CSc 1 - MedEd · Edited by Vinod Patel and John Morrissey. Oxford University Press 2011/2012. ISBN: 019958561X and 2. Macleod’s Clinical Examination: Latest Edition 13th 2013. Edited

CSc 1

Clinical Skills Course

2016 Cohort

Delivering ‘Tomorrow’s Doctors’

Term 1

Clinical Skills 1 – 2016 Cohort 1


Table of Contents

Clinical Skills Course 1: Introduction to Clinical Skills

•3Clinical and Administration Staff

•4Aims and Objectives of CSc 1

•5CSc 1: Teaching Timetable

•7Learning Resources

•8Learning Outcomes for CSc 1

•10Student Preparation for CSc 1

•12Session 1: Clinical History -Examination and Communication Skills

•26Session 2: General Examination and Vital Signs

•36Session 3: Communication Skills 1

•38Session 4: Gastrointestinal History and Examination

•42Session 5: Thyroid Examination and Clinical History Review

•48Session 6: Communication Skills 2

•50Session 7: Respiratory History and Examination

•54Session 8: Cardiovascular History and Examination

•56Session 9: Making Every Contact Count: Lifestyle Advice

•60Session 10: OSCE Skills / Revision

•62Procedural Skills

•64Appendicies


Theme Lead: Dr. Vinod Patel

BSc (Hons.) MD FRCP FHEA MRCGP DRCOG

Principal Clinical Teaching Fellow Theme Lead in in Clinical Skills

Education & Development, Warwick Medical School The University of Warwick, Coventry, CV4 7AL, UK Room 017, Medical Teaching Centre

Hon. Consultant in Endocrinology and Diabetes

George Eliot Hospital NHS Trust College Street Nuneaton, CV10 7DJ, UK

Contact: Tel: +44 (0)2476 865212 Email: [email protected]

Clinical Education Fellows: Dr. David Tweedie

Email: [email protected] Dr. Aimee Palace Email: [email protected] Mr Patrick Henry Email: [email protected] Dr. Laura Reeves Email: [email protected] Room 113, 1st Floor, MTC. Tel: 024 7657 4497 / 4495 Administration: Mrs. Lorraine Brown Phase I Administrative Lead Room 014, Medical Teaching Centre Warwick Medical School Tel: 02476 573813 Email: [email protected] Mrs. Anj Kang Phase I Secretary Room 012, Medical Teaching Centre Warwick Medical School Tel: 02476 573815 Email: [email protected]

Clinical and Administration Staff

mailto:[email protected]








The aim of the clinical skills course is to ensure that the Warwick Medical School graduate is

competent in the wide range of clinical skills that are necessary for good medical practice at the

F1 level. There will be particular emphasis within the remit of the CSc on history-taking and

communication skills, clinical examination and practical procedures. The latter would include skills

such as: venepuncture, peripheral venous cannulation, suturing, competence in cardiopulmonary

resuscitation, respiratory function tests, oxygen therapy, nebuliser use, bladder catheterisation.

The objective is to be able to demonstrate that Warwick Medical graduates have a degree of

competence in the above skills that ensures patient safety and effectiveness of clinical care in the

graduate’s first post as a medical doctor and provides a platform for future learning. The

importance of not exceeding the limits of clinical competence will be made clear together with

teaching on seeking further clinical assistance. The Warwick MB ChB course has clinical skills

teaching throughout the course. The Duties of a Doctor, enshrined in Good Medical Practice

(GMC) remain central to our overarching objectives and are stated later on (appendix 1).

The 2015 GMC Document Outcomes for Graduates (Tomorrow’s Doctors) specifically lists the

clinical and practical skills which medical students should gain competency in, prior to

qualification. These are detailed in its Appendix. It is clear that medical students should have both

the competency and confidence to carry out specific practical and procedural skills safely before

qualifying as doctors. In many cases the skills will also be used during the junior and senior clinical

attachments in clinical settings in the community and acute Trusts. A formal assessment of

competency is essential to promote and ensure patient and staff safety.

It would not be desirable to teach clinical and practical skills in isolation of other parts of the

curriculum. The graduate will be expected to acquire skills such as effective prescribing, teaching

skills, and general skills (patient safety, time management, reflection, research skills, study skills,

numerical analysis, and medical ethics). A good understanding of the clinical working environment

at the local and national level is also expected. It is essential that the Clinical Skills Programme

integrates well with all the teaching and clinical experience that accrues from the clinical

attachments throughout the whole course.

Aims and Objectives of CSc 1


CSc 1: Introduction to Clinical Skills.

Year 1, Term 1: An Introduction to Clinical Skills is taught in a non-clinical setting.

Specifically Clinical History-taking and basic Clinical Examination.

Mainly using role-play with fellow students and some clinical videos.

Clinical Skills procedures: In-hospital resuscitation, Infection control, First Aid,

Movement & Handling.

Formatively assessed by OSCE examination in Block 3.

University Hospitals Coventry & Warwickshire (UHCW)

Lectures

Clinical Science Building (CSB) Lecture Theatre 8.00 - 9.00

Clinical Skills Lab (Hospital & CSB)

AM Group: 9.15-12.30

PM Group: 13.30-16.45

Clinical Anatomy Labs

AM Group: 9.15-12.30

PM Group: 13.30-16.45

Clinical Skills 1 - Teaching Timetable

Clinical Skills Session Date Topic

1

Friday 7th October The Clinical Consultation

2

Friday 14th October General Examination, Vital Signs and BMI

3

Friday 21st October Communication Skills 1: Person Centred Care

4

Friday 28th October Gastrointestinal History and Examination

5 Friday 4th November Thyroid Examination and Clinical History Review

6

Friday 11th November Communication Skills 2: Patient Doctor Relationships

7

Friday 18th November Respiratory History and Examination

8

Friday 25th November Cardiovascular History and Examination

9

Friday 2nd December Making Every Contact Count: Lifestyle Advice

10

Friday 9th December OSCE Skills and Revision

Procedural Skills will be carried out in the individual hospital trusts – see page 62 for more details.

Clinical Skills Timetable 2016

Reading “To study the phenomena of disease without books is to sail an uncharted sea. Whilst to study books without patients is not to go to sea at all”.

William Osler (1840-1919)

Essential Core Textbooks 1. Practical and Professional Clinical Skills (CSc textbook).

Edited by Vinod Patel and John Morrissey. Oxford University Press 2011/2012. ISBN: 019958561X

and

2. Macleod’s Clinical Examination: Latest Edition 13th 2013.

Edited by Graham Douglas, Fiona Nicol and Colin Robertson. Churchill Livingstone 2013. ISBN: 0702047287

Other Useful Textbooks 3. Introduction to Clinical Examination.

M J Ford, I Hennessy, A Japp, Elsevier 2005.

4. Clinical Medicine (not a clinical skills text but very useful). Praveen Kumar and Michael Clark. Latest Edition, W B Saunders.

Clinical Equipment You will need to purchase a pen torch and a stethoscope. Ideally a BP cuff and reflex hammer as well. Clinical Skills Additional Content 17 Clinical skills videos are available on Moodle or YouTube:

https://www.youtube.com/WarwickMedicalSchool

Learning Resources

https://www.youtube.com/WarwickMedicalSchool

http://www.amazon.co.uk/Practical-Professional-Clinical-Skills-Vinod/dp/019958561X/ref=sr_1_1?ie=UTF8&qid=1410509782&sr=8-1&keywords=clinical+skills+patel

http://www.amazon.co.uk/Macleods-Clinical-Examination-STUDENT-CONSULT/dp/0702047287/ref=sr_1_1?ie=UTF8&qid=1410509930&sr=8-1&keywords=macleods+clinical

http://moodle.warwick.ac.uk/course/view.php?id=2907


Curriculum

The following list illustrates how the Clinical Skills theme learning outcomes map to GMC Outcomes for Graduates 2015 (Tomorrow’s Doctors) curriculum learning outcomes and the Warwick MB ChB outcomes. The “P” and bracketed letter, refer to the paragraph sections of the Tomorrow’s Doctors document. These learning outcomes will apply throughout the whole course and will be revisited at other points during the MB ChB course. Block Learning Outcomes P9: Apply psychological principles, method and knowledge to medical practice. The graduate will be able to: (e) Discuss psychological aspects of behavioural change and treatment compliance Summarise key influences on long-term physical illness including effects of diet, exercise, weight and, smoking and alcohol on cardiovascular disease

P9

P13: The graduate will be able to carry out a consultation with a patient. The graduate will be able to: (a) Take and record a patient's medical history, including family and social history, talking to relatives or other carers where appropriate

List the elements of a standard medical history that allows the details of a patient's presenting issue and background to be elicited

List basic abbreviations and their meanings commonly used when recording medical histories

Recognise and ensure accurate documentation of patient's level of functioning in activities of daily living and requirements for social support by informal or professional carers

Identify attitudes commensurate with patient-centred interviewing

List skills associated with effective patient-centred interviewing. List the tasks and functions in the Calgary Cambridge Model. Explain the use of structured communication assessments (Such as the Leicester Assessment Package or LAP) in clinical practice.

Define a patient-centred interview; explain reasons for adopting a patient-centred approach and contrast this with alternatives

(b) Elicit patient's questions, their understanding of their condition and treatment options, and their views, concerns, values and preferences Demonstrate accepted methods of allowing patients to ask questions and discuss their views, concerns and preferences (c) Perform a full physical examination State the elements of a full clinical examination including the overall structure and steps involved in examining each system Demonstrate ability to communicate appropriately with patient while performing a physical examination; to explain what is going to be done; reassure during performance; continual observance of patient's non-verbal and verbal cues during examination

P13

Learning Outcomes for CSc 1


P14 Diagnose and manage clinical presentations. The graduate will be able to: (c) Formulate a plan of investigation in partnership with the patient, obtaining informed consent as an essential part of this process Outlines the process of formulating a plan of investigation/care and how to discuss this with a patient (and carers/family if appropriate). Demonstrates how to check understanding by the patient (and carers/family if appropriate)

P14

P15 Communicate effectively with patients and colleagues in a medical context (a) Communicate clearly, sensitively and effectively with patients, their relatives or other carers, and colleagues from the medical and other professions, by listening, sharing and responding. Identify and reflect on the communication practices of and amongst different groups of health professionals (d) Communicate appropriately in difficult circumstances, such as when breaking bad news, and when discussing sensitive issues, such as alcohol consumption, smoking or obesity. List reasons why people do not adhere to behaviour change options. Identify the domains to be considered when promoting behaviour change. Identify the stages in the trans-theoretical Model of Behaviour Change. Identify patient’s thoughts and feelings at each stage of the model. Show how to assess motivation and self-efficacy in changing (e) Communicate appropriately with violent patients. Explain the operation of the zero tolerance policies for violence against NHS staff

P15

P16: Provide immediate care in medical emergencies. The graduate will be able to: (d) Provide immediate life support Demonstrate in-hospital resuscitation skills including chest compressions, ventilation, recovery position, use of pocket mask

P16

Tomorrow’s Doctors Appendix 1: Practical Procedures for Graduates Diagnostic procedures Measuring pulse rate and blood pressure Therapeutic procedures Correct techniques for ‘moving and handling including patients General aspects of practical procedures Giving information about the procedure, obtaining and recording consent, and ensuring appropriate aftercare Hand washing Use of personal protective equipment (gloves, gowns, masks) Safe disposal of clinical waste needles and other ‘sharps


Please read carefully. Each week we will be covering a different clinical topic and these sessions will be largely interactive so please be prepared to get involved and take part. The sessions themselves can be quite intense so in order to prepare you for this there is a small amount of work to do before each session. This is detailed at the beginning of each session chapter. Please also read the relevant chapter in the suggested course textbook prior to the session. Thank you.

Student Preparation for CSc 1



The Clinical Consultation

Recommended Reading

1. Practical and Professional Clinical Skills : 1.1, 1.2

2. Macleod’s Clinical Examination : History Chapter

Session 1: Clinical History - Examination and Communication Skills

• To introduce you to the clinical consultation and introduce techniques (models) of how to structure it in order to fully explore the patient’s problems.

• To introduce you to useful tools which will help you when taking a clinical history and performing an examination.

• To provide an early introduction to the knowledge, skills and attitudes necessary to conduct a clinical history.

Aims

• By the end of this session you should:

• Appreciate and understand how the use of a model in a clinical consultation can elicit important clues as to the diagnosis.

• Have learnt and practised how to take histories using this approach.

• Appreciate how to utilise a simple proforma to attain a comprehensive history and examination.

• Have learnt and practised how to take histories and considered how to use this strategy with examinations using this approach.

• At the end of the session, a student should be able to carry out and present a basic clinical history in role play.

Objectives


Pre-session work

Q1. What is the crucial medio-legal point at the start of any consultation?

Q2. What is the general structure of a clinical history?

Q3. Define the following prefixes;

A- (e.g. aphasia)

Dys-

Hyper-

Hypo-

Mal-

Q4. Define the following suffixes;

-itis

-emia

-ology

-kinesia

-phagia


Introduction As clinicians, we have three ways of obtaining the information we need about our patients in order to help them: engaging in clinical conversation with them, examining them and carrying out investigations. The introductory clinical skills course provides an overview of the first two of these. The Consultation

The consultation starts when the patient presents with what he or she believes to be a health problem, or problems. It ends with agreement on a management plan which is acceptable to both patient and clinician. Consultations are almost infinite in their variety: part of the fascination of medicine is that no two will ever be the same. Those in primary and secondary care are very dissimilar, not least because the former are usually much shorter. Whether in primary care or secondary care, the approach to an emergency situation is necessarily very different to one which is less acute. But whatever the setting and the situation, the consultation must be structured. An aimless haphazard consultation will not result in an accurate diagnosis, a successful management plan or indeed a satisfied patient or carer. Many structures for the consultation have been proposed but our strong preference is for the Calgary-Cambridge model, which is used in most UK medical schools. It is fully described in Skills for Communicating with Patients by Jonathan Silverman, Suzanne Kurtz and Juliet Draper (Radcliffe Publishing, 2nd edition, 2005). The Calgary-Cambridge Model

This model organises the consultation into five tasks which are performed in sequence:

Initiating the session: explanation, consent, infection control.

Gathering information: conducting the clinical history.

Physical examination: general and specific examination.

Explanation and planning: considering diagnosis, management, explanation.

Closing the session: follow up, documentation.

To this we have added a sixth:

Differential diagnosis: which in Calgary-Cambridge is subsumed into explanation and planning. In addition there are two tasks which are continuous throughout the consultation: providing structure and building the doctor-patient relationship.

The Calgary-Cambridge model is applicable to almost any consultation, irrespective of the patient’s problems or the setting. One of its great strengths is its integration of content – what the doctor does – and process – how he or she goes about it.


Content and process

The introductory clinical skills course is mainly concerned with initial components of the Calgary-Cambridge model: initiating the session, gathering information and physical examination. With regard to “gathering information” we have reverted to traditional medical terminology: “taking the history”. “History” derives from the Latin historia, a story, and suggests and reminds us that immersion in and interpretation of the clinical narrative is an essential part of the practice of medicine. Our main focus is on the content of the consultation: in Figure 1 we map that content against the Calgary-Cambridge structure. But it must be stressed that mastery of process is as important as understanding of content. Process skills – also called communications skills - can only be acquired through experience but it is also essential to refer to a good textbook. Skills for Communicating with Patients is excellent in this regard. There is the specific Clinical Communications course that will run alongside this introductory clinical skills course. History taking

The purpose of taking the history is twofold: firstly, to assemble the information required to make a diagnosis and, secondly, to understand the patient’s perspective on the problem and assess the impact of the illness on his or her life. In the interests both of accuracy and of immersion in the patient’s experience it is necessary he or she be encouraged to tell their story in their own fashion: the record of the consultation should also be in the patient’s own words not a translation into medical jargon. In many direct quotes from the patient (or indeed observations of carers/relatives) should be stated verbatim. History taking is undertaken in stages: the identification of the patient’s immediate symptoms, then the detailed exploration of those symptoms, followed by their location in the wider circumstances of the patient’s previous medical history and life in general. It is frequently stated that 80% of diagnostically useful information comes from the history and most of the rest from examination and initial investigations. Often it is possible to make a diagnosis on the history alone. Alternatively, the history will suggest a range of diagnostic hypotheses - the differential diagnosis - which will indicate what physical examination and subsequent investigation is necessary. In clinical practice, the “natural history” or simply “what happens over a period of time” is often key to defining a final diagnosis or diagnoses. Physical examination

The purpose of examination is also twofold: firstly, to elicit signs which by their presence or absence help to confirm or refute diagnostic hypotheses erected on the basis of the history and, secondly, to assess the severity of the patient’s condition. The examination is also performed in stages: the general inspection, also called the “general look” or “end of the bed inspection”; the general examination, which is more or less the same in every patient; then examination of the body system in which the problem is thought to reside; and finally seeking additional relevant signs and bedside investigations. In the core textbook, the sections on systems examinations have not sought primarily to describe each step in detail. For this the relevant sections in Macleod’s must be studied. The main intention is to situate the main stages and elements of the examination in their clinical context: why they are necessary and how they contribute to the process of diagnosis. But each section includes a


clinical skills competency assessment proforma and this does list the main steps in a basic systems examination. This can be used for self and peer assessment. This division of the body into systems, especially for purposes of the physical examination, is now near-universal practice. Organising our understanding of the body and the information we gather from patients in this way makes the task more manageable. However, it is in many ways artificial. We do not interrogate or examine “systems”: we talk with and examine our patients. It is frequently necessary to examine more than one system and most patients admitted to hospital require comprehensive assessment by a full clinical history and physical examination (Unit 6: Practical and Professional Clinical Skills). Differential diagnosis The process of using the information gathered from the history and the physical examination to arrive at a diagnosis or differential diagnosis is sometimes called “clinical reasoning”. We have included differential diagnosis as a discrete step in the structure of the consultation. However, clinical reasoning is undertaken continually from its commencement as diagnostic hypotheses are erected, tested, confirmed or discarded. Even before greetings are exchanged a patient’s appearance or demeanour may suggest a possible diagnosis. Diagnostic hypotheses may be anywhere on the spectrum from the totally confident to the extremely tentative. For example, a fracture of the femur may be the definitive diagnosis with almost 100% certainty based on:

History: patient fell down a ladder, from 3 metres above the ground, onto concrete

Examination: a bend in the mid-shaft of the femur consistent with a broken bone

Investigation: a clean snap across the femur on the x-ray On the other hand we may be less confident of concluding that a patient has a pulmonary embolus (PE) from the following scenario. Even though the certainty may only be 70%, the PE has to be treated as it is potentially life-threatening not to treat an actual PE.

History: patient woke up with chest pain, worse on taking a deep breath. Recent back from holiday in Spain but also caught up with gardening work day before.

Examination: All observations normal, distinct pleuritic chest pain on inspiration.

Investigation: Chest x-ray normal, ECG tachycardia (rate > 100 beats per minute), D-Dimer elevated.

Definite later Investigation: CT Pulmonary Angiography normal. Clinicians concluded that musculo-skeletal origin of chest pain more likely in view of investigations and patient’s rapid improvement to asymptomatic state.

Clinicians have to deal with uncertainty all the time- indeed this one of the most difficult clinical skills to master. Constructing working diagnoses requires consideration and analysis not only of the symptoms and signs of biomedical disease but also of the patient’s perspective and the social context. The consultation then enters its final stage, the one which matters most to the patient: an explanation, however provisional, on what is troubling him or her and agreement on what is to be done about it. This is the care planning stage.


Summary

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Initiating the session

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Preparation - including infection control

Identifying the patient’s problem(s)

Gathering information : taking the history

Biomedical perspective (“disease”)

Sequence of events

Analysis of symptoms

Review of relevant system(s)

Patient’s perspective (“illness”)

ICE

Effects of symptoms on life

Feelings Context: Background information

Past Medical History

Treatment history and allergies

Personal and social history

Smoking, alcohol, recreational drugs, lifestyle

Family history

Review of other systems

Physical examination

Explanation and consent

Correct position and adequate exposure

General inspection

General examination

System(s) examination(s)

Additional examination

Differential diagnosis

Biomedical

Patient’s perspective

Social context

Explanation and planning

Clinician’s plan of management

Explanation and negotiation

Shared decision-making & care planning

Self-management by patient

Closing the consultation

Forward planning

Ensuring appropriate point of closure

Documentation


Proformas

Having considered the clinical consultation as a whole, what is that we actually do in clinical practice? Essentially we write down the clinical history, examination finding, and a list of working diagnoses. A management plan follows. Many clinicians, particularly in GP consultations or out-patient clinics will start with a blank piece of paper or a computer screen. You should learn to take a history using a blank piece of paper only (see clinical history quick template on next page). The contribution of good clinical notes, in any format, is paramount to good clinical care. Clinical notes should provide:

A succinct summary of clinical findings on history, examination, diagnosis

Information given to patient/carers

A summary of investigations

A legal record of care given: legibility essential.

Support of clinical audit, evidence-based practice, use of guidelines

There are many clinical notes proformas in existence (see appendices) and all will vary from one clinical environment to another. The hospital admission proforma is comprehensive and covers all the main aspects of a clinical consultation and management. The RCP cites evidence that improving clinical records can enhance clinician performance and improve patient outcomes. In a project co-ordinated by the Royal College of Physicians (RCP), in partnership with NHS Connecting for Health and endorsed and agreed by the Academy of Medical Royal Colleges, an agreed proforma for hospital admission has been produced.

Clinical History: Warwick 4 Frames Approach


Clinical History: Process vs Content

Clinical History: Warwick 4 Point Presentation


Clinical history: Quick template

PC

HPC

► “open”

► “closed” ? SQITAS ► specific system ► ?red flags

► systems review

CVS, RS, GIT UT, CNS Locomotor/Skin Endo (Red flags)

SH

• Smoking, Alcohol,

• Other Lifestyle Factors

• Occupation

• Home Circs

• Effect of condition on life and

ADL

Family Hx

PMH, Drugs, Allergies

• Ops, Serious illnesses, Past and current

• Drugs: POM, OTC, Recreational

• Allergies: drugs, penicillin, foods

ICE ??

Ideas, Concerns,

Expectations

Do you have any other

information for me?

Do you have any questions

for me?

Summary:

General overview, Main positive findings, Main “Negative” finding. Clinical Conclusion


Clinical history-taking tips History of Pain: SQITAS

With a history of pain be sure to explore all aspects of the mnemonic ”SQITAS”: (Also see the Mnemonic SOCRATES – vide infra)

Exploration of Patient Values: Ideas/Concerns/Expectations (ICE).

For every consultation you should actively consider the patient’s ICE.

Pain

Site

Can you tell me where the pain is worst?

Quality

How would you describe

the pain?

Intensity

On a scale of

1-10

Timing

Is the pain related to

anything that you do?

Aggrevating/Relieving

Anything making the

pain better or worse?

aSsociatedfactors

e.g. nausea, vomiting, dizziness

IdeasWhat do you think is going

on?

e.g. the patient with a migraine may be

worried about a brain tumour

ConcernsWhat concerns you most about this problem?

e.g. the patient may be concerned

about losing their job

ExpectationsHow can we best

help you with this problem?

e.g. the patient may reply: I think I

should have a CT scan of my head"


Red Flag Symptoms

Always ask about the “red flag” symptoms during a clinical history. These are symptoms that should be asked about to exclude “serious pathologies” such as cancers. Red flag symptoms will specifically dependent on the case under consideration. Ask as part of the “History of Presenting Complaint” or “Systems review”. You should almost always ask the following (being gender specific where necessary):

“Blood anywhere?” “Have you noticed any blood in your motions? Urine? Discharge (other than menstruation)? Coughing up blood? Vomiting blood or vomit that looks like coffee grounds?

“Any lumps and bumps?” “Have you noticed any lumps and bumps (esp. in breast or testicular area)? Skin lesions? Abdominal masses?

“Any change in bowel habit?” “Have you noticed any dark stools? Blood when opening your bowels? Any diarrhoea or constipation?”

“Any change in weight or appetite?” “Have you noticed any change in your weight or appetite recently? Are your clothes looser these days?”

“Any nausea or vomiting?” “Have you been sick or felt sick? If so what colour was it? Was there any blood?”

Increased risk of serious

pathology

Blood anywhere?

Any lumps or bumps?

Any change in bowel

habit? Any change in weight or

appetite?

Any nausea or

vomiting?


Sign-posting

Break up the history taking by introducing the main sections of the history clearly. This is called “sign-posting”. This creates structure and allows the history to continue to a different section. This will be clearly recognised by the patient.

Summarising: At the end it is often useful to quickly summarise the main findings to the patient to check that the main findings have been elicited.

Final Part of the history: It is appropriate to ask the patient

“Is there anything that you wish to tell me or anything important that I may have missed out?” and then;

“Are there any questions that you would like to ask me at this stage?”

End of Consultation: Thanks patient.

SOCRATES: Another acronym to recall the full symptomatology of a pain

Site - Where is the pain? Where is it worst? Onset - When did the pain start, getting better or worse? Character - What is the pain like? e.g.: stabbing, burning, dull ache, boring Radiation - Does the pain radiate anywhere? Associations - Any associated symptoms or signs: e.g. nausea, vomiting, sweating,

abdominal distension, Time course - Does the pain follow any pattern? How long does the time last? How many

times a day? Exacerbating/Relieving factors - Does make the pain better or worse? Severity - How bad is the pain? 10 is very severe like a fracture, 1 very mild pain.

"Can I ask you about any tablets that you take...any other drugs...any inhalers?"

• Drug history.

"I am now going to ask you about your social history..."

• Then start to ask about accomodation, smoking, alcohol, occupation etc..

" I am now going to ask you about your general health..."

• This can then be followed by the systemic review of all the systems not covered in the history of the presenting complaint.

"I am now going to ask you about certain symptoms to make sure I know whether you have them or not."

• This can be followed with an exploration of the 'Red Flag' symptoms.

I am now going to ask about your own ideas regarding what may be causing this problem."

• "What do you think is going on?"

• "What concerns you most anout this problem?"

• "How can we best help you with this problem?"


Clinical Role Play Template for creating the Clinical History Scenario

Patient Name/Demographics

Presenting Complaint

History of Presenting Complaint

Red Flags

Past Medical History

Drug History

Allergies

Social History

Family History

ICE: Ideas Concerns Expectations

Further information and Questions from Patient

Working Diagnoses/Problem List

Information given to patient


History for Practise: 56 year Patient with Chest Pain

1 PC

Central chest pain

History of Presenting Complaint

6month history of severe epigastric pain:

Site: points to sternum and to left arm

Quality: crushing as if Toby, my Labrador is sitting on me!

Intensity: severe 9 out of 10,

Timing: especially when walking or even when stressed, especially if cold weather

Aggravating/relieving factors: worse on walking better after standing still for a few minutes

Associated feature: nausea, sweating

No orthopnoea, PND, palpitations

Systemic Review

Polyuria and polydipsia last 4 months. Nocturia. Bit anxious/stressed

2 Social History: Family History

Post Office worker: but now in sorting office and mainly desk job. Previously walking until 3 years ago

Smokes 15 last 40 years, half a bottle of wine most days

partner at home

Brother stroke, age 51. Sister died of heart attack, aged 61 3 PMH

Chest infection in childhood

Meningitis as child with red rash “nearly died”

Recent UTI with passing lots of urine and increased thirst

Diabetes diagnosed 2012 Drugs and Allergies

Metformin 500mg TDS, Lansoprazole 15mg BD, Atmlodipine 10mg OD

Nil else

Allergic to Strawberries has rash 4 Ideas, Concerns, Expectations

Brother has had a stroke (age 51), so worried ? family problem

Heart disease

Diagnosis and treatment Diagnosis

Working diagnosis: Angina (1HD)

Presentation General : “I took the history from this 56 year old patient who presented with a history of central chest pain. Important Positive Findings: “ My main findings were that she has severe chest pain that radiates to her shoulder. The pain is relieved by standing still. Her younger brother has had a stroke recently. She is a smoker and has had polyuria and polydipsia recently together with an urinary tract infection. Important “negative” findings: However, there is no history of orthopnoea or PND. There is no intermittent claudication or TIAs. Clinical Conclusion: In conclusion the most likely diagnosis is angina secondary to ischaemic heart disease. Diabetes mellitus control may be poor, in view of the history of polyuria and polydipsia and the UTI. Treatment will be geared towards treatment and prevention of CVD. This will include GTN spray, a statin and possibly an ACE-I. We would also need to consider….


Recommended Reading

1. Practical and Professional Clinical Skills : 7.1, 2.1, 8.1

2. Macleod’s Clinical Examination : General Examination, BP

Session 2: General Examination, Vital Signs and BMI

• This session will introduce the student to the opening stages of the clinical examination. Subsequent sessions will divide the body up by ‘systems’. Eventually, however, you will need to reintegrate these and learn to do everything in one longer examination

Aims


• Appreciate how an understanding of basic structure and function of organs is necessary to perform a clinical examination.

• Have learnt and practised how to approach patients when you need to examine them.

• Be able to perform reliable anthropometry.

• Describe the limitations in assessing body composition.

• By the end of this session you should be able to:.

• Initiate an examination sequence.

• Interact with the patient such that the examination is an appropriate, positive and useful interaction.

• Conduct a general inspection of the situation and patient.

• Perform inspection and palpation of the hands.

• Perform inspection of the head, eyes, mouth.

• Perform inspection and palpation of the neck for lymphadenopathy.

• Perform inspection and palpation for peripheral oedema and pulses.

• Perform blood pressure measurement and recording

Objectives


Pre-Session Work

Q1. Please complete the following table with the correct values.

Observation Normal Range

Temperature Centigrade

Blood pressure mmHg

Pulse Beats per minute

Respiratory rate Breaths per minute

O2 saturation (room air) %

Urine output (vol/weight/time) ml/kg/hr

Q2. Define systolic and diastolic BP. Systolic Diastolic Q3. What examination features are used to determine systolic and diastolic readings? Q4. How do you correctly size a blood pressure cuff, and why?


General Examination Sequence

Objective: specifically looking for JACCOLG: Jaundice, Anaemia, Clubbing, Cyanosis, Oedema, Lymphadenopathy, Goitre

Explanation and consent “WIPE”

Washes hands, Introduction, Patient Consent, Explains procedure


Positions patient flat with one pillow.

Adequately exposes the upper body (and legs where appropriate) whilst maintaining patient

dignity.

General inspection

Inspects patient from end of bed, commenting on any relevant findings.

Inspects patient’s surroundings for ‘clues’ eg walking stick, splints,

General examination

Hands and Palms: arthritis, temperature/sweaty, tremor, capillary refill time, peripheral

cyanosis, palmar erythema, Dupuytren’s contracture, palmar creases, tar staining

Nails: clubbing, leuconychia, koilonychia, splinter haemorrhages, peripheral cyanosis

Radial Pulse: for rate and rhythm - but-

Carotid or Brachial pulse: for character and volume

BP/Vitals: Takes the blood pressure, comments on need to take temperature and assess

respiratory rate. Oxygen saturations in most emergency cases

Eyes: pallor in conjunctivae, jaundice in upper sclerae, corneal arcus, xanthelasmata,

Thyroid eye signs if relevant (lid retraction, lid lag, exophthalmos)

Face and mouth: Inspected for malar flush, central cyanosis

o Smell: hepatic foetor, diabetic ketoacidosis, ethanol o Tongue: hydration, glossitis, central cyanosis, ? large, wasting o Mouth: ulcers, teeth, gingivitis, angular stomatitis

Neck

o Lymph nodes: submental, submandibular, tonsillar, preauricular, deep cervical chain

(jugular), supraclavicular, posterior cervical chain, postauricular, occipital. Consider

axillar lymph nodes/breast

Upper chest: ?Spider naevus, gynaecomastia, scratch marks

(Groin: Inguinal lymph nodes) if indicated

Peripheral Oedema: lower limb oedema and then sacral oedema if present

Additional examination bedside investigation: e.g. urine, glucose, stool

Professionalism

Covers patient, thanks patient, explanation to patient, washes hands.


Vital Signs Examination Sequence

Objective: specifically examining temperature, BP, Pulse, Respiratory rate, Oxygen saturation. Urine Output: Covered in Block Teaching




Ensure subject rested and calm, feet flat on the floor and back rested or supine. Arm

horizontal & supported (e.g. pillow)

Pulse

Measure pulse: radial artery for rate and rhythm, character and volume from major artery,

usually the carotid.

Respiratory rate

Measure the respiratory rate: usually over 30 seconds

O2 saturation and Temperature

Use non-invasive device.

Ensure optimal conditions for true reading for O2 saturation: hands not cold, device

correctly placed, no nail varnish.

BP Measurement

BP cuff: Check size: bladder 80% of arm circumference. Correctly place cuff in relation to

the brachial artery.

Brachial artery location by palpation (medial to biceps tendon), inflate cuff after BP bulb

locked, 70mmHg rapidly then in increments of 10mmHg until pulse disappears and then re-

appears during deflation.

Estimated systolic pressure: the pressure at which brachial pulse returns after deflation.

Auscultation: apply stethoscope to brachial artery just above the ante-cubital fossa. Inflate

BP cuff until 20 mmHg above the estimated systolic.

Systolic BP: deflate cuff 2 mmHg per second until repetitive, clear tapping sounds first

appear for at least 2 consecutive beats (Korotkoff’s first sound).

Diastolic BP: deflate cuff again. After Korotkoff’s fourth sounds (muffling then soft and

blowing) sounds disappear (Korotkoff’s fifth sound = Diastolic BP).

BP recoding: systolic and diastolic rounded upwards to the nearest even number e.g.

152/86. Write down BP. Avoid digit preference.

Additional examination bedside investigation: e.g. urine output, glucose,

Professionalism

Covers patient, thanks patient, explanation to patient, washes hands.


Group Work: Anthropometrics Learning Outcomes

1. Be able to perform reliable anthropometry 2. Describe the limitations in assessing body composition

Discuss the following in your groups (and have a go at performing these measures using the available equipment) Question 1: A. What equipment would you use to determine someone’s weight, consider the different types

in your answer (for example how you would weigh someone that isn’t able to stand)? B. What would you do if you didn’t have the appropriate equipment? C. How can you ensure this equipment gives a reliable measurement? D. Are there any considerations when weighing someone?

Question 2:

A. What are some of the limitations with using weight as a measure?


Question 3:

A. Get a few people in the group to have a go at measuring one person’s height

Use a height stick (stadiometer) where possible. Make sure it is correctly positioned against the wall.

Ask subject to remove shoes and to stand upright, feet flat, heels of foot against the height stick or wall (if height stick not used)

Make sure the subject is looking straight ahead and lower the head plate of the stadiometer until it gently touches the top of the head.

Read and document height.

B. How could you assess height if your patient is unable to stand?

A. One method is to measure ulna length, have a go at this in your groups;

Measuring ulna length Ask subject to bend an arm (left side if possible), palm across chest, fingers pointing to opposite shoulder. Using a tape measure, measure the length in centimetres (cm) to the nearest 0.5 cm between the point of the elbow (olecranon) and the mid-point of the prominent bone of the wrist (styloid process).


Use the following table to convert ulna length (cm) to height (m).

Height (m) Men (<65 years) 1.94 1.93 1.91 1.89 1.87 1.85 1.84 1.82 1.80 1.78 1.76 1.75 1.73 1.71 Men (>65 years) 1.87 1.86 1.84 1.82 1.81 1.79 1.78 1.76 1.75 1.73 1.71 1.70 1.68 1.67 Ulna length (cm) 32.0 31.5 31.0 30.5 30.0 29.5 29.0 28.5 28.0 27.5 27.0 26.5 26.0 25.5

Women (<65 years) 1.84 1.83 1.81 1.80 1.79 1.77 1.76 1.75 1.73 1.72 1.70 1.69 1.68 1.66 Women (>65 years) 1.84 1.83 1.81 1.79 1.78 1.76 1.75 1.73 1.71 1.70 1.68 1.66 1.65 1.63

Height (m) Men (<65 years) 1.69 1.67 1.66 1.64 1.62 1.60 1.58 1.57 1.55 1.53 1.51 1.49 1.48 1.46 Men (>65 years) 1.65 1.63 1.62 1.60 1.59 1.57 1.56 1.54 1.52 1.51 1.49 1.48 1.46 1.45 Ulna length (cm) 25.0 24.5 24.0 23.5 23.0 22.5 22.0 21.5 21.0 20.5 20.0 19.5 19.0 18.5 Women (<65 yrs) 1.65 1.63 1.62 1.61 1.59 1.58 1.56 1.55 1.54 1.52 1.51 1.50 1.48 1.47 Women (>65 yrs) 1.61 1.60 1.58 1.56 1.55 1.53 1.52 1.50 1.48 1.47 1.45 1.44 1.42 1.40

e.g. man 77yrs old, ulna length 30. His height will be 1.81m

woman 64yrs old ulna length 23.5cm. Her height will be 1.61m

B. Discuss limiting factors (for example certain conditions) that may affect someone’s height measurement

Question 4 Calculate one of your group member’s BMI and discuss the limitations of using BMI

BMI calculation

Equation Weight kg

Height m 2

How does your answer using the equation compare with the chart?


Question 5

A. Have a go at measuring Mid Upper Arm Circumference (MUAC), it’s good for a few people to measure the same person and compare measurement readings

How to measure MUAC

The subject’s left arm should be bent at the elbow at a 90 degree angle, with the upper arm held parallel to the side of the body. Measure the distance between the bony protrusion on the shoulder (acromion) and the point of the elbow (olecranon process). Mark the mid-point. Ask the subject to let arm hang loose and measure around the upper arm at the mid-point, making sure that the tape measure is snug but not tight. If MUAC is <23.5 cm, BMI is likely to be <20 kg/m2. If MUAC is >32.0 cm, BMI is likely to be >30 kg/m2. The use of MUAC provides a general indication of BMI and is not designed to generate an actual score.

B. Discuss the limitations with measuring MUAC

Question 6:

A. Have a go at measuring someone’s waist circumference, discuss in your group where and how to take the measurement.

B. What considerations are there when measuring waist circumference? C. What limitations are there?

Increased

Risk

Substantially

increased risk

Men >=94 cm >=102 cm

Women >=80 cm >=88 cm




See Moodle for further details.

Session 3: Communication Skills 1: Person-Centred Care

• This integrated teaching session will introduce you to the concept of person-centredness and its relevance for you, as doctors. It forms part of your clinical skills learning. Mandates from the UK government and professional guidelines from the GMC emphasise the need to put patients, as people, at the centre of all care. This session will examine definitions and key elements of person-centred care, why it is important, the ethical rationale for it, and what it means in terms of the clinical consultation. Providing person-centred care requires a high level of clinical skill and experience. This introductory session is the beginning of a long journey towards becoming a person-centred doctor.

Aims


• Outline the key concept of person-centred care

• Describe the key elements of person-centred care

• Outline the values underpinning person-centred care

• Describe a person-centred consultation

• Outline the Calgary-Cambridge model of the consultation

Objectives


Clinical Notes


Recommended Reading

1. Practical and Professional Clinical Skills : 2.3

2. Macleod’s Clinical Examination : Abdominal Examination

Session 4: Gastrointestinal History and Examination

• To introduce students to the skills required to take an effective gastrointestinal history and perform the relevant examination.

Aims

• By the end of the session you should be able to:

• Conduct a gastrointestinal history.

• Conduct a comprehensive abdominal examination.

Objectives



Pre-session work

Q1. Please name the 9 quadrants of the abdomen.

1. __________________________________

2. __________________________________

3. __________________________________

4. __________________________________

5. __________________________________

6. __________________________________

7. __________________________________

8. __________________________________

9. __________________________________

Q2. What are the red flags that you would want to elicit from an abdominal history?

(Please classify these into upper gastrointestinal and lower gastrointestinal categories)

UPPER GI

LOWER GI

Q3. During your clinical examination to assess for ascites you would look for shifting dullness.

(a) Explain how you would perform this technique.

(b) Describe the findings you would expect if; (i) ascites was present and (ii) if ascites were not present

(i)

(ii)


Abdominal Examination Sequence

Objective: General Examination in relation to abdominal disease, specifically for jaundice, liver, spleen, kidneys, bladder, abdominal aortic aneurysm, ascites



Positions patient flat with one pillow, arms by side

Adequately exposes the abdomen whilst maintaining patient dignity.

General inspection

End of bed: comment on any relevant findings eg Well, comfortable, nutritional status,

distressed, pain, colour – jaundice, surroundings, drains

General examination: Consider Vital signs

Hands and nails: palmar erythema, Dupuytren’s contracture, liver flap, clubbing,

leuconychia, koilonychia,

Skin: jaundice, scratch marks, bruising

Pulse: tachycardia, bounding

Eyes: anaemia (conjunctivae), jaundice (upper sclerae)

Mouth: ulcers, dentition, gingivitis, angular stomatitis, hydration

Perioral telangiectasia or pigmentation

Smell: hepatic foetor, diabetic ketoacidosis, ethanol

Tongue: size, surface (smooth may indicate glossitis), candidiasis,

Neck and Chest: Lymph nodes (neck, Virchow’s, axillary), spider naevi, gynaecomastia

Abdominal examination

Inspection

Distension, swellings eg herniae

Visible peristalsis or pulsation

Scars, skin changes or fistulae

Dilated veins

Palpation (enquire about pain and start away from site of pain)

Superficial: Palpate each region in turn. Look for tenderness and guarding.

Deep: Palpate each region in turn for masses and palpate for enlarged organs: liver, spleen, kidneys, abdominal aortic aneurysm.

Percussion

Liver, spleen, bladder, ascites (shifting dullness).

Auscultation

Bowel sounds, renal bruit

Groin: Inguinal lymph nodes , hernia orifices


Additional examination bedside investigation: e.g. rectal examination, external genitalia,

urine, glucose, stool

Professionalism: Covers patient, thanks patient, explanation to patient, washes hands.


Recommended Reading


2. Macleod’s Clinical Examination : Thyroid Examination

Session 5: Thyroid Examination and Clinical History Review

• To introduce students to the skills required to take an effective thyroid history and perform the relevant examination.

Aims

• By the end of the session you should be able to:

• Conduct a thyroid history.

• Conduct a comprehensive thyroid examination

Objectives



Pre-session work

Q1. In hypothyroidism what signs would be seen relating to:

Hair

Weight

Neurological

Pulse

Nails

Reflexes

Shins

Eyes

Neck

Q2. In hyperthyroidism what signs would be seen relating to:

Hair

Weight

Neurological

Pulse

Eyes

Pulse

Neck

Q3. What features/comments in the history may be suggestive of a thyroid dysfunction?


Thyroid Examination Sequence




Positions patient upright. Exposes neck and upper chest (maintaining patient dignity).

General inspection

End of bed: comment on any relevant findings eg Well, level of activity (hyper/hypo), tremor,

weight gain/loss, general facies (eg skin and hair: waxy skin, balding, loss of lateral eyebrows),

voice

General examination:

Hands and nails: Temperature, Sweaty, scaly/dry skin, palmar erythema, evidence of

carpal tunnel syndrome. Nails: brittle (hypothyroidism), onycholysis, clubbing (graves)

Tremor : Place sheet of paper on back of outstretched hand and observe

Pulse: Rate: tachycardia/bradycardia, Volume: ?bounding, Rhythm: AF (associated with

hyperthyroidism)

Eyes: Lid lag, lid retraction, exophthalmos, diplopia

Thyroid examination

Inspection (from front and side)

Swelling ?goitre

Scars, skin changes

Observe any masses while patient takes sip of water

Ask patient to stick out tongue to see if any mass moves (thyroglossal cyst)

Palpation (enquire about pain and be wary of discomfort during the exam)

Palpate thyroid gland from behind ?size ?shape ?consistency ?masses ?thrill

Test for movement of mass on swallowing

Measure any masses/nodules

Palpate cervical lymph nodes

Percussion

Over upper sternum for retrosternal goitre

Auscultation

Bruit (heard over the thyroid)

Exclude stridor due to tracheal compression

Lower legs: Inspect for pretibial myxoedema and test ankle reflexes.

Additional examination: BP, Muscle power (arms/legs), examine for carpal tunnel

syndrome

Professionalism: Covers patient, thanks patient, washes hands.


Clinical History Revision

A brief schema on how to allocate time during a Clinical History

There is of course a lot of flexibility around the above model. It is important to ensure that the initial part of the Clinical History taking has open questioning in it. For example ask a general question like:

“Please tell me about your tummy pain…..chest pain……shortness of breath?” Listen attentively with words, small phrases or non-verbal communication to allow elaboration. Then decide on which system the case best fits and ask remaining questions about that system. In the above scenario, the patient may give you most of the details about the chest pain but may not give further information facts about associated symptoms or other aspects of the specific system history such as weight loss, vomiting, dyspnoea, oedema, palpitations, and orthopnoea. Clinical risk factors for the patient’s problem can also be covered at this stage. What do you think the main risk factors could be in the above patient?

1 Minute

• Wash hands, Introduction, Patient consent, Explains (WIPE)

• Presenting Complaint (PC)

2-3 Minutes

• History of Presenting Complaint (HPC)

• Open Questions initially then move to Open/Closed

2-3 Minutes

• Past Medical History (PMH)

• Drugs and Allergies (Dx/Allergies)

2-3 Minutes

• Social and Family History (SH/FH)

• Systemic Review (SR)

2-3 Minutes• Ideas + Concerns + Expectations (ICE)


Presentation of findings

This is an extremely important skill. Clear and accurate communication is central to good clinical practice.

Practice presenting your Clinical History to your fellow students or the tutor.

Communicating to the patient

You should be prepared to explain to the patient in clear basic English the following:

The possible diagnosis.

Treatment including investigations.

Give the patient time to ask any questions.

Check understanding. If you are not sure, please do relay this to the patient and that you will seek help from another member of the healthcare team.

The Warwick 4 Point Presentation

Important “Negative” Findings“However, there was no ascites”

Clinical Conclusion“These findings would be consistent with malignancy.

Further tests would include urine examination and

an ultrasound scan of the liver.

General Findings“On Examination the patient was comfortable”

Important Positive Findings“My main findings were jaundice and

an enlarged liver that was hard and nodular”



Session 6: Communication Skills 2 - Patient-Doctor Relationship

• This lecture and Fridays group work will explore different models of the patient doctor relationship described in the literature, identifying similarities and differences, and consider the impact of different models on patient-centred decision making. The group work on Friday will provide you with the opportunity to practice different

models in a role play setting.

Aims


• Describe and critique different models of the patient doctor relationship recognising that the patient may prefer different models at different times and in different circumstances. (P10b, P20b)

• Recognise how doctor-patient relationships are affected by social forces and change over time. (P10)

• Recognise the plurality of values held by patients and the influence of a doctor's values on his or her approach to patient care. (P20b)

• State why it is important to adopt a patient-centered approach with respect to underpinning shared decision making. (P13f)

Objectives



Recommended Reading


2. Macleod’s Clinical Examination : Respiratory Examination Pre-session work

Q1. What extra-pulmonary features are indicative of respiratory pathology (e.g. clubbing)?

Q2. What is the purpose of the bell and diaphragm on the stethoscope – please give examples of use?

Session 7: Respiratory System History and Examination

• This session will introduce the student to aspects of the examination of the respiratory system. It will provide an opportunity for students to learn how to use the stethoscope correctly.

Aims

• By the end of this session you should be able to:

• Conduct a respiratory history

• Conduct a comprehensive respiratory examination

• Use and care for your stethoscope in respiratory auscultation practice

• Learn when infection control is necessary in relation to use of the stethoscope

• List the types of respiratory sounds – breath sounds (vesicular and bronchial) and added sounds

Objectives



Q3. Describe the abnormalities in these chest X-rays?

A = Air ’fields’, B = Bones, C = Cardiac silhouette, D = Diaphragms, E = Esophagus, F = Fluid, G = Gastric bubble

.A _________________________________

.B _________________________________

.C _________________________________

.D _________________________________

.E _________________________________

.F _________________________________

.G _________________________________

Conclusion: _________________________

.A _________________________________

.B _________________________________

.C _________________________________

.D _________________________________

.E _________________________________

.F _________________________________

.G _________________________________

Conclusion: _________________________

.A _________________________________

.B _________________________________

.C _________________________________

.D _________________________________

.E _________________________________

.F _________________________________

.G _________________________________

Conclusion: _________________________


Respiratory Examination Sequence

Objective: Examination in relation to respiratory disease, specific general examination, followed by system examination




Positions patient with trunk at 45°. Head comfortable.

Adequately exposes chest and arms. Cover females until removal is appropriate.

General inspection

End of bed: Comment on any relevant findings eg Well, comfortable, dyspnoea,

cachexia, accessory muscle use, oxygen therapy, inhalers/nebulisers, sputum pot

General examination: Consider Vital signs

Hands and nails: peripheral cyanosis, tremor, muscle wasting, tar staining, CO2

retention flap, clubbing.

Respiratory rate and rhythm (when examining hands)

Pulse: rate, rhythm, tachycardia, bounding

Eyes: anaemia (conjunctivae), Horner’s syndrome (pupils), jaundice

Mouth: hydration, central cyanosis, thrush

Neck and Chest: Lymph nodes (neck, supraclavicular, axillary), JVP hepato-jugular

reflux

Chest examination: Perform anteriorly then repeat all posteriorly

Inspection

Shape of chest: excavatum, carinatum,

scars, ? scars

Ask patient to take deep breath ?pain

?symmetrical, ? tracheal tug

Palpation

Trachea: Position: central, deviated

Chest expansion: symmetry, range

Apex beat position: ?displaced

Tactile vocal resonance or fremitus

(or after auscultation)

Percussion

Chest including the supraclavicular

fossae and axillae

Compare both sides

Absent (or ↓) cardiac or liver dullness

may indicate hyperinflation of lungs

Auscultation

Chest including the supraclavicular

fossae, clavicles and axillae, comparing

both sides.

Vocal resonance comparing both sides.

Tactile fremitus: Usually no need to examine for both tactile and vocal fremitus.

Groin: Inguinal lymph nodes ,


Additional examination bedside investigation: e.g. peak flow, oxygen saturation, spirometry



Recommended Reading


2. Macleod’s Clinical Examination : Cardiovascular Examination Pre-session work Q1. What are the four areas of the cardiac auscultation and their anatomical landmarks?

1. ________________________________________________________________

2. ________________________________________________________________

3. ________________________________________________________________

4. ________________________________________________________________

Q2. What is the relevance of the hepatojugular reflux (HJR)?

Q3. What are the features of the pulse and where could these be assessed?

Session 8: Cardiovascular System History and Examination

• This session will introduce the student to history taking and examination of the cardiovascular system. It will provide an opportunity for students to learn how to further develop their use of the stethoscope correctly.

Aims

• By the end of this session you should be able to:

• Conduct a cardiovascular history

• Specifically take a history focussing on CVS disease risk factors

• Conduct a comprehensive cardiovascular examination

• Use and care for your stethoscope in cardiovascular auscultation practice

• List the types of cardiovascular sounds – heart sounds (normal and murmurs), bruits, mechanical valves

Objectives


Cardiovascular Examination Sequence

Objective: Examination in relation to cardiovascular disease, specific general examination, followed by system examination



Positions patient with trunk at 45°. Head comfortable.

Adequately exposes chest and arms. Cover females until removal is appropriate.

General inspection

End of bed: Comment on any relevant findings eg well, comfortable, nutritional status,

Oxygen therapy, GTN spray? Down’s, Marfan’s

General examination: Vital signs

Hands and nails: temperature, capillary return time, peripheral cyanosis, Osler’s

nodes, clubbing, koilonychia, splinter haemorrhages, tar staining, Janeway lesions,

Radial Pulse: rate and rhythm. Radio-radial delay and for collapsing pulse

BP

Eyes: xanthelasmata, anaemia, jaundice, corneal arcus

Face/Mouth: malar flush, glossitis, hydration status, central cyanosis.

Neck: JVP inspected, elicits hepato-jugular reflux, measures in cm vertical height

above sternal angle: normal < 4cm

Carotid Pulse: for character and volume

Inspection

Precordium: scars (also check

axillae), pacemaker, visible pulsation

Palpation

Apex beat: lowest, most lateral position of

cardiac impulse

Heaves and thrills – apex and parasternally

Auscultation

Mitral: 5th ICS Mid-Clavicular Line, Aortic: 2nd ICS R parasternal border

Tricuspid: 4th ICS L parasternal border, Pulmonary: 2nd ICS L parasternal border

Carotid arteries (both sides for bruit)

Special manoeuvres

Mitral stenosis: roll patient to the left side, use the bell of stethoscope

Aortic regurgitation: lean forwards, hold breath after expiration, L sternal edge

Additional examination:

Lung bases: percussion & auscultation

Peripheral Pulses: Dorsalis pedis, posterior tibial, popliteal (if pedal pulses impalpable)

Femoral pulse (and radiofemoral delay),


Abdominal examination – Hepatomegaly, AAA

Bedside investigation: cardiac monitor, ECG



Recommended Reading

1. Practical and Professional Clinical Skills : 12.1, 12.2

Session 9: Making Every Contact Count:

Lifestyle risk factor reduction

• The groupwork will contribute to the following learning outcomes:

• Analyse how socio-economic position, gender, age and ethnicity may shape key health behaviours and act as barriers to health behavioural change (P10e)

• List the elements of lifestyle and behavioural choices important in the manifestation of common and important diseases (P8e)

• Understand the principles of risk factors for common disease. (P8e)

• Assessment of distribution of risk factors for common disease in individuals and the population. (P8e)

• Describe the risk reduction policies for common diseases in individuals and populations. (P8e)

• Identify patient’s thoughts and feelings at each stage of the Transtheoretical Model of Behaviour Change. Show how to assess motivation and self-efficacy in changing (P15d)

• Apply the 3 levels of prevention (primary, secondary, tertiary) to a chronic disease from the list of core diagnoses (P11i)

• To describe the range of activities that encompass health promotion (P11i)

• Identify the current policy approaches and evidence based lifestyle interventions in the primary prevention of a named health behaviour (P11i)

Aims

• Understand the importance of the “Making Every Contact Count” initiative

• Use the Health Passport to take a history of lifestyle risk factors

• Demonstrate an understanding of a behavioural change model

• Promoting Health and Preventing Illness: more than behaviour change

Objectives


Schedule Each group rotates through THREE stations (40 mins each):

Station

Facilitator(s)

Group 1 & 2

MECC & History Taking using the Health Passport (Double Station)

Jane Wright Vinod Patel Clare Blackburn

Group 3

Behaviour change strategies

Harbinder Sandhu Shilpa Patel

Group 4

Promoting Health and Preventing Illness: more than behaviour change

Wendy Robertson Clare Blackburn

Morning

Time

Group 1

Group 2

Group 3

Group 4

9:15 – 9:55 C1 C2 D1 D2

10:00 – 10:40 D2 D1

BREAK

11:00 – 11:40 D1 D2 C1 C2

11:45 - 12:25 C2 C1

Afternoon

Time Group 1

Group 2

Group 3

Group 4

13:30 – 14:10 A1 A2 B1 B2

14:15 – 14:55 B2 B1

BREAK

15:15 – 15:55 B1

B2

A1 A2

16:00 – 16:40 A2 A1


Introduction - The HEALTH Passport.

The HEALTH passport is an evidence-based approach to risk assessing individuals with respect to their

future health. It is estimated that these 10 risk factors account for around 75% of all long-term conditions,

including cancer, before the age of 75 years.

The Individual is assessed and a personalised action plan constructed according the individual’s desire

for optimising future health and local available resources to help change behaviour.


HEALTH Passport: Facts and Action Plan

Physical Activity

Regular exercise can reduce the risk of becoming obese or developing diabetes by 50%.

Weight bearing exercise reduces osteoporosis and fracture risk. Exercise for 30 mins., 5 times a week, reduces the risk of heart disease and stroke.

5 Fruit and Vegetables Daily

Reduces risk of heart disease (20%), stroke (11%), cancer, asthma symptoms of asthma.

Nutrients in fruit and vegetables support bone health and reduce the risk of osteoporosis. Aim to eat 400g of fruit and vegetables daily; this is around 5 handfuls. .

Normal Weight

Being overweight increases risk of diabetes, breast and colon cancer, stroke and heart disease.

If overweight, 5% weight loss reduces diabetes risk by 50% and reduces blood pressure. Reduce your fat, sugar and carbohydrate intake and increase physical activity.

Smoking

Smokers have a 15 times increased risk of lung cancer.

On average, smokers die 10 years earlier than non-smokers. 1 in 6 people successfully stop smoking with Nicotine Replacement Therapy.

Alcohol, Sex and Drugs

Heavy drinkers have 13 x increased risk of liver cirrhosis, increased risk of stroke and dementia.

Over 100000 men and women are diagnosed with the STD Chlamydia every year in UK

Drug use is linked to anxiety, depression and psychosis. Drink responsibly; maximum 2 drinks per day for women and men. Practise safe sex!

Cancer Screening

Cervical screening prevents 6000 women dying of cervical cancer per year in UK.

Up to 1 in 6 colon cancer deaths can be prevented with bowel screening. Be aware of signs and symptoms of cancer (blood anywhere, lump anywhere, weight,

bowel habit change). Attend all invitations to cancer screening. Emotional Well Being

Aerobic and strength exercises can reduce anxiety, stress and mild to moderate depression.

Insomnia leads to increased risk of a psychiatric disorder. Every day try to be physically active, connect with family, friends and neighbours, help

others and positively reflect on one aspect of the day. Learn a new skill.

Blood Pressure

A blood pressure of 140/90mmHg or higher increases the risk of heart attacks and stroke.

Improving your diet and doing more exercise reduces high blood pressure in overweight individuals.

Reduce salt intake to 5g per day, exercise and get your blood pressure checked regularly.

Cholesterol

Too much cholesterol can cause blockages in the arteries leading to heart attacks and stroke.

Statins (cholesterol lowering drugs) can reduce heart disease by 33%. Aim for a cholesterol of below 5mmol/l or below 4 mmol/l in heart disease, stroke or

diabetes patients.

Diabetes Prevention & Control

Men who smoke 40 cigarettes a day are 45% more likely to develop diabetes than non-smokers.

People aged over 45 years or with a waist circumference above 94cm (men) or 80cm (women), a family history of diabetes or history of high blood pressure or heart disease are at greater risk.

4 in 5 cases of type 2 diabetes below the age of 65 can be prevented by weight management (normal BMI), exercise and a healthy diet.



Session 10: OSCE Skills / Revision



Infection Prevention

In Hospital Resuscitation

Moving and Handling

First Aid

Procedural Skills


Procedural Skills

1. Infection Prevention (appendix 4). 2. In-Hospital resuscitation (appendix 5). 3. Moving and Handling (trust specific). 4. First Aid (practical class).

Recommended Reading

1. Practical and Professional Clinical Skills : 7.1, 10.2, 10.3, 7.4 These sessions will be held at one of the following Trusts: 1. George Eliot Hospital in Nuneaton (GEH). 2. University Hospitals Coventry and Warwickshire (UHCW). 3. Warwick Hospital (Warwick).

Students will be allocated to one of the three Trusts for the duration of Phase I.

Attendance at all sessions is compulsory.

Information pertaining to these sessions will either be distributed by the trusts at the sessions or on Moodle.

Trust Induction and Training All students are requested to complete and return the UHCW Occupational Health Questionnaire before starting the course. You will be given an individual appointment with an occupational nurse within the first few weeks of arriving. Each individual Trust will provide training in Infection Prevention, In-hospital resuscitation, First Aid, Moving and Handling. You will each receive an appointment to attend two separate sessions at your allocated trust to complete this training. This training is mandatory and must be completed in Block 1 or 2. Timetables for training will be published on-line and you will be informed by email.


1. GMC - Good Medical Practice 2. Teaching Clinical History and Examination Proforma 3. Joint Medical Colleges Clinical History and Examination Proforma 4. Infection Prevention 5. In-Hospital Resuscitation

Appendices



Appendix 1: GMC - Good Medical Practice

Good Medical Practice: Duties of a doctor registered with the General Medical Council

Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and make sure your practice meets the standards expected of you in four domains. Knowledge, skills and performance Make the care of your patient your first concern. Provide a good standard of practice and care.

Keep your professional knowledge and skills up to date.

Recognise and work within the limits of your competence. Safety and quality Take prompt action if you think that patient safety, dignity or comfort is being compromised. Protect and promote the health of patients and the public. Communication, partnership and teamwork Treat patients as individuals and respect their dignity.

Treat patients politely and considerately.

Respect patients’ right to confidentiality.

Work in partnership with patients.

Listen to, and respond to, their concerns and preferences.

Give patients the information they want or need in a way they can understand.

Respect patients’ right to reach decisions with you about their treatment and care.

Support patients in caring for themselves to improve and maintain their health.

Work with colleagues in the ways that best serve patients’ interests. Maintaining trust Be honest and open and act with integrity. Never discriminate unfairly against patients or colleagues. Never abuse your patients’ trust in you or the public’s trust in the profession. You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions.

GMC 2013



Appendix 2: Teaching Clinical History and Examination Proforma

Teaching Clinical History and Examination Proforma





Appendix 3: Clinical History and Examination Proforma

Clinical History and Examination Proforma Medical Admission Proforma

Patient Details

NHS No: Hospital No:

Name: (First Name, Surname) Address: Post Code:

Telephone: Gender: Male Female Age

Next of Kin: Name Relationship Address Telephone:

GP

Episode Details

Date patient Seen: Time Patient seen

Patient’s Location Source of Referral: GP A&E OPD Other

Clerking Doctor Grade Bleep

Date of Clerking Time of Clerking

Responsible Consultant Other Consulting:

Presenting Complaint (s)

Reason for Admission & Presenting Complaints (include age)

Source of History (patient, relative, interpreter etc):


History of Presenting Complaint (s)

History of each Presenting Complaint:

Relevant Risk Factors:

Past Medical, Surgical and Mental Health History

Significant Co-morbidities: circle and add details ► CVD: Acute Myocardial Infarction, Congestive Failure Respiratory: Pulmonary Disease Neurological: Stroke (CVA), Dementia, Paraplegia Metabolic/Endocrine: Renal Disease, Diabetes, Diabetes Complications Gastro Intestinal: Liver Disease, Peptic Ulcer, Severe Liver Disease Others: PVD, Cancer, Metastatic Cancer, HIV

Details of Operations/Procedures

Mental Health N/Y

Other


Medication Record - Current Medications (including self-medication) in CAPITALS

APPROVED NAME DOSE FREQUENCY INDICATION

1

2

3

4

5

6

7

8

9

10

11

12

Continue here if needed

Relevant Previous Medications

Name: Dose, Frequency, Relevant details

Allergies & Adverse Reactions (including details of reaction)

Relevant Legal Information

Advance decisions to refuse treatment, lasting power of attorney or deputy, organ donation, (mental capacity)


Social History

Lifestyle Functional Status

Current Smoker: _____ per day for _____ years, = ____ pack years

Ex-smoker : _____ per day for ______ years

Never smoked

Alcohol consumption: Units per week = ? binge (6 U women, 8 U men)

Physical Activity: Minimal Active Regular Exercise/Very Active

Diet: Driving Status:

WHO Functional Status: 0 Asymptomatic

1 Symptomatic but completely ambulatory

2 Symptomatic, <50% in bed during day

3 Symptomatic, >50% in bed, not bedbound

4 Bedbound

Social and Personal Circumstances

Occupation: Current Previous (where relevant)

Marital Status: Single Married Widowed Divorced Partner

Housing: House Flat Bungalow Sheltered flat Residential home Nursing home Other Lives alone? Y/N

Communication Language and Communication Difficulties

Services and Carers:

Main Carer Home care (frequency) District nurse Meals on wheels Other Needs and Services

Other relevant social history (eg. recent travel):

Family History

Systems enquiry

CVS RS GIT UT CNS MS ENDO OTHER ?RED FLAGS

Patient’s Ideas, Concerns, Expectations


Clinical Observations and Examination

Vital Signs:

Date & Time:

BP HR Temp.

B Glucose Resp. R O2 Sats % on

Weight Height BMI

General Appearance:

Jaundice N/Y= Pallor N/Y=

Cyanosis N/Y= Lymphadenopathy N/Y=

Oedema N/Y= Clubbing N/Y=

Unwell N/Y= Other

Cardiovascular System:

Rate Apex Beat Rhythm Pulse character Heart sounds JVP Other: eg oedema, lung bases

Peripheral Pulses R Femoral Popliteal Dorsalis pedis Post tibial

L Femoral Popliteal Dorsalis pedis Post tibial

Respiratory System:

Resp Rate /min Breath sounds ? Peak flow:

Abdomen:

Notes: PR: Normal Abnormal Not done


Nervous System:

Fundi R L

Pupils Tone: UL

Cranials Nerves:

LL

Power: UL

LL

Co-ordination Reflexes: Biceps

Sensation Supinator

Gait Triceps

Other: Knee

Ankle

Plantars

Structured scales:

Glasgow Coma Scale (GCS)

Eyes opening Motor response Verbal

1: None 2: To pain 3: To speech 4: Spontaneous

1: None 2: Decerebrate extension 3: Decerebrate flexion 4: Flexion withdrawal 5: Localises to pain 6: Obeys commands

1: Silent 2: Incomprehensible sounds 3: Inappropriate words 4: Confused 5: Orientated

Coma < 8 GCS Total = Max 15

Mini Mental Score (MMS)

1: Age 1: Date of Birth

1: Recall 42 West Street, Salford 1: Dates of World War II (recall at end)

1: Present Monarch 1: Name of Hospital

1: Count down from 20 1: Year

1: Time to nearest hour 1: Recognises 2 people or objects

MMS Score = Max 10

Physical Function eg Barthel Cognitive Function (eg AMT, MMSE)

Genito-Urinary:

Musculo-skeletal:

Skin:

Other Observations


Problem list , Working Diagnosis, Differential Diagnosis

Discharge Planning

Investigations & Initial Procedures : Tick if requested, insert results (abnormal results underlined or in red):

FBC U&Es LFTs Calcium

Group & Save Amylase INR ABG

Urine Dip MSU βHCG

ECG CXR Abdo Film CT Head

Other Ix requested:

Results

Hb Na ABG 2 on: ABG 1 on:

WCC K H+ H+

Plts Urea pH pH

HCT Creatinine pCO2 pCO2

MVC eGFR pO2 pO2

Neutrophils Glucose Bicarb. Bicarb.

Lymphocytes Calcium Base Excess Base Excess

Eosinophils LFT: Normal or Abnormal

O2 Sats %

O2 Sats %

Basophils Total Protein Other Investigations

Monocytes Albumin

Blood Film Bilirubin

Alk Phos

CRP ALT

GTT LDH

Amylase

Urine Analysis

Leucocytes Protein: Blood: Ketone: Glucose: HCG:

ECG ECG Normal/Abnormal:

Rate Rhythm Axis/BBB ? old MI ? ischaemic ?MI

Conclusion:

Other Imaging/Investigation CXR


Management Plan

Summary and interpretation of findings: Initial Plan

Information given to the patient and/or authorised representative:

Next steps:

Monitoring required:

Specialist Registrar/Senior Review

Person Completing Clerking: (Doctors name, grade and signature) GMC No:


Post Take Ward Round

In Charge Person Conducting Post-Take Ward Round: (Doctors name, grade and signature) GMC No: Discharge Plan:

Resuscitation status


Appendix 4: Infection Control Hand Washing with Soap and Water: When can you use gel wash?



Appendix 5: In-Hospital Resuscitation

In Hospital Resuscitation: 2015 UK Resuscitation Council Algorithm

Documents

CSc 1 - MedEd · Edited by Vinod Patel and John Morrissey. Oxford University Press 2011/2012. ISBN: 019958561X and 2. Macleod’s Clinical Examination: Latest Edition 13th 2013. Edited