MB ChB Programme

Headache block GP teacher guide,

Effective Consulting, Year 2 Academic Year 2018-2019

University of Bristol, 2018

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Introduction and link to course and teaching information Clinical Contact, Primary Care in Teaching Block Two, Year 2 2018-19

Dear GP tutor,

This is the session guide for headache. This session is slightly different from previous sessions in that

the Year Two students have their first OSCE exams the week after this session and will appreciate

being able to practice skills in the clinical environment during their time with you. I suggest half the

session looks at gathering the history in headache, but the second half of the session is a chance to

practice examinations and skills.

All the main information on the course is available in the year 2 18-19 GP handbook so please refer

to this for information on how key dates, how the course is structured including assessment, your

role, expectations of your students and teaching tips such as giving feedback. This is available here:

https://www.bristol.ac.uk/media-

library/sites/primaryhealthcare/documents/teaching/handbooks/Year%202%20Effective%20Consult

ing%20Primary%20Care%20Teacher%20Guide%202018-19.pdf

This also contains information on the support that is available for students, however I am always

happy to discuss any student you have concerns about.

I would encourage you to find a couple of minutes for each of the students at the end of the session

to give them individual feedback.

I am always happy to be contacted if you wish to discuss any aspect of the course and welcome your

comments, feedback and suggestions. With all best wishes for teaching in the year ahead.

Dr Jessica Buchan

GMC Outcomes for Graduates

The GMC have updated guidance on what they expect newly qualified doctors to be able to know

and do. The outcomes have been aligned to Good medical practice and are categorised as

professional values and behaviours, including professional and ethical responsibilities and patient

safety; professional skills including communication and interpersonal skills and diagnosis; and

professional knowledge. Please be familiar with this document:

https://www.gmc-uk.org/-/media/documents/dc11326-outcomes-for-graduates-2018_pdf-

75040796.pdf

The outcomes of particular relevance to teaching in Clinical Contact in Year 2 are; 2d, e, j & u. 5a, b &

d. 6a. 7b & h. 10a. 11a, b, c & d. 12. 13. 14a, b, c & d. 20. 22b & c. 23a, c, d, &e. 24d &e. 25a

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Structure of the Effective Consulting Day and Key Dates

The ILOs for each EC day covered in this session plan cover the whole EC day, which is delivered to

varying degrees by lecture, EC lab and clinical contact.

Clinical contact alternates for each student in each CBL “case” between primary and secondary care.

We try and align the teaching across settings much as possible.

In both primary and secondary care students should:

• Have a brief tutorial (to orientate the students to the task)

• Meet patients to practise focused gathering of information from history and examination

and consider clinical reasoning.

• Present back the patients they’ve met

• Be helped to consider the patient perspective, impact of the illness or problem on patient

lives, and to consider what support and future needs patients have.

• Be starting to consider variations in presentation, differential diagnosis and what they might

do next.

• Get feedback on any observed history and examination, and on their clinical reasoning and

presentation skills

• Debrief in the group (usually without the patient present) to ask questions and consolidate

learning

Dates Case Based learning symptom

Key learning goals in clinical contact

Types of patients

Thursday 23rd May 2019

Headache Clinical presentation and assessment of patients with headaches. OSCE revision: CVS & respiratory examination and manual blood pressure

Patients with recurrent headaches e.g. migraines or previous significant headache e.g. Temporal arteritis, Subarachnoid haemorrhage, raised ICP. Any patient suitable for examination or skills practice

May 29th/30th OSCE EXAM

Thursday 13th June 2019

Collapse Assessment of patient with history of collapse. Introduction to Neurological examination

Ideally patient with previous collapse (fit or faint) from any cause including seizure. Patient suitable for neurological examination

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Framing teaching the medical history and examination in the “Clerking Consultation” &

COGConnect

Medical students do not yet “consult” with patients as such, as they are still learning how to.

Instead, on the Effective Consulting course we talk about the “clerking consultation” they “clerk”

patients for training purposes in part to learn about medicine from the patient's narrative—what

happened, what symptoms the patient experienced and what the outcome was. In this way student

doctors build up a bank of illness scripts. We know the more exposure student doctors get to

patients, the more experience they build up, so we are very grateful you help provide this

experience. They also practice speaking to patients to learn how to talk to patients and assess

problems—in other words they are learning how to consult. Therefore, here in Bristol we call the

process the clerking consultation, as we want to emphasise the active hands on practice students get

in consulting. You can help this process by spending some time directly observing the students

speaking to patients, and by listening to them presenting summaries back to you. Where you have

observed, please give feedback not only on the content of the clerking, but on the process. It’s also

particularly helpful to students learning if you get them to commit to what they think is going on and

what they might want to do next—to start student “thinking like a doctor”.

In MB21 in Bristol we have taught the medical students to think about all aspects of consulting with

patients, we call this systematic approach COGConnect. This describes the different stages of

consulting with patients that we want students to consider whenever they meet patients. We would

be grateful if you could highlight these stages in your feedback.

Preparation: It has been emphasised to students that any clinical encounter begins with

preparation. A doctor will prepare to see their next patient by reading the notes, a referral letter,

perhaps looking at the medication screen. Doctors also prepare themselves to see the next patient

perhaps they have just had a difficult consultation or need to finish a task before calling in the next

person.

You can help students think about this stage when they prepare to see the patient you are bringing

in.

Example questions to discuss with students to consider preparation: As a GP, when you find out the next person has “headache” how do you prepare? What do you need to do or know before you phone the patient or call them in? What information is particularly useful and why? Are there any key risk factors for types of headaches that you need to know about before you see the patient e.g. temporal arteritis is usually diagnosed in people over the age of 50. Preparing the students for meeting the patients today: Discuss any brief information you want the students to know before they see the patient. Briefly recap main causes of headache—what information will they want to find out from the patient? Do they have any questions? Preparing the patient: Please prime the patient as to where to start their story and what to focus on. For example, if the patient has multiple problems you may need to tell the patient that the students are particularly interested in when & how they were diagnosed with migraine. You may also want to say how much information to give, for example “Please don’t tell them straight away that you suffer with migraines, just start by saying what symptoms you experience, and how it makes you feel. They will ask you some questions and try and work out what might have happened to you.”

Opening: All the students should be familiar with introducing themselves to the patient, checking

the patient’s details and checking permission to talk to/examine the patient. Remind them to do so if

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they do not do this automatically. They should make sure the patient is comfortable, knows what is

going to happen e.g. how long it should take, and start with open questions and attentive listening.

Gathering: We teach students to “gather information” around a presenting problem. The medical

history is an essential, structured part of gathering information that students need to learn and learn

how to adapt for different situations. We emphasise that the medical history is one part of broader

assessment of patients' problems including information from the notes, observation of the patient’s

presentation and non-verbal communication, examination findings, and results from investigations,

and where appropriate, from third parties. We also want to emphasise that gathering is partly about

how to find out information (the process which includes listening skills and how to phrase questions)

as well what they find out (the content—which is forms the medical history).

Patients often come with a problem or problem list (which is not necessarily a symptom) and we

want students to be able to form a holistic assessment of the situation. The GMC’s outcomes for

graduates does require that newly qualified doctors can “elicit and accurately record a patient’s

medical history, including family and social history (Outcome 11a)” but of note is that graduates

should be able to “work collaboratively with patients, their relatives, carers or other advocates to

make clinical judgements and decisions based on a holistic assessment of the patient and their

needs, priorities and concerns, and appreciating the importance of the links between

pathophysiological, psychological, spiritual, religious, social and cultural factors for each individual

(Outcome 14)”

When students learn to gather a comprehensive assessment of the patient through systematic

history and examination, they need to continue to consider the patients understanding, beliefs,

fears, expectation and impact of the problem on their lives. Sometimes as they learn a “list” of

questions to ask they can start to be so focused on remembering what to ask, they forget to respond

to patient cues, for example a patient might respond to a question about smoking with the

information that their Dad died from smoking related disease and the student ignores that to move

on to asking about alcohol intake. Remind them to acknowledge what they are hearing and seeing.

This is where you can help by spending some of the time observing the students talking to patients

and giving feedback and helping the other students observe and give effective feedback to their

peers.

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Key consultation skills to practice • Attentive listening, picking up cues • Open and closed questions

o Open questions tend to begin with ‘What, where, when and how?’ o Closed questions tend to start with ‘Have you, did you, could you...?’ o Questions starting with ‘Why’ are difficult for patients, better to say; ‘What made you think

that?’ rather than ‘Why did you think that?’ • Jargon free language • ICEIE – ideas, concerns, expectations, impact of the problem, and emotions. It is very important to

understand where the patient is coming from, what they are worried about, what they need, and how the problem is affecting them.

• Clarification - what did the patient mean by saying ‘couldn’t breathe’? • Summarising – This helps you to review the information you have already gathered, and the

patient can tell you whether you understood correctly and what information is still missing. • Acknowledgement: ‘I am sorry to hear that’, ‘That must have been difficult for you’

Formulating: What do I think so far, and what next?

Students may find it helpful to keep these questions in mind while talking to patients, and

systematically consider them when they feel they have come to the end of the information gathering

stage. You can ask your students:

1. Can you summarise what you have been told so far? 2. Does it tell a story from beginning to end? 3. Is the story unique to the individual and their situation? 4. Can you tell what the probable diagnosis is (main problem)? 5. And what is less likely (differential diagnosis)? 6. What is the worst thing it could be (What you must not miss, red flags)? 7. Do you know what the patient thinks is wrong? And what they worry about?

Here is an example

GP Students

“What is your diagnosis at this point?” A mind map might help

Students brainstorm possible diagnoses

How can you differentiate between these diagnoses?

Students ask further questions to try and work out which diagnoses are more or less likely

What does this sound like? What can we rule out at this point?

Decide what they can exclude at this point

What other questions could you ask to differentiate?

e.g. additional symptoms, risk factors

What have you learned from asking those questions?

Can you now say what is more or less likely

What is more likely/less likely Get students to state what is most likely

Would you like to ask more questions about that?

What evidence do they need to test that diagnosis?

What does that tell us about the diagnosis? E.g. that x is most likely, but we need to bear y & z in mind and organise further investigation or follow up the patient.

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Explaining

Are they any elements that the students could practise explaining to a patient or each other?

Activating

The students have been introduced to activating patients. By activation we mean empowering and

motivating people to manage their own health. Different people need different interventions to feel

more able to manage their health & wellbeing. You can read more here:

https://www.kingsfund.org.uk/publications/supporting-people-manage-their-health

When students meet patients with you, you can help them think about this by discussing areas of

the patient's lifestyle or how they manage their condition that are ripe for intervention e.g.

encouraging regular exercise, stopping smoking or motivating patients to adhere to a treatment

regime.

Planning

Try asking the students “If you had met this patient when they had just developed this symptom

what would you do next?” Help them consider a wide range of options e.g. reassurance, further

investigations, treatment, referral...

Doing

Some consultations have a procedure as part of them. In Primary care this might be a minor surgical

procedure, or doing a joint injection, also taking a smear, doing an ECG, giving a flu jab. Over their

training students will learn an increasing number of practical procedures.

Closing

Closing a clinical encounter needs specific skills. Students should be encouraged to help the patient

summarise, ask any further questions, and make sure the patient is clear on what will happen next

including follow up, getting results, hearing about a referral. They can practise safety netting for

example in a patient with stable angina.

Integrating

This is the stage after the patient has left the room. Both doctors and patients “integrate”. For the

doctor this is where they write up the notes, make a call to a colleague or write a referral letter, or

look something up. Students can be helped to assess their learning needs at the end of the session.

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Headache session guide for Thursday 23rd May 2019 Primary Care Clinical Contact, Year Two 2018-19

Intended Learning Outcomes. Be able to:

• Compare and contrast common causes of headaches, describe the red flags that indicate of serious causes of headache

• Describe how to gather a well- rounded impression of a patient presenting with

headaches, including clinical examination

• Be introduced to fundoscopy (clinical contact)

• Practise examination of the cardiovascular and respiratory systems (clinical contact)

• Perform manual blood pressure (clinical contact)

• Describe how to effectively bring consultations to a close

• Describe the importance of integrating and learning from clinical encounters

Resources:

Core reading is available to students via on-line library textbooks. Macleod’s clinical diagnosis and

clinical examination (Chapter 12 The renal system).

Hippocrates, the Bristol Medical School website, has some tutorials on headache under Year 3

neurology material http://www.bristol.ac.uk/medical-school/hippocrates/medsurg/neurology/

The British Association for the study of headache has useful information: http://www.bash.org.uk/

National Institute of Health and clinical excellence - diagnosis and management of Headache in Over 12s https://www.nice.org.uk/guidance/cg150/chapter/Recommendations#assessment

British Association for the study of Headache http://www.bash.org.uk/ has guidelines which can be found here:

http://www.bash.org.uk/wp-content/uploads/2012/07/10102-BASH-Guidelines-update-2_v5-1-indd.pdf

Migraine trust charity: https://www.migrainetrust.org/

Early diagnosis of brain tumours: https://www.headsmart.org.uk/

Cluster headache charity: https://ouchuk.org/

Giant Cell Arteritis: https://www.versusarthritis.org/media/1319/giant-cell-arteritis-information-booklet.pdf

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Suitable patients for the headache block:

• A patient with current chronic/ recurrent headaches e.g. migraine

• A patient with a history of acute headache e.g. Subarachnoid or meningitis NB/ the students are being introduced to cranial nerve examination in a campus-based tutorial session, so you don’t need to do this. It would be helpful to discuss what aspects you should examine in a patient with headaches and to let the students have a go with fundoscopy. Please bring in a second patient who is willing to let the students practise CVS/RESP examinaiton

• Any patients to recap the cardiovascular/respiratory system on and practice blood pressure on (the students can also practice manual BP on each other)

Headache session activities:

Introductory tutorial (30 minutes)

1. Assess learning needs; discuss the students’ learning during their headache CBL case and

what they feel confident in and what they want to practise.

2. Prepare for the session; brainstorm causes of headache, the underlying pathology and how

to assess and differentiate between causes of headache. Identify specific areas of the history

that are important.

3. Recap an overview of the medical history (overview is in year 2 18-19 GP handbook

https://www.bristol.ac.uk/media-

library/sites/primaryhealthcare/documents/teaching/handbooks/Year%202%20Effective%2

0Consulting%20Primary%20Care%20Teacher%20Guide%202018-19.pdf ).

4. Brief students on the first patient. Cover specific features of the history relevant to the

patient seen.

Patient one (30 minutes)

5. Patient One Arrives. Brief information on the patient you are going to see together. Allocate

one student to practice gathering information (you might want to allocate one student to

take over 1⁄2 way so that 2 students get a turn). The other students should be given

observation tasks. One could look at content of the history (anything missed?), one could

look at body language and non-verbal communication, and one could look at process e.g.

active listening, building rapport with the patient. When the student/s have finished talking

to the patient help them summarise what they have heard—can they tell the patients story?

BREAK—offer students a snack and drink and toilet break. (10 minutes)

6. Preparation for examination teaching/recap—focus on the CVS/RESP examination (10

minutes) Discuss with students how much examination practice have they had and what

they would like to learn? Ask them to describe the CVS/RESP examination. Consider

brainstorming or drawing the thorax and running through the elements of the examinations

and what they are looking for.

Patient two (30 minutes)

7. Patient Two Arrives. Brief information on the patient you are going to see together.

Introduce the patient to the students and briefly recap any medical information (but do not

take a detailed history) Explain you want to show the students how to examine a patient.

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Demonstrate first talking through the steps and involve the students. Include verbal consent,

making the patient comfortable and a systematic examination starting at the hands and

moving to the chest. Allocate 1 student to have a go or ask different students to do different

parts of the examination.

8. Run through how to do a manual blood pressure.

9. Debrief, questions and identify further learning needs and resources.

Tutorial notes (available to students via OneNote) Please note these are designed to be quick

reference notes so are brief and do not replace core textbooks.

Some headaches that present in clinical practice:

• Tension headache

• Migraine

• Cluster headache (less common but important to recognise)

• Medication-overuse headache/chronic daily headache

Surgical Sieve Method: there are different mnemonics for this; for example, VITAMIN C: 1. Vascular 2. Infective 3. Traumatic 4. Autoimmune 5. Metabolic 6. Idiopathic / Iatrogenic 7. Neoplastic 8. Congenital

Key points in headache

“Headache affects nearly everyone at least occasionally. It is a problem at some time in the lives of

an estimated 40% of people in the UK. It is one of the most frequent causes of consultation in both

general practice and neurological clinics. In its various forms, headache represents an immense

socioeconomic burden. Migraine occurs in 15% of the UK adult population, in women more than men

in a ratio of 3:1. An estimated 190,000 attacks are experienced every day, with three quarters of

those affected reporting disability. Whilst migraine occurs in children (in whom the diagnosis is often

missed) and in the elderly, it is most troublesome during the productive years (late teens to 50’s). As

a result, over 100,000 people are absent from work or school because of migraine every working day.

The cost to the economy may exceed £1.5 billion per annum. Tension-type headache in its episodic

subtype affects up to 80% of people from time to time, many of whom refer to it as “normal” or

“ordinary” headache. Consequently, they mostly treat themselves without reference to physicians

using over-the-counter (OTC) medications and generally effectively. Nevertheless, it can be a

disabling headache.”

From introduction http://www.bash.org.uk/wp-content/uploads/2012/07/10102-BASH-Guidelines-

update-2_v5-1-indd.pdf

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History:

A key aspect to ascertain if a patient presents with headache is to decide whether there is a serious

cause for the headache which needs urgent intervention. Both the NICE guidance and BASH

guidelines are clear that scans should not be done for reassurance purposes in patients with a clear

diagnosis of a primary headache condition (based on history and examination), in whom there are

no red flags.

The following features of a headache should alert you to the possibility of an alternative, serious

diagnosis:

• Onset after age of 50. Migraine does not usually start at this age • Worst headache patient has ever had/very rapid onset (subarachnoid haemorrhage) • History of cancer, especially lung or breast (cerebral metastasis) • Headache that progressively gets worse over days (tumour or cerebral abscess) • Headache that wakes patient at night (tumour) • Early morning vomiting (raised intracranial pressure) • Unilateral loss of power (TIA/stroke) • Seizure (tumour) • Weight loss (tumour or cerebral TB) • Altered consciousness (meningitis) • Fever (meningitis) • Immunodeficiency

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There are no diagnostic tests for migraine, tension headache, cluster headache (primary headache

disorders) or medication-overuse headache. This means that the history is vital in making the

diagnosis, and time to elicit an accurate history +/- the keeping of a diary for the pattern of attacks

can help make a diagnosis.

Get the students to think about what sorts of symptoms patients present with for each of the three listed primary headache types but encourage them to write down what patients might say rather than the 'textbook' answers, and to have a think about how they might elicit that information.

The BASH guidelines are helpful for thinking about an approach to headache questions, however it doesn't emphasise enough the importance of gathering a WELL-rounded impression, taking into account the relevant background as well as the patient's perspective. It's so important in a headache history to ensure you fully appreciate the ideas the patient has about what's going on, the underlying fears and worries they may have, whether they want reassurance, diagnosis, medication or referral, what impact the headache is having on their life, and how it is making them feel (ICEIE).

The headache history Site

• Global or a specific area? Pain & tenderness in the temples in someone over 50 can indicate temporal arteritis, a band like pain round the head indicates tension headache, one sided headache may be migraine, the occiput may be a sub arachnoid haemorrhage.

Onset

• How recent in onset?

• When did they start?

• How does an episode begin e.g. sudden/gradual? Beware the sudden headache at the back of the head, it could indicate a subarachnoid bleed. These tend to be severe and the patient may describe feeling like they've been hit across the back of the head.

Character

• Nature and quality of pain

• State of health between attacks completely well, or residual or persisting symptoms A migraine may be severe or have neurological features, but patients are symptom free between episodes

Radiation

• Spread of pain

Associated symptoms

• A fever or systemic illness may indicate a viral headache or if very unwell, meningitis • In migraine patients may experience aura or transient neurological features

Timing

• Why consulting now?

• How frequent, and what pattern (especially distinguishing between episodic and daily or unremitting)?

• How long do they last? Exacerbating/relieving factors?

• Predisposing and/or trigger factors

• Aggravating and/or relieving factors

• What medication has been and is used, and in what manner?

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Severity

• Intensity of pain

• What does the patient do during the headache?

• How much is activity (function) limited or prevented? Patient perspective

• Concerns, anxieties, fears about recurrent attacks, and/or their cause

• What else might be going on their lives? What is the background/context to the problem? Past and family history

• Family history of similar headache

Teaching notes - the NICE guidelines provide a useful summary table for primary headache symptoms. National Institute of Health and clinical excellence - diagnosis and management of Headache in the over 12’s https://www.nice.org.uk/guidance/cg150/chapter/Recommendations#assessment

Examination:

If you are in any doubt about the diagnosis you should do the following examination:

• Pulse & BP • Look at optic fundi (papilloedema warrants emergency admission) • Test for neck stiffness • Palpate scalp for tenderness • Examine cranial nerves • Assess power & co-ordination in all 4 limbs

BASH guidelines say:

4.8 Physical examination of headache patients All of the headaches so far discussed are diagnosed solely on history, with signs present in cluster headache patients if seen during attacks (occasionally, ptosis may persist between). The purpose of physical examination is sometimes debated but, for reasons given below, the optic fundi should always be examined during the diagnostic consultation. Blood pressure measurement is recommended: raised blood pressure is very rarely a cause of headache but patients often think it may be. Several drugs used for migraine prophylaxis affect blood pressure so it is important to have a baseline measurement. Drugs used for headache, especially migraine and cluster headache, affect blood pressure and vice versa. Examination of the head and neck for muscle tenderness (generalised or with tender “nodules”), stiffness, limitation in range of movement and crepitation is often revealing, especially in TTH. Positive findings may suggest a need for physical forms of treatment but not necessarily headache causation. It is uncertain whether routine examination of the jaw and bite contribute to headache diagnosis but may reveal incidental abnormalities. In children, some paediatricians recommend that head circumference is measured at the diagnostic visit, and plotted on a centile chart. For many people with troublesome but benign headache, reassurance is very much part of successful management. The physical examination adds to the perceived value of reassurance and, within limits, the more thorough the examination the better. The time spent will likely be saved several times over, obviating many future consultations by a still-worried patient. A recent outpatient study found only 0.9% of consecutive headache patients without neurological signs had significant pathology. This reinforces the importance of physical examination in diagnosing serious causes of headache such as tumour, although the history would

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probably be revealing in these cases. A prospective study has suggested that isolated headache for longer than ten weeks after initial presentation will only exceptionally be due to a tumour.

What next? NICE say:

Consider using a headache diary to aid the diagnosis of primary headaches and to monitor effectiveness of treatment.

If a headache diary is used, ask the person to record the following for a minimum of 8 weeks:

o frequency, duration and severity of headaches o any associated symptoms o all prescribed and over the counter medications taken to relieve headaches o possible precipitants o relationship of headaches to menstruation

Give verbal and written information and support for people with headache disorders, including; o a positive diagnosis, including an explanation of the diagnosis and reassurance that

other pathology has been excluded and o the options for management and

o recognition that headache is a valid medical disorder that can have a significant impact on the person and their family or carers.

o information about support organisations. o Explain the risk of medication overuse headache to people who are using acute

treatments for their headache disorder.

Cardiovascular examination:

This is a useful revision video to watch:

https://geekymedics.com/cardiovascular-examination-2/

It might help to visualise the different parts of the examination by drawing a stickman on a flipchart and discussing what you would examine and what you would expect to find. This helps you anticipate what signs you expect to find with a given history.

Setting up: Use the acronym WIPPPE to help you remember what to do: Wash hands Introduce yourself and identify patient Permission (gain from patient) Position (45 degrees for CVS/resp) Pain (check if patient has any pain) Exposure (adequately expose patient)

General Examination: Recognise pallor, central and peripheral cyanosis.

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Does the patient appear to be in pain or unwell? What is the nutritional status like? Any obvious clues e.g. presence of oxygen, GTN spray, Down's syndrome/Marfan's. Comment on relevant findings.

Hand and nails: Temperature, capillary return, peripheral cyanosis, clubbing, koilonychia, splinter haemorrhages, tar staining, janeway lesions * (see further info) Look for finger prick testing of glucose to suggest diabetes, and evidence on arms of IV drug use.

Pulse: Ability to measure radial pulse, rate, rhythm. Count for 15 (you will multiply by 4) and count respiratory rate for the next 15 (if you hold the pulse you can count the respiratory rate without making this obvious) If the pulse is irregular, you should check it for 30 seconds Assess radio-radial delay (coarctation of the aorta and aortic dissection which will also cause a discrepancy in blood pressure between both arms) Collapsing pulse occurs in aortic regurgitation, lift the patient's arm into the air (explain what you are going to do first!) with the palm of your hand over the radial pulse, if the pulse is collapsing you will feel the pulse fall away under your fingers. TIP: the carotid pulse coincides with systole Palpate the carotid pulse for character and volume Assess the jugular venous pressure (JVP) This can be a difficult sign to illicit. It is important that the patient is reclined at an angle of 45 degrees. The JVP gives a proxy measure of right atrial pressure, and the most common cause of an elevated JVP is heart failure. We look for the internal jugular which has a pulsation visible behind the sternocleidomastoid muscle. The JVP is measured

vertically from the sternal angle and should be less than 4 cm high.

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Respiratory examination:

This is a useful revision video to watch: https://geekymedics.com/respiratory-examination-2/

Setting up for examination WIPPPE: Wash hands Introduce yourself and identify patient Permission (gain from patient) Position (45 degrees for CVS/resp) Pain (check if patient has any pain) Exposure (adequately expose patient)

General examination Look to see if comfortable or obviously dyspnoeic. A breathless patient may use accessory muscles of respiration and lean forward using their arms to brace the chest to help get air in. Is the patient using supplemental oxygen? Comment on any relevant findings. Vital signs (if acutely breathless or infection suspected

Hands and nails

o Look at the hands first then move up to wrist to check pulse.

o Check respiratory rate when feeling the pulse (but you would do both of these things earlier if the patient is visibly breathless/clearly unwell)

Hands: Look for clubbing, tar staining and cyanosis. Clubbing: Here there is loss of the angle between the nail and the nail bed. You do not need to put two fingernails together if they are obviously not

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clubbed. Thoracic causes of clubbing include: Bronchial carcinoma, chronic lung suppuration (empyema/abscess, bronchiectasis, cystic fibrosis), fibrosing alveolitis Check pulse. Count respiratory rate—breaths in 15 seconds x4. Normal is 12-15 at rest (15-20 in some patients e.g. anxiety) Ask patient to hold arms outstretched – is there a fine tremor? Common cause: β-agonist medications Ask patient to cock their wrists back – is there a flapping tremor-- CO2 retention

Neck JVP can be raised in Cor Pulmonale* or SVC obstruction and acutely raised in tension pneumothorax and PE. Tracheal deviation can be assessed by placing 3 fingers (gently and with warning) into the sternal notch – if central, the trachea should be felt under your middle finger Examine the lymph glands by standing behind the patient (easier to do when examining the posterior chest).

Face/Mouth Central cyanosis—check under tongue. Pursed lip breathing on expiration. A dusky appearance and swelling of the face and neck can be caused by a mediastinal tumour pressing on the SVC.

Eyes Tumour pressing on the sympathetic nerves to the eye causes Horner's syndrome—a unilateral pupil constriction and ptosis Check for conjunctival pallor (anaemia)

EXAMINATION SEQUENCE Examine anterior chest then get patient to sit forwards to examine the posterior chest.

Inspection Shape of chest and movements of chest wall. A barrel shaped chest indicates hyperinflation from chronic airway obstruction. You may see scars on the chest wall. Is there any intercostal recession indicating forced rapid inspiration seen in acute infection and asthma?

Palpation Apex beat: lowest, most lateral position of cardiac impulse. Should be 5th intercostal space, mid-clavicular line. Mediastinal masses may displace the apex, the apex beat may be absent in large pleural effusion or pneumothorax. Hyperinflation may make it difficult to feel (and hear). Feel for right ventricular heave (palm left anterior chest with a straight arm—see video) Check for expansion—cup your hands (fingers spread) around the patient's upper anterior chest pressing finger tips into the mid axillary line, pull your hands slightly together and raise your thumbs

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off the chest wall, as the patient breathes in you can see how much each of your thumbs move and if there is an asymmetry. Repeat on the lower anterior chest wall and on the back.

Percussion Produces a hollow resonance, it produces a dull thud without resonance over fluid and consolidation. Apply middle finger of your non-dominant hand along an intercostal space and tap it with the flexed index or middle finger of your dominant hand. Percuss down the chest comparing left with right, avoid the scapula so move out as you move down. Hyperresonance can be hard to assess but accompanied by absent breath sounds indicates pneumothorax.

Auscultation

Ask patient to take normal breaths in and out through their mouth (can ask patient to breathe more deeply if breath sounds are quiet) Compare left to right starting with the bell of the stethoscope over the apex of the lung. Work your way down comparing left to right. Think about the surface anatomy of the lungs as you listen. Listen to the lateral chest in the mid axillary line. Note if the breath sounds are soft and muffled, or absent, or loud and harsh. Note asymmetry (if they are different side to side) and if there are any added sounds (wheeze, crackles and rubs) If you hear crackles, ask the patient to cough. Decide if they are fine or coarse and if they change with the breath. Vocal resonance: Breath sounds can reveal consolidation (bronchial breath sounds) air or fluid in the pleura (absent breath sounds) this can be confirmed by asking the patient to generate laryngeal sounds on purpose (Ask the patient to say “99” and move the stethoscope in the same places you auscultate).

Lower limb Check for swelling indicative of DVT. Pitting oedema.

Investigations Check Peak expiratory flow rate Look at Chest X-ray—if available (secondary care)

Closing Cover patient/help them dress or get off couch if required, thank patient. Explain any findings to patient. Wash hands.

Examining Blood pressure

Please make sure they are aware of the CAPS logbook protocol COMPETENCE IN MEASURING BLOOD

PRESSURE, videos for clinical skills are available here; http://www.bristol.ac.uk/medical-

school/hippocrates/medsurg/core/ (also see here https://bihsoc.org/resources/bp-

measurement/measure-blood-pressure/)

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• Explain procedure and obtain consent. • Ensure that patient has rested. • Check sphygmomanometer and stethoscope are clean and in good working order. • Select arm that is most comfortable for patient -if equally comfortable student should chose

right arm. • Ensure that patient’s sleeve is rolled up high enough for cuff to be applied. • Ensure that patient is comfortable with arm extended and supported—ensure the brachial

pulse is at the same level as the heart. • Choose correct size cuff.

o -Length of bladder should be >2/3 of circumference of arm. o -Width (height) of bladder should be >1/2 circumference of arm.

• Wrap cuff around patient’s arm, the centre of the bladder is above the brachial artery, the lower border of the cuff is 2-3cm above the antecubital fossa.

• Position sphygmomanometer so that it is facing them (the student) with the gauge level with their eye.

• Palpate the brachial artery and make a rough assessment of its rate and rhythm. Keep thumb or fingers on the brachial pulse

• Inflate the cuff with the hand bulb until the brachial pulse can no longer be felt and make a mental note of this pressure

• Inflate the cuff by another 20-30mmHg • Quickly place diaphragm of stethoscope over the brachial pulse and begin deflating the

bladder whilst listening with the stethoscope. • Deflate the bladder at a speed which is proportionate to the patient’s pulse so that the

blood pressure can be measured to 2mmHg. So if patient’s pulse is 60bpm, deflate by 2mmHg every second.

• Note the pressure at which the 1st Korotkoff sounds appear (systolic) • Note the pressure at which Korotkoff sounds completely disappear (diastolic) • Release the valve in order to deflate the bladder completely • Remove the bladder from the patient’s arm • If Korotkoff sounds did not disappear repeat the measurement but this time note the point

of muffling the 4th Korotkoff sound) • Repeat the reading if first reading is abnormal • Explain the result to the patient and record the result in the patient’s note. • Describe how to perform postural blood pressure • Perform blood pressure recording using an automatic electronic device

Introduction to fundoscopy

Students are not expected to be competent at fundoscopy but please show them how to

hold a fundscope and how to darken the room and what they are looking for. Can they see

the fundus and the optic disc where the vessels converge?

https://www.ole.bris.ac.uk/bbcswebdav/institution/Faculty%20of%20Health%20Sciences/

MB%20ChB%20Medicine/Year%203%20MDEMO%20-

%20Hippocrates/Hippocrates/eye%20final%20v4.mp4?_ga=2.34965665.1020131537.15571

50383-48899176.1536683376

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They might view this video on-line; https://geekymedics.com/eye-examination-osce-guide/

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Case Based Learning overview for Headache Year Two: FYI ONLY.

Case-Based Learning Cases in Headache

A 90-year old woman presented to the emergency department with a skin tear of her left forearm

after bumping in to a doorframe (see figure 1).

Figure 1.

Her husband was very anxious, he’d noticed that she often bumped into things on the left had begun

to struggle to get dressed often putting the wrong limb through the sleeve of a dress. Several weeks

earlier she had stopped listening to music because of difficulty recognising melodies.

On review of systems she mentioned a continual right sided headache for the previous month. She

described it as a dull ache, worse in the morning and exacerbated by coughing or bending forward.

The pain was initially helped by taking paracetamol at the maximum daily dose.

Her previous medical history included primary hypothyroidism, depression, gastro-oesophageal

reflux disease (GORD) and hypercholesterolaemia for which she was prescribed levothyroxine,

sertraline and atorvastatin daily. She had never smoked and enjoyed a small glass of wine with

dinner. She lived with her husband and, up until recently, they both enjoy gardening, brisk walks in

the countryside and spending time with their children and grandchildren.

A primary survey reveals:

• Airway Clear

• Breathing Vesicular breath sounds SaO2 99% breathing air Bilateral air entry

• Circulation Capillary refill time 2 seconds Pulse rate 68 beats per minute Blood pressure

126/84 mmHg

• Disability Alert Pupils equal in size and responsive to light and accommodation Boehringer-

Mannheim (BM) test 6 mmol/L

• Exposure Temperature 36.5oC Minor bruising of left arm and skin tear

Examination of her cranial nerves revealed a left homonymous hemianopia. She had full power

in all limbs without any sign of upper or lower motor neuron lesions. Her dorsal column and

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spinothalamic pathways were intact. She did not have any signs of meningism but she had tactile

sensory inattention on her left side and was unable to recognise a key by touch with her left

hand (astereognosis).

Her blood results were:

Reference range

Full Blood Count (FBC) Haemoglobin 138 135-180 g/l

White cell count 7.53 4.0-11.0 x 109/l

Platelets 268 150-400 x 109/l

Urea and Electrolytes (U&E)

Sodium 137 135-145 mmol/l

Potassium 4.5

3.5-5.0 mmol/l

Urea 6.6 2.5-6.7 mmol/l

Creatinine 82

79-118 micromol/l

Serum glucose Serum glucose 6.0 4.0-7.0 mmol/l

Liver Function Tests (LFTs) Total bilirubin 9 3-17 micromol/l

Alanine aminotransferase (ALT) 30 5-35 IU/l

Alkaline phosphatase (ALP) 125 30-150 IU/l

Albumin 39 25-50 g/l

Miscellaneous

C reactive protein 2 0-10 mg/l

Thyroid stimulating hormone (TSH) 4.0 0.27-4.2 mU/l

PvCO2 6.6 5.5-6.8 kPa

Carboxyhaemoglobin

(CO-HB) 0.1 <1.5% (non-smoker)

The skin tear was cleaned, closed with Steri-Strips™ and dressed.

An urgent magnetic resonance imaging (MRI) scan of her head was requested and the patient

was referred to the on-call neurosurgical team.

*****Information for third CBL session**** THIS IS AFTER EC SO DO NOT GIVE DETAILS

TO STUDENTS.

MRI report shows mass, and MDT decide palliative care. A care package was put in place so that

the patient could die in her home. She died four weeks later surrounded by her family.

It is important to put this case in context. Headache accounts for approximately 5% of

attendances at Emergency Departments, the majority of these (≈90%) do not have a life-

threatening cause. The medical adage “common things occur commonly” means that most

consultations for headache will be due to conditions such as tension-type, migraine, benign

paroxysmal, analgesic-induced or cluster headache.

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Questions for Facilitators

Sessions 1&2

• Did the patient’s headache have any features suggestive of raised intracranial pressure

(ICP)?

• Which lobes of the brain are important in (a) recognising melodies and (b) the spatial

awareness required for dressing?

• How are the visual pathways tested using the pupillary light and accommodation reflexes?

• What is a left homonymous hemianopia? Which part(s) of the visual pathways must me

damaged to explain this sign?

• What is meant by the terms upper and lower motor neurons? What are the typical features

of (a) upper and (b) lower motor neuron lesions?

• What information is relayed by the dorsal column and spinothalamic sensory pathways?

How are they testing during the neurological examination?

• What is meningism? What are the signs of meningism?

• What is tactile sensory inattention? Which lobe(s) of the brain is/are likely to be damaged?

• Which lobe of the brain is required for stereognosis?

• Does the normal white cell count and C reactive protein help to narrow the differential

diagnosis?

• Not all patients with headache require measurement of carboxyhaemoglobin or the venous

partial pressure of carbon dioxide. When should you suspect that headache is due to (a)

hypercapnia or (b) carbon monoxide poisoning?

• What are Steri-Strips™?

• What are the differences between a computerised tomography (CT) and magnetic

resonance imaging (MRI) scan?

• In which lobe(s) of the brain is this patient’s lesion? What is your differential diagnosis?

Lectures and practicals: Lecture 1: Cerebral circulation

Lecture 2: Intracranial pressure

Lecture 3: Bleeding and imaging

Lecture 4: Intracranial and extracranial infections leading to headache

Lecture 5: Primary and secondary tumours of the brain

Lecture 6: Lumbar puncture

Lectures 7 & 8: Differential diagnosis of headache

Lecture 9: Pathophysiological and pharmacological principles of headache management

Lecture 10: Headache as a presentation of domestic violence

Cross-Disciplinary Session: Clinical Ethics and Whole Person Care

Practical class: Cranial nerve examination

Applied Anatomy and Imaging Practical (headache).

Guest Lecture – TBC