Dear UWSMS Members The slow transition to a clinical education, in terms of setting, content and learning styles brings

with it great excitement. The opportunity to practice clinical skills in the early years is an exclusively modern component of medical school curricula. This transition to clinical learning begins with ICM, and for the vast majority of you it is in this unit you will first interact with patients in a medical role. This new position and the set of skills you acquire and, indeed, require can be daunting to many students. Such different skills necessitate new methods of assessment and, consequently, new methods of study and revision and it is with this in mind that the academic branch of UWSMS has produced a set of history taking flash cards that allow you to see briefly the key features that you should know for OSCEs. These flash cards only cover interviews relating to the gastro intestinal, biliary, cardiac, arteriovenous and respiratory system and so physical examinations and the alcohol audit are not covered. Being flash cards they are in no way comprehensive or a substitute for the tutorial notes however they do point out the key features to look for in each history. The practice of medicine however is extremely variable and so remember, while these provide specific features to ask for, you need to ask open questions too. I wish you happy and effective study for your OSCEs and the years to come. Kyle Sheldrick UWSMS Academic Officer

EMESIS Sources of confusion: Distinguish vomiting from regurgitation, which has no muscular involvement or nausea Severity How much, how many times. Character Amount, colour. Context new or poorly prepared food, travel, new medication, did anybody else have it? Time course - how long has it lasted, relationship to eating food, periodicity if more than one episode Aggravating + relieving does eating make it better or worse, has the patient taken medication? Associated features nausea, hematemesis, dry retching Interpretation: If other people had it usually an infectious cause, if associated with jaundice usually food poisoning with Hep A. Vomiting, has a huge list of causes. HAEMATEMESIS Sources of confusion: Be sure to distinguish haematemesis from haemoptysis. Severity How much blood, how many times, ask the patient to describe in terms of cups. Character Distinguish frank blood (not digested, from upper GI tract) from coffee grounds vomit (digested, spent at least some time in the stomach). Context did it follow retching? Time course Was the onset sudden, how long has it lasted for, periodicity if more than one episode Associated features Melena, dry retching. Interpretation: if coffee grounds its normally stomach or duodenal bleeding, think perforated ulcer. If theres a little bit of frank blood after retching think oesophageal tears. If theres LOTS of frank blood quickly, especially in an alcoholic or with signs of portal hypertension think burst oesophageal varices, a result of portal hypertension this is a MEDICAL EMERGENCY RECTAL BLEEDING Sources of confusion: There are no major mimics, but ensure rectal bleeding is not undigested red foodstuffs. Severity How much blood was there? Character Colour, smell, distinguish melena from frank blood. Context Recent operations etc, ever had a polyp Time course - How long has it lasted, periodicity if more than one episode, ask whether its getting better or worse. Aggravating + relieving Usually none. Associated features Ask about peri-anal pruritis, pain (especially when sitting), prolapse and symptoms of anaemia. Interpretation: Melena is from the proximal colon or higher, bright blood from the distal colon rectum or anus. If the blood appears as a coating rather than mixed through the stool it indicates a lower source of bleeding. Blood appearing only on the toilet paper and not in the stool indicates bleeding is very low in the anus.

DYSPHAGIA Sources of confusion: Distinguish dysphagia (difficulty swallowing) from odynophagia (pain on swallowing) though patients will sometimes have both. Site Does food get caught when initiating swallowing or lower down? Character Does it effect only solids or solids and liquids? Context Has the patient had a recent stroke. Time course onset of symptoms, if liquids were involved were they effected right from the start or did they become involved later. Aggravating + relieving Usually none Associated features Weight loss, coughing, choking or regurgitation, especially nasal regurgitation. Other symptoms of a stroke or MS. Interpretation: There are three kinds of dyspahagia: -Oropharyngeal: problem initiating swallowing, food gets caught at the top of the throat, associated with coughing, choking and regurgitation, normally a stroke or MS -Oesophageal (Motility): Problem finishing swallowing, food gets caught retrosternally, loss of peristalsis. Effects liquids from the outset. E.G. Achlasia -Oesophageal (Mechanical: Problem finishing swallowing, food gets caught retrosternal. Doesnt effect solids at first. E.G. Cancer. JAUNDICE Sources of confusion: Patients with orange rather than yellow skin may have beta-carotene poisoning. Site Is it just the sclera or is the skin also affected? Severity - The darker the yellow the more severe, site is also an indication of severity. Jaundiced sclera indicate 50 micro grams per litre or more of bilirubin. Context Has the patient eaten poorly prepared foods, taken any new medications, been fasting, been ill or taken I.V. drugs? Time Course Onset is the most important feature of time course in jaundice. Aggravating + relieving Normally none Associated features Dark urine, pale stools, pruritus and abdominal pain Interpretation: Abrupt onset jaundice tends to be acute hepatitis or gall stones. Slow onset suggests cirrhosis of the liver or chronic hepatitis. Dark urine suggests the excess bilirubin is unconjugated. Specific risk factors tend to have obvious implications, e.g. I.V. drug use suggests hepatitis C. Jaundice on fasting indicates Gilberts syndrome CHEST PAIN DUE TO MYOCARDIAL ISCHEMIA Sources of confusion: Not all chest pain is myocardial ischemia Site Diffuse, retrosternal or left sided. Often radiates to jaw or left arm Severity Severe Character Tends to be crushing, constrictive or pressure pain. Context Was the pain brought on by exercise? Does the patient smoke, have diabetes, hyperlipidemia, hypertension or a family or personal history of ischaemic heart disease? Time course Sudden onset, see interpretation below for more info. Aggravating + relieving Does the pain improve with rest? Associated features Diaphoresis, anxiety. Interpretation: History cant confirm or rule out ischaemic heart disease due to the variability of presentation, deviation from the classical presentation above simply makes it a less likely cause. Pain brought on only by certain level exertion and relieved with rest is stable angina, pain coming on at a variable level of exertion or at rest is unstable angina, pain lasting more than 20 minutes is likely to be a myocardial infarct.

INTERMITTENT CLAUDICATION Sources of confusion: Be sure to distinguish intermittent claudication from a deep vein thrombosis caused by blood stasis or hypercoagulability. Site Calves Severity This is determined b how far the patient has to walk before they become pained. Character Often described as cramping Context Was the pain brought on by exercise? Does the patient smoke, have diabetes, hyperlipidemia, hypertension or a family or personal history of ischaemic heart disease? Time course How long has this been occurring?. Aggravating + relieving Does the pain improve with rest? Associated features Diaphoresis, anxiety. Interpretation: Intermittent claudication is judged by how far a patient can walk pain free. Being a disease rather than a symptom it only has one pathogenesis, atherosclerosis. There is little beyond severity that can be determined from the history one the diagnosis is made. SYNCOPE Sources of confusion: Must distinguish from epileptic seizure Severity Did the patient actually lose consciousness. Character Did the patient . Context Was the patient trying under significant amounts of heat stress, very anxious, dehydrated or had they been standing a long time? Time course How long did the event last, if multiple episodes then ascertain periodicity. Aggravating + relieving factors The patient should have regained consciousness Associated features Ask about light headedness, feeling faint and memory loss. Interpretation: Very difficult to interpret without an observer. Generally vasovagal syncope has an obvious precipitating factor whereas cardiac syncope does not. Vasovagal syncope generally resolves more quickly than cardiac syncope. OEDEMA Sources of confusion: None Site Where has the swelling been? Severity How bad has the swelling been? Character Was appetite decreased or increased. Context Was the patient trying to lose weight? Time course Over how long a period has the swelling developed, is it worse at any particular time of day. Aggravating + relieving Is it affected by posture? Does lying down or standing up for long periods make it worse? Associated features Shortness of breath, polyuria, fever, leg pain. Is the patient sleeping on more pillows. Interpretation: There are 3 main causes of oedema Volume overload: Caused by things like heart failure, presents with oedema in the legs due to the effect of gravity. Obstruction: Usually from a DVT and limited to one leg. Increased capillary permeability: generalised oedema, look especially for oedema around the eyes, called periorbital oedema, cause by liver cirrhosis or protein loss in the urine or bowels

SMOKING When did the patient start smoking? How long ago did the patient quit if applicable? How many packs (20 cigarettes) a day did they smoke on average? How early after waking is the their first cigarette? How do they tolerate being unable to smoke in movies or on planes? Have they tried to quit before? How willing are they to quit now? How confident are they that they could quit? Ask about passive smoking, in family members, friends and the workplace. Interpretation: Smoking is reported in pack years which is packs (standardised to 20 cigarettes a pack) multiplied by the years smoked. Eg somebody whos smoked 2 packs a day for 5 years has a 10 pack year smoking history. HAEMOPTYSIS Sources of confusion: Be sure to distinguish haemoptysis from haematemasis Severity How much blood, how many times, ask the patient to describe in terms of cups. Character Should be bright and frothy Context Ask about prodromal symptoms, irritation of the chest and desire to cough. Time course Was the onset sudden, how long has it lasted for, periodicity if more than one episode Associated features Fever, chest pain - especially on inspiration, weight loss, coughing, green sputum. Interpretation: Greater than 200ml in a day is Massive haemoptysis. Commonly its a result of bronchitis causing stress tears. Weight loss could indicate lung cancer. Fever, ain on inspiration or green sputum could indicate pneumonia. ASTHMA Sources of confusion: Remember that just because a patient has asthma it doesnt mean they cant have other respiratory illnesses such as pneumonia or bronchitis. These can trigger asthma too though. Severity Peak flow, has the patient been hospatilised for it, how often do they have to use their puffer? Time Course How often are attacks, are they becoming more or less frequent, how long does each attack last, when did they first get asthma? Triggers Have they identified any triggers, do attacks occur in a particular setting, do attacks occur at a particular time of year? Specifically ask about viruses, pollen, cold air andexercise/ Medication Are patients on glucocorticoids or bronchodilators. Puffers can be identified by colour, aqua coloured ones are salbutamol, purple are steroid puffers. Management Are they taking their medication? Is it working? Other illnesses: Ask about heyfever, dermatits and rhinitis. Interpretation: Any asthma which results in hospitalisation is poorly controlled. You will learn more about asthma as part of the atopic sequence in 2nd year.

HYPERSOMLENECE Sources of confusion: Differentiate hypersomlenece (sleepiness) with fatigue from over exertion. Quantity of sleep How many hours of sleep does the patient get. Quality of sleep Does the patient wake up during the night? How refreshed does the patient feel when they wake up? Time course How long has hypersomnelence been a problem? Context, Environmental Is there noise or light where the patient tries to sleep? Context, Chemical Ask about caffeine, sleeping tablets and alcohol. Associated features Snoring, choking or nocturia. Interpretation: Almost all hyersomlenence is a result of insufficient quantity or quality of sleep. Things like narcolepsy are so rare you will probably never see them. Snoring or choking could indicate sleep apnoea which will disturb sleep. Nocturia interrupts sleep directly.

WEIGHT LOSS Sources of confusion: None Site Has the weight been lost more from certain areas? Severity How much was lost? Character Was appetite decreased or increased. Context Was the patient trying to lose weight? Time course Over how long a period has it been lost. Aggravating + relieving Usually none, sometimes a new medication. Associated features Diarrhoea, steatorrhea, polyuria, polydipsia. Interpretation: More than 5% of bodyweight in a year is significant. With increased appetite could be hyperthyroidism, diabetes (with polydipsia or polyuria), malabsorption (with diarrhoea or steatorrhea) or increased exercise. With decreased appetite could be cancer (particularly if old), medication side effects or eating disorders (particularly if young).

POLYURIA Sources of confusion: Polyuria is an increased volume of urine output. An increase in how often a patient urinates is increased frequency. Severity Estimate volume? Character Colour Context Is the patient drinking more? Time course Onset, worse at day time or night time? Aggravating New meds, alcohol, caffeine and salt. Relieving: Has the patient self restricted fluids? Was it helpful? Associated features Polydipsia, increased frequency of urination, thirst, sugar or salt craving.

Interpretation: Way beyond 1st year level. Sugar craving tends to be DMT1 of DMT2.