Assessing a patient with memory problems

History

• NB It is vital to get a corroborative history from a relative close friend, particularly where it is them that are more concerned about memory problems than the patient themselves.
  • It may be useful to interview them separately
  • If the patient comes alone worried about memory problems, it is often a sign that lessens the likelihood of dementia
• In general, consider the age of the patient
• Assess what the patient means by memory problems
  • Are they having trouble finding words?  Are they losing/forgetting things?  Are they getting lost?
    • i.e. is it a problem with working memory? (immediate memory)
    • is it a problem with episodic memory? (short term/anterograde or old/retrograde)
    • is it a problem with semantic memory? (word meaning and general knowledge)
    • is it a problem with implicit memory? (learned/automatic responses- can be complex tasks e.g. driving, or more simple ones e.g. dressing)
  • What sort of problems is this causing? (impact on life)
• Take a history of PC
  • Onset
    • Particularly- any triggers such as adverse life events
      • Depression is not an uncommon cause of memory problems- important to ask about mood and other associated symptoms e.g. sleep
  • Tempo/progression
    • Have things been deteriorating?  Are the problems constant or are there particular times of day when things are worse (sunset- ‘sundowning’)
    • Is there a step-wise progression?
  • Impact on work/family and any issues about safety e.g. driving/cooking, or self-care/hygiene e.g. shopping
  • Ask about associated symptoms/features
    • Mood, enjoyment in activities, personality changes, psychotic symptoms etc
    • Appetite and sleep changes
    • Walking or balance problems
    • Anorexia, weight loss, incontinence, change in bowel habits
    • Any changes in consciousness
• Past medical history
  • Detailed medical and drug history (including compliance) are very important, particularly in identifying an iatrogenic cause (drug induced problems)
    • Vascular disease e.g. TIA/stroke, hypertension, ischaemic heart disease
  • Past psychiatric history
• Family history
  • e.g. Alzheimer’s disease
• Social history
  • Are they living alone (in own home or another residence)?
  • Do they have any routine?
  • Alcohol consumption (past and present)?

Examination

• Cognitive testing (most commonly tested using Mini-mental state examination ©– good screening tool)
  • Orientation (time, place, person)
  • Attention
  • Memory
  • language
  • executive function
  • praxis e.g. hand movement/coordination
  • visuaspatial function
• If there is concern over whether the memory problems are associated with delirium, the patient can be screened for features (e.g. 4AT score)
• For a thorough assessment, the Addenbrookes cognitive assessment (ACE) is a more in depth assessment used for the formal diagnosis of dementia
  • see here for ACE example along with other forms of cognitive tests
• Perform a routine physical exam to note any signs which may suggest a treatable underlying cause

Investigations

• Imaging
  • CT scan of the brain is usually done in all patients to rule out an organic cause of confusion/dementia
  • SPECT/PET/MRI imaging is becoming more useful at diagnosing different types of dementias e.g. fronto-temoral
• Blood tests
  • B12, TFTs

Differential Diagnosis

• Dementia (of which there are differentials within this)
• Delirium
• IMPORTANT TO RULE OUT OTHER POTENTIALLY TREATABLE CAUSES OF COGNITIVE IMPAIRMENT
• 

Counselling about Down’s syndrome in pregnancy

Intro

• Wash hands, introduce self, check patient name and DOB, explain role/interview and gain consent

Check situation

• History of the current pregnancy
  • Was it planned?
  • When was the LMP? or How far along are you?
  • Are you wanting to keep the pregnancy?
  • Have there been any problems during this pregnancy so far e.g. bleeding, pain etc?
  • What is the social situation?
    • NB Ideally, the partner would also be present.  Check whether the partner is involved/supportive if not
    • Are you working?  Who’s at home with you?  (social support etc)
• At this point it would also be a good idea to take a full obstetric history (previous pregnancies) +/- gynaecological history (as appropriate)

Check understanding

• What do you know about Down’s syndrome and how it can be tested for?

Explain the tests

• If <14 weeks
  • Combined test
    • Nuchal translucency (more fluid between body and neck in DS)
      • Measured at scan
    • β-HCG (low in Down’s)
    • PAPP-a (Pregnancy associated plasma protein alpha)
    • Woman’s age
• If >15 weeks
  • Triple
    • Maternal AFP; unconjugated oestriol and β-HCG
  • Quadruple
    • +Inhibin A
• These are used to calculate the chance of having Down’s syndrome
  • If >1/250, this is ‘positive’
    • Further diagnostic tests used
      • ONLY if the patient is considering TOP (often risk of these procedures outweighs their benefits where this is not the case)
• Invasive tests
  • If <15 weeks- chorionic villous sampling (risk of abortion 2%)
  • If >15/16 weeks- amniocentesis (risk 1%)

Explain about Down’s

• People with Down’s syndrome often have characteristic appearance (e.g. low set ears and wide-set eyes); they also quite often have mild learning disabilities (although IQ is often >80).
• Also associated with some serious heart defects
  • May cause problems early or later in life
  • Can be treated surgically but often a large operation
• There is an increase in mortality in the first year of life (five times increased risk- NB STILL SMALL absolute risk of ~1%)
• Most will now live into late 50s-60s
• There are many services available to help with care (both health and social)
• Answer any questions the patient may have as they ask them.  Give time after chunks of information to do this.

Abortion/TOP and Down’s

• As with other TOPs, a reason must be specified.  In the case of possible Down’s pregnancy, the category is
  • “to prevent grave permanent injury to the physical or mental health of the pregnant woman”

Examination of the Eye

Intro

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

Inspection (as with every other examination!!)

• General: look at the patient and their surrounding (e.g. glasses, walking aids, blind stick, a guide dog!)
• Eye
  • Pupil size and symmetry; strabismus (squint); ptosis; proptosis; sclera/conjunctiva (e.g. redness); surrounding structures (lids, nose etc for scarring, lesions, rash); pus; discharge; swelling etc

AFROES

Acuity

• Without glasses: test acuity one eye at a time using
• Snellen chart (distance vision);
  • NB record findings as distance/smallest size type e.g. 6/9.  If the patient is unable to see the largest letter, try counting fingers or reducing the distance.
• text book (close vision);
• Ishihara plates (colour vision)

Fields

• Visual inattention
  • With both the patient’s eyes open and focused on your eyes (at level, about 1m away), hold your fists out to either side (at equal distance to you and patient) and wiggle the finger of one hand.  Ask the patient to identify which side was active.
• Field testing
  • In the same position, ask the patient to cover one eye whilst you cover your ipsilateral eye (i.e. same side).
  • With the patient focused on your eye, bring a pin/your finger in from the periphery (test four corners- make sure to maintain equal distance from yourself and the patient).  Ask the patient to say when they see the pin/finger (should be similar to your own sight).
    • Test both eyes
• Blind spot test
  • In the same position, testing one eye at a time with the patient focused on yours, hold a red pin midway between your open eyes and move it peripherally/horizontally until they say it disappears.  Map out the area of the blind spot (should be similar to your own).
    • (large blind spots may be a sign of papilloedema)

Reflexes

• Accommodation: ask the patient to focus on your finger about a metre away.  Bring your finger close to the patient’s face and watch for eye convergence and pupillary constriction
• Direct and consensual light reflexes: In a dimmed room, as the patient to focus on a distant point.  Shine a light into each eye and look at the ipsilateral (direct) and contralateral (consensual) pupil for constriction
  • Afferent defect (CN2): pupils are symmetrical at rest but when light is shone in affected eye- neither eyes constrict.  When light is shone in contralateral eye, both constrict
  • Efferent defect (CNIII): pupils are asymmetrical at rest (affected eye permanently dilated throughout, whereas non-affected eye will respond to light being shone in either eye)
• Swinging light test
  • Test for relative afferent (i.e. CNII) pupillary defect by swinging light between eyes.  Both should remain constricted but will dilate when light is shone in affected eye

Ophthalmoscopy

• Preparation
  • Dim lights
  • Consider mydriatic drops (e.g. tropicamide)
• Red reflex
  • Ask the patient to focus on a distant point
  • Look at the patient’s eyes through the scope from 1m away
    • The eyes should ‘flash’/reflect red/orange
    • Loss of red reflex suggests cataract (or rarely, in children, retinoblastoma)
• Through the eye
  • With your contralateral hand on the patients forehead (for support), hold the scope in the ipsilateral hand (i.e. right eye, right hand)
  • Set the focus wheel to 10 and look at the eye from 1m away
  • Approach the eye from the side and above
  • Once the front of the eye comes into focus, move closer to the eye and turn the wheel down (keeping the front of the eye in focus)
  • Once close to the eye, rotate the wheel further- the focus will move through the eye until the retina comes into focus
    • Comment on any findings if relevant (NB In most OSCE and clinical scenarios, the slit lamp is much better at looking at the anterior segment of the eye and is generally preferred)
• Locate the following structures
  • Optic disc
    • Comment on cup size, colour, contours
  • Track the 4 retinal artery branches to look at the 4 quadrants of the eye
    • This may be made easier by asking the patient to look in a certain direction
  • Look for signs of
    • Hypertensive retinopathy e.g. silver wiring, AV nipping, cotton wool spots, papilloedema
    • Diabetic retinopathy e.g. microaneurysms; dot/blot haemorrhages, cotton wool spots, neovascularisation, fibrotic changes)
    • Drusen
    • Pigmentation
    • NB In an OSCE, the model may have a letter on the fundus for you to identify.
  • Macula
    • Ask the patient to look directly into the light (should be pink)

Extra-ocular muscles

• Check eye movements (H-test)
  • Failure to move the eye laterally (CN6 palsy)
  • Failure to move the eye inferomedially (CN4 palsy)

Strabismus

• Perform cover tests for strabismus

Finish

• Thank patient, wash hands
• Explain/record findings
• Suggest any further investigations/management

Upper limb

Bones

• Clavicle
  • Connect trunk (sternoclavicular joint) to upper limb (acromioclavicular joint)
  • Medial 2/3 convex anteriorward and arches anterior to brachial plexus and subclavian vessels
    • Also attachment for costoclavicular ligament and subclavius (attach to 1st rib) (muscle pulls the clavicle down; ligament resists downward movement)
  • Lateral 1/3 concave anteriorward and flattened.
    • Also attachment of coracoclavicular ligament (attach to coracoid process) (keeping clavicle in place resisting upward movement)
  • First bone to begin ossification
• Scapula
  • Connects the clavicle to humerus, resting on the superior part of the posterolateral thorax
  • The dorsal surface is divided by a spine- with a supraspinatous fossa above and an infraspinatous fossa below
  • The trapezius and deltoid attach to the crest of the spine
• Humerus
  • Articulates with the scapula at the glenoid (shoulder) and the radius and ulna
  • Proximal end consists of head, anatomical neck (the surgical neck is different- where the superior part meets the shaft- the axillary nerve lies in contact with this), and greater and lesser tubercles (separated by intertubercular groove)
    • The greater tubercle projects laterally beyond the acromion and is covered by the deltoid
    • The lesser tubercle projects anteriorly
    • The intertubercular groove provides origin for the tendon of the long head of the biceps
  • The deltoid muscle inserts into the deltoid tuberosity on the anterolateral surface of the shaft near the middle
  • The radial nerve runs inferiorward and lateral on the posterior surface in a groove of the humerus
  • Distal end consists of lateral and medial epicondyles separated by capitulum and trochlea
    • The lateral epicondyle gives origin to supinator and extensor muscles
    • The capitulum articulates with the head of the radius
    • The trochlea is a pulley-shaped projection that articulates with the ulna (trochlear notch of ulna)
    • A deeper olecranon fossa is located posteriorly and superiorly
    • The medial epicondyle gives origin to the flexor muscles of the forearm
      • The ulnar nerve lies in a groove posterior to the medial epicondyle (funny bone)
• Radius
  • Proximal end articulates with humerus, medial aspect with the ulna and distally with the carpi bones
  • Proximal end consist of head, neck and tuberosity.  Articulates with the capitulum of the humerus
  • The medial (interosseus) surface of the shaft connects with the lateral (interosseus) surface of the ulna via an interosseus membrane
  • Distal end consists of styloid process laterally- gives attachment to radial colateral ligament of the wrist; and ulnar notch medially which articulates with the ulna
• Ulna
  • Longer and medial to radius; and articulates with the humerus proximally, radius laterally and articular disc distally
  • Proximal end includes olecranon and coronoid process.
    • Olecranon is prominence of the elbow.  The superior part receives insertion of the tendon of the triceps.  The anterior part forms part of the trochlear notch, articulating with the humerus.
    • The coronoid process completes the trochlear notch and also forms a radial notch laterally for articulation with the radius
  • Distal end includes the styloid process and the head
    • Styloid process is posteromedially
    • The head articulates with the ulnar notch of the radius and the inferior aspect articulates with the articular disc (separating from the carpi)
• Carpal Bones
  • Mnemonic (from lateral to medial, proximal row first then distal row)
    • “Some lovers try positions that they can’t handle”
      • Scaphoid
      • Lunate (articulates with radius)
      • Triquetrum
      • Pisiform
      • Trapezium (articulates with the first (thumb) MC)
      • Trapezoid
      • Capitate (largest- articulates with 3rd MC)
      • Hamate (gives attachment to flexor retinaculum)
    • NB the trapezium and scaphoid make up the floor of the anatomical snuff box- the radial artery crosses it

Veins

• Superficial
  • Variable but two large superficial veins can usually be found in most- the cephalic and basilic
    • Cephalic vein begins posterior to the styloid of the radius, winds anteriorly around the lateral border of the forearm, reaches the antecubital fossa lateral to the elbow, ascends laterally to the biceps, then in the groove between the deltoid and pectoralis major and drains into the axillary vein
    • Basilic vein curve anteriorly round the medial border of the forearm up to the medial epicondyle, ascends medial to the biceps, pierces the fascia and accompanies the brachial artery to the axilla, where it joins the brachial veins and becomes axillary vein
  • In the cubital fossa, they are often joined by via a medial cubital vein
• Deep 
  • Largely accompany arteries

Arteries

• In order (proximal to distal)-
  • Subclavian, axillary and brachial
    • Subclavian arches above the first rib to become the axillary.
      • The axillary apex is the interval between the clavicle, superior border of scapular and external border of the 1st rib.  The axillary vessels/nerve pass through this
      • Pec minor crosses the axillary, dividing is into 3 (medial, posterior and lateral)
    • At the base of the axilla (inferior border of teres major), the axillary becomes the brachial.
      • NB the brachial artery supplies the deep flexor muscles of the forearm (injury results in flexion deformities)
  • Immediately distal to the elbow, the brachial divides into radial and ulnar arteries
    • the radial artery lies lateral to the flexor carpi radialis tendon and can be readily palpated at the wrist here.

Nerves

• Arise from brachial plexus (posterior triangle of neck, under the clavicle with the axillary artery under the pec major in the axilla- C5-T1)
• Divides into
  • Trunks
    • Upper (C5, 6- flexion)
    • Middle (C7- pronation and supination)
    • Lower (C8, T1- extension)
  • Trunks-> cords
    • Upper and middle anterior divisions form lateral cord (in relation to axillary artery)
    • Lower anterior division forms medial cord
    • Posterior divisions from all trunks forms posterior cord (supplies the dorsal arm)
  • Cords -> branches
    • Lateral cord
      • Musculocutaneous (C5-7)
        • Pierces corachobrachialis; may carry all or part of the lateral head of the median nerve
        • Supplies flexor muscles (biceps, coracobrachialis and brachialis) of the anterior arm and the skin on the lateral forearm
        • Terminates as the antebrachial cutaneous nerve
      • Median (C6-T1)
        • Arises from both lateral and medial cords (lateral and medial heads of median nerve)
        • Supplies flexors and pronators in the forearm, most of the thumb muscles and skin of the lateral (radial) hand
        • Doesn’t give off any branches in the arm, but crosses anteriorly and descends medially before entering the forearm in the antecubital fossa between the heads of pronator teres muscle and descends between the bones of the forearm until it reaches the styloid processes where it moves anteriorly between the flexor digitorum superficialis (medially) and flexor carpi radialis (laterally).  It enters the hand through the ‘carpal tunnel’ posterior to the flexor retinaculum and anterior to the flexor tendons.
    • Medial cord
      • Ulnar nerve (C7-T1)
        • Supplies some of the flexor muscles of forearm, short muscles of the hand and skin of the ulnar and dorsal aspect of the hand
        • The ulnar nerve does not give off any branches in the arm but enters the forearm between the heads of the flexor carpi ulnaris at the posterior surface of the medial epicondyle.  It travels down the medial forearm towards the hamate/pisiform.  It lies between the flexor digitorum superficialis (laterally) and the flexor carpi ulnaris (medially) and passes anterior to the flexor retinaculum
    • Posterior
      • Axillary (C5,6)
        • Transverses through the quadrangular space between the long and lateral heads of the triceps
        • Anterior branch winds around the surgical neck of humerus and supples deltoid
        • Posterior branch supplies teres minor and deltoid and becomes the upper lateral brachial cutaneous nerve (supplying the ‘badge-patch’ area of skin over the lateral upper arm)
      • Radial (C5-T1)
        • Continuation of posterior cord
        • Spirals round posterior aspect of humeral shaft under the long and lateral head of triceps, deep into the antecubital fossa between the brachioradialis and brachialis muscles.  At the antecubital fossa it divides into deep and superficial branches, the former supplying cutaneous innervation to the dorsum of the hand and the latter winds round the radius between layers of supinator close to the radius (can be injured) to supply posterior muscles of the forearm as the posterior interosseus nerve
        • Supplies the extensors and supinators of the posterior arm and forearm and the skin on the posterior arm, forearm and over the anatomical snuffbox of the hand

Muscles of the Shoulder/Axilla

• Upper limb connected to the trunk ventrally by
  • Pectoralis major
    • Origin: Medial half of clavicle (head); anterior sternum; costal cartilages; aponeurosis of external oblique
    • Insertion: Lateral lip of intertubercular groove of the humerus
    • Innervation: Lateral and medial pectoral nerves (from lateral and medial cords of plexus, respectively; C5, 6 and 7, and C8 and T1, respectively)
    • Action: Arm adductor
  • Pectoralis minor
    • Origin: Ribs 2-5
    • Insertion: Coracoid process (scapula)
    • Innervation: medial and lateral pectoral
    • Action: adducts and depresses shoulder
  • Subclavius
  • Serratus anterior
    • Origin: Ribs 1-8
    • Insertion: Costal aspect of the superior, medial and inferior angles/borders of the scapula
    • Innervation: Long thoracic nerve (C5-7)
    • Action: rotates scapula (paralysis causes ‘winging’)
• Muscles of the back
  • Latissimus dorsi and trapezius (also levator scapulae and rhomboid muscles)
    • Trapezius
      • Large, superficial triangular muscle
      • Origin: Spines of cervical vertebrae (C7,8) and thoracic vertebrae T1-12
      • Insertion: Lateral third of clavicle, acromion and spine of scapula
      • Innervation: CNXI and C3,4
      • Action: Elevates shoulder and retracts and rotates scapula
    • Latissimus dorsi
      • Origin: Spines of T7-12; iliac crest; lower ribs and inferior angle of scapula
      • Insertion: intertubercular groove of humerus
      • Innervation: thoracic nerves
      • Action: Adducts and extends arm
• Muscles of the shoulder
  • Deltoid
    • Origin: Lateral third of clavicle, acromion and spine of scapula
    • Insertion: deltoid tuberosity of humerus
    • Innervation: Axillary nerve (posterior cord: C5/6)
    • Abducts arm (30-120°)
  • Supraspinatous
    • Origin: Supraspinatous fossa of scapula
    • Insertion: greater tubercle of humerus
    • Innervation: suprascapular nerve (C3-4)
    • Action: abducts arm (0-30°)
  • Infraspinatous
    • Origin: infraspinatous fossa
    • Insertion: greater tubercle
    • Innervation: suprascapular nerve
    • Action: Externally rotates shoulder
  • Teres minor
    • Origin: Lateral part of dorsal surface of scapula
    • Insertion: Greater tubercle
    • Innervation: Axillary nerve (C5/6)
    • Action: external rotation
  • Teres major (NB divided from teres minor by the long head of the triceps, which forms a triangular space medially (subscapular artery space) and quadrangular space medially (posterior circumflex humeral artery and axillary nerve space)
    • Origin: Dorsal inferior angle of scapula
    • Insertion: Medial lip of intertubercular groove of humerus
    • Innervation: Lower subscapular
    • Action: Adducts arm
  • Subscapularis
    • Origin: Subscapular fossa of scapula
    • Insertion: Lesser tubercle
    • Innervation: Subscapular (upper and lower: c5/6)
    • Action: Internal rotation

Muscles of the Arm

• Biceps, coracobrachialis and brachialis (musculocutaneous nerve); Triceps (radial nerve)
  • Separated (anterior and posteriorly) by intermuscular septa
• Biceps brachii
  • Origin: Supraglenoid tubercle of scapula (long/lateral head) and tip of coracoid process (short/medial head)
  • Insertion: Tuberosity of radius, fascia of forearm, and ulna (bicipital aponeurosis)
    • NB the brachial artery and median nerve lie medial to the biceps tendon in the cubital fossa
  • Innervation: Musculocutaneous (c5-7)
  • Action: Flexes arm and supinates forearm
• Coracobrachialis
  • Origin: Tip of coracoid process
  • Insertion: medial border of humerus
  • Innervation: musculocutaneous (pierces the muscle)
  • Action: assists in flexion
• Brachialis
  • Origin: Anterolateral (next to deltoid insertion) and anteromedial surfaces of humerus
  • Insertion: Front or coranoid process and tuberosity of ulna
  • Innervation: musculocutaneous
  • Action: Flexes forearm
• Triceps brachii
  • Origin: Infraglenoid tubercle of scapula (long head) and posterior surfacne of humerus (lateral and medial heads)
  • Insertion: Upper surface of olecranon and fascia of forearm
  • Innervation: Radial (C5-T1)
  • Action: extends forearm

Muscles of the Forearm

• Split into 2 compartments: ventromedial or flexor (anterior), and dorsolateral or extensor (posterior)
• NB Most of the anterior superficial group arise from common flexor tendon (medial epicondyle) and most of the posterior superficial group arise from common extensor tendon (lateral epicondyle)
• Anterior (superficial)
  • Pronator teres
    • Origin: Medial supracondylar ridge and coranoid process of ulna (deep head)
    • Insertion: lateral surface of radius
    • Innervation: Median (C6-T1)
    • Action: Pronates and flexes forearm
  • Flexor carpi radialis
    • Origin: medial epicondyle
    • Insertion: bases of 2/3rd MCs
    • Innervation: median
    • Action: Flexes and abducts hands
  • Palmaris longus
    • Origin: Medial epicondyle
    • Insertion: Flexor retinaculum and palmar aponeurosis
    • Innervation: median
    • Action: hand flexion
  • Flexor carpi ulnaris
    • Origin: Medial epicondyle and olecranon
    • Insertion: pisiform, hamate and 5th MC
    • Innervation: Ulnar (C7-T1)
    • Action: Flexes and adducts the hand
• Intermediate
  • Flexor digitorum superficialis
    • Origin: Medial epicondyle and anterior border of radius
    • Insertion: Middle phalanges of digits 2-5
    • Innervation: Median
    • Action: Flexes middle fingers
• Deep
  • Flexor digitorum profundus
    • Origin: Front of ulna and interosseous membrane
    • Insertion: distal phalanges of digits 2-5
    • Innervation: Anterior interosseous (median)
    • Action: Flexes distal phalanges
  • Flexor pollicis longus
    • Origin: Front of radius and interosseous membrane
    • Insertion: Distal phalanx of thumb
    • Innervation: anterior interosseous
    • Action: Flexes distal phalanx of thumb
  • Pronator quadratus
    • Origin: Front of distal ulna
    • Insertion: Front of distal radius
    • Innervation: anterior interosseous
    • Action: pronates forearm
• Posterior (superficial)
  • Brachioradialis
    • Origin: Lateral supracondylar ridge
    • Insertion: Lateral distal radius
    • Innervation: radial
    • Action: Flexes forearm
  • Extensor carpi radialis longus
    • Origin: Lateral supracondylar ridge
    • Insertion: Base of 2nd MC
    • Innervation: Radial
    • Action: Extend and abducts hand
  • Extensor carpi radialis brevis (NB common site for ganglion formation)
    • Origin: Lateral epicondyle
    • Insertion: Bases of 2/3rd MC
    • Innervation: Radial
    • Action: Extends and abducts hand
  • Extensor digitorum
    • Origin: Lateral epicondyle
    • Insertion: Middle and distal phalanges of 2-5
    • Innervation: Deep branch of radial
    • Action: Extends proximal phalanges
  • Extensor digiti minimi
    • Origin: Lateral epicondyle
    • Insertion: Extensor expansion of 5th finger
    • Innervation: deep branch of radial
    • Action: Extends proximal phalanx of 5th finger
  • Extensor carpi ulnaris
    • Origin: Lateral epicondyle and posterior border of ulna
    • Insertion: base of 5th MC
    • Innervation: deep branch of radial
    • Action: extends and adducts hand
  • Anconeus
    • Origin: Lateral epicondyle
    • Insertion: olecranon
    • Innervation: radial
    • Action: stabilise elbow
• Deep
  • Supinator
    • Origin: lateral epicondyle
    • Insertion: Upper third of radius
    • Innervation: Deep branch of radial
    • Action: supinates forearm
  • Abductor pollicis longus
    • Origin: Interosseous membrane, radius and ulna
    • Insertion: Base of 1st MC
    • Innervation: Posterior interosseous (deep branch of radial)
    • Action: Abducts 1st phalanx
  • Extensor pollicis brevis
    • Origin: Interosseous membrane and radius
    • Insertion: proximal phalanx of thumb
    • Innervation: posterior interosseous
    • Action: Extends thumb
  • Extensor pollicis longus
    • Origin: Interosseous membrane and ulna
    • Insertion: Distal phalanx of thumb
    • Innervation: Posterior interosseous
    • Action: Extends distal thumb

Hip Examination

Intro

• Wash hands, Introduce self, Check patient name and DOB/CHI, Explain procedure and gain consent

Look

• General: age, mobility, mobility aids, trauma etc
• Standing:
  • Posture, asymmetry, muscle wasting, scars, deformity (also look at the back for scoliosis and the gluteal muscles
  • Trendelenburg’s test
    • Look at the patient’s ASIS and ask them to stand on one leg (you may want to be ready to support them)
    • Normally the gluteals will contract so that the contralateral (unsupported) leg rises to balance.  If the contralateral side dips, the abductor muscles are weak on the side they are standing.
• Gait:
  • Speed, limp, arm swing, abnormal gaits e.g. Trendelenburg (wide-based waddle); antalgic
• Lying
  • Look at leg length, comparing symmetry and rotation, scars, sinuses, skin changes etc
  • Measure apparent (xiphisternum/umbilicus to medial malleolus: if unequal, spinal or pelvic problem) and true leg length (from ASIS to medial malleolus: if unequal, true limb shortening e.g. fracture)

Palpate/Feel

• Start on normal side
• Bony landmarks (where possible) e.g. greater trochanter, ASIS, pubic rami
• Temperature and skin etc

Move

• Do all movements actively (except rotation) then passively
• Test leg movement roughly by rolling the legs gently on the bed
• Flexion (130°); (NB Extension is not routinely tested on the couch);
• Test Abduction (45°) and adduction (30°)
  • NB Abduction/adduction is not always tested actively
• Test Internal rotation passively by flexing the hip and knee to 90° and rotating the leg so that the knee points inwards (vice verse for external rotation)
  • Internal rotation lost early in osteoarthritis

NB Some practitioner’s will still perform Thomas’ test for fixed flexion deformity.  However, in Tayside, at least, it is becoming less routine and is no longer part of the hip examination.

Knee Examination

Intro

• Wash hands, Introduce self, Check patient name and DOB/CHI, Explain procedure and gain consent

Inspection

• General: patient; mobility aids
• Gait: any antalgic gait, limp, locking knee
• Standing: alignment, varus/valgus deformity, swelling, redness, asymmetry
• Lying: skin (scars, swelling, bruising); joints (effusion, nodules, psoriasis/skin changes); alignment and position
• Measure quadriceps bulk (hand’s breadth above the patella) (NB not always performed)

Feel

• Skin- temperature
• Joint
  • with the knee at 90° flexion, feel the patella, along the joint line
  • note any tenderness, synovial thickening etc
  • also feel for any abscesses/popliteal bursitis
• Effusion
  • Patellar tap
    • Empty the suprapatellar pouch with one hand and push down on the patella with one/two finger(s) of the other hand (positive if the patella sinks before hitting the femur)
  • Cross fluctuation may be performed if there is a large effusion
    • Empty the suprapatellar pouch with the other hand below the patella.  Positive if the pressure/ripple is felt with either hand with alternating compressions
  • For smaller effusions (more common) the bulge test is performed
    • ‘Sweep’ the fluid out of the patella bursa, beginning infero-medially and moving superiorly (superomedial aspect); the repeat laterally beginning superiorly and ending inferiorly.  Positive it there is a ‘bulge’ on the medial side after emptying when the lateral side is swept.

Move

• NB Good to compare with the non-affected knee- test active and passive movements (palpating the joint with passive movement)
  • Flexion (normal 140°) and Extension (normal 0°) (also lift the foot off the bed and look for any hyperextension (normal up to 10°))
• Special tests
  • Collateral ligament stress tests
    • Hold the ankle/lower leg in one arm, and, with the knee at 0 and 30° flexion, apply varus (LCL) and valgus (MCL) stresses
    • Excessive movement suggests tear
  • Cruciate ligaments
    • Drawer test
      • With the knee flexed at 90° and the foot on the bed (often useful to sit on the patient’s foot to support it), with your fingers in the popliteal fossa and thumbs on the tibial tuberosity, apply anterior (ACL) and posterior (PCL) forces on the tibia
    • Lachman’s test
      • with the knee slightly flexed, one hand supporting the thigh, pull the calf anterior (ACL laxity)
  • Menisci
    • McMurray’s test
      • Flex the knee as much as possible, externally rotate the foot, apply a lateral force to the knee and extend the leg (med meniscal stress)
      • Flex the knee, internally rotate and apply a medial force and extend the leg (lat meniscal stress)
    • Apley’s manoeuvre (rarely done in practice)
      • With the patient prone (on front); apply downwards force to knee whilst flexed at 90°, and rotate the foot.
  • Patellofemoral apprehension
    • Flex the knee whilst pushing on the patella laterally

Finish

• Thank patient, wash hands,
• Document/explain findings and suggests further investigations/management

Breaking Bad News

For breaking bad news- a good method to use is SPIKES

Setting

• Make sure you have a quiet, comfortable room where you will not be interrupted

Intro

• Wash hands, Introduce self to patient, Check patient name and DOB

Perception

• Check with the patient what has happened up to know, what they know, what they understand about the investigations etc, what they expect
• If you get the impression the patient is expecting the diagnosis, try and wait until they say it out loud

“Could you tell what’s happened so far?”; “Have you had any ideas about what the problem might be?”; “Is there anything that is particularly worrying you?”

Invitation

• Check what the patient wants to know
• Also good practice to check if they have anyone with them (particularly a spouse/family member) whom they would like to know
  • these people are often most useful for the patient once they get home (also whether they have someone to take them home)

“I have the results- would you like me to explain them to you?” (Granted, this is not an ideal question, and may not be necessary if the patient has already made their feelings clear); “Would you like it if a family member/friend were present?”

Knowledge (NB this is what most of the OSCE marking schemes are geared towards as there are several skills used in this section)

• Giving the diagnosis
  • Do NOT give the diagnosis immediately – give a ‘warning shot’ e.g.

“As you know we wanted to take a biopsy.  Unfortunately the results are not good.”

 

• cont
  • PAUSE/WAIT for the patient to respond if they wish (it may be an idea to ask if they want to know again)
• Give the diagnosis in small bits of information at a time (Chunk and check)

“I’m afraid it is cancer.”

• Pause/wait again- if the patient has any thoughts/worries/questions, they will not be able to process any more information you try to give them, so give them time to voice these.
  • Answer any questions in a similar way-
  • Pause/wait after every piece of information you give
• You can give treatment and management plans (if known) if the patient requests, but do not overburden the patient with information.
• BE HONEST- If there is a question you do not know the answer too, don’t attempt to answer it blindly, but instead say that you will find out (if possible/appropriate).

Emotion/Empathy

• Acknowledge and reflect their emotions back (in a professional manner)
• DO NOT try and solve problems, or reassure the patient (NEVER give false hope BUT you can give hope within reason)
  • Summarise (ALWAYS try to acknowledge that you have heard it) and expand on their concerns
  • NB Patient’s (almost) always have concerns
• If the patient goes silent, you may ask them how they are feeling (“You’re very quiet.  May I ask what’s going through your mind?”)

Summary/Strategy/Support

• Agree on a follow up plan (may include nurse specialist)
• Summarise concerns and ask how the patient is feeling
• Express support, concern, understanding, willingness to help

Finish

• Thank the patient and wash hands

Polycystic Ovarian Syndrome

Background

• Complex endocrine disorder characterised by excess androgen, metabolic syndrome and multiple cysts in the ovary (amongst other features)
• PCOS is common
  • polycystic ovaries occur in up to a third of women of reproductive age
  • 5-7% have features of PCOS

Causes/Pathophysiology

• Unknown- multifactorial (genetic and environmental)
• Theca cells produce excess androgens (may be due to hyperinsulinaemia or increased GnRH pulsations with increased LH levels)
  • Decreased peripheral insulin sensitivity (insulin resistance) and consequent hyperinsulinaemia may be a key process in some but not all women
  • Excess adrogen stops follicular development and ovulation/menstrual cycle
  • Insulin also inhibits the hepatic production of sex binding globulin so there is more free androgen circulating in the blood
  • Increased LH also causes a relative increase in androgen production
  • NB Patients with PCOS tend also to have high oestrogen levels (testosterone converted to oestrogen and less oestrogen is opposed by follicular progesterone so can cause hyperplasia of the endometrium and associated cancer risk)

Presentation

• Suspect PCOS in women with
  • Oligo-/amenorrhoea (oligo-/anovulation) or infertility
  • Features of hyperandrogenism e.g. hirsutism, acne vulgaris after adolescence or male pattern alopecia
  • There may also be psychological features e.g. mood swings, depression, anxiety etc
• Often women also have features of the metabolic syndrome e.g.
  • Obesity (often central)
    • Sleep apnoea
  • Acanthosis nigricans
• There can be a family history

Diagnosis

• Two out of
  • Oligo-anovulation or anovulation
  • Clinical and/or biochemical signs of hyperandrogenism
  • Polycystic ovaries (12 or more follicles measuring 2-9mm in diamete in one or both ovaries and/or increased ovarian volume (>10ml))

Investigations

• Pregnancy test (amenorrhoea)
• Total testosterone (often elevated (>5nmol/l (norm 0.5-3.5nmol/l)))
  • If considerably elevated, consider also congenital adrenal hyperplasia, Cushing’s, or an androgen secreting tumour
• Sex-hormone binding globulin (low)
• => Free Androgen Index
  • (testosterone/SBG)- often high in PCOS
• Also measure LH/FSH (to rule out premature ovarian failure (increased) or hypogonadotrophic hypogonadism (low))
  • Prolactin (may be mildly elevated)
  • TSH/T4
• NB Oestrogen levels not routine
• Ovary USS (unless the diagnosis has already been made)

Management

• First line treatment is the COCP (or other hormonal contraceptive)- particularly for menstrual irregularity, symptoms of hirsutism, and acne
  • It may be sensible to induce a bleed with progestogen (medrocyprogesterone- provera) every 3-4 months to reduce the risk of hyperplasia
• Advise on lifestyle and weight management where possible/appropriate for weight management and diabetes/IGT
• Metformin can also be used first line (particularly in women wanting to conceive) for cutaneous manifestations (2nd line for weight management/diabetes/IGT after lifestyle and 2nd line for menstrual irregularity after OCT
  • DO NOT USE TZDs for diabetes/insulin resistance
• For treatment of infertility, clomiphene citrate (+ metformin) is recommended

Pelvic Organ Prolapse

Background

• Abnormal descent/herniation of one or more of the pelvic organs as a result of failure of ligamentous and fascial supports, resulting in the protrusion of the organ beyond its normal anatomical confines
• Can occur
  • Anteriorly (urethrocele, cystocele, cystourethrocele)
  • Middle/Apically (uterine, vaginal vault (post-hysterectomy), enterocele)
  • Posteriorly (rectocele)
• Can also be classed by severity
  • Stage 0- no prolapse
  • Stage 1- more than 1cm above the hymen
  • Stage 2- within 1cm of the hymen
  • Stage 3- more than 1cm below the hymen but less than 2cm away from the introitus
  • Stage 4- protrusion out of the introitus
    • Alternatively
  • 1st degree- prolapse contained within the vagina
  • 2nd degree- prolapse through the introitus
  • 3rd degree- entire uterus outside the introitus
• Common: mild prolapse can be found in up to 50% of parous women (many asymptomatic)

Risk factors

• Multiparity and vaginal child birth
• Age
• High BMI
• Others include family history, intrapartum complications e.g. macrosomia, prolonged labour, assisted labour; young pregnancy; constipation;

Presentation

• General sensation of pressure, fullness, heaviness (‘something coming down’)
  • Bulge/protrusion may be felt/seen
  • Difficulty with tampons
  • Spotting
• It is important to ask about urinary symptoms e.g. frequency, incontinence, urgency, incomplete emptying; weak flow;
  • Rarely, some need to manually reduce the prolapse prior to urination.  More commonly, some women need to change positions to empty the bladder
• Ask also about sexual difficulty including dyspareunia; loss of sensations
• Ask about any bowel symptoms e.g. constipation, urgency, incontinence, incomplete evacuation/straining, change of position etc
• On examination
  • Ideally examine standing and lying (flat and left lateral)
  • Use a Sims speculum (if available) to look at the walls of the vagina and/or a bivalve to look at the cervix/uterus
  • Ask the patient to strain/cough to exacerbate any findings
  • Ulceration may be seen on the prolapsing part

Investigations

• Usually a clinical diagnosis but some investigations may be warranted e.g.
  • in the case of urinary sx (e.g. urinalysis, residual volume scan, urodynamics etc)
  • bowel symptoms may warrant anal manometry/USS

Management

1. Watchful waiting, with observation for development of any new symptoms/complications
   1. for stage 1 or asymptomatic patients
2. Conservative management
   1. Lifestyle
      1. e.g. weight loss, treat constipation, reduce heavy lifting
   2. Physiotherapy (pelvic floor)
      1. Useful for stage 1/2 symptomatic patients
   3. Local oestrogen creams may be trialled in conjunction with physiotherapy, particularly in post-menopausal women
3. Pessaries
   1. Considered effective in most women if tolerated and suitably fitting
      1. (many different sizes/shapes)- ring pessary often very effective although accurate fitting is recommended
      2. Usually replaced every 3-6 months
4. Surgery
   1. NB The evidence for classical prolapse surgeries e.g. tapes/colposuspension/fixation, is lacking and these are becoming less routine
   2. Only considered if there is failure of management with pessary; prolapse is symptomatic i.e. incontinence, difficulty with voiding/defecating etc; and where patient preference is a strong factor

Suicide/Self Harm Risk Assessment

Intro

• Wash hands; Introduce self; Check patient name and DOB/CHI; Explain and gain consent

The Event (PC/HPC)

• Before
  • Events leading up to attempt e.g. triggering life events, chronic depression
  • Planning
    • How long have you felt like this?
    • Did you think about how, where, when?
    • Did you tell anybody? Leave a note?
    • Precautions e.g. where were they (and would they be found)?; Were other aspects of life accounted for e.g. childcare, job, money etc?
• During
  • How?
    • e.g. how many tablets, what tablets, where were they got,
    • What did they expect?
    • When/where?
    • How they came to be in hospital?  Were they discovered or brought themselves?
    • Associated alcohol/drug use?
• After
  • Feelings now
    • Angry (either that they attempted or they attempted and failed)
    • Regretful
  • Feelings of the future
    • If you went home now, what would you do?
    • If changed mind, why? what changed?
    • It can be useful to be blunt- would you try this again? / Have you made any plans if the attempt failed (positive or negative)?

Assessing risk

• Depression screen
• Past medical history including full psychiatric history and past suicide attempts/self harm
• Social History
  • Drug/Alcohol
  • Employment
  • Family/Household/Relationships
  • Social factors e.g. money, housing etc
• Family history (included in full psych history)
• Ask about willingness to seek help

Finish

• Thank patient, wash hands
• Record summary in notes and note any suggestions or take for further action as appropriate
  • (the majority will be ok to go home with follow-up in the community)

Risk factors

• Male; old or young
• Unemployed, depressed, lack of or breakdown of social support (including relationships)
• Chronic illness, previous attempts; alcohol/drug abuse