2017/2018 Ace the 2a OSCE – Part 1

CVS & Respiratory Phase 2b Revision Session Eleanor Rosario Laura Horseman 03/10/2017 The Peer Teaching Society is not liable for false or misleading information…

OSCE revision series 03/10/17 CVS & respiratory 05/10/17 GI & Liver 10/10/17 Neuro & Endocrine 12/10/17 MSK & Rhematology Covering mainly history taking. Practice examinations on anyone and everyone. The Peer Teaching Society is not liable for false or misleading information…

Revision resources Your green handbook! OSCE – A teaching manual for undergraduates Peer teachers Peer teaching website Each other! And non-medic friends for examinations, maybe buy them chocolate in return The Peer Teaching Society is not liable for false or misleading information…

Taking a history Wash your hands. Practice your intro. Presenting Complaint Specific problem e.g. “chest pain” History of Presenting Complaint Explore PC (SOCRATES) Ask about other relevant complaints (lots of marks available here!) RED FLAGS The Peer Teaching Society is not liable for false or misleading information…

Taking a history Past Medical History Drug History Anything you see your doctor about regularly? Any surgery/hospital admissions? MJ-THREADS can help jog memory Anything especially relevant to PC Drug History Any medications? Any allergies? Medications can give you a clue if you missed anything in PMH! The Peer Teaching Society is not liable for false or misleading information…

Taking a history Family History Social History Anything run in the family? Anything relevant (e.g. atopy, autoimmune, MI) Social History Alcohol/drugs Smoking Occupation Housing situation Anything relevant (e.g. pets in asthma) The Peer Teaching Society is not liable for false or misleading information…

Taking a history Summarise ICE Systems review if time Ideas Concerns Expectation Systems review if time Thank the patient and smile! The Peer Teaching Society is not liable for false or misleading information…

Cardiac presenting complaints Chest pain SOB (dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea) Ankle swelling Cough, sputum and haemoptysis Dizziness Presyncope and syncope Palpitations Leg pain on exertion The Peer Teaching Society is not liable for false or misleading information…

Chest Pain Cardiac: Myocardial infarction Musculoskeletal: Pericarditis Angina AF Acute myocarditis Aortic dissection Musculoskeletal: Costocondritis Trauma Muscle sprain Gastrointestinal: GORD Peptic ulcer disease Oesophageal spasm/stricture Chest Pain Respiratory: - PE - Infection (pneumonia, TB etc) Pneumothorax Malignancy Other: Anxiety Sickle cell crisis (acute chest syndrome) Shingles

CHEST PAIN Site – where is the pain? Can you point with one finger to the pain? Onset – when did the pain start? What were you doing when it started? Character – how does the pain feel? Sharp, crushing, stinging, boring etc Radiates – does the pain move around your chest or anywhere else? Associated symptoms Timing – has it progressed since it started? Exacerbating/alleviating factors – does anything make it better? Does anything make it worse? Severity – rate /10 The Peer Teaching Society is not liable for false or misleading information…

Clues from site, radiation and character: MI – central, crushing, radiates down left arm and jaw Pericarditis – central pain, bores through to back, better if sat forward, worse if lying down Angina – central tightness or heaviness, radiates to arm(s) and jaw. Key is link to exertion and relief by rest! Acute myocarditis – key in history will be preceding flu symptoms Aortic dissection – ‘tearing’ pain, central or abdominal The Peer Teaching Society is not liable for false or misleading information…

Associated Symptoms: NB MI can be ‘silent’, esp if diabetics/diabetics – unlikely to be a history station but useful info for a question. Syncope, epigastric pain, vomiting.

ANY CV HISTORY PMH – hospital/A&E visits, seeing GP regularly? Previous stents etc? Smoking history Alcohol Diet and lifestyle Occupation – sedentary? Home – carers? Coping with household activities? FMH – MI < 55years 1st degree relative significant What’s your main concern/which symptom is most problematic? The Peer Teaching Society is not liable for false or misleading information…

ANGINA Stable vs acute angina Stable – exertion key, relieved by rest. Quantify exertion! Other precipitants – cold, emotion, heavy meals How frequent are the attacks? How is this affecting your life? What do you do to stop the pain when the attacks happen? Is this worsening of existing angina or a new diagnosis? Associated symptoms, lifestyle, PMH Caused by athema mostly therefore ask re CV disease risk factors (diet, sedantary lifestyle etc) and past cardiac history Are they taking a statin or using a GTN spray? Have they had a past MI? are they on aspirin? Can be caused by anaemia, thyroxicosis, hyperlididaemia, aortic stenosis – modify these risk factors in treatment The Peer Teaching Society is not liable for false or misleading information…

ACUTE ANGINA With MI = acute coronary syndromes Chest pain at rest >20 minutes and associated symptoms Risk factors – non modifiable vs modifiable PMH – history of hypertension or IHD? FH – significant = IHD 1st degree relative <55 years old Non modifiable – male, age, family history IHD Modifiable – smoking, hypertension, hyperlidiaemia, obesity, sedantary life style The Peer Teaching Society is not liable for false or misleading information…

The Peer Teaching Society is not liable for false or misleading information…

SOB Onset Pattern – constant? Daytime variation? How is this affecting your daily life? QUANTIFY PMH – asthma? Malignancy? CV history? Anaemia? Drug history Associated symptoms – wheeze? Weight loss? Swelling?

Key for CV…Heart Failure Differentials – heart failure, PE and other respiratory causes Left ventricular failure New York Association Classification of HF symptom severity What was normal for the patient before diagnosis? Quantify activity Pillows at night. Are they sleeping in a chair/can they climb the stairs? Dyspnoea, PND, orthopnoea, poor exercise tolerance, fatigue, cough, wheeze – ‘cardiac asthma’. Dyspnoea – shortness of breathe Orthopnea – SOB on lying flat PND – SOB at night, waking from sleep I – no limitations, ordinary physical activity doesn’t cause above symptoms II – slight limitation of physical activity, comfortable at rest but ordinary physical activity causes sympto s III – marked liitation of physical activity IV – CCF symptoms present even at rest, any physical activity = symptomatic

PERIPHERAL SWELLING Think RV heart failure!! Pitting oedema of the legs – check in CV exam Sacral oedema – don’t forget in respiratory exam + ascites, nausea, facial engorgement, anorexia The Peer Teaching Society is not liable for false or misleading information…

Cough, Sputum and Haemoptysis Overlap with resp LV failure – cough with pink frothy sputum RV failure – lung disease a cause, therefore may have cough Nocturnal cough – asthma a Dx, also heart failure Haemoptysis, think PE and malignancy. The Peer Teaching Society is not liable for false or misleading information…

PALPITATIONS Frequency Onset Duration ‘Describe the last episode to me’ Can you tap out the rhythm? Dizziness or LOC Anxiety Hx PMH – diagnosis of AF? Are you on any blood thinners? Have you ever had a stroke or mini stroke? History of valve disease? Learn CHADS2VASC (risk of a stroke if patient has AF), HASBLED (risk of bleeding on warfarin) The Peer Teaching Society is not liable for false or misleading information…

DIZZINESS, PRE/SYNCOPE Postural hypotension, vasovagal attack, severe aortic stenosis, AF When do you get dizzy How many episodes/week Have you had any blackouts Associated symptoms – palpitations, sweating, hyperventilation, chest pain, headache etc Pick up marks by covering all systems in brief The Peer Teaching Society is not liable for false or misleading information…

LEG PAIN ON WALKING Intermittent claudication SOCRATES history Calf (femoral) vs buttock pain (iliac) QUANTIFY! Claudication distance – how far before pain starts Ask re risk factors – smoking, alcohol, diabetes, hypertension, hyperlipidaemia Associated symptoms – gangrene, burning, foot pain (‘I’m hanging my foot off the bed at night’) = critical ischaemia. Impotence. The Peer Teaching Society is not liable for false or misleading information…

EXAMINATION TIPS Patients with pacemakers Difference between a pacemaker and a ICD Murmurs – likely aortic stenosis/mitral regurg Aortic stenosis – ejection systolic murmur heard loudest over aortic region, potentially radiates to carotids, loudest sat forward in held expiration. Caused by old age calcification of valve. Mitral regurg – pansystolic murmur loudest in axilla. Causes – lv hypertrophy, IE, valve calcification. Mitral regurg

Respiratory presenting complaints 2 minutes to chat to the person next to you What questions would you like to ask about the PC Why? We will discuss Please don’t be shy! The Peer Teaching Society is not liable for false or misleading information…

Cough What do you want to know? And what will get you marks… The Peer Teaching Society is not liable for false or misleading information…

Cough HPC Duration Dry or productive? Sputum (consistency, colour, odour) Any blood (how much, fresh or old, bleeding elsewhere, DVT symptoms) Worse at any time of day? Exacerbations (pets, pollen, dust, weather, occupation) The Peer Teaching Society is not liable for false or misleading information…

Cough Other important symptoms Wheeze Chest pain (varying with breathing suggests respiratory cause) Shortness of breath FEVER, WEIGHT LOSS, NIGHT SWEATS Do they feel unwell? The Peer Teaching Society is not liable for false or misleading information…

Cough PMH DH Acid reflux Asthma COPD (prone to infections) TB ACE inhibitors Allergies Inhalers TB jab The Peer Teaching Society is not liable for false or misleading information…

Cough FH SH Asthma, hayfever, exzema Pneumonia contacts TB contacts Occupation – specifically industry Pets SMOKING Pollution Foreign travel The Peer Teaching Society is not liable for false or misleading information…

Relevant questions for respiratory History of TB, asthma, PE, pneumonia, GORD, allergies, rheumatoid Family Hx of CF, TB, asthma, eczema, hayfever, emphysema ACE inhibitors, inhalers, immunisations, NSAIDs, methotrexate Crowded accommodation, damp, occupation, foreign travel, pets The Peer Teaching Society is not liable for false or misleading information…

Shortness of breath What do you want to know? And what will get you marks… The Peer Teaching Society is not liable for false or misleading information…

Shortness of breath HPC Describe the sensation Duration Constant or intermittent Activity limitation (how far can you walk?) Is it getting worse Any exacerbations (e.g. weather) Any relieving factors (e.g. inhaler) The Peer Teaching Society is not liable for false or misleading information…

Shortness of breath Other important symptoms CHEST PAIN (is it cardiac?) Can they lie flat at night? (heart failure??) How many pillows? Waking from sleep Ankle swelling Wheeze Cough Systemic illness (fever, weight loss, night sweats) Anxiety and panic attacks (tingling feeling associated with hyperventilation) Fatigue (anaemia) The Peer Teaching Society is not liable for false or misleading information…

Shortness of breath PMH DH Asthma COPD TB Cardiac disease Severe lung infections Blood clot DH Inhalers Allergies The Peer Teaching Society is not liable for false or misleading information…

Shortness of breath FH SH Asthma Cardiac disease SMOKING and ex-smoking! Occupation Stress and anxiety The Peer Teaching Society is not liable for false or misleading information…

Asthma assessment Ask about symptoms Walking at night Wheeze Cough Shortness of breath Infections Diurnal variation Walking at night Symptoms in morning Reliever use Activity limitation School, work, exercise The Peer Teaching Society is not liable for false or misleading information…

Asthma assessment Allergies Social Coping with medications Smoking Occupation Pets The Peer Teaching Society is not liable for false or misleading information…

Any questions about resp examination? The Peer Teaching Society is not liable for false or misleading information…

History 1 Barry is a 67 year old man who comes to the GP with “chest pain”. What do you want to know? SOCRATES It’s central and comes on when he walks more than 200m. It goes away when he rests. Sometimes he feels a bit sick with it and it goes to his jaw. It’s a 6/10 in severity. Which system is this? The Peer Teaching Society is not liable for false or misleading information…

History 1 What other cardiac symptoms will you ask about? What PMH is important? What FH is important? What drugs might he be on? What SH is important? SOB, palpitations, nausea, sweating, leg swelling, PND, orthopnoea SH smoking, alcohol, diet, sedentary occupation Hx MI, angina, HTN, cholesterol, diabetes, stroke FH of MI and stroke esp at young age, CV disease Antihypertensives, statin, diabetes medication GTN spray The Peer Teaching Society is not liable for false or misleading information…

History 1 Sometimes feels faint No previous heart problems He takes amlodipine for hypertension He smokes 20/day He’s a lorry driver What condition is this? What lifestyle advice do you give him? What medication do you offer? What are the side effects? SOB, palpitations, nausea, sweating, leg swelling, PND, orthopnoea SH smoking, alcohol, diet, sedentary occupation Hx MI, angina, HTN, cholesterol, diabetes, stroke FH of MI and stroke esp at young age, CV disease GTN spray (low BP, dizziness), beta-blocker reduces symptoms, may also need long acting nitrate, give aspirin, give statin if high cholesterol Antihypertensives, statin, diabetes medication GTN spray The Peer Teaching Society is not liable for false or misleading information…

History 2 Sylvia is a 75 year old lady. She comes to you as she’s been getting more out of breath. What do you want to know? Nature of the SOB It’s been getting worse for the past few months and now she has difficulty getting to the shops which she was always able to do before. There’s no diurnal variation. She has no chest pain or HF symptoms. Which system is this? The Peer Teaching Society is not liable for false or misleading information…

History 2 What other symptoms will you ask about? She often coughs up white sputum, but no blood, and she feels she wheezes. She’s always been thin and hasn’t noticed any drastic weight loss. She often feels very tired but has no fevers or night sweats. What PMH is important? She’s had 3 chest infections in the last year The Peer Teaching Society is not liable for false or misleading information…

History 2 What medications might give her a cough? What family history are you interested in? Her dad and sister both has a similar thing. What social history do you ask about? She lives on her own in a bungalow. She used to smoke 30/day but stopped when her sister got this condition. She used to work as a teacher. She hasn’t been away. The Peer Teaching Society is not liable for false or misleading information…

History 2 What condition are you thinking? What does this show on spirometry? What reliever might you offer her? What genetic condition is associated? The Peer Teaching Society is not liable for false or misleading information…

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