OBJECTIVE)STRUCTURED)CLINICAL)EXAMINATION)(OSCE’s)) ! There!are!5!stations:! 1.! History)Taking)) 2.! Physical)Examination) 3.! Clinical)Reasoning)) 4.! Clinical)Communication)Skills)) 5.! Procedural)Skills)) ! How$much$time$do$I$get$at$each$station?$$
What$can$they$ask$me$about?$$
! ! ! What$are$some$typical$presenting$complaints?$ Chest!pain,!SOB,!dizziness,!abdominal!pain,! nausea/vomiting,!diarrhoea,!headache,!special!senses! (hearing/vision),!joint!pain,!cough,!collapse,!tiredness,!fever!! $ $ !
STATION)1)–)HISTORY)TAKING)!
! This!station!is!designed!to!allow!you!to!demonstrate!your!skills!in!taking!focused!or!systematic!medical!histories!from!patients.!! It!will!also!test!your!ability!to!develop!rapport!with!your!patient.!!The!examiner!will!let!you!know!when!there!is!1!minute! remaining,!and!you!must!give!the!examiner!your!provisional)diagnosis!(but!you!will!not!be!asked!to!justify!this).! ! EXAMPLE! Clinical'Scenario:'Christine)Black,)45yo)lady!complaining!of!urinary!frequency!and!lethargy.!She!is!seeing!you!for!the!first!time.!' ! Candidate!Tasks! 1.! You!have!eight)(8))minutes)to)take)a)history.!You!are!to!interact!with!the!patient!as!in!a!consultation.!! 2.! The)examiner)will)observe)and)notify)you)when!there!is)one)(1))minute!remaining.!! 3.! In!the!final!minute,!you!need!to!conclude)the)consultation)and)provide)one)(1))likely)provisional)diagnosis.!You!do)not) need)to)justify!this.!! 4.! Do!not!make!any!inferences!based!on!the!appearance!of!the!simulated!patient! ! MARKING)SHEET! Score)sheet)–)How)well)were)the)components)demonstrated?) 1.!General) Introduces!self!to!patient! Speaks!clearly!and!fluently! Conveys!caring!and!empathic!manner! Clear!communication!skills!O!verbal!and!nonOverbal! Good!use!of!open!and!closed!questions! 2.!History)of)Presenting)Complaint) Presenting!complaint!clearly!identified!) NILDOCAAFIAT!specifics! Timeline!of!symptoms!clearly!elicited! 3.)History)of)Presenting)Systems)&)Systems)Review) Red!flags!noted!! Systems!review!adequately!performed!in!sufficient!depth! 4.)Important)Past)History)Items) PMHx!! PSH!! Medications/allergies! Substance!Use!! Screening/Immunization/Diet/Exercise!noted! 5.)Social)History)&)Conclusion) Social!History!! Provisional!Diagnosis! Overall)impression)and)comments!
!
Rated!from:!! Not!at!all! Poorly! Partially!! Well! Very!Well!
Overall:!! Unacceptable! Not!satisfactory! Borderline! Satisfactory!! Proficient!
STATION)2)–)PHYSICAL)EXAMINATION)!
! The!physical!examination!station!requires!you!to!demonstrate!focused!or!systematic!physical!examination!skills!on!a!simulated! patient.!!You!will!be!given!a!clinical!scenario!(eg.!presenting!complaint!or!diagnosis_!and!asked!to!perform!the!appropriate! examination!or!examination(s).!!You!may!find!your!scenario!requires!a!combined!examination!approach!(eg.!SOB!–!combine! Resp!and!CVS).!!You!will!be!required!to!explain!to!the!examiner!throughout!your!examination!what!you!are!looking!for!and!what! you!might!expect!to!find!in!the!particular!clinical!scenario.! ! It!is!not!expected!that!you!will!be!able!to!complete!a!comprehensive!examination!within!8!minutes.!!For!this!reason,!the! examiner!has!been!instructed!to!politely!interrupt!you!and!ask!you!to!move!on!so!that!you!might!demonstrate!a!wide!range!of! examination!techniques!during!the!time!frame!(eg.!you!may!be!asked!to!move!on!before!completing!your!full!peripheries! inspection!or!your!complete!lung!auscultation.!!The!examiner!may!ask!you!to!perform!only!part!of!an!examination!(eg.!examine! only!the!first!5!cranial!nerves).!!However,!it!is!up!to!the!examiner,!not!the!student,!to!decide!which!parts!other!examination!may! be!omitted.!!! ! You!must!treat!the!simulated!patient!with!the!same!respect!and!professionalism!as!a!real!patient.! ! All!required!equipment!will!be!provided!by!the!School!of!Medicine,!but!you!are!allowed!to!bring!your!own!stethoscope,!if! preferred.!! ! EXAMPLE! Clinical'Scenario:))The!patient!you!are!about!to!examine!is!Matthew)Smith,)a)68)year)old)man!who!has!presented!with!acute!left! sided!abdominal!pain!and!recent!change!in!bowel!habit.!) ! Candidate!Tasks:! 1.! You)have)eight)(8))minutes)to!perform!an!appropriate)examination.!! 2.! Explain)to)the)examiner)during)the)examination)the)reasoning)for)the)examination)that)you)do)and)the)specific)findings! that!you!may!expect!in!a!patient!with!this!presentation.!! ! MARKING)SHEET! Score)sheet)–)How)well)were)the)components)demonstrated?) 1.!Introduction)and)Consent) Candidate!introduces!self!–!name!and!role! Explains!examination/s!!&!!obtains!consent!! Washes!hands!! Interacts!with!simulated!patient!appropriately! Appropriate!exposure!! 2.)General)Observations)) Discusses!general!appearance!! Dependent!on!required!examination! 3.)Appropriate))Examination)) Dependent!on!required!examination! 4.)Appropriate))Examination)) Dependent!on!required!examination! 5.)Appropriate)Examination) Dependent!on!required!examination! Overall)impression)and)comments)
Rated!from:!! Not!at!all! Poorly! Partially!! Well! Very!Well!
Overall:!! Unacceptable! Not!satisfactory! Borderline! Satisfactory!! Proficient!
! Notes:! O! All!equipment!required!for!this!station!will!be!supplied! O! You!may!bring!your!own!stethoscope!and!watch! O! If!fundoscopy,!otoscopy!is!indicated!please!MENTION)THIS!to!the!examiner,!but!you!will!not!be!expected!to!do!it!! !
STATION)3)–)CLINICAL)REASONING)!
! The!Clinical!Reasoning!station!is!designed!to!assess!the!following!skills:! O! !Your!ability!to!formulate!differential!diagnoses!from!a!medical!history!provided!to!you! O! Your!ability!to!do!an!oral!presentation!of!your!clinical!reasoning!to!another!medical!professional! O! Your!ability!to!justify!your!choices!of!differential!diagnoses!in!a!logical!manner!and!in!response!to!questioning!! ! EXAMPLE! Clinical'scenario:''The!patient!in!the!next!room!is!Thomas)Brown,)a)42)year)old)man!who!presents!complaining!of!rectal! bleeding.!!You!have!been!given!this!patient’s!history.' ! !
Candidate!Tasks:! 1.! You!have!a!total!of!four)(4))minutes!to!peruse!this!information!! •! two!(2)!minutes!in!the!perusal!time!and!! •! a!further!two!(2)!minutes!after!the!station!begins.!The!examiner!will!notify!you!when!you!need!to!start!talking.! 2.! You!then!have!six)(6))minutes!to!discuss!with!the!examiner!three)possible)differential)diagnoses,)starting)with)the)most) likely)diagnosis.! ) 3.! You!should!include!positive)and)negative)features)of)this)history!which!support!or!refute!your!diagnoses.! ' MARKING)SHEET! Score)sheet)–)How)well)were)the)components)demonstrated?) ' 1.)General)–)summary) ' Organised!summary!of!diagnoses! ' Logical!structure!to!presentation! ' Appropriate!diagnoses!chosen! Prioritises!diagnoses! ' ! ' Rated!from:!! Overall:!! 2.)Differential)Diagnosis)ONE) ' Not!at!all! Unacceptable! Diagnosis:! ' Appropriate!supportive!points! Poorly! Not!satisfactory! ' Appropriate!negative!points! Partially!! Borderline! Logical!presentation!of!reasoning! ' Well! Satisfactory!! 3.)Differential)Diagnosis)TWO) ' Very!Well! Proficient! Diagnosis:! ' Appropriate!supportive!points! ' Appropriate!negative!points! Logical!presentation!of!reasoning! ' 4.)Differential)Diagnosis)THREE) ' Appropriate!supportive!points! ' Appropriate!negative!points! ' Logical!presentation!of!reasoning! ' 5.)Adequate)Reasoning! Oral!presentation!O!clear!and!fluent!! ' Appropriate!medical!terminology!used! ' No!major!hesitation! ' Minimal!irrelevant!material!included! ' Overall)impression)and)comments! ' Notes:' O! !Your!reasoning!will!be!based!on!history!alone!–!including!HPC,!HPS,!systems!review!and!past!medical!history!! O! You!will!not!be!given!examination!findings!or!investigation!results!to!interpret!! !
STATION)4)–)CLINICAL)COMMUNICATION)SKILLS))! ! This!station!will!test!your!ability!to!communicate!with!patients!in!varying!and!difficult!circumstances.! ' EXAMPLE) Clinical'Scenario:!You!are!a!medical!student!on!clinical!placement!in!general!practice.!!Your!next!patient!is!Grant!Writer,!a!60yo! man.!!The!GP!is!running!late,!and!asks!you!to!interview!Graham!regarding!a!particular!health!or!behavioural!issue.! ! Candidate!Tasks:! 1.! You!have!a!total!of!eight)(8))minutes!to!! •! Assess!Grant! •! Convey!to!the!examiner!(when!asked)!your!assessment!of!Grant!! •! Utilize!strategies!learnt!in!Clinical!Communication!Skills!to!communicate!with/counsel!the!patient!appropriately!! ) MARKING)SHEET! Score)sheet)–)How)well)were)the)components)demonstrated?) 1.!General)communication) Uses!active!listening!skills!and!open!questions! Asks!for!clarification;!paraphrases;!summarises!to!check! understanding! Picks!up!cues!from!patient! Shows!empathy!&!sensitivity!to!patient’s!concerns! 2.)Consultation)structure) Logical!and!organized!structure! ! 3/4/5)Criteria)dependent)on)case) Overall)impression)and)comments!
!
Rated!from:!! Not!at!all! Poorly! Partially!! Well! Very!Well!
Overall:!! Unacceptable! Not!satisfactory! Borderline! Satisfactory!! Proficient!
STATION)5)–)PROCEDURAL)SKILLS))!
! The!Procedural!Skills!station!is!designed!to!test!your!competency!in!basic!procedural!skills!learned!in!Years!1!and!2!PSWs.!!You! ma!be!required!to!report!findings!to!the!examiner.! ! EXAMPLE)! Clinical'Scenario:''You!have!been!asked!to!perform!the!following!procedural!skill/s.!!The!equipment!required!for!the!task!is! provided!at!the!station.' ! Candidate!Tasks! 1.! You!have!seven)(7))minutes!to!do!the!following!procedural!skill/s..! 2.! After!7!minutes,!the!examiner!will!stop!you.!You!then!have!one)(1))minute)to)report)your)findings!to!the!examiner!or! answer)the)examiner’s)questions.) ! MARKING)SHEET)) Rated!from:!! Overall:!! Score)sheet)–)How)well)were)the)components)demonstrated?) Not!at!all! Unacceptable! 1.!General)communication) Poorly! Not!satisfactory! Communication!skills! Consent! Partially!! Borderline! 2/3/4/5)Criteria)dependent)on)case) Well! Satisfactory!! Criteria!are!taken!from!the!PSW!competency!sheets ! Very!Well! Proficient! ) Notes:! O! !You!will!be!asked!to!perform!a!skill!on!either!a!simulated!patient,!partOtask!trainer!or!mannequin! O! You!are!not!required!to!verbalise!your!actions!to!the!examiner!during!this!station,!however!they!can!ask!you!to!clarify! technique! O! You!will!NOT)BE)EXAMINED)ON)CANNULATION)OR)VENEPUNCTURE! ! ! !
YOU)MUST)PASS)ALL)5)STATIONS)TO)PASS)
GOODLUCK)!)! ! ! !
! ! ! ! HISTORY!TAKING! ! ! ! ! ! ! ! ! ! !
History Presenting Complaint & HPC For each symptom SOCRATES (UK) or NILDOCAAFIAT (UQ) Site Onset (sudden/gradual) Character Radiations Associations (e.g. pain with food intake) Timing (duration) Exacerbating and alleviating factors Severity (1-10)
Family History (FH) Nature Intensity Location Duration Onset Contributing factors Aggravating factors Alleviating factors Frequency Impact Attribute Treatment
Past Medical History (PMH)
• • • •
Social History (SH) • • • • •
Hospital visits, previous illness, previous operations
• •
•
Specifically: diabetes, asthma, bronchitis, TB, jaundice, high BP (don’t say hypertension), heart disease, stroke, epilepsy, peptic ulcers
•
•
Medications - tablets, injections, prescriptions, herbal remedies, the pill
•
Allergies & adverse drug reaction
•
Vaccination history
• • • •
Indications to ask – urethral/vaginal discharge, genital ulcer/rash, abdominal pain, pain on intercourse Last date of intercourse, # partners, homosexual/bisexual, prostitutes Type of sexual practice (vaginal, oral, anal, ano-oral) History of sexual abuse
All women; esp. abdominal pain, ? endocrine disease, genitourinary symptoms Date of last menstrual period, whether or not periods are regular Age at menarche, whether menopause has occurred Symptoms related to menstruation – pain etc.
Alcohol – average per day, CAGE (Cut down, Annoyed, Guilty, Eye opener) Smoking - pack years (= # of packs (20 cigarettes) smoked per day * # of years patient has smoked)
Recreational drugs
Systems Review •
General - weight loss, night sweats, lumps, fevers, fatigue / malaise / lethargy, appetite, sleeping (sleepiness, early waking, being woken by pain), itch / rash, recent trauma
•
Cardio-respiratory - chest pain, dyspnoea (exertional, PND, orthopnoea), oedema, palpitations, cough, wheeze sputum production, haemoptysis
•
Gastrointestinal – abdominal pain, difficulty / pain on swallowing, indigestion, nausea / vomiting, change in bowels (constipation / vomiting), stools (colour, consistency, blood, slime, difficulty, urgency, tenesmus)
•
Genitourinary – incontinence, dysuria, haematuria, nocturia, frequency, polyuria, hesitancy, terminal dribbling
•
Neurological – sight, hearing, smell, taste, seizures, faints, dizzy spells, headaches, paraesthesia, limb weakness, poor balance, function
•
Musculoskeletal – pain / stiffness / swelling of joints / muscles, changes throughout the day, functional impact
Menstrual History • • • •
Home life – marriage, children, living situation Vocation - job, education, hobbies, spouse’s job Mobility – need for walking aids, stairs in home Diet – average day Exercise
Substance History
•
Sexual History
Do any conditions run in the family? Parents, siblings, grandparents etc. (pedigree) Alive – health, age, any conditions, similar presenting complaint Dead – age at death, cause of death
! ! ! ! SYSTEMS!SUMMARIES! ! ! ! ! ! ! ! ! ! !
Gastrointestinal System Presenting Complaints
Examination
•
Appetite changes – anorexia, hyperphagia
•
Weight loss (malabsorption, malignancy, diabetes, thyroid, IBD, eating disorder, depression)
•
Weight gain
•
•
Dysphagia (oesophagus, nodes, goitre)
Mental state – alert, confused, coma
•
•
Indigestion / heartburn – reflux
Body habitus – weight, wasting, oedema, hydration
•
Nausea / vomiting – onset, frequency, contents (infection, inflammation, obstruction)
•
Colour – pallor, jaundice, haemochromatosis
•
Vital signs – Temp, HR, BP, RR, O2
•
Haematemesis – frank or coffee ground (ulcer, varices, Mallory Weiss tear, malignancy)
•
•
Abdominal pain – colicky (biliary, GI), severe (peritonitis)
•
Jaundice (haemolysis, liver, biliary)
Hands – leukonychia (↓albumin), koilonychia (spooning, ↓iron), clubbing (cirrhosis, IBD), pallor in palmar creases, palmar erythema (oestrogen), wasting, dupuytren’s contracture
•
Change in bowel motions – volume, frequency, consistency, colour, tenesmus, blood
Patient History •
PMH – abdominal surgery
•
Family – colorectal cancer, haemochromatosis, IBD, ulcers
•
Medications – NSAIDs (ulcers), metformin (diarrhoea), opioids (constipation), antibiotics (bowel changes), bisphosponates (oesophagitis), SSRIs (nausea)
•
Social – smoking, alcohol, IV drugs, travel, vaccinations, birth country
Patient lying supine with one pillow Inspection • General – age, gender, comfort/distress
•
Hepatic flap
•
Arms/shoulders – spider naevi (oestrogen), bruising, wasting, scratch marks (?obs jaundice)
•
Eyes – xanthelasma, icterus, conjunctival pallor, uveitis, KayserFleisher rings (Wilson’s disease)
•
Salivary glands – parotid & submandibular glands & ducts
•
Lips – hydration, agular cheilitis, ulceration, pigmentation, telangiectasia
•
Mouth – foetor, stomatitis, candidiasis/leukoplakia (L won’t scrape off, C will), gums, glossitis, central cyanosis, teeth
Red Flags •
Lymph nodes – cervical & axillary
•
Chest – spider naevi (oestrogen), loss of hair distribution, gynaecomastia (oestrogen)
•
Abdomen – scars, striae, bruising, stoma, distension (8 Fs), masses, veins, peristalsis, pulsations
Palpation • Superficial – tenderness, masses •
• • • •
Deep – masses, guarding, rigidity, rebound tenderness, McBurney’s point,Rosving’s sign Liver & gallbladder (Murphy’s sign) Spleen Kidneys Abdominal aorta
Percussion • Liver • Bladder • Shifting dullness Auscultation • Bowel sounds • Epigastric bruits • Renal bruits Other •
• • •
DRE – inspection (fissure, fistula, tags, blood, rash, ulcer, mucus); palpation (wall consistency; prostate size, surface, tenderness) Urinalysis Pregnancy test Bowel chart
• • • • • • • • • • • • •
Sudden onset of pain Increasing severity of pain Syncope / pre-syncope Vomiting Haematemesis Abdominal distension Pallor & sweating Tachycardia & atrial fibrillation Hypotension Fever Rebound tenderness, guarding, rigidity Oliguria / anuria Positive pregnancy test
Respiratory System Presenting Complaints •
Cough – nature, onset, wet (viral, LRTI, COPD, bronchiectasis), dry (viral, asthma, GI reflux, restrictive, ACEi), night (asthma LVF, post-nasal drip), morning (smoking), whooping, bovine (laryngeal nerve), croup
•
Sputum – colour, volume, type (purulent, mucoid), blood
•
Haemoptysis – acute (malignancy), chronic (bronchiectasis), pink frothy (pulmonary oedema)
•
Dyspnoea / shortness of breath – onset, nocturnal (asthma/LVF), on waking (COPD), duration, relieving factors, severity, exertional change
•
Wheeze (high pitch) – when, ∆ with coughing, exercise (asthma)
•
Stridor (inspiratory rasp) – onset (respiratory obstruction)
•
Chest pain – nature, intensity, exertional change (chest wall, pleura or mediastinal causes)
•
Sleep apnoea – snoring or waking up dyspnoeic (airway obstruction)
•
Voice change - dysphonia, aphonia
Patient History
Examination Patient sitting upright, general inspection then entire back exam → entire front exam Inspection • General – age, gender, body habitus, oxygen equipment, posture (?dyspnoeic), respiratory distress, cough, sputum •
Hands – clubbing (pus in lungs), peripheral cyanosis, wasting (brachial plexus), pallor in creases
•
Asterixis (CO2 retention)
•
Radial pulse, respiratory rate, breathing (Cheyne-Stokes = alternating, Kussmaul = shallow)
•
Eyes – conjunctival pallor, Horner syndrome (miosis, partial ptosis, lower lid elevation, enopthalmos, anhydrosis)
•
Nose (straight in) – polyps, enlarged turbinates, displaced septum
•
Mouth – central cyanosis, erythema, tonsils, exudates, candidiasis
•
Voice
•
Sinuses – frontal, ethmoidal, maxillary
•
Lymph nodes – cervical & axillary
•
PMH – hay fever, eczema, HIV
•
Trachea – cartilage, tug, deviation
•
Family – atopy, CF, α1-antitrypsin, TB asbestos, same symptoms
•
•
Occupation – asbestos, chemicals
•
Meds – ACEi, β-blockers, NSAIDs
Chest – shape, symmetry, scars, tattoos, scoliosis, pigeon chest, funnel chest, barrel chest, breathing
•
Social – smoking, travel, pets
Red Flags Palpation • Back – chest expansion, tenderness, spring chest (front, back, sides), tactile fremitus • Front – tenderness, tactile fremitus, apex beat (lying) Percussion • Lungs (remember dullness over liver & heart) Auscultation • Breath sounds - vesicular (normal), bronchial (hollow, consolidation) •
Added sounds – stridor (inspiratory, upper airway obstruction) wheezing (narrowed airways), crackles (fine=fibrosis, medium=pulmonary oedema, coarse=pneumonia/COPD), pleural rub (pneumonia, infarction)
•
Vocal resonance
Other • • •
Temperature Pulse oximetry Spirometry – FVC, FEV1, PEFR
•
Haemoptysis – URTI, LRTI, bronchiectasis, bronchial carcinoma
•
Sudden onset dyspnoea – ? PE or pneumothorax
•
Sudden onset stridor – anaphylaxis, inhaled foreign body, acute epiglotitis (may block airway), gas inhalation
Cardiovascular System Presenting Complaints •
•
•
•
Chest pain – crushing (MI), angina (tight, retrosternal, exertional), sharp inspiratory (pericarditis, pleuritic), interscapular (dissecting aneurysm, back pain), acid taste/burping (GI reflux), chest wall (costochondritis, rib fracture, skin) Dyspnoea – precipitating factors, exertional (CCF, angina), orthopnoea (CCF, LVF), paroxysmal nocturnal dyspnoea (LVF, silent MI) Palpitations – fast (SVT, heart cond., hyperthyroid, stress, meds), slow Peripheral oedema – where, when, pitting (CCF), generalised (kidney, liver), unilateral (DVT, lymph obstr.)
•
Syncope / pre-syncope –postural (postural hypotension), lightheaded, sudden collapse (arrhythmia)
•
Sputum – pink frothy (LVF)
•
Leg pain – calf (DVT), exertional (intermittent claudication)
Examination Patient sitting initially and lying at 45° (starting at neck) Inspection Sitting • General – age, gender, comfort, dysmorphism (Downs, Turner, Marfan), mental state, body habitus, oedema •
Surroundings - cigarettes, O2 devices, GTN spray, holter monitor, ECG leads
•
Colour – pallor (anaemia/ vasoconstriction), cyanosis
•
Hydration status
•
Hands – pallor of nail bed, peripheral cyanosis, capillary refill, clubbing (congenital heart disease, IE), xanthomata, signs of infective endocarditis (Janeway lesions, splinter haemorrhages, Osler nodes)
•
Patient History •
•
PMH – HTN, lipids, BMI, diabetes, CKD, AF, previous cardiac events, rheumatic fever, renal disease, Marfan / Downs / Turner syndrome Family – IHD, lipids, HTN, CKD, DM, sudden cardiac death
•
Meds – T4 (angina), β-agonists (↑HR), β-blockers (↓HR)
•
Social – smoking, IV drugs (IE), alcohol (AF, HTN), job (pilot / driver)
Arms - radial pulse (rate, rhythm), radio-radial delay (aortic coarctation, subclavian stenosis), respiratory rate, blood pressure (+pulsus paradoxus)
•
Eyes – xanthelasma, conj. pallor
•
Mouth – central cyanosis, higharched palate (Marfan), gums, dentition (poor → ?IE)
•
Neck (lying 45°) – JVP, carotid pulse (rhythm, character)
Red Flags Chest Lying 45° • Inspection – scars, deformities, pacemaker / defibrillator, visible apex beat •
Palpation - apex beat, thrill (LVF), heave (palpable murmur)
•
Diaphragm of steth (A,P,M,T,axilla) – heart rate, heart sounds (S1, S2, S3, S4), carotid, murmurs (intensity, timing, location, breathing insp→↑right, exp→↑left)
•
Bell of steth – mitral area
•
Left lateral position (MS)
•
Sitting forward holding breath after expiration (AS, AR, pericardial rub)
Abdomen • Palpate – tenderness, masses, organomegaly, AAA • Back Sitting • • • •
Auscultate – aortic, renal, iliac, femoral bruits
Inspect – scars, deformities Palpate – sacral oedema Percuss – lung bases (effusion) Auscultate – lung bases
Lower Limbs • Inspection – varicose veins, colour, trophic ∆s (thin/dry/shiny skin, hair, nails, ulcers), xanthomata, clubbing • Palpation – temp., tenderness, pulses (F, P, PT, DP), pitting oedema
•
Irregularly irregular pulse (arrhythmia e.g. AF)
•
Six Ps (acute limb ischaemia) – pallor, pulseless, pain, paraesthesia, perishing cold
•
Unilateral leg swelling (DVT)
•
Very sudden & severe tearing pain (thoracic aortic dissection)
Musculoskeletal System Presenting Complaints •
Pain – site, symmetry, radiation, mono/polyarticular, acute/chronic, bone, nociceptive/neuropathic, inflammatory/noninflammatory
•
Morning joint stiffness – brief & worse w/ movement (osteoarthritis) vs. prolonged & improved with exercise (rheumatoid arthritis)
•
Muscle stiffness (polymyalgia rheumatica)
•
Joint abnormalities - locking (loose body, meniscal tear), instability (ligamentous stretching / rupture), triggering (tendon thickening)
•
Swelling – location, shape, size, consistency, surface texture, mobility, tenderness, pulsation
•
Tenderness (inflamm., infection)
•
Skin changes – erythema, shiny skin, ulceration, rash (psoriasis, SLE)
•
Loss of function
•
Other symptoms – fever, weight loss, bowel symptoms, urethritis, uveitis, conjunctivitis, dry mouth
Red Flags • • • •
Regular night sweats Unintentional weight loss Constant (day & night) pain >50 or <20 years old
• • • •
Significant trauma History of cancer or osteoporosis IV drug user Immunosuppressed
Knee Examination Look • •
General – age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast) Rashes, scars, erythema, swelling, gluteal folds, popliteal folds, bursae (supra-, infra-, pre-patellar)
•
Muscles (wasting, spasm) – esp. quadriceps
•
Deformities – genu valgum (knock-knee), genu varum (bow-leg), genu recurvatum (back-knee)
•
Gait & posture – leg length, 10 steps, sitting, squat
Feel • •
Quadriceps - tenderness, wasting, spasm
•
Bursae – supra-/infra-/pre-patellar, popliteal Bony landmarks – joint line, femoral condyles & epicondyles, fibular head, Gertie’s tubercle, patella
•
Simple backache – mechanical pain in 20-55 y.o.
•
Nerve root pain – unilateral leg pain, motor / sensory change
•
Ligaments & tendons – M & L collateral ligaments, biceps, semimembranosus, semitendinosus tendons
•
Patella tap – slide hand down thigh to upper edge of patella, tap on patella (clunk → effusion)
•
Bulge test – stroke hand medial, up & around to lateral patella (bulge in medial patella → effusion)
Cauda equina syndrome – urinary/ faecal incontinence, perineal anaesthesia, leg weakness
Patient History •
PMH – joint or back problems, IBD, anterior uveitis, urethritis, malignancy
•
Family – RA, OA, gout, osteoporosis
•
Meds – analgesics, NSAIDs
•
Loss of function – brushing teeth (elbow), buttoning shirt (wrist, hands, walking (lower limb)
Move Supine, stabilise pelvis with other hand Active → passive (crepitus) → resisted •
•
Collateral ligament stress test – supine (once 20° once straight); brace medial knee & apply varus force (medial collateral ligament), brace lateral knee & apply valgus force (lateral collateral ligament)
•
Anterior & posterior draw test (start by looking for posterior draw) – sit on patient’s foot, both hands around upper tibia, thumbs over tibial tuberosity, pull forwards (anterior cruciate lig), push backwards (posterior cruciate lig) (laxity/pain)
•
Lachman’s Test (anterior cruciate ligament) – supine, 15° of flexion, examiner’s knee under their knee, stabilise femur & apply pressure to posterior upper tibia (laxity/pain)
•
McMurray’s test – valgus force on lateral knee, flex to 90°, hold sole of foot, rotate leg internally & extend knee (lateral meniscus); varus force on medial knee, flex to 90°, hold sole of foot, rotate leg externally & extend knee (lateral meniscus) (pain)
•
Apply’s grind test – prone, knee flexed to 90°; compress knee while internally & externally rotating (medial & lateral menisci), pull on knee while internally & externally rotating (collateral ligaments)
Skin temperature
•
•
Special Tests • Patella apprehension (patella dislocation) – apply laterally directed force on medial patella with thumbs (feels like patella will dislocate)
Flexion (closing), extension (opening), internal rotation, external rotation
Hip Examination
Ankle & Foot Examination
Spinal Examination
Look •
Look •
Look •
General – age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast)
General – age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast) Footwear – abnormal, asymmetric, poor fit, orthotic
Deformities (true/false scoliosis), swelling, scars, gluteal folds, popliteal creases, ASIS level
•
•
Muscles (gluteus, adductors, iliopsoas, quads) – wasting, spasm
•
Ankles – swelling, bruising, deformities, tibialis posterior, FDL, FHL
•
Gait & posture – walking 10 paces, sitting, squatting
•
Feet – posture, arch, skin changes, colour, swelling, rashes, ulcers, infection ,calluses, plantar surface
•
Toes – alignment (straight, hammer, claw, mallet), nail changes, swelling, hallux valgus (bunions)
•
Feel Supine • Swellings (hernia) •
Landmarks – greater trochanter of femur, ASIS, PSIS, ischial tuberosity, pubic symphysis
•
Muscles – gluteus, adductors, iliopsoas, quadriceps
•
Leg length – true (ASIS → medial malleolus) vs. apparent (umbilicus → medial malleolus)
Move Supine, stabilise pelvis with other hand Active → passive → resisted •
Flexion (anterior), extension (posterior, prone), adduction (medial), abduction (lateral), internal rotation, external rotation
Special Tests •
Thomas test (fixed flexion hip deformity) – patient supine, bring knee a to chest (leg b raises off ground → deformity in leg b)
•
Trendelenberg test (glut med weakness, short femoral neck, unstable hip) – hold patient’s hands, ask them to stand on foot a and lift foot b off ground (hip b falls)
Feel •
Temperature
•
Ankle – distal 1/3 of fibula, malleoli, tendons (peroneal, tibialis posterior), joint line, PT pulse
•
Foot – navicular bone, calcaneus (medial tubercle), MTP & IP joints, metatarsal heads, tendons (TA, FHL, FDL), DP pulse
Move Active → passive → resisted •
Tibiotalar joint – dorsiflexion, plantar flexion
•
Subtalar joint – inversion, eversion
•
Chopard’s joint – toe dorsiflexion & plantar flexion
Special Tests • Thompson’s test (calcaneal tendon) – prone, foot over edge of bed, squeeze calf muscles (no passive plantar flexion)
General – age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast), gait, cushingoid facies
•
Skin – scars, rashes, ulcers
•
Muscles – bulk, wasting, spasm
•
Joints – swelling, deformities (scoliosis, thoracic kyphosis, loss of lumbar lordosis)
•
Foot posture
Feel Supine • Muscles (wasting / spasm) – levator scapulae, trapezius, semispinalis capitus, rhomboids • Prone • •
Move •
•
Bones & ligaments – costochondral & sternochondral joints Muscles (wasting / spasm) – SCM, scalenes, levator scapulae, erector spinae, gluteal, hamstrings Bones & ligaments – spinous processes, interspinous ligaments, cervical facet joints, costovertebral articulation, sacroiliac joint Cervical – flexion (down), extension (up), L / R lateral flexion (tilt), L / R rotation (turn), extension + rotation Thoracic & lumbar – extension (back), flexion (forward), L / R rotation (sitting, turn), L / R lateral flexion (hand down thigh)
Special Tests • Femoral nerve stretch (L3 radiculopathy) – prone, flex knee with hand on hamstring (pain in femoral nerve distribution) •
Straight leg raise (sciatic nerve) – supine, flex hip with leg straight (pain in back of leg from 30-70°)
Shoulder Examination Look • • •
• Feel • •
•
General – age, gender, body habitus, comfort Skin changes, symmetry, posture, swelling, deformities (scoliosis, dislocation) Muscles (wasting / spasm) – deltoids, biceps, triceps, supraspinatus, infraspinatus, trapezius, rhomboids, pectoralis major, latissimus dorsi Scapular winging (push against wall) Temperature Bony landmarks – SC joint, clavicle, AC joint, acromian, subacromial space, coracoid, scapula, thoracic vertebrae Muscles – as above
Move Bilaterally at the same time for comparison Active → passive → restricted •
Flexion (forward), extension (backward), abduction (laterally, externally rotate at 90°), drop-arm test (internally rotate while coming down) adduction (medial), internal rotation, external rotation (flexed 90°), push shoulders back
Special Tests • Apply’s scratch test – patient reaches over opposite shoulder (adduction), behind neck (adduction & external rotation), behind back (internal rotation) •
•
•
Supraspinatus tests – resisted internal rotation into abdomen (Napoleon test); resisted internal rotation away from back (lift off test); resisted abduction from 90° + resisted abduction from 30° while internally rotated (empty can test) (pain) Hawkins-Kennedy test (impingement) – flex patient’s elbow & shoulder to 90°, support shoulder & forcibly internally rotate shoulder (pain)
•
Apprehension/relocation test (anterior stability) – supine, abduct patient’s arm to 90° & externally rotate & apply posterior pressure to humerus (apprehension of dislocation), internally rotate & apply anterior pressure (relocation) Neer’s test (subacromial impingement) –flex patient’s straight arm with their thumb down (pain)
Elbow Examination Look •
General – age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast)
•
Swelling, asymmetry, deformities, nodules
•
Rashes – anterior (eczema), posterior (psoriasis)
Feel •
Bony landmarks – olecranon, lateral & medial epicondyles, head of radius, radiohumeral joint
•
Muscles – flexors & pronators (medial), extensors & supinators (lateral), brachioradialis
•
Tendons (triceps, biceps), ulnar nerve
Move Active → passive → resisted • Flexion, extension, pronation (palm down), supination (palm up), flexion in semipronation (brachioradialis) Special Tests • Lateral epicondylitis tests – resisted wrist extension with extended elbow; resisted middle finger extension; tight fist (pain) •
Medial epicondylitis – resisted wrist flexion (pain)
•
Valgus & varus stress tests – elbow flexed to 20° and supinated, support humerus and gently stress medial side (lateral ligaments) and then lateral side (medial ligaments) of the elbow joint
•
Nerve entrapment tests – extend thumb (radial), abduct thumb (median), adduct thumb (ulnar)
Wrist Examination Look •
General – age, gender, body habitus, comfort, assistance devices (stick, brace, sling, cast)
•
Scars, rashes, colour, wounds, nail changes, wasting, swelling, ganglia, deformities, symmetry
•
Nerve lesions – wrist drop (radial), hand of benediction (median), claw hand (ulnar)
Feel •
Dorsal wrist – distal forearm, ulna, radius, lunate, metacarpals, snuff box, PIP & DIP joints
•
Palmar wrist - pisiform, hook of hamate, flexor retinaculum, Guyon’s canal
•
Hand – swelling, tenderness, warmth, nodules
Move Active passive resisted (not resisted for wrist) • Wrist – flexion, extension, ulnar deviation, radial deviation, pronation, supination •
Fingers – flexion, extension, abduction, adduction
•
Thumb – opposition, abduction, adduction, flexion, extension
Special Tests • Phalen’s test (median nerve compression) – reverse prayer sign (flex wrists), normal prayer sign (pain) •
Tinel’s sign (carpel tunnel syndrome) – percuss over flexor retinaculum (paraesthesia)
•
Nerve entrapment tests – extend thumb (radial), abduct thumb (median), adduct thumb (ulnar)
Neurological System Presenting Complaints •
• • •
Headache – onset, severity, location, aggravating factors, relieving factors Vision changes – blurring, diplopia, flashes Hearing/balance changes – vertigo, tinnitus, hearing loss Weakness in face, arms, legs – time course, generalised / specific, unilateral / bilateral, proximal / distal, sudden (vascular)
•
Burning, tingling, numbness
•
Fits, faints, mood changes – aura, LOC, tongue biting
Patient History •
PMH – neurological events, HTN, DM, AF, CV risk factors, pregnancy
•
Family – neurofibromatosis, tuberose sclerosis, Hungington’s disease, Friedrich’s ataxia, DMD
•
Medications
•
Social – toxin exposure, alcohol, smoking, level of function
Cranial Nerve Examination
Upper Limb Neuro Examination
Upper Limb Neuro Examination
Patient sitting on edge of bed • Inspection – craniotomy scars, neurofibromas, facial asymmetry, ptosis (Horner’s, oculomotor lesion, myasthenia gravis), exophthalmos, enothalmos, eye deviation, pupils
Patient sitting on edge of bed
Patient supine
Inspection • Posture (decerebrate), nerve signs (wrist drop, claw hand, hand of benediction), muscles (wasting, fasciculations), tremor at rest, abnormal movements, skin change
Inspection • Gait - 10 steps
•
Olfactory (CN I) – ask patient re: smell, inspect nares, present smells
•
Optic (CN II) – visual acuity, visual fields (peripheral & central), fundoscopy (disc, retina)
•
Eye reflexes (CN II, III) – inspection (shape, size, ptosis), direct response (ipsilateral), consensual response (contralateral), swinging light test (partial), accommodation
• •
•
•
Tone – flaccid, decreased, normal, increased Power - 0 (no contraction), 1 (flicker), 2 (w/o gravity), 3 (vs. gravity), 4 (mild resistance), 5 (normal) Reflexes – 0 (absent), + (reduced), ++ (normal), +++ (~increased), ++++ (greatly increased
Trigeminal (V) – sensation (light touch, pain), corneal reflex (opthalmicfacial), muscles of mastication & jaw jerk (mandibular)
•
Facial (VII) – raise eyebrows, close eyes, smile, puff out cheeks
•
Vestibulocochlear (CN VIII) – otoscopt, auditory acuity (rub fingers), Weber’s test (forehead), Rinne’s test (mastoidear)
•
Throat (IX, X) – say ahh, gag reflex, hoarseness, cough
•
Hypoglossal (XII) – protrude tongue, deviate each side, push vs. cheek
Grading Guide •
Eye movement (CN III, IV, VI) – modified H, asking about diplopia
•
Accessory (XI) – torticollis (tilted head), turn head vs. resistance (SCM), shrug vs. resistance (traps)
•
Walking on heels (L4/L5), toes (L1)
•
Tandem walking – R heel in front of L toe etc. (cerebellar lesion)
Positional drift – (arms out, eyes closed) - down & pronation (weakness), up & pronation (cerebellar disease), all directions (loss of proprioception)
•
Proximal myopathy – sit & rise without assistance, Trendelenberg test (stand on one foot, supported)
•
Proprioception – stand, feet together, eyes open (station), closed (Romberg test)
Motor • Tone – active movement, passive movement (elbow & wrist), grade (flaccid, , normal, )
•
General inspection – skin, muscles (wasting, fasciculations)
•
•
Power – movement vs. resistance
•
Reflexes – biceps (C5, C6), triceps (C7, C8), supinator (C5, C6)
•
Coordination – finger-nose test (their nose examiner’s finger), rapid alternative movement (quickly turning hand over)
Sensory • Pain – dermatomes •
Vibration (128Hz) – pulp of middle finger, ulnar styloid process, olecranon, clavicle etc.
•
Proprioception – distal IP joint
•
Soft touch - dermatomes
Motor • Tone – active movement, passive movement •
Clonus – push on superior patella, rotate then dorsiflex ankle (UMN)
•
Power – movement vs. resistance
•
Reflexes – knee (L3, L4), ankle (S1, S2), Babinski (L5, S1, S2)
•
Coordination – drag heel down shin & back up; toe-finger test (bed examiner’s finger), rapid alternating movement (tap foot against palm of hand quickly)
Sensory • Pain – dermatomes •
Vibration (128Hz) – 1st metacarpal head, malleoli, patellae, ASIS
•
Proprioception – distal IP joint
•
Soft touch - dermatomes
Haematological System
Thyroid
Presenting Complaints
Presentations
• • • • • • • •
Tiredness Weakness Dyspnoea Fatigue Postural dizziness Bruising Blood in stool Lumps – neck, armpit, groin
•
Hyperthyroidism - appetite, weight loss, diarrhoea, sweating, dry skin, hair thinning, preference for cold
•
Hypothyroidism - appetite, weight gain, constipation, lethargy, heavy periods, preference for warm weather
Thyroid Disease Examination
Hyperthyroidism
Hypothyroidism
General
Weight loss, anxiety
Mental / physical slowness, voice change
Hands
Tremor, onycholysis (nail separates from bed), clubbing, palmar erythema, sweaty palms
Peripheral cyanosis, pigmentation, cool / dry hands, pallor
Pulse
Sinus tachycardia / atrial fibrillation
bradycardia
Face
Exophthalmos (sclera visible below iris & eye protruding beyond orbit Grave’s disease), lid retraction (sclera visible above iris), lid lag
Skin pigmentation (hypercarotinaemia), skin thickening, alopecia (hair loss), periorbital oedema, xanthelasma, swelling of tongue
Patient History • • •
PMH – infections, fever, chills Social – diet (meat) Menstrual history – blood loss
Examination •
General - age, gender, racial origin (thalassaemia), pallor (anaemia), bruising (coagulopathy), jaundice (haemolytic anaemia), scratch marks (lymphoma)
•
Hands – koilonychias, pallor of nail beds / palmar creases, bruising
•
Radial pulse (tachycardia)
•
Lymph nodes (site, size, fixation, consistency, tenderness) – cervical, axillary, trochlear, supraclavular
•
Face – scleral icterus (jaundice), conjunctival pallor, gums, oral mucosa, tongue (glossitis), tonsils
•
Thyroid Examination Patient sitting on edge of bed •
Inspection - scars (thyroidectomy), veins (retrosternal goitre), redness (suppuratives thyroiditis), swelling (generalised / localised), during swallowing (moves superiorly normal, goitre, thyroglossal cyst)
•
Palpation (from behind; lobes & isthmus) – size; shape; nodules; thrill (hyperthyroidism); fixation (carcinoma); consistency: firm (goitre), rubbery hard (Hashimoto’s thyroiditis), stony hard (thyroiditis), tenderness (thyroiditis)
•
Percussion – upper part of manubrium (retrosternal goitre)
•
Auscultation – over each lobe for bruits (hyperthyroidism, antithyroid medication)
Chest – press sternum & clavicles with heel of hand, push shoulders together
•
Peberton’s sign (thoracic inlet obstruction e.g. retrosternal goitre) – patient lifts both hands as high as possible, look for signs of congestion / cyanosis / respiratory distress
•
Abdomen – masses, liver, spleen, inguinal nodes
•
Chest (auscultate heart & lungs) – systolic flow murmur, CCF, pericardial / pleural effusion (all hyperthyroidism)
•
Legs – bruising, pigmentation, scratch marks, ulcers, sensation, popliteal nodes
•
Legs – pretibial myxoedema (bilateral, firm, elevated dermal nodules; Grave’s disease), non-pitting oedema (hypothyroidism), reflexes ( hyperthyroidism, hypothyroidism)
•
Other – fundoscopy (papiloedema, haemorrhage), temperature, urinalysis, rectal / pelvic examination
! ! ! ! EXAMINATIONS!–!MARKING! SHEETS! ! ! ! ! ! ! ! ! !
The Gastrointestinal System
Gastrointestinal system - assessment sheet 2012 Detail
Process Introduction
Wash hands, introduction, obtain consent.
Position/exposure
Position and expose as necessary.
General inspection Vital signs / Hydration
Hand and upper limb
Face
Neck and chest
General observation, mental state, body habitus, colour Temp, PR, BP, RR (O2 sats, Wt, BSL, WTU) ⋅ Nails (leukonychia, koilonychia). ⋅ Hands (clubbing, palmar erythema, pallor, Dupuytren’s contracture). ⋅ Hepatic flap (if indicated), tremor. ⋅ Arms (spider naevi, bruising, wasting, scratch marks). ⋅ Eyes: xanthelasma, conjunctival pallor, jaundice, iritis. ⋅ Parotid glands: inspect, palpate. ⋅ Mouth: foetor, lips, oral mucosa, tongue, gums, teeth. ⋅ Inspect for spider naevi, hair distribution, gynaecomastia. ⋅ Palpate lymph nodes: submental, submandibular, jugular chain, supraclavicular, posterior triangle, occipital, pre/post auricular, axillary.
Mention – not performed Y1
Inspect ⋅ skin: scars, striae, bruising, pigmentation. ⋅ abdomen: distension, masses, veins, peristalsis, pulsation. Palpate superficial (herniae) and deep (ask about tender areas) ⋅ tenderness: localised (Murphy’s sign, McBurney’s point), referred (Rovsing’s sign), and rebound (watch face) ⋅ guarding (voluntary and involuntary) ⋅ masses: describe ⋅ organs liver (gallbladder), spleen, kidneys, bladder, AAA. Percuss ⋅ - liver span, bladder ⋅ - shifting dullness. Auscultate ⋅ bowel sounds ⋅ bruits over renal and aortic areas. Examination of groin region (hernias and lymphadenopathy), genitalia, DRE +/- vaginal examination
Legs
Skin changes, sacral and leg oedema.
Discuss
WTU, urine preg test if not already done
Abdomen
Tick if Demonstrated
Professional Behaviour (Critical Error) all the criteria below must be fulfilled to pass ⋅ confident professional approach to task / professionally dressed ⋅ treated patient and examiner with respect ⋅ clear instructions to patient. No jargon ⋅ fluid performance. Minor hesitation only ⋅ technique correct in all or most areas ⋅ able to answer questions from handbook
Overall Mark
Pass Fail
Comments - to be recorded over page Examiner’s name and signature:
Date:
University of Queensland
91
The Respiratory System
Respiratory system - assessment sheet 2012 Process
Detail
Introduction
Wash hands, introduction, obtain consent.
Position and exposure
Lying or sitting with chest exposed as necessary.
General inspection Vital signs/hydration
Hands/upper limbs
Face/neck
Chest inspection Palpation Percussion
Ausculation
Further assessments
Tick if Demonstrated
General observation, Mental state, Body Habitus, Colour Temp, PR, BP, RR, , (O2 sats, BSL) ⋅ ⋅ ⋅ ⋅ ⋅
clubbing, cyanosis, tar staining, pallor, cyanosis, wasting flapping tremor radial pulse - rate, rhythm respiratory rate, accessory muscle use BP/pulsus paradoxus.
⋅ eyes: conjunctival pallor, Horner’s syndrome ⋅ nose: polyps, enlarged turbinates, displaced septum, sinus tenderness ⋅ tongue: central cyanosis ⋅ sinus tenderness ⋅ pharynx: tonsil size/exudate oral candidiasis. leukoplakia, teeth ⋅ palpate trachea for displacement / tug ⋅ lymphadenopathy – submental, submandibular, jugular chain, pre/post auricular, occipital, posterior triangle, supraclavicular. (Start posterior chest and repeat all examination below anteriorly also) Shape, symmetry, scars, deformities, respiratory movement and supraclavicular, and intercostal and subcostal recession. Measure expansion / Note asymmetry. Position (arms crossed for posterior chest), compare symmetry, include axillae/supraclavicular fossa/clavicles. Compare symmetry: ⋅ breath sounds: vesicular/bronchial ⋅ added sounds ⋅ stridor ⋅ wheezes (inspiratory/expiratory) ⋅ crackles (fine, medium, coarse) ⋅ vocal resonance ⋅ observation chart ⋅ respiratory function tests (Peak flow meter, spirometry)
Professional behaviour (Critical Error) all the criteria below must be fulfilled to pass ⋅ confident professional approach to task / professionally dressed ⋅ treated patient and examiner with respect ⋅ clear instructions to patient . No jargon ⋅ fluid performance. Minor hesitation only ⋅ technique correct in all or most areas ⋅ able to answer questions from handbook
Overall Mark
Pass Fail
Comments - to be recorded over page Examiner’s name and signature:
Date:
University of Queensland
76
The Cardiovascular System
Cardiovascular system - assessment sheet 2012 Process Introduction
Detail Wash hands, introduction, obtain consent.
Position/exposure
Couch raised to 30–45°, exposed only as necessary.
General inspection
General observation, Mental state, Body Habitus, Colour
Vital signs/hydration Hands
Temp, PR, BP, RR, (O2 sats, BSL, urinalysis) Pallor, cyanosis, xanthomata, clubbing, signs of endocarditis.
Radial pulse/ respiratory rate
Radial pulse: rate and rhythm Radio-radial, radio-femoral delay, respiratory rate.
Blood pressure
Demonstrate technique and /assess for postural hypotension.
Face
⋅ Eyes: xanthelasma, conjunctival pallor, jaundice ⋅ Mouth: central cyanosis, palate, teeth, gums.
Neck
JVP Carotid palpate pulse — note character, auscultate for bruits.
Chest
Scars, deformities, apex beat, thrills, parasternal and LV heave.
Heart
Auscultate ⋅ two heart sounds ⋅ added sounds ⋅ murmurs Listen in three positions: ⋅ lying down ⋅ left lateral position ⋅ sitting forward after full expiration and breath hold.
Back
⋅ inspect for scars, deformity ⋅ palpate for sacral oedema ⋅ percuss the lung bases looking for effusion due to pulmonary oedema ⋅ auscultate the lung bases for crackles due to pulmonary oedema.
Abdomen
Supine on one pillow ⋅ palpate: tenderness, masses, organomegaly, aortic aneurysm, ascites ⋅ auscultate for bruits: aortic, renal, femoral
Legs
Further assessments
Tick if demonstrated
⋅ Look for: varicose veins, colour and temperature of legs, trophic changes, ulceration of the skin, clubbing of toes, xanthomata, oedema. ⋅ Compare pulses both limbs: femoral, popliteal, posterior tibial, dorsalis pedis. fundoscopy, ECG.
Professional behaviour (Critical Error) all the criteria below must be fulfilled to pass ⋅ confident professional approach to task / professionally dressed ⋅ treated patient and examiner with respect ⋅ clear instructions to patient . No jargon ⋅ fluid performance. Minor hesitation only ⋅ technique correct in all or most areas ⋅ able to answer questions from handbook Comments - to be recorded over page Examiner’s name and signature:
Overall Mark
Pass Fail Date:
University of Queensland
63
The Neurological System
Neurological system - assessment sheet 2012 Process
Tick if Demonstrated
Detail CRANIAL NERVES EXAMINATION
Positioning General inspection CN I – Olfactory CN II – Optic CN III, IV, VI – Oculomotor, Trochlear, Abducens CN V – Trigeminal CN VII – Facial CN VIII – Acoustic CN IX, X – Glossopharyngeal and Vagus CN XI – Accessory CN XII – Hypoglossal Positioning Inspect Tone Power Reflexes Coordination Sensation Functional tests
Inspect Tone Power
Reflexes Coordination Sensation
Scars, neurofibromas, facial asymmetry, ptosis, proptosis, deviation of eyes, unequal pupils Ask patient if they can smell normally Visual acuity, visual fields, fundi Inspect pupils, test pupillary reaction to light and accommodation, assess eye movements – look for failure of movement and nystagmus, ask about diplopia Corneal reflex, face sensation, mastication muscles, jaw jerk Facial muscle power – forehead, wrinkle eyes, grin and compare nasolabial folds, puff out cheeks Whisper tests, inspect auditory canals and drums if indicated, Weber + Rinne’s tests with a 256 Hz tuning fork Inspect palate and uvula Assess palatal movement Assess cough and speech Inspect for torticollis, shrug shoulders, assess sternomastoid Inspect tongue, protrude tongue UPPER LIMB EXAMINATION Sitting upright Posture, wasting, fasciculation, pronator drift Wrist, elbow Shoulder abduction and adduction, elbow flexion and extension, wrist flexion and extension, finger extension, flexion and abduction Biceps, triceps, supinator – reinforce if necessary Finger-nose test, rapidly alternating movements Light touch, pain, vibration sense, proprioception LOWER LIMB EXAMINATION Observe/test gait, heel-toe, tiptoes, heels. Observe/test proximal myopathy Romberg test Skin changes, muscle wasting, fasciculation Knee, ankle Hip flexion, extension, abduction and adduction, knee flexion and extension, ankle plantar flexion and dorsiflexion, tarsal joint eversion and inversion Knee jerk, ankle jerk, plantar reflex – reinforce if necessary Observe/test for coordination Light touch, pain, vibration sensation, proprioception
Professional Behaviour (Critical Error) all the criteria below must be fulfilled to pass: ⋅ ⋅ ⋅ ⋅ ⋅ ⋅
confident, professional approach to task / professionally dressed treated patient and examiner with respect clear instructions to patient . No jargon fluid performance. Minor hesitation only technique correct in all or most areas able to answer questions from handbook.
Overall Mark
Pass Fail
Comments - to be recorded over page
Date
Examiners name and signature:
University of Queensland
141
The Musculoskeletal System
Spine examination - assessment sheet 2012 Process
Introduction
Detail
Tick if Demonstrated
Wash hands, introduction, consent obtained.
Position/exposure
Initially upright and appropriately exposed depending on region to be examined, then recumbent.
General inspection
Age, gender, well/unwell, mental state, body habitus, assistance devices, general posture (check for normal spinal curvature), deformity.
Look
⋅ Look specifically at bony/muscular landmarks (assess vertebral levels). ⋅ Check for posture, deformity, symmetry (landmarks), spasm, swelling, skin changes, scars, and wasting. ⋅ Check skin temperature.
Feel
⋅ Palpate spine (spinous processes, interspinous ligaments, facet joints), all bony landmarks, and surrounding muscles, note tenderness. ⋅ Palpate paravertebral muscles for bulk, spasm, and tenderness. ⋅ Assess full range of active and passive movement.
Move
⋅ Note symmetry, restriction, pain, or neurological symptoms. ⋅ For thoracic spine sitting will fix the pelvis. ⋅ Assess how daily function is affected.
Function
⋅ Cx spine: driving, sleeping. ⋅ Thoracic spine: twisting. ⋅ Lumbar spine: bending over, tying laces. Cervical spine: neurological assessment of arms. Thoracic spine: Assess for scoliosis.
Special tests
Lumbar spine: ⋅ femoral nerve stretch ⋅ straight leg raise (sciatic nerve) ⋅ neurological assessment of lower limb.
Professional Behaviour (Critical Error) all the criteria below must be fulfilled to pass
Overall Mark
⋅ confident professional approach to task / professionally dressed ⋅ treated patient and examiner with respect ⋅ clear instructions to patient. No jargon
Pass
⋅ fluid performance. Minor hesitation only ⋅ technique correct in all or most areas
Fail
⋅ able to answer questions from handbook Comments - to be recorded over page Examiner’s name and signature:
Date:
University of Queensland
176
The Musculoskeletal System
Knee examination - assessment sheet 2012 Process
Introduction Position/exposure
General inspection
Look
Detail
Tick if Demonstrated
Wash hands, introduction, consent obtained. Begin with patient in standing position in exercise shorts or underwear. Assess the patient’s age, body habitus, posture, general health, and behaviour. Observe gait, undressing, sitting and rising from chair, removing shoes and socks. Inspect for posture, deformity (genu valgum/varum), symmetry (landmarks), spasm, swelling (joint effusion, bursae), skin changes, scars and wasting (esp, quads). Inspect from front, side, and behind (Baker’s cyst). Skin temperature, swellings, tenderness. Palpate: ⋅ bony landmarks for swelling, tenderness, or deformity (patella, patella ligament, tibial tuberosity, medial and lateral femoral and tibial condyles and head of fibula)
Feel
⋅ joint line ⋅ muscles: quads (bulk, spasm, tenderness) and quad tendon ⋅ bursae ⋅ popliteal fossa for Baker’s cyst. Test for effusion: patella tap, bulge test.
Move
Function
Active movement. Passive movement. Assess symmetry, quality of movement, grade restrictions. ⋅ Flexion, extension, rotation. Assess gait, squatting, sitting and rising from chair, removing shoes and socks. ⋅ Patella apprehension test ⋅ Medial and lateral collateral ligament test
Special tests
⋅ Anterior draw test ⋅ Lachman’s test ⋅ McMurray’s test for medial/lateral meniscal tear
Professional behaviour (Critical Error) all the criteria below must be fulfilled to pass
Overall Mark
⋅ confident professional approach to task / professionally dressed ⋅ treated patient and examiner with respect
Pass
⋅ clear instructions to patient. No jargon ⋅ fluid performance. Minor hesitation only
Fail
⋅ technique correct in all or most areas ⋅ able to answer questions from handbook Comments - to be recorded over page Examiner’s name and signature:
Date:
University of Queensland
178
The Musculoskeletal System
Shoulder examination - assessment sheet 2012 Process Introduction
Tick if Demonstrated
Detail Wash hands, introduction, consent obtained
Position/exposure
Comfortable position for patient — preferably standing Both shoulders fully exposed — for males, shirt off; for females, bra/sports top.
General inspection
Assess the patient’s age, body habitus, posture, general health, and behaviour. Observe patient undress to assess functional impairment.
Look
Inspect for posture, deformity (dislocation), symmetry (landmarks), spasm, swelling (joint effusion), skin changes, scars and wasting (esp. deltoid). Inspect from front, side, and behind (muscles of scapula).
Feel
Skin temperature, swellings, tenderness. Palpate: ⋅ Bony landmarks for swelling, tenderness or deformity (sternoclavicular joint, clavicle, acromioclavicular joint, coracoid and acromion processes, spine, and borders of scapula) ⋅ Joint line ⋅ Muscles - deltoid, biceps, triceps
Move
Assess symmetry, quality of movement, grade restrictions of – abduction/elevation, flexion/elevation, internal rotation, external rotation, extension, adduction ⋅ active movement: from front and back to assess symmetrical scapulohumeral rhythm. ⋅ passive movement.
Function
Special tests
Assess brushing hair, doing up bra in women, hanging out washing Apprehension Test - for anterior stability. Rotator Cuff impingement tests. Hawkin’s Test, Empty-can test. Biceps tendon tests Winged Scapular test
Professional behaviour (Critical Error) all the criteria below must be fulfilled to pass ⋅ confident professional approach to task / professionally dressed ⋅ treated patient and examiner with respect ⋅ clear instructions to patient. No jargon ⋅ fluid performance. Minor hesitation only ⋅ technique correct in all or most areas ⋅ able to answer questions from handbook
Overall Mark
Pass Fail
Comments - to be recorded over page Examiner’s name and signature:
Date:
University of Queensland
180
The Haematology System
Haematological Examination
Tick if demonstrated
Process
Detail
Introduction
Wash hands, introduction, consent obtained.
Positioning/exposure General inspection Hands
Palpate lymph nodes
Face
Chest Abdominal examination
Lower limbs
Discuss further examination
⋅ Expose only the minimum necessary at one time. ⋅ Ask the patient to expose themselves where possible. Look for pallor, bruising, jaundice, scratch marks, rashes. ⋅ Inspect for koilonychia, pallor of nail beds/palmar creases, joint/connective tissue disease. ⋅ Palpate for radial pulse. Assess lymph nodes for site, size, consistency, tenderness, fixation, overlying skin changes. ⋅ Epitrochlear (elbow) ⋅ Axillary ⋅ Cervical/Occipital ⋅ Supraclavicular ⋅ (Inguinal – with abdominal examination) ⋅ (Popliteal – with leg examination). ⋅ Eyes: jaundice, haemorrhage, conjunctival pallor. ⋅ Mouth: mucosa, tongue, gums, tonsils. Check for bony tenderness: ⋅ Tap fist over spine. ⋅ Press sternum and clavicles with heel of hand. ⋅ Push shoulders together. Examine for: ⋅ masses ⋅ organomegaly ⋅ inguinal lymphadenopathy. Inspect for bruising, pigmentation, scratch marks, ulceration ⋅ Palpate regional nodes. ⋅ Test for peripheral neuropathy. Consider fundoscopy DRE and VE.
Comments
Overall Mark
Pass Fail
Date: Examiner’s name: Examiner’s signature:
University of Queensland
103
The Endocrine System
Thyroid examination Tick if demonstrated
Process
Detail
Introduction
Wash hands, introduction, consent obtained.
Position/exposure
Expose only the minimum necessary at one time. Ask the patient to expose themselves where possible. Offer patient sheet or modesty blanket.
General inspection
Look for: ⋅ evidence of weight loss, anxiety (hyperthyroidism) ⋅ mental or physical sluggishness (hypothyroidism)
Hands
Look for: ⋅ tremor, onycholysis, clubbing, palmar erythema, warmth/sweatiness (hyperthyroidism) ⋅ cyanosis, swelling, cool/dry hands (hypothyroidism) Palpate for radial pulse (tachycardia, atrial fibrillation – hyperthyroidism, bradycardia – hypothyroidism).
Arms
Lift arms above head (proximal myopathy). Reflexes.
Face
Look for: ⋅ Exophthalmos, lid retraction, lid lag (hyperthyroidism) ⋅ Thickening of skin, pigmentation, alopecia, periorbital oedema, loss of outer one-third of eyebrows, xanthelasma, tongue swelling, voice change (hypothyroidism).
Neck
Inspect for scars, goitre, thyroid nodules — ask patient to swallow Palpate thyroid — repeat with patient swallowing Palpate cervical lymph nodes, carotid arteries, position of trachea Demonstrate testing for Pemberton’s sign
Chest
Auscultate heart for murmurs. Auscultate lungs for signs of CCF (basal crackles) or pleural effusion.
Legs
Look for pretibial myxoedema. Test for power (proximal myopathy). Test reflexes.
Overall mark
0 = no skills or critical error 1 = novice 2 = more practice required 3 = competent and confident 4 = expert
Comments
Overall Mark
Pass Fail Date:
Examiner’s name: Examiner’s signature:
University of Queensland
111
The Endocrine System Diabetic examination
Process
Detail
Introduction
Wash hands, introduction, consent/chaperone, any pain?
Positioning
Supine with pillow
General inspection
General observation (distress/discomfort), body habitus (obesity, weight loss), mental state, hydration, signs of Cushing’s, acromegaly, haemochromatosis (2° diabetes), Kussmaul’s respiration (ketoacidosis)
Lower limbs
Inspection: colour, skin changes (hair loss, atrophy, dryness, pigmentation), ulceration/infection, injection sites, muscle wasting (quads) Palpation: temperature, cap refill, bilateral peripheral pulses (femoral, popliteal, post tibial, dorsalis pedis) Neuro exam: sensation (light touch, pain, vibration, proprioception), reflexes (knee & ankle), proximal myopathy (squat & stand), + tone, power & coordination if indicated
Upper limbs
Inspection: nails (candida), ulceration/infection, injection sites Radial pulse – rate, rhythm Blood pressure: lying, standing
Eyes
Visual acuity Argyll Robertson pupils (small, irregular, unequal, brisk accommodation, ↓response to light) CN III, IV, VI – inspect pupils, reaction to light, accommodation, eye movements, nystagmus, diplopia Fundoscopy (if available) – cataracts, inspect retina for proliferative (new vessels, vitreal haemorrhage, scars, retinal detachment) and non-proliferative change (dot/blot haemorrhages, microaneurysms, cotton-wool spots)
Ears/Mouth
Mouth: candida Ears: inspect for infection (if indicated only)
Neck
Carotid arteries – palpate & auscultate for atherosclerosis Examine & palpate thyroid
Chest
Signs of infection (if indicated only)
Abdomen
Hepatomegaly
Discuss
Vitals, WTU (glucose, ketones, protein, nitrites, blood )
Tick if demonstrated
The Urinary System
Urinary system examination Process
Detail
Tick if demonstrated
Introduction
⋅ Wash hands, introduction, consent obtained.
Positioning and exposure
⋅ Expose only the minimum necessary at one time. ⋅ Ask the patient to expose themselves where possible. ⋅ Offer patient sheet or modesty blanket.
Vital Signs
⋅ Temp, PR, BP, RR, (O sats, Wt/Ht/BMI, BSL, WTU)
General inspection
⋅ Mental state, complexion, fetor, hydration.
Hands
⋅ Leukocychia, pallor, asterixis.
Arms
⋅ ⋅ ⋅ ⋅
Face
⋅ Anaemia, jaundice, fetor, mouth ulcers, thrush, gingivitis.
Neck
⋅ Measure JVP. ⋅ Auscultate for carotic bruits.
Chest
⋅ Auscultate heart and lungs.
Abdomen
⋅ ⋅ ⋅ ⋅ ⋅
Back
⋅ Palpate for bony tenderness, renal tenderness, sacral oedema.
Legs
⋅ Inspect for oedema, purpure, pigmentation, excoriation, gouty tophi. ⋅ Palpate for oedema, peripheral pulses. ⋅ Check sensation (peripheral neuropathy).
Discuss
⋅ Consider fundoscopy, temperature chart, urine analysis.
Inspect for AV fistulae, bruising, pigmentation, excoriation. Test for sensation (peripheral neuropathy). Pulse. Measure blood pressure.
Inspect for scars, distension, catheter. Palpate for masses, liver, kidney, bladder, aortic aneurysm. Percuss for shifting dullness, bladder. Auscultate for renal bruit. (Discuss rectal examination for prostatomegaly).
Comments
Overall Mark
Pass Fail
Date: Examiner’s name: Examiner’s Signature:
University of Queensland
97
! ! ! ! CLINICAL!REASONING! ! ! ! ! ! ! ! ! ! !
The Unconscious Patient Pathogenesis
Clinical Approach OSCE Prep General The Unconscious Patient Headache Chronic Tiredness Fever Lymphadenopathy Bleeding Pelvic & Scrotal Masses Sudden Collapse Seizure Cardiorespiratory Cough Chest Pain Breathlessness Hoarseness Gastrointestinal Abdominal Pain Constipation Diarrhoea Jaundice Upper GI Bleeding Anorectal Symptoms Urinary Dysuria Haematuria Proteinuria Urinary Incontinence Musculoskeletal Lower Back Pain Leg Pain Knee Pain
Reticular activating system (RAS) – responsible for regulating arousal and sleep-wake transitions •
Non-specific arousal of most parts of the brain in response to ascending sensory input
•
Made up of parts of the midbrain, mesencephalon, thalamus, hypothalamus and tegmentum
•
Stimulated by toxins, temperature, thyroid, too much of anything seizures
•
Inhibited by direct pressure – tumours, bleeds, trauma
•
Starved – hypoxia, hypoglycaemia, hypotension
Aetiology COMA
AEIOU TIPS • Alcohol / drugs • Endocrine / electrolytes • Insulin • Oxygen • Uraemia • Trauma • Infection / intracranial pressure • Poison / porphyrins • Seizure / stroke / space-occupying lesion / sub-arachnoid haemorrhage
•
Cerebral cause
•
Overdose / organ failure
•
Metabolic (glucose / urea / electrolytes)
•
Asphyxia
Assessment Glasgow Coma Scale • Good for tracking progress • <9/15 consider intubation 1
2
3
4
5
Eyes
Does not open eyes
Opens eyes to painful stimuli
Opens eyes to voice
Opens eyes spontaneously
Verbal
Makes no sounds
Incomprehensible sounds
Inappropriate words
Confused / disoriented
Oriented, converses normally
Motor
Makes no movements
Extension to painful stimuli (decerebrate)
Abnormal flexion to painful stimuli (decorticate)
Flexion / withdrawal to painful stimuli
Localizes painful stimuli
AVPU • • • •
A - alert V – responds to voice P – responds to pain U – unresponsive
6
Obeys commands
Stages of Anaesthesia
Headache
•
Stage 1 – amnestic but still staggering and talking, some protective reflexes
•
Stage 2 – eyes shut, amnestic, often hyperreflexic (gag, cough), irregular RR, BP, HR
•
Pain or discomfort between the orbits and occiput, arising from pain sensitive structures.
•
Stage 3 – deeply asleep, stable slow HR and RR, low but stable BP, no protective reflexes
•
•
Stage 4 – HR, BP, RR not enough to maintain life
A very common presenting complaint o 85% of the population will experience headache within 1 year o 38% of adults will have had a headache within 2 weeks o 40% of children will have experienced one or more headaches by the age of 7 (75% by age 15)
•
Needs a sound diagnostic strategy - careful history, high index of suspicion, judicious use of CT scanning
Management CLOBBERED •
Call for help
•
Lie on side, protecting neck
•
Oxygenate
•
Blood pressure – maintain
•
BSL
•
Environment – check temperature
•
Responsiveness – GCS, AVPU, stages
•
Examine – possible causes / associations (trauma, track marks, med alerts, organ failure)
•
Differential diagnosis – intracranial vs. extracranial, local vs. global damage
Aetiology •
Tension / combination / exertional / post-traumatic headache
•
Migraine
•
Drugs o o o o o o o o o o o o o o o o o
Alcohol Aspirin, codeine Antihypertensives Oral contraceptives Sympathomimetics Caffeine Corticosteroids Cyclosporin Dipyridamole H2-receptor antagonists MAO inhibitors Nicotine Nitrazepam Nitrous oxide Retinoids Theophylline Vasodilators
Most Probable • Respiratory infection • Tension-type headache • Combination headache • Migraine
Most Serious • Cardiovascular – subarachnoid / intracranial haemorrhage, carotid / vertebral artery dissection, temporal arteritis, cerebral venous thrombosis • Severe infection – meningitis, encephalitis, intracranial abscess • Neoplasia – cerebral, pituitary • Haematoma – extradural / subdural • Glaucoma • Benign intracranial hypertension Often Missed • Dental disorders • Refractive errors of eyes • Sinusitis • Opthalmic herpes zoster • Exertional headache • Hypoglycaemia • Post-traumatic headache • Post-spinal procedure • Sleep apnoea
•
Infection – respiratory, meningitis, encephalitis, abscess
•
Haemorrhage – subarachnoid / intracranial
•
Dissection – carotid / vertebral artery
•
Neoplasia – cerebral / pituitary
•
Haematoma – extradural / subdural
•
Inflammation - temporal arteritis, sinusitis
•
Visual disorders – refractive errors, glaucoma, opthalmic herpes zoster
•
Benign intracranial hypertension
•
Dental disorders
•
Hypoglycaemia
•
Sleep apnoea
•
Psychogenic – depression, anxiety
Children • Infection • Psychogenic • Migraine • Meningitis • Post-traumatic
Assessment History • SOCRATES • Frequency • Pain in back of head or neck • Diurnal variation • Associated symptoms o Nausea, vomiting o Dizziness, weakness o Light sensitivity o Blurred vision o Watering / redness of eyes o Pain / tenderness of scalp o Rhinorrhoea o Fever, sweats • Stress • Medications • Recent trauma Examination • Temperature • Blood pressure • Fundoscopy • Inspect temporal arteries, facial / neck muscles, sinuses, Cspine, teeth, TMJ • Mental state examination • Neurological examination – visual fields, acuity, pupillary reflexes, eye movements • Upper cervical pain sign – palpate over C2 and C3 – tender headache of cervical origin • Ewing’s sign for frontal sinusitis – press finger gently upwards and inwards against the orbital roof medial to the supraorbital nerve – pain frontal sinusitis Investigations • Haemoglobin – anaemia • WCC – leukocytosis (bacterial infection) • ESR – temporal arteritis • Radiography o CXR o Cervical spine o Skull X-ray – brain tumour, Paget’s o Sinus X-ray – sinusitis o CT scan – brain tumour, CVA, SAH • Lumbar puncture – meningitis
Diurnal Pain Patterns
Chronic Tiredness • •
Normal tiredness – due to increased mental/physical demands; relieved by rest Chronic tiredness – rest provides partial/no relief; present for >6 months
Causes Common • Idiopathic – life factors • Psychological – stress, anxiety, depression • Sleep disorders • Medications • Iron deficiency • Glandular fever
Infrequent • Pregnancy • Menopause • Physical disease • Domestic violence
Rare • • • • • • •
Psych. disease e.g. eating disorder Rheumatological disorders e.g. SLE Lyme disease Neurological disorders Tuberculosis Endocrine disorders Narcolepsy
Chronic Fatigue Syndrome – Diagnostic Criteria 1. Persistent tiredness or fatigueability that persists or relapses for >6 months 2. >4 of the following symptoms persistent for >6 months: o Multi-joint pain o New headaches o ↓memory, concentration o Sore throat o Unrefreshing sleep o Tender cervical/ axillary lymph o Muscle pain nodes
Clinical Approach
Red Flag Symptoms • Sudden onset • Severe and debilitating pain • Fever • Vomiting • Disturbed consciousness • Worse on bending or coughing • Worst in the morning • Neurological symptoms / signs • Young obese female • New headache in elderly Red Flag Signs • Altered consciousness • Altered cognition • Meningism • Abnormal vital signs – BP, temp, RR • Focal neurological signs – pupils, fundi, eye movement • Tender, poorly pulsatile cranial arteries
History • Onset, duration, relation to other symptoms • Attributions – what the patient thinks is the cause, how it is affecting them • Physical features – general health, diet, appetite, systems review • Recent infection e.g. glandular fever Investigation • Medications Tired all the time (TATT) screen • Substance use – alcohol, marijuana, other illicit drugs • Full blood count • Depression/anxiety history • Erythrocyte sedimentation rate • Sleep – quality, snoring, apnoea • Urea, electrolyes, creatinine • Social history – relationships, work, stress, last holiday • Urine culture and microscopy • Sexual history + HIV, Hep C • HIV, hepatitis B and C • Occupational exposure – heavy metals, CO • Liver function tests • Iron studies – serum iron and Examination Ferritin • Lymphadenopathy • Thyroid stimulating hormone • Cardiovascular signs • Glucose • Full mental state examination
Management 1. Treat the pathological condition if one is identified 2. If all tests are normal → possible psychiatric disorder → full psych and mental exams o Usually only mild to moderate psychiatric disorder e.g. depressed mood or anxiety disorder o Consider counselling and cognitive behavioural therapy before medication 3. If still complaining of fatigue despite normal results, consider more detailed tests – cortisol, calcium, magnesium, rheumatoid factor, infection screen (EBV, CMV, lyme disease, tuberculosis), chest X-ray, echocardiogram, sleep studies
Fever • •
Lymphadenopathy Aetiology
Normal body temperature: 36.8 ±0.4°C at ~6am and is higher between 4-6pm Fever: >37.2°C (at 6am, or 37.7°C at 4pm)
Pathogenesis •
↑ hypothalamic set point → ↑body temp. until affector neurons register blood temp. at new set point
Mechanism 1. Pyrogens → release of prostaglandin E2 (PGE2) by hypothalamic endothelial cells 2. ↑PGE2 → release of cAMP by glial cells in the hypothalamus o PGE2 release in peripheral cells → muscle and joint pain 3. ↑cAMP → ↑ set point by neuronal cells in the thermoregulatory centre Muscle/joint pain
Endogenous Pyrogens IL-1, IL-6, TNF-α, IFN- α
↑PGE2 Exogenous Pyrogens Bacteria, endotoxins, hormones, medications
↑cAMP
2. Benign immune disorder o Autoimmine - rheumatoid arthritis, systemic lupus erythematosus o Serum sickness o Drug reactions (e.g. to phenytoin) o Langerhans cell histiocytosis
Vasoconstriction ↑ Set point
Hypothalamus
Shivering
1. Infection o Bacterial – all pyogenic bacteria, syphilis o Mycobacterial – tuberculosis, leprosy o Fungal – histoplasmosis o Chlamydial o Parasitic – toxoplasmosis, trypanosomiasis, filariasis o Viral – Epstein-Barr virus, cytomegalovirus, rubella, hepatitis, HIV
↑"Temperature
↑ Liver metabolism
3. Malignant immune disorder o Leukaemia – acute/chronic, myeloid/lymphoid o Lymphoma – Hodgkin’s, non-Hodgkin’s o Monoclonal gammopathy - multiple myeloma, Waldenström’s macroglobulinaemia o Malignant histiocytosis 4. Other malignancies – breast, lung, melanoma, head & neck, GIT, germ cell
Aetiology 1. Infections – viral bacterial, malaria, syphilis etc. 2. Malignancy – lymphoma, carcinoma 3. Rheumatological disorder – SLE, sarcoid, rheumatoid arthritis 4. Drug fever – reaction with medicine (usually accompanied by rash) 5. Pulmonary embolism (mild fever) 6. Osteomyelitis
5. Lipid storage diseases – Gaucher’s disease, Niemann-Pick disease 6. Endocrinopathies o Thyroid disease - hyperthyroidism; thyroiditis o Andrenal insufficiency 7. Miscellaneous o Sarcoidosis o Amyloidosis o Dermatopathic lymphadenitis
History •
Age, sex, occupation o Children – usually benign e.g. viral, bacterial, toxoplasmosis o > age 50 – incidence of malignant disorders increases significantly
•
Localised symptoms – suggests infection or malignancy
•
Exposure – cats, undercooked meat, travel, unsafe sexual or drug activity
•
Indicators of systemic involvement -suggest tuberculosis, lymphoma or other malignancy o Fever o Night sweats o Unexpected weight loss of >10%
•
Medications – e.g. phenytoin
•
Generalised pruritis
•
Pain – from inflammation
Bleeding
Examination 1. Location – localised or generalised 2. Size o o o
• <1cm →$benign 1+2.25$cm$→$8%$malignant >2.25$cm$→$38%$malignant
3. Consistency o Hard – malignant leading to fibrosis o Firm/rubbery – lymphoma or chronic lymphocytic lymphoma 4. Fixation - chronic infection or malignancy 5. Tenderness – due to inflammation o Infection → rapid growth within capsule → tenderness o Malignancy → gradual expansion of entire encapsulated node → no tenderness 6. Signs of inflammation over the node 7. Splenomegaly – systemic illness e.g. infectious mononucleosis, lymphoma, leukaemia, SLE, sarcoidosis
Investigations 1. Observe for 3-4 weeks if there are no clues about aetiology 2. Full blood count 3. Serology – EBV, CMV, toxoplasmosis, HIV, Bartonella henselae, syphilis, TB 4. Chest X-ray 5. Biopsy Types of Biopsy 1. Excision biopsy – for when malignancy is suspected and the patient has no history of malignancy 2. Core biopsy – for when lymphoma is suspected and lymph nodes are not easily obtainable 3. Fine needle aspirate (FNA) – to confirm recurrence of malignancy, but not for diagnosis
Who to Biopsy • Patients >40 years • > 2cm in size • Abnormal chest X-ray • Supraclavicular LN involvement • Hard consistency • Generalised pruritis • No symptoms of local/systemic infection
Purpura: bleeding into the skin or mucous membranes o Petechiae: smaller purpuric lesions ≤2mm o Ecchymoses: purpuric lesions >2mm
Aetiology Vessel Wall Abnormalities Platelet count, bleeding time, PT and aPTT are usually normal 1. Infections: meningococcaemia, septicaemia, infective endocarditis, rickets o Microbial damage to microvasculature, or DIC 2. Drug Reactions: usually vascular injury is mediated by deposition of drug-induced immune complexes 3. Scurvy & Ehlers-Danlos Syndrome: microvascular bleeding resulting from defects in collagen Platelet Deficiency Thrombocytopenia: reduced platelet number - <100,000 platelets/μL 1. Decreased production o Depression of bone marrow – aplastic anaemia, leukaemia o Selective depression of megakaryocytes – drugs, alcohol, measles, HIV, myelodysplastic syndromes 2. Decreased survival o Immunological platelet destruction – autoimmune, alloimmune (post-transfusion), drugs, infection o Non-immunological destruction – DIC, mechanical injury 3. Sequestration – splenomegaly 4. Dilution – massive transfusions Defective Platelet Function 1. Defective adhesion to subendothelial matrix – e.g. Bernard-Soulier syndrome (defect in vWF receptor) 2. Defective aggregation – e.g. Glanzmann thrombasthenia 3. Disorders of platelet secretion – defective release of factors e.g. TXA2, ADP – e.g. aspirin intake Abnormalities in Clotting Factors 1. Hereditary deficiencies typically affect a single clotting factor o Haemophilia A – factor VIII o Haemophilia B – factor IX o Von Willebrand disease – vW factor 2. Acquired deficiencies usually involve multiple coagulation factors o Vitamin K deficiency →$↓ factors, II, VII, IX, X, protein C
Most Probable Simple purpura Senile purpura Corticosteroid-induced purpura Immune thrombocytopaenic purpura
Most Serious Malignancy – leukaemia, myeloma Aplastic anaemia Myelofibrosis Severe infection – septicaemia, meningococcal, measles, typhoid Disseminated intravascular coagulation
Pelvic and Scrotal Masses
Assessment History Trauma General health – tiredness, weight loss, fever, night sweats Medications o Steroids o Cytotoxic drugs o Gold
o o o
Heparin Phenylbutazone Sulphonamides
o o o
Quinine Thiazide diuretics Chlorampenicol
o o o
Aspirin NSAIDS Warfarin
Family history o Sex-linked recessive – haemophilia A/B o Autosomal dominant – von Willebrand disease, dysfibrinogenaemias o Autosomal recessive – coagulation facor V, VII, X deficiency Factors suggesting a bleeding defect – spontaneous haemorrhage, sever/recurrent bleeding episodes, bleeding from multiple sites, bleeding out of proportion to trauma o Early bleeding following trauma → platelet deficiency o Delayed bleeding after initial homeostasis → coagulation factor deficiency o Normal history of previous coagulative stresses → acquired problem → drugs, malignancy, liver Examination Nature of bleeding and rash distribution o Senile purpura – dorsum of hands, extensor surface of forearms and shins Lips and oral mucosa – telangiectasia, gum hypertrophy Signs of malignancy – sternal tenderness, lymphadenopathy, splenomegaly Urinalysis Investigations Tests
Method
Normal
Platelets
An automated cut with a BP cuff set to 40mmHg
2-8 min
Prothrombin Time
Extrinsic & common pathways
Tissue factor and Ca2+ are added to a plasma sample, coagulation time is measured
12-15 sec
↓ vitamin K, DIC, GIT malabsorption, warfarin
Activated Partial Thromboplastin Time (aPTT)
Intrinsic & common pathways
Contact activation by phospholipid, Ca2+ added, coagulation time is measured
25-39 sec
Heparin, haemophilia
Common pathway
An excess of thrombin is added to a plasma sample, coagulation time is measured
12-18 sec
Can occur at any age Usually a diagnosis can be made clinically; ultrasound can be helpful Scrotal lump = cancer until proven otherwise Acute, tender enlargement of testes = torsion until proven otherwise
Aetiology Pelvic Masses • Lymphadenopathy (tender / non-tender) • Femoral hernia (painful if strangulated) • Psoas abscess (painful) • Skin lumps – e.g. epidermal cyst • Testis – undescended, maldescended, ectopic • Femoral artery aneurysm • Saphena varix – varicosity of the saphenous vein Scrotal Masses • Testicular torsion (very painful) • Orchitis / epididymo-orchitis (painful) – Chlamydia, E. coli, mumps, N. gonorrhoea, TB • Inguinal hernia (painful if strangulated) • Hydrocoele – collection of fluid within the two layers of the tunica vaginalis • Varicocoele – varicosity of pampiniform plexus (‘bag of worms’ with a dull ache) reversible subfertility • Haematocoele – blood within the tunica vaginalis • Spermatocoele – cyst containing spermatozoa • Testicular tumour • Haematoma
Abnormal Result Von Willebrand disease, ↓platelets, DIC, aspirin
Bleeding Time
Thrombin Time
• • • •
Normal
Hydrocoele
Testicular tumour
Epididymitis
Spermatocoele
Varicocoele
↓ vitamin K, warfarin
Orchitis
Indirect inguinal hernia
Sudden Collapse
Assessment History • Duration and onset • Change in size • Pain • Does it reduce (e.g. on lying down) • Any abdominal symptoms o Torsion of testis may have pain referred to the abdomen o Intestinal obstruction symptoms are likely with strangulated hernia • Occupation & hobbies Examination • Tenderness infection, ischaemia testicular torsion, strangulated hernia, epididymo-orchitis • Hernias o Femoral hernias are below and lateral to the pubic tubercle o Cannot feel the upper border of a hernia – can you feel above it? o It is not necessary to distinguish between direct and indirect inguinal hernias • Is the lump separate from the testis? • Cough impulse → hernia or saphena varix • Varicocoeles typically feel like a ‘bag of worms’ and are more left-sided Investigations • Ultrasound of scrotum and/or groin • If testicular tumour suspected → blood for AFP and β-HCG (tumour markers)
Aetiology • •
Can have syncopal or non-syncopal causes Syncope (fainting): transient loss of consciousness due to reduced cerebral blood flow Mechanism
Causes Syncopal Causes Vasovagal syncope – ↑vagal tone + ↓ sympathetic tone • Preceded by presyncope - nausea, pallor, sweating • Stimulated by pain, sight of blood etc.
Structures and Landmarks • Inguinal ligament • Femoral artery • Pubic tubercle • Testis • Epididymis • Spermatic cord
Neurally Mediated
↑PSNS (bradycardia) & ↓SNS (vasodilation)
Postural (orthostatic) hypotension – hypovolaemia, drugs Carotid sinus hypersensitivity Situational reflex-mediated syncope • On coughing, exercise, micturition Autonomic dysfunction
Cardiac
↓ cardiac output
Tachyarhhythmias / Bradyarrythmias • abnormal impulse generation (e.g. sinoatrial arrest) • abnormal conduction (e.g. AV block) Myocardial ischaemia Obstructive – aortic stenosis, mitral stenosis, HCM
Cerebrovascular
Cerebral ischaemia
Transient ischaemic attack Subarachnoid haemorrhage Non-Syncopal Causes
•
Epilepsy – grand mal (LOC) or complex partial (impairment of consciousness) preceded by aura
•
Hypoglycaemia – tremor, hunger and perspiration; rare in non-diabetics
•
Drop attacks – sudden weakness of the legs, especially in older women (no LOC)
•
Anxiety – ↑RR, tremor, sweating, ↑HR, light-headedness, no LOC panic attack
•
Choking – patient may collapse, turn blue and be unable to speak
Assessment •
History 1. Before the attack – any warning (e.g. epileptic aura, presyncope), circumstances (watching TV) 2. During the attack – ask a witness o Loss of consciousness o Change in complexion (white/red arrythmia) o Injury following collapse o Duration o Incontinence o Patient movement – floppy or stiff 3. After the attack – patient’s memory, patient confused/sleepy; muscle pain afterwards (tonic/clonic seizure)
•
Examination – cardiovascular and neurological exams; BP lying & standing
•
Investigations – ECG, FBC, Hb, electrolytes, LFTs, echocardiogram, CT/MRI, PaCO2 (hyperventilation)
Seizure
Cough
Abnormally high frequency discharge of a neurone group motor, sensory & behavioural areas Unconsciousness if the reticular formation is involved
• •
Aetiology •
Epilepsy
•
Drug withdrawal
•
Meningitis
•
Alcohol withdrawal
•
Head injury
•
Poisoning
•
Haemorrhage – subarachnoid / cerebral
•
Hypercapnia
•
Mass-occupying lesion – tumour / abscess
•
Hypoxia
•
Stroke
•
Encephalitis
•
Poisoning
•
Psychogenic
Classification of Seizures I – Partial (focal) seizures A – simple partial seizures (consciousness not impaired) B – complex partial seizures (consciousness impaired) C – partial seizures evolving to secondarily generalised seizures II – Generalised seizures of non-focal origin A – absence seizures (petit mal) B – myoclonic seizures / jerks (single / multiple) C – tonic-clonic seizures (grand mal) D – tonic seizures E – atonic seizures III – unclassified epileptic seizures
Diagnosis History Ask a friend as well – patient may be confused • What drugs has she taken • Medical history – epilepsy • Incontinence
Investigations • FBC – especially white cells • Blood glucose and electrolytes • ABGs – test for acidosis • Liver function – test for toxins • CT – if no history of epilepsy • Drug screen – heroin, alcohol, amphetamines, cocaine
Examination • Mental confusion • GCS • Odour • Neurological signs – paresis, facial symmetry, muscle tone, reflexes (Babinski is upgoing after a seizure) • Fundoscopy – haemorrhage, oedema
Treatment •
Protect the patient
•
Acute treatment – benzodiazepine (PR if seizing)
•
Anticonvulsants – carbemazepine, valproate
Aetiology Dry Cough Productive Cough • Infection • Chronic bronchitis o Upper respiratory tract infection • Bronchiectasis o Lower respiratory tract infection • Pneumonia o Tuberculosis • Asthma o Whooping cough • Foreign body (late response) • Inhaled irritants – smoke, dust fumes • Lung abscess • Inhaled foreign body • Tuberculosis (when cavitating) • Bronchial neoplasm • Smoking – morning coughs • Interstitial lung disorders o Fibrosing alveolitis Most Serious Most Probable o Extrinsic allergic alveolitis LVF URT infection o Pneumoconioses Neoplasm Postnasal drip o Sarcoidosis Severe infection Smoking • Left ventricular failure Asthma Acute bronchitis • GORD; hiatus hernia CF Chronic bronchitis • Postnasal drip Foreign body • Pleural irritation Pneumothorax
Assessment History Cough • Character o Brassy → tracheitis and bronchitis o Barking → laryngeal disorder o Croupy → laryngeal disorders o Bovine (no power) → vocal cord paralysis o Paroxysmal with whoops → whooping cough o Painful → tracheitis, left ventricular failure •
Timing o Nocturnal → asthma, LVF, postnasal drip, chronic bronchitis, whooping cough o Waking → bronchiectasis, chronic bronchitis, GORD
•
Associations o Changing posture → bronchiectasis, lung abscess o Meals → hiatus hernia, oesophageal diverticulum, trachea-oesphageal fistula o Wheezing → asthma o Breathlessness → asthma, LVF, COPD
Sputum • Amount •
•
Character o Clear white → normal / uninfected bronchitis o Yellow / Green (purulent – cellular material) → infection, asthma, bronchiectasis o Rusty → lobar pneumonia (blood) o Thick & sticky → asthma o Profuse, watery → alveolar cell carcinoma o Thin, clear mucoid → viral infection o Redcurrent jelly → bronchial carcinoma o Profuse & offensive → bronchiectasis, lung abscess o Thick plugs → allergic bronchopulmonary aspergillosis, bronchial carcinoma o Pink frothy sputum → pulmonary oedema Haemoptysis → acute infection, chronic bronchitis, bronchiectasis, pneumonia, TB, neoplasm, PE, foreign body, LVF, mitral stenosis, anticoagulant therapy, idiopathic
Other History • Any other symptoms – chest pain, fever, shivers, sweats, leg swelling, wheeze • Family history – asthma • Smoking history • Occupational history • Including exposure to asbestos • Birds – as pets or near home • Inhalation of foreign body • Recent operation or confinement to bed Examination General examination + lung & cardiac • Enlarged cervical or axillary lymph nodes → bronchial carcinoma, Horner’s syndrome • Fine crackles → oedema of heart failure, interstitial pulmonary fibrosis, early lobar pneumonia • Coarse crackles → resolving pneumonia, bronchiectasis, TB • Sputum – colour, consistency, particulate matter Investigations • Haemoglobin, blood film, white cell count • Sputum cytology and colour • ESR - ↑→bacterial infection, bronchiectasis, TB, lung abscess, bronchial carcinoma • Respiratory function tests • Radiology – CXR, CT, tomography, bronchography, V/Q isotope scan • Skin tests • Lung biopsy • Bronchoscopy
Chest Pain Causes Cardiovascular • Myocardial Infarction • Angina Pectoris • Pericarditis • Aortic dissection Respiratory • Pulmonary embolism • Pneumothorax • Pneumonia • Lung cancer Functional • Anxiety • Hyperventilation
Chest Wall • Trauma • Fracture • Costochondritis Gastrointestinal • Oesophageal reflux • Oesophageal spasm • Peptic ulcer • Aerophagy • Gall bladder disease
Most Probable • Musculoskeletal • Psychogenic • Angina
Most Serious • Cardio – MI/UA, aortic dissection, Pulm. embolism • Neoplasia – lung, spinal cord, meninges • Infection – pneumonia, mediastinitis, pericarditis • Pneumothorax
Assessment History • SOCRATES – site, onset, character, radiation, exacerbating/relieving factors, severity • Associated symptoms o Syncope → MI, pulmonary embolism, dissecting aneurysm o Pain on inspiration → pleurisy, pericarditis, pneumothorax, musculoskeletal o Thoracic back pain → spinal dysfunction, MI, angina, aortic dissection, pericarditis, GIT • Cough – productive, blood in sputum, colour of sputum etc. • History of trauma Examination • Pale and sweating → AMI, dissecting aneurysm, pulmonary embolism • Blood pressure – hypotension (AMI, DA), hypertension (early AMI) • Palpitation – chest wall (tenderness), legs (DVT), abdomen (tenderness) • Auscultation o Reduced breath sounds, hyper-resonant percussion, vocal fremitus → pneumothorax o Friction rub → pericarditis / pleurisy o Basal crackles → heart failure o S3 / S4 → AMI Investigations • ECG – to differentiate between MI, pulmonary embolism and pericarditis • Stress ECG – to diagnose myocardial ischaemia • Holter monitor – silent ischaemia and arrhythmias • X-ray – chest or spinal • Full blood count – anaemia may be associated • Cardiac markers • Oesophageal endoscopy
Breathlessness
Differentiation of Important Causes Myocardial Ischaemia • Typically retrosternal • Common sites of radiation – neck, inside of arms, epigastrium, interscapular
• • • • •
1. Stable angina – lasts ~3-5 minutes, relieved by rest and GTN; may be precipitated by arrhythmia 2. Unstable angina – pain 15-20 minutes or more; can be at rest, with effort, post infarction or post coronary surgery 3. Myocardial infarction – pain >15-20 minutes, typically heavy & crushing, with pallor, sweating or vomiting
Causes Sudden (seconds to minutes) • Pneumothorax • Pulmonary embolism • Pulmonary oedema • Aspiration • Anaphylaxis • Anxiety • Chest Trauma
Aortic Dissection • Usually sudden, severe and midline • Tearing sensation retrosternally and between scapulae • Inequality of carotid, radial and femoral pulses
Most Probable • Asthma • Left heart failure • COPD • Obesity • Lack of fitness
Pulmonary Embolism • Usually retrosternal chest pain • May be associated, with syncope and breathlessness • Massive embolus – hypotension, right heart failure or cardiac arrest Pneumothorax • Acute onset of pleuritic pain and dyspnoea • Often in a patient with a history of asthma or emphysema (due to rupture or a subpleural cyst) Gastrointestinal
Character Site Precipitation Relief
Orthopnoea – breathlessness when lying down lfat Paroxysmal nocturnal dyspnoea – breathlessness causing waking from sleep Tachypnoea – fast breathing Hyperpnoea – increased level of ventilation (e.g. during exertion) Hyperventilation – overbreathing
Acid reflux
Oesophageal spasm
Peptic Ulcer
Gallbladder disease
Burning
Constricting
Gnawing
Deep ache
Epigastric
Retrosternal
Retrosternal
Right hypochondrium
Heavy meals
Food and drink
Eating
Fatty food
Standing Antacids
Antispasmodics GTN
Antacids
Psychogenic • Can occur anywhere in the chest, but often in the left submammary region, usually without radiation • Continuous and sharp / stabbing • May mimic angina but tends to last for hours or days • Usually aggravated by tiredness or emotional tension • May be associated with shortness of breath, fatigue and palpitations
Acute (hours to days) • Asthma • Respiratory infection • Lung tumour • Pleural effusion • Metabolic acidosis
Chronic (months to years) • COPD • Cardiac failure • Anaemia • Arrhythmia • Valvular heart disease • Chest wall deformities • Cystic fibrosis • Pulmonary hypertension
Most Serious • Cardio – AMI, arrhythmia, pulmonary embolism, DA, cardiomyopathy, anaphylaxis • Neoplasia – bronchial carcinoma • Infection – SARS, avian flu, pneumonia • Respiratory – foreign body, obstruction, pneumothorax, pleural effusion, tuberculosis
Assessment History • Identify what the patient means by breathlessness • Onset; provoking factors • Associated symptoms - wheeze (asthma, COPD), cough (pulmonary causes) Examination • Inspection – cyanosis, clubbing, alertness, dyspnoea at rest, use of accessory muscles, rib retraction • Tremor of outstretched hands → CO poisoning • Tracheal displacement - bronchial collapse (toward affected side), pleural effusion, pneumothorax (away) • Chest expansion • Percussion • Breath sounds - vesicular / bronchial • Vocal fremitus • Crackles – LVF, alveolitis, pneumonia, bronchiectasis, chronic bronchitis, asbestosis, pulmonary fibrosis • Wheeze – partial obstruction, asthma, bronchitis, bronchiolitis Investigations • Pulmonary function tests – PEF, FEV1, FVC • Blood count • Arterial blood gases • Pulse oximetry
• • • •
Cardio tests – ECG, echo, cardiac markers Imaging – MRI, CT, V/Q scan Bronchoscopy Lung biopsy
Hoarseness
Abdominal Pain
Aetiology
Aetiology
•
Laryngitis o Assorted viruses – parainfluenza, coronavirus, influenza, rhinovirus, adenovirus o Excessive abuse of voice o Bacteria – Moraxella catarrhalis, haemophilis influenzae o Irritants – cigarette smoke, alcohol, caustic chemicals (e.g. HCl in GORD)
•
Benign laryngeal growths – papillomas, cysts, polyps, chondromas, lipomas, nodules
•
Laryngeal cancer
•
Compression of larynx – e.g. oesophageal cancer
•
Thyroid disease – thyroiditis, goitre
•
Vocal cord pathology o Trauma – blunt, penetrating, iatrogenic (intubation / surgery) o Stenosis / calcification
•
Nerve pathology o Left recurrent laryngeal nerve palsy o Left recurrent laryngeal nerve compression – apical lung cancer, oesophageal cancer o Motor neurone disease
•
Foreign body
History • • • •
• • • •
Nature and duration of hoarseness History of excessive voice straining Respiratory symptoms Symptoms of hypothyroidism - depressed, slow, tired, thin hair, croaky voice, heavy periods, constipation, dry skin, prefers warm weather Medications – corticosteroid inhalations Recent surgery Smoking Exposure to environmental pollutants
Examination • • •
Neck palpation – enlargement of thyroid or cervical nodes Oropharyngeal examination – epiglottis Signs of hypothyroidism – coarse dry hair and skin, slow pulse, mental slowing
Investigations • • • •
Thyroid function tests Chest x-ray (if lung carcinoma is suspected) Indirect/direct laryngoscopy CT if suspected neoplasia/laryngeal tumour
Management • • • • •
Diagnose and treat the cause Vocal rest and minimal usage Avoid irritants e.g. dust, cigarettes, alcohol Cough – consider cough suppressants Consider referral to an ENT specialist if o Acute - unexplained, fail to respond (3-4 weeks) or recur o Chronic (all cases) o Presenting with strider or non-tender lymphadenopathy o Sever vocal abuse (voice therapy is needed)
Inflammation • Inflammatory bowel disease • Appendicitis • Cholecystitis • Pancreatitis • Salpingitis • Diverticulitis Perforation • Duodenal ulcer • Gastric ulcer • Faecal peritonitis • Biliary peritonitis • Appendicitis Obstruction • Biliary colic • Acute small / large bowel obstruction • Ureteric colic • Acute urinary retention • Intestinal infarction
Most Probable - Acute • Gastroenteritis • Appendicitis • Dysmenorrhoea • Irritable bowel syndrome Most Serious - Acute • Cardio – MI, AAA rupture, aortic aneurysm, mesenteric artery occlusion • Neoplasia (bowel obstruction) • Infection – salpingitis, peritonitis, cholangitis, abscess • Ectopic pregnancy • Obstruction • Sigmoid volvulus • Perforation – duodenal ulcer, colonic / Meckel’s diverticulum, colonic cancer
Haemorrhage • Ruptured ectopic pregnancy • Ruptured spleen / liver • Ruptured ovarian cyst • Ruptured AAA Torsion (Ischaemia) • Sigmoid volvulus • Torsion ovarian cyst • Torsion of testes
Most Probable - Chronic • Irritable bowel syndrome • Dysmenorrhoea • Peptic ulcer / gastritis Most Serious - Chronic • Cardio – mesenteric artery ischaemia, AAA • Neoplasia – bowel, stomach, pancreas, ovaries • Infection – hepatitis, PID
Common Causes in Children •
Infantile colic (2 weeks – 16 weeks) – regular, unexplained, inconsolable crying, usually in the afternoon
•
Intussusception (3 months – 2 years) – severe colicky abdominal pain; very serious condition
•
Acute appendicitis (school age / adolescence) – usually occurs with vomiting (80%) or diarrhoea (20%)
•
Mesenteric adenitis – similar Hx to appendicitis, except with high fever and preceding URTI / tonsillitis
•
Child abuse
•
Testicular Torsion
•
Recurrent abdominal pain – three distinct episodes of abdominal pain over 3+ months – occurs in 10% of school-aged children; only 5-10% have an organic cause
Assessment History • SOCRATES o Constant / coming and going o Severity (1-10) o Contributing / relieving factors o Response to milk, food, antacids • Previous attacks with similar pain • Associated symptoms – sweats, chills, burning urination • Bowel motions – constipation, diarrhoea, blood • Urine • Medications – aspirin • Smoking, alcohol, drugs • Recent travel • Menstrual history • Past medical history – e.g. appendectomy
Pain Patterns Examination • General appearance • Oral cavity • Vital signs • Heart & lungs • Abdomen – inspection, palpation, percussion, auscultation • Inguinal region – hernias • DRE • Vaginal examination – for suspected problem with fallopian tubes, uterus, ovaries • Thoracolumnar spine – referred spinal pain • Urine analysis – WBC, RBC, glucose, ketones, porphyrins
Investigations • Haemoglobin - ↓ → anaemia due to chronic blood loss (peptic ulcer, carcinoma, oesophagitis • Blood film – e.g. sickle cell anaemia • WCC – leukocytosis → appendicitis, pancreatitis, mesenteric adenitis, cholecystitis, pyelonephritis • ESR - ↑ → carcinoma, Crohn’s, abscess • CRP - ↑ →$infection, inflammation • LFTs – hepatobiliary disease • Serum • Abdominal X-ray – see features → • ECG • Upper GIT endoscopy • Sigmoidoscopy / colonoscopy
Acute Pain
Chronic Pain
Red Flag Features Symptoms • Collapsing at toilet → intra-abdominal bleeding • Lightheadedness • Progressive intractable vomiting • Progressive abdominal distension • Progressive intensity of pain • Prostration (appearance of praying)
Timing • Colicky pain: rhythmic pain with regular spasms of recurring pain building to climax then fading • Usually indicative of intestinal obstruction
Signs • • • • • •
Pallor & sweating Hypotension Atrial fibrillation / tachycardia Fever Rebound tenderness & guarding Decreased urine output
Constipation
Diarrhoea
Aetiology • • • •
Dietary/exercise causes Dehydration Faecal impaction Intestinal obstruction
• • • •
Volvulus Irritable bowel syndrome Depression Anorexia nervosa
History • • • •
Ask patient what they mean by ‘constipation’ Diet Medications Lumps in the perianal area
• • • •
Acute appendicitis Spinal cord compression Hypokalaemia Hypercalcaemia
Examination • •
Digital rectal examiniation – always Abdominal examination
•
A relative increase in stool volume, frequency and/or fluidity (compared to normal) Technically – stool weight >200g / day (difficult to assess)
•
Consider: frequency, volume, consistency, content, colour, smell
•
Consequences– dehydration, electrolyte loss, cardiovascular collapse, chronic malnutrition
Classification By Time Course •
Acute (<2 weeks) o Usually caused by infection (viral, bacterial) o Self-limiting - doesn’t damage gut mucosa
•
Persistent (2-4 weeks)
•
Chronic (> 4 weeks) o Many causes (chronic infection, hormones, enzyme dysfunction, osmosis) o Usually watery, fatty or inflammatory o Generally causes damage to gut mucosa
Investigations
Bowel Motions • What are they normally like? • Frequency • Consistency - bulky, hard, soft • Pain on opening bowels • Blood • Soiling in underwear (?incontinence)
• • • •
Endoscopy Stool – occult blood biochemistry, culture Radiological studies – e.g. barium enema Physiological tests o Anal manometry – testing anal tone o Rectal sensation and compliance
Management Advice • Adequate exercise • Plenty of fluids – water, prune juice • Optimal bulk diet – fruits, vegetables, cereals • Defecate as soon as possible when the need strikes • Avoid laxatives and codeine compounds Medication 1. First line – bulking agent e.g. psyllium 2. Second line – osmotic laxative or fibre-based stimulant preparation (e.g. sorbitol) 3. Third line – magnesium sulphate
By Location •
Small Intestinal – large volume; usually malabsorptive or secretory
•
Colonic – smaller volume but frequent; usually exudative, loss of electrolytes, osmotic, nervous.
Pathogenesis (DOMES)
Mechanism
Examples
Deranged Motility
Dysfunction of neuromuscular control Decreased transit time (↓ absorption)
Hyperthyroidism, IBS, diabetic neuropathy
Osmotic
Osmotic pressure generated by non-absorbed molecules draws water into lumen
Lactose intolerance, laxatives
Correlates with ingestion of food (slows with fasting)
Malabsorptive
Impaired absorption Often ↓ fat absorption (steatorrhoea) Slows with fasting
Physical blanketing (Giardia), reduced surface are (coeliac disease), mal-digestion (pancreatic insufficiency)
Exudative
Inflammation & destruction of mucosa Small volume, high frequency Blood/pus/mucus in stools Persists with fasting
Inflammatory bowel disease, Infection (shigella/ entamoeba)
Secretory
Secretion > absorption Large volume stools, no blood/pus/mucus Persists with fasting
Enterotoxin-mediated (cholera), hormonal, villous adenoma
Aetiology •
Infection – bacterial, viral, parasitic
•
Bowel inflammation – inflammatory bowel disease, appendicitis, diverticulitis, ischaemic colitis
•
Colorectal cancer
•
Drugs – alcohol, antibiotics, antihypertensives, cytotoxic agents, heavy metals, H2 receptor antagonists, iron-containing compounds, laxatives, metformin, NSAIDs, quinidine, salicylates, statins, theophylline
•
Malabsorption – coeliac disease, lactase deficiency, tropical sprue, pancreatic insufficiency
Jaundice • • • •
Yellowish colouration of the body due to build-up of bilirubin (hyperbilirubinaemia), also known as icterus A symptom, not a disease Clinically noticeable (in the skin/sclera of the eyes) at plasma [bilirubin] > 50μmol/L Increased bilirubin can be from disturbance in heme catabolism or in conjugation/excretion of bilirubin
Aetiology heme oxygenase
Macrophages
reductase
Hemoglobin
•
Endocrine – hyperthyroidism, diabetic neuropathy
•
Psychogenic – irritable bowel syndrome
Diagnosis
Frequency
•
Associated symptoms – abdominal pain, fever, nausea, vomiting
•
Food intake in the past 72 hours – chicken (Salmonella, Campylobacter), seafood (Vibrio)
•
Recent travel abroad
•
Medications – antibiotics
•
Normal diet (if chronic) – milk, alcohol, vitamin C supplementation, wheat
Examination •
GIT examination – especially for masses, hepatomegaly, splenomegaly, tenderness, skin changes, iritis
•
Stool examination - blood, mucus, steatorrhoea
Investigations •
Stool microscopy, culture and sensitivity
•
Blood tests – FBC, iron studies, folate, B12, calcium, electrolytes, thyroid function tests, HIV tests
•
Antibodies – e.g. transglutenaminade for coeliac disease
•
Malabsorption studies
•
Endoscopy – proctosigmoidoscopy, flexible sigmoidoscopy + biopsy, small bowel biopsy (coeliac)
•
Radiology – barium enema
Unconjugated Bilirubin
pre-hepatic Jaundice
Globin (protein) Plasma
disturbance causes unconjugated hyperbilirubinaemia
Unconjugated Bilirubin (bound to albumin)
Liver 1. Uptake
History • Nature o Amount – small volume (inflammation, cancer), large volume (laxative abuse, malabsorption) o Consistency – liquid (gastroenteritis), bulky/pale (malabsorption) etc. o Blood – present (more likely to be bacterial), profuse (diverticulitis, cancer) o Mucus – inflammatory bowel disease •
Biliverdin biliverdin
Heme
Unconjugated Bilirubin + 2 glucuronic acid UDP-glucuronyl
hepatic Jaundice
transferase
2. Conjugation
Conjugated Bilirubin 3. Excretion
Bile.
post-hepatic Jaundice
Conjugated Bilirubin
Duodenum Unconjugated Bilirubin
disturbance causes conjugated hyperbilirubinaemia
Conjugated Bilirubin
Urobilinogen through plasma
Colon
(80-90%) Urobilinogen
Stercobilinogen Stercobilin (colours stools)
Kidney Urobilinogen (10-20%) Urobilin (colours urine)
If there is blockage of the flow of bile (conjugated bilirubin) then these result: •
Pale stools - ↓bile in the duodenum → ↓stercobilin (stool pigment) excretion
•
Dark Urine - ↑ conjugated bilirubin backflows into liver and is taken up by the kidney$→↑urobilin (urine pigment)
Upper Gastrointestinal Bleeding
Pre-Hepatic Jaundice • Excessive bilirubin production from Haemolysis, glomerular nephritis etc. • ↑ unconjugated bilirubin in blood • ↑ urobilinogen in urine & stools • Normal urine and stool colour
• • •
Hepatic Jaundice • Impaired liver function or hepatocellular damage from hepatitis, toxins, cirrhosis • Three processes that can be affected
Aetiology • • • • •
1. ↓Uptake + ↑ unconjugated bilirubin in blood + Normal urine colour, pale stools 2. ↓Conjugation + ↑ unconjugated bilirubin in blood + Normal urine colour, pale stools
• • • •
3. ↓Excretion (hepatic cholestasis) + ↑$conjugated bilirubin in blood + Dark urine & pale stools Post-Hepatic Jaundice • Blockage of outflow from liver from gallstones, head of pancreas cancer • ↑ unconjugated bilirubin in blood • Dark urine & pale stools
Hepatic
Bilirubin in Plasma
Urine
Stool
AST/ALT
ALP
Urine Bilirubin
Urine Urobilinogen
Unconjugated
Normal
Normal
Normal
Normal
Absent
↑$
↓Uptake
Unconjugated
Normal
Pale
↓Conjugation
Unconjugated
Normal
Pale
Conjugated
Dark
Pale
Conjugated
dark
pale
↓Excretion Post-Hepatic
! ! !
Gastritis Ulcer – gastric, duodenal, stomal (can be caused by NSAIDs, alcohol) GORD Oesophageal varices – due to portal hypertension (usually due to cirrhosis) Mallory-Weiss syndrome o Tears at lower end of oesophageal mucosa due to an episode of severe vomiting / coughing o Blood in vomitus after a bout of heavy vomiting / dry retching o Usually seen in alcoholic patients Carcinoma - gastric / oesophageal Anticoagulant therapy Vascular malformations Hereditary haemorrhagic telangiectasia
Assessment
Differential Diagnosis
Pre-Hepatic
Haematemesis: vomiting of blood (fresh blood or ‘coffee ground’) Melaena: black tarry stools with distinctive odour Severe upper GI haemorrhage is life-threatening (melaena is less life-threatening than haematemesis)
↑$
Normal
↑$
↓$
Normal
↑$
↑$
Absent
History • Amount and appearance of vomit - black dots like coffee grounds? • Indigestion, heartburn, stomach pain • Appearance of stools • Medications – especially aspirin and NSAIDs; also prednisolone, warfain, clopidogrel, SSRIs • Alcohol history • Previous operations on stomach – especially for peptic ulcer • History of normal vomiting before blood in vomit Examination • General state – haemodynamic status (heart rate, blood pressure, postural change) • Abdominal examination including DRE – looking for a mass, hepatomegaly or splenomegaly Investigations • Upper GIT endoscopy – detects cause in >80% of cases • Haemoglobin - <90 g/L → transfusion
Management 1. Restore effective blood volume o Two large-bore IV lines → infusion of colloid o Plasma expander o NG tube to evacuate blood from the stomach and reduce vomiting o Intubation – to protect the airway and prevent aspiration of gastric contents 2. Diagnose and treat the cause o Endoscopy – to identify site, assess bleeding and give treatment o Treatments – adrenaline, sclerotherapy, variceal banding
Anorectal Symptoms Include: • Bleeding • Pain • Lumps • Discharge • Pruritis
Anorectal Pain Pain Without Swelling • Anal fissure • Anal herpes • Ulcerative proctitis • Solitary rectal ulcer
Pain With Swelling • Perianal haematoma • Strangulated internal haemorrhoids • Abscess – perianal / ischiorectal • Pilonidal sinus
Anorectal Lumps Prolapsing Lumps • 2nd / 3rd degree haemorrhoids • Rectal prolapse • Rectal polyp • Hypertrophied anal papilla
Persistent Lumps • Skin tag • Perianal warts • Anal carcinoma • 4th degree haemorrhoids • Perianal haematoma • Perianal abscess
Anal Discharge
Rectal Bleeding •
Bright red blood in toilet separate from faeces – internal haemorrhoids
•
Bright red blood on toilet paper – internal haemorrhoids, fissure, anal carcinoma, pruritis, anal warts
•
Blood on underwear o Mucus - 3rd/4th degree haemorrhoids, prolapsed rectum, mucosal prolapse o No mucus – ulcerated perianal haematoma
•
Blood in faeces o Mucus – colorectal carcinoma, proctitis, colitis, mucosal polyp, ischaemic colitits o No mucus – small colorectal polyp, small colorectal carcinoma o With mentstruation (rare) – rectal endometriosis
•
Melaena – GIT bleeding (usually upper) with long transit time to anus
•
Torrential haemorrhage (rare) – diverticular disorder, angiodysplasia
History • Nature of the blood – bright red, dark red, black • Nature of the bleeding – smear, streaked on stool, mixed with stool, massive • Smell (melaena) • Frequency of blood o High frequency – rectal tumour / proctitis o Lower frequency – proximal tumours, extensive colitis • Associated symptoms – pain, diarrhoea, constipation, lumps, urgency, tenesmus, change in bowel habit Examination • General inspection • Anal inspection • DRE • Proctosigmoidoscopy
Continent • Anal fistula • Pilonidal sinus • STIs – anal warts, gonococcal ulcers, herpes • Solitary rectal ulcer • Carcinoma of anal margin
Incontinent • Minor – weakness of internal sphincter • Major – weakness of levator ani & puborectalis Partially Continent • Faecal impaction • Rectal prolapse
Pruritis Ani Aetiology • Psychological – stress, anxiety, fear of cancer • Systemic / skin disorders – eczema, DM, candidiasis, psoriasis, antibiotic treatment, pinworm / threadworm, excoriation (due to diarrhoea) • Localised anorectal conditions – piles, fissures, warts • Excessive hygiene • Contact dermatitis – dyed / perfumed toilet paper, soap, powder, clothing • Excessive sweating
Diagnosis • Urinalyisis – for diabetes • Anorectal examination • Scrapings & microscopy to detect organisms • Stool examination for parasites
Treatment • Stop scratching • Avoid hot water when bathing • Keep the area as dry and cool as possible • Keep bowel motions regular • Clean gently after bowel motions • No perfumed soaps or powders • Loose clothing & underwear
Tenesmus • •
Unpleasant feeling of incomplete emptying of the rectum – mostly caused by irritable bowel syndrome Also caused by rectal / anal mass – carcinoma, haemorrhoids, hard faecal mass
Dysuria
Haematuria
Difficult and/or painful micturition • Due to passage of urine across inflamed mucosa of lower genitourinary tract (urethra, bladder, prostate) • Dysuria and frequency commonly coexist • Sometimes accompanied by haematuria and systemic symptoms
Presence of blood in the urine • Macroscopic haematuria - bladder, urethra, prostate, kidney •
Microscopic urine - >2,000 RBCs / mL urine using light microscopy o Glomerular (from kidney parenchyma) or non-glomerular (urinary tract) o Athletes can develop transient microscopic haematuria following vigorous exercise
•
Often a sign of a serious underlying disorder
Aetiology •
Infection – cystitis, urethritis, vaginitis, prostatitis, urethral syndrome (males), gonorrhea, genital herpes
•
Neoplasia – bladder, prostate, urethra
•
Calculi – e.g. in the bladder
•
Foreign body in lower urinary tract
•
Acidic urine
•
Vaginal prolapse
•
Obstruction – BPH, urethral stricture, phimosis, meatal stenosis
Most Likely • Cystitis (females) • Urethritis • Vaginitis Most Serious • Neoplasia • Severe infection • Reiter’s Syndrome • Calculi
Aetiology • • • • • • • • •
Assessment History • Description of discomfort o Timing i. Pain at onset of micturition urethritis ii. Pain at end of micturition cystitis o Location - suprapubic cystitis • Colour of urine • Discharge – could it be sexually acquired • Painful intercourse (women) • Systemic features – fever, sweats, chills Examination • Vitals – HR, temp, BP • Abdominal palpitation – loins & suprapubic area • Vaginal, rectal, genital examination – may be appropriate Investigations • Urine dipstick • Urine microscopy & culture (midstream)
•
Contamination of urine specimen Infection – bladder, kidneys, urethra, epididymis, testes Coagulopathy Vascular – endothelial injury Necrosis Autoimmune / inflammatory – nephritic / nephrotic syndrome Neoplasia – prostate, kidney, bladder, external genitalia Benign prostatic hyperplasia Trauma o Blunt abdominal trauma o Penetrative trauma o Iatrogenic - surgery, catheterization, self-inflicted o Kidney stones Fistula – labour complications, Crohn’s disease
Non-Blood Causes of Dark Red Urine • Dietary colour – beetroot, berocca, berries, confectionary • Drugs – rifampicin, phenolphthalein • Porphyria • Breakdown products – bilirubin, myoglobin, free haemoglobin
Most Likely • Infection – cystitis, urethritis, prostatitis • Calculi – kidney, ureter, bladder Most Serious • Cardiovascular – kidney infarction, kidney vein thrombosis, prostatic varices • Neoplasia – kidney, urothelium, prostate • Severe infection – IE, kidney tuberculosis, acute glomerulonephritis • IgA nephropathy • Kidney papillary necrosis
History •
Is it really haematuria – could be haemolysis / red food dye / breakdown products
•
Trauma to loin, pelvis, genital area
•
Timing o First part of stream urethral / prostatic lesion o Terminal bladder
•
Associated symptoms o Pain infection, calculi, kidney infarction o Painless infection, trauma, tumours, polycystic kidneys o Frequency o Bleeding elsewhere – skin, nosebleeds
•
Possibility of the condition being sexually acquired
•
History of kidney problems
•
History of diabetes
Examination
Proteinuria • •
Can originate from the glomeruli, tubules or lower urinary tract Healthy people excrete some protein in the urine, which can vary from day-day or hour-hour Microalbuminuria
Macroalbuminuria
Albumin / creatinine ratio
F: 3.6-35 mg/mmol M: 2.6-25 mg/mmol
F: >35 mg/mmol M: >25 mg/mmol
Dipstick
>3mg/dL (albumin)
>20mg/dL
Protein / creatinine ratio
-
Proteinuria 1+ or more
-
>0.3 g/24 hours
Aetiology •
Transient - benign o Contamination from vaginal secretions o Urinary tract infection o Pre-eclampsia
•
Kidney disease o Glomerulonephritis o Nephrotic syndrome o Congenital tubular disease – polycystic kidney, kidney dysplasia o Acute tubular damage o Kidney papillary necrosis o Overflow proteinuria o Systemic diseases – DM, HTN, SLE, malignancy, drugs
•
Non-kidney disease o Orthostatic proteinuria o Exercise o Fever o Post-operative o Heart failure
Investigations •
Urine dipstick
•
Urine microscopy o Formed RBCs true haematuria o Red cell casts glomerular bleeding o Dysmorphic RBCs glomerular bleeding
•
Urine culture
•
Urine cytology – to detect malignancies of the bladder / lower UT (not kidney)
•
Blood tests – FBC, ESR, urea, creatinine
•
Radiology o IV urography (UVI) o Ultrasound – better for kidneys than lower UT o CT o Kidney angiography o Retrograde pyelography
•
Direct imaging – urethroscopy, cystoscopy
•
Kidney biopsy – indicated if glomerular disease is suspected
Orthostatic Proteinuria • •
Significant proteinuria after the patient has been standing but absent after sitting for several hours Occurs in 5-10% of people, especially during adolescent years
Diabetic Microalbuminuria • •
Presence of small amounts of protein in urine is a sensitive marker of diabetic nephropathy Dipstick is helpful, radioimmunoassay is better
Consequences of Proteinuria >3g / 24 hours • Oedema • Intravascular volume depletion • Venous thromboembolism • Hyperlipidaemia • Malnutrition
Urinary Incontinence • • • • • • •
Urinary incontinence: involuntary urine loss during the day / night Nocturnal enuresis (bed-wetting): involuntary urine loss during sleep Urge incontinence: urgent desire to void followed by involuntary urine loss Overactive bladder (detrusor instability): involuntary bladder contractions sudden urge to urinate Stress incontinence: involuntary urine loss on coughing, sneezing, straining, lifting Voiding dysfunction: urinary difficulties, detrusor instability, overflow incontinence Function incontinence: loss of urine secondary to factors outside of the urinary tract
Aetiology DIAPPEERSS • Delerium •
Infection of urinary tract
•
Atrophic urethritis
•
Pharmacological – e.g. diuretics
•
Psychological – acute distress
•
Endocrine – e.g. hypercalcaemia
•
Environmental – e.g. unfamiliar sounds
•
Restricted mobility
•
Stool impaction
•
Sphincter damage / weakness
Management •
Exclude UTI & drug causes
Stress Incontinence • Weak pelvic floor – exercises • Obesity – weight reduction • Menopause – HRT / vaginal oestrogen creams • Chronic cough – physiotherapy Urge Incontinence • Neurological signs neurologist • Abnormal voiding pattern bladder retraining Voiding dysfunction • Neurological signs neurologist • Gynaecological cause gynaecologist • Bladder atony anticholinergics
Lower Back Pain • • •
• •
The most common cause of back pain in people <45 years, and the 3rd most common in those >45 years 60-80% of people will experience lower back pain in their lives Grading: o Acute: <4 weeks o Subacute: 4-12 weeks o Chronic: >12 weeks Predisposition to lower back pain is mostly inherited Work has been shown to contribute up to 25% of variance in lower back pain
Causes 1. IV discs o Degeneration o Herniation
Mechanical – Bones, discs, SC, nerves Non-mechanical – inflammatory, infective, neoplastic Non-spinal – viscerogenic, psychogenic
2. Vertebrae o Spondylolisthesis (forward displacement of a vertebral body onto another) o Scheuermann’s kyphosis (adolescents – vertebral wedging, schmorl’s nodes, disc degeneration) o Fractures (may be from osteoporosis) o Spinal stenosis o Infection o Tumours o Osteomalacia o Paget’s disease 3. Spinal Cord a. Epidural abcess b. Intradural tumours 4. Joints o Apophyseal osteoarthritis (facet joints) o Rheumatoid arthritis o Ankylosing spondylitis (chronic inflammation of spinal and sacroilial joints that leads to joint fusion) o Chondrocalcinosis (accumulation of calcium pyrophosphate dehydrate crystals in CT) 5. Misalignments – postural, differences in leg length, misaligned pelvis, abnormal foot pronation 6. Referred Pain – from pelvic or abdominal organs 7. Psychogenic/Neurogenic – stress, depression
Risk Factors • • • • • •
Family history Heavy manual work Sedentary lifestyle Obesity, tallness Low socioeconomic status Stress
Red Flags • • • • • • • •
Age >50 years History of cancer Unexplained weight loss Unexplained fever Steroid or IV drug use Severe, unremitting pain at night Significant trauma No improvement over 1 month
Clinical Features
Treatment
Nature of Pain
• Nature of Pain Aching throbbing pain Deep diffuse aching pain Superficial steady diffuse pain Boring deep pain Intense sharp or stabbing pain
Likely Cause Inflammation Referred pain Local pain Bone disease Radicular pain
Examples Sacroileitis Dysmenorrhoea Muscular strain Neoplasia, Paget’s disease Sciatica
Inflammatory vs. Mechanical Causes History
Inflammation Insidious onset
Nature
Aching, throbbing
Stiffness Effect of rest Effect of activity Radiation Intensity
Severe, prolonged morning stiffness Exacerbates Relieves More localised, bilateral or alternating Night, early morning
Major Conditions to Exclude Can cause major morbidity or mortality • Fractures (4%) • Tumours (1%) • Infections (<1%) • Rheumatoid and other related conditions (0.1%)
Mechanical Precipitating injury/previous episodes Deep dull ache / Sharp (root compression) Moderate, transient Relieves Exacerbates Tends to be diffuse, unilateral End of day, following activity
Conditions that Masquerade as Back Pain • • • • • •
Depression Diabetes Drugs Anaemia Thyroid disease Urinary tract infection
Diagnosis •
Once tumours, fractures, infection, disc herniation and rheumatological conditions have been excluded, there is no certainty about diagnosis
Spinal/Neurological Examination • Palpation – checking for tenderness • Movement o Range of movement o Symmetry o Power (MRC grading) • Tendon Reflexes • Special tests o Walking on heels (L4/L5) o Walking on toes (S1) o Squatting (quadriceps power, femoral nerve, L3/L4)
Imaging Decision to perform imaging is made taking into account findings of examination and presence of red flags • CT • MRI • Myelogram – injection of contrast medium into lumbar spine, followed by x-rays (useful when MRI is contraindicated)
Most conditions are self-limiting and will recover with little to no treatment
1. Management: mostly conservative involving o Heat/cold o Physical therapy o Avoidance of heavy manual labour 2. Mobilisation vs. bed rest: for acute cases, the priority is early mobilisation o A brief period of rest may be necessary (<3 days) o Prolonged immobilisation can lead to bone weakness, muscle atrophy etc. 3. Analgesics: NSAIDs can provide some pain relief 4. Surgery: patients with cauda equina syndrome or spinal abcess may require surgery
Leg Pain
Knee Pain
Aetiology •
•
•
Musculoskeletal o Cramps o Strain o Osteoarthritis o Overuse injury – Osgood-Schlatter o Ruptured baker’s cyst o Paget’s disease Peripheral neural o Nerve root pain – prolapsed disc o Sciatica (pain in sciatic nerve distribution) o Nerve entrapment o Spinal canal stenosis Vascular o Arterial occlusion – claudication, rest pain o Thrombosis – DVT o Varicose veins
•
Common presenting symptoms of the knee – pain, stiffness, swelling, clicking and locking
•
Neoplasia o Primary – myeloma o Secondary metastasis
•
Infection o Osteomyelitis o Septic arthritis o Lymphangitis o Gas gangrene o Herpes zoster
•
Ligamentous conditions o Strains & strains o Cruciate ligament tear
•
Menisceal tears
Referred pain o Spondylogenic (vertebral joints, IV discs, ligaments, muscle attachements) o Sacroiliac dysfunction
•
Arthritis o Osteoarthritis o Rheumatoid arthritis o Juvenile chronic arthritis
•
Ruptured popliteal cyst
•
Osgood-Schlatter disorder
•
Foreign bodies
•
Fractures
•
Patellofemoral syndrome
•
Bursitis – prepatellar / patellar
•
Crystals – gout / pseudogout
•
Vascular disorders – DVT, superficial thrombophlebitis
•
Neoplasia – primary bone, metastases
•
Infection – septic arthritis, tuberculosis
•
Referred pain o Hip joint – mainly innervated by L3 pain radiates from the groin to the frontal & medial thigh o Lumbosacral spine – worse on sitting, coughing or straining; but not walking o L3 nerve root pressure from L2-3 prolapse
•
Psychogenic – imaginary or exaggerated pain
•
Most Probable • Cramps • Sciatica • Muscular injury • Osteoarthritis • Overuse injury
Most Serious • Vascular • Neoplasia • Infection
Assessment History • Site – and whether the site of pain is the same as the site of trauma • Acute / chronic (acute + no Hx of trauma → vascular) • Mechanical / postural / related to walking • Arising from joint or bone Examination • Gait & stance – especially antalgic gait, symmetry • Swelling, bruising, rashes • Trophic changes – colour, hair distribution, wasting, temperature, dryness, ulceration • Palpate for pain – ischial tuberosity, trochanteric area, hamstrings, tendon insertions, superficial LN • Palpation of lower limb pulses • Neurological examination – for nerve root lesions and entrapment neuropathies • Joint examination Investigations • FBC + ESR • Radiology – X-ray of leg, X-ray/CT/MRI of lumbosacral spine, bone scan • Vascular – arteriography, duplex ultrasound, contrast venography, D-dimer
Aetiology Most Serious • Cruciate ligament tear • Vascular disorders • Neoplasia • Infection • Rheumatoid arthritis
Most Probable • Ligament strains & sprains • Osteoarthritis • Patellofemoral syndrome • Prepatellar bursitis
Assessment History Related to injury • Mechanism of injury • Twisting of leg or popping sound • Swelling – haemarthrosis (torn ligaments, synovium, fractured bones) • Feeling of bones separating • Onset of pain / swelling after injury • Ability to walk afterwards • Previous knee injury / surgery
General Features • Locking – torn meniscus, loose body, torn ACL, dislocated patella, gross effusion
No history of injury • Onset – with walking, jogging, other activity • Kneeling – scrubbing floors, cleaning carpets • Locking or catching of the knee • Variation through the day
•
Catching – osteochondritis dessicans, dislodged osteophyte, osteochondral fracture
•
Clicking – patellofemoral subluxation, loose intra-articular body, torn meniscus
•
Anterior pain – patellofemoral syndrome, osteoarthritis, patellar tendonopathy, osteonecrosis
•
Lateral pain – osteoarthritis, lateral meniscus lesion, patellofemoral syndrome
•
Medial pain – osteoarthritis, medial meniscus lesion, patellofemoral syndrome
Physical Examination •
Look – while the patient is walking, standing, lying supine o Deformities – genu valgum (knock-knee), genu varum (bow legs), genu recurvatum (back knee) o Swelling o Muscle wasting
•
Feel – patella, patellar tendon, joint lines, tibial tubercle, bursae, popliteal fossa o Fluid, warmth, swelling, synovial thickening, crepitus, clicking, tenderness o Popliteal cyst o Bulge sign (fluid effusion) – compress the medial side of the joint
•
Move – extension (0-5°), flexion (135°), rotation (5-10°)
•
Special tests o Collateral ligaments – varus & valgus stresses o Cruciate ligaments – anterior draw test o Menisci – McMurray’s test, Apley grind test o Patella – patellar apprehension test
Investigations • Blood tests – rheumatoid factor, ESR, blood culture • Radiology – plain x-ray, bone scan, MRI, arthrography, ultrasoung • Special – examination under anaesthesia, arthroscopy, knee aspiration
!
! ! ! ! CLINICAL!COMMUNICATION! SKILLS! ! ! ! ! ! ! ! !
MEDI2021 & MEDI2022 Clinical Communication Skills Program – 2015 Module
Semester
Topic
Lecture Series
Learning Activity
4a
1
Breaking Bad News
Communicating in Difficult Circumstances
1 x 2hr tutorial in groups of 12
4b
1
Communicating in a Palliative Care Setting
Palliative Care
1 x 2hr tutorial in groups of 24
5
1
Summative Assessment: Breaking Bad News DVD Recording and review
1 x 1.5 hr tutorial in groups of 6
6
1
History Taking in a Mental Health Setting
2 x 2hr tutorials in groups of 24
7
2
Facilitating Behavioural Change/Motivational Motivational Interviewing Interviewing Facilitating Behavioural Change (VOPP)
3 x 2hr tutorials in groups of 24
8
2
Sexual History Taking
1 x 2hr tutorial in groups of 24
Taking a Sexual History
• INFORMATION SHEET 4b COMMUNICATION WITH A PALLIATIVE CARE PATIENT
fears of the medical hierarchy. (e.g., the young intern not wanting to upset the consultant by asking the patient the “wrong” thing)
(B) DEFINITIONS AND STANDARDS OF PALLIATIVE CARE Palliative care has been defined by the World Health Organisation (WHO) as:
“Effective symptom control is impossible without effective communication.”
The social denial of death
“…an approach that improves the quality of life of individuals and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”
Lack of experience of death in the family, high expectations of health and life, high value placed on material possessions and the changing role of religion all contribute to a process where dying is perceived as alien and fearsome.
The WHO further states that palliative care:
Patient’s fears of dying
•
provides relief from pain and other distressing symptoms
Every person dying has a unique combination of fears and concerns in facing the prospect of dying. Some commonly expressed fears are about:
•
affirms life and regards dying as a normal process
•
intends neither to hasten nor postpone death
•
Physical illness (e.g., symptoms, disability, disfigurement)
•
integrates the psychological and spiritual aspects of care
•
Psychological effects (e.g., not coping, dementia)
•
offers a support system to help patients live as actively as possible until death
•
Dying (e.g., religious concerns, existential concerns)
•
•
Treatment (e.g., side effects, mutilation/change in body image)
•
Family and friends (e.g., being a burden, loss of family role)
•
Finances, social status and job
offers a support system to help the family cope during the patient’s illness and in their own bereavement uses a team approach to address the needs of patients and families, including bereavement counselling, if indicated will enhance quality of life, and may also positively influence the course of illness
(A) SOURCES OF DIFFICULTY IN COMMUNICATING WITH DYING PATIENTS
Factors originating in the health care professional
• • •
is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life, such as chemotherapy or radiation therapy, and includes those investigations needed to better understand and manage distressing complications
Results of a survey (Buckman, 1984) suggest a number of factors may be operating that contribute to the discomfort of talking with a dying person:
Standards of palliative care
•
Sympathetic pain (overwhelmed by the patient’s distress)
Palliative Care Australia has developed national palliative care standards based on the principals of
•
Fear of being blamed (“blaming the messenger for the message”, a sense of therapeutic failure) Fear of the untaught. As professionals we like to follow guidelines to do things “properly”.
•
Dignity of the patient, caregiver/s and family
•
Empowerment of the patient, caregiver/s and family
Often there are not rigid guidelines to follow in palliative care.
•
Compassion towards the patient, caregiver/s and family
•
Fear of eliciting a reaction.
•
Respect for the patient, caregiver/s and family
•
Fear of saying “I don’t know.”
•
Equity in access to palliative care services and resources
•
Fear of expressing emotions (while it is appropriate not to show panic or rage, a doctor who shows no emotions when the patient is facing death is likely to be perceived as cold or insensitive.) ambiguity of phrase “I’m sorry” (doctors may fear it sounds as though they are apologising b and taking blame) own fears of death and suffering
•
Advocacy on behalf of the expressed wishes of patients, families and communities
•
Excellence in the provision of care and support
•
Accountability to patients, caregivers, families and community
•
• •
Putting the standards into practice….
(C) BASIC COMMUNICATION SKILLS FOR PALLIATIVE CARE
•
Physical context: ensure privacy wherever possible.
•
Introductions: ensure the patient knows who you are and what you do. You may wish to shake hands. Offer handshake as well to spouse if present.
•
Sit down: conveys a willingness to listen and conveys an attitude of unhurriedness that is helpful.
•
Body language. Maintain a comfortable distance and lean forward slightly. Eye contact is important in conveying attention, understanding, and concern.
•
Touch: may be very helpful, but need to be sensitive to reactions of patient.
•
Facilitate the flow of the dialogue with general communication skills (e.g., ask open-ended questions, don’t speak on top of the patient, use minimal encouragers)
•
Tolerate short silences. Silences don’t mean the patient has stopped thinking. S/he may be experiencing feelings that are too intense to easily express. If you have to break the silence, it may help to ask gently, “What were you thinking about just then?” or “What made you pause just then?” Silence may also indicate the patient is weary or breathless and needs to pause.
•
Repetition and reiteration. Use patient’s key words to convey that you have been listening carefully.
•
Identify the patient’s emotion and its origin, and respond in a way that tells the patient you have made the connection; e.g., It must be very distressing for you to know that all that chemotherapy didn’t give you a long (or any) remission.” Professionals don’t have to feel the same emotion as the patient (sympathy) but it is important they convey to the patient that they are making an effort to understand his/her experience (empathy).
•
Dignity offers a useful overarching framework to guide palliative care staff, patients and significant others in defining goals and considerations at the end of life. Patients feel worthy and esteemed when they are treated with respect and their symptoms are well managed. Some examples of dignity-promoting questions are: - “Is there anything we can do to make you more comfortable?” - “Is there anything further about your illness that you would like to know?”
•
As death approaches, patients will communicate increasingly nonverbally. This should not stop professionals talking to them, describing what they are doing, and treating them as people with feelings. Patients may still hear though be unable to speak (be careful of what is discussed around the bed). Relatives may feel tense and distressed and need to be supported sensitively. Needs and wishes need to be regularly reviewed.
•
Cultural/religious practices are to be respected and should be discussed when the patient is admitted to the palliative care unit/home visiting service.
(D) OTHER CONSIDERATIONS As well as fear, dying patients may experience a range of other distressing emotions. Anger: at the rest of the world; who will survive after s/he has gone; anger at God/fate; anger at any one who is trying to help. Behind anger are often feelings of powerlessness and a desperate search to regain some sense of control and meaning. It is often helpful for the patient/family’s anger to be acknowledged and respectfully explored. (“I can understand that you feel very angry that…… . Would you like to tell me more about …”). Remaining calm and non defensive are key tasks for professionals in these situations.
Denial: Denial is a useful protective mechanism in a dangerous situation. Professionals need to understand the individual’s need to protect themselves, without colluding with the denial by pretending to share it. A supportive comment such as, “When things are difficult, it helps to think about something pleasant.” recognizes the pain of the situation, but also notes the patient’s avoidance. Professionals should not collude with patients’ denial such that key information is withheld; for example, regarding diagnosis (ie, disseminated cancer) and prognosis (eg, not more than a few months). However, this does not mean that every conversation between the patient and doctor needs to involve confrontation or argument about the “facts”. (Over time, the inevitable deterioration in a patient’s condition usually breaks down his/her initial use of denial as a coping strategy.) Denial may need to be confronted openly (but still sensitively) in some circumstances, e.g., when a single parent is dying and plans are not in place for the care of young children.
Depression, sadness and despair: Sadness at the ending of one’s life is a normal reaction and patients should not be “jollied out” of their legitimate feelings. However, clinical depression needs to be treated and not ignored just because the patient is terminally ill. Patients often feel lonely as they progress toward death. Supportive communication (between patient and significant others, including palliative care staff) will help to reduce these painful feelings of isolation.
- “Is there anything in the way you are treated that is undermining your sense of dignity?” - “What about yourself or your life are you most proud of?” - “What are your biggest concerns for the people you will leave behind?” - “How do you want to be remembered?” See Chochinov, 2002, for a discussion)
Asking for euthanasia: From time to time, patients ask to have their death actively hastened. (“You wouldn’t let a dog live like this”.) It is helpful to explore with the patient/carer what aspects of the situation are most painful. Acknowledge and empathize with the emotional pain as well as the physical suffering. Gently explore fears, maybe previously not expressed. (“I’m wondering what else you may be fearful/concerned about, perhaps some things you haven’t mentioned yet.”). Only after exploring and hearing concerns should the professional outline the boundaries set by the law and conscience regarding euthanasia. This needs to be done in a way that does not make the patient feel abandoned or reproached for expressing the wish. It is usually helpful to give reassurance that life
will not be unnecessarily prolonged (e.g., through heroic, medical gestures). Furthermore, the patient and their family need to understand that symptomatic treatment will be administered even to the extent that the nature and dose of medication may contribute to significant side effects.
CONCLUSION Sheldon (1993) has observed, “It is not possible to be perfectly prepared for whatever comes. So courage is needed along with a solid value base and some understanding of basic skills. Most important though is a faith in the potential of the partner in the dialogue, whether that person is dying or bereaved, to change and grow in response to the crisis of loss and death.”
(Professionals can grow and change too!) References Buckman, R., (1993). “Communication in palliative care: a practical guide.” In D.Doyle, G.Hanks and N.MacDonald (Eds), Oxford textbook of Palliative Medicine. (pp.47-61). Oxford University Press. Chochinov, H.M. (2002). Dignity-conserving care: a new model for palliative care. JAMA, 287, (17) 2253-2260. Mitchell, G. (2010). Communicating with dying patients and their families. In M.Groves and J Fitzgerald (Eds.), Communication skills in Medicine: promoting patient-centred care (p.159170). Melbourne .IP Communications Palliative Care Australia (2005). Standards for providing quality palliative care to all Australians, Canberra. Sheldon, F. (1993). “Communication”. In C Saunders and N.Sykes (Eds.), The management of terminal malignant disease. (pp.15-32). London: Edward Arnold. World Health Organisation (2002). National Cancer Control Programmes: Policy and Managerial Guidelines (2nd Edition). Geneva: World Health Organisation. Students are also encouraged to consult Clinical practice guidelines for the psychosocial care of adults with cancer (2003). (Prepared by the National Breast Cancer Centre and National Cancer Control Initiative)
CCS#Module#6#“Communicating#in#Mental#Health”# Semester#1,#2013# # #
CCS#Module#6#“Communicating#in#Mental#Health”# Semester#1,#2013# # #
INFORMATION(SHEET(6.1(
Impaired(attention(&(concentration(
COMMUNICATING(WITH(PATIENTS(WITH(MENTAL(ILLNESS(
Psychotic#processes#consume#a#lot#of#the#resources#of#brain#and#mind#making#people# distracted#and#impaired#in#attention#and#concentration.##This#will#make#listening#to,#and# answering,#questions#more#difficult#for#them.##Keeping#the#focus#of#the#question#clear#and# concise#will#help#and#avoid#longZwinded#vague#questions.##They#can#still#be#open#questions,# but#you#may#have#to#narrow#down#to#closed#questions#earlier#to#get#the#information#you# need.##Sometimes#you#may#need#to#refocus#the#patient,#particularly#if#they#appear#to#be# having#difficulty#maintaining#the#topic#of#conversation#in#working#memory.##Similarly,#sedation# from#medication#can#produce#impairments#of#attention#and#concentration#requiring#gentle# prompting#to#maintain#engagement.#
Building(rapport( Patients#presenting#with#mental#health#problems#frequently#feel#apprehensive,#uncomfortable# or#anxious.##It#may#have#taken#a#long#time#and#much#courage#to#seek#help.#The#practitioner# needs#to#establish#rapport#to#assist#patients#to#relax#and#tell#their#stories.##Some#ways#to#do# this:# •# •# •#
•#
•#
Introduce#yourself#and#find#out#how#the#patient#would#like#to#be#addressed.# Smile#and#be#friendly,#but#take#the#patient’s#concerns#seriously.## Recognise#signs#and#respond.##Attend#carefully#to#the#patient’s#facial# expressions,#tone#of#voice,#body#language#and#metaphors.#You#can#respond#in#a# range#of#different#waysP#for#example,#with#a#frown,#smile#or#raised#eyebrow#that#is# appropriate#to#the#emotion#expressed#and#conveys#interest#and#respect.##If#the# patient#uses#a#metaphor#such#as,#“It#feels#like#there#is#no#light#at#the#end#of#the# tunnel”,#you#could#respond#by#asking,#“For#how#long#has#it#felt#so#dark?”# Identify#the#patient’s#distress#and#empathise.##Help#the#patient#to#put#his/her# distress#into#words#by#asking#questions#that#facilitate#the#expression#of# experience.##E.g.,#“What#is#troubling/bothering#you?”,#“How#did#that#make#you# feel?”#Let#the#patient#know#that#you#are#getting#a#sense#of#his#experience.##E.g.,# “That#must#be#very#hard#for#you.”P#“This#has#been#a#very#stressful#time#for#you.”# Endeavour#to#help#the#patient#feel#you#are#for#rather#than#against#him/her.## Remember#an#intake#interview#does#not#usually#have#to#be#completed#in#one# session/visit.#Assessment#is#a#process,#not#an#event.##If#the#patient#is#overly# fatigued#or#strained,#slow#down#and#return#later#to#gather#more#information.# Identify#what#is#important#to#the#patient…why#is#s/he#seeking#help#at#this#time?## What#symptom/s#causes#most#distress?##What#are#his/her#questions/fears?#
Delusions((and(other(psychotic(beliefs)( Patients#who#are#acutely#psychotic#will#often#be#preZoccupied#with#the#delusional#content#of# their#thoughts#and#difficult#to#steer#on#to#other#topics.##Novice#interviewers#are#often#unsure# as#to#how#to#handle#delusional#beliefs.##The#general#rule#is#to#avoid#confirming#or#colluding# with#these#false#beliefs.##Conversely,#attempting#to#convince#a#patient#that#their#beliefs#are# false#is#likely#to#dissuade#them#from#talking#to#you#at#best#and#provoke#aggression#at#worst.## Often#it#is#possible#to#“agree#to#disagree”#to#enable#you#to#gain#information#about#the# delusional#beliefs#without#needing#to#collude#with#the#patient.##You#may#also#need#to#check#if# there#is#some#psychotic#reason#why#they#may#be#reluctant#to#talk,#e.g.#the#voices#are#telling# them#not#to#trust#you.# Paranoia(in(particular(
#COMMUNICATION(WITH(A(PERSON(WITH(PSYCHOSIS(
When#patients#are#suffering#persecutory#delusions#(people#are#out#to#harm#them#in#some# way)#they#can#be#particularly#difficult#to#interview.##If#they#believe#that#you#are#a#part#of#the# conspiracy#against#them,#they#may#be#particularly#reluctant#to#discuss#anything#with#you.# Remember:#persecutory#delusions#are#when#people#are#out#to#harm#themP#paranoid# delusions#include#an#element#of#grandiosity,#e.g.#the#government#is#out#to#get#them#because# they#are#important.#
Sources(of(difficulty(in(communicating(
Thought(Disorder(
Agitation#
Disorders#of#formal#thought#can#make#communication#very#difficult.##If#the#patient#is#having# difficulty#maintaining#any#logical#train#of#thought,#then#understanding#your#questions#and# generating#a#logical#response#may#be#dramatically#impaired.##Often#you#begin#to#feel#as# confused#as#the#patient#by#the#conversation.##Be#prepared#to#slow#down#and#use#very# straightforward#interviewing#questions#so#that#you#can#be#clear#where#the#confusion#is# coming#from.#
•#
People#suffering#acute#psychosis#are#frequently#agitated#and#aroused.##This#can#cause# difficulties#in#communication.##First#and#foremost,#you#should#always#be#mindful#of#your# personal#safety.##Always#be#aware#of#the#level#of#arousal#that#a#patient#is#showing.##In# particular,#be#aware#if#this#appears#to#be#increasing#as#a#result#of#your#interview.##If#this# happens#you#may#need#to#terminate#the#interview#and#try#again#later.# When#people#are#agitated#or#aroused#you#often#see#problems#with#poor#concentration#and# attention#(see#next#section).##Modelling#calm#behaviour#with#your#own#body#language#and# verbal#communication#will#often#help#to#calm#the#situation.##Avoid#confrontational#statements# where#possible#(see#section#on#delusions,#below).# (
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Information#Sheets#6.1#and#6.2#(Students(to(Bring(to(tutorial)##
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COMMUNICATION(WITH(A(PERSON(WITH(SUICIDAL(SYMPTOMS( Sources(of(difficulty(in(communicating( Patients#who#are#experiencing#suicidal#thoughts#may#be#feeling#ashamed,#hopeless,#angry# and/or#overwhelmed.#It#is#likely#that#part#of#the#patient#wants#to#keep#the#suicidal#thoughts# and#plans#a#secret,#so#that#others#do#not#impede#the#carrying#out#of#the#plans.##On#the#other# hand,#another#part#of#the#patient#is#likely#to#be#feeling#burdened#by#the#dark#thoughts,# frightened#and/or#lonely.##If#the#patient#has#voiced#suicidal#thoughts#or#made#previous#
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Information#Sheets#6.1#and#6.2#(Students(to(Bring(to(tutorial)##
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CCS#Module#6#“Communicating#in#Mental#Health”# Semester#1,#2013# # #
CCS#Module#6#“Communicating#in#Mental#Health”# Semester#1,#2013# # #
attempts,#s/he#may#fear,#or#have#experienced,#ridicule#from#family#members#or#health# professionals#(“Why#would#you#want#to#do#such#a#ridiculous#thing?”#is#not#a#helpful# response.)#
and#impaired#concentration#are#also#common.##It#is#important#to#record#signs#and#symptoms# of#withdrawal,#also#try#to#differentiate#between#reported#subjective#levels#and#observed# objective#levels.#
Suggestions(for(managing(difficulties(
Judgemental#Attitudes#
It#can#be#a#relief#for#suicidal#patients#to#talk#about#their#distress.##An#accepting#and#calm# response#from#the#practitioner#will#contribute#to#a#problemZsolving#approach.#Enquire#(slowly# and#patiently)#about#the#nature#of#the#suicidal#ideas,#any#plans#to#carry#out#the#ideas#and# what#means#the#patient#may#have#to#complete#the#plans.##Further,#it#is#useful#to#establish#the# patient’s#strength#of#belief#that#s/he#will#carry#out#the#plans.#It#is#usually#useful#to#refer#to#the# patient’s#suicidal#ideas#in#a#matterZofZfact#manner,#noting#that#these#ideas#are#a#symptom#of# depression/#distress#(rather#than#a#statement#of#fact#that#the#situation#is#truly#hopeless#and# the#patient’s#life#is#worthless).##Realistic#hope#may#be#engendered#with#a#comment#such#as# “Symptoms#come#and#goP#with#support#and#appropriate#treatment,#this#symptom#is#likely#to# subside.”##
Patients#will#often#expect#you#to#be#judging#them#adversely#as#a#result#of#their#substance# use.##Adopting#an#open#and#accepting#manner#will#help#to#get#more#useful#information#and# foster#a#better#therapeutic#alliance.##Patients#will#often#volunteer#small#amounts#of# information#to#“test#the#water”#and#gauge#your#response#before#deciding#how#honest#to#be# about#their#consumption.#
#If#the#patient#is#estimated#to#be#at#risk#of#selfZharm#and#cannot#guarantee#safety#until# another#consultation#in#the#near#future,#the#practitioner#needs#to#act#on#a#safety#plan.#This# may#mean#(a)#contacting#next#of#kin#who#will#take#responsibility#for#supervision#of#the#patient,# (b)#arranging#voluntary#admission#to#an#appropriate#hospital#or#(c)#arranging#involuntary# admission.### COMMUNICATION(WITH(A(PERSON(WITH(ALCOHOL(&/OR(DRUG(DISORDERS( Sources(of(difficulty(in(communicating( Intoxication# Trying#to#interview#someone#acutely#intoxicated#with#one#or#more#substances#is#a#challenge.## Blood#levels#of#drugs#&#alcohol#are#not#necessarily#a#good#guide#to#the#degree#of#impairment# as#many#heavy#users#will#be#significantly#tolerant.##The#old#response#of#“I’m#not#interviewing# them#until#their#blood#alcohol#is#less#than#0.05”#is#not#good#enough#but#is#still#sometimes# used#as#a#way#to#dismiss#patients.# You#have#to#weigh#the#quality#of#information#gathered#against#the#level#of#functional# impairment#demonstrated#by#an#intoxicated#person.##In#many#cases#the#best#approach#is#to# get#what#you#need#immediately#and#then#come#back#to#get#the#rest#once#they#are#less# impaired.# It#is#important#to#remember#that#intoxication#often#causes#disinhibition,#which#increases#the# risk#of#violence#to#self#and#others.##As#always,#be#aware#of#your#personal#safety#and#the#level# of#agitation#and#arousal#being#displayed#by#the#patient.# Try#to#avoid#labelling#statements#like#“drunk”#and#record#observable#signs#of#intoxication,#e.g.# slurred#speech,#ataxia,#dilated#pupils,#etc.# Withdrawal# Withdrawal#is#a#significantly#unpleasant#stateP#potentially#lethal#in#the#case#of#alcohol# withdrawal.##Irritability#is#a#common#symptom#and#can#lead#to#difficult#interviews.##Confusion#
Information#Sheets#6.1#and#6.2#(Students(to(Bring(to(tutorial)##
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Shame#&#Guilt# For#many#patients,#these#are#common#emotions#concerning#their#substance#misuse.##In# some#cases,#e.g.#for#Muslims,#being#a#drinker#has#significant#cultural#implications.##People# are#often#willing#to#boast#about#excessive#consumption,#but#would#be#ashamed#to#be# considered#alcoholic.##There#is#a#marked#stigma#attached#to#being#“a#junkie”.##Parents#may# also#be#feeling#guilty#about#the#impact#of#their#substance#use#on#their#children#or#conversely# be#blaming#themselves#for#their#child’s#substance#use.# Suggestions#for#taking#a#reliable#drug#&#alcohol#history# This#is#always#a#challenge.##For#multiple#reasons,#patients#may#inflate#or#minimise#their# reported#consumption.##Asking#in#different#ways#helps#to#develop#a#clearer#pictureP#for# example,#comparing#an#estimate#of#the#amount#spent,#number#of#days#spent#usingP#weekly# average#etc.#will#give#the#opportunity#to#explore#inconsistencies#and#arrive#at#a#more# accurate#estimate#of#drug#use.##You#should#also#ask#about#patterns#of#use,#routes#of# administration#and#symptoms#of#dependence#for#all#the#drugs#used.#Remember#to#ask#about# age#of#onset,#duration#of#use,#previous#treatments#and#episodes#of#sobriety#or#abstinence.# # COMMUNICATION(WITH(A(PERSON(WITH(DEMENTIA( Sources(of(difficulty(in(communicating( People#with#dementia#often#have#normal#attention#but#poor#recall#and#understanding.#Some# will#have#dysphasia#(language#difficulty),#dyspraxia#(difficulty#with#complex#motor#function)#or# agnosia#(difficulty#recognising#objects,#including#people).#They#often#have#greatly#impaired# insight#into#their#impairment.#As#most#people#with#dementia#are#over#the#age#of#75#years,# many#also#have#impaired#hearing#and#eyesight.#The#interviewer#is#often#much#younger#than# the#patient#and#has#often#had#entirely#different#life#experiences.## Suggestions(for(managing(difficulties( It#is#often#helpful#for#the#interviewer#to#employ#greater#formality#than#usual#when#interviewing# an#older#person#with#dementia.#It#is#important#to#look#the#part#and#take#care#in#making# introductions.#If#the#person#with#dementia#has#severe#amnestic#difficulties,#as#is#often#the# case,#a#formal#introduction#might#need#to#be#undertaken#each#time#the#person#is#interviewed.# You#should#not#only#enunciate#your#name#clearly#but#also#indicate#your#role#(medical#
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Information#Sheets#6.1#and#6.2#(Students(to(Bring(to(tutorial)##
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CCS#Module#6#“Communicating#in#Mental#Health”# Semester#1,#2013# # #
CCS#Module#6#“Communicating#in#Mental#Health”# Semester#1,#2013# # #
student).#It#is#often#helpful#to#indicate#that#you#are#speaking#with#them#at#the#suggestion#of# the#consultant#or#registrar#(mention#them#by#name#as#Dr#‘X’#or#Dr#‘Y’).#It#is#best#to#interview# people#with#dementia#in#an#environment#that#is#free#of#extraneous#noise#and#other# distractions.#It#is#essential#also#to#ensure#that#they#have#their#hearing#aids#and#spectacles# with#them.#It#may#be#advantageous#to#allow#the#older#person#to#visit#the#bathroom#before#you# begin#an#extended#interview.#Allow#sufficient#time#to#conduct#the#interview#and#make#sure# you#have#the#necessary#materials#with#you#before#you#start.#These#might#include#cognitive# assessment#tools#such#as#the#MiniZMental#State#Examination#(MMSE)#and#rating#scales#for# depression#(GDS)#and#anxiety#(GAI).##
COMMUNICATION(WITH(A(PERSON(WITH(MENTAL(HEALTH(PROBLEMS(RELATED( TO(PHYSICAL(ILLNESS((e.g.,(cancer,(renal(failure)(
The#person#with#dementia#often#has#limited#insight#into#the#nature#and#severity#of#their# cognitive#impairment.#They#often#provide#unreliable#historical#details#so#an#informant#should# always#be#interviewed#–#preferably#alone.#Some#patients#with#dementia#have#such#poor# recall#ability#that#psychiatric#interview#is#restricted#to#the#mental#state#examination.#Some# patients#with#dementia#will#exhibit#pathological#crying#or#laughing.#Some#will#confabulate# (make#up#historical#details).#Some#will#have#delusional#beliefs#or#hallucinatory#experiences.# Occasionally,#the#person#with#dementia#will#exhibit#a#‘catastrophic#reaction’#in#which#they# react#dramatically#to#the#frustration#they#experience#with#their#cognitive#impairment.#Some# will#be#so#agitated#that#they#refuse#to#be#separated#from#their#spouse#or#other#carer.#
Furthermore,#the#precise#meaning#of#the#condition#and#stage#of#life#cycle#will#affect#response# –#for#example#whilst#a#diagnosis#of#epilepsy#may#not#be#lifeZthreatening#it#represents#a#major# threat#to#a#young#man#who#is#thus#unable#to#drive.#Past#history#will#also#influence#the# response#to#illness#–#for#example#the#woman#who#has#been#diagnosed#with#early#breast# cancer#may#appear#to#be#distressed#out#of#proportion#to#the#prognosis,#however#if#she#has# witnessed#her#mother,#sister#and#aunt#die#from#the#disease#her#distress#becomes#more# understandable.##
Do#not#commence#the#interview#with#an#older#person#suspected#of#having#dementia#by# immediately#undertaking#cognitive#testing.#If#you#do#this#you#are#likely#to#get#the#interview#off# to#a#very#poor#start.#However,#cognitive#testing#should#not#be#left#to#the#end#of#a#long# interview#as#the#older#patient#may#by#then#be#starting#to#tire.#It#is#far#better#to#engage#them#in# talking#about#something#they#have#no#difficulty#talking#about,#often#their#early#years#or# wartime#experiences.#If#their#remote#memory#is#so#poor#that#they#are#unable#to#chat#about# earlier#times,#concentrate#on#the#here#and#now.#Ask#them#how#they#are#feeling#right#now.# Comment#on#things#that#are#happening#right#before#them#during#the#interview#(e.g.#things# that#can#be#seen#through#the#window,#such#as#the#weather#or#passing#traffic).## People#with#dementia#are#often#repetitive.#The#interviewer#simply#has#to#tolerate#this# although#it#might#mean#hearing#the#same#story#several#times#during#a#relatively#brief# encounter.#It#is#often#helpful#to#use#a#direct#and#concrete#approach#to#interviewing,# minimising#the#use#of#jargon.#It#is#sometimes#useful#to#repeat#the#question#in#a#different#way# if#the#patient#does#not#seem#to#understand#it#the#first#time#round.### Nonverbal#prompts,#including#encouraging#social#gestures#and#appropriate#body#language# are#essential#if#you#wish#to#gain#the#most#from#the#interview#with#the#person#with#dementia.#It# is#often#necessary#to#conduct#the#interview#in#a#series#of#short#bursts#spread#over#time,# rather#than#as#one#long#event.# As#a#general#rule,#older#people#are#more#interesting#to#interview#than#younger#people#as#they# have#experienced#more#of#life#and#have#often#survived#significant#challenges.#They#have# usually#had#steady#employment#and#normal#interpersonal#relationships.#They#frequently# have#stable#accommodation#and#a#steady#income.#They#are#much#less#likely#than#younger# people#to#have#abused#illicit#drugs.#However,#they#almost#always#have#general#medical# problems#that#interact#with#their#mental#health#issues.#### #
Information#Sheets#6.1#and#6.2#(Students(to(Bring(to(tutorial)##
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People#who#are#coping#with#physical#illness#have#high#rates#of#anxiety#and#distress,#including# depression.#In#addition#to#the#obvious#impact#of#a#diagnosis#of#serious#illness,#adjustment# can#be#influenced#directly#by#the#condition,#for#example#cerebral#metastases#from# melanoma,#and#particular#treatments#such#as#steroids#which#powerfully#affect#mood.#There# is#good#evidence#that#emotional#adjustment#is#also#influenced#by#physical#symptoms#such#as# pain#and#dyspnoea.##
Times#of#especial#vulnerability#to#distress#include#the#initial#diagnosis,#completion#of#active# treatment#(such#as#completion#of#chemotherapy#and#radiotherapy#after#surgery#for#breast# cancer)#and#diagnosis#of#recurrent#or#progressive#disease.# Sources(of(difficulty(in(communicating( The#circumstances#of#the#diagnosis#of#the#condition#may#be#an#important#determinant#of# adjustment#and#response#to#an#interviewer.#In#cases#where#the#person#feels#that#there#was#a# delay#in#the#diagnosis#of#their#condition,#it#is#common#to#wonder#if#this#has#adversely#affected# the#prognosis.#It#may#also#lead#to#problems#with#trust#with#other#health#professionals#or#even# frank#hostility.# Physical#incapacity#or#pain#will#affect#the#ability#or#willingness#of#the#person#to#be# interviewed.#However#some#people#are#reluctant#to#accept#analgesia#for#fear#that#they#are# seen#as#weak,#or#apprehension#that#the#medication#will#become#ineffective#if#their#disease# progresses.# Cognitive#impairment#is#common#in#many#patients#with#serious#illnesses#such#as#renal#failure# or#brain#tumours.#This#may#be#obvious#in#terms#of#reduced#attention#and#concentration,#or# more#subtle#in#the#form#of#mild#rigidity,#perseveration,#asking#frequently#for#questions#to#be# repeated,#or#even#seeming#just#vague.# Patients#who#are#facing#a#very#poor#prognosis#may#be#reluctant#to#openly#discuss#their# feelings#because#of#their#desire#to#“be#strong”#or#they#may#become#very#distressed.# Sometimes#the#interviewer#is#uncertain#about#the#patient’s#understanding#of#the#condition# and#may#be#apprehensive#about#“overstepping#the#mark”.#Especially#in#young#patients#for# whom#the#diagnosis#is#untimely,#or#those#who#may#die#leaving#dependent#children,#open# expressions#of#intense#grief#may#feel#overwhelming#for#the#inexperienced#interviewer.## It#is#tempting#to#assume#that#distress#is#natural#and#understandable#in#the#person#with#a# serious#medical#illness#and#thus#fail#to#explore#symptoms#which#might#lead#to#a#diagnosis#of# depression.#Even#if#sadness#seems#in#keeping#with#the#situation#it#is#important#to#explore#
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Information#Sheets#6.1#and#6.2#(Students(to(Bring(to(tutorial)##
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CCS#Module#6#“Communicating#in#Mental#Health”# Semester#1,#2013# # #
CCS#Module#6#“Communicating#in#Mental#Health”# Semester#1,#2013# # #
depressive#symptoms#in#detail#as#patients#with#medical#illness#are#vulnerable#to#experiencing# depression#and#anxiety.#Remember#that#depression#may#present#with#irritability#and# withdrawal,#not#just#depressed#mood.##
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Sources(of(difficulty(in(communicating( (
Suggestions(for(managing(difficulties(
Partners#and#family#members#may#be#very#distressed,#angry#or#confused,#especially#at#the# time#of#a#patient’s#initial#diagnosis,#or#suicide#attempt#or#if#the#patient#has#behaved# aggressively#toward#them.#It#is#often#the#case#that#partners/family#members#have#ambivalent# feelings#toward#the#patient#(that#is,#they#may#love#the#person,#but#find#the# problems/symptoms/behaviours#very#disruptive,#upsetting#or#exhausting).##It#is# understandable#that#partners#and#family#members#can#become#fatigued,#irritable#and# impatient#with#the#needs#and#demands#of#the#patient.#Many#partners/family#members#feel#“at# their#wit’s#end”.###
Ensure#that#the#person#is#comfortable,#that#if#they#require#analgesia#this#has#been#given,#and# that#they#have#access#to#water#if#they#have#a#dry#mouth.#Always#ask#if#the#timing#is#suitable# for#an#interview.#If#the#person#has#to#move#from#one#site#to#another#for#the#interview#(for# example#into#an#office#off#the#ward)#check#beforehand#that#the#person#is#fully#mobile#or#if# they#need#assistance,#such#as#a#wheelchair.## Adopting#a#neutral#interested#style#of#questioning#initially#can#be#helpful#to#make#the#person# feel#that#you#are#comfortable#discussing#their#condition#e.g.,#“I#understand#that#you#were# diagnosed#with#epilepsy#about#5#months#ago.#I#wonder#if#you#could#tell#me#a#little#about#how# the#diagnosis#was#made#and#what#you#understand#about#the#condition?”#If#the#person#relates# a#series#of#complaints#about#doctors#do#not#become#defensive,#nor#agree#with#the#person# that#they#have#been#treated#poorly,#instead#focusing#on#their#feelings:#“It#seems#as#though# this#has#been#a#really#difficult#time#for#you.”# Never#presume#to#know#how#the#diagnosis#affects#the#individual#person,#but#be#aware#that# questions#about#adjustment#can#sometimes#seem#“duh”.#For#example#it#might#be#helpful#to# ask:#“Everyone#responds#differently#to#a#diagnosis#like#this.#Are#you#able#to#tell#me#how#it#has# affected#you?”#and#perhaps#clarify#with:#“What’s#the#worst#thing#about#it#for#you?”#It#can# strengthen#rapport#to#make#an#educated#guess#such#as:#“It#must#be#tough#if#the#doctors#say# you#can’t#drive#at#present.”## If#you#anticipate#that#the#person#may#have#some#cognitive#difficulties#such#as#due#to#cerebral# metastases,#ask#at#the#outset#if#they#have#any#problems#with#their#memory#or#concentration.# If#the#person#appears#to#be#struggling#to#respond#to#questions#during#the#interview,#step#back# and#reflect#if#you#have#“pushed”#them#too#far#in#exploring#emotional#issues,#or#if#cognitive# issues#are#relevant.#A#direct#question#could#be#asked#such#as:#“I’ve#asked#a#lot#of#questions# and#I’m#sure#it#must#be#tiring#for#you.#Do#you#find#that#focusing#on#things#is#more#difficult#now# than#before?”#
COMMUNICATION(WITH(PARTNERS(AND(NEXTROFRKIN(
Suggestions(for(managing(family(interviews(( Practitioners#need#to#maintain#a#respectful#attitude,#and#refrain#from#being#judgemental# wherever#possible.#Aim#to#adopt#an#interested,#concerned#but#neutral#stance#when#family# matters#are#discussed.#If#there#is#open#conflict#amongst#family#members,#politely#but#firmly# inform#them#that#you#are#interested#to#hear#their#perspectives,#but#would#prefer#to#speak#to# them#individually,#one#at#a#time.##(Take#individual#to#a#nearby#interview#room#if#available.)## These#situations#often#require#empathic#containmentP#for#example,#“I#understand#that#this# has#been#a#very#stressful#time#for#you.##(empathic#reflection)P#I#would#like#to#ask#you#some# questions,#so#I#need#you#to#stay#as#calm#as#you#can,#and#answer#as#accurately#as#possible# (containment).”#Be#careful#not#to#get#embroiled#in#family#disputes,#and#be#cautious#in#offering# opinions#or#comments#until#a#careful#history#has#been#taken.#Willingness#to#answer# questions#and#explain#distressing#symptoms#or#behaviours#will#be#appreciated.# (SUMMARY(OF(BASIC(COMMUNICATION(SKILLS(( •# •#
If#exploring#the#person’s#prognosis#or#concerns#for#the#future#acknowledge#at#the#outset#that# this#could#be#challenging.#Be#gentle#and#lower#your#voice#and#quietly#comment:#“You’ve# been#very#generous#in#sharing#a#lot#of#information#about#your#condition,#and#I#can#see#that#it# hasn’t#been#easy.#This#is#personal#and#you#may#not#want#to#answer,#but#I#wonder#how#you# see#things#in#the#future#with#your#condition?”#
•# •#
Exploring#mood#can#seem#absurd#to#the#patient#who#is#clearly#distressed,#and#is#best# addressed#directly#with#an#explanation.#“This#is#obviously#very#distressing,#and#I#imagine# anyone#in#your#situation#would#feel#upset.#But#sometimes#being#upset#can#really#become# quite#marked,#and#we#then#start#to#think#about#depression.#Would#it#be#OK#if#I#asked#a#little# more#about#that?#Picking#up#on#depression#is#really#important#because#it#can#be#effectively# treated.”#
Information#Sheets#6.1#and#6.2#(Students(to(Bring(to(tutorial)##
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Physical#context:#ensure#privacy#wherever#possible,#but#be#mindful#of#your# personal#safety.# Introductions:#ensure#the#person#knows#who#you#are#and#what#you#do.#You#may# wish#to#shake#hands.##Offer#handshake#to#carer#as#well,#if#present.#Clarify#the# identity#of#the#person#with#the#patient#–#it#may#be#a#carer#but#could#equally#be#a# casual#visitor# # Sit#down:#conveys#a#willingness#to#listen#and#conveys#an#attitude#of# unhurriedness#that#is#helpful.# Body#language.##Maintain#a#comfortable#distance.##Eye#contact#is#important#in# conveying#attention,#understanding,#and#concern.##Be#wary#of#appearing#to#stare# at#selfZconscious#or#paranoid#people.# Touch:##is#seldom#a#good#idea#unless#the#person#is#acutely#distressed,#and#even# then#to#be#used#with#caution.# Facilitate#the#flow#of#the#dialogue#with#general#communication#skills#(e.g.,#ask# openZended#questions,#don’t#speak#on#top#of#the#patient,#use#minimal# encouragers).##Some#patients#may#need#help#to#refocus#on#the#topic#at#hand,# especially#if#distracted#by#hallucinations#or#other#forms#of#interference#with# thought#processes.#
Information#Sheets#6.1#and#6.2#(Students(to(Bring(to(tutorial)##
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CCS#Module#6#“Communicating#in#Mental#Health”# Semester#1,#2013# # #
•#
•# •#
•#
•#
Tolerate#short#silences.##Silences#don’t#mean#the#person#has#stopped#thinking.## S/he#may#be#experiencing#feelings#that#are#too#intense#to#easily#express,#or#their# thinking#may#be#slowed.##Look#for#signs#that#they#may#be#responding#to# hallucinations#and#it#may#be#prudent#to#ask#if#something#is#distracting#them,#if# they#appear#to#have#“tuned#out”.# Repetition#and#reiteration.##Use#the#person’s#own#words#when#summarising#to# convey#that#you#have#been#listening#carefully.## Identify#the#person’s#emotions#and#respond#in#a#way#that#tells#them#that#you#have# made#the#connectionP#e.g.,#“It#must#be#very#distressing#for#you.”##Professionals# don’t#have#to#feel#the#same#emotion#as#the#patient#(sympathy)#but#it#is#important# they#convey#to#the#patient#that#they#are#making#an#effort#to#understand#his/her# experience#(empathy).#Often#this#is#where#Doctor#and#Patient#can#agree#common# goals,#as#neither#wants#the#patient#to#feel#distressed.# Dignity#People#are#often#resentful#at#being#detained#and#treated#against#their#will.## Engaging#them#in#their#recovery#and#agreeing#on#common#goals#is#important#in# building#the#therapeutic#alliance.#Simple#questions#can#help,#e.g.# ,# “Is#there#anything#further#about#your#illness#that#you#would#like#to#know?”# Cultural/religious#practices#are#to#be#respected#and#it#is#important#to#check#their# possible#impact#on#beliefs#about#the#illness,#its#cause#and#treatment.#
#
INFORMATION(SHEET(6.2((( OUTLINE(OF(AN(INTERVIEW(WITH(A(PATIENT(IN(A(MENTAL(HEALTH(SETTING( # Presenting#complaint#and#history#of#presenting#complaint## Past#psychiatric#history# Past#medical#history/Medications/Allergies# Family#historyP#family#psychiatric#history# Personal#history# Birth#and#early#life# Schooling# Higher#education/training# Employment#history# Psychosexual#history#(relationships)#
#
Forensic#history#
Further(reading(
Use#of#alcohol#and#other#drugs#
Othmer,#E.#and#Othmer,#S.#(1994).##The#clinical#interview#using#DSMZIV.##Volume#1:# Fundamentals.##Washington:#American#Psychiatric#Association# #
CCS#Module#6#“Communicating#in#Mental#Health”# Semester#1,#2013# # #
Premorbid#personality# Suicide#risk#assessment##
#
History#of#previous#selfZharm# Presence#of#depression# Suicidal#ideation# Plans# Means#to#carry#out#plans# How#close#to#attempting#to#carry#out#plans# # # For#more#comprehensive#risk#assessment,#see#Adult#Mental#Health#Services#Risk#Screening# Tool.# #
Information#Sheets#6.1#and#6.2#(Students(to(Bring(to(tutorial)##
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Information#Sheets#6.1#and#6.2#(Students(to(Bring(to(tutorial)##
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CCS#Module#6#“Communicating#in#Mental#Health”# Semester#1,#2013#
CCS#Module#6#“Communicating#in#Mental#Health”# Semester#1,#2013#
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INFORMATION(SHEET(6.3(
Mood(
CONDUCTING(A(MENTAL(STATUS(EXAMINATION(
Mood#refers#to#the#patient’s#internal#feelings#and#emotional#state,#which#the#patient#may# verbalise#during#an#interview.#Mood#generally#remains#stable#over#time,#and#may#change# over#days#and#weeks.#The#onset#of#the#patient’s#mood,#the#intensity,#and#level#of#fluctuation# is#assessed.#Assessment#of#mood#is#subjective#as#it#is#based#on#the#patient’s#selfRreport.# Rating#scales#can#be#used#to#examine#intensity#of#mood#from#1#(not#at#all#intense#to#10# (extremely#intense).#Normal#mood#is#described#as#euthymic.#Other#mood#states#are:# dysphoric#(sad#or#depressed),#euphoric#(elation#and#happiness),#angry#or#irritable,#and# apprehensive.#If#a#patient#appears#to#be#experiencing#symptoms#of#depression,#it#is# necessary#to#conduct#a#suicide#risk#assessment.##
The#mental#status#exam#(MSE)#represents#a#crucial#part#of#the#psychiatric#interview#that#is# important#in#diagnosis,#differential#diagnosis,#and#treatment#planning.#The#aim#of#the#MSE#is# to#provide#a#systematic#framework#for#the#evaluation#of#a#patient’s#current#mental#functioning# that#also#increases#objectivity#and#reliability#of#the#information#gathered.#It#is#an#essential#tool# for#all#medical#health#professionals.#The#role#of#the#doctor#in#conducting#a#MSE#is#to#assess# the#patient’s#current#state#of#behaviour#and#cognitive#functioning.#The#MSE#consists#of# observations#of#the#patient’s#verbal#and#nonverbal#behaviour.#The#majority#of#the#MSE#can# be#conducted#informally#during#the#interview,#while#discussing#the#medical#history#and# performing#a#physical#examination.#To#ensure#accuracy,#the#MSE#should#be#recorded#as# soon#as#possible#following#the#end#of#the#interview.# Appearance(and(Behaviour(( Appearance#refers#to#the#physical#features#of#the#patient.#An#individual’s#appearance#should# be#documented#in#sufficient#detail#so#that#when#another#person#reads#the#description,#they# are#able#to#form#a#vivid#picture.#Physical#features#include:#facial#features#and#expressions,# height,#weight,#hair#colour#and#style,#body#shape,#cleanliness,#posture,#eye#contact#and# movements,#scars,#clothing,#tattoos,#jewellery,#actual#and#stated#age,#signs#of#intoxication,# and#any#physical#disabilities.## Assessing#behaviour#involves#observations#of#the#how#the#patient#acts,#both#verbally#and# nonverbally.#Level#of#consciousness#can#be#described#on#a#continuum#from#a#low#level#of# consciousness#to#hypervigilence.#A#patient#with#a#normal#level#of#consciousness#is#generally# defined#as#alert,#and#provides#appropriate#responses#and#is#aware#of#internal#and#external# stimuli.#A#patient#with#a#low#level#of#consciousness#often#has#reduced#alertness#and#may# appear#lethargic,#while#a#hypervigilent#patient#may#appear#restless,#easily#startled,#and#wellR attuned#to#the#environment.## Motor#activity#is#the#type#and#quality#of#the#patient’s#movements.#The#patient’s#gait#and# freedom#of#movement#is#observed.#It#is#also#important#to#note#the#strength#and#quality#of#the# patient’s#handshake,#any#mannerisms,#which#are#exaggerated#behaviours#that#are#socially# appropriate#but#unusual,#involuntary#and/or#repetitive#movements#such#as#tremors.#The# patient’s#degree#of#agitation#is#evidenced#by#their#degree#of#pacing#and#hand#wringing.#The# extent#to#which#the#patient#coRoperates#during#the#interview#and#can#build#rapport#with#the# interviewer#is#also#important#to#record.# Speech( Listening#to#the#patient’s#speech#involves#observing#their#rate#of#speech,#spontaneity#of# responses,#the#range#of#voice#intonation#patterns,#and#volume.#The#presence#of#stuttering#is# also#notable.#A#patient’s#speech#can#provide#information#about#their#current#emotional#state.# Mood#disorders#and/or#substance#use#disorders#may#affect#the#rate,#volume,#and#amount#of# speechU#neurological#disorders#may#affect#clarity#of#speech.#Also#pay#attention#to#their#use#of# language,#e.g.#use#of#neologisms.# (
(
Information#Sheets#6.3#and#6.4#(Students(to(Bring(to(lecture#
!
Affect#refers#to#the#patient’s#external#expression#of#emotional#state,#and#is#influenced#by# context#and#may#change#moment#to#moment.#Assessment#of#affect#is#more#objective,#as#it# may#involve#observations#of#the#patient’s#body#language.#Examples#of#adjectives#to#describe# mood#are:#anxious,#worried,#tense,#sad,#bright,#bitter,#defensive,#distant,#and#disgusted.# Appropriateness#of#affect#involves#considering#to#what#extent#the#patient’s#affect#matches# what#he#or#she#is#saying.#Patients#with#discordant#mood#and#affect#may#be#experiencing#a# psychotic#disorder.# Thought(and(Perception( Assessment#of#the#patient’s#thoughts#involves#observations#of#how#well#they#formulate,# organise,#and#express#the#internal#dialogue#in#their#mind.#Coherent#thought#is#clear,#easy#to# follow,#and#logical.#Stream#of#thought#refers#to#the#quantity#and#rate#of#the#patient’s#thoughts,# ranging#from#a#paucity#of#thoughts#to#a#flooding#of#thoughts.#When#a#patient’s#thoughts#are#at# a#rapid#rate#and#changes#from#topic#to#topic,#this#is#referred#to#as#a#flight#of#ideas.#Other# thought#disturbances#are:## •# Circumstantial#–#a#mild#form#of#thought#disorder#that#involves#patient’s#providing# detailed,#very#elaborative#responses#that#eventually#get#to#the#pointU# •#
Tangential#–#thoughts#move#away#from#the#topic#at#hand#and#never#returnsU#
•# Word#salad#–#the#most#extreme#form#of#thought#disorder#in#which#there#is#no#logical# association#between#wordsU# •#
Neologisms#–#madeRup#wordsU#
•# Perseveration#–#repetition#of#a#word#or#phrase,#or#idea#resulting#from#an#inability#to# inhibit#a#response#when#it#is#no#longer#appropriateU# •# Thought#blocking#–#when#a#patient#loses#their#train#of#thought#midRsentence,#and# when#they#return#to#talking,#they#have#changed#the#topic#and#cannot#remember#what#they# were#talking#about.# Thought#content#refers#to#what#the#patient#thinks#and#talks#about.#Assessment#of#thought# content#begins#at#the#start#of#the#interview.#The#topic#that#the#patient#wishes#to#talk#about#first# in#the#interview#may#indicate#what#is#important#to#the#patient.#The#presence#of#obsessions# such#as#fear#of#contamination,#a#need#for#order,#aggressive#impulses#are#often#accompanied# by#compulsions,#such#as#washing,#checking#and#need#for#order.#To#find#out#if#a#patient#is# experiencing#obsessions,#you#may#ask#them:#do#you#experience#any#repetitive#thoughts#that# you#can’t#stop?#Presence#of#any#phobias#is#also#notable.#
Information#Sheets#6.3#and#6.4#(Students(to(Bring(to(lecture#
1# !
2#
CCS#Module#6#“Communicating#in#Mental#Health”# Semester#1,#2013#
CCS#Module#6#“Communicating#in#Mental#Health”# Semester#1,#2013#
# Perception#is#the#patient’s#interpretation#of#external#events#and#situationsU#delusions#are# impairments#in#this#interpretation.#Delusions#are#false,#fixed#beliefs,#out#of#keeping#with#the# person’s#culture#or#background#that#have#no#rational#basis#in#reality,#and#are#not#corrected# by#an#appeal#to#reason#or#contradictory#evidence.#Delusions#range#from#plausible#to#bizarre.# Some#types#of#delusions#include#those#of#persecution,#grandeur,#jealousy,#and#love.# Paranoid#delusions#of#persecutory#type#are#the#most#common#in#psychiatric#patients.#If# delusions#are#suspected,#you#may#wish#to#ask:#do#you#feel#that#anyone#has#it#in#for#you#or# that#you#are#being#watched?#Or,#do#you#have#experiences#that#you#don’t#think#you#could# easily#explain#to#others?## Perceptual#distortion#may#also#consist#of#hallucinations,#which#are#experiences#for#which# there#are#no#external#stimulus.#Auditory#hallucinations#are#most#commonU#for#example,# command#hallucinations,#voices#arguing#or#discussing,#and#running#commentary.#There#are# also#other#types#of#hallucinations#such#as#visual,#tactile#(feeling#sensations#when#there#is#no# stimulus),#gustatory#(tasting#sensations#when#there#is#no#stimulus),#and#olfactory#(smelling# odours#that#are#not#present).#Visual#hallucinations#are#also#commonU#however,#they#often# reflect#neurological#dysfunction.## Primary#psychotic#disorders#such#as#schizophrenia,#substance#use,#and/or#delirium#may# affect#thoughts#processes,#delusions,#and#hallucinations.## Cognition( This#is#usually#an#informal#assessment#of#orientation,#concentration,#attention#and#memory.## Where#a#more#formal#test#is#indicated,#most#clinicians#in#routine#clinical#practice#would#use# the#Mini#Mental#State#Examination#(MMSEU#Folstein,#Folstein#&#McHugh,#1983).## Assessment#of#orientation#to#time,#place,#person,#and#situation#reflects#the#patient’s#ability#to# know#who#they#are,#where#they#are,#what#the#date#and#time#is,#and#their#present# circumstances.## Concentration#refers#to#the#patient’s#ability#to#focus#and#maintain#attention#during#the# interview.#Difficulties#with#concentration#may#be#evidenced#by#the#patient#asking#questions#to# be#repeated#or#distractibility.# The#extent#to#which#the#patient#can#recall#past#events#earlier#in#life#(from#childhood),#recent# past#events#from#the#past#few#days,#and#shortRterm#memory#is#assessed.#Questions#to# examine#these#aspects#of#memory#may#refer#to#the#patient’s#first#job#or#where#they#went#to# school,#naming#significant#historical#people#or#events,#what#the#patient#had#for#breakfast#or# how#they#found#their#way#to#the#appointment,#and/or#ask#the#patient#to#recall#what#has#been# discussed#in#the#interview#thus#far.#ShortRterm#memory#can#be#examined#more#formally#by# asking#the#patient#to#remember#three#words,#and#five#minutes#later#asking#the#patient#to# recall#these#words.# Delirium#may#causes#fluctuations#in#level#of#alertness,#disorientation,#and#problems#with# concentration.#Dementia#may#reflect#memory#problems.##
# think#you#have#been#having#these#problems?”#or#even#“Do#you#think#you#are#unwell#at#the# moment?”# A#reduced#level#of#insight#is#often#associated#with#psychosis#or#cognitive#impairment.## AGE(AND(CULTURAL(CONSIDERATIONS(( It#is#often#necessary#to#modify#the#MSE#and#the#interpretation#of#the#MSE#when#working#with# children,#adolescents,#and#older#adults,#and#people#from#different#cultural#backgrounds.## It#is#generally#recommended#that#clinicians#interview#young#children#in#the#presence#of#a# caregiver,#at#least#initially,#due#to#developmental#limitations#in#social#skills#and#separation# issues#from#their#caregiver.#For#older#children#(aged#5R11#years),#there#should#be#greater# attempts#to#separate#a#child#from#the#caregiver,#in#order#to#interview#them#alone.#For#children# that#are#slow#to#warm#or#may#be#showing#symptoms#of#anxiety,#time#may#be#spent#engaging# in#play#and#building#rapport.## With#older#adults,#the#clinician#may#need#to#speak#more#slowly#and#loudly.#Also,#there#needs# to#be#consideration#of#the#older#patient’s#educational#background,#as#some#of#these#patients# may#have#experienced#low#levels#of#education.#Also,#circumstantial#speech#is#common# among#older#adults,#sometimes#as#a#result#of#stories#they#often#like#to#share.#Further,#older# adults#have#higher#rates#of#depression#and#suicide.#Indicators#for#depression#are#largely#the# same#as#younger#adultsU#however,#older#adults#tend#to#have#more#somatic#complaints,#and# physical#symptoms#are#not#as#reliable#an#indicator#of#depression.## When#interviewing#people#from#different#backgrounds,#special#consideration#is#given#when# evaluating#thought#content,#perception,#and#speech.#For#example,#in#some#cultures#it#may#be# common#for#people#to#see#visions#of#loved#ones#who#have#passed#away.##It#can#sometimes# be#difficult#to#determine#if#the#religious#or#cultural#beliefs#of#a#person#from#another#culture#are# appropriate#or#signs#of#psychosis.##In#difficult#cases#it#may#be#necessary#to#seek#advice#from# others#within#the#patient’s#own#culture#or#religion.# Sources:(( Daniel,#M.#&#Carothers,#T.#(2007).#Mental#status#examination.#In#M.#Hersen#&#J.#C.#Thomas## (Eds),#Handbook#of#clinical#interviewing#with#adults.#United#States#of#America:#Sage# Publications.## # Casat,#C.#D.#&#Pearson,#D.#A#(2001).#The#mental#status#exam#in#child#and#adolescent# evaluation.#In#H.#B.#Vance#&#A.#Pumariega#(Eds),#Child#and#adolescent#behaviour.#Canada:# John#Wiley#&#Sons.# # #
#
Insight( The#patient’s#level#of#insight#is#the#patient’s#awareness#and#understanding#of#the#current# problem#or#illness,#its#causes#and#possible#solutions.#Level#of#insight#can#provide#an# indication#of#the#extent#to#which#they#may#benefit#from#treatment.#Questions#to#elicit#insight# may#include#“what#do#you#think#needs#to#happen#for#your#life#to#improve?”#or#“why#do#you#
Information#Sheets#6.3#and#6.4#(Students(to(Bring(to(lecture#
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Information#Sheets#6.3#and#6.4#(Students(to(Bring(to(lecture#
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CCS#Module#6#“Communicating#in#Mental#Health”# Semester#1,#2013#
# INFORMATION(SHEET(6.4( OUTLINE(OF(MENTAL(STATUS(EXAMINATION(( Appearance#and#Behaviour# #
Eye#contact#and#Rapport#
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Personal#Hygiene#
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Facial#Expressions#
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Motor#behaviour#
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Autonomic#arousal/Level#of#consciousness##
Speech# #
Form#
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Volume#
#
Content##
Mood# Affective#expression# Appropriateness# Presence#of#suicidal#ideation# Thoughts# #
Stream#of#thought#
#
Form## #
Thought#content#
Perceptions## Delusions# Presence#of#hallucinations# Cognition# #
Orientation#
#
Concentration#and#attention#
Registration# #
Memory#Recall#
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General#knowledge# #
Insight# # Information#Sheets#6.3#and#6.4#(Students(to(Bring(to(lecture#
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INFORMATION SHEET 8.1 COMMUNICATING ABOUT SEXUAL HEALTH AND FUNCTIONING Communicating with patients about their sexual health and functioning requires skill and sensitivity. Such a conversation will be required in a range of different situations; for example, when the patient presents with explicit problems with sexual health or functioning (such as abnormal vaginal or urethral discharge, loss of libido, erectile dysfunction, pain associated with intercourse; concerns about sexual orientation); or when discussing relationship distress; when providing contraceptive advice; when discussing side effects of medications/surgery. PROFESSIONAL DISCOMFORT There are a number of reasons why medical students and doctors experience difficulty talking to patients about sex. For example: There may be embarrassment and personal unease with the subject Students and junior doctors may feel they are too young to ask older patients about the details of their sexual relationships There may be concern that the patient will be offended by questions There could be a belief that a sexual history is not relevant to the complaint It may be assumed it is someone else’s task (eg., a clinical psychologist or genitourinary specialist) There may be lack of skills in dealing with the complexity of patients’ personal relationship problems The medical student may feel inadequately trained for the task STEREOTYPES Further, stereotypes and assumptions about behaviour and lifestyle may be a barrier to open communication. Some common assumptions and misconceptions about sexuality: Older adults don’t have sex Gay men only have sex with men A married person couldn’t possibly have a sexually transmitted disease Everyone understands the basics of reproduction You can tell a person’s sexual orientation by their appearance SKILLS Clinicians need to be sensitive to the patient’s embarrassment. Some suggestions for dealing sensitively with a patient’s embarrassment include: Acknowledge your own anxiety/discomfort (don’t pretend it is not there) Practise (alone or with peers) the use of questions that are comfortable for you Aim to use the same tone of voice and manner as you would when enquiring about other parts or functions of the body Where possible, it may be more comfortable to start with more general questions first (eg, general health, general relationship functioning) before moving to more sensitive topics. Speak clearly and purposefully, without being apologetic. - Example: “I would like to find out something about your relationships to help make an assessment of this problem. I need to ask you some personal questions about your sexual relationships.” Listen respectfully to patients’ stories; respond non-judgmentally and empathically to sensitive issues. Acknowledge patient’s discomfort (if perceived), eg, “I understand that it has probably been quite difficult to come and talk about this problem.” Some
doctors add, “It might be helpful for you to know that I sometimes find it a bit difficult to ask some of these questions!” Use concrete and specific terms. - Example 1: “For how long have you had this dull pain in your scrotum?” (NOT: “For how long have you had the trouble ‘down below’?”) - Example 2: “Do you ever engage in sexual activities with partners other than your wife?” (NOT: “Do you, you know, go elsewhere for it?”) Remain non-judgemental about lifestyle. Avoid stereotyping. It may be better to ask, “Was that relationship/contact with a man or a woman?” rather than, “Are you gay?” Normalise as much as possible (eg, “Many men when they get older experience difficulties with erections. Can you tell me some more about the problem that you and your partner are experiencing?”) ASSESSMENT OF SEXUAL DYSFUNCTION For details of the categories of sexual dysfunction, see DSM IV-TR Some patients will present with sexual difficulties and describe their symptoms quite matterof-factly. Others will need to be prompted, for example, “Has your illness affected your sexual functioning?” Even when asked about any sexual concerns or problems, some patients may answer “no” but appear hesitant in their denial. It can be helpful to observe, “You seem a little doubtful. I’m wondering if everything is not that great?” Key areas of assessment typically include: The nature of the problem needs to be examined frequency (“How often does this problem occur?”) intensity (“How would you rate the intensity of this pain?”) duration (“When did you first become aware of this problem?” Is the problem primary versus secondary? e.g., “Have you experienced this problem all your life, or just recently?” Is the problem generalised or situational, that is, is the problem present in all relationships or only a specific one? e.g., “Do you have any partners other than your wife? Does this difficulty occur in all/both those relation ships?” Is the sexual difficulty reported a single problem or are there multiple problems? (Premature Ejaculation and Erectile Dysfunction; Anorgasmia and Hypo Active Desire Disorder). Enquire about partner’s perspective: “How is your partner responding to this problem?” COMMUNICATING ABOUT SEX AFTER SURGERY OR CHRONIC ILLNESS Patients may experience a range of problems following illness/ surgery that impact on sexual functioning. For example, Mechanical (eg., arthritis, surgical wounds) Physiological (eg., fatigue, shortness of breath) Neurovascular (eg., damage to nerves to bladder, pelvis) Psychological (eg., change to body image owing to colostomy, mastectomy, disfigurement) Do not assume that a person with a debilitating illness or disfigurement is not interested in sex. Ask. Suggested reading: Atken, S. and Pavlin, N (2010). Talking about sex. In M. Groves and J. Fitzgerald (Eds.), Communication skills in medicine (pp75-90). Melbourne: IP Communications
INFORMATION SHEET 7.1
INFORMATION SHEET 7.2 STAGES OF CHANGE
The capacity to act on advice varies widely across patients. The patients’ willingness to accept the need for change or responsibility for change can inform the type of approach taken. The patient engaging in the harmful behaviour will be somewhere along the continuum of the Stages of Change (Prochaska & DiClemente 1982). Note that a patient might fluctuate between stages. 1. Pre-contemplation • No interest in changing their behaviour. • Unaware of or minimise health risks or harms. • Benefits of unhealthy behaviour outweigh possible concerns. Doctor’s task is primarily to give information and feedback, raise awareness and develop rapport. 2. Contemplation • Ambivalent and undecided, considering costs and benefits of unhealthy behaviours. • Do not necessarily perceive risks and harms of unhealthy behaviour outweighing benefits • Might accept information about change. • Not currently planning to change, but considering it in the next six months. • Might stay in contemplation for two or more years before moving to next stage. Doctor’s task is primarily to examine the pros and cons of behaviour and to help them tip scales in favour of change. 3. Preparation • Concerns (perceived risks and harms) far outweigh the benefits of unhealthy behaviour. • Making specific plans to undertake change within next 30 days. • Setting a date to commence change. • Doctor’s task is not so much motivating as matching change strategies that are acceptable, accessible and appropriate and effective. Doctor’s task is not so much motivating as matching change strategies that are acceptable, accessible, appropriate and effective. 4. Action • Implementing new behaviour/skills. Doctor’s task is to assist patient in operationalising change and to assist in removing road blocks. 5. Maintenance • Maintaining new behaviour, including coping with temptation or minor slips. • Development of relapse prevention strategies. Doctor’s role is one of reinforcement of patient’s self-efficacy beliefs 6. Relapse • Reverting to the previous or an earlier stage is likely when initially making change attempts and can happen at any time. Doctor’s role is to educate that relapse is not unusual and frame this experience as an opportunity to learn
PRINCIPLES OF MOTIVATIONAL INTERVIEWING Express Empathy – Reflective listening is the fundamental clinical skill Understanding, unconditional acceptance (not identifying with) without judging, criticising, or blaming supports patient’s self-esteem and promotes an effective relationship. Unconditional acceptance of person does not imply agreement or approval of specific behaviours. Accept ambivalence as normal. Develop Discrepancy Facilitate patient clarification of goals and awareness of consequences of present behaviour. Clarify and amplify discrepancy between present behaviour and broader goals until it overrides attachment to behaviour (ie. motivates change.) Facilitate patient arguing for change. Avoid Arguments It is important for the consultation to not become adversarial. Direct confrontation and arguing evoke defensiveness and denial, are counterproductive and do not motivate change. Acknowledge patient’s decisions and feelings. Keep the door open to future help. Roll with Resistance Resistance can be related to: - Reluctance – Inertia. - Rebellion – Hostility, arguing, challenging, denying, blaming. - Resignation – Hopelessness, pessimism, lack of energy. - Rationalisation – “Yes but”, point-counterpoint debate, minimising adverse effects. Reluctance, rebellion, resignation, and rationalisation are all signals to back off. Respectfully acknowledge (reflective listening) patient’s personal responsibility and choice. You can’t force change. Shift focus, move around road blocks. “Okay, let’s not get stuck on that point. What about (another subject)? Can you tell me a bit about that?” Support Self-Efficacy Patient’s belief in self and ability to carry out specific task (change) – important motivator. Patient is responsible for choosing and carrying out change. Positive expectations of outcome. Other patients have found these approaches very effective. Reframe self-defeating thoughts, “treatment failures”, relapses etc. into opportunities to learn, overwhelming tasks into achievable step-by step process to final goal, success stories of third-parties similar to patient. For example, “It’s great that you were able to quit for two weeks. You’re almost there”.
INFORMATION SHEET 7.3
INFORMATION SHEET 7.4 DEALING WITH RESISTANCE
REVISION OF MICRO-SKILLS Ask students for useful micro-skills they might remember, and examples of each. Revise and clarify common misunderstandings. Vital skills from last year to incorporate: Be empathic See Principles of Motivational Interviewing. Use open-ended questions To establish relationship of trust and acceptance, help patient take responsibility, and ensure the doctor doesn’t funnel prematurely. Patient should do most of the talking, particularly at the start of the consultation. Reflective listening. (Including paraphrasing and reflection of feelings) Means making a guess as to what the person means to say (content and feeling), and reflecting it back as a statement. , Eg. “You sound pretty fed up with what’s been happening to you.” Often the most effective way of dealing with an angry patient is with empathy, reflective listening, and affirming so they feel acknowledged and accepted. Ordering, warning, advice, persuasion “shoulds”, disagreeing, judging, labeling, interpreting, questioning, humouring, agreeing, approving, reassuring, sympathising are not reflective listening. They are roadblocks and can engender resistance; particularly if there will be an ongoing clinical relationship. There is a place for some of these responses but not at the opening stages. Affirm Support in the form of compliments, appreciation, and understanding (It is important to distinguish from agreeing, approving, reassuring etc) Eg. “That must have been hard for you,” “It takes a lot of courage to do what you’re doing,” “I can understand why you feel so frustrated,” “I can imagine how difficult it must have been for you to come here,” etc. Probe: Elaboration – “Can you tell me a bit more about that?” Clarification – “What do you mean when you say….?” Or “In what way?” Avoid leading and loaded questions: Leading: Suggests how the patient should be feeling or the presence or absence of symptoms without reasonable supporting information. (Observation as opposed to inference) eg. “So you’re feeling quite depressed, are you?” “Was the pain crushing?” (can quickly be converted to non-leading one: “Or was it dull or burning, or would you describe it some other way?” Loaded: Extreme form of leading question with a clear social-judgmental bias, “You’re not still smoking I hope, are you?” Summarise Should occur progressively and before terminating consultation. To integrate key themes or issues, to allow both to review content, facilitate further discussion or change of subject
Resistance is the hallmark of the pre-contemplation stage, but a patient can revert to this stage at any time and resistance is what you will experience. It is imperative that the consultation should not become an adversarial or hostile experience. The 4 “R’s” Resistance falls into four categories: Reluctance, rebellion, resignation and rationalisation. Reluctance Defining features: - Through lack of information or inertia do not want to consider change. - Not fully aware of information or impact of behaviour. Strategy: - Provide feedback in an empathic manner. Rebellion Defining features: - Hostile, resistant to change. - Argumentative (challenging accuracy, expertise or integrity of doctor) - Have heavy emotional investment in problem behaviour and in making own decisions. - Denying, blaming. Strategy: - Provide choices. - The real task is trying to facilitate them shifting their energy in to contemplating change. Resignation Defining features: - Lack of energy and investment. - Given up on possibility of change. - Might feel overwhelmed by problem, having made many attempts to quit. - Might feel hopeless and pessimistic, that it’s too late for them. Strategies: - Instil hope (personal feedback, successful examples of change in others.) - Supporting self-efficacy. (See Principles of Motivational Interviewing) - Explore barriers to change. Rationalisation Defining features: - Has all the answers, blaming, “yes but”, minimising. -- Consultation can turn into a debate – point-counterpoint. Strategies: - Empathy and reflective listening. - Extended discussion will only serve to facilitate their habit of strengthening their argument.
INFORMATION SHEET 7.5 MOTIVATIONAL INTERVIEWING STAGES OF CHANGE: CONTEMPLATIVE USING CIGARETTE SMOKING AS AN EXAMPLE Contemplative Always keep in mind the Principles of Motivational Interviewing. The doctor’s primary task is to help tip the balance in favour of change. Depending on time, tasks may include: Assess behaviour • Get estimate of cumulative exposure to cigarettes • Specific tar content and number of cigarettes, years smoked. • Assess dependence severity Assess past attempts • Withdrawal symptoms, patterns, high risk situations. • Eg. Have you ever stopped smoking before even for a few days? • How did you do it? What problems did you have? • What did you do to deal with those problems? Elicit pros and cons of behaviour and of change • “What are the good things about smoking?” • “What are some of the not so good things about smoking?” • Probe by asking “What else?” and “What others?” (Generates more options (more open) than “Anything else?” where the answer can be “No”). • “What are the good things about giving up smoking?” • “What are some of the not so good things?” Develop discrepancy. • “Does that concern you?” “What concerns you about it?” • Remember useful clarification and elaboration probes: “What do you mean by…?” “Can you tell me more about that?” Summarise pros and cons. • Verbally reinforce statements that indicate that change is being considered. Provide information and encourage patient to interpret it. • Advantages of change. • Remember immediate, personal and concrete information is more motivating. • Identify treatment options. • Provide self-help material. • Provide objective feedback and have the patient discuss the impact of the results. Support self-efficacy. • Highlight patient’s personal strengths or “I’ve seen other patients who feel like you and they’ve successfully…..” • Highlight any past successes in abstaining even for short periods of time. Follow-up. • With agreement, negotiate at appropriate time.
Student Resources
INFORMATION SHEET 7 MOTIVATIONAL INTERVIEWING – STAGES OF CHANGEPREPARATION AND ACTION PREPARATION The doctor’s primary task is facilitating patient’s choice of an appropriate change strategy that is acceptable, accessible, appropriate and effective. Preparation is more a matter of matching than motivating. Tasks to achieve: • Self-monitoring. • Encourage patient to keep diary. Direct feedback is powerful tool. •
Identify high risk situations. • Elicit from patient.
Brainstorm Strategies. • Elicit from patient and suggestions from doctor “I can tell you what works for others” and “There are lots of options.” Eg. Trans-dermal patches are recommended for all but they are the most highly nicotine dependent. • Help patient to develop situation-specific strategies. Goals.
• • •
Negotiated with patient. Small achievable steps if most suitable. Eg daily average and weekly totals. Set a quit date and finalise a plan.
Support self-efficacy. • Verbally reinforce value of any past attempts, reframe. ACTION The doctor’s primary task is to ensure that the attempt to change behaviour is more likely to be successful. • Support self-efficacy. • Very important in action stage. • Focus on their successful activity, reaffirm decisions, help them make intrinsic attributions of successes (and take the credit for it). •
Give information. • Successful models which have used a variety of action options. • Purpose of models is not to offer rigid prescription for change, but to engender a sense that success is possible for someone like the patient.
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Follow-up. • Reinforce small gains INFORMATION SHEET 7.7 MOTIVATIONAL INTERVIEWING – STAGES OF CHANGEMAINTENANCE/RELAPSE MAINTENANCE
Identify support. • Successful behaviour change is more likely in supportive environment. Roll with resistance. • If patient responds “that won’t work because…” “That’s fine, let’s not get too stuck on one idea. Let’s move on, what else could you do?” Self-help materials. • A preferred option by many patients and most successful in preparation and action stages and answer questions. Follow-up. • At follow-up monitor progress, reinforce small gains, review goals. Referral. • Appropriate if brief intervention is ineffective. Evidence of significant social disruption.
The doctor’s main task is to develop relapse prevention strategies with patient to ensure long-term sustained change over several years. Problem-solve in high-risk situations. Recognition of problem, brainstorming strategies, assess pros and cons of each strategy, choose suitable strategy, refine if necessary.
RELAPSE The reasons for relapse are typically a strong, unexpected urge or temptation, relaxing their guard or testing themselves, unexpected costs of change and commitment or self-efficacy erodes. Return to previous behaviour usually occurs gradually after an initial lapse (slip). Deal with the effects of lapses. • Cognitive dissonance, goal-violation effect, low self-efficacy
•
Strategies: Reframe lapse from failure to learning opportunity, and focus on what was achieved, emphasise how common lapses are, emphasise new skills needed and discuss how to achieve them.
INFORMATION SHEET 7.8 ADHERENCE Adherence (formerly referred to as “compliance” and sometimes referred to as “concordance”) is usually defined as the extent to which patients follow the treatment plan of their health care provider (e.g. taking prescribed medications, following a weight loss plan, completing a physiotherapy exercise schedule). Adherence rates are typically higher among patients with acute conditions, as compared with those with chronic conditions. Across a range of chronic conditions of varying severity, adherence rates can be as low as 20%, with an average of 50%. Further, after the first six months of treatment, adherence typically drops off dramatically. In some conditions such as HIV, adherence is literally a matter of life and death. In one study of an antiretroviral treatment regimen, > 95% adherence to treatment resulted in viral suppression, but failure rates increased sharply with < 95% adherence (Paterson et al., 2000). Even in a well-informed patient group, with established support networks and no cost disincentives, antiretroviral medication adherence rates can be as low as 50%, particularly in the maintenance stages of treatment (Descamps, et al., 2000). There are a number of factors that influence patient adherence.
Patient factors: - rapport with clinician - knowledge of the disease process and treatment principles - impact of treatment on daily life (e.g., injecting insulin at lunch time at work) - severity of side-effects - mood disorders, sleep deprivation, cognitive impairment, substance use - quality of social support
Clinician factors: - quality of patient-provider relationship - ability to provide clear information to patient on treatment - consistency in advice over time and across care givers - ability of health professional to detect non-adherence and work with it constructively
Institutional factors: - quality of environment (e.g., culturally sensitive, respectful) - cost of intervention/medication - continuity of care - availability of after-hours support for side- effects or crises - social work support to assist with financial and logistical barriers to adherence The World Health Care Organisation listed the physician-patient relationship as one of the five identified factors believed to enhance adherence (Sabate, 2003). Further, a recent meta-analysis of 127 studies examining physician communication and client adherence, concluded that the client is more than twice as likely to adhere to treatment recommendations if their physician has effective communication skills and improving
physician communication also led to a 12% increase in client adherence (Haskard Zolnierek & Dimatteo, 2009) •
Suggestions to increase patient adherence when starting a new treatment •
• • • • • • • • •
Educate patient about his/her disease process and the main principles of treatment, using language the patient can understand. Support your words with pictures, diagrams, written handouts. See CCS information sheet: Information Giving Outline the pros and cons of treatment. Discuss most likely side-effects If similarly effective evidence-based treatments exist, engage patient in decision- making process (eg. Nicotine replacement therapy using patches verses gum). Acknowledge the commitment required, the benefits of treatment and the consequences of non-adherence Recognise patient’s lifestyle and preferences (e.g. consider once a day versus more frequent dosing, particularly for person at work or school) Link treatment with daily routines (e.g. one tablet with breakfast and dinner; puffers twice a day when clean teeth, practise the exercises on waking and before going to bed) For young patients or other patients with carers, ensure parent/carer is informed of purpose and routine of treatment Ask the patient if s/he expects any difficulties in adhering to the treatment plan. Assess motivation and behavioural stage of change. Pre-contemplators will generally be less adherent than those in action stage. The emphasis for Precontemplators should be brief provision of clear, evidence-based information. Involve the pharmacist, who can then reinforce the message to the patient and informed carer.
Suggestions for dealing with suspected or confirmed noncompliance • •
• •
Ask about adherence in a non-judgemental way using pleasant and relaxed tone of voice (e.g., “People in your situation often have difficulty in taking their medicines all the time. How are you going?”) Review your relationship with this patient. Does he/she feel you are willing to listen to concerns and difficulties? Express empathy for the difficulty experienced in adhering to the plan (e.g., “It’s been hard for you to remember the tablets each day?”) Find out about the patient’s experience with the treatment (e.g., “Can you tell me some more about how the tablets made you feel?”) Review the patient’s understanding of the function and significance of the treatment (“Let’s go back to the problem you are having with….Tell me what
• • •
you understand about how these tablets are going to help you.”). Build on the patient’s understanding and knowledge. Explore health beliefs with patient. (“What are your thoughts on how things are going with your health at the moment?”) Consider other barriers to adherence such as financial problems, memory impairment, mood disorders, poor family support, lack of continuity of care. Address/treat where possible. Engage assistance of calendars, dosage dispensers (eg. Webster Packs), family support. Always anticipate relapse in adherence (particularly for chronic conditions), even after long-term use
Selected References Deschamps, D, et al (2000). Mechanisms of virologic failure in previously untreated HIV-infected patients from a trial of induction-maintenance therapy. Journal of the American Medical Association, 283, 205-211. Haskard Zolnierek, K. B., & Dimatteo, M. R. (2009). Physician communication and patient adherence to treatment: A meta-analysis. Medical Care, 47(8), 826834. Ickovics, J. (1997). Adherence in AIDS clinical trials: a framework for clinical research and clinical care. Journal of Clinical Epidemiology, 50, 385-391. McDonald, H., Garg, A., and Haynes, R. (2002). Interventions to enhance patient adherence to medication prescriptions. Journal of American Medical Association, 288, 2868-2879. Osterberg, L. and Blaschke, T. (2005). Drug therapy: Adherence to medication. New England Journal of Medicine, 353, 487-497. Paterson, D. Swindells, S., Mohr, J., Brester, M., Vergis, E., Squier, C., Wagener, M., and Singh, N. (2000). Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Annals of Internal Medicine, 133, 21-30. Sabate, E. (2003). Adherence to Long-Term Therapies: Evidence for Action. Geneva: World Health Organization. Spoont, M., et al (2005). PTSD and Treatment Adherence: The Role of Health Beliefs. Journal of Nervous and Mental Disease,193, 515-522 Weaver, K. et al (2005). A Stress and Coping Model of Medication Adherence and Viral Load in HIV-Positive Men and Women on Highly Active Antiretroviral Therapy (HAART). Health Psychology, 24, 385-392. See also School of Medicine Portal/Therapeutic Guidelines/Psychotropic/Pertinent practical points for psychotropic drugs/Compliance
! ! ! ! PSW!–!STEPS!AND!MARKING! SHEETS!
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Steps for Routine/Social Hand wash Liquid Soap and Water
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6. Rub back of fingers with hands clasped
Hands should be washed vigorously for 15-30seconds (Total duration of hand wash: 40-60 seconds) 1. 2. 3. 4.
Remove jewellery (may wear a plain wedding band) Wet hands and wrists thoroughly and apply soap Rub hands palm to palm Rub back of hand with palm of other hand with fingers interlaced. Repeat on other hand
7. Clasp thumb and clean in a circular motion and repeat on other thumb
5. Rub palm to palm with fingers interlaced
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8.
Rub tips of fingers into palm of one hand in a circular motion and repeat on other hand
9.
Rub around the wrists
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11. Pat hands dry with a paper towel, starting at fingers then moving towards wrist and forearm. (Patting the skin dry prevents chapping. Hands are dried first because they are considered the cleanest and least contaminated area)
12. If using a sink without an auto-sensor regulator or elbow controls, don’t touch taps with clean hands. Use paper towel to turn off taps
10. Rinse hands under running water with fingertips uppermost, allowing water to run down towards wrist
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Competency for Routine/Social Hand wash Liquid soap and Water Hands should be washed vigorously for 15-30seconds (Total duration of hand wash: 40-60 seconds) 1. Removes jewellery (may wear wedding band) 2. Wets hands thoroughly and applies soap using elbow on soap dispenser 3. Rubs hands palm to palm 4. Rubs back of hand with palm of other hand with fingers interlaced. Repeats on other hand 5. Rubs palm to palm with fingers interlaced 6. Rubs backs of fingers with hands clasped 7. Clasps thumb and cleans in a circular motion. Repeats on other thumb 8. Rubs tips of fingers into palm of one hand in a circular motion. Repeats on other hand 9. Rubs around each wrist 10. Rinses hands under running water 11. Doesn’t touch taps with clean hands – if elbow controls are not available, uses paper towel to turn off taps 12. Pats hands dry using paper towel
STEPS FOR MEASURING TYMPANIC TEMPERATURE
Start Button
Probe cover Release button
1. Perform hand hygiene (Moment 1) 2. Remove thermometer from handheld unit 3. Place cover over probe of earpiece. The thermometer turns on automatically 4. Wait for the ready signal beep. The display screen will show -5. Gently pull ear straight up and back for adults and back for children (Straightens external auditory canal, allowing maximum exposure of the tympanic membrane)
6. Insert the probe snuggly into the auditory canal using gentle but firm pressure
Steps for measuring tympanic temperature (2014)
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7. Push and release the start button (A green light on the top of thermometer will flash during the measuring process) 8. Leave probe in place until audible signal occurs (If the probe has been fitted correctly into the ear canal a long beep will signal within 3 seconds) 9. Read temperature on display screen
10. Press release button just above display screen to discard cover into bin 11. Perform hand hygiene (Moment 4)
Steps for measuring tympanic temperature (2014)
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STEPS FOR MEASURING PULSE AND RESPIRATION RATE (RR): 1. Perform hand hygiene (Moment 1) 2. Determine previous baseline pulse rate and RR from patient’s notes 3. Place patient’s forearm straight alongside or across lower chest or upper abdomen with wrist extended straight 4. Place pads of the index and middle fingers at the base of the patient’s thumb, and slide down about 2cms in the groove of the inner wrist. 5. Lightly compress the artery so pulsations can be felt (The pads of your fingers are more sensitive)
6. Assess the rhythm and amplitude/strength of the pulse and note whether pulse is bounding, strong, weak or thready 7. Count pulse for 30 seconds and multiply by 2. If pulse is irregular count for 60 seconds 8. While your fingers are still in place for the pulse measurement, observe the patients’ RR 9. Observe a complete respiratory cycle (1 inspiration and 1 expiration) 10. Count the number of respirations for 30 seconds. If respirations are abnormal in any way, count for 60 seconds 11. Record results in patient’s chart 12. Perform hand hygiene (Moment 4) Steps for measuring pulse rate and respiratory rate (2014)
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! STEPS!FOR!MEASUREMENT!OF!A!B!RACHIAL!BLOOD!PRESSURE!(2014)! ! ! 1.! Perform!hand'hygiene'(Moment'1)' ' 2.! Explain!procedure'to'patient'and'gain'verbal'consent;'Check!for'any'clinical'conditions'that' may'prevent'taking'BP'on'a'particular'arm'(e.g.'mastectomy'etc)' ' 3.! Position'patient'correctly'–'Seated'with'back'supported,'legs'uncrossed,'feet'flat'on'the'floor' and'arm'supported'so'brachial'artery'is'level'with'the'heart' ' 4.! Remove'excess'clothing'from'the'arm'that'may'interfere'with'BP'cuff'or'constrict'blood'flow' to'the'arm''' ''''''''''''''''''''''''''''''''''''' 5.! Choose!appropriate'sized'cuff''(Measure'cuff'around'patient’s'arm'and'ensure'index'line'is' within!the'range'area)''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' ''''''''
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6.! Palpate!the'brachial'artery'and'position'cuff'so'‘artery’!marker'on'cuff'points'to'the'brachial' artery'' '
'''''''''''''''''' ' ''''''''''''''''''Use'the'pads'of'your'fingers'
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Steps!for!Measurement!of!Blood!Pressure!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 2014!
2! ''''
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''''''' ' ' ' 7.! Wrap!BP'cuff'snuggly'around'the'arm.''The'bottom'edge'of'the'cuff'should'be'2.5'–'5'cms' above'the'crease'of'elbow.''Ensure'you'are'directly'facing'the'pressure'manometer/gauge' to'ensure'a'correct'reading'(avoid'parallax'error)' ' 8.! Palpate'radial'pulse''''''''' ''''''''''''''' '''''''''''''''''''''''''''''' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' 9.! Close'valve'of'pressure'bulb'clockwise'until'tight'and'inflate!cuff.''Note'on'pressure'gauge' where'the'radial'pulse'disappears'and'continue'to'inflate'a'further'30'mm'Hg'above'this' pressure''' ' 10.! Turn'valve'anticlockwise'to'slowly'release'air'from'cuff'(maximum'rate'of'3'S' 4mmHg/second)'noting'on'the'pressure'gauge'where'radial'pulse'reappears.'(This'is'an' estimate'of'the'patient’s'systolic'reading);'Rapidly!deflate'cuff''
Steps!for!Measurement!of!Blood!Pressure!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 2014!
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' '''''''''''''''''''''''''''''''' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' ' 11.! Wait'30'seconds!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! ' 12.! Palpate'brachial'pulse'and'position'diaphragm'of'stethoscope'over'the'brachial'artery'in'the' antecubital'fossa''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''(Make'sure'the' diaphragm'does'not'touch'the'cuff'or'tubing'to'minimise'artifact/stray'sounds)' ' '
'''''''''''''''''''''''''''''''''' ' ' 13.! Rapidly!reSinflate'cuff'30mm'Hg'above'that'at'which'radial'pulse'reappeared'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' (This'ensures'avoiding'BP'measurement'during'any'auscultatory'gap)' ' st 14.! Slowly!deflate'cuff'(at'a'maximum'rate'of'3'S'4mmHg/second)'and'listen'for'the'1 'of'2' consecutive'beats'(Korotkoff,'phase'1),'even'if'the'sounds'disappear'temporarily'(the' auscultatory'gap).'This'is'the'systolic!BP.'''The'diastolic!reading'is'recorded'at'where'sounds' disappear'(Korotkoff,'phase'5).'' 15.! !Rapidly!deflate'cuff' 16.! Record!systolic'and'diastolic'BP'to'the'nearest'2'mmHg' 17.! Wait!for'at'least'30'seconds'before'repeating'BP'on'the'same'arm' 18.! Average!the'2'readings' 19.! Perform'hand'hygiene'(Moment'4)'
Steps!for!Measurement!of!Blood!Pressure!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 2014!
STEPS FOR THE COLLAPSED PATIENT:
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ADULT BASIC LIFE SUPPORT COMPETENCY (2014) UNIVERSITY OF QUEENSLAND Name: ___________________________________________________________ Date: ___________________________ PERFORMANCE CRITERIA Checks area for potential danger/hazards to self, patient and others If danger identified, discusses management Uses PPE if required (gloves, pocket mask) ensuring safety of self Assesses patient’s response using verbal and tactile stimuli Asks simple questions: Can you hear me? What’s your name? Squeeze my hands? Speaks into both ears (in case patient is deaf) Gently squeeze patient’s shoulders Stays with patient Calls for help Presses emergency buzzer Notes time Checks airway by opening mouth (no head tilt) Removes foreign body by turning head gently to side (if no risk of spinal injury) Allows drainage via gravity Finger sweep for visible material No blind finger sweep Leaves well fitting dentures Uses suction (if available) Performs head tilt/chin lift and assesses breathing for up to 10 secs: Looks for chest rise and fall Listens for escape of air from the nose and mouth Feels for movement of chest and expired air on cheek If patient breathing – rolls into the recovery position
DANGER
RESPONSE
SENDS FOR HELP
AIRWAY
BREATHING
•
If patient not breathing - Immediately commences 30 compressions
PBL Number: _______________ Session Time: _______________ 1st ATTEMPT
2nd ATTEMPT
COMMENTS
2
COMPRESSIONS
Demonstrates: • • • States:
RESCUE BREATHS
DEFIBRILLATION
Perform 30 compressions: 2 rescue breaths Perform 100 compressions/min Rotate compressor role every 2 mins Compressions are paused for ventilations Demonstrates the correct technique for mouth to mask: Mask placed in correct position with a good seal Performs head tilt/jaw lift Inflates lungs with enough air to achieve chest rise Delivers each breath in 1 second Removes mouth from mask to look, listen and feel for the escape of air and chest fall Allows chest to fully recoil before giving next breath. Does not deliver extra breaths if chest rise is not seen • Turns on AED and follows prompts: States: Correct placement for pads in Anterior/Lateral position – • (L) mid-axillary line across from xiphoid process in 6th intercostal space • (R) side of upper sternum in mid-clavicular line 2nd intercostal space • No contact with patient during ‘analyse’ • Calls ‘stand clear’ and performs visual sweep prior to pressing SHOCK button States safety principles: • Don’t place pads over: Implantable devices, ECG electrodes & leads Medication patches, jewellery Excessive chest hair/moisture • Avoid defibrillation when: Direct/indirect contact with the patient during defibrillation Patient in contact with metal surfaces e.g. bedrails or IV therapy poles Responders standing in water/ urine An explosive or flammable environment Free flowing (move oxygen mask at least 1 meter away )
Date: ________________________
C/NYC
Correct hand position (centre of chest/lower ½ of sternum) Interlocks fingers or locks hand around the wrist of the compressing hand with fingers raised off chest Keeps compressing arm straight with shoulders vertical over sternum Compresses chest with heel of hand 1/3 depth of chest (>5cms)
Assessor’s Signature: 1st attempt: _____________________________
If NYC: Student’s signature: ______________________________
2nd attempt ______________________________
