1. 2018/2019

2. 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)
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3. CVS and Respiratory OSCE History Taking
Phase 2b Revision Session
Melanie Coulson and Lauren Langham
15/10/18
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4. 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
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5. 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?
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6. 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
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7. 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
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8. 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
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9. 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
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10. 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)
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11. 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
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12. 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?

13. 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
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14. 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
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15. 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…..
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16. 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)

17. 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.
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18. CVS Examinations Likely examinations; Pacemakers Murmurs AF GTN spray
CABG scars on legs
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19. Respiratory Examinations
Likely examinations;
Look for sputum pots, oxygen tanks and inhalers
Tar staining on fingers
Walking stick
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20. History: WHAT ARE WE GOING TO ASK?
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21. History:
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22. History:
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23. History:
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24. History:
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25. History: What is the most likely diagnosis?
What 2 pre hospital treatments should be given?
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26. History: What is the most likely diagnosis? MI
Give 2 pre hospital treatments should be given?
MONA
-morphine, oxygen, (GT)N, aspirin
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27. ANY QUESTIONS?? History 2:
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