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Complete OSCE Skills for
Medical and Surgical Finals
This page intentionally left blank
Complete OSCE Skills for
Medical and Surgical Finals

KATE TATHAM BSC (HONS) MB BS MRCP FRCA

Specialty Registrar, Anaesthetics and Intensive Care Medicine
Imperial School of Anaesthesia
London, UK

KINESH PATEL BA (HONS) MB BS MRCP

Specialty Registrar, Gastroenterology
Chelsea and Westminster NHS Foundation Trust
London, UK
First published in Great Britain in 2010 by
Hodder Arnold, an imprint of Hodder Education, an Hachette UK company,
338 Euston Road, London NW1 3BH

http://www.hoddereducation.com

© 2010 Kate Tatham and Kinesh Patel

All rights reserved. Apart from any use permitted under UK copyright law, this publication may only
be reproduced, stored or transmitted, in any form, or by any means with prior permission in writing
of the publishers or in the case of reprographic production in accordance with the terms of licences
issued by the Copyright Licensing Agency. In the United Kingdom such licences are issued by the
Copyright licensing Agency: Saffron House, 6–10 Kirby Street, London EC1N 8TS.

Whilst the advice and information in this book are believed to be true and accurate at the date of going
to press, neither the author[s] nor the publisher can accept any legal responsibility or liability for any
errors or omissions that may be made. In particular, (but without limiting the generality of the
preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that
errors have been missed. Furthermore, dosage schedules are constantly being revised and new side-
effects recognized. For these reasons the reader is strongly urged to consult the drug companies’
printed instructions before administering any of the drugs recommended in this book.

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

Library of Congress Cataloging-in-Publication Data

A catalog record for this book is available from the Library of Congress

ISBN 978-0-340-97424-7

1 2 3 4 5 6 7 8 9 10

Commissioning Editor: Joanna Koster

Project Editor: Sarah Penny
Production Controller: Karen Dyer and Kate Harris
Cover Design: Amina Dudhia

Typeset in 10 on 13pt Minion by Phoenix Photosetting, Chatham, Kent

Printed and bound in India

What do you think about this book? Or any other Hodder Arnold title?
Please visit our website: www.hoddereducation.com
Contents

Preface vii
Acknowledgements ix
List of abbreviations xi

1 History 1

2 Examination 27

3 Procedures 167

4 Emergency 199

5 Interpretations 205

6 Communication skills 237

7 Obstetrics and gynaecology 253

8 Paediatrics 281

9 Genitourinary medicine 289

Index 297
To our partners and families
Preface

Clinical examinations are a stressful but necessary part of medical school finals. However,
with the appropriate preparation and practice they can become significantly less daunting
and even an opportunity to prove your clinical skills.
The aim of this book is to help in this process of revision by providing an overview of
common clinical situations encountered in OSCE stations. This quick reference text allows
you and your peers to test each other’s skills both at the bedside and in role play scenarios.
Although this book has not been written as an exhaustive guide, it provides the essential
knowledge necessary to succeed in your exams.
Good luck!
This page intentionally left blank
Acknowledgements

We would like to thank Dr Andrew Thillainayagam for his help and guidance.
We would also like to thank the following for their contributions and advice:
● Heidi Artis BSc, MB BS
Specialty Registrar
Acute Care Common Stem, Anaesthetics & Intensive Care
● Catherine Bennett BSc, MB BS, DFSRH
General Practice Registrar
● Sarita Depani BSc, MB BS, MRCPCH
Specialty Registrar
Paediatrics
● Rebecca Evans-Jones BA, MB BS, MRCOG
Specialty Registrar
Obstetrics and Gynaecology
● Lucy Hicks BSc, MB BS, MRCP
Specialty Registrar
Gastroenterology
● James Waller BSc, MB BS, MRCP
Specialty Registrar
Cardiology
We would especially like to thank Paolo Sorelli for his continuing support, helpful com-
ments and enthusiasm.
This page intentionally left blank
List of abbreviations

5-HT 5-hydroxytryptamine
AAA abdominal aortic aneurysm
ACE angiotensin-converting enzyme
ACTH adrenocorticotropic hormone
AF atrial fibrillation
AFP a-fetoprotein
AIDS acquired immune deficiency syndrome
AP anteroposterior
ASIS anterior superior iliac spine
BCC basal cell carcinoma
BMI body mass index
CABG coronary artery bypass graft
CAPD continuous ambulatory peritoneal dialysis
CIN cervical intraepithelial neoplasia
CK creatine kinase
CNS central nervous system
COPD chronic obstructive pulmonary disease
COX-2 cyclo-oxygenase-2
CPR cardiopulmonary resuscitation
CRP C-reactive protein
CSF cerebrospinal fluid
CT computed tomography
CTG cardiotocograph
CXR chest radiograph
DIP distal interphalangeal
DMARD disease modifying antirheumatic drug
DNR do not resuscitate
ECG electrocardiogram
EEG electroencephalography
EMG electromyography
ESR erythrocyte sedimentation rate
FBC full blood count
FEV1 forced expiratory volume in 1 second
FiO2 fraction of inspired oxygen
xii List of abbreviations

FSH follicle stimulating hormone

FVC forced vital capacity
GCA giant cell arteritis
GCS Glasgow Coma Scale
GP general practitioner
GTN glyceryl trinitrate
HIV human immunodeficiency virus
HLA human leucocyte antigen
HOCM hypertrophic obstructive cardiomyopathy
HRT hormone replacement therapy
HSMN hereditary sensory and motor neuropathy
ICE ideas, concerns and expectations
ICP intracranial pressure
IPF idiopathic pulmonary fibrosis
IUGR intrauterine growth restriction
JVP jugular venous pressure
LDH lactate dehydrogenase
LFT liver function tests
LH luteinizing hormone
LMN lower motor neurone
LMP last menstrual period
LUQ left upper quadrant
MCP metacarpophalangeal
MDI metered-dose inhaler
MI myocardial infarction
MMR measles, mumps and rubella
NSAID non-steroidal anti-inflammatory drug
OSA obstructive sleep apnoea
PALS Patient Advice and Liaison Service
PCI percutaneous coronary intervention
PCKD polycystic kidney disease
PEFR peak expiratory flow rate
PEP post-exposure prophylaxis
PET positron emission tomography
PFT pulmonary function test
PID pelvic inflammatory disease
PIP proximal interphalangeal
PND paroxysmal nocturnal dyspnoea
POC products of conception
PUO pyrexia of unknown origin
RIF right iliac fossa
RUQ right upper quadrant
SACD subacute combined degeneration of the cord
SCC squamous cell carcinoma
SFH symphysis–fundal height
SFJ saphenofemoral junction
 List of abbreviations xiii

STI sexually transmitted infection

SVT supraventricular tachycardia
TIA transient ischaemic attack
U&E urea and electrolytes
UMN upper motor neurone
UTI urinary tract infection
VT ventricular tachycardia
This page intentionally left blank
 C H A P T E R 1

History
History taking skills 1 Tiredness 13
Chest pain 3 Headache 15
Shortness of breath 5 Collapse 17
Fever/pyrexia of unknown origin 7 Alcohol misuse 19
Abdominal pain 8 Psychiatric history and risk 20
Change in bowel habit 11 assessment

HISTORY TAKING SKILLS

Familiarity with the key components of a history is invaluable when taking a history from
any patient.

INTRODUCTION
● Introduce yourself to the patient
● Confirm the reason for the interview
● Ensure the patient is sitting comfortably, alongside and not behind a desk

PATIENT DETAILS
● Confirm the patient’s details:
䡩 Full name
䡩 Age and date of birth
䡩 Occupation

PRESENTING COMPLAINT
● Ask the patient to describe their problem by using open questions
● The presenting complaint should be expressed in their own words, e.g. ‘heaviness in
the chest’
● Do not interrupt their first few sentences
● Try to elicit their ideas, concerns and expectations (ICE)

HISTORY OF PRESENTING COMPLAINT

● Interrogate the patient further about the presenting complaint
● A useful guide, e.g. for pain, is the mnemonic ‘SOCRATES’
䡩 Site
䡩 Onset
䡩 Character
2 History

䡩 Radiation
䡩 Alleviating factors
䡩 Timing
䡩 Exacerbating factors
䡩 Severity scale (1–10)
䡩 And associated Symptoms

PAST MEDICAL HISTORY

● Enquire about diseases relating to the presenting complaint. For example, for chest pain:
䡩 Coronary heart disease/angina/myocardial infarction
䡩 Indigestion/reflux/hiatus hernia
䡩 Asthma/chronic obstructive pulmonary disease (COPD)/pulmonary fibrosis
䡩 Deep vein thrombosis/pulmonary embolism/hypercoagulability
● Ask all patients if they have a history of important diseases
(mnemonic ‘MJ THREADS Ca’):
䡩 Myocardial infarction
䡩 Jaundice
䡩 Tuberculosis
䡩 Hypertension
䡩 Rheumatic fever
䡩 Epilepsy
䡩 Asthma
䡩 Diabetes
䡩 Stroke
䡩 Cancer

DRUG HISTORY
● Enquire about all medications including creams, drops, the oral contraceptive and
herbal/vitamin preparations
● Specify:
䡩 Route
䡩 Dose
䡩 Frequency
䡩 Compliance
● Take a detailed allergy history, e.g. which medications/foods and the symptoms

FAMILY HISTORY
● Ask the patient about any relevant family diseases, e.g. coronary heart disease, diabetes
● Enquire about the patient’s parents, and the cause of death if deceased
● Sketch a short family tree, including any offspring (Fig. 1.1)

SOCIAL (AND PSYCHIATRIC) HISTORY

● Assess any alcohol use in approximate units/week
● Ask about tobacco use – quantify with ‘pack years’ (number of packets of 20 cigarettes
smoked per day multiplied by number of years smoking)
● Employment history, including exposure to pathogens, e.g. asbestos
 Chest pain 3

Key:

Male

Female

Deceased

Disease sufferer
e.g. haemophilia

Married

Offspring

Figure 1.1 Example family tree

● Enquire about home situation, including any pets

● Enquire about any history of psychiatric disease

SYSTEMS REVIEW
● Run through a comprehensive list of symptoms from all systems:
䡩 Cardiovascular, e.g. chest pain, palpitations
䡩 Respiratory, e.g. cough, dyspnoea
䡩 Gastrointestinal, e.g. abdominal pain, diarrhoea
䡩 Genitourinary, e.g. dysuria, discharge
䡩 Neurological, e.g. numbness, weakness
䡩 Musculoskeletal, e.g. aches, pains
䡩 Psychiatric, e.g. depression, anxiety

SUMMARY
● Provide a short summary of the history including:
䡩 Name and age of patient
䡩 Presenting complaint
䡩 Relevant medical history
● Give a differential diagnosis (e.g. ‘This could be a myocardial infarction or
oesophageal spasm’)
● Formulate a short investigation and treatment plan

CHEST PAIN
INTRODUCTION
● Introduce yourself
● Confirm patient’s name
● Confirm reason for meeting
● Adopt appropriate body language

HISTORY OF PRESENTING COMPLAINT

The mnemonic ‘SOCRATES’ is useful for assessing chest pain (see p. 1). Enquire about:
4 History

● Site – central or left chest, retrosternal, epigastric

● Onset – sudden, gradual, related to trauma/exertion
● Character – crushing, heavy, tight band, pleuritic, burning
● Radiation – radiating to left arm, neck, jaw or back
● Alleviation – rest, glyceryl trinitrate (GTN) spray, sitting forward (pericarditis)
● Timing – related to exertion
● Exacerbating factors – effort, emotion, movement, food, respiration, cold weather
● Severity scale – 1–10
● And associated Symptoms:
䡩 Dyspnoea, palpitations
䡩 Syncope/collapse
䡩 Sweating, burping, nausea/vomiting
䡩 Ankle swelling
䡩 Calf swelling
䡩 Paroxysmal nocturnal dyspnoea (PND) or orthopnoea
䡩 Cough, haemoptysis, sputum
䡩 Fever, constitutional upset, coryza
䡩 Panic attacks, anxiety

PAST MEDICAL HISTORY

● Vascular disease:
䡩 Angina, previous myocardial infarction (MI), previous angioplasty or coronary
artery bypass graft (CABG) surgery
䡩 Claudication
䡩 Cerebrovascular disease, transient ischaemic attacks
䡩 Risk factors
® Hypertension
® Hyperlipidaemia
® Diabetes
® Smoking
® Family history (MI <60 years, hyperlipidaemia)
● Thromboembolic disease:
䡩 Recent surgery, cancer, immobility
䡩 Inherited hypercoagulable state, e.g. protein S or C deficiency
䡩 Oral contraceptive/hormone replacement therapy
䡩 Smoking
● Pneumothorax:
䡩 Tall, thin man
䡩 Connective tissue disease (e.g. Marfan’s)

DRUG HISTORY
● Cardiac medications: b-blockers, diuretics, antiplatelet agents, GTN spray
● Recreational drug use, e.g. cocaine (coronary artery spasm)
● Chronic non-steroidal anti-inflammatory drug (NSAID) use causing
gastritis/oesophagitis/reflux
 Shortness of breath 5

SOCIAL HISTORY
● Smoking
● Alcohol intake
● Diet (fatty food, salt intake)
● Lifestyle, exercise
● Recent immobility/major surgery/long-haul travel

BOX 1.1 DIFFERENTIAL DIAGNOSIS: CHEST PAIN

Cardiovascular: Respiratory:
● Myocardial infarction ● Pulmonary embolism
● Acute coronary syndrome (non-ST ● Pneumonia
elevation MI, unstable angina) ● Pneumothorax
● Angina (induced by effort and relieved
Musculoskeletal:
by rest)
● Costochondritis (Tietze’s syndrome)
● Acute aortic dissection
● Chest wall injuries
● Pericarditis
Psychosomatic:
Gastrointestinal:
● Anxiety/depression
● Reflux oesophagitis
● Oesophageal spasm
● Peptic ulcer disease

SHORTNESS OF BREATH
INTRODUCTION
● Introduce yourself
● Confirm patient’s name
● Confirm reason for meeting
● Adopt appropriate body language

HISTORY OF PRESENTING COMPLAINT

Enquire about:
● Onset and duration – acute, chronic, constant, intermittent
● Exacerbating factors – effort, emotion, movement, cold weather
● Alleviation – rest, inhalers
● Timing – related to exertion
● Associated symptoms:
䡩 Wheeze
䡩 Stridor
䡩 Cough – productive or dry, colour of sputum
䡩 Fever, night sweats or weight loss
䡩 Haemoptysis – how much: teaspoon, cup-full
䡩 Chest pain – pleuritic, cardiac
6 History

䡩 Palpitations
䡩 Nausea and vomiting, sweating, dizziness
䡩 Ankle swelling
䡩 Paroxysmal nocturnal dyspnoea (PND)
䡩 Orthopnoea – number of pillows
䡩 Exercise tolerance – quantify, e.g. number of stairs, distance on the flat

PAST MEDICAL HISTORY

● Asthma: frequency of attacks, admissions to hospital or intensive care unit
● COPD: frequency of exacerbations, admissions (as for asthma), use of home oxygen
(number of hours) and home nebulizers
● Recurrent lower respiratory tract infections
● Cardiac failure or structural disease
● Arrhythmias
● Deep vein thrombosis, procoagulant states (e.g. pregnancy, cancer, surgery)

DRUG HISTORY
● Nebulizers
● Cardiac medications
● Diuretics, e.g. furosemide
● Angiotensin-converting enzyme (ACE) inhibitors

FAMILY HISTORY
● History of atopy – asthma, eczema, hay fever
● Tuberculosis

SOCIAL HISTORY
● Smoking history (active and passive)
● Occupation and exposure to coal, dust, asbestos
● Animal exposure (pets, farming)
● Tuberculosis exposure
● Limitation of daily activities by shortness of breath

BOX 1.2 DIFFERENTIAL DIAGNOSIS

Acute: Chronic:
● Asthma ● COPD
● Acute exacerbation COPD ● Cardiac failure
● Lower respiratory tract infection ● Pulmonary fibrosis
● Pulmonary oedema ● Anaemia
● Pulmonary embolism ● Arrhythmias
● Pneumothorax ● Cystic fibrosis
● Pleural effusion ● Pulmonary hypertension
● Lung cancer
● Anxiety/panic attack
● Metabolic acidosis
 Fe v e r / p y r e x i a 7

FEVER/PYREXIA OF UNKNOWN ORIGIN

INTRODUCTION
● Introduce yourself
● Confirm patient’s name
● Confirm reason for meeting
● Adopt appropriate body language

HISTORY OF PRESENTING COMPLAINT

● Onset – sudden, gradual
● Character – constant, intermittent
● Frequency of peaks in temperature
䡩 Has the temperature been recorded?
● Alleviation – rest, paracetamol
● Timing – related to exertion
● Exacerbating factors – climate/weather, time of day
● Associated symptoms/signs:
䡩 Rigors or shivering
䡩 Sweating (especially at night)
䡩 Weight loss
䡩 Anorexia
䡩 Feeling faint or dizziness, syncopal episodes
䡩 Fatigue
䡩 Lumps, tender lymph nodes
䡩 Pain
䡩 Cough and sputum (lower respiratory tract infection)
䡩 Diarrhoea and vomiting, abdominal pain (gastroenteritis)
䡩 Urinary frequency, dysuria, haematuria (urinary tract infection [UTI])
䡩 Rashes or skin changes, areas of erythema (viral illnesses, cellulitis)
䡩 Headache, neck stiffness, photophobia (meningitis)
䡩 Heart failure, track marks, lethargy, rash, new murmur (infective endocarditis)

PAST MEDICAL HISTORY

● Recent surgery
● Recent illness, e.g. upper respiratory tract infection
● Blood transfusions

DRUG HISTORY
● Intravenous drug use
● Appropriate malaria prophylaxis when travelling and compliance
● Immunizations up to date

FAMILY HISTORY
● Any family members with contagious disease
● Animal – contact, bites
8 History

SEXUAL HISTORY
● Sexual history – recent sexual practice (see p. 289)

TRAVEL HISTORY
● Travel history – location, appropriate vaccinations, diet, food hygiene, swimming

SOCIAL HISTORY
● Tattoos
● Piercings
● Occupational exposure, e.g. to animals

BOX 1.3 COMMON DIFFERENTIAL DIAGNOSES OF PYREXIA OF UNKNOWN ORIGIN

Infective:
● Bacterial: e.g. pneumonia, urinary tract infection, meningitis, endocarditis,
abdominal/pelvic abscess
● Viral: e.g. gastroenteritis, hepatitis, HIV seroconversion
● Parasitic: e.g. malaria, schistosomiasis
Inflammatory: e.g. systemic lupus erythematosus, rheumatoid arthritis, Crohn’s disease
Malignancy: e.g. lymphoma, leukaemia, hepatocellular carcinoma
Others: e.g. pulmonary embolus, factitious, recent vaccination, thyrotoxicosis

INVESTIGATIONS
There are numerous investigations, depending on the history, including:
● FBC, urea and electrolytes (U&E), liver function tests (LFTs), C-reactive protein
(CRP), erythrocyte sedimentation rate (ESR), viral screen, Toxoplasma antibodies,
Paul Bunnell test, thyroid function tests
● Hepatitis screen
● Blood cultures
● Sputum culture
● Mid-stream urinalysis
● Stool culture
● CXR
● ECG
For difficult cases, echocardiography (endocarditis), CT and positron emission
tomography (PET) can help localize abnormalities giving rise to the fever.

ABDOMINAL PAIN
INTRODUCTION
● Introduce yourself
● Confirm patient’s name
● Confirm reason for meeting
● Adopt appropriate body language
 Abdominal pain 9

HISTORY OF PRESENTING COMPLAINT

Enquire about:
● Site – where did it start and has it moved?
● Onset – sudden, gradual
● Character – crampy, colicky, sharp, burning
● Radiation – e.g. loin to groin (renal colic)
● Alleviation – relieved by opening bowels or vomiting?
● Timing – related to eating/bowels/micturition/menstruation/movement?
● Exacerbating factors
● Severity scale – 1–10, does it wake you?
● Associated Symptoms:
䡩 Nausea and vomiting – haematemesis, coffee-grounds, bile-stained or feculent?
䡩 Dysphagia
䡩 Dyspepsia
䡩 Change in bowel habit – diarrhoea/constipation, altered frequency, colour,
consistency, pale, offensive smell, frothy, hard to flush away (steatorrhoea), blood
or mucus present
䡩 Rectal bleeding
䡩 Bloating, flatulence
䡩 Weight gain/loss
䡩 Appetite change
䡩 Jaundice, pruritus, dark urine, pale stools
䡩 Rigors/fever
䡩 Haematuria, dysuria, vaginal discharge

Right Epigastric Left Right Left

hypochondrium region hypochondrium
upper upper
quadrant quadrant
Right Umbilical Left
lumbar region region lumbar region
Right Left
lower lower
Right Supra- Left
quadrant quadrant
iliac fossa pubic iliac fossa
region

(a) (b)

Figure 1.2 Areas of the abdomen: (a) ninths or (b) quadrants

10 History

PAST MEDICAL HISTORY

● Inflammatory bowel disease – Crohn’s, ulcerative colitis
● Diverticular disease
● Previous abdominal/pelvic surgery (adhesions causing bowel obstruction)
● Recent trauma or injury (e.g. splenic rupture)
● Menstruation (pregnant/ectopic) and sexual history (pelvic inflammatory disease)
● Other common diseases: MJ THREADS Ca (see p. 2)

DRUG HISTORY
● NSAIDs
● Laxatives
● Opiates
● Antibiotics, e.g. erythromycin

FAMILY HISTORY
● Inflammatory bowel disease
● Polyps, bowel cancer
● Jaundice
● Family members with diarrhoea and vomiting

SOCIAL HISTORY
● Alcohol intake
● Recreational drug use
● Travel abroad
● Recent potentially infected food intake
● Blood transfusions, tattoos
● Sexual history (see p. 289)
 Change in bowel habit 11

BOX 1.4 DIFFERENTIAL DIAGNOSIS OF ABDOMINAL PAIN

Gastrointestinal: Splenic:
● Gastritis, dyspepsia, peptic ulcer ● Infarction
disease (PUD) ● Rupture
● Appendicitis Genitourinary:
● Peritonitis ● Acute pyelonephritis
● Perforated gastric ulcer ● Renal colic
● Bowel obstruction ● Cystitis/urinary tract infection
● Diverticulitis ● Ectopic pregnancy
● Gastroenteritis ● Torsion or rupture of ovarian cyst
● Inflammatory bowel disease ● Pelvic inflammatory disease
● Mesenteric adenitis ● Salpingitis
● Strangulated hernia ● Endometriosis
● Volvulus ● Fibroids
● Intussusception ● Dysmenorrhoea
● Irritable bowel syndrome ● Referred pain of testicular torsion
● Pancreatitis
Other:
● Malignancy
● Abdominal aortic aneurysm
Hepatobiliary: ● Mesenteric thrombosis or embolus
● Cholangitis ● Diabetic ketoacidosis
● Acute cholecystitis ● Sickle cell crisis
● Cholelithiasis (gall stones) ● Acute porphyria
● Hepatitis ● Acute MI
● Fitz–Hugh–Curtis syndrome
(chlamydial perihepatitis)

CHANGE IN BOWEL HABIT

INTRODUCTION
● Introduce yourself
● Confirm patient’s name
● Confirm reason for meeting
● Adopt appropriate body language

HISTORY OF PRESENTING COMPLAINT

Enquire about:
● Normal bowel habit (for patient)
● Changes:
䡩 Symptoms:
® Frequency of bowel opening
® Constipation
® Diarrhoea – watery, loose
12 History

® Steatorrhoea – pale, offensive smell, frothy, hard to flush away

® Rectal blood – mixed in, on paper, in toilet pan, altered or frank blood
® Any pus, slime or mucus
䡩 Onset – sudden, gradual
䡩 Duration
䡩 Timing – any relation to food, menstruation, activity level, time of day
䡩 Alleviating factors – e.g. certain food avoidance
䡩 Exacerbating factors – e.g. exercise, sleep patterns, food
䡩 Associated symptoms:
® Nausea and vomiting – haematemesis, coffee-grounds, bile-stained or feculent
® Dysphagia
® Dyspepsia
® Bloating, flatulence
® Weight gain/loss
® Appetite change, diet change
® Jaundice, pruritus, dark urine, pale stools
® Rigors/fever
® Haematuria, dysuria, vaginal discharge

PAST MEDICAL HISTORY

● Inflammatory bowel disease – Crohn’s, ulcerative colitis
● Coeliac disease
● Diverticular disease
● Groin/midline/incisional hernias
● Previous abdominal surgery (e.g. adhesions causing bowel obstruction)
● Metabolic disturbances, e.g. thyroid disease

DRUG HISTORY
● NSAIDs
● Laxatives
● Opiates
● Antibiotics, e.g. erythromycin

FAMILY HISTORY
● Inflammatory bowel disease
● Polyps, bowel cancer
● Family members with diarrhoea and vomiting

SOCIAL HISTORY
● Alcohol intake
● Recreational drug use
● Travel abroad
● Recent potentially infected food intake
● Sexual history (see p. 289)
 Ti r e d n e s s 13

BOX 1.5 DIFFERENTIAL DIAGNOSIS OF CHANGE IN BOWEL HABIT

Gastrointestinal: Infective:
● Appendicitis ● Bacterial, e.g. Salmonella species
● Peritonitis ● Viral
● Perforated gastric ulcer ● Fungal
● Bowel obstruction ● Protozoan
● Ileus, e.g. postoperative Drugs:
● Diverticulitis ● Opiates
● Gastroenteritis ● Laxatives
● Inflammatory bowel disease (Crohn’s ● Antibiotics
or ulcerative colitis) ● Tricyclic antidepressants
● Strangulated hernia
Metabolic:
● Volvulus
● Thyroid disease
● Intussusception
● Diabetes (autonomic disease)
● Irritable bowel syndrome
● Carcinoid
● Pancreatitis
● Malignancy Others:
● Biliary obstruction, e.g. gallstones ● Anxiety
● Anal pain, e.g. fissure, fistula ● Depression
● Diet

TIREDNESS
INTRODUCTION
● Introduce yourself
● Confirm patient’s name
● Confirm reason for meeting
● Adopt appropriate body language

HISTORY OF PRESENTING COMPLAINT

Enquire about:
● Onset and duration:
䡩 Sudden onset and short history, e.g. post-viral cause
䡩 Long duration (more suggestive of emotional origin)
● Related factors:
䡩 If related to exertion – more likely organic cause
䡩 Time of day, e.g. rheumatoid arthritis worse on waking
䡩 Improved after rest, e.g. myasthenia gravis
● Associated symptoms:
䡩 Weight loss, anorexia, dyspnoea – suggest underlying pathology, e.g. cancer
䡩 Weight gain, constipation, dry skin and hair, cold intolerance – e.g.
hypothyroidism
䡩 Chronic pain
䡩 Rectal bleeding, abdominal pain, menorrhagia, e.g. anaemia
14 History

● Sleep patterns:
䡩 Early morning waking – depression
䡩 Snoring, daytime somnolence, early morning headaches, obesity – obstructive
sleep apnoea (OSA) (see Box 1.6)

BOX 1.6 EPWORTH SLEEPINESS SCALE – ESTABLISHES POSSIBLE DIAGNOSIS OF OSA

For each question score for chance of dozing (0 = no chance, 1 = slight, 2 = moderate,
3 = high; score >11/24 significant)
Likelihood of falling asleep when:
● Sitting and reading
● Watching television
● Sitting inactive in a public place
● Passenger in a car for 1 hour
● Lying down to rest in the afternoon
● Sitting and talking to someone
● Sitting quietly after lunch (without alcohol)
● Sitting in the car in traffic for few minutes

PAST MEDICAL HISTORY

● Recent viral illnesses
● Sleep apnoea
● Cardiac disease
● Hypothyroidism (or previous thyroid-related treatment including surgery)
● Endocrine diseases including diabetes mellitus
● Renal failure
● Psychiatric problems

DRUG HISTORY
● Thyroid-related medications or treatments
● Recent changes in dose of regular medication
● Use of analgesics and sedatives

FAMILY HISTORY
● Endocrine dysfunction

SOCIAL HISTORY
● Impact on work, family and relationships
● Occupation and exposure to chemicals or toxins
● Alcohol – i.e. excess, especially in the evenings

SYSTEMS REVIEW

Full systems review to elicit symptoms overlooked by patient.

 Headache 15

BOX 1.7 DIFFERENTIAL DIAGNOSIS OF TIREDNESS

● Anaemia ● Chronic pain

● Hypo- or hyperthyroidism ● Post-viral syndrome
● Malignancy ● Chronic fatigue syndrome
● Sleep apnoea ● Fibromyalgia
● Infections ● Medication side effects
● Diabetes mellitus ● Depression, anxiety, chronic stress
● Inflammatory conditions, e.g. ● Insomnia
rheumatoid arthritis

HEADACHE
INTRODUCTION
● Introduce yourself
● Confirm patient’s name
● Confirm reason for meeting
● Adopt appropriate body language

HISTORY OF PRESENTING COMPLAINT

Enquire about:
● Site
䡩 Where did it start, has it moved?
䡩 Unilateral: migraine, cluster headache, giant cell (temporal) arteritis giant cell
arteritis (GCA)
䡩 Bilateral: tension headache, subarachnoid headache
● Onset – sudden, e.g. ‘thunder-clap’, gradual
● Character:
䡩 ‘Tight band’ or pressure – tension headache
䡩 Throbbing/dull ache – migraine
䡩 Lancinating – trigeminal neuralgia
䡩 Tender to touch (e.g. on combing hair) – temporal arteritis
● Radiation – e.g. throat, eye, ear, nose – neuralgia
● Alleviation – relieved by analgesia, posture, darkened room (migraine), sleep
● Timing and frequency:
䡩 Migraines 24–72 hours, cyclical in nature
䡩 Cluster headaches >1 hour
䡩 Neuralgia; paroxysms of seconds to minutes
䡩 Raised intracranial pressure (ICP) – worse on waking
● Exacerbating factors:
䡩 Loud noises (phonophobia), bright light (photophobia)
䡩 Bending/straining (with raised ICP)
䡩 High body mass index (BMI), steroid or oral contraceptive use – idiopathic
intracranial hypertension
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