2018/2019

Peer Teaching Society OSCE History Taking Sessions 2018 15/10/18- CVS and Respiratory 17/10/18- Neuro and Miscellaneous 18/10/18- GI and GU (No MSK history teaching by PTS as anatomy society are doing revision session on this) The Peer Teaching Society is not liable for false or misleading information…

CVS and Respiratory OSCE History Taking Phase 2b Revision Session Melanie Coulson and Lauren Langham 15/10/18 The Peer Teaching Society is not liable for false or misleading information…

History taking structure USE YOUR GREEN BOOK! Name and introduction Age (ask age never DOB otherwise you have to do ‘QUICKMATHS’) History – SOCRATES PMH/Allergies Drug history Social history FH ICE The Peer Teaching Society is not liable for false or misleading information…

Specific Questions for CVS 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…

Specific Questions for Respiratory History HPC- cough, wheeze, fever, haemoptysis, dyspnoea, Family hx of CF, asthma/eczema/hayfever Medical hx- ACEI, inhalers, immunisations SH- foreign travel, pets, occupation, living conditions, hobbies (e.g. pigeon fancying), long haul flights PMH- asthma, TB, PE, allergies, pneumonia, home oxygen, inhalers The Peer Teaching Society is not liable for false or misleading information…

Common CVS and Respiratory Presenting Complaints CVS Common HPCs Respiratory Common HPCs Chest Pain Cough Palpitations Shortness of Breath Ankle Swelling Asthma Leg pain COPD Pulmonary fibrosis Syncope and presyncope The Peer Teaching Society is not liable for false or misleading information…

Causes of Chest Pain Cardiac causes: - Acute coronary syndrome: Stable or unstable angina, NSTEMI, STEMI Pericarditis Aortic stenosis (triad of chest pain, syncope, heart failure) - Aortic dissection Respiratory causes: Pulmonary embolism Pneumonia Pneumothorax GI causes: GORD Peptic ulcer disease Other: - Worth considering MSK causes such as chest wall injuries or rib injuries The Peer Teaching Society is not liable for false or misleading information…

Chest Pain SOCRATES SITE CENTRAL/ LEFT/ RIGHT SIDED ONSET SUDDEN OR GRADUAL? WHAT WERE THEY DOING WHEN PAIN ONSET? CHARACTER CRUSHING, TEARING, HEAVY, TIGHT, BURNING? RADIATION JAW/ DOWN THE LEFT ARM/ BACK/ NECK TRAPEZIUS RIDGE/ SHOULDER ASSOCIATED SYMPTOMS SOB (ask about exercise tolerance), nausea, vomiting, sweating, palpitations, ankle swelling, syncope, calf swelling, haemoptysis, sputum or trauma TIMING HOW LONG DOES IT LAST? HAVE THEY HAD MULTIPLE EPISODES? EXACERBATING/ RELIEVING EXERCISE, POSITION (LYING BACK OR SITTING FORWARD), SEVERITY Out of 10 The Peer Teaching Society is not liable for false or misleading information…

Palpitations Cardiac causes: Cardiac arrhythmias (inc AF), valve pathology, heart failure, congenital heart disease Other causes: Psychosomatic (anxiety, panic disorder), hyperthyroidism, anaemia, medication or recreational drugs, high levels of caffeine What to ask: What do they mean by palpitations? Can they tap out the beat, if so is it regular? How often does it happen and how long do they last? Associated symptoms Sweating or breathlessness Syncope or pre-syncope CHEST PAIN Palpitations associated with EXERCISE Family history of cardiac disease (in particular <55 and 1st degree relative) The Peer Teaching Society is not liable for false or misleading information…

Ankle swelling …Generally think HEART FAILURE (other cardiac/respiratory cause of leg swelling could be DVTPE) Left ventricular failure (LUNG SYMPTOMS) Right ventricular failure aka. Cor pulmonale (BODY SYMPTOMS) Exertional SOB Ankle oedema Paraoxysmal nocturnal dyspnoea Sacral oedema Orthopnoea Cough (as RVF can be caused by lung disease) Cough Ascites Pink ‘frothy’ sputum (Most commonly caused by PE) + Can also get elevated JVP and pleural effusion. May hear bi-basal crackles O/E The Peer Teaching Society is not liable for false or misleading information…

Ankle swelling If you suspect heart failure … (3 cardinal signs of exertional SOB, ankle swelling and fatigue) Ask: How many pillows are you using at night? Are they sleeping in a chair? Can they climb the stairs? Exercise tolerance? What was normal for them before?

Leg Pain Generally think DVT Symptoms to ask about: Leg swelling (usually unilateral) Increase in skin temperature Skin discolouration (erythema) Risk assessment questions Recent surgery? Long haul flight? History of malignancy? Immobility (inc post fracture) Previous VTE Family history of VTE The Peer Teaching Society is not liable for false or misleading information…

Leg Pain Generally think DVT Measured with - ABPI ….but do not rule out… INTERMITTENT CLAUDICATION; Ask ‘how far can you walk’ before the pain starts? Ask re risk factors for CVS– smoking, alcohol, diabetes, hypertension, hyperlipidaemia Associated symptoms – gangrene, burning, foot pain (‘I’m hanging my foot off the bed at night’) = critical ischaemia. Impotence. Measured with - ABPI The Peer Teaching Society is not liable for false or misleading information…

Causes of Shortness of Breath Acute In between Chronic Pulmonary Embolism Carcinoma of the lung COPD Asthma attack Pleural effusion Pulmonary fibrosis Pneumonia TB Heart failure Pneumothorax There are plenty of other causes: Valvular disease, arrythmias, MI, pericarditis – but the above are probably the main ones….. The Peer Teaching Society is not liable for false or misleading information…

Shortness of Breath SOB Presenting complaint History of presenting complaint When? How long does it last? Any associated: Chest pain, palpitations, orthopnoea/PND, nausea or vomiting, cough (blood/sputum colour etc) calf /ankle swelling or pain. What makes it better or worse? Rest, exertion, position, fresh air, inhalers? Past medical history Asthma, COPD, VTE Risk factors for heart disease – Diabetes, high cholesterol, high BP Drug history Inhalers, allergies Social history Smoking (remember to ask if they ever have even if they don’t now!! Occupation Family history In particular of asthma or cardiac disease Important extras SYSTEMIC FEATURES: Fevers, night sweats, weight loss Risk factors for VTE (on previous slides)

Syncope and Pre Syncope Causes: Vasovagal syncope, postural hypotension, aortic stenosis, cardiac arrhythmias (Worth considering that it may not actually have been a faint.. Possible seizure??) Ask about: Onset and duration – how long did it last and what were they doing when it occurred? Previous episodes, how frequently? Associated symptoms – palpitations, sweating, chest pain, headache etc. The Peer Teaching Society is not liable for false or misleading information…

CVS Examinations Likely examinations; Pacemakers Murmurs AF GTN spray CABG scars on legs The Peer Teaching Society is not liable for false or misleading information…

Respiratory Examinations Likely examinations; Look for sputum pots, oxygen tanks and inhalers Tar staining on fingers Walking stick The Peer Teaching Society is not liable for false or misleading information…

History: WHAT ARE WE GOING TO ASK? The Peer Teaching Society is not liable for false or misleading information…

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

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

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

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

History: What is the most likely diagnosis? What 2 pre hospital treatments should be given? The Peer Teaching Society is not liable for false or misleading information…

History: What is the most likely diagnosis? MI Give 2 pre hospital treatments should be given? MONA -morphine, oxygen, (GT)N, aspirin The Peer Teaching Society is not liable for false or misleading information…

ANY QUESTIONS?? History 2: The Peer Teaching Society is not liable for false or misleading information…