Histories

Cardiovascular History:Chest Pain

Respiratory History:Productive Cough

GI History:Abdominal Pain

GI History:Diarrhoea

Neurological History:Headache

Intermittent Claudication

Back Pain History

Haematological History

Breast History

Sexual History:Vaginal Discharge

Station 1 CARDIOVASCULAR HISTORY: CHEST PAIN

Candidate Briefing: Mrs. Jones is a 60 year-old lady who presented with a two-hour history of central chest pain, shortness of breath and sweating. Please take a history from Mrs. Jones and then present your findings.

Patient Briefing: You are 60 years old and your name is Mrs. Jones. You have presented to the emergency department today with a two-hour history of central chest pain. The junior doctor has come to take a history from you.

The chest pain is central and came on gradually 2 hours ago. The pain is dull in character and radiates to your left arm. The pain came on whilst you were watching television and has not yet gone away. At the moment there is nothing that is making the pain worse although you do not feel like moving. You took some paracetamol earlier but this did not relieve the pain. The pain is eight out of ten in severity.

In addition to the chest pain you are also feeling short of breath and sweaty; both of which have come on over a similar time period to the chest pain. You have no nausea, palpitations, presyncope, syncope, ankle swelling, cough, sputum or haemoptysis.

You are known to have unstable angina and recently you have noticed that your angina pain is coming on with less and less exertion and it has been associated with breathlessness. You did not seek any help for the chest pain and hoped that it would get better again.

You also have high blood pressure and diabetes. You have never had a heart attack, a mini stroke, stroke or problems with circulation in your legs. You have never been told you have high cholesterol.

You take amlodipine 5mg and aspirin 75mg once a day and your diabetes is diet controlled. You have no drug allergies. Your father died of a heart attack aged 50 and your mother has type 2 diabetes. You currently smoke 20 cigarettes a day and have done for the last 40 years. You drink 2-3 glasses of wine every evening. You eat a lot of takeaways and do not eat much fruit or vegetables. You do not do any regular exercise. You are a retired secretary.

If asked, your main concern is that you are having a heart attack and are worried that you are going to die. You are hoping that the doctor will be able to reassure you.

Mark Scheme for Examiner

Introduction

Clean hands, introduce self, confirm patient identity and gain consent for history taking

Chest Pain History

Site

Onset

Character

Radiation

Timing and duration

Exacerbating factors

Relieving factors

Severity

Previous episodes of chest pain

Associated Symptoms / Systemic Enquiry

Shortness of breath

Autonomic symptoms (nausea, vomiting, sweating)

Palpitations

Presyncope and syncope

Ankle and calf swelling

Cough and sputum production

Haemoptysis

Past Medical History

Previous chest pain. Angina or myocardial infarction

Previous interventions (angiography/CABG)

Stroke or peripheral vascular disease

Diabetes mellitus

Hypertension

High cholesterol

Drug History

Drug and allergy history

Family History

Family history of heart disease (including age of any significant events e.g. myocardial infarction)

Social History

Smoking status. Duration and quantity of cigarettes smoked

Alcohol intake, lifestyle (diet, exercise) and occupation

Finishing the Consultation

Elicit patient concerns

Summarise history back to patient

Thank patient and close consultation

General Points

Polite to patient

Maintain good eye contact

Appropriate use of open and closed questions

Presentation of case

Questions And Answers for Candidate

With a convincing history, what ECG changes would support immediate percutaneous coronary intervention?

• With a convincing history, I would be concerned by ST elevation of 1mm or more in consecutive limb leads (I, II, III, aVF, aVL, aVR); or ST elevation of 2mm or more in consecutive chest leads, or new onset left bundle branch block (though some centres are now using ST elevation of 1mm in the limb leads as the criteria for PCI)

What artery supplies the sinoatrial tissue of the heart?

• The right coronary artery supplies the sinoatrial nodal artery 60% of the time, the remaining 40% of the time it is supplied by the left circumflex artery

What areas of the heart are supplied by the left anterior descending artery?

• The left anterior descending artery supplies the anterolateral myocardium, the apex and the interventricular septum. Typically it supplies up to 55% of the left ventricle

Additional Questions to Consider

1 // What is the differential diagnosis of chest pain?

2 // How might you differentiate the pain of an MI from pericarditis on history?

3 // What are the immediate and later complications of myocardial infarction?

4 // What is the role of primary angioplasty in acute myocardial infarction?

5 // What advice would you give this patient on discharge?

6 // According to current recommendations, what drugs should be on a patient's discharge letter post acute MI?

7 // What groups of people are at higher risk of a silent myocardial infarction?

Patient Briefing: You are 60 years old and you are called Mr. Gordon. You have presented to hospital with a three-day history of a productive cough. You have been finding it increasingly difficult to sleep and get around your house because of breathlessness.

Your cough started three days ago and has been getting gradually worse. You are now having severe coughing bouts eight times a day and producing sputum each time. You estimate that you are producing two cupfuls of sputum a day. Your sputum is yellow / green in colour and is thick in consistency. You have not coughed up any blood.

You have been feeling increasingly short of breath over the last three days which came on relatively quickly. You are now breathless at rest and you also feel "wheezy". You can normally walk about 400 yards on the flat before you become breathless.

You have also been experiencing chest pain for the last two days. The pain is in the right side of your chest and is sharp in character. The pain does not move anywhere else, it is constant but is worse when you take a deep breath. It has been relieved slightly by taking paracetamol. At worst it is a six out of ten in severity. You normally have some mild ankle swelling which has not changed recently. You have lost 3kg of weight in the last two months.

You were diagnosed with COPD five years ago and take inhalers for this. You have never needed hospital admission for your COPD before. You have never had tuberculosis or a DVT. You do not know what a pulmonary embolism is but you have never had a clot on the lungs. Regarding medications you use a tiotropium inhaler once a day and a salbutamol inhaler when you need to. You have no drug allergies. Your father was a lifelong smoker and suffered from chronic bronchitis.

You are also a lifelong cigarette smoker. You have smoked approximately 20 cigarettes a day for the last 50 years. You have not had any recent travel. You no longer work but used to be an IT consultant. You have never been exposed to asbestos. You drink 5 pints of alcohol a week and do not keep any pets.

Your main concern is that you are becoming increasingly reliant on your wife for help with general day to day activities and feel that you are struggling at home.

Introduction

Clean hands, introduce self, confirm patient identity and gain consent for history taking

Cough

Duration, character and frequency

Sputum production and frequency

Sputum colour, volume and consistency

Haemoptysis (volume and frequency)

Shortness of Breath

Duration

Speed of onset

Exacerbating/relieving factors

Usual exercise tolerance (how far can they walk on the flat?) and current exercise tolerance

Orthopnea

Paroxysmal nocturnal dyspnea

Associated symptoms/Systemic Enquiry

Chest pain (SOCRATES assessment)

Wheeze

Ankle swelling

Weight loss

Stridor

Temperature / rigors / night sweats

Past Medical History

Previous breathlessness and investigations

Asthma/COPD (including disease control, previous admissions to hospital and ITU)

Tuberculosis

DVT/PE

Chest trauma/Operations

Malignancy

Drug History

Drug history (including inhalers, courses of steroids and antibiotics) and allergies

Family History

Family history of respiratory disease and atopic illness

Smoking History

Smoking status (including duration and quantity of cigarettes in the past)

Social History

Recent travel

Occupation and any exposure to asbestos in lifetime

Pets

Alcohol intake

Finishing the Consultation

Elicit patient concerns

Summarise history back to patient

Thank patient and close consultation

General Points

Polite to patient

Maintain good eye contact

Appropriate use of open and closed questions

Presentation of case

Questions And Answers for Candidate

Classify the causes of pleural effusion and list two causes in each category.

• Transudative and exudative pleural effusions

• Transudative – cardiac failure, renal failure, hepatic failure, hypothyroid, Meigs' syndrome

• Exudative – pneumonia, pancreatitis, malignancy (primary or secondary) TB, trauma, abscess, connective tissue diseases e.g. rheumatoid arthritis, SLE

List 3 common bacteria associated with community acquired pneumonia?

• Strep pneumoniae

• Mycoplasma pneumoniae

• Staph aureus

• Haemophilus influenzae

Which cancer is most associated with asbestos exposure?

• Malignant mesothelioma

Additional Questions to Consider

1 // Can you list some of the red flag symptoms that would raise your suspicion of possible lung cancer?

2 // Which type of asbestos fibre is considered the most carcinogenic?

3 // List 5 possible causes of haemoptysis

4 // List 2 occupational lung diseases

5 // List 2 lung diseases caused by exposure to animals

6 // List 5 causes of lung fibrosis. (Supplemental question: can you classify this further into causes of upper zone fibrosis and lower zone fibrosis?)

Patient Briefing: You are 25 years old and your name is Mrs. Smith. You have presented to hospital with abdominal pain and vomiting.

You were completely well until two days ago when you started to develop abdominal pain. The pain is on the right side in your lower abdomen. The pain came on suddenly and is sharp in nature; however it doesn't move around your abdomen. The pain is constant and has been getting gradually worse. The pain is made worse if you move around and is better if you stay still. At worst the pain is 8/10 in severity. You have never had this type of pain.

You currently do not feel like eating but your weight has been stable recently. You are feeling sick and have been vomiting for the last 12 hours. You have vomited 4 times but there has not been any blood. You have not had any problems with swallowing. Your bowels have been normal and you last opened them yesterday. You do not know what the word jaundice means but your skin has not turned yellow. You have not experienced any urinary frequency, dysuria or haematuria. You have had no vaginal discharge, bleeding or pain on intercourse (not that you've been trying and with the pain at present you are not remotely interested in finding out). Your last menstrual period was 7 weeks ago.

You have no significant medical or surgical history, except recurrent episodes of chlamydia infection which have required multiple courses of antibiotics. You are not taking any regular medications and do not have any allergies. There is no significant family history. You have never smoked and drink 1-2 glasses of wine a night. You have not had any recent travel and do not know anybody else who has had similar symptoms.

Your main concern is that you think you might have appendicitis and are worried you might need an operation. You hope the doctor will be able to tell you what he thinks is wrong with you.

Introduction

Clean hands, introduce self, confirm patient identity and gain consent for history taking

Abdominal Pain History

Site

Onset

Character

Radiation

Timing, frequency of pain and duration

Exacerbating factors

Relieving factors

Severity

Associated Symptoms

Anorexia and weight loss

Nausea, vomiting (including haematemesis and bilious vomiting), abdominal distension

Dysphagia

Dyspepsia

Change in bowel habit (frequency and consistency of bowel motions)

Blood or mucus per rectum

Jaundice

Urological symptoms (frequency, dysuria, haematuria)

Gynaecological symptoms (vaginal discharge, bleeding, dyspareunia)

Last menstrual period

Past History

Past medical history (including previous abdominal pain and investigations)

Past surgical history

Drug History

Drug history

Allergy history

Family History

Family history (e.g. inflammatory bowel disease, coeliac disease)

Social History

Smoking history

Alcohol history

Recent travel

Contact with infectious sources (e.g. family, friends)

Finishing the Consultation

Elicit patient concerns

Summarise history back to patient

Thank patient and close consultation

General Points

Polite to patient

Maintain good eye contact

Appropriate use of open and closed questions

Presentation of case

Questions And Answers for Candidate

If this patient's LMP was 7-weeks late, what tests would you perform?

• Pregnancy test or urinary beta-hCG

What are the common causes of acute pancreatitis in the UK?

• The commonest causes of acute pancreatitis in the UK are gallstones, ethanol and trauma (be it iatrogenic – ERCP, or blunt trauma e.g. handlebar injuries)

Can you list the structures found in the transpyloric plane (L1)?

• Lumbar vertebra L1, spinal cord (and upper part of the conus medullaris)

• Origin of superior mesenteric artery from the aorta, termination of superior mesenteric vein

• Pylorus of the stomach, 1st part of duodenum & duodenojejunal flexure

• Fundus of the gallbladder, neck and body of the pancreas

• Spleen

• Upper pole of the right kidney and hilum of the left kidney

• Left and right colic flexures

Additional Questions to Consider

1 // Give five differential diagnoses you would include as causes of an acute abdomen.

2 // List three causes of haematemesis.

3 // Relating to hernias, what is the difference between incarceration and strangulation?

4 // Please tell me some of the radiological findings in small bowel obstruction.

5 // What are the causes of large bowel obstruction?

6 // What is a volvulus and how is it managed?

7 // Define intussusseption.

8 // What is a Meckel's diverticulum?

9 // What is a Richter's hernia?