case 2

Case 2 - History taking (CNS)

History taking script

·         Personal details

o   65 year old

o   Male

o   Government servant (retired 5 years ago)

o   Married with 2 children

·         PC

o   - his left body is stiff, and not moving according to his will -

o   since 2 days ago.

·         HPC

o   2 days ago, had the worst headache ever on the right side of his head at 7pm

o   Vomited 3 times after that

o   Took aspirin and slept it off

o   Next morning felt dizzy - and his left body was limp

o   Completely unable to move his left side of body now.

o   Left side of body feels numb as well.

·         PMH

o   Diagnosed of Polycystic Kidneys at age of 40. - on regular checkup

o   Diagnosed of DM2 at age of 50 - on medication

o   Diagnosed of Hypertension at age 53. - on medication

·         Family history

o   Father died at age of 70 - from diabetes foot infection

o   Mother died at age of 76  - she had hypertension, stroke 4 years before death and bedridden - died of pneumonia

·         Social history

o   Drinks 1 can of beer every night - 2 in the weekend since 25

o   Non-smoker now

o   Smoked for 30 years since 23 to 53, 1 packet / day.

o   No exercise hobbies - sedentary lifestyle

·         worries

o   he is afraid he will be bedridden like his mother

o   why afraid ? - don’t want to be a  burden to his family - would rather die.

Question variation 1

1.       ask…

a.       PC

b.      HPC

c.       PMH

2.       Questions

a.       How old is he? (1m)

b.      What was his occupation? (1m)

c.       What is his presenting complaint? (2m)

d.      Elaborate on his history of presenting complaint (6m)

e.      Elaborate on the past medical history (5m)

f.        What is his probable diagnosis? (2m) state 3 risk factors. (3m)

Question variation 2

1.       Ask…

a.       PC

b.      HPC

c.       Family history

2.       Questions

a.       What is his presenting complaint? (2m)

b.      Elaborate on his history of presenting complaint (6m)

c.       Elaborate on the family history (4m)

d.      What is his probable diagnosis? (2m)

e.      state 3 risk factors. (3m)

f.        from his symptoms, where is the lesion in the brain? Be specific. (2m)

                                                               i.      right cerebral hemisphere hemorrhage infarct due to ruptured artery of the middle meningial artery

possible PE case related to this case

man had SubArachnoid Haemorrhage.

1.       Examine his lower limbs - emphasis on motor functions

a.       Inspections

b.      Palpation

c.       Movements

d.      Power

e.      Deep tendon reflexes

2.       Viva - state whether you would expect a UMN lesion / LMN lesion in this case

What are the differences of UMN/LMN lesions?

case 1

Case 1 - History taking (MSK)

This is the history taking script. You may memorize this and ask your friends to take the history in 5 mins.

·         

      24 yearold

·         Male

·         Presenting Illness

o   Lower back pain - been there for 6 months

·         HPI

o   It’s a dull pain

o   started as a slight ache in the back

o   Its worse in the night

o   When I wake up, it takes effort to get up from bed

o   Requires a lot of bending and stretching before it gets better

o   Pain radiates from the back to the buttocks

o   It gets better as day progresses

o   have a slight hunch on the back (cervical kyphosis)

·         systemic review

o   no weight loss

o   no change in eating habits

o   no dizziness

o   hearing okay

o   my eyes seems to be red - for 1 year

o   diarrhea is a normality for me. Got used to it already - 3 years

·         family history

o   mother is well at 52

o   father 55, has DM2.

o   Brother is 20, healthy

·         Social history

o   Nonsmoker

o   Does not drink

o   Swimmer - national squad

o   Also does badminton once a week with friends

·         Worries

o   Might not be able to continue his swimming career

o   (because it is getting worse and worse)

o   He is a backstroker - but his coach keeps commenting on his form - said his back is too bent and is creating water resistance.

o   He is afraid his younger brother might get the same condition

Question variation 1 -

1.       Take…

a.       PC

b.      HPC

c.       Social history

2.       Questions

a.       What is his Presenting Complaint? (2m)

b.      Elaborate on his History of Presenting Complaint (6m)

c.       Will Rheumatoid factor aid in his diagnosis and state the reason why. (2m)

d.      What is his probable diagnosis? (2m)

e.      What are the other possible manifestations of this illness? Give 3. (3m)

f.        Elaborate on his social history. (3m)

g.       Are his hobbies helpful to the prognosis of this disease? State why. (2m)

(full marks 20)

Question variation 2 -

1.       Take…

a.       PC

b.      HPC

c.       Systemic review

2.       Questions

a.       What is his Presenting Complaint? (2m)

b.      Elaborate on his History of Presenting Complaint (6m)

c.       Elaborate on his systemic review. Give 2 positive findings. (4m)

d.      What is the probable diagnosis? (2m)

e.      What are the 3 manifestations of the disease is the patient having? (3m)

f.        State 2 diagnostic procedures you would like to use on this patient.(2m)

g.       State 1 other possible associated conditions with this illness. (1m)

(full marks 20)

Question variation 3 (BS station)

1.       Take…

a.       PC

b.      HPC

c.       Social history

2.       Questions

a.       What is his Presenting Complaint? (2m)

b.      Elaborate on his History of Presenting Complaint (6m)

c.       What is the probable diagnosis? (2m)

d.      What are his worries? (4m)

e.      What advice would you give to his worries? (4m)

(full marks 16)

Possible PE stations related to this case

1.       Examine his spine. - patient know case of Ankylosing spondylitis

a.       Inspection

                                                               i.      Special attention to kyphosis

b.      Palpation

                                                               i.      Special attention to sacroiliac joint - tenderness?

c.       Movement (passive)

2.       Viva - what special test would you perform on this patient, and what would you expect?

3.       Viva - what other places would you be interested in?

a.       Peripheral joints - for enthesitis

b.      Eye - for uveitis

c.       Heart- for aortitis, fibrosis, heartblock.

d.      Signs of IBD (aphtous ulcers etc)

history taking - Female Repro

Female Reproductive History Taking

This is sem 4  repro component
*female reproductive history taking is unique at some points – look at the bolded parts*

Things to ask;

1. demographics
2. chief complaint
3. history of chief complaint
4. menstrual history*
5. pregnancy history*
6. past medical history
7. social history

·         demographics

                                                               i.      Name

                                                             ii.      Age

                                                            iii.      Address

                                                           iv.      Religion

                                                             v.      Occupation

                                                           vi.      Marital status

                                                          vii.      Ethnicity

• Chief complaint – expect anything along the lines of…
• Abdominal cramps
• Contraception advice
• Trouble conscieving
• Vaginal itching / pain
• Menopausal symptoms
• Cancer checkup
• Amenorrhea
• Pain on lower back
• Infertility
• Irregular menstruation

Basically just ask what is the purpose of visit, and ask how long. It is the most important thing. You will need to change your question according to the chief complaint.

Menstrual history

• When was your first period?
• (if menopausal) – when was your last period?
• Most recent menstruation started on….. (date)
• Most recent menstruation ended on….
• Length of menstrual cycle? *in average – when short, when long.*
• How long does the menstruation last? (in days)
• How much is the menstrual blood loss?
• Any discomfort during menstruation?
• Any pre-menstrual symptoms?

Pregnancy history

• LMP - When was your first day of your last menstruation?
• How many times have you been pregnant? (gravida)
• *current pregnancy included*
• How many times have you given birth? (para)
• *twins / triplets are considered one para*
• Any miscarriages?
• Any complications during childbirth?
• How are the children?

You may be asked to calculate the EDD –Estimated Date of Delivary from the LMP

the expected date of delivery (EDD) is obtained by adding one year, subtracting three months, and adding seven days to the first day of a woman's last menstrual period (LMP).

Some extra points to remember –

fetal stage of prenatal development starts at the beginning of the 11th week in gestational age, which is the 9th week after fertilization.

Neonate - <28days after birth


the condition at which the pregnant mother feels nauseated for a prolonged period of time - is termed hyperemesis gravidarum

pulmonary history taking

some specific questions that may interest us when asking questions regarding pulmonary diseases.

---------------------------------

upon collecting personal details, the

NASAROME

Name

Address

Sex

Age

Religion

Occupation

Marital status

Ethnicity

the Occupation may be important to assess occupational diseases of the lungs,

the address may be important to assess infectious diseases.

---------------------------------

History of presenting complaint;

S.O.C.R.A.T.E.S

Site

Onset

Charactor

Radiation

Associated symptoms

Time factors (when does it get worse? how long have you had what?)

Exeberating and relieving factor

Severity

Blue - less relavant

red - more relavant

in pulmonary medicine, the charactor of...

Cough

Sputum

may be particularly important.

refer to reference 1 -http://tatsukiatimu.blogspot.com/2010/04/reference-1.html

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also, for well-known or more frequently prevalent diseases like asthma, it may be important to assess the severity, e.g.

can you excersize?

how many days off work do you have in a month?

how many sleep disturbances in a month?

CSU - history taking2

History taking 2.

today i did the whole 5-mins thing for our first time.

first feedback

-too slow

-use codes for note-taking

-don't take too much notes

-don't waste time on spelling etc

-ask more open-ended quesitons

-ask specific questions only when needed

second feedback

-good social skills

-need to work on speed

-good to address emotional aspect

-almost perfect except knowledge aspect - constant blood transfusions can cause Fe overload, multiple organ failure.

thank michelle and Tej for the lab-coat.

CSU - history taking

some points i noticed in CSU history taking.

ask open ended questions, followed (must) by specific question

-most of us know that we're supposed to do this but do not know how.

when given history of fever, ask for temperature!

when given history of "back excersise", ask what kind!,

when you notice patient has low compliance, try to find out why!

(drug incompliance - ask why - they might be having side effects)

WHAT WHY WHEN

summerising the history will help the patient arrange things for you.

they may give you a few more stuff when you summerise for them.

also good to use as "glue" for the next section.

be observant.

Respi specific history - drug history

there are 3 types of commercial asthma drugs.

blue - reliever, brown - preventer, grey - mixture.

CSU - history taking

i almost forgot to record the procedure for history taking.

3 feb 2010

with Dr.Sow (who is in charge of CSU history taking curriculum decisions)

she mentioned merging the behavioral study CSU station with the actual long history taking Stations in the future.

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long history taking.

there are 9 components in long history taking.

Personal Detail,

Presenting Complaint,

History of Presenting Complaint,

Systemic Review,

Past Medical History

(Drug History)

Family History

Social History

-------------------------------------------

Personal Detail has several components.

Name

Age

Sex

Address

Race

Religion

Occupation

Marital Status

-------------------------------------

Presenting Complaint should be "in patient's own words".

e.g. chest hurts and feels tired

-------------------------------------

history of presenting complaint has several components.

Site

Onset

Character

Radiation

Associated symptoms

Time (when it started, how long it lasts)

Exeberating factor and relieving factor

Severity

Perhaps it would be nice to add this too;

How it may affect his life, what concerns he has for the symptoms

----------------------------------------------

Systemic Review - the reason for systemic review questioning is to

1) make sure s/he does not have other illness

2) narrow down diagnosis.

go from a general review

-weight change

-apatite change

-"Are you stressed?"

to...

head

eye

nose

ear

lungs

CVS

Bowel

Urinary

Limbs

Muscular

etc etc

----------------------------------------

jan04

orthopnia - short breath when lying supine. needs to sit up to breathe.

level can be measured by no. of pillows used.

http://www.gpnotebook.co.uk/simplepage.cfm?ID=-939130869

pneumothorax could be diagnosed by percussion, where patient is placed supine, and tapped on the sternum while being auscultated on the anterior lung fields. if there is a one-sided pneomothorax, the sound is resonant, booming and exaggerated.

http://bja.oxfordjournals.org/cgi/content/abstract/83/6/960

upon taking CVS history;

qOnset ( abrupt or gradual )

how did the pain start?

qNature ( character)

tell me about the pain, how is it like?

qCourse

did it become worse/better at some point?

qSite

where is the pain?

qRadiation

does the pain spread>?

qDuration

how long have you had this pain for>

qPrecipitating Factors

what makes it worse?

qRelieving factors

what makes it better?

qOther relevant symptoms

do you have other things that may bother you>