Clinical

features of disease
week 1 (17/3/17)
Subject code 99584

Dr Cecile Chu
Cecile.chu@uts.edu.au

Rm 4.6.332
(Please email ahead to make appointment)
 Todays outline

Who am I?
Introduction to the program
Taking a medical history
Role plays
Emergency medicine
 Who am I?

Chinese Studied medicine at

Grew up in Sydney University of NSW
I can speak Cantonese Worked at Bankstown
Hospital
GP in Western Sydney
Second time teaching this
course
 Complementary medicine

Personally tried remedial massage and Chinese herbal

medicine
Respect patients wishes to try alternative medicines
Wary of interactions with specic herbs (St Johns
wort) and conditions (liver conditions)
What is a GP?
(What do you see your GP for?)
 Typical week in GP land
Lots of colds Doc I think I have the u (runny nose, sore
throat) common cold and may not be the flu virus

Alternative diagnoses - glandular fever, bacterial tonsillitis,

pertussis, measles, sinusitis, otitis media, pneumonia, allergic
sinus infection middle ear infection
rhinitis
(hayfever)

Common infections urinary tract infections, gastroenteritis can lead to dyhydration

Lots of kids
National immunisation program
Anxious parents - chronic health issues eg cancer, intellectual disability,
learning disability, genetic syndromes, autism
Normal development
Every once while a really sick kid asthma, bronchiolitis,
dehydration
Behavioural issues, developmental problems
Lots of mental health
Depression and anxiety
, biopolar disorder, schziphrninea
 Typical week contd
Lots of preventative health For cervical cancer

Proactive screening hypertension, pap smears, diabetes risk,

cardiovascular risk, breast cancer, bowel cancer
Lifestyle advice
Travel advice vaccines, general precautionary measures
Female reproductive presentations
Pregnancies and antenatal care
Contraception
Preconception
Infertility
Menstrual issues
Vaginal discharge/itch
 Typical week contd

Lots of aches and pains

Back pain
Sporting injuries
Fractures
Degenerative In older people
Lots of skin stu
Fungal infections skin, nails
Is it skin cancer?
Eczema
Weird rashes
And other stu as well less often
 Introduction to the program

Lectures and interactive sessions weeks 1 to 6

Next week ear nose and throat
The cardiovascular system
The respiratory system
The gastrointestinal system
The central nervous system/psychiatry
Mid term exam on topics covered in weeks 1 to 6
Conducted the week after STUVAC 5th of may will be our roleplay exam
More lectures and interactive sessions weeks 7 to 11
Urogenital/endocrine
Haematology
Rheumatology
Dermatology
End of term exam (content from all weeks)
MCQ+ short answers will be the final exam
 Typical session

A revision quiz will be available online usually after each

session
Formative task, marks not counted
The following week well start with feedback for the quiz
Around maximum 2 hours of lecturing with 5-10 min
breaks per hour
Case studies
Interactive session at the end in the plinth room
practicing examinations
What youll hopefully get out of this
course

Consolidate learning of previous western medicine

subjects
Understand how to apply learning to real patients
Recognise when to worry and refer
 Taking a medical history
A skill to be learnt by practising but nevertheless some
general guidelines and tips
 Prior knowledge

Waiting room list

how long i kept them waiting
Name, arrival time, appointment time
Snapshot of their possible ethnicity and how inpatient
ethnicity: may tll what kind of k=conditions to expect
they might be
Also know your local demographic
Information already in their le
AGE AND GENDER these factors help in
If new, only their age and gender know what type of questions to ask eg
pap smears are needed for age
If previously attended, lots of info!...
 Patient is known to you

When did they last visit, who did they see, why, what
treatment Good to see whether the previous treatment has worked
Past medical history
Medication list prevents adverse drug interactions
Allergies
Smoking, alcohol
Family history Genetic disorder: infuences how likely someone may have
a particular medical conditions
Social history diet, who they live with
eg if vegan: check for vitamin B12
OCCUPATION; is also important in the social history part
NOTE: need to fill out all the blank positions eg medication, previous examination they did before
 How can I help you today?

Start with open questions let the patient tell you in their
own words their experience (dont talk for 1 min) Hi, how can I help you today?
Further clarify with more directed questions to help
achieve your agenda (specic symptom searching to
support/refute a diagnosis, explore alternative diagnosis)
Systematic review so you dont forget anything
Body systems Ask them in chronological order according to their body systems so that you dont forget anything
All history components
OPEN questions: is when you cant answer YES or NO. you need the patient to tell you what they have on their mind
 Start with open questions

Open questions encourage the patient to talk

Avoid yes/no questions
E.g. Whats the story?/Whats happened?
Some patients dont know how to explain how they
are feeling be patient, still a useful technique to
start with
 SOCRATES

A useful tool to help further clarify

Site of symptom (works well for pain, but also rashes, itch,
injury,
Onset when did it start, and also how (sudden severe
pain or gradual onset)
Character some patients are good at this, others you
might need to give a few suggestions (would you say the
pain was burning/shooting/dull/pins and needles?)
infections in the soft tissue pins and needles: nerve pain
Radiation does the symptom travel anywhere else
Source of pain is important, eg left should pain could indicate that the spleen has a problem
 SOCRATES contd
Associated symptoms For every body system you will have a different set of questions

This will depend on the body system involved (think of their

function) and knowledge of specic diseases and their associated
symptoms
Knowledge picked up slowly through the course
But common ones are
Nausea, vomitting, abdominal pain, diarrhoea, fever, per rectal
bleeding, pain with defecation gastrointestinal
Runny nose (rhinorrhoea), sore throat, cough, fever respiratory systems
Joint pain, swelling, stiness joints
Chest pain, shortness of breath (dyspnoea), palpitations, dizzyness,
nausea heart/lungs
Cough, haemoptysis (blood in sputum), inspiratory (pleuritic) chest
pain lungs specifically
Vaginal discharge, intermenstrual bleeding, post coital bleeding, pain
with sex (dyspareunia) female reproductive
Dysuria (painful peeing), frequency, urgency, loin pain (mid back
pain), haematuria (blood in the urine) urinary tract/ kidney
Skin lesions itch, pain, change in appearance
Ask questions about all these systems according to the presented situation
 SOCRATES contd

Timing duration, time of day eg headaches in the morning are more concerning than ones in the nigh
Exacerbating/relieving factors what makes it better
or worse/triggers what treatment have you tried already and has it worked
Severity on a scale of 1 to 10 what cant you do because of this strength of pain? TO GAIN A BETT
UNDERSTANDING OG OF THE SEVERITY OF PAIN
10 being the worst pain you can imagine
0 being no pain at all
 Other useful questions for the
presenting complaint

Have you had this before?

What triggered it (e.g. recent trauma ask! Patients can
forget)
Any overseas travel (up to one year!) eg HIV is more revalent in some countries than others
If they look worried or say they are very worried, ask them
what they think might be going on
Get an understanding of patients health literacy, particular
concerns founded or unfounded, their agenda (do I have
cancer)
Helps you make sure you can answer their question by the
end of the consult
 Body systems review

With experience and understanding of common

diseases one can be selective about relevant reviews
But a useful tool when someone comes in with a very
poorly localised symptoms like fatigue, generalised
itch, nausea, multiple joint pains, insomnia, weight weight loss:itcancer but where is
located
loss eg lupas and rhumtoid arthritis

look for patterns of the symptoms and check whether they fall under a particular categorie of the body systems
from Clinical Examination: A Systematic
Guide to Physical Disease 5th Edition.
Nicholas J Talley and Simon OConnor
from Clinical Examination: A Systematic
Guide to Physical Disease 5th Edition.
Nicholas J Talley and Simon OConnor
from Clinical Examination: A Systematic
Guide to Physical Disease 5th Edition.
Nicholas J Talley and Simon OConnor
from Clinical Examination: A Systematic
Guide to Physical Disease 5th Edition.
Nicholas J Talley and Simon OConnor
 Then ll in all the gaps

Past medical history (just asking this often isnt enough,

patients need memory prompts, or sometimes forget
certain conditions are illnesses)
Have you ever been given a diagnosis Ask SPECIFIC questions as patients may forget
Do you take medications for anything
Have you ever had to see a specialist
Have you ever been to hospital
Have you ever needed a procedure/operation/surgery
Women pregnancy/complications e.g. diabetes/delivery/
outcomes
 Medication history

Do you take any medications on a regular basis? If yes

What for
How (especially puers, with/without food)/when/how
much
Do you sometimes forget? (compliance/adherence)
Any over the counter medication?
Any puers? (often forgotten)
What about the pill? (often forgotten)
Immunisation history (especially kids!)
alternative health
 Allergies

Do you have any allergies to medications

What happens?
Dierentiate between allergy/known side eect of a
drug/other adverse reaction
Sometimes a side effect is expected and it is not necessary to be an allergy
 Family history
Any diseases that run in the family?
Specically diabetes, hypertension, heart attack/stroke,
cancers
If yes to cancers what cancer, what age if someone is you and got cancer, it means that it
is most likely inherited, thus age is important
Anyone die suddenly from unknown cause e.g. driving
alone/drowning (?sudden cardiac death)
Specic questions for particular ethnicities/countries
cystic brosis more common in caucasians, thalassaemia in
middle east/subcontinent/mediterranean, hepatitis B and C
in south east asia family history

Other common conditions thyroid issues, autoimmune

diseases (rheumatoid arthritis, type 1 diabetes, coeliac
disease)
 Social history
Smoker, ex-smoker, how many cigarettes a day, how many
years, previous attempts to quite
Opportunistically how do you feel about your smoking?
Brief motivational interviewing what do you get out of
smoking? What are the bad parts about smoking
Alcohol how much, how often How often do you drink rather than do you drink to
CAGE tool to screen for issue normalise the question so they dont get offended!!
Cut down has anyone asked you to cut down
Angry do you get angry when others suggest you might have
an issue with drinking
Guilty felt bad about drinking
Eye-opener needing to drink rst thing in the morning
Also any black outs, unable to fulll responsibilities because
of drinking
 2 drinks a day is
normal for healthy
person

http://www.druginfo.sl.nsw.gov.au/images/drugs/standard_drinks.jpg
 Social history
Recreational drugs
Especially for the elderly
Who lives with you?
What do you need help with
Showering
Dressing
Eating
Cooking
Shopping
Cleaning
Any services
Any family nearby
Occupation can be very relevant e.g. musculoskeletal presentations,
coughing exposure to asbestos/farmers (Q fever)
Recent travel eg malaria if recent relevant travel and spiking temperatures
When relevant sexual history
Men who have sex with men (dont assume! Ask ALL men!)
Number of partners
Use of protection
Children daycare? (exposure to illnesses!)
Special paediatric considerations

Cannot speak for themselves

5 functions of a child vomiting a couple of times and not just once as once is normal
Eat has their appetite gone o, vomitting (non specic but
important)
Pee number of wet nappies
Poo colour, blood, loose
Play
Sleep Are they waking up from pain?
Is the parent worried?
Even if they are an anxious parent, always take seriously can
the parent cope, but also is something seriously wrong
Special paediatric considerations
Mothers health during pregnancy gestational
diabetes, drug dependence, hiv/hepatitis B/C
Gestational age at birth (correcting growth
parameters for prematurity, diseases of prematurity)
Issues at birth (more relevant when seeing newborns)
e.g. neonatal jaundice, sepsis
When relevant
Developmental milestones
School performance (?learning diculties)
Behavioural issues
And always are their vaccinations up todate
 The blue book
Growth trajectory
Immunisation record Everyone born in NSW will get this book of record
 Role plays
- Pair up
- Each person takes a turn to play the medical clinician role
- Aim as a doctor is to not miss any vital information that
would lead you to miss something serious
- As a role player try to only give information when it is
specically requested!
 Please do scenario 1 rst

Allow some time to familiarise with the role (3 min)

Take about 12 min to play out the scenario
We will then reconvene for 15 min for feedback and
answers
 Time to do scenario 2

Allow some time to familiarise with the role (3 min)

Take about 12 min to play out the scenario
We will then reconvene for 15 min for feedback and
answers
Emergency medicine
 DRS ABCDE

Danger ensure you are not putting yourself in

danger, that others are not at imminent risk
Response check for response. If no response, the
rst step is to
Send for help. If you are by yourself you still need to
do this rst.
Airway needs to be patent
Breathing any eort of breathing
Circulation is the blood circulating
 Assessing airway

A talking patient has a patent airway

Signs of blocked/impending blocked airway
Blockage
Signicant drooling
Stridor
Decreased oxygen
Agitation
Cyanosis
Preceding inhaled foreign body/choking episode, exposure
to allergen leading to anaphylaxis
Check by opening mouth with the chin
 Cyanosis

http://www.nhs.uk/Conditions/cyanosis/
PublishingImages/
cyanosis_300x174_M1300068.jpg
 Breathing

Look for chest rising and falling. Normal respiratory

rate 18-25
Listen with a stethoscope you can hear inspiratory
and expiratory noises
Feel air coming out of mouth/fogs up a spoon

If no breathing start CPR

 Circulation

Warm peripheries
Capillary rell less than 2 seconds
Pulse, normal rate 50-100
Carotid pulse in the neck

If poor circulation, start CPR

 CPR

Cardiopulmonary resuscitation
Lower half of sternum using heel of hand
Compress chest halfway
Rate of staying alive (100 bpm)
2 breaths per 30 compression (not absolutely necessary)
Improves survival before debrillation
For 2 minutes
Check for signs of life every 2 minutes
http://s297.photobucket.com/user/lisalabanana/media/cpr-1.jpg.html
 Debrillation

Automated external debrillators

Attach pads as per diagrams
Follow voice prompts
Can provide shocks
Only for suitable heart rhythms
http://www.aedgrant.com/images/OnSite_wAccessories1.jpg
Ventricular tachycardia
Ventricular brillation
 Exposure

Look for obvious injuries major fractures

Any major source of bleeding
Other clues such as epipen, medic alert bracelet,
medications such as insulin, carrying jelly beans/
glucose tablets, track marks
 Disability

AVPU
Alert
Responds to voice
Responds to pain
Unresponsive
Chest pain
 Approach

Collapse follow DRSABCDE

If in doubt, call an ambulance
Whilst waiting, patient to remain sitting
Give emergency medication if on the person
Glyceryl trinitrate spray, repeat if no change in 5 minutes
300mg aspirin
Reassure patient
Oxygen if available
Indications of cardiac ischemic pain

Pale
Sweaty
Nausea and vomitting
Any past history of previous ischemic heart disease
angina, myocardial infarction, stenting, CABG
 Everything is based on risk
Age (especially >60)
Smoking within the last year
Diabetes
Past history of stroke, cardiac disease, peripheral vascular
disease
Hypertension
Hypercholesterolaemia
Overweight/obesity
Sedentary lifestyle
Poor diet
Depression
Low socioeconomic status
Male
 Deep vein thrombosis (clot)

Calf swelling
Erythema (redness)
Calf pain on dorsiexion (bend towards the dorsum/
back)
Unilateral (one sided)
Calf tenderness
Warmth
 DVT or cellulitis?

DVT Cellulitis
Calf swelling Fever
Erythema Hot to touch
Calf pain on dorsiexion Induration (rmness)
Unilateral And all of the same signs and
Calf tenderness symptoms as DVT
Warmth And there could be an
Pitting oedema underlying DVT
 Pulmonary embolus

The danger of DVT is that it can lead to pulmonary

embolus
Clot travels to the heart and then gets stuck in the
blood vessels leading to the lungs
Obstructive cardiogenic shock
 Response in the community

Collapse DRSABCDE
Unilateral leg swelling and redness seek semi-urgent
medical attention
With the advice that any chest pain, cough, diculty
breathing should escalate to urgent medical attention
 Asthma
Can be life threatening
Acute major airway bronchospasm leading to airway
obstruction
Pneumothorax
http://www.fpnotebook.com/_media/lungPtxComplete_PA.jpg
 Acute asthma attack

Known asthmatic
Context of recent upper respiratory tract infection/
exposure to usual trigger
Diculty talking in full sentences
Breathless
Chest tightness
Coughing
Increased use of ventolin puer
 Response - adults

Sit comfortably
12 pus of ventolin every 20 minutes, up to three
times
If no signicant improvement after rst 12 pus, call
an ambulance
If response but requiring 20 minutely ventolin, seek
urgent medical help (self-presenting to emergency is
appropriate)
 Children under 5y.o.

Tracheal tug, intercostal (between ribs) recession

lift up their shirt to look
4 pus every 4 minutes
Nil improvement ambulance
Some improvement, can do 3 lots of 20 minutely 6
pus
Will need urgent medical attention
 Anaphylaxis

Severe life threatening allergic reaction

Severe erythematous itchy rash with cough/
abdominal pain/lip swelling
Anaphylactic shock (diversion of cardiac output) and
air obstruction from bronchospasm

Give epipen adrenaline. They still need to go to

hospital via ambulance.
 Stroke

Clot in the brain (in the artery)

More than 10 minutes of dysphasia (diculty talking),
unilateral facial weakness, hemiparesis (one sided
limb weakness) warrants immediate investigation
Clot can be brinolysed (dissolved) within 4 hours of
symptom onset signicantly improves mortality and
morbidity
 Acute abdomen

Severe pain
Vomitting
Abdominal bloating
Obstipation (no atus or bowel motion)
Fever
Syncope (faint)
 Seizure

Time seizure
Recovery position
Dont put anything in the mouth
Seek immediate medical attention, especially if seizure lasts
longer than 5 minutes
If lasts >5 min, urgent medical attention
Not to travel alone
If seizure recurs, immediate medical attention
If seizure terminates but patient does not regain consciousness
within 30 minutes, immediate medical attention
 Recovery position

https://s-media-cache-ak0.pinimg.com/
originals/f0/28/7a/
f0287ad6e74041a1d89b4ea5f68a396b.jpg
 Febrile convulsion

6 months to 6 years
In the context of fever
Aects both sides of the body
Lasts less than 10 minutes
Does not recur within 24 hours
Recovery within 30 minutes with no residual decits
Often a family history of febrile convulsions
Does not mean child with have epilepsy
 Red ags any symptoms that is progressive

The end learning outcome of this subject is recognising

the signicance of red ags. These are good revision
tools. The lectures, booklets and quizzes are designed to
help you understand and remember.
 Next week

Formative quiz online to be done before class (marks

not recorded)
Revision of this week at start
Ear, nose and throat lecture
Practice ENT physical examinations

Feedback, questions, requests

cecile.chu@uts.edu.au