Ethics and Comms Asking for post-mortem Brainstem death and organ donation Breaking bad news Consent A. Procedure/treatment B. Mentally incapacitated patient/emergency C. Children D. Clinical trial Counseling A. Genetics B. HIV testing C. Non-compliance D. Smoking E. Organ transplant F. Hormone replacement therapy G. Compensation Negligence – Dealing with the Angry Patient Resuscitation in a terminally ill patient To ventilate or not Withdrawing treatment History General 1. Cardio 2. Respiratory 3. Gut 4. Genitourinary 5. Neurological 6. Musculoskeletal 7. Thyroid Chest pain Dyspnoea Palpitations Syncope Cough Dysphagia Nausea and vomiting Dyspepsia Diarrhoea Constipation Upper GI bleeding Anaemia Headache Blackouts Dizziness/vertigo Rheumatological history Back pain Inflammatory arthritis

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Asking for post-mortem

A. Academic 1. Introduction and niceties - introduce yourself - clarify relatives identity and relationship - establish that he is main spokesperson - condolences - pause – allow relative to express emotion 2. Summary of events - establish level of understanding - current admission - clinical condition leading to death - explain doctors surprised by suddenness of death - possible explanations/causes of death, doctors unsure - pause: absorb news, may challenge on why these alternative explanations 3. Issues a. Establish level of understanding b. Did deceased express any objections previously c. Aims of post-mortem - cause of death, family to come to terms - information for familial disease - information for doctors treat other patients - research d. Details of post-mortem i. full vs limited ii. logistics - within 2-3 working days - pathologist - 3h with lab Inx up to several weeks - body released on day of examination unless in late pm - delay if relative requests for parts/organs to be reunited iii. details - detailed internal examination - may not be 100% conclusive - pathologist, hospital mortuary - external exam - internal exam via incision anteriorly: internal organs - incision at base of scalp - not disfigured

e. In event of suspicious findings i. retention of tissue and fluids for Inx to establish cause ii. retention of organ if agreeable (research, education) - consent form - inform in writing if organ retained - information on length of retention - if any point relative wants back, will dispose in proper way or return for cremation/burial iii. fixed and returned to body iv. results of findings can be obtained from consultant in charge 4. Closing a. depending on decision re organ retention - yes: will still give death cert for funeral arrangements - no: respect her wishes and explain death certificate diagnosis

B. Coroner's case or procurator fiscal 1. As above 2. Except - coroner is an independent officer - drs have discussed case with coroner - coroner will ask pathologist to carry out post-mortem - findings will be sent to coroner who will then issue death certificate - representative of the coroner will inform relatives when to proceed with funeral arrangements

Brainstem death and organ donation 1. Introduction and niceties - introduce yourself - clarify relatives identity and relationship - establish that he is main spokesperson - comfortable 2. Summary of events - establish level of understanding - current admission 3. Issues a. Brainstem death - no signs of improvement - not regaining consciousness in spite of sedation turned off - reason - irreversible brain damage, will never wake up - relient on machine to breathe - tests, pronounced dead - patient has passed away - inappropriate to continue ventilating a dead person - next step – stop the machine, what would happen

- clarify that turning the machine off will not cause death as already dead b. Organ donation i. Explain - dead but no damage to other organs - as doctors, it's our responsibility to discuss with you about organ donation for such situations - clarify o objections: deceased, family, religious o signed donor card, donor registry ii. Decision (1) any objections, not for organ donation (2) no objections - indications and benefits for other people - Procedure o transplant coordinator and team o they will speak to family o ensure no cancer/hep B/hep C o if agreeable, will continue ventilation till organs are retrieved o no pain as brainstem dead (3) if need time to think - I understand that you and your family is going through a difficult time - I do not expect you to make a decision right now - I will be around the whole of today and we can meet up later 4. Closing a. Summarise (skip) b. Advice and assure: offer condolences c. Course of action - continue ventilation till we meet later - preparation of death procedures - time of death would be when test was done this am d. Support - provide a room for you and your family - nurse, counsellor e. Next appointment

Breaking bad news *Anticipate other ethical issues as well*

1. Introduction and niceties - Introduce - Confirm identity - Ask if she has brought a family member and she wants him to be around 2. Opening statement - state purpose of visit

- how have you been since procedure/last visit - what previous doctor explained/what patient understands 3. Issues a. BBN - warning shot - tell report/news - allow pauses - expect: anger, denial, expecting worst - what she understands about report - explain simply - silver lining o treatable o well established treatment o not all patients have bad prognosis - allow pauses and reaction - more detailed explanation if patient is ready b. Concerns - ICE c. Plans - refer immediately to specialist: I am not expert, best available therapy - investigations - management plans and treatment options - assure: integrated centre - social support: friend, work, others eg church 4. Closing - summarise management plan - assure patient - arrange another appointment few days time to answer queries - bring family/friend next appointment - offer contact number - support group - contact GP if she wants as may be comfortable with him - arrange transport

Consent

A. Procedure/treatment 1. Introduction and niceties - introduce - clarify identity, official proxy (Scotland) 2. Summary - purpose of interview - what he/she understands - explain condition leading to procedure, update condition

3. Issues a. Indications b. Contraindications c. Procedure details - pre - during - post d. Side effects and monitoring after that e. Consequences of not doing procedure f. Explore concerns and expectations 4. Closing a. Check if patient understands b. Offer options and option not to treat c. Give time to consider

B. Mentally incapacitated patient/emergency 1. Introduction and niceties - introduce - clarify identity 2. Summary - purpose of interview - what he/she understands - explain condition leading to procedure, update condition 3. Issues a. Procedure - Indications - Contraindications - Procedure details: pre, during, post - Side effects and monitoring after that - Consequences of not doing procedure - Explore concerns and expectations b. Assessment of mental capacity - It is the responsibility of the doctor to decide mental capacity - if limited, have to explain to patient still in simple terms - if discrepancy regarding capacity, engage senior psychiatrist opinion or 'appointed medical practitioners' (in Scotland) - assessment with ReC test (comprehend and retain treatment information, believe it, weigh it up and arrive at choice) c. Best interest principle - options considered and individualised - patient's opinion previously, advance statement (autonomy overrides beneficence) - patient's views from a third party eg close relative - necessity principle: o procedure to ensure improvement or prevent deterioration, save patient's life o if in emergency, if patient has refused treatment

d. Advance directives - patient has a right to refuse treatment - patient can request for treatment but doctors not obliged to followe - only exception is CPR if patient insist even if doctors feel not appropriate 4. Closing a. Check if relative understands b. Offer options and option not to treat c. Give time to consider

C. Children i. Gillick in Scotland - if child deemed to understand and make his/her own decision, child can make decision ie Gillick competent - this applies only to consent and not refusal of treatment - If there is discrepancy between child and doctors opinion in 'best interest' principle, seek advice from courts ii. Parental consent - just one parent is sufficient - both parents must be married at time child was conceived and born - if not married, only mother has parental rights iii. For consent, 16-17 yo considered as adult (even though adult is 18 and older) iv. Pregnant female - makes decision for both herself and child even though decision may endanger life of unborn child

D. Clinical trial 1. Introduction and niceties - introduce - clarify identity 2. Summary - purpose of interview - what he/she understands - update condition 3. Issues a. Background - aim and purpose of trial - suitable candidate - providing an option for him - assure that it has been approved by Ethics committee b. Explain trial - method of treatment - drug vs placebo - blinding - advantages - side effects - monitoring c. Reassure - no change in standard medication and care of treatment whether or not he wants or not to

participate - treatment of complications - others have participated in trial - autonomy: can opt out anytime - beneficience: trial may stop prematurely if there is an obvious danger/advantage - confidentiality: assure this but sponsors & ethics committee & GP - financial aspects of extra Inx and Mx 4. Closing a. Check if understands b. Give time to decide - information and phone number - obtain consent in writing

Counseling A. Genetics 1. Introduction and niceties - introduce - clarify identity 2. Summary - what she understands about the condition - why she wants test - must not be coerced - ICE 3. Issues Definition = analysis of human DNA, RNA, chromosomes, proteins, or certain metabolites in order to detect alterations related to a heritable disorder a. Clarify about index case - diagnosis and accuracy - draw family tree: parents, siblings, cousins, aunts, uncles - is she married - is there a confidante (should not be someone who is also at risk) b. Explain the condition (check what she knows and what she wants to know) - nature: symptoms and signs - treatment - prognosis - AR, AD, X-linked c. Procedure - pre-test counselling, referral to regional genetic centre - test itself: blood test, genetic make-up - false positive and false negative - post test follow-up, assignment of counsellor d. Implications - medical, worry

- social: job, marriage, children - financial: insurance, social security - careful o test may reveal status of relative who does not want to know o test may reveal other information eg parent may not be biological parent - may need DNA from a relative who may not want to do or know the test 4. Closing (Plan) - advice to make another appointment in 1 month's time to think about it - options: not taking test, deposit for research of future use - there is time: no need to make the decision now - referral to regional genetic centre if she wants to proceed with the test o multidisciplinary team: neurologist, geneticist, MSW, psychiatrist

B. HIV testing 1. Introduction and niceties - introduce - clarify identity 2. Scenarios a. Patient wants test - find out why b. Referred for possible AIDS defining illness - find out about his condition eg SOB - explain results of Inx which led to possible diagnosis of HIV - ICE c. Screening - pregnancy - blood donation - insurance 3. Issues a. Nature of HIV infection - transmission - difference between HIV and AIDS - how to reduce transmission b. Risk activities, last date of such a risk and perception of need of test - sex - drugs - blood products - occupational risk, tattooing, travel - previous HIV test c. Benefits/advantages i. Patient - allow appropriate medical care - prophylactic care - future decisions - reduce anxiety about not knowing

ii. Loved ones - subsequent sexual partners, spouse - vertical transmission d. Difficulties - anxiety - impact on family, partners and work - insurance - explore how he would take it if test if positive e. Test - procedure: blood test, detection of antibodies to HIV - sensitive test: if negative no retesting; if positive will do confirmatory test - results ready within 24 hours - confidentiality - negative results: no antibodies detected = no HIV or window period (usually 3 months but maybe longer --> repeat 3-6 months later if recent exposure) - positive results: very rarely false positive - indeterminate: follow-up blood test for direct virus testing and repeat Ab testing, could be seroconverison period f. Support - who he wants to inform him of test result eg GP - who he wants to be present - who to share result with: regular sexual partner, GP - post-test counselling, support group, leaflets, internet, phone number g. Informed decision and consent form voluntarily 4. Closing - summarise - advice and that he need not decide right away - advice on current problem and treatment plan - avoid transmission - ask if he wants to screen for other STDs, Hep B, C and syphilis 5.Special situation: Pregnant mother - TOP (24 wk in UK) - prophylactic treatment with AZT to reduce vertical transmission - avoidance of breast feeding

C. Non-compliance 1. Introduction and niceties - introduce - clarify identity 2. Summary - ask how he has been - update that condition not improving based on objective findings - offer reasons eg meds not taken properly, have you been having difficulty with meds

3. Issues a. If confess and justify - side effects - inconvenience - inability to hold meds - forgetfulness - unsure indications - don't know how to take the medications or the right dose, complicated - not working and he feels fine - cannot swallow, bad taste - too many tablets b. If deny and say everything is fine - explain you are concerned he is not improving - explain test shows no improvement - ask how many tablets left at home - aware he has not collected prescription - ask for effect eg red discolouration of urine with rifampicin - explore above reasons c. Advice - Acknowledge difficulty with long term meds and side effects, understand difficulties - Explain condition and importance of treatment 4. Plan - to solve problems he had earlier attributed to, explain side effects - eg DOT, 3x/week rather than daily, less tablets with combinational - involve GP - alternative employment (infectious risk)

D. Smoking 1. Smoking history - how long, how many packets, type and brand - increasing/decreasing - pleasure, after work, when stress - tried quitting, what happened then - withdrawal symptoms - illness – cough, dyspnoea CVS - FH of smoking and illness 2. Social history - married, children - who he lives with - what are their opinion 3. Benefits of quitting - CVS, resp - breathe easier, taste sharper - financial

- good for children and loved ones - many have been successful 4. Fears and offer solution a. Withdrawal (restless, irritable, lack of sleep) - nicotine replacement (gum, patches, inhalers) and bupropion - these double the chance of successfully quitting - NRT start on quit date (2 weeks supply initially); have localised reaction and may have mild sleep disturbancde - bupropion start 1 week before quit date (3 weeks supply initially); 0.1% of seizures and 0.1% of severe hypersensitivity reaction; 3% has rash/urticaria/pruritus and c/o dry mouth and insomnia - not for 3-6 months because systemic absorption of oestrogen - tablets, patches, implants, nasal spray (oestrogen), Mirena (IUD with progesterone), vaginal ring with oestrogen only and for hysterectomised patients and bleed free HRT - all women with uterus must have progesterone

3. Uses a. for menopausal symptoms (normally lasts 6 months to 2 years) - hot flushes - vaginal atrophy - frequency, urgency, dyspareunia, night sweats, irritability b. premature menopause up to age 50 c. Osteoporosis d. Reduce risk of colorectal cancer 4. Risks - CHD - CVA - PE/VTE - breast cancer, ovarian cancer, uterine cancer - dementia 5. Side effects - breast tender - vaginal discharge - nausea, weight gain, irregular bleeding, headaches - progesterone: premenstrual tension, depression, ankle swelling, jaundice - increase size of gallstones 6. Alternatives - homeopathic - phyto-oestrogens

G. Compensation 1. Indications - asbestosis - silicosis - coal worker's pneumoconiosis - byssinosis - mesothelioma 2. Details - form B1 - MO from Social Security visit - compensation backdated 3/12 except for mesothelioma - have up to 1 month to dispute degree of disability

Negligence – Dealing with the Angry Patient Scenarios - delay in investigative management - postponing an investigation - adverse event (wrong medication)

1. Introduction 2. Acknowledge/apologgise - serious - sorry to have caused so much work and distress - I want to let you know that as we speak, your mother is now stable 3. Listen - look in the eye - expect anger, crying, wanting to complain/sue doctor 4. Explain a. Never openly criticize colleague/department b. Factual - eg: breakdown in communication which should not have happened - reason for mishap – eg sincerely did not know, best interest c. Corrective measures 5. Plan a. Patient (rectify problem) - calling/speaking to person eg radiologist - get patient's phone number, stay in clinic and I'll get it sorted out now - other measures to speed up process from now onwards o make up for lost time o earlier report date o earlier referral to oncologist/surgeon b. Consultant - inform consultant c. Clinical incident report to management team - this is a mistake that should not have happened - measures to ensure that this does not happen again - inform of outcome in 3 days time 6. Closing - patient satisfied, proceed as above - patient wants to complain, obtain contact information for him to do so

Resuscitation in a terminally ill patient 1. Introduction - introduce - clarify - comfortable 2. Summary - aim

- what relative understands 3. Issues a. Grave prognosis - elaborate from what she understands - offer condolences - patient is very ill - explain o underlying condition o Inx o what has been done o what doctors have discussed with him - ask if patient had discussed condition with family - remove guilt eg patient did not want to burden (reason), family could not have prevented this - get her to agree main aim – as comfortable as possible, free of pain - inform that patient likely to die this admission and possibly in next few hours b. Resuscitation - ask if she understands what this is - if she does not o if patient stop breathing/heart stop beating o give oxygen through a plastic device in throat o give medication to artificially make heart beat o give chest compressions - has patient expressed wishes - ask her about her thoughts - this may bring heart back for a while o but painful process for patient and does not help him o it will be unsuccessful, prolonging suffering o comfortable with dignity and self esteem o medical team has made decision re DNR 4. Closing a. Plan - admit to side room for privacy - comfort: O2, fluids, subcutaneous morphine - ask religion, offer hospital chaplain to say prayer b. If she insists - respect her wishes - offer plan as above - will speak to consultant and arrange another appointment - if religion is issue, engage spiritual guide of her faith

To ventilate or not 1. Introduction - introduce - clarify identity

- comfortable 2. Summary - purpose - what he understands 3. Issues a. Informing how ill patient is - update latest findings and Inx - coupled with underlying condition - currently how doctors are managing him - patient is ill such that he will pass away soon unless he is artificially supported by machine to breathe - in order to advice on options, need to discuss re condition b. Premorbid - normal state, ADLs - ex tolerance - depressed? - condition: severity and management eg LTOT/neb, admission, ICU, intubation, Cx, difficulty weaning off - other condition c. Ventilation - options: FM/NIPPV/ventilation 1st 2 likely fail and risk of death quite high - aims and benefits: remedial reason, first episode, acceptable quality of llife - discouraging factors: advanced COPD with poor quality of life - procedure: plastic tube passed into windpie and connected to a machine, tubes in arms and neck for fluids and antibiotics - risks: infection, pneumothorax, lung bursting, difficulty weaning off, psychosis, death - check if patient has stated any wills, living will - check family and relatives' vies 4. Closing - summarise - support - plan - next appointment, pager number

Withdrawing treatment 1. Introduction - introduce - clarify identity, decision maker - comfortable 2. Summary (see next heading) 3. Issues a. BBN

- find out what relative understand - summarise events so far - sorry that he has not responded to treatment and remains ill despite all efforts to treat him - outlook poor and patient going to die b. Withdrawing treatment - everyday, team discusses treatment regimens as well as withdrawing and withholding treatments - ITU team feels that continuing treatment not going to help patient - difficult decision for ITU team to make, withdrawing is a sad undertaking for medical team - aim to do what is best for patient - does relative understand 'withdrawing treatment' - find out o pt's wishes, requests, AMD, living will o relative's wishes - procedure of withdrawing and outcome - say should not feel guilty as decision to withdraw is a medical one - reassure palliative measures 4. Closing - do not need to make decision right away - summarise, support, advice, next appointment, oager Note legal – withdrawing artificial nutrition and hydration for persistent vegetative state, court's decision

History

General 1. Cardio - chest pain - exertional dyspnoea - exercise tolerance and change - PND, orthopnea and quantify - oedema - palpitations (awareness of heartbeats)

2. Respiratory - cough - sputum - haemoptysis (coughing up blood) - wheeze

3. Gut a. abdominal pain - constant or colicky - sharp or dull - site - radiation

- duration - onset - severity - relationship to eating and bowel action - alleviating or exacerbating - assoc features b. other questions - swallowing - indigestion - nausea/vomiting - haematemesis - bowel habit c. Stool - colour, consistency, blood, slime - difficulty flushing away - tenesmus or urgency - melaena

4. Genitourinary a. Urine - incontinence: stress or urge - dysuria - haematuria - nocturia - frequency, polyuria - hesitancy - terminal dribbling b. O&G - vaginal discharge - menses: frequency, regularity, heavy or light, duration, painful - first day of LMP - menarche, menopause - any chance of pregnancy now

5. Neurological a. Special senses - sight, hearing, smell, taste - seizures, faints, funny turns - headache - pins and needles (Paraesthsiae) or numbness - limb weakness - poor balance - speech problems - sphincter disturbance - higher mental function, psychiatric b.Function

6. Musculoskeletal - pain

- stiffness - swelling of joints - diurnal variation - functional deficit

7. Thyroid a. Hyperthyroidism - prefers cold weather - bad tempered - sweaty - diarrhoea - oligomenorrhoea - LOW (often increased appetite) - tremor - palpitations - visual problems b. Hypothyroidism - depressed, slow, tired - thin hair - croaky voice - heavy periods - constipation - dry skin - prefers warm weather

Chest pain 1. Nature - constricting: angina, oesophageal spasm, anxiety - sharp: pleura, pericardium - MI: prolonged (>30min), dull central crushing pain/pressure 2. Radiation - cardiac: shoulder, either/both arms, neck/jaw, epigastric - aortic dissection: instantaneous, tearing, interscapular/retrosternal 3. Precipitants a. Cardiac/Anxiety - cold - exercise - palpitations - emotion b. Oesophageal spasm - food - lying flat - hot drinks - alcohol c. Inspiration - pleuritic: pulmonary infection, inflammation, infarction

- musculoskeletal - fractured rib (+ gentle pressure on sternum) - subdiaphragmatic pathology eg gallstones 4. Relieving - rest/GTN: angina (minutes), oesophageal spasm (slow) - antacids: GI - leaning forward: pleuritic pain 5. Associations - dyspnoea (cardiac, PE, pleurisy, anxiety) - nausea, vomiting, sweating (MI) - anaemia: angina - tenderness (Tietze's syndrome) - AS, HOCM, pSVT: angina

Dyspnoea 1. Severity - at rest - exertion, exercise tolerance - daily tasks - eg not a/w exertion, at rest: psychogenic eg prolonged hyperventilation causing respiratory alkalosis and apprent hypocalcaemia 2. Associations - heart failure: orthopnoea, PND, peripheral oedema - PE: acute onset, pleuritic chest pain, risk factors for DVT - ascites - metabolic acidosis with respiratory compensation eg ketoacidosis, aspirin poisoning - S/S apparent hypocalcaemia: peripheral and perioral paraesthesiae +/- carppedal spasm 3. Precipitating factors - occupational allergen - anaemia

Palpitations 1. Nature - irregular fast: pAF, atrial flutter with variable block - regular fast: pSVT/VT - dropped or missed beats (related to rest, recumbency, eating): atrial/ventricular ectopics - regular pounding: anxiety - slow palpitations: drugs eg beta blockers, bigeminus 2. Previous episodes 3. Precipitating/relieving factors - worse at night: anxiety 4. Duration of symptoms

5.Associated - chest pain - dyspnoea - dizziness - faints

Syncope 1. Prodromal - cardiac: chest pain, palpitations, dyspnoea - CNS: aura, headache, dysarthria, limb weakness 2. During episode - pulse (eg vasovagal: pulse reduced, pupils dilated) - limb jerking - tongue biting - urinary incontinence 3. Recovery - rapid: arrhythmia - prolonged, with drowsiness: seizure

Cough 1. Timing - chronic: pertussis, TB, foreign body, asthma (eg nocturnal) - dry chronic: oesophageal reflux, ACEI - nocturnal (asthma) 2. Character - loud, brassy: pressure on trachea eg by tumour - hollow, bovine: recurrent laryngeal nerve palsy - barking: Acute epiglotitis 3. Exacerbating factors 4. Sputum/haemoptysis - black carbon specks: smoking - yellow/green: infection eg bronchiectasis, pneumonia - pink frothy: pulmmonary oedema - haemoptysis: malignancy, TB, infection, trauma

Dysphagia 1. Nature - solids and liquids from start: motility disorder (achalasia, neurological) or pharyngeal causes - solids then liquids: stricture (benign or malignant) 2. Difficulty making swallowing movement - bulbar palsy (esp if coughs on swallowing) 3. Odynophagia - cancer, severe oesophagtitis, achalasia, oesophageal spasm

4. Timing - intermittent: oesophageal spasm - constant and worsening: malignant stricture 5, Neck bulge or gurgle on drinking - pharyngeal pouch

Nausea and vomiting 1. Timing - relationship to meals 2. Amount 3. Content - liquid, solid, bile, blood, coffee grounds 4. Others - associated symptoms - past medical history

Dyspepsia 1. Non-specific symptoms - epigastric pain related to hunger - eating specific foods - time of day - bloating +/- fullness after meals - heartburn (retrosternal pain with demonstrable acid reflux) 2. Alarm symptoms - anaemia (iron deficiency) - loss of weight - anorexia - recent onset of progressive symptoms - melaena/haemtemesis - swallowing difficulty

Diarrhoea 1. Onset a. Acute: gastroenteritis - travel - change in diet - contact history b. Chronic diarrheoa alternating with constipation - irritable bowel 2. Organic cause - anorexia - weight loss - nocturnal diarrhoea - anaemia

3. Bleeding - bloody diarrhpea - Mucus: IBS, colorectal cancer, polyps - Pus: IBD, diverticulitis, fistula/abscess 4. Large bowel symptoms - watery stool +/- blood or mucus - pelvic pain relieved by defecation - tenesmus - urgency 5. Small bowel symptoms - periumbilical or RIF pain not relieved by defecation - watery stool or steatorrhoea 6. Non GI causes a. Drugs - antibiotics - PPI - cimetidine - propranolol - cytotoxics - NSAIDs - digoxin - alcohol - laxative abuse b. Medical conditions - thyrotoxicosis - autoimmune neuropathy - Addison's disease - carcinoid syndrome

Constipation 1. Stool - frequency - nature - consistency - blood/mucus in/on - diarrhoea alternating with constipation - recent change in bowel habit - diet - drugs

Upper GI bleeding - previous GI bleeds, dyspepsia, known ulcers - known liver disease/oesophageal varices - dysphagia

- vomiting - weight loss - drugs, alcohol - serious co-morbidity (bad for prognosis): cardiovascular disease, respiratory disease, hepatic or renal impairment, malignancy

Anaemia - underlying cause - fatigue - dyspnoea - faintness - palpitations - headache - tinnitus - anorexia - angina (existing CAD)

Headache 1. Acute single episode - meningitis: fever, photophobia, stiff neck, rash, coma - encephalitis: fever, odd behaviour, fits, reduced consciousness - tropical illness: malaria, +ve travel history, flu like illness - subarachnoid: haemorrhage – sudden headache +/- stiff neck - sinusitis: tender face + coryza + post-nasal drip - head injury: cuts, bruises, reduced consciousness, lucid interval, amnesia 2. Acute recurrent attacks - migraine: pre-attack aura, visual aura, vomiting, sensitivity to light/noise/movement - cluster headache: nightly pain in one eye for 8 wk then ok for next few months, intermittently repeated - glaucoma: red eye, sees haloes, fixed big oval pupil, reduced acuity - recurrent (Mollaret's meningitis): fever, access to subarachnoid space via skull fracture, recurring cause of aseptic meningitis (SLE, Behcet's, sarcoid) 3. Subacute - giant cell arteritis: tender scalp, >/= 50 years old, threat to vision 4. Chronic - tension headache: tight band round head, stress at work/home, low mood - chronically high ICP: worse on waking, focal signs, BP high, pulse low - medication misuse headache

Blackouts 1. Meaning - LOC

- fall to ground without loss of consciousness - clouding of vision, diplopia or vertigo 2. Before attack - warning: typical epileptic aura, pre-syncope - in what circumstances (eg TV – epilepsy) - can prevent attacks? 3. During attack - lose consciousness - injure self - move: floppy or stiff (epilepsy) - incontinence (epilepsy: faeces) - complexion change (white/red: arrhythymia, temporal lobe epilepsy) - bite tongue (epilepsy) - pulse - assoc symptoms: palpitations, chest pain, dyspnoea - how long does attack last - is patient sleepy before attack 4. After attack - amnesia - muscle pain: tonic/clonic seizure - confused/sleepy: post-ictal, narcolepsy 5. Background to attacks - increasing frequency - family history, hereditary cardiomyopathy

Dizziness/vertigo 1. Assoc symptoms - difficulty walking/standing - relief on lying or sitting still - nausea, vomiting - pallor - sweating - fall suddenly to rgound - assoc hearing loss/tinnitus: labyrinth or 8th nerve involvement

Rheumatological history 1. Presenting symptoms a. Joints - pain, morning stiffness (eg RA) - pattern of distribution - swelling - loss of function

b. Extra-articular - rashes, photosensitivity (eg SLE) - Raynaud's (SLE, CREST, dermato/polymyositis) - dry eyes/mouth (Sjogren) - red eyes (ankylosing spondylitis) - diarrhoea/urethritis (Reiter's) - nodules or nodes (RA, TB) - mouth, genital ulcers (Behcet's) - weight loss (TB, arthritis) 2. Age, occupation, origin 3. Related diseases - Crohn's/UC - ankylosing spondylitis - psoriasis - gonorrhoea - Reiter's associated arthritis 4. Drugs - DMARDs - NSAIDs 5. Family history - arthritis - psoriasis - autoimmune disease 6. Social history - functioning eg dressing, writing, walking - domestic situation - social support - home adaptations - smoking (may worsen RA)

Back pain 1. Onset: sudden (related to trauma?), gradual 2. Motor or sensory symptoms 3. Bladder/bowel involvement 4. Sciatica Red flags - age 55 yo - acute onset in elderly - constant or progressive pain - nocturnal pain - increasing pain on being supine - morning stiffness - fever, night sweats, weight loss - history of malignancy

- thoracic back pain - bilateral or alternating symptoms - neurological disturbance - sphincter disturbance - leg claudication (spinal stenosis) - current or recent infection - immunosuppression eg steroid/HIV - abdominal mass

Inflammatory arthritis - pain - stiffness (esp early morning >30 min) - joint inflammation (swelling, redness, warmth) - loss of function