including short cases, OSCEs and scenarios
|Clinical history taking|
|Patient Demographics||name age gender occupation|
|PC||main problem(s) with duration in patient’s own words|
|HPC||OPQRST for each symptoms treatments tried|
|PMH||DM Asthma/COPD Epilepsy Hypertension Heart disease MI Stroke TB Rheumatic Fever DVT PE Operations Hospitalisations Blood Transfusions|
|Drugs Allergies||Current Medications Dose Frequency Inhalers COC HRT OTC Herbal Supplements Alternative TherapiesMedications Vaccines Elastoplast Iodine Latex – Evidence for allergy – what happened?|
|Family History||Age Health/Cause of Death Parents Siblings and Partners Children illness in the family|
|Cardiovascular risk factors||Fixed (male, age, race)Modifiable (smoking BP cholesterol)Partially-modifiable (CVD, CKD, DM PVD)|
|General||General Health and Well-being Wt-loss Fever Night-sweats Chills Sleep pattern|
|CVS||Chest pain SOB Calf Pain Claudication Palpitations Syncope Presyncope Ankle Swelling|
|Respiratory||SOBAR SOBOE (walking distance MRC Scale) Orthopnoea PND Pillows Cough Haemoptysis Sputum Wheeze Chest Pain|
|GIT||Appetite, weight, dysphagia, nausea, vomitting, abdo pain indigestion, altered bowel habitConstipation Diarrhoea Blood Slime Mucous Haematemesis Maleana Fresh Blood PR|
|GU||Dysuria Frequency Hesitancy Nocturia Incontinence (urge/stress) HaematuriaProstatism (stop start poor stream terminal dribbling ISPSS)|
|Obs Gyne Menarche Menopause||General Health and Well-being Wt-loss Fever Night-sweats Chills Sleep pattern|
|LMP Regular length of cycle length period length||Heavy Painful Contraception UPSI Pregnancy? Cervical SmearSTI Vaginal dischargePregnancies Miscarriage TOP PND Breast Problems Post Natal Depression|
|CNS||Fits faints funny turns TIA/Stroke Weakness NumbnessProblems with walking or Coordination|
|HEENT||Head Injury Headache Visual Disturbance Spectacles/LensesHearing Loss Vertigo Tinnitus Rhinorrhoea Polyps Tonsils|
If in doubt go back to first principles. The traditional medical history may seem like a mechanistic trawl but in fact most patients love the attention to detail and it may in fact lead to a comprehensive and useful picture of themselves and their problems cf the dubious medical record or even more dubious “knowledge of the patient” source?
|Health related behavior history“Healthy SEEDS”|
|Substances||alcohol, tobacco, IV drugs?|
|Environment||hazards at home or work? feel safe?|
|Exercise||what do you do? how often do you do it?|
|Diet||any special diet?|
|Sex||active with m/f/both? >1 partner? safe sex? STD history? difficulty with arousal or orgasm? history of abuse?.|
|from http://www.valuemd.com/clinical.php …this order works well: patients most expect to be asked about alcohol and they least want to talk about their STD history, but taking a solid HRB history first reassures them that it’s all part of good medical care.|
A few routines checklists mnemonics and frameworks
for Good Clinical Communication and thinking on your feet in exams (inc OSCES and CSAs) , interviews and difficult real-life situations
Whilst geared to OSCES and Exams these frameworks are relevant to all patient interactions – that’s why you learn them in the first place.
The busy exprienced clinician can modify and tailor their approach to their circumstances – but none of this stuff is superfluous only for the exam stuff
Maybe you can drive how you like after passing the driving test but it has to be said there are a lot of avoidable accidents on the roads.
As a doctor you always have a patient to consider – right there in the room with you.
The upside is a win win situation – embed a systematic clinically-based approach into your training and practice, don’t slip or wander too far and you will not only pass your exams easy, you will thrive, prosper and enjoy life a clinician.
ICE Ideas Concerns Expectations
|ICE TCT (Passtest) examinations/intearctions/ interventions|
|C||obtain consent for the examination|
|E||Explain – at the start and throughout before each individual stepExpose – Expose the necessary parts of the body and position the patientExamine|
|T||Thank the patient|
|T||Turn and face the Examiner|
|WINCER Blundell and Harrison OSCES at a glance Wiley 2009|
|I||Introduce Yourself (and Check patient ID)|
|N||Notice / Observe|
|Interview questions CAMP STAR SPIES|
|CAMP for background and motivation questions|
|STAR for questions requiring an example|
|Result / Reflect|
|SPIES for questions on difficult colleagues|
|S||Signs and Symptoms (History and Exam)|
|M||Medications (inc OTC herbals and vitamins)|
|P||Pertinent Past History and Pregnancy|
|L||L Last oral intake (last ins and outs)|
|E||Events leading up to the episode/injury|
|Socrates Pain/Symptom History|
|OPQRST AAA Pain/Symptom History|
|O||Onset How and when did the pain (or other symptom) begin?|
|P||Precipitating/palliating factors What makes the pain feel better or worse? Point to where the pain is|
|Q||Quality Can you describe the pain? Sharp Dull Crushing etc|
|R||Radiation Relief Does the pain go anywhere? What relieves the pain?|
|S||Severity How severe is the pain? (Scale of 0-10 0 no pain 10 worse pain imaginable)|
|T||Time Duration Variation over time Previous Episodes?|
|T||Treatment tried so far and effect|
|A||Aggravating / Alleviating Factors|
|OLD CART symptom description|
|T||Treatments so far|
|T||trauma, temp., thiamine|
|S||space occupying lesion, stroke, intracranial hemorrhage, shock, status epilepticus|
|A||Alcohol, drugs, toxins|
|E||Endocrine, liver, lytes.|
|I||Insulin, oral hypoglycemic agents, diabetes mellitus|
|O||O2, CO2, CO, opiates|
MPS mnemonics ACCORD ASSIST
Gawande Checklist Manifesto vs managerial/political checklists
Problem Oriented Medical Record
|SOAPIE SNCSG/Wardrope Driscoll Community Emergency Care|
|S||subjective||what the patient says.|
|O||Objective||what the examiner observes including labs|
|A||Assessment||what the examiner thinks is going on – may be a numbered list in|
|P||Plan||what they intend to do about it.|
|Useful phrases for consultations, COT competencies, and being a good doctor|
|How can I help you today?||The Golden Minute– dr michael thomas / calgiari-cambridge – don’t speak just allow the patient to talk uninterrupted for one whole minute Effective Personal Interactions
whilst head nodding, “umming and ahhing”, and making eye contact – if you so wish and can do it without looking like Churchill the dog – all the world’s a stage but the authentic practitioner should talk/perform to patients like he/she talks to anyone else
|Tell me more about that||whilst shuffling some papers, looking at the computer, checking your iphone for texts or staring at the ceiling /out the window
Anything else that you have noticed? (yes you, you Bastard staring at the ceiling)
|Cues||You look (tired, sad, low, stressed, anxious), is that how you feel? (or is that how I feel?)
You sound (tired, sad, worried etc), is that how you feel?
You seem ………
You mentioned ******, tell me more …….
|Echoing|| back statements and using a hanging (unfinished) sentence or even a single word followed by silence, which encourages them to complete and expand e.g.
You mentioned work …
|ICE||What does all this mean to you?
What do you make of all this?
What do you think might be the cause?
Can I ask you what you mean by……?
Tell me what you mean by ******?
Have you considered what might be causing these problems?
How/what do you think this has happened?
Some people with this problem find ……., has that been a problem for you?
If I were to say that you may have **** what does that mean to you?
Are you worried about anything in particular?
Is there anything you’re worried this might be?
Anything else worrying you?
Do you have any specific worries about this?
Have you thought how I might be able to help?
Have you had any thoughts on investigation/treatment.
|How’s all this affecting you at home or at work?
How are you coping with all of this?
|Before I examine you I just need to check that I’ve got to grips with all that’s going on.
Summarise the problems and then ask – Have I missed anything?
So just to make sure I’ve got things right, you have ………
Just to recap, you have had………..
Explaining the problem
Do you know much about?
If I were to say to you I thought you had …. what does that mean to you?
Use pictures, patient information leaflets and the internet to facilitate explanation.
|Sharing options||There are a number of options:***, **** and ******. Which do you prefer?
Do any of these options particularly appeal to you?
|Checking understanding||Do you have any questions?
Is there anything you want to ask me?
Does my explanation make sense?
Is there anything I haven’t explained?
Just to check that I have explained things clearly can you tell me what you’re going to do/how you’re going to take your medication?
Just to check that I’ve explained things clearly, how are you going to take …. or what are you going to do?
|Safety netting||I’ll see you in ….. weeks.
Come back if thing don’t get better.
Come back if things don’t get better by ……
Come back if XXXXX develops
Don’t get me wrong – it’s not that I knock it – these are undoubted good-things – but can lead to an insincere patronising approach if paid lip service and done without conviction and heart – it might almost seem possible to pass an assessment by making all the right noises without actually drawing upon much clinical knowledge.
However most patients seem to appreciate more rather than less attention to detail on these points and most doctors may fail to achieve their objectives by paying too little rather than to much attention to these considerations.
We hope to expand this page to a whole section of videos, phrases tricks and tips for jobbing Drs and students alike. This is partly the reason we’ve included so much patient oriented material amongst the videos and links on the site already. Being smooth and credible makes for a better experience for clinician and patient alike.
Pulse – rate rhythm character volume
|Sinus rhythm||40-60 athletes betablockers post MI hypothyroid hypothermia, raised ICP|
|CHB||30-45 +/- cannon waves in JVP post MI cardiomyopathy idiopathic drug induced|
|Sinus tachycardia||>100 anxiety fever anaemia ccf thyrotoxicosis|
|SVT||120-200 paroxysmal idiopathic or due to thyrotoxicosis, ihd, nicotine, caffeine, or preexcitation syndromes.|
|Sinus arrythmia||variation with respiration common in young adults|
|VEBs||ischaemia, hyperthyroidism, cardiomyopathy, caffeine, alcohol, nicotine, young adults (abolished by exercise)|
|Coupled beats||(bigeminy) digoxin toxicity|
|Dropped beats||2nd degree heart block|
|Atrial fibrillation||irregularly irregular in rhythm and volume- may be pulse deficit between radial pulse and apical/ventricular rate.
Causes IHD mitral valve disease CCF hypertension alcohol thyrotoicosis
|Atrial flutter||with varial block may be intermittently irregular whilst atrial flutter with 2:1 block is a regular 150 bpm – causes IHD thyrotoxicosis digoxin toxicit|
|VT||120-200 irregular and weak|
|Collapsing||rises rapidly and falls away abruptly- seen in AI and v rarely PDA.
Demonstrate increased pulse volume on elevation by grasping volar surface of patients wrist with right palm and elevating arm vertically – keeping patients elbow straight with left hand
|Bisferiens||Combined aortic valve disease|
|Dicrotic||fever and hyperdynamic states|
|Alterans||alternate high and low volume beats – severe LVF|
|Paradoxus||exaggeration of normal pulse volume decrease in inspiration (severe asthma, cardiac tamponade and constrictive pericarditis)|
|Pulse Volume (reflects LVSV)|
|Low volume pulse||aortic stenosis (slow rising plateau pulse), mitral stenosis, CCF, pulmonary hypertension and hypovolaemic shock|
|High volume pulse||high output states (pregnancy, severe anaemia, fever and sepsis, CO2 retention, thyrotoxicosis, cirrhosis)|
|Unequal pulses||Takayasu’s disease, aortic aneurism|
|Absent radial||congenital, arterial embolus, Blalock shunt|
|Radiofemoral delay||aortic coarctation|
|furthest downward and ouward point cardiac impulse is felt||normally 5th ICS mid clavicular line.|
|tapping apex||(due to palpable S1) mitral stenosis|
|double impulse||dyskinetic or aneurysmal LV segment, HOCM|
|Absent impulse||obesity, pericardial/pleural effusion, emphysema, dextrocardia|
|Apical thrill||mitral regurgitation and papillary muscle rupture (systolic) mitral stenosis (diastolic)|
|Left Parasternal heave||RVH|
|Heart sounds and murmurs|
|First heart sound||mitral valve (mainly) + tricuspid valve closure||loud in mitral stenosis and hyperdynamic circulationsoft in mitral regurgitation, calcified mitral stenosis, hypotension, severe heart failurevaries in intensity in CHB and VTNormal splitting more pronounced in RBBB|
|Second heart sound||aortic A2 and pulmonary P2 closure||aortic component occurs first and is louder (in adults) splitting diminishes in expirationincreases in pulmonary stenosis and RBBB fixed splitting ASD RBBB reversed split – LBBB severe aortic stenosis, LVF PDAsingle S2 calcified aortic stenosis, pulmonary stenosis, common truncus, some normal elderly patients|
|Third heart sound||ventricular filling at time of av valve opening||normal in young people at apex also occurs in rapid ventricular filling – MI, VSD, CCF constrictive pericarditis|
|Fourth heart sound||ventricular filling due to atrial contraction against a stiff ventricle||CCF, MI, hypertension, HOCM|
Mighty Ape MighTy M1 T1 AP A2 P2 first heat sound is made up of mitral component and tricuspid component (in that order) the second heart sound is closure of aortic then pulmonary valves.
|Murmer||turbulent blood flow within the heart heared with the stethoscope|
|Thrill||palpable murmer – like a cat purring|
|Heart sound sites|
|Grading Heart Murmers|
|II||quiet and soft|
|IV||loud with a thrill|
|V||very loud with thrust or thrill|
|VI||can be heard with stethoscope not touching chest|
|Midsystolic||A Stenosis – midsystolic RUSE radiating to neck (+/- apex)A Sclerosis – similar with mewing seagull cryPS /ASD/ MVP/ HOCM -mid-late systolic at LSEInnocent – LSE – hyperdynamic states, pregnancy, chest wall deformity|
|Pansystolic||MI – apex radiating to axillaVSD – apex radiating to LSERuptured chordae apex-right upper chestTI – RLSE especially on inspiration|
|Early diastolic||AI – LSE on expirationPulmonary Regurgitation – louder on inspirationGraham Steel – pulmonary hypertension due to mitral stenosis|
|Mid diastolic||MS – low pitched rumbling, apical louder left recumbant or exercisemay be presystolic attenuationAustin Flint apical diastolic mumer in AITricupid Stenosis (rare) RLSECarey Coombs – short diastolic murner in acute rheumatic mitral valvitis|
|Continuous||Aortic coarctation, AV shunts, PDA ruptured valsalva sinus Aortic StenosisCombined aortic and combined mitral valve disease|
Visible pulsations of internal jugular vein.
Patient reclined at 45 degrees with neck relaxed. Pulsations visible between heads of sternomastoid.
Differentiate from carotid pulse: not (usually) palpable, biphasic, slow rising and falling, rises if pressure applied over upper abdomen (hepato jugular reflex)
Measure vertical height of column of blood above sternal angle.
If JVP very high may not be visible – look for ear lobe pulsations or sit/stand patient up.
Kussmauls sign – elevation of jvp with respiration – due to obstructed venous filling eg constrictive pericarditis.
Corrigans sign – easily visible carotid pulse in Aortic Regurgitation. May also be seen in older patients with arteriosclerotic or aneurysmal dilation (aortic coarctation in the young)
Bruits may be heard in carotid or subclavian stenosis, or radiating murmers especially aortic stenosis.
|Carcinoma lung stomach GI lymphoma|
|Cardiac – cyanotic CHD bacterial endocarditis|
|Cervical rib – neurovascular compression upper limb|
|Chest – CF bronchiectasis TB fibrosing alveolitis empyema lung abcess|
|Circulation – AV fistula|
|Colonic – crohns UC coeliac|
|Cyanotic congenital heart disease Crohns disease|
|Lung disease (chronic suppurative eg empyema CF, abcess), fibrosing alveolitis and cancer (bronchial, mesothelioma) liver disease|
|Thyrotoxicosis – thyroid acropachy|
|crackles||inspiratory or expiratoryintermittent like rice crispies or hairs rubbing together|
|pleural rub||inspiratory continuous superficial low pitched squeekink or grating – like sandpaper ot velcrow|
|rhonchi||low pitched monophonic snoring mainly but not wholly expiratory|
|wheeze||high pitched continuous musical whistling mainly expiratory sometimes on inspirationWheeze is an expiratory noise caused by narrowing of airways. Expiratory as intrathoracic pressure is highe in expiration further narrowing the airways.Usually high pitched poyphonic due to narrowing of multiple small airways (asthma, COPD, LVF – airways narrowed by interstitial oedema).Low pitched monophonic wheeze suggests obstruction of large airway (bronchus, trachea) by tumour FB stricture.|
|stridor||high pitched monophonic crowing heared on inspiration louder in the neck than the chest wall.(ER facts incredibly quick Lipincott 2007)|
Ask patient to remove bra and tops.
Cover with a blanket when you are not examining the breasts.
Position the back of the bed at 45° to the horizontal.
Examine both breasts on all occasions, starting with the normal breast
|Three positions used in examining the breast|
|hands by the side|
|hands behind the head|
|hands on the hips|
Ask the patient remove pants and to lie on the bed face up, bringing their feet up to their bottom, and letting the knees fall to the sides.
Ensure that the area to be examined is adequately illuminated using a lamp
Examination (with Chaperone)
Inspection From the end of the bed
Scan the patient from head to toe, and note:
Does the patient look well or unwell?
Does the patient have any obvious conditions eg prolapsed uterus.
Note the following:
Pay particular attention to any swellings, discharge or bleeding.
Ask if there is any pain before beginning palpation, and watch the
patient’s face throughout the examination.
Part the labia majora using the index and middle fingers of your left hand in a ‘scissor-like’ motion. Ask the patient to cough, and look for any
discharge or abnormalities of the vagina walls.
Gently palpate Bartholin’s glands (situated at the 5 and 7 o’clock positions of the labia). Normally, these cannot be palpated. Note any tenderness or swelling.
If appropriate, gently ‘milk’ the urethra, and note the presence of any discharge.
Examination with a bivalve speculum
Inform the patient that you are going to pass a small device into the front passage in order to look at the cervix
Lubricate the speculum with some lubricating jelly. Inform the patient that you are about to insert the speculum.
Pass the speculum slowly, with gentle pressure exerted backwards and downwards. Rotate the speculum as you insert in order to follow the
contour of the vagina. The device should be inserted in a vertical plane, and rotated to lie in a horizontal plane.
When it is in position, open the speculum out, and inspect the cervix.
Look at the shape and size of the cervix, and note any abnormalities. such as erosions, polyps or discharge.
Tell the patient that you are going to remove the speculum, before doing so slowly and gently.
Inform the patient that you are going to insert two fingers into the front passage in order to feel the womb.
Lubricate the index and middle fingers of your gloved right hand. Pass the fingers in gently. Rotate the fingers as you insert in order to follow the
contour of the vagina. The fingers should be inserted in a vertical plane, and rotated to lie in a horizontal plane.
Feel the cervix with the tips of your fingers.
Using your left hand, palpate the abdomen starting near the xiphisternum, and work downwards. Try to feel the uterus between your two hands.
Assess its size. shape, motility and tenderness. It may be possible to palpate the ovaries also, and any tenderness or other abnormalities
should be noted.
Tell the patient that you are going to remove your fingers, before doing so slowly and gently.
Clean any lubricating jelly from the patient with a tissue.
From the end of the bed
Scan the patient from head to toe, and note:
Does the patient look well or unwell?
Does the patient have any obvious conditions, eg prolapsed rectum?
Perianal area Expose the perianal area by lifting up the right buttock. Look for:
skin tags or rashes
Ask the patient to ‘strain down’, and note any rectal prolapse.
Palpate goitre bimanually from behind with patients head in neutral or slightly flexed position.
Note size and texture of gland, and whether it moves with swallowing.
Enlargement may be diffuse (Graves, Autoimmune thyroiditis, simple goitre) or nodular (toxic nodular goitre, late simple goitre, Ca)
Tenderness suggests viral thyroiditis but may be seen in autoimmune and Ca. Bruit suggests toxic goitre
Check for downward retrosternal extension by palpating suprasternal notch and percussing sternum.
See also Panaural Welch Allwyn
|3 minute neurological examination Dr Michael Ingram|
|1||Romberg’s test Patient falling with eyes closed.|
|2||Tandem gait test Heel-to-toe walking|
|3||Walking on heels Tests pyramidal tractDorsiflexion Plantarflexion|
|4||Drift of outstretched arms Tests pyramidal tract|
|5||Finger-nose test Tests coordination|
|6||Fine finger movements Tests pyramidal and extrapyramidal tracts.|
|7||Hand tapping. Cerebellar and brainstem disease|
|8||Visual fields to confrontation|
|10||Face and tongue movements|
Rapid screening examination to rule out brain tumour or haemorrhage in patients with headache Dr Michael Ingram
|3 4 6|
|Cranial nerve examination|
|1 Olfactory||Smell||Ask patient to identify 2 distinct smells eg coffee/mint through each nostril individually with eyes closedAnosmia may be heriditary, post skull fracture, frontal lobe tumour meningioma, rhinitis|
|2 Optic||Vision.||Test visual acuity, fields by confrontation and examining the fundus with an opthalmoscope.|
|3 Oculomotor||Pupillary constriction and eye movement||Examine 3/4/6 together by testing pupillary response to light, ensuring both pupils are equal size.Have the patient follow the examiner’s finger through the entire range of ocular movements.|
|4 Trochlear||Downward, inward movement of eye|
|5 Abducens||Lateral movement of eye.|
|6 Trigeminal||Motor function includes jaw muscles for clenching teeth and moving jaw sideways.Provides sensation to the entire face in three distinct areas:forehead for the 1st branch;cheeks/maxillae for the 2nd branch;mandible for the 3rd branch||Palpate the patient’s jaw while they clench their teeth (masseter) and also by touching both sides of the face in all three distinct areas of sensory innervationAsk patient to open and close jaw against resistance (pterigoid)Test jaw jerk (increased in UMN)Corneal Reflex|
|7 Facial||Motor function includes eye closing, mouth closing, and wrinkling forehead.Sensory function includes taste on the anterior 2/3 of the tongue||Have the patient puff out their cheeks, show teeth/frown, raise their eyebrows and try to keep their eyelids shut as the examiner attempts to open the lids.Unilateral UMN lesions spare the forehead.Bells sign – exaggerated upward movement of the eyeball on attempted eye closure seen in LMN lesions|
|8 Auditory||Hearing(vestibular function not routinely tested)||Test overall function by whispering a word into one ear at a time while occluding the other ear.Test Rinnes Weber and perform otoscopy.|
|9 Glossopharyngeal||Movement of the pharynx and taste sensation in the posterior tongue||Ask patient if there is any change in their voice (dysphonia) or if they have difficulty swallowing. Have them say “ah” and watch for rise of the soft palate (vagus)Check gag or palate reflex (glossopharyngeal) by touching the posterior throat or palate on each side with a tongue depressor or orange stick.|
|10 Vagus||Movement of the soft palate, larynx, and pharynx|
|11 Spinal accessory||movement of the sternomastoid and upper trapezius muscles.||Patient shrugs shoulders and attempts to turn their head to the side against resistance. Turning head away from affected side is weak in accessory nerve palsy.Bilat trapezius weakness suggests MND or polio. Weakness of sternomastoid occurs in muscular dystrophy, myotonic dystrophy and MND|
|12 Hypoglossal||tongue movements||Examine tongue for fasiculations and wasting (LMN)Ask patient to protrude the tongue from the mouth and then move it from side to side.Tongue will deviate to affected side. Tongue movement may be sluggish in bilateral UMN lesions.|
The twelve pairs of cranial nerves are responsible for specialized motor and sensory functions. Strokes, injuries and other intracranial pathology may cause deficits to the function of one or more these nerves – cerebrovascular accident; Bell’s palsy; intracranial hemorrhage/hematoma; elevated intracranial pressure; meningitis
Mental State Examination
|AMTS Abbreviated Mental Test Score (Hodkins)|
|1 Date of birth||Score for correct date and month (year not required)|
|2 Year||Score for current year only|
|3 Time of day||Score if correct to the nearest hour|
|4 Place||Score if exact address or name of hospital given (“in hospital” is insufficient)|
|5 Monarch / PM||Score for current monarch only|
|6 Year of WW1||Score for year of start or finish (both not necessary)|
|7 Count backwards from 20-1||Score if no mistakes or subject corrects himself or herself spontaneously|
|8 Recognition of two people||Score if roles of two people correctly recognised–for example, doctor and nurse|
|9 Recall of three point address 42 West Street.||Score if registered correctly near start of test and at end|
|Score below 7 suggests cognitive impairment AMTS ncbi.nlm.nih.gov|
|Six item cognitive impairement test 6CIT|
|1 What year is it?||Correct answer scores zero (no errors), otherwise score 1||4|
|2 What month is it?||Correct scores zero – wrong scores 1|
|3 Memory Phrase Im going to tell you an address and would like you to try memorise it then repeat back to me later.Say “John / Brown / 42 / West Street / Bedford” (or similar address with 5 elements)||Make sure patient is able to repeat address correctly before moving on and warn them to try memorise itNo score is made at this stage as you are going to ask them to repeat it again in a few minutes|
|4 What time is it?||Within 60 mins / 1 hr of correct time then score zero, if not score 1||W3|
|5 Count backwards from 20 to 1||If they do this correctly they, score zero, one error then score 1 and for 2 or more errors score max 2 w25 Ask patient to say months of year backwards from December. allow plenty all correct then score zero, one error – score one. 2 or more errors score 2 w2|
|6 Finally ask them to repeat address back to you||All correct = zero, one bit wrong = 1, 2 parts wrong = 2 , 3 parts wrong = 3, 4 parts wrong = 4 and all wrong = 5 w2|
|Mini mental state examination MMSE|
|I would like to ask you some questions to test your memory. Is that OK?|
|Can you tell me today’s date, month and year?|
|Which day of the week is it today?|
|Can you also tell me which season it is?|
|What city/town are we in?|
|What county and country?|
|What building are we in and on what floor?|
|Immediate Anterograde Recall||I would like you to remember three objects – orange ball treeAsk for the words to be repeated (registration)||3 pointsscore 1 for each correct wordRepeat until all three are remembered, allowing up to six attempts. First repetition determines score|
|Attention and calculation||5 points|
|Serial 7s.||Starting with the number 100, subtract 7 and repeat, ie 100, 93,86… Stop at 5 subtractions 65.Alternatively, for those who have a dislike for numbers, ask them to spell the word ‘WORLD’ backwards.||Score 1 for each correct numberScore 1 for each letter DLROW|
|Delayed Verbal Recall||What are the three words I asked you to remember earlier?Score 1 for each correct word remembered – orange ball tree.||3 points|
|Naming||Name these objects (show the patient two easily recognisable objects, eg watch, pen)||2 points|
|Writing||Write a short, simple sentence (eg ‘I went to the shops yesterday’)||1 point|
|Repetition||Repeat the following phrase: ‘no ifs, ands or buts’.||1 point|
|Reading||Read this sentence and do what it says(Show ‘CLOSE YOUR EYES’ card)||1 point|
|3 Stage||Take this piece of paper in your left hand, fold it in half and put it on the floor.||3 points for take/fold/put|
|Visuospatial – Copying||Can you copy this drawing ?(both pentagons must have five sides and overlap)||1 point|
|25-30 out of 30 are considered normal18-24 indicate mild to moderate impairment17 or less indicate severe impairment (adapted from Passstest / Folstein et al)|
|Examination of a Lump|
|6 Students and 3 Teachers go for CAMPFIRE|
|Site, Size, Shape, Surface, Skin, Scar|
|Tenderness, Temperature, Transillumination|
|Regional lymph nodes|
|Gynae history and exam|
|Paeds history and exam|
|LOOK||– inspect – including gait posture and habitus|
|MEASURE||– rom, swelling|
|MOVE||– active (patient) passive (examiner – watch for pain) and against resistance
(helps define site of lesion or identify partially damaged tendons
|Special Tests and tests of function|
|In addition all patients with musculoskeletal or soft tissue injury should have full assessment of neurovascular supply to limb joint or digit.|
The key to effective, rapid and thorough MSK examination is to establish and perform systematic set routines.
Demonstrate the movements you would like the patient to make rather than try to explain.
Always compare both sides of the patient front and back.
Expose/undress the patient fully
Consider/examine joints above and below that which is being inspected and also the neck and lower back for the upper and lower limbs.
Always fix the limb near the joint to be examined to properly isolate movements at that joint .
e.g. Knee examination may be indicated for a number of reasons such as direct or indirect trauma to the joint itself, as part of the examination of an injured limb (the joint above and below the injury should always be examined) or due to chronic or acute pain in that or other joints.
|GALS Gait Arms Legs Spine|
|Musculoskeletal screening routine covering essential aspects of individual joint examinations|
|Three questions||Have you any pain or stiffness in your muscles, joints or back?Can you dress yourself completely without any difficulty?Can you walk up and down stairs without any difficulty?|
|Gait||Ask the patient to walk to the other side of the room, tum, and walk back to you.|
|Spine||Inspect the patient standing: from in front, the side and behind.Ask the patient to bend over and touch their toes, keeping the knees straight (lumbar flexion).Estimate the amount of lumbar flexion by putting your lingers on the adjacent vertebrae and noting the distance that they separate duringflexion.Ask the patient to put ‘their ear to their shoulder’ on each side in turn (lateral cervical flexion).Squeeze the supraspinatus muscles
|Arms||SuprasinatusInfraspinatusInspect the patient’s arms, with the elbows extended by the sideThe position of the arms for inspectionKeeping the elbows by the side (so fixing them), ask the patient to flexthe elbows to 90″ and ask the patient to tum their palms towards the ceiling (supination), then down to the floor (pronation).
Squeeze across the 1st-5th metacarpophalangeal (MCP) joints, and note any pain.
Ask the patient to touch each finger, in tur, onto the thumb.
Ask the patient to make a fist.
Ask the patient to put their hands behind their head and to push the elbows backwards.
|Legs||With the patient standingInspect when standing from the front, side and from behind (pay special attention to the popliteal fossa).With the patient on the bed (see hip and knee examinations for further details]Inspect the legs close up.Feel the temperature of the knee by placing the back of your hand overthe anterior aspect.
Carry out the bulge test (with or without the patellar tap) for a fluid effusion in the knee.
Ask the patient to put each heel up to their bottom (active knee and hip flexion).
Passively flex the hip.
While the hip is still flexed, test internal rotation passively.
Extend the knee, keeping one hand over the patella to feel for crepitus.
Squeeze across the 2nd-5th metatarsophalangeal (MTP) joints.
Inspect the foot closely for callosities and other abnormalities. Look
between the toes, at the metatarsal heads and at the heel.
|ARC MSK Examination for Med Students|
|SOFTER Tissues Acronym for non-traumatic MSK problems|
|Fractures (pathological and stress)|
|Tendon and Muscle problems|
|Epihyseal and other conditions of childhood|
|Refered pain and nerve root|
compression……including…Tumours,Ischaemia, Seropositive & seronegative Arthritides, Uric Acid (gout and other crystal arthropathies) Extra Articular Rheumatism (endocrine metabolic) Skin fat and bursae
|MRC scale for strength of muscle contraction|
|5/5||normal||FROM against gravity with full resistance|
|4/5||good||FROM against gravity with moderate resistance|
|3/5||fair||FROM against gravity only|
|2/5||poor||FRO passive movement (gravity eliminated)|
|1/5||trace||of muscle contraction (palpable) but without joint movement|
|0/5||zero||no evidence of muscle contractio|
|MRC Grading for strength of muscle contraction|
|M4||some diminished strength compared to other side|
|M3||weak but stromg enough to overcome gravity|
|M2||muscle can perform work if gravity is eliminated|
|M0||no motor activity|
|Biceps C5, C6|
|C3,4 and 5||supply the diaphragm|
|C5 deltoid||C5 deltoid|
|T1 –T12||the chest wall & abdominal muscles.|
|S1||plantar flexion (??)|
|S3,4 and 5||bladder bowel genitalia anus and other pelvic muscles|
Arm Shoulder Movements
Flexion Extension at the Shoulder
Knee Examination Knee Meniscal Tests
Ankle foot movements
Plantar Flexion Dorsiflexion
Pronation Supination Hands
Pronate for pressups
Abduction Adduction at the wrist
Remain professional and calm
Try not to be defensive or aggressive
Attempt to diffuse the situation
Listen and be attentive, allow patient to speak
Do not blame others, e.g. “The hospital/nurse is so disorganised”
Ask questions Be inquisitive – allows patient to voice their concerns and also stops the doctor from being defensive: why is patient unhappy? what exactly happened?
Apologise Even if you have done nothing wrong you can apologise, e.g. “I’m sorry you had to go though that”
Acknowledge This makes the patient feel heard and allows them to vent and empathise their anger
This can be done in several ways:
Summarise their concern “So you waited 10 weeks for the appointment?”
Acknowledge emotion “I can see that made you angry”
Empathise “It’s very annoying to wait so long”
Thank the patient “Thank you for bringing this to my attention”
What does Find out what they want you to do, e.g. “Is there anything in patient want? particular you were hoping I could do?”
Emphasise your commitment to helping the patient and ensure there are no other issues that have not been dealt with
“I will raise this at a practice meeting”
“Let’s see if we can stop this occurring again”
Formal Direct patient to official complaints procedure if appropriate complaint “Would you like to make a formal complaint?”
Explanation and apology
How it will be put right
In writing on practice leaflet
|Breaking bad news SPIKES|
|Setting up||allow sufficient time, privacy and minimise interruptions.|
|Perception||what the patient knows (his perceptions), so that you tailor your explanation according to his understanding|
|Invitation||get the patient’s permission to break the bad news and ask if the patient wants basic information or a detailed disclosure.|
|Knowledge||give the patient sufficient information, using jargonfree language to enable him to make informed decisions|
|Emotions||acknowledge the patient’s feelings. Use silence allow the patient to vent his emotions.|
|Strategy||summarise the information discussed, check comprehension, provide written plans/information and make followup|
|Baile WF, Buckman R, Lenzi Ret al. (2000)|
Avril Danczack Manchester University
Explaining Diagnoses and Treatments
iTunes U Combating microaggressions and bullying Columbia University