's problem in the context of their life and appreciating its impact upon them. Without addressing these points an assessment is incomplete and the final management plan may not be right for the patient in question. How much social history is required will depend on the individual patient – different questions will need to be asked of a young man who has had his first seizure (work, home life, hobbies, transport links) than will need to be asked of an older woman with new jaundice (tattoos, sexual contacts, injecting drug use, recent travel) for example. The art of 6emergency medicine requires careful consideration regarding what to ask to whom – in the exam the global score will certainly reflect the degree of a candidate's success in this area.

Mr Parsons is a 76-year-old retired bus driver. He fell over at home and called an ambulance. His only injury is to his left wrist. His wrist X-ray does not demonstrate a fracture. Take a history from him and then explain your management plan to him.

You are a 76-year-old retired bus driver. After watching television you got up to go to the kitchen and forgot to use your walking stick. You lost your balance and fell over, landing on your left side. You could not get up, but were able to crawl to the phone and call an ambulance. You are left handed and have a lot of pain and bruising in your wrist. You have no other injuries.

Curriculum code: CC1, CC12, CAP1, PAP1, HAP1

Abdominal pain has a wide differential diagnosis. The College curriculum states that the trainees should know common and serious causes and be able to differentiate between surgical, medical, gynaecological and urological causes of this presentation. In addition candidates should appreciate that chest conditions like an inferior myocardial infarction or lower lobe pneumonia can also present with abdominal pain.

Sudden onset pain is often serious. Perforation of gut or an aortic aneurysm leak can present suddenly, as can stone disease. Patients will remember what they were doing at that time and are able to give a specific time of onset. Remember though that the sudden severe pain may come with a history of a lesser background pain for a longer period of time.

One of the first steps is to differentiate whether the pain is coming from intra-abdominal organs or if there is any peritoneal irritation. Visceral pain is dull and poorly localised to the upper, mid or lower abdomen depending on whether the foregut, midgut or hindgut structures are involved.

Referred pain is localised to an area distant from its origin. Perhaps the best example is shoulder tip pain in patients with a ruptured ectopic pregnancy or a ruptured spleen. The physiological explanation for this pain is irritation of the diaphragm from intraperitoneal blood. The nerve supply of the diaphragm is from C3,4,5 (remember ‘C3,4,5 keeps you alive’) and somatic afferent nerve fibres from the shoulder also enter at the same level, hence the pain is referred to the shoulder.

Distension of hollow organs (because of obstruction or pseudo-obstruction) produces colicky pain, e.g. biliary, ureteric or intestinal. The pain comes in waves, settling down in between. Beware of colicky pain in women of child-bearing age (ectopic pregnancy).

Syncope with abdominal pain is an indication of serious pathology. Ruptured ectopic pregnancy or aortic aneurysm should be excluded. Vomiting is often associated with abdominal pain and if pain started first then it is said that a surgical cause is more likely. Dysuria or other urinary symptoms suggest a renal tract cause. Abnormal vaginal discharge with lower abdominal pain raises the suspicion of pelvic inflammatory disease.

Claire Parker is a 38-year-old woman with abdominal pain for the last 2 days. She has been taking painkillers with no effect.

You are a 38-year-old female and have had abdominal pain for last 2 days. You noticed it first on your way to work (office secretary), but ignored it. It feels like ‘belly ache’ around the belly button and lower abdomen and has got worse over the last 2 days. The pain does not move or radiate anywhere but is worse when you are passing urine.

Curriculum code: CC1, CC12, CAP2, HAP4

Rectal bleeding is a common ED presentation. When taking the history, you are aiming to establish the anatomical location and severity of bleeding along with risk factors for a further bleed. As always, the goal of history-taking is to be able to plan a focused examination and make a management plan appropriate to the severity of symptoms and the differential diagnosis.

Meckel's diverticulum and intussusception are causes of small bowel bleeding in children, which can cause rectal bleeding. Meckel's diverticulum causes dark red blood or occasionally melaena. Intussusception typically causes ‘redcurrant jelly’ stools.

The history should also cover some specific questions:

Enquire about any change in bowel habit. Establish what is normal for the patient and what has changed. Is it a change in consistency or frequency of bowel motion? Establish what constipation and diarrhoea mean for this patient and whether there are any alternating symptoms. Various medical causes of change in bowel habit such as hypothyroidism, hypercalcaemia, diabetic neuropathy, and chronic pancreatitis may be relevant and need to be screened for in the history.

Mrs Taylor is a 68-year-old lady who noticed blood in her stools this morning. She called her son and he brought her to the ED. Take a history and explain a management plan to her.

You are Mrs Taylor, a 68-year-old lady. You felt some abdominal pain this morning with an urge to go to the toilet. You initially thought you might have had an infection that is causing the bellyache. You passed a loose stool that was mainly bloody and dark red or brown in colour. It seemed like a large volume and filled the toilet bowl. When you got up you felt dizzy, light-headed, sweaty, and had to hold on to the door to avoid falling over. This has never happened before.

Curriculum code: CC1, CC12, PAP3

An apparent life-threatening event (ALTE) is a presentation in infants, which has a wide differential diagnosis. The aim of the history in this station is to establish the facts around the event, enquire about the child, assess the risk of death, check for potential non-accidental injury (NAI) and handle parental anxiety.

There is an increased risk following an ALTE if:

Exaggerated airway protection reflexes are often the physiological basis of these episodes. In some infants, the laryngeal chemoreceptors, on coming in contact with saliva or vomitus produce apnoea with cyanosis and change in muscle tone, rather than a simple cough. This sensitivity may also be increased by upper respiratory viral infections like respiratory syncytial virus.

An ambulance has brought in Mrs Davis and her son Chris who is 2 months old. While he was asleep his mother noticed that he seemed to have choked and then stopped breathing for some time. She called an ambulance straight away. Chris is well now and is playful and active. Please take a history from Mrs Davis and explain a management plan to her.

Your name is Julia Davis. You have come to the ED by ambulance because when putting your son Chris in his cot after feeding he coughed and seemed to go blue and stop breathing. Eventually he started breathing after you picked him up and patted his back but was floppy for several minutes. He started crying soon after and seems to have got better now. You called an ambulance immediately and are still worried about whether Chris is going to be alright or could the same thing happen again.

Curriculum code: CC1, CC12, CAP3, HAP2

Most patients presenting with back pain have mechanical lumbar back pain. But one must exclude other important diagnoses like an aortic dissection, abdominal aortic aneurysm, cauda equina syndrome, epidural abscess, osteomyelitis and cancer.

Mr Redfern is a 49-year-old presenting with back pain. He has been taking painkillers but today he is finding it difficult to walk.

You are Julius Redfern, a 49-year-old man. You are a forklift operator who returned from work 3 days ago and felt some back pain. You took some paracetamol and slept. Next morning the pain was worse and you now have sharp pain in your lower back. It seemed to spread to the left leg as far as your ankle, with pins and needles in your foot. You have rested for the last 2 days, taking analgesia, ‘co-something’, as advised by your general practitioner. You now find it difficult to walk, and today you were not able to stand up.

Curriculum code: CC1, CC12, CAP5, CAP32, HAP5

Syncope is defined as a transient loss of consciousness due to global cerebral hypoperfusion that is characterised by a rapid onset, short duration and quick recovery leaving no sequelae. Therefore, it is important to clearly establish whether there was any loss of consciousness or not. The key features of a syncopal episode to elicit for making a diagnosis are discussed in Tables 1.7.1, 1.7.2 and 1.7.3.

Mr Chaudhary, a 65-year-old man, presents with a fall whilst shopping. He is well and has not had any injuries. Take a detailed history regarding the fall and make a management plan.

You are 65-year-old Mahesh Chaudhary, who was brought to emergency department after falling in the street earlier in the day. You had a dental appointment this morning for a check-up. The next bus home was after an hour and you decided to take a walk around the town rather than stand at the bus stop. You sat down on a bench when you felt tired. On getting up, you felt light headed, had blurred vision and then blacked out. You tried to hold on to the bench but could not, and you cannot remember anything after that. When you regained consciousness, you were on the floor with a passer by helping you to sit up and asking you how you were. You felt a little confused but that improved soon after. You did not hurt yourself, were not incontinent and did not bite your tongue.

Curriculum code: CC1, CC12, CAP7, HAP8

A thorough history is essential to establish the probability of cardiac, pulmonary, vascular or other potentially serious causes of chest pain.

This is typically:

If the pain described has all the features as above, it is typical angina. If two features, it is atypical and if one or none of the above, it is classed as non-angina pain. Features that make angina unlikely are:

Pleuritic pain is typically sharp, localised, peripheral and worse with breathing. Rather than true breathlessness patients may describe shallow breathing because pain increases with deep inspiration.

The typical patient is a male in his 60s with a history of hypertension and sudden onset pain, maximal at the time of onset, described as sharp, tearing or stabbing in nature. As the dissection progresses the site of pain changes from retrosternal to interscapular or even back pain. Patients may present with syncope, myocardial infarction (occlusion of coronary arteries at the ostia), hemiplegia (dissection extending to the internal carotid artery) or paraplegia (spinal cord infarction due to anterior spinal artery occlusion). Be warned that not all cases are typical however and this diagnosis can easily be missed.26

This causes relatively sudden onset pain that is retrosternal, sharp and pleuritic in nature. It often occurs following forceful vomiting or an impacted food bolus. The patient is usually unwell and may have a history of swallowing problems or gastro-oesophageal reflux disease (GORD). Prolonged sharp pain which is worse with food and improving with antacids, associated with heartburn or dysphagia could be of oesophageal origin.

Risk factors for the various causes of chest pain should be assessed routinely as part of the history. If cardiac pain is part of the differential diagnosis, enquire about risk factors for ischaemic heart disease and if suspecting PE, enquire about risk factors for venous thromboembolism.

Mr Potts is a 43-year-old male who is presenting with chest pain. He was driving to work when he felt pain in his chest. He stopped the car and decided to come to hospital and is currently pain free. Take a history and make appropriate management plan.

You are a 43-year-old self-employed plumber named Marcus Potts. Driving to work this morning you developed chest pain. You left home as usual after eating cereals and toast, and were driving to work when you felt discomfort in the chest, like indigestion. You could also feel this around your neck and shoulders. It was quite severe and you felt short of breath with it. You stopped the car, came out and felt better after taking a few deep breaths and burping. You felt as if you were sweating at the same time. You have never had this pain before, but you do feel short of breath when you walk uphill or do any heavy work. You did not feel any palpitations or back pain and although you feel pain free now, the chest still fells a bit sore. You think the episode lasted some 30–40 minutes.

Curriculum code: CC1, CC12, C3AP4

Hypoglycaemia can be attributed to a variety of clinical presentations. The patient can present with altered mental status, confusion, delirium, suspected stroke, seizures, palpitations, anxiety, collapse or loss of consciousness. All these presentations have a wide differential diagnosis, but hypoglycaemia should always be suspected and checked with a simple bedside measure of capillary blood glucose and can be easily reversed if the blood sugar is found to be low.

Mrs Desai is 55 years old; she presents with confusion and sweating. She felt tired and weak so phoned her daughter who called an ambulance. The paramedics ascertained that her blood sugar was 2.3 mmol/L. She was given intravenous dextrose and her blood sugar now is 7.2 mmol/L. She is currently feeling much better. Take a history and explain a management plan to Mrs Desai.

You are a 55-year-old solicitor, who lives alone. You woke up at 7 am, but were not feeling well. You took your morning 12 units of fast-acting subcutaneous insulin as usual and 16 units of your once daily background insulin. You started feeling worse at about 8 am, and didn't think you could go to work. You called your daughter and on her arrival, you were profoundly sweaty and feeling unwell.

Curriculum code: CC1, CC6, CC12, CAP12, CAP13, HAP13

Being dizzy can have different meaning for different patients. The first thing to do is to clarify what it is that the patient is experiencing. They should be encouraged to describe what they feel with some input from the clinician.

This is the sensation of disorientation in space, with the hallucination of movement. This is often associated with nausea or vomiting. Once it is confirmed that the patient is describing vertigo, you should try to ascertain whether this is peripheral, e.g. due to a labyrinthine disorder, or central, e.g. due to a cerebellar stroke, transient ischaemic attack (TIA) or posterior fossa mass (Table 1.10.1).

There will not be a true sensation of vertigo, but patients may experience imbalance when standing or walking. This could be due to peripheral causes such as neuropathy or central causes like spinal cord compression.

Patients describe the sensation of feeling light-headed, as if going to faint. If this is related to postural change, or is happening each time the patient is getting up, they may be experiencing orthostatic hypotension. There are various other causes of syncope and they are discussed in detail in section 1.7, page 22.31

Anaemia, viral illness or even malignancy can make patients feel generally weak and lethargic and they may be using ‘dizziness’ to describe the feeling of malaise rather than true vertigo.

While dizziness could be a cause of falls, patients can fall for a variety of reasons. Elderly patients presenting with a fall require a detailed history of the circumstances around the fall. Remember it is unlikely that this was a simple slip or ‘mechanical fall’ – there is an underlying condition which led them to fall over. Always ask yourself ‘Why did they trip on that rug today when they cross it successfully every day?’

Even though the patient may present with an injury it is essential to elicit the circumstances around the fall.

Mr Stephens is an 83-year-old presenting after a fall. He is complaining of left hip pain and is feeling nauseated. Take a history and discuss investigations and a management plan with him.

Your name is Mark Stephens. You live in a ground floor flat, by yourself and are self-caring. Your daughter helps you with shopping once a week, and cleaning at home, but you manage to take a shower and go to the toilet yourself.

Curriculum code: CC1, CC12, CAP31, CAP36

Any difficulty in swallowing is termed dysphagia. Painful swallowing is termed odynophagia.

This can have a variable aetiology from simple viral pharyngitis to epiglottitis or a deep neck abscess (which is fortunately rare). Some degree of speech impairment is common with a sore throat, but presence of drooling, and muffled voice may indicate a serious infection. Enquire about systemic symptoms, fever, abdominal pain, chest pain and risk factors such as diabetes or immunosuppression.

Mr Robinson is an 87-year-old. He is finding it difficult to swallow and has developed an ache in the middle of his chest. Take a history and formulate a management plan.

You were eating a piece of steak when you felt you could not swallow it. Since then it feels like it is stuck in your chest. You have tight pain just in the front of your chest that increases with movement or inspiration. Since the event the pain has stayed the same. You have had an endoscopy here 10 or 15 years ago that showed ‘Barratt's something’ and you are taking antacid tablets. You have diabetes and hypertension and both are drug-controlled but you cannot remember the names. It seems as if something is stuck just near the bottom of your breastbone. On attempted swallowing at home, you were able to swallow some water, but it comes out within a few minutes. You think there may be something stuck in the food pipe.36

Curriculum code: CC1, CC12, CAP15, PAP10

This should be considered in conjunction with section 2.12 on febrile convulsions in the communication skills chapter. For a seizure to be classified as a febrile convulsion, it should:

The history is best taken from someone who witnessed the event.

Parents should be given the following information:

Zak is a 4-year-old boy who has been brought in by paramedics following a seizure at home. They checked his blood sugar on scene and it was 6.2 mmol/L. The seizure self-terminated. He is now settled and sleeping in the cot. Take a history from his mother, Mrs Russell, and make a management plan.

You are Mrs Russell, mother of a 4-year-old boy Zak. He has been unwell since yesterday and you did not send him to nursery today. He has had a fever overnight of 39°C. You gave him paracetamol last night and this morning, and he seemed a bit better with it. He has had a cough and runny nose. He is usually a good eater, but yesterday he ate much less. He continued to drink well so you weren't too worried. You tried to give him some breakfast this morning, but he wouldn't eat it.

Curriculum code: CC1, CC12, CAP11, CAP14

Presentations related to travellers such as diarrhoea or fever can arise in an OSCE. Traveller's diarrhoea (TD) is more common in people who travel from developed to developing countries upon their return. The history in this station should focus on the clinical presentation (fever or diarrhoea) as well as aspects related to travel which aim to elicit the patient's exposure to infectious diseases (Table 1.13.1).

Firstly, it is important to clarify the details of the clinical presentation. Is fever or diarrhoea the predominant symptom? Classical TD presents with ≥3 unformed stools in 24 hours with at least one of the following symptoms: fever, cramps, nausea, vomiting, tenesmus or bloody stools (dysentery). Mild TD does not have any systemic symptoms and patients are well.

Mr David Sutton is a 39-year-old man who returned from Thailand this morning. He has had diarrhoea for 2 days and is now getting abdominal pain. Take a history and make a management plan.

You are David Sutton, a 39-year-old plumber, returned this morning after a holiday in Thailand. You went with your friends and spent a week in Bangkok. This was your first trip there and you ate a lot of local food. You spent most of your time in the city and stayed in a luxury hotel. You started feeling unwell just before returning and have been going to the toilet every 2 or 3 hours. You are passing watery stools, have abdominal cramps and noticed blood this morning. You are also feeling hot and cold and don't feel like eating anything.

Curriculum code: CC1, CC12

History taking for haematuria is focused on finding the cause and assessing how sick the patient is.

Mr David is a 53-year-old man presenting with blood in the urine. Take a history and make a management plan with him.

You are a 53-year-old bus driver, who noted blood in the urine last night and this morning. You felt a bit uncomfortable when you went to pass urine but no pain or burning. All the urine was dark red in colour and there were no clots that you could see. You have had problems passing urine for a few months. You find it difficult to control your bladder on long routes and notice that the stream is getting weaker. You have to wake up in the night to go to the toilet a few times and feel that you haven't emptied your bladder completely. You have no pain, fever or weight loss. You have high blood pressure and take a water tablet for it. You have no history of kidney problems but your father had an operation for enlarged prostate.

Curriculum code: CC1, CAP16, HAP16

This is a common emergency presentation. The first thing to ensure (like in many stations, but more so in someone with upper gastrointestinal bleeding) is that the patient is well and not in need of any immediate resuscitation. Usually, patients with on-going bleeding or those who have lost a significant amount of blood are unwell and need initial resuscitation before an attempt to find the cause.

Upper GI bleeding can be divided in to variceal or non-variceal bleeding. In general, variceal bleeding is more concerning, because the volume is often larger and it can be difficult to control. Gastric or oesophageal varices are caused by portal hypertension usually because of underlying liver cirrhosis. This is often secondary to excess alcohol use, but can also be caused by other diseases such as hepatitis C infection and autoimmune cirrhosis.

Mr Powell is a 45-year-old man presenting with dark stools. Take a history and explain a management plan.

You are a 45-year-old van driver, Mr Powell, who has noticed dark coloured stools for the last 3 or 4 days. You noticed this while you flushed the toilet and again on the toilet paper. You open your bowels once a day and your stools have been soft. It was a small amount initially but today you passed dark black almost tar-like stools, enough to make you feel concerned. You feel nauseated, but haven't vomited and feel off your food. You have felt tired and washed out for several days and don't feel like you have the energy for work.

Curriculum code: CC1, CC12, CAP17, HAP17

Knowledge of the causes of headaches and the fundamental differences in their presentation is required. As discussed in the introduction to the chapter there is a clear set of questions that relates to any presentation where pain is a key feature. These questions, coupled with pertinent detailed enquiry into key areas, will assist the candidate in refining a differential diagnosis.

These headaches are of sudden onset. Patients usually complain of the worst-ever headache which may feel like having been hit over the head. They often occur on exertion and may present with no additional clinical features. Vomiting, drowsiness and confusion may be present as well as focal neurology. In an acute setting, headaches of this nature with no other explanation should very rarely be dismissed without further investigation. It is also important to remember that patients often have a ‘herald bleed’ prior to a subarachnoid haemorrhage. This is a smaller bleed with understandably less severe symptoms. If this bleed is noticed by the astute physician, (perhaps presenting as a less severe, sudden occipital headache, or even as sudden neck pain), then much subsequent morbidity and even mortality can be avoided. Symptoms of such an episode should also be sought in the history of a patient who may have a more severe subarachnoid bleed.

They are generally a bilateral ache or feeling of pressure, which is (at worst) moderately severe. The duration may vary significantly. These headaches are very common but should only be diagnosed in the ED in the absence of any sinister features.

The nature of pain with these headaches is variable but is normally severe. The pain tends to be unilateral around an eye. There may be conjunctival irritation, lacrimation, nasal congestion, eyelid swelling or drooping, facial sweating and miosis. Episodes may last 1–3 hours and occur in clusters with periods of remission in between.

These can be unilateral or bilateral headaches of a moderate to severe nature (otherwise patients with known migraines rarely present). They may be triggered by exposure to specific stimuli. Often they are accompanied by a specific prodrome or associated with an aura such as visual disturbance or varied sensory symptoms. Vomiting and photophobia can both occur.

Causes include a space occupying lesion (e.g. tumour or abscess), arteriovenous malformation or benign intracranial hypertension. The headache worsens with lowering the head, lying flat and coughing or sneezing. It can be associated with nausea, vomiting and blurred vision.

This is associated with temporal tenderness and jaw claudication. It occurs usually in patients over the age of 50 years who may experience low-grade fevers, weight loss and visual disturbance that, if untreated, may result in blindness.

Headaches may also be caused by trigeminal neuralgia, sinusitis, meningitis or be the result of medications and procedures. Coital cephalgia is a rare but severe headache that occurs during sex (including masturbation) just before orgasm. In each case a thorough history will assist in making a clear diagnosis.

Miss Finch is a 48-year-old woman. She has attended today with a headache. Please take a history from her. Then explain your differential diagnosis and management plan to the patient.

You are a 48-year-old school teacher and have come to the ED today as you had to take the day off sick and couldn't get a general practitioner appointment.

Curriculum code: CC1, CC12, CAP19

The condition refers to a raised serum bilirubin, which presents as yellowish discolouration to the conjunctiva, mucous membranes and the skin. A normal bilirubin level is considered to be < 17 μmol/L. Once this rises past approximately 35 µmol/L the discolouration begins to become visible, normally at the sclera. Occasionally, patients do indeed present with this as their only symptom though more often it occurs during a pathological process with other associated symptoms.

This is often caused by haemolysis – so patients may therefore be anaemic. There is a rise in unconjugated bilirubin, which is not water soluble and therefore does not enter the urine. Urine and stool remain their normal colour and liver enzyme tests are within the normal range.

This is the result of hepatocellular damage and the subsequent inability of the liver to metabolise bilirubin normally. There is a rise in unconjugated and conjugated bilirubin. Causes include those for hepatitis and chronic liver disease (infection, malignancy, metabolic disorders and alcohol). These precipitating factors should become clear if a thorough history is taken. There can be a failure to excrete conjugated bilirubin normally (to the duodenum in bile) which is then excreted in the urine giving it a dark colour and leaving the patient's stools pale.

Also known as cholestatic or obstructive jaundice, this occurs when there is obstruction to the outflow of conjugated bilirubin via the bile duct. The conjugated bilirubin level in the blood rises and leads to dark urine, but as less enters the bowel stools become paler. 53Causes include impacted gallstones in the bile duct, primary biliary cirrhosis or sclerosing cholangitis and malignancy (commonly pancreatic in origin).

Mr Dukes is a 52-year-old journalist who has come to the ED because his wife noticed that over the weekend the whites of his eyes have begun to look yellow. He has lost his appetite in the past 2 weeks but has otherwise felt ok. Take a history and then explain your management plan to Mr Dukes.

You are a 52-year-old newspaper journalist. You have come to the ED because your wife pointed out yesterday that your eyes looked a bit yellow and today you think they have got worse and your skin is beginning to look yellow. You had generally not been feeling great for a fortnight and have lost your appetite. You have also lost around 5 kg over the same period of time. You have had no pain at any time. Today you did notice your urine seemed very dark but didn't think to look at you stool when you had an otherwise normal bowel movement. You have had no other symptoms.

Curriculum code: CC1, CC12, PAP16, PAP17

This scenario requires the candidate to demonstrate knowledge of certain issues relating specifically to paediatrics. As well as knowing the causes for a paediatric limp it is also important to take a clear developmental history and social history. Non-accidental injury must be a consideration for any child presenting to the ED and certain questions should be asked to address this area of concern.

This is clearly a common cause of a child developing a limp and a history of a specific event should be sought. After a full history is taken (regardless of whether or not there has been trauma), a full examination is needed to check for areas of tenderness or bruising (do not forget the sole of the foot). Also the rest of the child should be examined to ensure there are no other injuries to suggest non-accidental injury. A Toddler's fracture is an oblique fracture through the tibia, typically resulting from a fall in those (as the name suggests) who have recently learnt to walk. This fracture may not be apparent on initial X-rays, so if it is considered to be the likely cause of the limp then it is appropriate to immobilise the lower leg in an above-knee backslab with follow up in fracture clinic.

This is a mild inflammatory process in the joint, which commonly follows another illness, often an upper respiratory tract infection. The degree of impairment it causes is variable although it is indeed transient. The child remains systemically well and their inflammatory markers are not significantly elevated. There may be a joint effusion visible on ultrasound which can be aspirated for microscopy, culture and sensitivity (MC&S) if the diagnosis is unclear.56

This usually presents with systemic features of infection, decreased range of movement in the affected joint, inability to weight-bear and raised inflammatory markers; the more of these features that are present, the more likely the diagnosis. Again a joint effusion may be visible on ultrasound and can be aspirated for MC&S. It is normally necessary for a septic joint to be washed out in theatre as an emergency.

This is avascular necrosis of the femoral head. It tends to occur between the ages of 3–10 years old and is commoner in boys. It presents with a painful limp. Inflammatory markers are normal and it is classically diagnosed on X-rays, which show a femoral head of increased density that becomes fragmented and irregular.

The epiphysis of the femoral head displaces inferiorly and posteriorly. This process is most common in 10–15-year-old boys, particularly if they are obese. It again presents with hip pain or a limp and there may be limited abduction and internal rotation of the joint. X-rays are required to make the diagnosis and treatment normally requires surgical intervention.

For a routine developmental history a child's ‘red book’ is used as their health record from birth. This should be asked for and checked if available. Specific areas that should be asked about include:

It is helpful to develop and practice a series of standard questions to elicit this information. Doing so will help the candidate to sound natural and relaxed, and it will allow the candidate to focus on processing the answers rather than worry about formulating the questions.

This is an area that should be addressed in every child seen in an ED. The decision as to whether or not there are any concerns regarding the potential for child abuse should be based on the presentation, history, examination and interaction of the child with its parents/guardians and with staff in the ED. The National Institute for Health and Care Excellence has issued guidance to assist in detecting child abuse and the College of Emergency Medicine also has recommendations on how cases should be managed based on the level of concern.

Jamie is a 4-year-old boy who has been brought in to the ED because he has been limping for 2 days and does not seem to be getting better. Take a history and develop a management plan.

You have brought Jamie, your 4-year-old nephew to the ED as he has had a limp for the past 2 days affecting his left leg. You had given it a day to see if it passed but it has not. There has not been any trauma that you are aware of and he has been well recently except for a runny nose and cough a week ago. Apart from the limp he has behaved normally with no fevers or change in his behaviour.

Curriculum code: CC1, CC12, CAP25, HAP23

A thorough history from someone presenting with palpitations should serve to identify the probable diagnosis and thereby risk-stratify the patient to help form a plan for further management.

These are normally benign but some patients may be aware of them to such an extent that they present to the ED. If no other abnormalities are found further investigation is rarely necessary.

Given the nature of this arrhythmia patients may describe a fast regular heart rate. It is more common in younger patients who may have had several episodes previously. These patients may be aware of manoeuvres that terminate their symptoms (vagal manoeuvres). Causes include stimulant use, Wolff–Parkinson–White syndrome or other conduction anomalies.60

Patients are more likely to be older, describe irregular palpitations and may have one of several risk factors. These include ischaemic heart disease, hypertension, alcohol excess, thyroid disease or valve disease.

This fast regular arrhythmia is more common in elderly patients and particularly those with ischaemic heart disease.

Miss Forbes is a 26-year-old school teacher who attended the ED after palpitations earlier in the day. Take a history and explain your diagnosis and management plan to her.