Dizziness

Dizziness may mean one thing to a patient but another to clinician.  It may even mean different things between clinicians!  It is important to clarify the exact symptom being described.

History

• Wash hands, introduce self, check patient name and DOB, build rapport and gain consent
• PC
  • Ask the patient to describe what they mean (without using the word dizziness/dizzy).  Do they feel spinning? light headed? nauseous? like they are about to collapse/fall? floating? etc etc
• HxPC
  • If it is true vertigo, how long does it last?
    • If seconds and associated with head positional change- likely BPPV
    • If hours-days, more likely to Meniere’s (+ ear fullness/tinnitus/hearing loss – sickness) or vestibular neuronitis (- ear fullness) or labyrinthitis (+ hearing problems etc) (+sickness)
    • If sudden onset, lasting minutes, you can consider central causes too (specifically vascular problems if risk factors are present) as well as vestibular neuronitis/labyrinthitis
      • Usually this will be present with other neurological signs e.g. dysarthria/dysphasia, diplopia, ataxia (and inability to mobilise properly), dysdiadochokinesis, weakness etc
  • Is it associated with anything else?
    • Migraines?
    • Autoimmune conditions?
  • If it is light-headedness- are there possible CVS risk factors? e.g. high/low BP, orthostatic BP problems, history of heart failure
• In other aspects of the history, you need to explore
  • PMHx and RHx
    • Particularly polypharmacy and heart problems, but also diabetes, epilepsy, cancers (brain mets?) and any other significant conditions and/or drug therapies
  • SHx
    • Alcohol intake is particularly important here
    • Effect on life is important and you should always ask every patient about what their main concerns are
    • Travel Hx

Examination

• Cardiovascular examination
• Ear exam
• Dix-Hallpike test and Epley manouvre (see BPPV)

Manual Blood Pressure

• Wash hands, introduce self and check patient name and DOB.
• Explain to the patient that this might be uncomfortable but if they cannot tolerate it, let you know.  Gain consent.
• Position the patient’s arm level with their heart and relaxed.  This is most easily done by putting it on a pillow.
• Without the use of the stethoscope first:
  • Wrap the sphygmomanometer cuff around the patients bicep belly with the artery arrow overlying the brachial artery.
  • With your fingers feeling for the radial pulse at the wrist, inflate the cuff until this disappears.  This estimates systolic BP. Deflate the cuff
  • Next using the stethoscope (whether to use the bell or diaphragm is debated) over the cubital fossa, inflate the cuff to the estimated SBP +20 mmHg and slowly deflate the cuff at around 2 mmHg/sec.
    • At the SBP, you should begin to hear pulsatile noises (Korsakoff sounds).
    • At the DBP, these sounds disappear.
  • Deflate the cuff and record SBP/DBP.

Jaundice

Jaundice can be either a symptom or a sign or both.  It is confirmed by a high serum bilirubin and is usually clinically evident at levels above 35μmol/l.

In the history (and examination) it is useful to try and distinguish what type of jaundice (pre-hepatic, hepatic, post-hepatic) is present.  This will help to guide the diagnosis.

History

• Wash hands, introduce self, check name and DOB, establish initial rapport, start with open question etc
• HPC:
  • Onset and progression
  • Colour:
    • Pale yellow more associated with pre-hepatic jaundice (anaemia and jaundice)
• Other symptoms/signs:
  • Dark urine (hepatic/post-hepatic jaundice) and/or pale stools (post-hepatic)
  • Pruritis?
  • Abdo pain
    • Painful: Alcoholic; infection; biliary colic; pancreatitis; cholecystitis; metastasis
    • Painless: Haemolysis; Primary Biliary Sclerosis; Pancreatic/biliary malignancy; cirrhosis; haemochromatosis
  • nausea/vomiting
  • haematemesis
  • fatigue/malaise
  • fever
  • loss of apetite/weight loss
  • Rash/arthritis
  • Abdominal swelling
  • Confusion
  • Sleep disturbance
  • Cardiac/resp symptoms
• PMHx
  • Previous jaundice? Previous gallstones? Malignancy? Recent anaesthesia? Blood transfusion? Autoimmune disorders? etc
• RHx including illicit drugs
  • Antibiotics, antirheumatics
• FHx
• Social Hx
  • Full Alcohol history including FAST/CAGE
  • Sexual history
  • Travel History
  • Tattoos/piercings

Examination

• General Examination is important
  • Look for signs of liver disease; any tattoos (risk of Hep C); jaundice in the sclera (may be more apparent than skin);
• see also Abdominal Examination

Headache

In real life, many people will have a single headache due to a viral URTI or dehydration etc that will require some paracetamol, fluids and some TLC.  If a patient comes to you with headache- it is far more likely to be a more chronic/episodic/severe headache that will possibly need some form of management.

History

• Wash hands, Introduce self, check patient name and DOB, begins with an open question.
• HxPC
  • Site: Frontal, temporal, occipital, unilateral/bilateral,
  • Character and radiation: throbbing; stabbing; burning
  • Radiation: Behind the eyes; neck; ear; jaw; forehead
  • Onset: Hyperacute; Acute; subacute; chronic; episodic
  • Timing: When is the headache worst? How have the symptoms progressed?  How many episodes? Duration/Frequency?
    • Acute onset and rapidly developing headache is more likely to be sinister
  • Exacerbating factors: photophobia; phonophobia; movement; lying down/standing
  • Relieving factors: lying down/standing up; drugs (paracetamol/NSAIDs)
  • Severity
• Associated Symptoms:
  • Nausea & Vomiting
  • Neck pain/stiffness
  • Fever
  • Double vision
  • Photophobia
  • Rash
  • Tender temporal artery/Jaw pain
  • muscle pain
  • altered level of consciousness
  • other neurological problems

RED FLAG SYMPTOMS: 
SUPER-ACUTE ONSET (Subarachnoid haemorrhage; cerebral venous sinus thrombosis; meningitis)
FOCAL NEUROLOGICAL SYMPTOMS (other than typical of migraine): Intracranial mass lesion (vascular, neoplastic, infective)
CONSTITUTIONAL SYMPTOMS (e.g. weight loss; malaise; pyrexia; meningism; rash): Meningoencephalitis; neoplasia; inflammatory e.g. vasculitic
FEATURES OF RAISED INTRACRANIAL PRESSURE (e.g. worse on wakening/lying down, associated vomiting, papilloedema): Intracranial mass lesion
NEW ONSET AGED >60 YEARS: Temporal arteritis

• Other Hx e.g. PMHx, RHx, FHx, SHx
• Ideas, concerns and expectations

Examination

Most cases can be diagnosed either on history alone or with investigation, but examination is rarely a big part of dealing with cases of headaches.

see Cranial Nerve Examination and other neurological examination may be required.  Fundoscopy is of importance if worried about increased intracranial pressure (papilloedematous optic disc).

Causes

• Primary Headache Syndromes
  • Migraine
  • Tension-type Headache
  • Trigeminal autonomic cephalalgia (including cluster headache)
  • Primary stabbing/coughing/exertional/sex-related headache
  • Thunderclap headache
• Secondary causes
  • Medications
  • Intracerebral bleeding e.g. in subdural, subarachnoid or intracerebral haemorrhage
  • Raised intracranial pressure e.g. brain tumour, idiopathic intracranial hypertension
  • Infection e.g. meningitis, encephalitis, brain abscess
  • Inflammatory diseases e.g. temporal arteritis, other vasculitides
  • Referred pain e.g. from orbit, TMJ, neck

A note about facial pain

• Can be due to a number of problems
  • Sinusitis is a common cause of transient facial pain (rarely persistent)
  • TMJ joint/dental issues
  • Trigeminal neuralgia- bouts of brief (seconds) lancinating/electric shock type pain, commonly in the V2/3 distribution and elicited by talking/chewing
  • Herpes zoster- most common V1; pain usually precedes the rash but the pain can often persist long after resolution of the rash (post-herpetic neuralgia- conitnuous burning pain)

Anxiety

Presented with an anxious patient:

A good way of taking a history is using SEDATE:

• Symptoms
  • Physical (increased autonomic response, hyperventilation, sweating, palpitations, loss of sleep/memory/concentration)
  • Psychological (Agitation, irritable)
  • Fear
• Episodic/continuous
• Depression, drinking, drugs (including caffeine and smoking)
• Avoidance/Escape
• Triggers and timing
• Effect on life

To Differentiate between:

• GAD– persisten, no phobic stimulus, must be present for at least 6 months
• PTSD– symptoms >1 month after traumatic incident, at least lasting 1 month
  • Trauma
  • Re-experiencing: flashbacks, nightmares
  • Avoidance
  • Hyperarousal e.g. hypervigilance
  • Blunting of affect
• OCD– unwanted obsessions, compulsions, INSIGHT
  • Compulsion should interfere with life for >1hr /day
  • Takes an average of 9 years from onset to Dx and a further 9 years on average to successfully treat
• Phobias- create fear -> result in avoidance
  • Agoraphobia, simple phobia, social phobia
  • specific stimulus, panic only lasts during that time
  • cannot be reasoned away
• Panic disorder- discrete episodes, extreme, symptoms for >1 month
  • Often described as ‘fear of fear’
  • Avoidance, drug abuse

Good questions:

• Are you troubling by any recurrent worrying thoughts?
• Has something happened to you recently to trigger these thoughts?(PTSD)
• Do these thoughts cause you troubling sleeping?
• Do you have recurrent or unexpected panic attacks?
• Are you worries about a significant change in behaviour duringthese attacks?
• Do you avoid certain activities (e.g. meeting people,eating/speaking in public?)
• Have you had the feeling that things around you were not real(derealisation)?
• Have you yourself felt unreal/ not living in the world?(depersonalisation)

Consider also asking about suicide if appropriate.

 

Mental State Examination

• Appearance
  • May be a bit unorganised/dishevelled
• Behaviour
  • May seem irritable, may be fidgeting
  • Hypervigilance, hyperalert
• Speech
  • May have increased rate of speech, reduced volume
• Mood
  • May be low, may be irritable
• Affect
  • May be blunted (PTSD) or expansive (during a panic attack). 
• Thought process
  • May have a racing thought process (possibly flight of ideas)
  • May have obsessions (OCD)
• Insight
  • Almost always preserved unless associated with psychosis

NB Anxiety as a primary disorder rarely presents with disorders of perception (hallucinations/illusions/delusions).  However, anxiety may present secondary to a psychosis or delirium in which these features may be present.

Vaginal Bleeding in Pregnancy

When presented with vaginal bleeding in pregnancy, there are several important things to enquire about:

• Gestation:
  • If the pregnancy is <24 weeks gestation, bleeding is technically described as miscarriage
    • If painless, closed cervix and only a little bleeding: likely threatened miscarriage
    • If painful, more blood and open cervix: more likely inevitable, incomplete or complete miscarriage depending on the location of the products of conception
  • If the pregnancy is >=24 weeks gestation, this is technically antepartum haemorrhage
    • If painless (relatively), fresh bleeding with high presenting foetus: likely placenta praevia or vasa praevia
    • If painful, dark blood: more likely placental abruption
• Blood loss
  • How much?  Colour?  Clots?
• Associated symptoms
  • Pain/cramps?  Nausea?
• Other Hx
  • Trauma?  Pre-eclampsia?  Obstetric Hx.  Hx of antenatal checks.

Examination of the pregnant abdomen

Bimanual Examination

Bimanual Examination

NB Because of the nature of this exam, you should ALWAYS have (not just offer) a chaperone present, whoever this may be.  Also, bimanual examination is contraindicated in placenta praevia.  The only time when these rules are not adhered to is in the emergency situation.

Getting started

• Wash your hands, introduce self, check patient name and DOB, inform patient of what you are about to do and gain consent.
• Make sure a chaperone is present
• Let the patient undress, and offer her something to cover herself e.g. a gown or sheet or even a piece of bed paper
• Position the patient so that her knees are bent and spread apart, and her feet together
• Put on gloves

Inspection

• Look at the vulva for any signs before separating the labia with your thumb and forefinger.  Look at the vaginal introitus and the urethra.
  • Any discharge? inflammation? atrophy? ulceration? swelling (Bartholin’s glands)?
  • Ask the patient to cough/valsava manouvre and look for prolapse and/or stress incontinence

NB You should always perform a cervical swab/speculum examination (should it be required) before a bimanual examination.

Palpation

• Make sure you put some lubrication on your index finger.  Insert it into the vagina, looking to see if the patient is in any pain or discomfort.  If this is the case, only use this finger to examine her.  If she is ok, try also inserting your middle finger to better examine her.
• Feel for the cervix at the upper vagina.  Often described as feeling like the end of the nose.  Note any cragginess, tenderness on movement (cervical excitation- sign of infection) and any masses.
• With your fingers behind the cervix and your other hand flat over and just above the symphysis pubis, ballot the uterus between your hands.  If the uterus is retroverted, this may be difficult.
• With your pelvic hand in a lateral fornix and your abdominal hand on the ipsilateral lower abdomen, try to do the same with the adnexae (tubes and ovaries).  This is mainly to look for anytenderness or large masses/cysts (normal adnexae are not usually felt).

After the exam

• Make sure that there is no blood on your examining hand.
• Offer the patient tissues (should she need them) and draw the curtain to allow her to dress.
• Dispose of gloves (orange bin), wash hands.
• Thank the patient and discuss any findings.

A note about bimanual examination in pregnancy- determining effacement/dilation

• In pregnancy, bimanual examination is of particular use to determine which stage of labour the patient is at.
• Effacementis the thinning of the cervix (estimated as a percent).  As the foetal head descends into the pelvis and lower uterus, the cervix is stretched and seems to almost retract.
• Dilation is the diameter (in cm) of the cervical os during labour.  It is normally <1cm and usually will reach 10cm (full dilation) before delivery.

See also Bishop’s score re labour- effacement/dilation.

Examination of the Pregnant Abdomen

NB The examination of the pregnant abdomen is not technically an intimate exam, and thus does not require a chaperone.  However, it is often suitable to ask if the patient has a partner/friend/family member with them whom they would like to be with them for the examination.

Intro

• Wash hands, introduce self, check patient name and DOB/CHI, explain procedure and gain consent

Before you start/General Examination:

• Does the patient look well?  Is she happy with the pregnancy?  Or is she tired/exhausted/in pain/pale etc?
  • Signs of anaemia may be seen
• Offer the patient the opportunity to empty her bladder prior to examining her.
  • You may use this sample for urinalysis.  This is important as part of the antenatal check-up routine.
• Also, you would want to check her height/weight and BP
• Have the patient lie/sit on a bed at around a 30° angle, so that she is comfortable.  Expose her abdomen and use a sheet to cover up any exposed underwear (for the comfort of the patient).

Inspection

• Look at the pregnant abdomen,
  • linea nigra (the dark line from the pubis symphysis caused by increased melanocyte activity),
  • any striae (pink- striae gravidarum; white- striae albicantes (old pregnancy)),
  • any scars (previous caesarean) or excoriations (obstetric cholestasis)
  • any distended veins (IVC compression)
  • umbilical eversion
• Ask the patient to cough to look for any hernias

Palpation

• With your left hand (if examining from the right), feel for the top of the uterus and estimate the height of the fundus from the symphysis pubis.
  • Now is a good time to measure the height with a tape measure
    • If beyond 20 weeks gestation: 1cm=1 week gestation (roughly)
• Palpate down the sides of the abdomen (you may wish to change your position as you do this i.e. start by facing the patient to feel the superior abdomen and turn to face the end of the bed to feel the inferior abdomen).  Note any tenderness, rigidity, guarding etc.
  • Feel for the landmarks of the foetal lie (head, shoulders, back) and describe the foetal lie, presenting part and orientation.
    • Lie can be longitudinal, transverse or oblique.
    • Presentation can be head first (cephalic), feet first (breech) or another part (e.g. shoulder)
    • Orientation/position refers to the direction the foetus is facing e.g. left occiput anterior (LOA) position is when the occiput faces anteriorly and to the left.
    • Also feel around the head (if presenting part) to estimate degree of engagement
      • You do this by loosely determining how many fifths of the foetal head can be palpated through the abdomen
        • 5/5 – the head is ‘floating’
        • 3/5 means the head is fixed
        • 2/5 the head is usually engaged
        • 0/5 the head is at the ischial spines
    • Also feel for the anterior shoulder (for auscultation later, but also to estimate position)
      • A shallow groove between the presenting part (head) and rest of foetus
      • usually in the right or left lower quadrants
• NB Percussion is only useful if you suspect polyhydramnios, where fluid thrill would be illicited but no shifting dullness

Auscultation

• Using a Pinard stethoscope held over the foetus’ shoulders, using your head/ear to stabilise it on the mother’s abdomen (i.e. not holding it), listen for a faint ticking sound of the foetal heart
  • normally 100-120bpm and may be slightly erratic
  • NB this is only really effective after 28 weeks gestation, before which time an US doppler scan is used

Other investigations

• It is a good idea to measure BP and take a urine sample if this has not been done already

After you have finished

Make sure you let the patient dress herself comfortably, record all findings, thank the patient and end the consultation.  Wash hands.

Nasal Congestion

I doubt that examination of the nose will be expected in an OSCE station (it is possible to ask you to inspect the external nose- for symmetry, masses, deformity etc- and to check air flow through each of the nostrils- simply close one and ask the patient to take a deep breath).  This is far more likely to be a history station.

• Introduce yourself, wash hands, check name and DOB etc
• HxPC
  • Any discharge blocking nose? (Check if watery, mucoid, purulent, bloody)
  • Chronic, recurrent, acute
  • Related to location, season, exposure
  • Foreign body?
  • Nose bleeds
• Systemic review
  • fever, facial pain (sinusitis)
  • watery, itchy eyes (allergies)
  • sore throat, malaise, fever, cough (URTI)
  • Headaches (can occur with Headaches with autonomic features)
  • Also ask about other ENT conditions/infections
• Red flags
  • Unilateral discharge, particularly if purulent or bloody
  • Facial pain, tenderness, or both
• PMHx/RHx
  • Atopy
  • Diabetes
  • Immunocomprimise
  • Decongestant/antihistamine/cortisol spray use
  • Broken nose/other trauma
  • Surgery (Facial)

Family Planning

The family wanting to get pregnant

• This is often used as a communication skills OSCE station, and involves discussion with the patient, the partner or both.
• It is important to find out the patient’s I.C.E (Ideas, concerns and expectations) on the issue
  • Remember to explore the impact of stress, low libido, fatigue, previous marriage/children, everyday responsibilities e.g. job, etc
• You should advise them:
  • Have regular intercourse (at least 2-3 times a week, particularly around the end of the second and start of the third week (of the menstrual cycle) i.e. at day 12-14)
  • They should be trying for at least 6 months before assisted conception can be considered
    • If this is the case, see Infertility treatments for information on this

NB This may be complicated by a lot of social history that will need to be addressed for family planning to be effective

Regular Contraception

For more details on specific types of contraception, see here.  You should have at least a vague idea of each, how they work, their side effects, how to use them etc

In short, there are several types of contraception:

• Barrier protection e.g. condoms, femdoms, diaphragms and caps
• Hormone (Pill) e.g. Combined oral pill, progesterone only pill
• Hormone (Injection/Implant)
• Copper coil and other IUCD

Emergency Contraception

Termination of Pregnancy