MRCEM Part C: 125 OSCE Stations Nitin Jain, Kiran Somani
INDEX
×
Chapter Notes

Save Clear


History takingChapter 1

  • 1.1 Introduction
  • 1.2 Fall — patient centred history taking
  • 1.3 Abdominal pain
  • 1.4 Rectal bleeding
  • 1.5 Apparent life-threatening event
  • 1.6 Back pain
  • 1.7 Syncope
  • 1.8 Chest pain
  • 1.9 Diabetes mellitus — hypoglycaemia
  • 1.10 Dizziness and falls
  • 1.11 Dysphagia
  • 1.12 Febrile convulsion
  • 1.13 Traveller's diarrhoea
  • 1.14 Haematuria
  • 1.15 Upper gastrointestinal bleeding
  • 1.16 Headache
  • 1.17 Jaundice
  • 1.18 Limping child
  • 1.19 Palpitations
  • 1.20 Purpuric rash
  • 1.21 Sexual history
  • 1.22 Cough
  • 21.23 Myalgia
  • 1.24 Transient ischaemic attack
  • 1.25 Weight loss
  • 1.26 Shortness of breath
  • 1.27 Seizure
  • 1.28 Pelvic pain
  • 1.29 Ankle swelling
  • 1.30 Non-accidental injury
  • 1.31 Visual disturbance
3
 
1.1 Introduction
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.
The most commonly used framework for history taking is the Calgary–Cambridge framework by Kurtz et al (Table 1.1.1). This describes the processes involved in a patient interview to generate a professional rapport and then exchange information. This should not be confused with the traditional model of history taking, i.e. presenting complaint, history of presenting complaint, past medical history etc. which is the content of patient history.
Initiate the discussion with introductions and greetings – remember these seemingly straightforward things score ‘easy’ marks. Ask open questions, ‘How can I help you today?’, or ‘What made you come to hospital?’ Sometimes patients have more than one complaint. In this situation, it is important to negotiate the agenda at the beginning and establish the focus of the consultation.
Start gathering information with open questions, e.g. ‘Tell me more about the headache’, and then progress to closed questioning to clarify the details, e.g. ‘Did it start suddenly, or did it come on gradually?’ Summarise frequently in order to clarify the facts – ‘so, it was the worst headache you've ever had: it came on suddenly and felt like you'd been whacked on the back of the head, but it's a little better now.
Table 1.1.1   Approach to communication during history taking (the process in each of the columns occurs simultaneously).
Providing structure
Initiating the session
Building relationship
  • Preparation
  • Establishing initial rapport
  • Identifying the reason(s) for the consultation
  • Making organisation overt
  • Attending to flow-logical sequence and timing
Gathering information
  • Using appropriate non-verbal behaviour
  • Developing rapport, empathise
  • Involving the patient, explaining rationale
  • Demonstrating appropriate confidence
  • Exploring patient problems – use open and closed questioning techniques
  • Establishing patient's ideas, concerns and expectations
  • Background information
Explanation and planning
  • Providing correct amount and type of information
  • Aiding accurate recall and understanding
  • Achieving a shared understanding – avoid jargon
  • Planning-shared decision making
Closing the session
  • Ensuring appropriate point of closure
  • Forward planning
4Your 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:
  • Avoid jargon
  • Give information in chunks so it can be absorbed
  • Check understanding
Always give patients an opportunity to ask questions and clarify their understanding of what you have said as you go along.
At the end, make a plan, discussing the different options available and provide a safety net in case the plan is not working.
Keep the history focused to the problem at hand. In addition to asking the relevant questions about the specific complaint, think about the red flag symptoms and attempt a risk assessment as part of the history, e.g. chest pain assessment includes risk of ischaemic heart disease or risk of pulmonary embolism; self-harm and risk of suicide; back pain and risk of cauda equina. You should then reflect back on the patient problems and address the concerns raised by patient or their carer.
Given below is a generic plan for history taking. This should be used along with the specific mark sheets for each objectively structured clinical examination (OSCE).
MARK SHEET
Achieved
Not achieved
Initiating a session
Introduces self
Appropriately greets the patient
Gathering information
Starts with appropriate opening question
Establishes reason for attendance
Explores presenting complaint
Encourages patient to tell the story
Uses open and closed questioning technique appropriately
Listens attentively
Confirms
Past medical history
Surgical and gynaecological history if appropriate
Drug history
Allergies
Social history
Explanation and planning
Explores patient's ideas regarding their problem
Asks about any specific concerns or expectations they have
5
Summarises and confirms patient understanding
Provides understandable information without using medical jargon
Gives appropriate differential diagnosis
Makes a shared management plan
Outlines further examinations
Outlines further investigations
Closing the session
Summarises and closes the session appropriately
Invites questions and addresses any concerns
Global score
Global score from examiner
Global score from patient/actor
 
Taking a history of pain
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:
  • Site: is it generalised, in a specific area, or like a band around the body area?
  • Onset: did the pain start suddenly or gradually? When did it reach its worst? Can the patient remember exactly what they were doing at the time? This often suggests an abrupt onset, and can sometimes help explain the cause.
  • Character: is it sharp, aching or throbbing in nature?
  • Radiation: does the pain spread or localise around a particular area?
  • Associations: is there any nausea, vomiting or other localising (or systemic) features?
  • Timing: is the pain related to posture or exercise?
  • Exacerbating: does posture, activity, diet make it worse? Does analgesia make it better?
  • Severity: how bad is it? Is it the worst pain ever?
 
Reference
  1. Kurtz S, Silverman J, Benson J, Draper J. Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides. Acad Med 2003; 78:802–809.
 
61.2 Fall — patient centred history taking
Curriculum code: CC1, CC6, CC12, CAP13, HAP13
 
Ideas, concerns and expectations
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:
  • ‘What do you think about… ?’
  • ‘What do you know (or have you heard) about this condition?’
  • ‘Is there anything specific that worries you…?’
  • ‘What are you worried about?’
  • ‘What would you like to do about…?’
  • ‘What would you like us to help with?’
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:
  • The patient with a headache is worried about having a brain tumour
  • The father accompanying his daughter is anxious because a friend's meningitis began with a sore throat
  • The frail patient will struggle to cope at home with even a minor injury
  • The suicidal patient has taken an overdose of which no one is aware
 
Social history
This is equally important in helping understand a patient's perspective on their situation. Areas to consider may include:
  • Social contact: spouse, partner, family, friends, carers (and the frequency of their visits)
  • Activities of daily living: who does the shopping, cooking, washing, cleaning
  • Accommodation: how many floors, stairs (indoors and outdoors), lift
  • Occupation (past and present), financial situation
  • Alcohol intake, tobacco smoking and recreational drug use.
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 of7 emergency 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.
 
Scenario
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.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Checks level of comfort offers analgesia
Establishes presenting complaint
Specifically enquires about:
– what patient was doing at the time?
– any clear cause for fall?
– any preceding symptoms?
– did they lose consciousness – if so for how long?
– any incontinence or tongue biting?
– injuries sustained?
– any witness?
– could they get up? If so, how? If not, how long on floor?
– any previous falls
Past medical history
Medications and allergies
Social history (and illicit drug use) – alcohol, smoking, occupation
Social history – mobility aids, type of accommodation, carers
Elicits patient's concerns
Explains plan: check blood pressure, blood sugar, blood tests, ECG
Recommends falls clinic
Recognises need for therapy-type assessment before discharge
Answers patient's questions appropriately
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
8
 
Instructions for actor
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.
You previously had a stroke, because of which you have mild right-sided weakness but you can get around in doors using a stick in your left hand. You no longer take any regular medicines and have no allergies. You live alone in a first floor flat and have no lift. Your family visit and do your shopping for you once every fortnight. You do not go out, and you are lonely. You have no other carers. You do not think you can manage at home now you have hurt your arm. You do not want to tell the doctor this unless they ask you directly as you do not want to be a nuisance or admit you are scared of how you will manage. You feel you have been enough of a burden to everyone anyway.9
 
1.3 Abdominal pain
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 (Table 1.3.1). In addition candidates should appreciate that chest conditions like an inferior myocardial infarction or lower lobe pneumonia can also present with abdominal pain.
Candidates should aim to:
  • Identify serious and common causes of abdominal pain
  • Differentiate which system is likely to be involved, based on:
    • Age (and, of course, gender!)
    • Site, onset, character, radiation, associations, type, exacerbating factors, severity of pain (SOCRATES)
    • Associated symptoms like vomiting or dysuria
    • Duration of symptoms
    • Previous surgical/gynaecological/urological history
    • Previous such presentations
    • Pregnancy status
    • Alcohol intake
  • Outline a differential diagnosis
  • Make a management plan. What examination is needed and what further tests to recommend?
 
Sudden, acute or delayed onset 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.
Presentation over a few days is usually acute onset. Appendicitis, pyelonephritis, cholecystitis and diverticulitis are examples of conditions that usually present with a few days history.
Delayed onset over a few weeks is usually not an emergency, although suspected sub-acute bowel obstruction or cancer still needs urgent management.
 
Somatic and visceral pain
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.
Once the parietal peritoneum is irritated due to any cause, pain becomes somatic in nature and is sharp and well localised. This is the reason why appendicitis patients initially10 have dull, poorly localised central abdominal pain. Once inflammation spreads to involve the peritoneum, it becomes localised to right lower quadrant.
 
Referred pain and radiation of pain
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.
Similarly pain can radiate from front to back (e.g. pancreatitis) or from loin to groin (e.g. ureteric colic).
 
Constant or colicky pain
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).
 
Other symptoms
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.
Table 1.3.1   Presentation of abdominal pain by cause
Condition
Classical presentation
Acute pancreatitis
Acute onset, constant epigastric pain radiating to the back
History of alcohol abuse or gallstones +/– previous pancreatitis
Infected obstructed kidney
Colicky flank pain (sharp and severe) with relief in between, radiating from loin to groin, may become constant
History of fever, dysuria, previous urolithiasis
Intestinal obstruction
Dull colicky pain, with vomiting, constipation and abdominal distension
History of previous abdominal surgery, cancer or hernia
Mesenteric ischaemia
Sudden onset, constant, severe, poorly localised pain
May start from periumbilical region and then becomes diffuse
History of atrial fibrillation, elderly patient with significant cardiovascular disease11
Perforated viscus
Sudden onset, constant, sharp pain, increasing with movement
History of diverticulitis or peptic ulcer disease
Ruptured ectopic pregnancy
Acute onset lower abdomen pain localised to effected side, with radiation to shoulder or back
Can be associated with syncope, gastrointestinal disturbance or vaginal bleeding
History of reproductive age group, missed period or confirmed pregnancy, previous ectopic or risk factors for it
Leaking abdominal aortic aneurysm
Sudden onset severe pain radiating to back, flanks or legs
Often associated with syncope or presyncope
History of cardiovascular disease, or risk factor for it like smoking, hypertension and diabetes
 
Scenario
Claire Parker is a 38-year-old woman with abdominal pain for the last 2 days. She has been taking painkillers with no effect.
At triage her temperature was 37.7°C, pulse 90 beats per minute, blood pressure 110/70 mmHg and respiratory rate 16 breaths per minute. She was given codeine 30 mg orally for pain relief. Take a history from her and then explain a management plan to her.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Checks level of comfort offers analgesia
Establishes presenting complaint
Specifically enquires about:
– duration, character, nature, site, radiation of pain
– exacerbating or relieving factors
– severity of pain
Past medical history
Past surgical history
Past gynaecological history
Medications and allergies
Social history (and illicit drug use)
Elicits patient's concerns
Suggests appropriate differential diagnosis
Explains plan:
– abdominal examination
12
– appropriate blood tests
– urine dipstick for pregnancy and infection
Answers patient's questions appropriately
Does not agree to a scan until the patient has been examined
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
 
Instructions for actor
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.
You have noticed that you are going to pass urine more often than usual and have felt a bit hot and cold. You tried taking paracetamol tablets, which helped on the first day but not today. Your pain is 5 out of 10 in severity but you are comfortable at the moment after being given codeine in the ED. You feel a bit sick but have not vomited and don't feel hungry at all.
You are usually healthy and well and never had this before. You have never had any abdominal surgery and don't have any abnormal vaginal discharge. Your last menstrual period was 1 month ago and you are due any time now. You have normal periods – you certainly do not have heavy bleeding.
You don't take any medications and are not allergic to any medications.
You are sexually active, use contraceptive pills and have not missed any tablets. You haven't had sexual intercourse with anyone except your husband for the 12 years that you have been married and you don't think he has either. You last had sex the weekend before last. If asked, you have not recently taken any antibiotics. Nor have you had any diarrhoea or vomiting in the last few months.
You are concerned that you may have appendicitis and don't want to have an operation as your mother had a bad experience with pain when she had a knee operation. You think that you should get a scan to find out what is going on.13
 
1.4 Rectal bleeding
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.
Since large bowel cancer and colitis are important possible causes, they should be explored specifically as part of the history.
 
Common cause of rectal bleeding (Table 1.4.1)
  • Haemorrhoids
  • Diverticulitis
  • Inflammatory bowel disease (Crohn's or ulcerative colitis)
  • Vascular malformations (angiodysplasia)
  • Neoplasia (carcinoma or polyp)
  • Massive upper gastrointestinal bleeding
  • Ischaemic colitis
  • Radiation enteropathy
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.
Table 1.4.1   Presentation of rectal bleeding by cause
Cause
Presentation
Haemorrhoids
Self-limiting bright red bleeding, painless, blood covering the stools.
History of constipation, bright red blood on toilet paper
Diverticular disease
Usually over 65, bleeding mixed with stools or dark red coloured stools.
History of left lower abdominal pain, constipation, bloating, diverticular disease on colonoscopy
Inflammatory bowel disease
Often relatively young patient, chronic diarrhoea presenting with blood in stools
History of intermittent lower abdominal pain, weight loss, fever and systemic symptoms
Angiodysplasia
Usually over 65, episodes of painless bright red bleeding which may be severe
History of renal disease, aortic stenosis, on oral anticoagulation
Colorectal cancer
Usually over 50, painless rectal bleeding, blood mixed with stools.
History of weight loss, change is bowel habit, family history of polyps or colon cancer, may experience tenesmus if rectal cancer
Ischaemic colitis
Age over 65, sudden onset lower abdominal pain or cramping and diarrhoea mixed with blood
History of diabetes, hypertension, haemodialysis
Radiation enteropathy
Persistent or severe bleeding.
History of radiotherapy for pelvic cancer, chronic diarrhoea, rectal pain, urgency, fecal incontinence. Most commonly 2–5 months after radiotherapy
14Sometimes acute upper gastrointestinal bleeding can be so severe as to cause fresh blood per rectum or bleeding from the caecum may present as melaena. Therefore, the colour of the stool can only be considered as a guide to the origin of the bleeding.
The history should also cover some specific questions:
  • The nature of the bleeding: duration, colour and amount of bleeding
  • Presence of systemic symptoms such as dizziness, syncope, confusion, postural symptoms, abdominal pain or fever
  • Risk factors:
    • Current medications, anticoagulant use, aspirin, anti-inflammatories, antibiotics
    • Alcohol use
    • Previous history of bleeding or of previous surgery or endoscopy
    • Comorbidities
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.
 
Scenario
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.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Checks level of comfort offers analgesia
Establishes presenting complaint
Specifically enquires about:
– nature of bleeding
– frequency of episodes
Previous history of bleeding
Presence of pain
Presence of systemic symptoms
15
Presence of altered bowel habit
Past medical history
Past surgical history
Previous endoscopies
Medications and allergies
Social history (and illicit drug use)
Elicits patient's concerns
Offers to call daughter to help with dog
Suggests appropriate differential diagnosis
Explains plan:
– abdominal (and rectal) examination
– appropriate blood tests
Answers patient's questions appropriately
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
 
Instructions for actor
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.
You felt a bit better once you lay down and then even managed to eat some breakfast. You have had a hysterectomy and are on warfarin, lisinopril and inhalers for chronic obstructive pulmonary disease. You don't know why you take these medications and have been on them for years.
You live by yourself and do your own shopping and cooking, with some help from your daughter on the weekends.
You are concerned about this episode and your dog, which is alone at home.16
 
1.5 Apparent life-threatening event
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.
An ALTE is defined as a sudden event, frightening to the observer in which the infant exhibits a combination of symptoms which may include a change in colour (cyanosis, pale, plethoric, redness), apnoea, change in muscle tone (floppy or rigid) with associated choking or gagging. It often provokes resuscitation attempts from the observer. The child then recovers spontaneously.
History taking (ideally from a first-hand observer) should cover:
  1. Description of the event
    • Circumstances – e.g. was the child awake or asleep? What position (prone, supine or on side) were they in, and where were they (crib, parent's bed, cot, car seat)? What else was nearby – bedclothes, blankets, pillows, toys, siblings, animals? Who was caring and where were they? What alerted them?
    • Activity at time of the event – feeding, coughing, gagging, choking, vomiting?
    • Breathing effort – none, shallow, gasping, increased?
    • Colour – pale, red, purple, blue? In what distribution (peripheral, circumoral, whole body)
    • Movement and tone – rigid, tonic-clonic, decreased or floppy
    • Observed cough or vomiting – mucous, blood or noise (silent, cough, gag, wheeze, stridor, crying)
    • Duration of the event – length of time required to reinstate normal breathing, tone and behaviour and length and time of resuscitation required
  2. Interventions that were performed (in order of severity)
    • None
    • Gentle stimulation
    • Blowing air in face
    • Vigorous stimulation
    • Mouth-to-mouth breathing
    • Cardiopulmonary resuscitation by medically trained personnel
  3. History of any current illness
    • Ill in days or hours leading up to event
    • Fever
    • Poor feeding
    • Weight loss
    • Rash
    • Irritability
    • Contact with someone who is sick, medications administered, immunization
  4. Medical history
    • Antenatal history of mother – use of drugs, tobacco or alcohol during pregnancy
    • Small for gestational age? Prematurity?
    • Birth history – birth trauma, hypoxia, sepsis
    • 17Feeding history – gagging, coughing, poor weight gain
    • Development history – appropriate milestones
    • Previous admissions – surgery, ATLE
    • Accidents – being dropped, tossed, possibility of NAI
  5. Family history
    • Congenital problems, neurologic conditions, neonatal/child deaths
    • Smoking in the home
    • Cardiac arrhythmias
    • Sudden infant death syndrome
 
Risk assessment
There is an increased risk following an ALTE if:
  • Age < 28 days
  • Significant prematurity
  • Significant prior medical illness
  • Clinically unwell
  • Recurrent events before presentation
  • More severe/prolonged ALTE
 
Risk factors indicating possibility of non-accidental injury
  • Previous cyanosis, apnoea or ALTE while in the care of same person
  • Age > 6 months
  • Previous unexpected or unexplained deaths of one or more siblings
  • Previous death of infants, under the care of the same person
  • Simultaneous or nearly simultaneous death of twins
  • Discovery of blood on the infant's nose or mouth in association with ALTE
 
Common causes
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.
Gastro-oesophageal reflux disease, seizures and lower respiratory tract infections account for 50% of the diagnoses associated with ALTE.
 
Management plan
  • Detailed physical examination of all systems, including retinal examination to check for retinal haemorrhage in suspected NAI
  • Consider investigation with full blood count, urea and electrolytes, blood glucose, nasopharyngeal aspirate for viruses and pertussis and ECG to check QT interval. Other investigations should be tailored to the presentation
  • In practice most of these patients are admitted for observation.18
 
Scenario
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.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self, appropriately greets the patient
Calms Mrs Davis, reassures about her son
Starts with appropriate opening question
Establishes presenting complaint
Specifically enquires about:
– location of child
– activity at time of the event
– breathing efforts
– colour and distribution
– movement and tone
– observed cough or vomiting
– duration of the event
– asks about interventions undertaken
– any current illness
Takes antenatal history
Takes birth history
Takes developmental history
Checks immunisation status
Takes feeding history – bottle or breast fed, volume taken
Asks about previous admissions, previous episodes
Asks about family history
Asks about home environment
Identifies duration of ALTE and of any preceding symptoms
Offers appropriate differential diagnosis
Outlines reasonable management plan
Invites questions and answers any concerns
Checks patient's understanding of diagnosis and plan
Global score from examiner
Global score from mother
19
 
Instructions for actor
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.
He has never had anything like this before. He was born a week early by a normal delivery in hospital. You were discharged the same day. He is now 2 months old and has been gaining weight appropriate to his age and drinks approximately seven to eight bottles a day of 60 mL of formula. He was a bit snuffly yesterday, but had no fever and has been feeding as normal. He is your first child and there are no other children at home. He had his first immunisations last week. There is no family history of anything similar.
If the doctor suggests you might go home now, you become distressed about the idea of the same thing happening again. If you are offered a period of observation for Chris you are reassured.
 
References
  1. Karen LH, Barry Z. Evaluation and Management of Apparent Life-Threatening Events in Children. Am Fam Physician 2005; 71(12):2301–2308.
 
201.6 Back pain
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.
Therefore when taking a history, it is essential to ask about systemic symptoms, identify any critical neurological symptoms as well as key ‘red flag’ symptoms which should provoke further investigation.
Red flag symptoms:
  • Age < 20 or > 50 years
  • Thoracic pain
  • Recent significant trauma or mild trauma in patients older than 50 years
  • Acute onset of back, flank or testicular pain
  • Constant pain worse at night or rest
  • Collapse or nausea associated with back pain
  • History of prolonged steroid use, osteoporosis, syncope, cancer, intravenous drug use, immunocompromised state, recent bacterial infection, morning stiffness lasting more than an hour
  • Unexplained fever > 38°C or unexplained weight loss
  • Neurological deficit
  • Spinal deformity
 
Specific features to ask about
  1. Character of pain.
    Pain localised to the lower back, gluteal area and thighs with varying intensity and better at rest in a patient with good health is usually mechanical back pain. Sciatica is pain originating in the lower back and radiating to the lower leg in lumbar nerve root distribution.
  2. Where is the pain and where does it radiate?
    Thoracic pain is a red flag. Radiation to the legs and specifically below the knees or in dermatomal distribution indicates nerve root involvement. L5 and S1 pain radiates distal to the knee and is more intense than the back pain. L3 and L4 pain radiates to the front or medial aspect of the thigh and medial side of the calf or foot. Radiation to the chest or abdomen should be a prompt to look for a more serious cause. Flank pain suggests a renal cause.
  3. When did the pain start?
    Acute onset while doing something specific suggests mechanical cause. Sudden onset severe pain suggests a vascular event like dissection or a leaking aneurysm. Slow onset pain, gradually worsening over time unrelated to activity raises the possibility of tumour or infection.
  4. Aggravating or relieving features
    Pain increasing with movement or cough is usually mechanical in nature. Nocturnal pain, or pain not relieved by analgesics could be tumour-related. Pain increasing with walking which radiates to the legs and eases with flexion of the back suggests lumbar canal stenosis.
  5. 21Neurological deficit
    Sensory or motor weakness, loss of bladder or bowel control and perineal sensory deficit all indicate possible cauda equina or spinal cord compression. The symptoms should be confirmed with detailed neurological examination and investigated as an emergency with an MRI.
  6. Associated history
    These should cover the red flag features like syncope, fever, intravenous drug abuse, medications like anticoagulants or steroids.
  7. Past medical history
    Ask specifically about cancer (risk of metastatic disease), inflammatory disease, intravenous drug abuse (risk of discitis), arthropathy (ankylosing spondylitis), endocrinopathy (hyperparathyroidism), bleeding disorders (retropharyngeal haematoma), osteoporosis (wedge fracture), or sickle cell disease (crisis).
 
Scenario
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.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Checks level of comfort offers analgesia
Establishes presenting complaint
Specifically enquires about:
– characteristics of pain
– duration of symptoms
– enquires about ability to walk
– presence of neurological symptoms
– presence of red flag symptoms
– presence of systemic symptoms
22
Past medical history
Medications and allergies
Social history (and illicit drug use)
Elicits patient's concerns
Suggests appropriate differential diagnosis
Explains plan:
– relevant examination
– appropriate blood tests
– bladder scan/urinary catheter
Answers patient's questions appropriately
Shows empathy
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
 
Instructions for actor
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.
The pain is getting worse and now involves both legs. You can't feel your left foot and are not able to sit up due to severe pain. This morning you wet yourself without realising it. You have never been incontinent and are very anxious.
You were not able to sleep last night due to the pain. You feel nauseated, but haven't vomited and have not felt feverish. You are otherwise healthy and well and do not take any medications. You have no allergies. You have had mild back pain in the past, but nothing like this.
You spoke to your GP again today and he advised you to go to hospital for an urgent scan of your back. You are worried that you may end up never being able to walk again.
 
Reference
  1. Marx J, Hockberger R, Walls R. Rosen's Emergency Medicine: Concepts and Clinical Practice, 7th ed. Mosby Elsevier,  Philadelphia:  2009.
 
231.7 Syncope
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.
Table 1.7.1   Causes of syncope
Reflex syncope
Orthostatic hypotension (OH) syndromes
Cardiovascular syncope
Vasovagal episode
Simple faint – emotional distress or orthostatic stress and associated typical prodrome. (3 Ps – posture, prodrome, provoking factors)
Situational syncope
During or immediately following specific triggers, e.g. after micturition, straining or pain
Carotid sinus syncope
Due to carotid sinus massage
Atypical
No typical trigger but classical history
Classical OH
> 20 mmHg drop in systolic or >10 mmHg drop in diastolic pressure within 3 minutes of standing
Initial OH
Immediate drop in blood pressure of > 40 mmHg on standing that corrects itself rapidly to normal
Delayed hypotension
Slow progressive decrease in systolic blood pressure on standing, usually in the elderly
Postural orthostatic tachycardia syndrome (POTS)
Usually in young females, marked heart rate increase (by > 30 bpm or to > 120 bpm) and instability of blood pressure.
Secondary autonomic failures e.g. in Parkinson's
Arrhythmias
Tachy-brady syndrome
Sick sinus syndrome
Paroxysmal atrial fibrillation
atrioventricular blocks - second or third degree
Long QT syndromes
Drug induced, e.g. beta-blockers, digoxin, and quinolones
Structural heart disease
Hypertrophic obstructive cardiomyopathy
Arrhythmogenic right ventricular cardiomyopathy
Myocardial infarction
Aortic stenosis
Pulmonary hypertension
Prolapsed atrial myxoma
Cardiovascular collapse
Pulmonary embolism
Aortic dissection
Table 1.7.2   Risk factors for cardiovascular syncope
From history
ECG features
During exertion or while supine
Palpitations before onset
Family history of sudden cardiac death or channelopathy
Known structural heart disease
Anaemia or electrolyte disturbance
Persistent sinus bradycardia <40 bpm or sinus pause >3 seconds
Mobitz II, complete heart block or ‘trifascicular’ block*
Alternating LBBB and RBBB
VT or rapid paroxysmal AF/SVT
Torsades or long or short QT
Brugada syndrome – RBBB with ST elevation in leads V1-V3
AVRC – Q waves in right precordial leads, epsilon waves, and ventricular late potentials
*Trifascicular block is the combination of first-degree heart block (prolonged PR interval), Right bundle branch block (RSR or M pattern in V1) and left anterior (left axis deviation) or left posterior (right axis deviation) hemi block.24
Table 1.7.3   Clinical features of syncope versus seizure
Feature
Syncope
Seizure
Trigger
Common
Rare
Prodrome
Presyncopal features like nausea, sweating, pallor
Aura – unpleasant smell, epigastric sensation
Onset
Gradual
Sudden
Duration
1–30 seconds
1–3 minutes
Colour
Usually pale
Cyanosed
Convulsions
May have movement after loss of consciousness (LOC)
Tonic-clonic movements, automatism, neck turned to one side
Tongue bite
Rare, usually on the tip
Common, on the side
Post event
Rapid recovery, nausea or vomiting afterwards
Confusion, aching muscles, joint dislocations
 
Scenario
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.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Checks level of comfort offers analgesia
Establishes presenting complaint
Specifically enquires about:
– circumstances prior to event
– any preceding symptoms?
– what the patient remembers about the event?
– did they lose consciousness – if so for how long?
– any incontinence or tongue biting
– any limb jerking
25
– duration of event
– injuries sustained
– any witness?
– history of recovery phase postevent
– any previous episodes
Past medical history
Medications and allergies
Social history (and illicit drug use) – alcohol, smoking, occupation
Social history – mobility aids, type of accommodation, carers
Elicits patient's concerns
Explains differential diagnosis
Explains plan: check postural blood pressures, blood sugar, blood tests, ECG
Recommends follow up in appropriate setting
Answers patient's questions appropriately
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
 
Instructions for actor
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.
You did not have breakfast as you were in a hurry but are feeling hungry now. You did take your blood pressure tablet however. You live by yourself and are self-caring with shopping, cooking and cleaning. Your daughter helps out on the weekends with meals. You are usually healthy and well and are eager to go home.26
 
1.8 Chest pain
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.
Important diagnoses to consider are acute coronary syndrome, pulmonary embolism, aortic dissection, pericarditis, oesophageal rupture and pneumothorax.
 
Angina
This is typically:
  • Constricting pain in the anterior chest radiating to neck, arms, shoulder or jaw
  • Exacerbated by physical exertion
  • Relieved by rest or glyceryl trinitrate within approximately 5 minutes
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:
  • Pain is continuous or very prolonged
  • Unrelated to activity
  • Brought on by breathing
  • Associated with symptoms such as dizziness, palpitations, tingling or difficulty in swallowing
 
Pleurisy
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.
  • Unexplained dyspnoea, tachycardia or a history of haemoptysis in a patient should prompt investigations to confirm or exclude a pulmonary embolus (PE)
  • Fever, yellowish sputum and confusion could be present in a patient with pneumonia. A history of travel makes atypical pneumonia more likely
  • Myalgia, prodromal illness, fever, cough, sore throat and runny nose could be feature of a viral infection with pleurisy
  • A young patient that is tall and thin with associated shortness of breath could have a spontaneous pneumothorax
 
Aortic dissection
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.27
 
Oesophageal rupture
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.
 
Assessing risk factors
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.
 
Scenario
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.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Checks level of comfort offers analgesia
Establishes presenting complaint
Specifically enquires about:
– characteristics of pain
– nature of onset of pain
– duration of pain
– associated symptoms
– asks about risk factors for ischaemic heart disease/PE as appropriate
– any previous episodes
Past medical history
Medications and allergies
Social history (and illicit drug use)
Elicits patient's concerns
28
Explains differential diagnosis
Explains plan: ECG, blood tests
Recommends follow up in appropriate setting
Answer patient's questions appropriately
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
 
Instructions for actor
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.
You have high blood pressure and smoke 10 cigarettes a day. You don't know about family history as you were adopted. You are on a tablet for blood pressure but don't know the name. You think that this was an episode of indigestion but wanted to get checked out just in case it was to do with your heart. You want to go to work as soon as possible because you are self-employed.
 
Reference
  1. Chest pain of recent onset. Clinical guideline 95. National Institute for Health and Care Excellence,  London, 2010. www.nice.org.uk/CG95
 
291.9 Diabetes mellitus — hypoglycaemia
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.
The commonest cause of hypoglycaemia is in known diabetics when there is a mismatch between insulin or oral hypoglycaemic agent and ingested calories or exercise. In this group, the symptoms may develop at a relatively higher level of blood sugar as the patients are used to a degree of hyperglycaemia.
In non-diabetic patients presenting with hypoglycaemia, it is useful to remember the mnemonic EXPLAIN:
  • Exogenous drugs (e.g. alcohol) or poisoning (e.g. beta-blockers)
  • Pituitary insufficiency
  • Liver failure
  • Addison's disease
  • Islet cell tumours, insulinoma
  • Nonpancreatic insulin secreting tumours
 
Scenario
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.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Checks level of comfort offers analgesia
Establishes presenting complaint
Specifically enquires about:
– patient's recollection of events
30
– symptoms experienced
– nature of onset
– duration and severity of symptoms
– how and when symptoms resolved
– history of diabetes
– use of insulin/medications
– any unusual activity or meals during day
– any previous episodes
– awareness of hypoglycaemic episodes
– symptoms of intercurrent illness
Past medical history
Medications and allergies
Social history (including driving)
Elicits patient's concerns
Explains differential diagnosis
Explains plan: examination, bloods tests, septic screen
Recommends follow up in appropriate setting
Answers patient's questions appropriately
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
 
Instructions for actor
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.
You can't remember whether you had your breakfast this morning or not or how you came to the hospital. After treatment you are feeling much better.
You have had diabetes for the last 45 years. You take a basal-bolus insulin regime. You use fast-acting insulin at meal times and long-acting insulin every morning. This is the first ‘hypo’ you have had for years. You also have high blood pressure and take lisinopril.
You are otherwise well. You don't drive anymore, because of vision problems. You are not allergic to anything and don't smoke, but drink a glass of wine with dinner.31
 
1.10 Dizziness and falls
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.
 
Vertigo
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).
Table 1.10.1   Characteristics of central and peripheral vertigo
Characteristic
Peripheral
Central
Onset
Sudden
Gradual or sudden
Intensity
Severe
Mild
Duration
Usually seconds or minutes; occasionally hours or days – intermittent
Usually weeks or months (continuous) but can be seconds or minutes with vascular causes
Direction of nystagmus
One direction, horizontal or rotatory, never vertical
Different directions in different positions
Effect of head position
Worsened by position, often single critical position
Little change, associated with more than one position
Associated neurologic findings
None
Usually present
Associated auditory findings
May be present including tinnitus
None
(Adapted from Marx JA et al. Rosen's Emergency Medicine, 7th Edn. Philadelphia: Mosby, 2010)
 
Disequilibrium
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.
 
Presyncope
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 1.7.32
 
Fatigue or general weakness
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.
This symptom clarification is often the most important part of the history in a patient presenting with dizziness. Once the true nature of the patient's problem is identified, further details can be asked as to the cause of their symptoms.
 
Elderly patients who fall
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?’
Causes of falls in elderly can be divided into causes intrinsic and extrinsic to the patient and often the cause is multifactorial. Attempts should be made to identify any reversible causes:
  • Intrinsic factors:
    • Gait and musculoskeletal dysfunction
    • Foot problems
    • Cognitive or other neurological impairment
    • Cardiovascular disease or other acute illness e.g. infections
  • Extrinsic factors:
    • Environmental hazards
    • Polypharmacy
    • Use of walking stick or frame
    • Prior history of falls
 
Approach to history
Even though the patient may present with an injury it is essential to elicit the circumstances around the fall.
  • Location of incident
  • Activity at the time
  • Any warning symptoms before (absence of warning is highly suggestive of cardiovascular causes)?
  • Was there loss of consciousness? Do they remember hitting the ground?
  • Events after fall: how did they get help? How long they stayed on the floor?
  • Injuries sustained
  • Are there any new symptoms like limb weakness or incontinence?
  • Were there any cardiovascular symptoms such as chest pain or palpitations?33
 
Scenario
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.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Checks level of comfort offers analgesia
Establishes presenting complaint
Specifically enquires about:
– what patient was doing at the time?
– any clear cause for fall?
– any preceding symptoms?
– establishes symptoms related to dizziness
– did they lose consciousness – if so for how long?
– any incontinence or tongue biting?
– injuries sustained?
– any witness?
– could they get up? If so, how? If not, how long on floor?
– any previous falls
Past medical history
Medications and allergies
Social history (and illicit drug use) – alcohol, smoking, occupation
Social history – mobility aids, type of accommodation, carers
Elicits patient's concerns
Explains plan: need to exclude hip fracture, check blood pressure, blood sugar, blood tests, ECG
Answers patient's questions appropriately
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
34
 
Instructions for actor
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.
You fell at home this morning when you got up to go to toilet. You felt dizzy as if you are in a whirlpool and were not able to balance yourself when you fell. You think that you lost consciousness, but are not very sure. You were not able to get up due to hip pain. You have no other injuries. You are still feeling very dizzy each time you try and move your head and are feeling nauseous and hearing a buzzing noise in your ears. The pain in your hip is still quite severe. You score it as 5 out of 10.
You got help by pressing your emergency buzzer for help. You have not fallen before, but have felt dizzy and were recently stated on a medication for it by your general practitioner. You take medications for blood pressure, angina, leg cramps, sleeping tablets, a tablet for depression and are on warfarin for recurrent PEs.
You are worried you may have broken your hip.35
 
1.11 Dysphagia
Curriculum code: CC1, CC12, CAP31, CAP36
Any difficulty in swallowing is termed dysphagia. Painful swallowing is termed odynophagia.
Dysphagia can either arise in the oropharyngeal or oesophageal phase of swallowing. Both have different causes and a careful history should be able to localise the cause.
Characteristic
Oropharyngeal dysphagia
Oesophageal dysphagia
Initial swallowing
Abnormal
Normal
Coughing or choking
Present
Absent
Difficulty with
Liquids
Solids
Odynophagia
Absent
Present
Reflux, dyspepsia
Absent
Present
Aspiration
Present
Absent
Causes
Neuromuscular e.g. CVA, myasthenia, Polymyositis
Structural – oesophageal stricture, cancer, external compression from mediastinal mass
(Adapted from Marx JA et al. Rosen's Emergency Medicine, 7th Edn. Philadelphia: Mosby, 2010.)
A common cause of dysphagia in the ED is food bolus obstruction. A detailed history of events can usually clarify the diagnosis. Patients often have some underlying abnormality of the oesophagus to precipitate a food bolus obstruction. These patients present with chest pain not dissimilar to angina, and therefore a careful workup with a detailed history is needed.
 
Sore throat
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.
 
Scenario
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.
zoom view
36
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Checks level of comfort offers analgesia
Establishes presenting complaint
Specifically enquires about:
– onset of symptoms
– characteristics of dysphagia
– severity of dysphagia
– any previous similar episodes?
– characteristics of pain
– identifies association with meal
Past medical history
Medications and allergies
Social history (and illicit drug use)
Elicits patient's concerns
Explains likely diagnosis
Explains plan
Answers patient's questions appropriately
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
 
Instructions for actor
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.37
 
1.12 Febrile convulsion
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:
  • Be a generalised convulsion
  • Last < 5 minutes
  • Occur in a child aged between 6 months and 5 years of age who is neurologically and developmentally normal
  • Occur in the presence of fever
  • Occur without any central nervous system (CNS) infection or alternate identifiable cause (such as hypoglycaemia or electrolyte imbalance).
 
Diagnostic approach
The history is best taken from someone who witnessed the event.
  1. Determine whether the event was truly a seizure
    • May be confused with syncope, rigors, breath holding spells, jitteriness in neonates or normal movements
    • What was the patient doing immediately before the event? Was there any warning or aura (e.g. visual or olfactory disturbance)?
  2. Determine the type of seizure
    • Was the child stiff or limp? Colour, movements, eye and head rolling, incontinence, loss of consciousness, any focality?
    • Immediately after the event – was there any post-ictal confusion, reduced level of consciousness or headache? Does the patient remember the episode?
  3. Identify the cause
    • Recent illness, fever, trauma and new medications, not taken antiepileptic medications, rash, hypoglycaemia, electrolyte disorder
    • Risk factor for epilepsy – previous head injury, meningitis, febrile seizures, congenital anomalies or family history of epilepsy.
Particularly in infants the signs of meningitis are often subtle and a septic screen (FBC, U&Es, blood cultures, MSU +/- CXR and lumbar puncture) should be strongly considered before excluding meningitis. Children older than 18 months may be discharged with appropriate advice and safety net if they:
  • Have fully recovered
  • Are clinically well with no signs of meningitis
  • Have an identified source for their fever
  • A previous history of febrile seizures and a typical story for it.
Parents should be given the following information:
  • Febrile seizures happen in approximately 3% of children
  • Almost 30% will have a recurrence, higher in younger children
  • Approximately 1% of children who have a febrile convulsion will go on to develop epilepsy.38
 
Scenario
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.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to mother and confirms their identity
Checks level of comfort offers analgesia
Establishes presenting complaint
Specifically enquires about:
– description of event
– location of event
– presence of limb jerking/body movement
– responsiveness during event
– duration of event
– events during recovery
– recent illnesses
Takes antenatal history
Takes birth history
Takes developmental history
Checks immunisation status
Asks about previous admissions, previous episodes
Asks about family history
Elicits mother's concerns
Explains likely diagnosis
Explains plan
Answers mother's questions appropriately
Checks mother's understanding of diagnosis and plan
Checks if mother has further questions
Global mark from patient
Global mark from examiner
39
 
Instructions for actor
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.
He had a high temperature and looked tired and lethargic. Suddenly, you noticed that he seemed to have stiffened up and shook his head and arms, his eyes rolled back in their sockets and it looked like he was having a seizure. It lasted for a minute or two and stopped on its own. You picked him up and he seemed unaware of what was going on around him. You immediately called the ambulance and tried to keep him on his side as advised by paramedics; soon after he appeared to fall asleep.
On further questioning, you remember that Zak had a similar episode 3 years ago, when he had a high temperature. He was kept in the hospital and tests were normal.
He is otherwise well and developing normally.
He is immunised appropriately and does not take any medications. His older brother has had a cold for the last week and he is recovering from it now.
There is no family history of epilepsy and you are scared that Zak may have developed epilepsy – you ask specifically about this if the doctor invites questions.40
 
1.13 Traveller's diarrhoea
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).
 
Approach to history
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.
Secondly, it is important to clarify some details related to the travel. Did the patient have any pretravel vaccination (e.g. for typhoid) or take any prophylaxis (e.g. for malaria). What preventive steps did they take during travel? Did they use mosquito nets? Where did they stay and what did they do? Were they on holiday or visiting family? Or was it a business trip, or charity work? What was their accommodation like (hotel, family home, cruise ship, rural or urban)? Did the patient take part in any particularly risky activities (freshwater swimming, unprotected sex, injected drugs)?
Next, enquire about food and drink. How careful were they about safe drinking water (did they use ice, or eat salads)? What did they eat? Did it include any uncooked or street food? Do they know if anybody else has been affected by the same symptoms?
Finally, come back to the subject of their health. Have they sought advice or taken treatment for this illness so far (if so what)? Do they have risk factors? Children warrant consideration of early antibiotic therapy but so do some adults (immunosuppression, chronic disease, pregnancy). Last of all, make sure that a broader differential diagnosis has been considered – irritable bowel syndrome, inflammatory bowel disease and C. difficile infection can all present in a patient who has recently travelled.
Table 1.13.1   Common pathogens in traveller's diarrhoea
Bacterial – commonest
Viral
Parasitic
  • Escherichia coli- enterotoxic or enteroinvasive – haemorrhagic
  • Shigella
  • Campylobacter
  • Salmonella
  • Others such as Vibrio, Yersinia
  • Rotavirus – children
  • Noroviruses – cruise ships
  • Giardia lambia
  • Entamoeba histolytica
  • Strongyloidis stercoralis41
 
Scenario
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.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Checks level of comfort offers analgesia
Establishes presenting complaint
Specifically enquires about:
– type of stool
– frequency in 24 hours
– duration of symptoms
– progression since onset
– blood or mucous in stool
– associated symptoms
Travel history:
– places visited
– duration of visits
– type of accommodation used
– other travellers affected
– other high risk behaviours
– pretravel vaccinations
Past medical history
Medications and allergies
Social history (and illicit drug use)
Elicits patient's concerns
Explains likely diagnosis
Explains plan
Answers patient's questions appropriately
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
42
 
Instructions for actor
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.
You did not eat or drink any raw food or juice and had been peeling fruits before eating. You only drank bottled water during your stay and you did not get any vaccination before travel.
None of your friends have had any problems and they have been there before. You are usually healthy and well with no medical problems and are not on any medications. You have not had any sexual relationships for the last year and do not take drugs.43
 
1.14 Haematuria
Curriculum code: CC1, CC12
History taking for haematuria is focused on finding the cause and assessing how sick the patient is.
Haematuria can be traumatic or nontraumatic. If there is any history of significant trauma and the patient presents with macroscopic haematuria, contrast-enhanced CT should be considered to investigate the extent of any kidney injury.
Causes of nontraumatic haematuria include urinary tract infection (UTI), kidney stones, bladder or renal cancer, urethritis and glomerulonephritis. While glomerulonephritis is more common in younger age groups, kidney stones are rarely seen in the young. Cancer is more common in older age. UTIs occur in both younger and older patients. Remember also that patients with coagulopathy or on warfarin can present with haematuria.
 
History to ascertain
  • Colour of urine
  • When noted
    • Initial phase of micturition suggests urethral bleeding
    • Towards the end suggests bladder neck or trigone bleeding
    • Urine mixed with blood could suggest pathology anywhere from bladder, ureter or kidneys
  • Whether passing clots which suggest bladder or renal (nonglomerular) bleeding
  • Whether symptoms are cyclical (endometriosis)
  • Any flank pain (stone, cancer, infarction)
  • Any fever, dysuria, frequency, suprapubic pain (cystitis)
  • Additional urinary tract symptoms (Table 1.14.1)
  • Additional history
    • Trauma or vigorous exercise
    • Medication (anti-inflammatories, anticoagulants)
    • Sexual history
    • Recent bacterial or viral infection may trigger glomerulonephritides
    • Chest symptoms such as haemoptysis, dyspnoea, pleuritic chest pain, epistaxis (Wegener's)
      Table 1.14.1   Lower urinary tract symptoms in men
      Overactive bladder
      Voiding
      Post micturition
      • Urgency
      • Increased day time frequency
      • Nocturia
      • Urinary incontinence
      • Hesitancy
      • Straining
      • Slow stream
      • Intermittency
      • Splitting or spraying
      • Terminal dribble
      • Post micturition dribble
      • Feeling of incomplete emptying
    • 44Systemic symptoms such as a rash, joint aches, myalgia (possible vasculitis)
    • Family history (polycystic kidney disease, clotting disorder).
 
Scenario
Mr David is a 53-year-old man presenting with blood in the urine. Take a history and make a management plan with him.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Checks level of comfort offers analgesia
Establishes presenting complaint
Specifically enquires about:
– onset of blood in urine
– progression of problem
– timing of blood in relation to urinary stream
– presence of pain
– passage of clots or difficulty passing urine
– associated symptoms
– bleeding tendency/anticoagulation
– any previous episodes
Past medical history
Sexual history
Medications and allergies
Social history
Elicits patient's concerns
Explains likely diagnosis
Explains plan
Answers patient's questions appropriately
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
45
 
Instructions for actor
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.
You are worried whether this is the cause and if anything can be done about it.
 
Reference
  1. Lower urinary tract symptoms in men. Clinical guideline 97. National Institute for Health and Care Excellence,  London, 2015. www.nice.org.uk/CG9746
 
1.15 Upper gastrointestinal bleeding
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.
 
Presentation
  • Haematemesis: Iron in haemoglobin in the blood is oxidised in the stomach and develops a dark ground coffee appearance. Therefore coffee ground vomitus usually indicates a slow bleed, unlike an actively bleeding varix or ulcer, which may present as vomiting fresh red blood.
  • Melaena: Black tarry stools result from slow passage of blood through the alimentary canal. Of note, patients can also have black stools due to iron supplementation.
  • Haematochezia or bloody stools: A large upper gastrointestinal (GI) bleeding may present with bloody stools. Patients are usually very unwell, as a large amount of blood must have passed through the bowel with very little transit time.
  • Non-Specific Symptoms: An upper GI bleed may not be immediately apparent as the underlying problem in a patient with syncope, angina, lethargy, confusion or abdominal pain.
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.
Non-variceal haemorrhage causes include peptic ulcer disease (PUD), gastroduodenal erosions and oesophagitis. Important things to elicit in the history include previous PUD, medications (anti-inflammatories, antiplatelets or anticoagulants) or a diagnosis of hiatus hernia or chronic heartburn symptoms. Malignancy and bleeding diathesis are less common causes of bleeding, but history of constitutional symptoms (e.g. weight loss, night sweats), or a bleeding disorder should be sought. A Mallory Weiss tear is caused by recurrent vomiting, and usually settles without the need for intervention.
The decision to discharge patients can be made objectively using the Glasgow—Blatchford score (Table 1.15.1). It uses clinical and biochemical indicators to identify low risk patients who can be managed safely as outpatients.
In addition there are important risk factors that should be assessed as part of the history. These risk factors help to predict adverse outcome after an upper GI endoscopy as part of Rockall score. Enquire about congestive heart failure, ischaemic heart disease, renal failure, liver failure or metastatic cancer.47
Table 1.15.1   Glasgow—Blatchford score
zoom view
 
Scenario
Mr Powell is a 45-year-old man presenting with dark stools. Take a history and explain a management plan.
zoom view
 
Instructions for actor
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.48
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Checks level of comfort offers analgesia
Establishes presenting complaint
Specifically enquires about:
– onset of blood in stool
– colour of blood
– quantity of blood
– progression of problem
– timing of blood in relation to stools
– associated symptoms
– any previous episodes
– bleeding tendency/anticoagulation
Past medical history
Medications and allergies
Social history
Elicits patient's concerns
Explains likely diagnosis
Explains plan
Answers patient's questions appropriately
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
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.
You are usually healthy and well, and have never needed to see a doctor. You get knee pain while driving and have been taking ibuprofen for the last 2 weeks. You felt some heartburn and indigestion, but it settled once you had some food. You drink 4–5 pints of lager at the weekends and have never abused any drugs.
You don't take any other medication. You have not lost any weight. You live at home with your wife and she is on her way to the hospital. You are concerned that you may have cancer as your father died of bowel cancer.
 
References
  1. Acute Upper GI Bleeding. Clinical guideline 141. National Institute for Health and Care Excellence,  London, 2012. www.nice.org.uk/CG141.
  1. Rockall TA, Logan RF, Devlin HB, Northfield TC. Risk assessment after acute upper gastrointestinal haemorrhage. Gut. 1996; 38(3):316–21.
  1. Stanley AJ, Ashley D, Dalton HR, et al. Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation. Lancet. 2009; 373(9657):42–47.49
 
1.16 Headache
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.
 
Types of headache
 
Subarachnoid haemorrhage
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.
 
Tension headaches
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.
 
Cluster headaches
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.
 
Migraines
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.
Caution should be exercised when diagnosing a migraine – particularly in patients with no relevant past history, as there are sometimes few distinguishing features between migraines and several serious pathologies.50
 
Raised intracranial pressure
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.
 
Temporal arteritis
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.
 
Other causes
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.
 
Scenario
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.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Offers analgesia
Establishes presenting complaint
Specifically enquires about:
– onset of symptoms
– nature and radiation of pain
– syncope
– vomiting
– relieving/exacerbating factors
– use of analgesia
Past medical history
Medications and allergies
51
Social history including illicit drug use
Elicits patient's concerns about managing work
Explains differential diagnosis
Explains plan: need for urgent investigations and likely admission
Answer, patient's questions appropriately
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
 
Instructions for actor
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.
You have had a headache for the last 2 months, which is gradually getting worse. It is mainly on the right side but also all over and feels like a general bad ache. It is worse in the morning and today it woke you up at 5 am and you felt very sick and your vision didn't seem quite right. The headache generally eases (but doesn't disappear) after you've been awake for a few hours. You have had no other symptoms. You've never had any headaches or any other medical problems in the past.
You take no medication, are a non-smoker and drink alcohol very rarely. You live alone and work full time. The headache is affecting your sleep and making you struggle with work. You have a family history of hypertension but nothing else.
You are very stressed as you are preparing for a parent's day meeting tomorrow and don't really want to stay for any tests.
 
Reference
  1. Headaches. Clinical guideline 150. National Institute for Health and Care Excellence,  London, 2012. www.nice.org.uk/CG150.52
 
1.17 Jaundice
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.
Initially, it is worth clarifying the time course over which the jaundice has developed and if it is still progressing. It is also worth finding out if the patient has any past experience of jaundice personally or within their family.
Additional symptoms that may be present are pruritus or a change in stool and urine colour. Further associated symptoms which may point towards the underlying cause are pain (presence or absence), fever, malaise, anorexia, weight loss or gain, rash and altered mental state. Jaundice without pain suggests the cause is more likely to be related to haemolysis, primary biliary cirrhosis or malignancy (pancreatic or hepatobiliary).
The causes of jaundice are traditionally divided into prehepatic, hepatic and posthepatic:
 
Prehepatic jaundice
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.
It may be associated with a haemoglobinopathy (such as sickle cell disease) or other conditions resulting in haemolysis (e.g. malaria or haemolytic-uraemic syndrome). Gilbert's syndrome is a common inherited disorder in which there can be episodes of mild hyperbilirubinaemia which settle spontaneously. These can be precipitated by intercurrent illness or stress.
 
Hepatic jaundice
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.
 
Posthepatic jaundice
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.53 Causes include impacted gallstones in the bile duct, primary biliary cirrhosis or sclerosing cholangitis and malignancy (commonly pancreatic in origin).
 
Scenario
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.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Offers analgesia
Establishes presenting complaint
Specifically enquires about:
– jaundice – onset, progression
– associated symptoms
– previous episodes
– contact history – foreign travel, sexual history
Past medical history
Medications and allergies
Social history - alcohol, smoking, illicit drugs, tattoos, occupation
Family history
Elicits patient's concerns
Explains differential diagnosis
Explains plan: need for further investigations
Answers patient's questions appropriately
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
54
 
Instructions for actor
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.
You have no other medical problems or any history of medications. You have not been abroad for many years, have never needed a blood transfusion and have only had one sexual partner in the last 20 years who is your wife. You drink half a bottle of wine a night and do not smoke or take any other drugs. You have never injected drugs.
You are worried that you are very dehydrated because you urine has become so dark but do not understand how that could be the case. You ask the doctor if they can explain why they think this has happened.55
 
1.18 Limping child
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.
Always begin an assessment of a child by confirming who the adult present is. The child's safety is paramount and it is vital to know whose care they are in. It is all too easy to assume a man is a child's father (or a woman their mother) when in fact it may be another family member, friend or teacher. This information also contributes to assessing the child's social situation and can occasionally be a cause for concern in itself.
The next step is to take a history relevant to the presenting complaint. In the case of a limp it is logical to begin with the nature and duration of the limp itself. It is clearly important to ask about recent trauma. However some caution should be used before attributing a limp to minor trauma as it is feasible that the trauma is coincidental and the limp represents an alternative pathology. Similarly, if a child is complaining of knee pain it is important to bear in mind that hip pathology can often cause pain that is referred to the ipsilateral knee.
Relevant question should be asked to address each of the following common causes of a limp:
 
Trauma
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.
 
Transient synovitis (irritable hip)
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
 
Septic arthritis
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.
 
Perthes’ disease
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.
 
Slipped upper femoral epiphysis
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.
 
Paediatric developmental history
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:
  • Did the pregnancy reach full term
  • Complications during pregnancy or delivery
  • Growth and feeding
  • Immunisations
  • Are developmental milestones being achieved
  • Are there any siblings and if so how is there health
  • What is the social situation at home, e.g. single parent family, financial situation, child-care arrangements, parental health
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.
For example, if talking to the mother of an 18-month-old called Poppy, consider asking: Was Poppy born on time? And was she born normally? Did you have any problems during the birth? Did Poppy have to go to Special Care when she was born? Did you both go home the same day or the next day? Has she had to come back into hospital for any reason since then? Did she smile, rollover and sit up at the same time as other babies of the same age? Do you have any concerns about how she's developing? Has she had all the immunisations that have been recommended? Who lives at home with you? Does Poppy have any brothers or sisters? Does she go to nursery?57
 
Safeguarding
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 Royal College of Emergency Medicine also has recommendations on how cases should be managed based on the level of concern.
 
Scenario
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.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and adult
Confirms the adult's identity and who has parental responsibility
Offers analgesia to patient
Establishes presenting complaint
Specifically enquires about:
– duration of limp
– nature of onset
– use of analgesia
– history of trauma
– history of recent illness
– any systemic symptoms now
– any similar problems in past
– developmental history as far as adult is aware
Past medical history
Family history
Social history - who is present at home, carers, nursery
Explains differential diagnosis
Explains need to examine the child fully
Explains plan: Pelvis and hip X-rays, blood tests
Explains need to speak to parent
58
Answers uncle's questions appropriately
Checks uncle's understanding of diagnosis and plan
Checks if uncle has further questions
Global mark from uncle
Global mark from examiner
 
Instructions for actor
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.
As far as you are aware he has had all his immunisations and there is no past medical history or family history of note. You do not have Jamie's red book. You gave him some paracetamol last night and some ibuprofen this morning but neither seemed to help. Jamie does not yet go to school, but he goes to nursery three times per week usually. He didn't go last week because he was unwell and isn't going this week because he's staying with you.
He is staying with you for the week while his parents have gone on a holiday for their wedding anniversary. You live with your wife and have no children of your own. You have his parents overseas phone number and do not mind if they are contacted.
 
References
  1. When to suspect child maltreatment. Clinical guideline 89. National Institute for Health and Care Excellence,  London, 2009. www.nice.org.uk/CG89
  1. Best practice for safeguarding children. Royal College of Emergency Medicine,  London:  2009. www.rcem.ac.uk59
 
1.19 Palpitations
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.
Some patients are able to give very clear descriptions of the nature of their palpitations. It may be possible to ascertain whether they are regular or irregular (in which latter case atrial fibrillation or ventricular ectopic beats are likely). In addition it is useful to know if they are fast or slow. Some people suggest patients tap out the rhythm of their palpitations to better inform the clinician.
Next it is important to ask about the duration of episodes and their frequency as well as any specific precipitants or relieving factors. Palpitations may be brought on by caffeine, stimulants (including recreational drugs) or stress. In the case of supraventricular tachycardia, patients may also become aware of specific manoeuvres that terminate episodes.
To clarify the degree to which a patient's physiology is compromised by these episodes it is important to ask about associated symptoms. Do patients lose consciousness or feel light headed? The severity of breathlessness, chest tightness or pain is an important consideration. However, these factors do not necessarily indicate the type of arrhythmia as most can cause a varying degree of compromise.
Past medical history, medications and family history may all assist in the assessment. Known or as yet undiagnosed medical problems may lead to palpitations e.g. hypertension, thyrotoxicosis and electrolyte imbalance.
Once these areas have been addressed clinical examination, blood tests and ECGs will provide further information. Subsequently a decision can be made as to whether a patient can be discharged home for outpatient investigation or needs to be admitted due to being at high risk of a significant arrhythmia or cardiac event.
 
Ventricular ectopic beats
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.
 
Supraventricular tachycardia
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
 
Atrial fibrillation/flutter
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.
 
Ventricular tachycardia
This fast regular arrhythmia is more common in elderly patients and particularly those with ischaemic heart disease.
 
Scenario
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.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Offers analgesia
Establishes presenting complaint
Specifically enquires about:
– nature of palpitations
– when episodes first began
– duration of recent episode
– frequency of episodes
– precipitating factors
– alleviating factors
– associated symptoms during palpitations
– elicits history of much lighter menstrual periods
Past medical history
Family history
Medications and allergies
Social history (and illicit drug use)
Elicits patient's concerns
Explains differential diagnosis
Explains plan: need for further investigations
61
Answers patient's questions appropriately
Shows empathy
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
 
Instructions for actor
You are Mary Forbes, a 26-year-old sports teacher in a secondary school. You have come to the ED because you had 30 minutes of palpitations after break-time at work. You felt your heart beating very fast and regularly. At the same time you felt breathless but did not have any pain, nor did you feel lightheaded. The palpitations settled after you arrived in the ED. Now you feel tired but otherwise ok. This is the third similar episode in 4 months and was the worst so far.
You have no other past medical history and take no medication. Over the past months you have lost weight unexpectedly and find you feel restless and hot a lot of the time and therefore don't sleep very well. If asked specifically, you report that your periods have recently become extremely light. There have been no other symptoms.
To keep going in the day you drink three or four coffees or may have an occasional energy drink. You do not smoke or drink alcohol. There are no medical problems in your family. You are worried, you might have a heart attack or cardiac arrest like you heard a sportsman did recently.62
 
1.20 Purpuric rash
Curriculum code: CC1, CC12, CAP28, PAP4, PAP6, PAP18, HAP28
Given the association with meningococcal sepsis this type of rash can cause much anxiety. Though it is indeed imperative to exclude serious infection as a cause there are several other causes for a purpuric rash that also need to be considered. Purpura or petechiae are caused by intradermal blood and may be caused by:
• Thrombocytopenia
Due to decreased platelet production in bone marrow
Increased platelet destruction (immune or non-immune mediated)
• Leakage from vascular walls
Vasculitis
Connective tissue disorders
• Trauma
The conditions in the list below (which is by no means exhaustive) represent some of those of which candidates should be aware.
 
Meningococcal infection
This should be considered for every child with a febrile illness and purpuric rash regardless of how well they initially look. Initially additional features may be non-specific symptoms of systemic upset such as poor feeding, lethargy, irritability or drowsiness. These may progress to headache, photophobia, neck stiffness, vomiting, seizures and collapse. The absence of any other features in a child with normal physiological markers is reassuring but discussion with someone senior is still advisable as even sick children may initially look quite well.
 
Idiopathic (immune) thrombocytopenic purpura
This condition results in autoimmune mediated platelet destruction. It normally presents acutely in children, approximately a week after a viral illness. Common features are bruising spontaneously or from minimal trauma, epistaxis, and potentially bleeding from other sites. In most cases, the condition is self-limiting though immunosuppression or splenectomy may be required.
 
Henoch–Schönlein purpura
This is a small vessel vasculitis. It may follow a viral illness and is common in young males but can affect any age group. There may be a low-grade temperature. One of the main features is a purpuric rash, which typically develops over the extensor surfaces and the buttocks. The rash may initially be urticarial. Additional features are joint pain, micro- or macroscopic haematuria, glomerulonephritis, abdominal pain and intussusception may occur. Those with renal involvement are followed up for a period of time to ensure they do not develop any progressive renal impairment. Though rare, gastrointestinal bleeding, ileus and central nervous system involvement are all possible complications.63
 
Trauma
Clearly this may explain what is essentially bruising and this should always be considered as a possibility. Consequently (and depending on the individual presentation), non-accidental injury is always in the differential diagnosis.
In order to assess the likely cause of a purpuric rash in a child a clinical assessment, a full blood count, clotting studies and a urine dip should normally be performed.
 
Scenario
Miss Ramesh has brought her 6-year-old son to the ED because he has developed a rash on his legs. Take a history from her and answer any questions she may have.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and parent and confirms their identity
Offers analgesia
Establishes presenting complaint
Specifically enquires about:
– onset of rash
– associated systemic upset – fevers, vomiting, malaise
– specific associated symptoms – joint pain, haematuria, epistaxis
– history of trauma
– developmental history, e.g. delivery, milestones, growth
Past medical history
Medications and allergies
Social history – who is present at home, carers, school
Acknowledges and discusses parent's concerns
Explains differential diagnosis
Explains need to examine the child fully
Explains plan: Blood tests, urine dip
Answers parent's questions appropriately
Checks parent's understanding of diagnosis and plan
Checks if parent or patient has further questions
Global mark from mother
Global mark from examiner
64
 
Instructions for actor
You have brought your 6-year-old son to the ED because when he woke up you noticed a new rash on his body at the top of both his thighs and buttocks. He also has an ache in his right knee but is able to walk normally. Neither the rash nor the ache was present yesterday. After checking on the internet you did the ‘glass test’ and when you pressed on his skin the rash did not go. The internet said this meant he had meningitis so you have rushed straight to the ED. The nurse took his temperature and it was 37.1°C.
He had a cough and cold last week but got better a few days ago. He has had no fever, diarrhoea, vomiting or other symptoms and you think he seems quite well.
He has recently been well otherwise and has no ongoing medical problems. He has not missed any of his immunisations. You, your husband and 2-year-old daughter all live together and everyone else has been well.
You want to know if he has meningitis and are frustrated by the doctor asking lots of questions you do not see the need for. However, if the doctor takes time to reassure you it helps you feel calmer and you answer the questions. Once the possible diagnoses are explained, you ask if there can be any serious consequences. If blood tests are suggested you do not object but ask if they are painful for a young boy.65
 
1.21 Sexual history
Curriculum code: CC1, CC12, HAP31
In the exam, it is common to be confronted by a station that demands candidates to ask sensitive questions of a reluctant patient. This task often takes the form of a sexual history, where the content of the history can be particularly delicate.
After an initial introduction to the patient it is important to build rapport and gain their trust by showing awareness that it is a sensitive subject. Candidates must demonstrate a high level of empathy. It is right to suggest the discussion takes place in a private room where the conversation cannot be overheard. Furthermore a reluctant patient may be reassured if they are reminded that everything they say is confidential.
When taking a sexual history, it will be necessary to ask for very intimate information. The best approach is to begin with one or two open questions to allow the patient to explain why they have come to the ED. Having done this, further focused questions should be asked. For these it is best to explain that you need to ask some personal but very important questions, and to acknowledge that they are difficult questions. It is crucial that all questions are asked in a ‘matter-of-fact’ manner and that any surprise at the answers is concealed from the candidate's face and voice. It is important to confirm:
  • Was the other person involved in the sexual contact male or female?
  • Where were they from?
  • Is the patient aware of whether or not the other person had any sexually transmitted infections (STIs) or medical problems?
  • What form did the sexual contact take? (vaginal, oral, receiving or giving anal sex)
  • Were condoms used?
  • Was the sexual act consensual?
  • Was it with a sex worker?
These questions should be asked for each sexual partner. It is also important to know if the patient has ever had a STI, and whether or not they are able to contact their sexual partners.
Following these questions it is then appropriate to continue by enquiring about the symptoms the patient is experiencing. Ask about both genitourinary and systemic symptoms. Following this, the remaining areas of a routine history should be covered. The social history should cover any further unanswered questions regarding on-going relationships.
Further management in this scenario should include a risk assessment for exposure to HIV or other STIs. This will be based on the information gathered from the history. A plan should then be discussed with the patient. It is almost always appropriate to advise or arrange follow up as soon as possible in a genitourinary medicine (sexual health) clinic. In the clinic further tests for STIs will be performed, and further management (including contact tracing) will be initiated as necessary. Until this follow-up appointment it is wise to recommend sexual abstinence or at least that barrier contraception is used until all test results are available.
In the exam, this often leads to a discussion about whether or not to involve the patient's partner. Clearly, if they are in a relationship where they have unprotected sex they may be putting their partner at risk. The patient must be made aware of this and strongly advised not to have unprotected sex. Under these circumstances patients should also be advised 66to inform their partner of what has happened. This obviously needs to be done in a firm yet supportive manner, as this will likely involve some very difficult conversations for the patient.
 
Further considerations
In cases where there is a medium or high risk of HIV transmission, consider treatment with post exposure prophylaxis, particularly if GU clinic follow up is not available immediately. Also, when the patient is a woman, it is appropriate to enquire as to whether or not emergency contraception is required. This could be in the form of a levonorgestrel pill, which is considered effective for 72 hours after sexual intercourse or an intrauterine contraceptive device, which is effective for 5 days after unprotected sex.
 
Scenario
Mr Smith is a 32-year-old man. He told the receptionist and the triage nurse that he needed to be seen because of a ‘personal problem’. Take a history from Mr Smith and explain your management plan to him.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Checks level of comfort offers analgesia
Comments on need for private room
Establishes presenting complaint
Reassures patient that discussion is confidential
Specifically enquires about:
– who sexual act was with?
– where person was from?
– any knowledge of their medical history
– were they a sex worker?
– nature of contact (penetrative, vaginal, anal, oral)
– use of condom
– any other sexual partners
– any history of sexually transmitted infections
Past medical history
Medications and allergies
Social history (and illicit drug use)
67
Elicits patient's concerns
Explains potential for infection
Explains plan: GU clinic, discuss telling wife
Answers patient's questions appropriately
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
 
Instructions for actor
You are a 32-year-old married sales assistant. You have attended ED today because you are worried about some penile discomfort you have had for a week. You are very reluctant to talk about your problem initially and are worried about other people overhearing or anyone else finding out. As you are embarrassed, you avoid giving specific details unless the doctor asks you direct questions.
You are concerned because while your wife was recently away you had sex with a woman you met in a bar. You both went back to your house and had unprotected penetrative sex twice. She then asked you for money before she left. You had no idea you had been expected to pay her and were shocked. However to avoid any further ‘trouble’ you did pay her.
You are worried about whether or not you have caught something and are not sure whether to tell your wife or not.
You have had no other symptoms apart from itching around your penis and have noticed some swelling in your groin. You have no past medical history, medications or allergies.
When the doctor suggests it, you become very upset at the idea of telling your wife what has happened. You are not sure she will forgive you. If the doctor understands and is sympathetic you accept you need to think about doing this.68
 
1.22 Cough
Curriculum code: CC1, CC12, CAP9
Certain causes for this presentation are discussed below. A cough can have a significant impact on individuals in terms of disturbance to daily life, particularly sleep, and also the degree of subsequent anxiety. Based on the history a candidate is required to derive the likely aetiology for this complaint and provide a sensible management plan for the patient.
Common causes for a cough are considered here:
 
Asthma
Wheeze, breathlessness, chest tightness and cough may be present in this condition. There is often diurnal variation in the symptoms. Patients may be aware of triggers for their symptom such as exercise, pets, pollen or cold weather. There may be an individual or family history of atopy. Wheeze may be present on auscultation of the chest.
In occupational asthma, symptoms are related to exposure to a specific trigger. Common professions to be affected are welders, spray painters and bakers.
 
Chronic obstructive pulmonary disease
A chronic cough is often present in this condition. Exertional breathlessness and sputum production are also common symptoms. There is usually a significant smoking history.
 
Infection
In cases of an upper respiratory tract infection (usually viral), the cough may be associated with a sore throat, coryzal symptoms and conjunctival irritation. It is not unusual for the cough to persist for several weeks. With lower respiratory tract infections (more likely bacterial), there is often a more significant degree of malaise. Fevers, rigors, breathlessness, green or yellow sputum and haemoptysis may all occur. These symptoms may also be present in pulmonary tuberculosis where in addition there may be weight loss. With infective causes in mind, care should always be taken to take a contact history and a history of recent and foreign travel.
 
Malignancy
Features that suggest a cough is caused by malignancy include weight loss, haemoptysis, a history of smoking and a history of previous cancer.
 
Post-nasal drip
This is a result of excessive secretions from the nasal mucosa. It can be a result of rhinitis, sinusitis and gastro-oesophageal reflux disease. The cough is often worse at night, and the patient may also complain of a sore throat.69
 
Drug induced
Angiotensin converting enzyme inhibitors cause cough in a significant minority of patients who are commenced on this treatment. Amiodarone, phenytoin, some antimalarial and several cytotoxic drugs can also cause damage to the lungs resulting in a cough.
 
Scenario
Mr Logan is a 23-year-old chef. He called an ambulance from work today as had a severe cough and couldn't breathe. He was treated on the way to hospital with nebulised bronchodilators and is feeling better. Take a history from Mr Logan.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Establishes presenting complaint
Specifically enquires about:
– onset of symptoms
– timing of symptoms – morning, evening
– associated symptoms – sputum, haemoptysis, fever, wheeze
– cardiac symptoms – dyspnoea, orthopnoea, ankle swelling
– contact history – foreign travel, Tuberculosis contacts
Past medical history - asthma, sinusitis
Medications and allergies
Social history (and illicit drug use)
Elicits patient's concerns
Explains differential diagnosis
Explains plan: need for further investigations, outpatient follow up
Answers patient's questions appropriately
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
70
 
Instructions for actor
You are Thomas Logan, a 23-year-old who called an ambulance because you couldn't breathe. Your chest felt tight and it had become hard to speak. You have had a cough and felt breathless every evening lately. The cough began about 4 weeks ago. You do not think anything specific triggered it. It began at the same time as you started a new job in a bakery. There has been no fever and you are not coughing anything up.
You have no other medical problems except hay fever and only take antihistamine tablets when necessary. You have not been abroad for many years. You live with your wife and neither of you smoke. You have no children or pets.
You are worried you may have cancer. You have seen public health advertisements saying a cough for more than 3 weeks can be serious. You don't understand why you got so breathless at work today when you spent the weekend away at the seaside feeling great.
 
References
  1. The British Guideline on the management of asthma. British Thoracic Society and Scottish Intercollegiate Guidelines Network. 2014. www.brit-thoracic.org.uk
  1. Chronic Obstructive Pulmonary Disease. Clinical guideline 101. National Institute for Health and Care Excellence,  London, 2010. www.nice.org.uk/CG10171
 
1.23 Myalgia
Curriculum code: CC1, CC12, CAP20, HAP18, HAP19
Like the last case, this OSCE begins with a non-specific presenting complaint – muscle pains. If the complaint relates to a specific region of the body this clearly points to a localised process (usually traumatic or, at least mechanical). However in cases of diffuse myalgia a more global underlying diagnosis should be sought.
Again with such non-specific presenting complaints the focus of the history can initially be unclear. The candidate must keep an open mind and allow their questions to be guided by the patient's responses. If a final diagnosis is unclear this may not be a problem as long as a sensible differential and management plan are formulated.
Aside from trauma, other common causes for a myalgia are considered below:
 
Rhabdomyolysis
There is a triad of weakness, muscle pain and dark urine (Figure 1.23.1). The main diagnostic test is an elevated creatine kinase. Causes are varied, but include trauma, infection, endocrine and metabolic disorders as well as drugs (recreational and prescription). The final common pathway is cell damage with release of intracellular components into the circulation. Electrolyte disturbance and acute kidney injury follow. Myoglobin is released into the urine causing a dark brown discolouration. Treatment is based on identifying and removing or treating the cause as well as supportive therapy – the mainstay of which is intravenous fluid therapy. Sometimes renal replacement therapy is needed.
zoom view
Figure 1.23.1: Myoglobinuria
72
 
Infection
Varying degrees of acute myalgia can occur during acute infection. In the context of a normal creatine kinase level no specific treatment is required except that for the cause.
 
Polymyalgia rheumatica
This condition results in pain and stiffness normally occurring in the back, shoulders, neck and hips. Sufferers tend to be over 60 years of age. It is associated with giant cell arteritis but they do not always occur together. Erythrocyte sedimentation rate (ESR) is often elevated but this is not diagnostic and creatine kinase levels are usually normal. Treatment normally comprises long-term steroids.
 
Fibromyalgia
This is a chronic disorder of altered pain perception and processing which results in muscle pain as well as several other symptoms. This is often a diagnosis of exclusion, and not one normally to be made in the ED. Treatment is based on analgesia and psychological therapies.
 
Polymyositis (or dermatomyositis)
These conditions result in proximal muscle weakness with pain being a less prominent feature as a result of skeletal muscle inflammation. They are associated with malignancy particularly if there are cutaneous features (dermatomyositis). Diagnosis is based on elevated creatine kinase, typical findings on electromyography, antibody testing and muscle biopsy. Management involves steroids or immunosuppressants and excluding malignancy as a cause.
 
Scenario
Mrs Ross is a 60-year-old lady who has presented to the ED with severe, all-over-body pain, which has developed over a few days. Take a history from her and explain your differential diagnosis and plan to her.
zoom view
73
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Offers analgesia
Establishes presenting complaint
– Asks pertinent questions regarding pain
Specifically enquires about:
– constitutional symptoms (fevers, night sweats, weight loss)
– system enquiry – gastrointestinal – appetite, vomiting, bowel habit
– system enquiry – respiratory – cough (productive), breathlessness
– system enquiry – cardiovascular – palpitations, chest pain, ankle swelling, orthopnoea
– system enquiry –genitourinary – polyuria, frequency, dysuria, haematuria
– system enquiry – neurological – headache, dizziness, visual problems
– system enquiry – musculoskeletal – limb weakness, rashes
Past medical history
Medications and allergies
Family history
Social history (and illicit drug use)
Elicits patient's concerns
Explains differential diagnosis
Explains plan: need for further investigations, outpatient follow up
Answers patient's questions appropriately
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
 
Instructions for actor
You are a 60-year-old teacher named Jeanette Ross. You called an ambulance and came to the ED because you feel very unwell. Over the past 3 days you have gradually developed pain in all the muscles of your body. Initially, it was a mild ache but now they are all quite painful and have become tender. You feel weak, clammy and tired. Also, if asked directly, you report that you noticed yesterday that your urine had become very dark. You have not passed urine at all today. You think this is strange, because you are drinking more water than usual in case you are dehydrated. You have had no other symptoms of note.
You are normally fit and well and have had no recent illnesses. Your only medical history is a mildly increased blood pressure and cholesterol. You also had your appendix removed when you were 17. You take ramipril and 2 weeks ago started taking simvastatin as your own doctor recommended.
You drink 2 or 3 glasses of red wine every week and do not smoke. You live with your husband who is well and have not recently been abroad.
If given the opportunity to ask questions you want to know why you feel so unwell and why your urine has become so dark.74
 
1.24 Transient ischaemic attack
Curriculum code: CC1, CC12, CAP37
A transient ischaemic attack (TIA) is a sudden-onset, focal neurological deficit caused by disruption of part of the cerebral circulation, which resolves completely in <24-hours. In fact, most true TIAs resolve within 10 minutes, and there is an increasing school of thought, which believes that anything lasting longer than 10 minutes should be classed as a stroke.
By far the most frequent cause is an embolus in the cerebral circulation. TIAs and strokes present with the same symptoms, the only difference being the degree to which they symptoms persist. As such they occur on a continuum and following a TIA a person is at higher risk of a stroke – hence the importance of prompt diagnosis and treatment of TIAs.
The history taking of a patient who may have suffered a TIA seeks to confirm the diagnosis and risk-assess the patient so further management can be planned. Though some presentations are typical, there can be wide variation in symptoms and signs depending on the cerebral territory involved (carotid or vertebrobasilar). TIAs do not normally present with loss of consciousness or seizure activity.
Possible differential diagnoses include hypoglycaemia, migraine (which may present without a headache) or focal epilepsy.
To assist in making the diagnosis of a stroke or TIA the recognition of stroke in the emergency room (ROSIER) scale can be used. Score 1 point for each of:
  • Asymmetrical facial weakness
  • Asymmetrical arm weakness
  • Asymmetrical leg weakness
  • Speech disturbance
  • Visual field defect
Subtract 1 point for each of:
  • loss of consciousness
  • seizure activity
If the total score is above 0, there is a high possibility of a stroke (once hypoglycaemia has been excluded). All of these features should be enquired about when stroke or TIA is considered.
In TIA patients with no on-going symptoms the ROSIER score is of no further benefit in terms of risk assessment. These patients should be assessed for their risk of stroke using the ABCD2 score (Table 1.24.1):75
Table 1.24.1   The ABCD2 score
Parameter of ABCD2 score
Score criterion
Score
Age
> 60
1
Blood pressure
> 140/90
1
Clinical features (maximum 2 marks)
Unilateral weakness
2
Speech disturbance
1
Duration of symptoms (maximum 2 marks)
> 60 minutes
2
10–59 minutes
1
< 10 minutes
0
Diabetes mellitus
Presence of disease
1
Patients who have had a TIA should be started on aspirin 300 mg daily and have admission or follow up arranged, according to local protocol. The higher the score, the higher the patient's risk of subsequent stroke, so the National Institute for Health and Care Excellence recommends that those with a score of 4 or above are assessed by a specialist within 24 hours while those with a score of 3 or less should have this assessment within a week. Practice varies in different departments as to whether high-risk patients are admitted or followed up within 24 hours as outpatients.
This scoring system does not take into account certain other variables that should also be considered. Patients who are having recurrent TIAs or are already on antiplatelet therapy or anticoagulation are also in a higher risk group and should be assessed sooner.
Before going home, it should be explained to all patients who have had a TIA that if symptoms recur they should come straight back to the ED – and if available locally they should be given details of the hyperacute stroke unit. It is also important to advise patients that after a TIA they must inform the Driver and Vehicle Licensing Agency and not drive for at least one month – depending on the type of license they possess.
 
Scenario
Mr Griffin is a 61-year-old man who has been brought to the ED by his wife. He had an episode of left-sided weakness earlier in the day. His blood pressure today is 132/68 mm Hg. Take a history from Mr Griffin. Then present your findings and explain your management plan to the examiner.
zoom view
76
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Establishes presenting complaint
Specifically enquires about:
– symptoms
– time of onset of symptoms
– persistence of symptoms
– nature of onset
– associated symptoms
– previous episodes
Past medical history
Enquires about diabetes control, blood sugar during/after episode
Medications and allergies
Social history – mobility aids, type of accommodation, carers
Social history (and illicit drug use) – smoking, occupation
Elicits patient's concerns
Explains differential diagnosis
Explains need to stop driving
Explains plan: need for further investigations, outpatient follow up
Answers patient's questions appropriately
Demonstrates knowledge of ABCD2 scoring and use
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from junior doctor
Global mark from examiner
 
Instructions for actor
You are Harry Griffin, a 61-year-old computer programmer. You have come to the ED with your wife because this morning after breakfast you suddenly found you couldn't move your left arm or leg. You had no other symptoms but struggled to stay upright in your chair. Luckily your wife was at home and you called her. Because you have type 1 diabetes mellitus she checked your blood sugar and it was 9.2 mmol/L. You waited at home to see if things would get better – your wife rang the general practitioner and left a message asking for a home visit. Your symptoms resolved within 5 minutes but when the doctor arrived he asked your wife to bring you straight to the ED.
You have been well recently and have no other medical problems apart from well-controlled hypertension. You are meticulous about controlling your blood sugar and it is normally around 7 mmol/L. You and your wife are both independent. You do not smoke; rarely drink alcohol and work from home so do not need to drive if the doctor advises you not to.
If you are asked about your concerns ask the doctor if you had (or are going to have) a stroke.77
 
References
  1. Diagnosis and initial management of acute stroke and TIA. Clinical guideline 68. National Institute for Health and Care Excellence,  London, 2008. www.nice.org.uk/CG068
  1. Scottish Intercollegiate Guidelines Network Guideline 108. Management of patients with stroke or TIA. SIGN 2008. www.sign.ac.uk
  1. At a glance guide to the current medical standards of fitness to drive. Driver's Medical Group, DVLA, Swansea. www.dft.gov.uk78
 
1.25 Weight loss
Curriculum code: CC1, CC12, C3AP4
The causes of weight loss are varied, as virtually any chronic condition may be a contributing factor. However in an emergency setting there are certain causes that should be considered and excluded early. These conditions are more likely to present to the ED with weight loss as a significant feature of the presenting complaint. In addition, given their acute nature, these conditions are more likely to require early diagnosis and treatment before possibly being followed up in an outpatient setting.
With presenting complaints which are as non-specific as weight loss, it is difficult to take a focused history. Initially, it is appropriate to enquire as to whether there are any associated features and then to perform a thorough system enquiry to elicit any facts that may identify the underlying problem.
Quantifying the degree of weight loss can also be difficult if a patient has not recently been weighed. It is however easy to ask if clothes have become looser or others have commented on a change in physical appearance. Also it is always worth clarifying whether or not the weight loss has been intentional, though if it is part of the presenting complaint this is unlikely. In basic terms weight loss is caused by:
  • An inadequate intake of calories
  • Poor absorption in the bowel
  • Poor utilisation by the body
  • A state of high energy usage caused by constitutional disturbance.
Weight loss, night sweats and fever are constitutional symptoms which when occurring in the context of lymphoma, are termed B symptoms. However these features can occur in malignancy or any infective or inflammatory process. Common causes for weight loss are considered below.
 
Malignancy
Generalised symptoms may include a past history of malignancy, anorexia, fevers and fatigue. To further localise any malignancy, a systems review aims to elicit further clues and clinical examination findings are also key. With regard to lung cancer, asbestos exposure and smoking history are crucial.
 
Tuberculosis
Initial symptoms are anorexia, fever, night sweats and fatigue. Pulmonary tuberculosis is the commonest form and presents with a persistent cough and possibly haemoptysis. Those most at risk are in contact with people from areas where tuberculosis is endemic. The incidence is also higher in those who are homeless, alcohol dependent or immunosuppressed by medication or other illnesses.79
 
Gastrointestinal pathology
Inflammatory bowel disease may cause altered bowel habit, the passage of rectal blood, abdominal pain and the constitutional symptoms listed above. Steatorrhoea may be present in coeliac disease or chronic pancreatitis.
 
Connective tissue disease
Acute flares of any connective tissue disease including vasculitis may cause weight loss. The symptoms are non-specific, but past medical history and associated findings from the history and examination may be suggestive of the underlying problem.
 
Diabetes mellitus
Weight loss is a common presenting feature of type 1 diabetes mellitus. It occurs with other features suggestive of hyperglycaemia such as polydipsia, polyuria, blurred vision and lethargy. There may be a family history of this or of other autoimmune/endocrine diseases.
 
Hyperthyroidism
In this condition, symptoms arise from the patient's increased basal metabolic rate. There is often weight loss with an increased appetite, heat intolerance, restlessness, sweating, diarrhoea, tremor and palpitations.
 
Scenario
Mr Stepping is a 27-year-old butcher. He has been brought into the ED today by his girlfriend as he seems too exhausted to do anything. She says he has lost a lot of weight recently and his clothes no longer fit him. Take a history from him and explain your differential diagnosis and management plan to him.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Offers analgesia
Establishes presenting complaint
Specifically enquires about:
– period and quantity of weight loss
80
– constitutional symptoms
– system enquiry – gastrointestinal – appetite, vomiting, bowel habit
– system enquiry – respiratory – cough (productive), breathlessness
– system enquiry – cardiovascular – palpitations, chest pain, ankle swelling, orthopnoea
– system enquiry –genitourinary – polyuria, frequency, dysuria, haematuria
– system enquiry – neurological – headache, dizziness, visual problems, limb symptoms
Past medical history
Medications and allergies
Family history
Social history (and illicit drug use)
Elicits patient's concerns
Explains differential diagnosis
Explains plan: need for further investigations, outpatient follow up
Answers patient's questions appropriately
Shows empathy
Checks patient's understanding of diagnosis and plan
Arrange for diabetes nurse/endocrinologist assessment
Checks if patient has further questions
Global mark from patient
Global mark from examiner
 
Instructions for actor
You are Tim Stepping, a 27-year-old man who works full time as a butcher. You have been brought to the ED today by your girlfriend. You didn't want to come, but she made you because you have been losing weight for the last month and guess you've lost at least 10 kg but you aren't sure.
Your clothes do not fit anymore. You have gradually begun to feel more and more tired and aren't sure why. You have been eating well and drinking well. In fact if asked specifically you realise you have been drinking all the time and passing urine a lot more than usual. You have even had to wake up in the night to pass urine. Your urine has been very clear and there has been no blood in it and no pain when you empty your bladder. You have otherwise felt ok. You have not been vomiting and have had no change in your bowel habit nor noticed any blood in your stools. You don't feel restless, just exhausted. You have not had any cough, fevers or sweats.
You have no past medical history and have not been abroad since going to Spain for a week 2 years ago. You live with your girlfriend and do not smoke or take any recreational drugs. You drink 4–5 pints of beer each week.81
You are adopted so you do not know if there is any family history of medical problems.
If the doctor mentions diabetes you are upset as you have colleague at work with diabetes that now needs dialysis. You are worried this means you will need dialysis too. You want to know who will give you help and advice on what to do next.
 
References
  1. Immunisation Against Infectious Diseases (The Green Book), 3rd ed. Department of Health, 2006. www.dh.gov.uk/greenbook
  1. Tuberculosis. Clinical guideline 117. National Institute for Health and Care Excellence,  London, 2011. Tuberculosis, 2011. www.nice.org.uk/CG11782
 
1.26 Shortness of breath
Curriculum code: CC1, CC5, CC12, CAP6, CAP9, HAP6
This is a common symptom for which the underlying pathology can be extremely varied. As well as first considering primary respiratory conditions it is necessary to also consider alternatives. These commonly include cardiac, renal, metabolic and haematological conditions to name only a few.
As always it is important to begin with open questions and allow patients the chance to tell their story. Further vital information is the time frame of the presenting complaint. Longer standing and progressive symptoms are likely to suggest chronic conditions such as chronic obstructive pulmonary disease (COPD), lung fibrosis or heart failure. This is in contrast to an acute or sudden onset of the problem which is more likely to suggest pulmonary embolism (PE) or pneumonia for example.
Next it is important to ask about associated features which may point to a likely aetiology or underlying diagnosis. A cough (whether productive or not), or wheeze are likely to suggest respiratory diagnoses. The presence of pain, depending on its characteristics, will allow consideration of cardiac causes, PE and pneumothorax. Orthopnoea, paroxysmal nocturnal dyspnoea (PND) and/or peripheral oedema are also important features suggesting heart failure.
With all broad presenting complaints always ask about further general/constitutional symptoms suggestive of an associated systemic process. Fever, weight loss, night sweats and loss of appetite are all important and identifying the presence (or absence) of these helps guide the diagnosis. Importantly they will also help understand the impact of the problem on the patient's daily life.
Questions regarding past medical history, medications and social history as always are vital. There may be relevant medical history or exposure to drugs and substances causing lung fibrosis or acute kidney injury (which may present as tachypnoea). Consider the patient's occupation in case it involves animals, feathers, dust, asbestos, etc., because these also point to specific diagnoses.
The best candidates are those who will also ask pertinent questions with the aim of understanding the impact of the problem on the patient's life. If it has not already been done, ask about the patient's exercise tolerance, their ability to cope with their day to day tasks and discuss any further concerns they have.
As always further investigations will be required. In addition the severity of the symptoms, the ability of the patient to cope and the likely underlying diagnosis will also guide whether they require admission.
 
Chronic obstructive pulmonary disease
Most candidates will be very familiar with this condition. Typical features are breathlessness, cough, sputum production and wheeze. It is usually associated with smoking, though emphysema can also be secondary to α1-antitrypsin deficiency. The severity may be reflected by previous admissions to hospital, numbers of medications, use of home nebulisers or oxygen, and exercise tolerance.83
 
Asthma
Intermittent shortness of breath, wheeze and cough are the typical symptoms of asthma. The breathlessness may be provoked by exercise, animal hair, cold air or allergens such as dust. If the cough is nocturnal it can have a significant impact on quality of sleep. Often there is a personal or family history of atopy. The patient's home circumstances may suggest a precipitant as could their occupation or work environment.
 
Heart failure
Causes of heart failure are varied. Symptoms depend on the underlying pathological process. Symptoms include shortness of breath which may be only exertional or progressive. Orthopnoea, paroxysmal nocturnal dyspnoea and a cough possibly productive of pinkish or frothy sputum are suggestive of left ventricular failure. Peripheral oedema and abdominal distension from ascites are suggestive of right ventricular failure.
These patients often have risk factors for hypertension or ischaemic heart disease, which are common causes. Additional clues to seek in the history are excessive alcohol use or a family history of heart failure (possibly including cardiomyopathy).
 
Pulmonary embolism
This is a possible diagnosis if the symptoms are of sudden onset and the breathlessness is associated with pain which is typically pleuritic, possibly with haemoptysis as well. Dizziness or collapse may also form part of the presentation. There may also be symptoms of calf pain or swelling suggesting a simultaneous deep vein thrombosis. Additional responses from the history help identify risk factors such as a previous venous thromboembolism, a recent operation resulting in immobility, malignancy, or a haematological disorder.
 
Pleural effusion
There are few symptoms specific to this except shortness of breath and possibly pleuritic chest pain. Patients may present acutely once the effusion has accumulated to the point where they are suddenly no longer able to compensate.
 
Scenario
Mr Bernacki is a 36-year-old business man who has come to the Emergency Department due to breathlessness. Take a history and explain the likely diagnosis and management plan.
zoom view
84
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Offers analgesia, ensures patient comfort
Establishes presenting complaint
Specifically enquires about:
– duration of symptoms
– presence of pain
– associated symptoms
– precipitating factors
– systemic features
– systems enquiry
Past medical history
Family history – heart disease
Medications and allergies
Social history (and illicit drug use) – smoking
Elicits patient's concerns
Explains differential diagnosis
Explains plan: need for further investigations
Answers patient's questions appropriately
Shows empathy
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
 
Instructions for actor
You are a 36-year-old business man named Jamie Bernacki. You have come to the hospital today because you have become very breathless. Your symptoms actually began a few months ago but you have been very busy and assumed you were recovering from a bad bout of flu.
At first you found you were breathless only when you walked a lot or did strenuous exercise. Over the last few weeks you have found that you are breathless even at rest. When you walk you get a mild ache in your chest but you have not had any pain. You have also started coughing and occasionally cough up some clear phlegm. You have gained weight and your ankles are quite swollen all the way up to your knees.
You have not been sleeping well because you have begun waking up in the night feeling panicked and breathless. You have added a second pillow when you sleep. You have attributed your sleep problems to lots of stress at work.
You are now breathless when you walk for 5 minutes on flat ground but used to be able to walk as far as you liked.
You have no other medical problems or medications. You smoke 10 cigarettes a day but do not drink alcohol. You have an uncle who had some heart problems. You think he had an operation for a new heart valve.85
 
1.27 Seizure
Curriculum code: CC1, CC5, CC12, CC13, CAP15, HAP15
Seizures are a common presenting complaint in the ED. The diagnosis of a seizure has significant implications for an individual in terms of lifestyle, employment, driving, insurance and possibly medication. Thus it should only be made when there is a relative certainty. History taking is key to distinguishing a seizure from other forms of collapse. The key features to consider and elicit during the history taking are described in Table 1.7.3. These relate to what happened before, during and after the episode in question:
  • Specific precipitants can include flashing lights, exhaustion, alcohol or drug withdrawal. Prior to the event was there an aura? Auras take the form of many sensory experiences, for example a strange sensation in the epigastrium, a hallucination or a sense of déjà vu. Was the onset sudden or gradual? Were there other preceding symptoms suggestive of syncope?
  • During the episode did the patient lose consciousness? What was the nature of any jerking movements and how long did these persist?
  • Afterwards was there a post-ictal phase and if so how long did it last? Can the patient remember events? Were there injuries, tongue biting or incontinence?
Seizures are either unprovoked or provoked. To identify those which are provoked questions must address the risk of electrolyte disturbance, hypoglycaemia, head injury, alcohol excess/withdrawal, cerebrovascular events or intracerebral neoplasm.
Ask questions about the patient's normal activities, work and hobbies to ascertain the risk to them if further seizures occur. Clearly activities such as window cleaning or open-water swimming will be extremely risky should a further seizure occur.
Other seizure types such as absence or complex partial seizures typically occur several times before the person or family seek medical help and are often not dealt with primarily in the ED.
Early neuro-imaging is required where:
  • the patient has not fully recovered,
  • the patient has focal neurological signs
  • there is focal or partial onset before generalization
  • there is a history of acute head trauma
  • malignancy is suspected
  • immunocompromise is suspected
  • HIV infection is suspected or already diagnosed
  • The patient is on anticoagulation.
Otherwise in patients with no ongoing symptoms or signs after a seizure, if baseline investigations are normal, further investigation can be on an outpatient basis, typically in a first fit clinic.
If a patient is to be discharged home for outpatient follow up they must first be given adequate information and advice. Alcohol and a lack of sleep can lower the seizure threshold. They must inform the driver licensing authority and must not drive until their follow-up appointment. Swimming, climbing and other isolated or high risk activities should be avoided because of the risks involved if there is a further seizure. Driving after a seizure is considered in section 2.8.86
 
Scenario
Miss Saul is a 28-year-old woman who has been brought to the ED by ambulance after a collapse at work. Take a history from her and explain your management plan.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Offers analgesia, ensures patient comfort
Establishes presenting complaint
Specifically enquires about:
– preceding symptoms
– description of events
– injuries sustained/tongue biting/incontinence
– recovery/post-ictal phase
– ongoing symptoms
– systems enquiry
Past medical history
Family history – epilepsy
Medications and allergies
Social history (and illicit drug use)
Asks specifically about driving
Elicits patient's concerns
Explains differential diagnosis
Explains plan: need for follow up and investigations
Answers patient's questions appropriately
Shows empathy
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
 
Instructions for actor
You are a 28-year-old woman named Katharine Saul. You work in a hotel reception at the front desk. You arrived in the ED by ambulance and cannot clearly remember what happened. You remember being at work and while sitting down having a strange ache in87 your stomach and feeling ‘not right’. After that you don't remember anything until arriving in the ED. A colleague of yours accompanied you to the ED and has since told you that you had glazed over in your chair and your whole body starting shaking. This lasted around 5 minutes. Colleagues lay you on the floor and called an ambulance.
You now feel exhausted but have no other complaints. If you are asked you become aware that your tongue is very sore and you may well have bitten it. Also if asked, you reluctantly admit that you were incontinent of urine and ask why this would happen.
You have recently felt well. You have no medical problems, take no medication, do not smoke and only drink alcohol occasionally on social occasions. You have an older brother who has epilepsy and takes tablets for it. You live with your partner and don't drive. You walk to work as it is not too far.
 
Reference
  1. Turner S, Benger J for the College of Emergency Medicine. Guideline for the management of first seizure in the Emergency Department. London: College of Emergency Medicine, 2009.88
 
1.28 Pelvic pain
Curriculum code: CC1, CC5, CC10, CC12, CAP1, CAP26, HAP1, HAP31
This is a challenging OSCE because there are several considerations which must all be managed well for a candidate to cover all relevant areas. In addition to the standard history this OSCE requires the asking of personal questions regarding gynaecological problems and a sexual history. It also requires appropriate questions to be asked to decide whether the lower abdominal symptoms are gynaecological or general surgical in nature.
Relevant questions must be asked to gain an understanding of the type of pain the patient is experiencing, as discussed in section 1.3. Low abdominal pain which radiates into the back or the legs is suggestive of a gynaecological cause. Uterine pain is often colicky and radiates to the sacrum. Ovarian pain is often located in an iliac fossa with radiation into the legs. Sudden onset pain may be related to ovarian torsion, a ruptured cyst or a vascular event. Pain that is more gradual in onset is more likely to arise from an inflammatory or infective problem.
Enquire whether the pain has any specific associations. Is it related to time of menstruation? Has the patient noticed vaginal discharge and if so what is its nature? Is the patient sexually active? If so, with whom? Based on this could she be pregnant or have been exposed to sexually transmitted infections?
Additional areas of the history relate to the patient's menstrual cycle. These include the date of the last menstrual period, whether it was normal in nature, its duration and the regularity of the cycle, and whether the patient usually experiences pain at any particular time during the menstrual cycle. Also take a brief obstetric history to discover whether the patient has been pregnant before and, if so, the outcome of each pregnancy.
In addition to asking the correct questions to gather necessary information, another important consideration during this OSCE is the nature of the information. Patients will be asked to discuss very personal and potentially embarrassing issues. These discussions must be handled in an extremely sensitive manner: this encourages the patient to be open and honest. It is helpful to say to the patient that many of the issues to be discussed are sensitive but they are important to help with correct diagnosis and management. Some related issues and taking a sexual history have already been covered in section 1.21.
Always consider pregnancy in patients who are sexually active.
 
Dysmenorrhoea
This is often physiological (or primary) and characterised by pain which occurs regularly at the beginning of a period. Pain commonly radiates to the back. It is crampy and in some patients is associated with nausea and vomiting. There should be no features in the history suggestive of alternative pathology. Initial treatment is anti-inflammatory drugs to reduce uterine contractions, which are due to excessive prostaglandin levels.
There are several causes for secondary dysmenorrhoea such as fibroids, endometriosis and chronic pelvic inflammatory disease.
 
Ovarian torsion
This results from an ovary twisting so that the respective blood vessels are occluded. Normally the arterial supply continues but venous outflow is restricted. There may89 be intermittent twisting and untwisting such that symptoms come and go. Pain is felt unilaterally and there is likely to be tenderness on abdominal and pelvic examination.
 
Pelvic inflammatory disease (PID)
This refers to infection which is ascending or spreading from the cervix. Symptoms are variable on a spectrum of acute to chronic or low-grade disease. Common symptoms include lower abdominal pain, vaginal discharge, fever, nausea and vomiting. Long-term consequences include decreased fertility and an increased risk of ectopic pregnancy.
Although in some patients PID is secondary to instrumentation during procedures, in the vast majority it is due to sexually transmitted infection, usually in young women. In addition to identifying and treating the infection, it is necessary to advise patients to refrain from sexual activity; if the cause is a sexually transmitted organism, contact tracing is likely to be required. It is advisable to refer the patient to a genitourinary medicine clinic. In sexually active women, always consider whether the patient could also be pregnant.
 
Ectopic pregnancy
This typically presents with unilateral lower abdominal pain, which may be followed by vaginal bleeding. The patient may experience a collapse or complain of shoulder tip pain. Risk factors relate to preceding disruption of the normal anatomy in a way that affects the transit of the fertilised ovum. These include pelvic inflammatory disease, endometriosis, previous surgery, the presence of cysts, tumours or a contraceptive device, and previous ectopic pregnancy.
 
Endometriosis
In this condition endometrial glandular tissue occurs in areas outside the uterus. Symptoms are variable depending on the extent and areas involved. Some women experience no pain; others have significant pain. Pain may be cyclical and occur during menstruation. Additional symptoms commonly include dyspareunia and dysmenorrhoea.
 
Scenario
Miss Wilkes has come to the Emergency Department with lower abdominal pain. Take a history from her and explain your differential diagnosis and management plan.
zoom view
90
Pass
Fail
Introduces self to patient and confirms their identity
Offers analgesia, ensures patient comfort
Establishes presenting complaint
Specifically enquires about:
• duration of symptoms
• nature of pain
• associated symptoms
• systemic features
• systems enquiry
• relevant sexual history
Gynaecological/obstetric history
Past medical history
Family history
Medications and allergies
Social history (and illicit drug use)
Elicits patient's concerns
Explains differential diagnosis
Explains plan: need for further investigations
Answers patient's questions appropriately
Shows empathy
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
 
Instructions for actor
You are a 26-year-old woman named Jenny Wilkes. You work as a primary school teacher. You have come to see a doctor because you have been getting lower abdominal pain for several weeks and today it was worse than previously. The pain is central and constant but sometimes gets worse and other times is not so bad. For the past 2 weeks you have noticed a vaginal discharge which is continuous, light and blood stained. You've lost your appetite but have had no other symptoms. Your pain is controlled by paracetamol and dihydrocodeine but you are worried about what's causing it.
Your periods are regular, every 4 weeks, and you have not noticed any significant changes to them.
You had sexual intercourse around 10 weeks ago with a man you met at a friend's party. You have not been sexually active since and have no regular partner. You have never been pregnant.
You occasionally have migraines but have no other medical problems or medications. You are allergic to penicillin which causes a very bad rash. You smoke 10 cigarettes a day and drink two or three glasses of wine each week.91
 
1.29 Ankle swelling
Curriculum code: CC1, CC5, CC12, CAP20, HAP18, HAP19
This is not an unusual presentation to the ED. In addition to the normal history, key questions to ask relate to:
  • Location – is it just the ankle or how far up the legs does the swelling extend? Is it unilateral or bilateral?
  • Time frame – did it begin suddenly or gradually? Has it been progressively getting worse or remained the same over time? Does it fluctuate, sometimes seeming better and then worse?
  • Precipitants – have there been recent illnesses, trauma or bites?
  • Associations – are there any additional symptoms that the patient is aware of?
As always ask about the impact of the presenting complaint on the patient's day-to-day life.
 
Deep vein thrombosis (DVT)
This is typically unilateral and of relatively acute onset. It is likely to be associated with pain and tenderness. This is distinct from many other causes of peripheral oedema where there may be a mild ache. The history will reveal whether there are risk factors such as a previous venous thromboembolism, immobility following a recent operation, malignancy or a haematological disorder. In patients diagnosed with DVT, always consider whether there could be an associated pulmonary embolus (see section 1.8 and 1.26).
 
Cellulitis
In cellulitis there is likely to be a change in the colour of the overlying skin, which will appear erythematous. The area may feel warm to touch and be tender. Often there is a predisposing condition such as recent trauma, diabetes mellitus or immunosuppression. The patient may also be systemically unwell with additional features suggestive of sepsis.
 
Heart failure
Causes of heart failure are varied and should also be considered to include respiratory conditions that lead to cor pulmonale. Symptoms include one or more of shortness of breath (exertional or progressive), orthopnoea or paroxysmal nocturnal dyspnoea. Peripheral oedema and abdominal distension from ascites are suggestive of right ventricular failure.
 
Liver or renal disease
Ask the patient about jaundice, pruritus and abdominal swelling. Also ask about the presence of any more generalised swelling and whether there have been any changes when the patient urinates (frothy urine in nephrotic syndrome).92
 
Additional causes
Additional causes of ankle swelling include thyroid disease, venous outflow compression secondary to malignancy, and medication.
 
Scenario
Miss Newchase is a 58-year-old woman who has presented because over the past week her left leg has become very swollen. Take a history from her and explain your management plan to her.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Offers analgesia, ensures patient comfort
Establishes presenting complaint
Specifically enquires about:
• duration of symptoms
• presence of pain
• associated symptoms
• precipitating factors
• systemic features
• systems enquiry
Past medical history
Family history
Medications and allergies
Social history (and illicit drug use)
Elicits patient's concerns
Explains differential diagnosis
Explains plan: need for further investigations
Answers patient's questions appropriately
Shows empathy
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
93
 
Instructions for actor
You are a 58-year-old woman named Denise Newchase. You have come to the hospital because over the past week your left leg has become quite swollen to the point that it is difficult to walk. The skin feels tight but there is no actual pain. Your other leg is fine. You can't think of any reason for this to have happened and have never had a similar problem before.
Over the last few weeks you have had an ongoing lower abdominal ache which is fairly continuous. Your abdomen is slightly swollen and you have not been eating very much as you haven't had an appetite. You think you may have lost a few pounds but do not weigh yourself. You have no other symptoms.
You have no other medical problems and take no medication. You work as a waitress, have no children and are not married. You do not smoke and you drink a small glass of red wine each evening.94
 
1.30 Non-accidental injury
Curriculum code: CC1, CC5, CC6, CC7, CC12, CAP38, PAP6, HAP34
NAI must be considered during every consultation that involves a child. Though there are several forms of child abuse, for example neglect or physical, sexual or emotional abuse, the following discussion and OSCE relates to NAI presenting with physical injuries. The key challenge is to recognise features of the presentation that are of concerning because they are suggestive of NAI, and then to be able to explain those concerns to family, carers or other staff in as non-confrontational and constructive a manner as possible.
There are specific features relating to a presentation that may indicate NAI. These are divided into those relating to the history, the examination or observed behaviour within the department. Clearly these features do not always represent NAI but their presence should increase a clinician's level of concern and prompt more thorough consideration.
 
Features of history suggesting potential NAI
  • The history changes when retold
  • The mechanism is not consistent with the injuries
  • The mechanism is not consistent with the child's developmental age or ability
  • There has been unreasonable delay in seeking medical attention
  • There have been multiple previous attendances
  • The child directly reports NAI
 
Features of examination suggesting potential NAI
  • Burns suggesting immersion in water
  • Cigarette burns
  • Linear marks from belts or sticks (or fingers from slapping)
  • High energy fractures not in keeping with age or mechanism
  • Bruising in young or immobile children
  • Injuries to the buttocks or perineum
  • Retinal haemorrhages
In addition, the child's behaviour and interaction with staff and parents or guardians may also be revealing. Is the child unusually withdrawn? Does the child make eye contact? Does the child appear to have an appropriate rapport or interaction with parents or guardians?
To fully understand and evaluate any concerns, a thorough history of any incident must be taken. Ideally the history would first be taken from the child and then also discussed with whoever else is present. It is important to understand the mechanism involved. Clarify:
  • Who else was present or in the vicinity at the time?
  • Who identified or noticed the injury (particularly if the mechanism is unknown)?
  • If there was a delay in attending hospital, was there a reasonable explanation?
  • What are the circumstances at home – who lives in and visits the house?
  • Has there been previous involvement with social services?
Also take a standard medical history to ensure legitimate medical pathology is not mistaken for NAI; for example, bruising or fractures may have been caused by an undiagnosed pathological process.
95If a presentation causes concern regarding possible NAI, the case should be discussed with a senior doctor within the department or a member of the hospital's child protection team. If it is agreed that there is sufficient concern it will be necessary to involve social services. In the short term, hospital admission may be necessary. Remember to check if there are other children at home who could be at risk.
 
Discussing concerns with parents or guardians
Once possible NAI has been raised as a concern, it will be necessary to discuss this with whoever is accompanying the child. Judgement and extreme tact are required for this. It may be tempting to simply delay treatment of an injury to ‘buy time’ so relevant discussions can be had by staff. However, if additional staff are going to see the child or if short-term admission is required it will probably be necessary to explain what is happening and, to some extent, why. Anyone accompanying a child with a seemingly minor injury who is then told the child needs to be admitted will ask why that is necessary.
Depending on the situation it is usually best to be honest but non-confrontational. Remember that it is rarely appropriate to diagnose NAI in the ED; the task is simply to recognise that NAI is a real possibility. Hence it is reasonable to explain that what is being done is in the best interests of the child and is for the child's safety, and that further assessment by more senior or experienced staff is needed. Do not directly accuse anyone of child abuse.
The adult who has accompanied the child is likely to be upset or angry and offended; be prepared for this. Remember that even if this is truly a case of NAI, this adult may not be the person responsible for inflicting the injury. The discussion involves some elements of breaking bad news. Allow the person time to understand the situation, allow silence while they are thinking, be supportive if they are upset and remain calm if they become angry.
 
Treating the injury
While considering these issues ensure that any injuries are treated appropriately and without delay. Ensure the child is comfortable, pain free and receiving whatever medical treatment is required.
 
Scenario
Bobby is a 5-year-old boy who has been brought to the ED from school because he had been crying with back pain. You have already examined him and found a mark on his back which looks like a burn from an iron. He also had some linear bruising on the backs of both his thighs. He is too upset to tell you how he got them.
His mother has just arrived after being phoned by the school. Take a history from her and explain your management plan to her.
zoom view
96
MARK SHEET
Achieved
Not achieved
Introduces self to mother and confirms her identity
Explains Bobby is safe and she can see him soon
Asks what mother knows so far
Explains Bobby's presentation to the ED
Enquires about his injuries
Specifically enquires about:
• mechanism of burn
• who was present
• what was done about the burn
• reason for not seeking medical attention
• mechanism of marks on legs
Detailed social history – family structure, siblings, problems at home
Ask about previous involvement of social services
Past medical history
Family history
Medications and allergies
Explains appropriate treatment for burn
Explains concerns about cause of injuries
Explains need to involve senior doctor/child protection team member
Supportive communication with mother
Explains the priority is Bobby's health/safety
Answer mother's questions appropriately
Shows empathy
Checks mother's understanding of diagnosis and plan
Checks if mother has further questions
Global mark from mother
Global mark from examiner
 
Instructions for actor
You are a 26-year-old mother named Naomi Clark. You have come to the ED because you received a phone call from your son Bobby's school saying he had been taken to hospital because of an injury to his back. You are anxious and upset when you arrive. You want to know what happened to Bobby's back.
If prompted or asked by the doctor you realise the concern is about a burn he got from an iron 3 days ago when playing in the sitting room. You weren't there at the time but Bobby's step-sister told you what happened. She had been ironing when Bobby knocked the ironing board over and the iron landed on his back. When you came home you ran the burn under cool water and gave him some pain killers. You talked to your husband, who is not Bobby's father, and together decided the burn wasn't too bad and would get better. Bobby is often looked after by his older step-sister Jenny who is 15 years old. You moved in with your husband and his daughter Jenny 8 months ago.
97You do not know about any marks on Bobby's legs but know he normally has some bruises from bumping into things.
Bobby has no medical problems or medicines. He is developmentally normal and otherwise well. He has no contact with his own father. You are a care worker and work shifts, so you often get his step-sister to look after him when she's not at school. Your husband works in an office as a salesman. You have never had any reason to worry about either of them looking after Bobby.
You don't see what all the fuss is about as children are bound to get some injuries from ‘messing around‘. Initially you are dismissive but when you realise the doctor is worried about the injuries you become angry. You feel that you are being treated as a liar and you are scared that the staff think you are a bad mother. You become very angry and defensive. You want to see Bobby and take him home. You are tearful and lose your temper.
You love Bobby and can see that looking after him is most important. Regardless you are still upset by the implication that someone has hurt him. You are also scared and angry that staff will want to take him away.
If the doctor is reassuring and explains they are trying to do the right thing for Bobby you slowly calm down. If their tone is aggressive or accusing you continue to be upset, angry and only wanting to leave.
If it has not been explained you, also ask if Bobby has been given some pain-killers, how his burn will be treated and what is going to happen next.
 
References
  1. When to suspect child maltreatment. Clinical guideline 89. National Institute for Health and Care Excellence,  London:  2009. www.nice.org.uk/CG89
  1. Best practice for safeguarding children. Royal College of Emergency Medicine,  London:  2009. www.rcem.ac.uk98
 
1.31 Visual disturbance
Curriculum code: CC1, CC5, CC12, CAP17, CAP 29, HAP17
Visual disturbances represent a variety of pathologies which may be due to a local or a central problem. As always the key is to identify instances that may lead to serious outcomes such as blindness. Begin by letting the patient explain the nature of the problem and then ask specific questions that will help to identify a possible aetiology.
Clarify whether there is actual loss of vision, blurring of vision, decreased colour vision or double vision.
 
 
Nature of visual loss
  • What was the speed of onset? If gradual how long has it developed over? Sudden onset disturbance may suggest a vascular cause. However beware the fact someone may become aware of a problem ‘suddenly’ when it has gradually progressed to reach a certain threshold.
  • Which areas of vision are involved? It may be the entirety or only a specific quadrant, half or region, say the centre, of the visual field.
  • Are one or both eyes involved? Where both eyes are involved pathology is likely to be central whereas if only one eye is involved it is likely to be within the eye or optic nerve distal to the optic chiasm.
  • What is the timescale? Is the defect intermittent, persistent, improving or getting worse?
  • Is there a loss of colour vision? This is typical of optic nerve pathology.
 
Double vision
  • If double vision is present ask about the images. Are they next to or above each other? In which direction of gaze is double vision present or worst?
 
Pain
  • The presence, nature and location of pain or discomfort is important. It may be within the eye, retro-orbital or better described as a headache.
 
Additional symptoms
  • Are there other visual symptoms such as haloes, flashing lights or strange patterns overlying images?
  • Does the eye get red or watery?
  • Does the eyelid seem to droop?
  • Is there an associated headache?
  • Are there any other focal neurological symptoms?
 
Migraine
Flashing lights or additional patterns such as zig-zag lines are associated with migraines, retinal detachments, or occipital lobe pathology. The onset, time course and association with headache/nausea will guide a candidate to this diagnosis. Clearly past medical history 99and previous episodes may also support this. Important differentials are space occupying lesions or intracerebral bleeding as discussed in section 1.16.
 
Giant cell arteritis
As well as transient visual loss a patient may complain of general malaise, scalp pain/tenderness and jaw claudication. The condition may progress to permanent vision loss and if not treated the other eye is also at risk. It is uncommon below the age of 50 years and is often associated with polymyalgia rheumatica.
 
Optic neuritis
There is progressive loss of visual acuity over a short number of days. The condition is usually painful and eye movements may hurt. Colour vision also deteriorates. This condition is associated with demyelinating diseases and diabetes. Vision may recover over a few weeks depending on the underlying cause.
 
Retinal detachment
This may be spontaneous or secondary to trauma. Patients experience flashes or floaters as well as loss of vision in the associated visual field and decreased visual acuity.
 
Papilloedema
This may result in blurring or loss of vision that lasts a few seconds. It may be monocular or binocular and symptoms may arise when activities cause raised intracranial pressure such as straining or bending down. Additional medical history or systems enquiry may indicate a systemic cause.
 
Glaucoma
In acute glaucoma a patient may report blurred vision or seeing haloes around lights. There may be severe pain with nausea/vomiting, decreased visual acuity and a fixed pupil.
 
Amaurosis fugax
This is transient visual loss which is typically described as a sensation that a curtain falls across over the visual field. It is commonly caused by a thromboembolic event but can also be caused by giant cell arteritis.
 
Central retinal artery or vein occlusion
These present with sudden visual loss which may only involve part of a visual field if a branch of the main retinal vessels is involved.100
 
Scenario
Miss Murray is a 64-year-old woman who has come to see a doctor because of problems with her vision. Take a history from her and explain your management plan to her.
zoom view
MARK SHEET
Achieved
Not achieved
Introduces self to patient and confirms their identity
Offers analgesia, ensures patient comfort
Establishes presenting complaint
Specifically enquires about:
• nature of vision loss
• relevant features of vision loss
• presence of pain
• presence of double vision
• associated symptoms
• precipitating factors
• systemic features
• systems enquiry
Past medical history
Family history
Medications and allergies
Social history (and illicit drug use)
Elicits patient's concerns
Explains differential diagnosis
Explains plan
Answers patient's questions appropriately
Shows empathy
Checks patient's understanding of diagnosis and plan
Checks if patient has further questions
Global mark from patient
Global mark from examiner
101
 
Instructions for actor
You are a 64-year-old woman named Jackie Murray. You have come to the ED because of problems with your vision. While reading the paper with your breakfast this morning you lost vision in your right eye for a few minutes. It was like something had covered your eye. Gradually it got better on its own. Now your vision is back to normal. You have never had anything like this before.
You are due to see your own doctor later in the week because you haven't felt well for several weeks. You've been feeling tired with most of your body seeming to ache and have also had a headache mainly on the right side of your head which is there most of the time. You haven't noticed anything making these problems better or worse.
You are normally fit and well, take no medications and have no allergies. You live alone, don't smoke and rarely drink alcohol. You work part-time as a secretary.102