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Clinical Skills VI

Instructional Book

Introduction to Clinical Medicine I

Faculty of Medicine
Pelita Harapan University
Karawaci – Tangerang
2015/2016

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Tutorial 1

Irritative Urinary Symptoms (Estimated time: 45 minutes)


Tutor Note

Tutorial 1 starts with a review of the cardinal features of a presenting symptom using dysuria as the example.
Like much of this introductory course, one of the aims is to help students develop their vocabulary of medical
terms. The notion of a symptom cluster is introduced during this tutorial by categorising dysuria, frequency
and urgency as “irritative voiding symptoms”. Discuss the notes on dysuria with your students and make sure
they understand the concepts involved. Then play Case Study 5.01 and ask your students to identify the
cardinal features of the patient’s presenting problem.
Tutorial One
During the first three tutorials of this semester, the focus will be on aspects of the medical
interview and physical examination that relate to the genito-urinary system. The course
material is designed to link with your studies in the basic sciences of this body system. The
first tutorial provides an opportunity to review the cardinal features of a presenting problem
and to apply these to interviewing a woman about dysuria and vaginal discharge.
Tutor Note
The Urinary System
The urinary system consists of the kidneys, ureters, bladder and urethra. These tutorials will
concentrate mainly on symptoms relating to the lower urinary tract, particularly the bladder
and
the urethra. Many disorders of the upper urinary tract such as kidney failure do not produce
symptoms until quite late in the disease and the symptoms can be quite complex. You are
not
required to interview a patient about these symptoms at this stage of your medical career.
Dysuria
Urination is the process by which urine is excreted from the bladder through the urethra. It is
also known as micturition or voiding. The term dysuria is used to refer to urination that
causes pain, burning or discomfort. Dysuria is a common symptom that is usually caused by
an infection of the lower urinary tract, although it can be due to non-infectious disorders of
the bladder and prostate. Urinary tract infections (UTIs) are more common in women than
men. They are most likely to occur in young, sexually active women. Men are more prone to
develop UTIs as they become older.

Other symptoms, such as urinary frequency and urgency, are often associated with dysuria.
Urinary frequency is the term used when a person feels the need to void at more frequent
intervals than usual. This occurs when the bladder is irritated, such as by a urinary tract
infection, resulting in a sensation that the bladder is full, even when it is not. Urinary
frequency needs to be distinguished from polyuria, which refers to the production of
excessive volumes of urine. Urinary urgency is the term used when a person feels a
compelling need to empty their bladder as soon as possible, even if the bladder is not full.
Dysuria, frequency and urgency are often grouped together under the term “irritative voiding
symptoms”.

Dysuria can be accompanied by a range of other symptoms, especially in the setting of a


UTI.
Patients may report that their urine is bloody (haematuria), cloudy or malodorous. They may
also describe the presence of suprapubic pain. As you learn more about conditions that
affect
the urinary tract, you will be able to ask specific questions directed at establishing the
underlying
diagnosis.

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Case Study 5.01

Emma Vaughn, a 25-year-old university student with a history


of migraines and gastroenteritis, has presented to her
general practitioner with dysuria. She is being interviewed by
Jane Lee, a second year medical student.

Watch the interview and write down the cardinal features of


her presenting problem. Pay particular attention to the
associated features.

Medical interviewing component: Vaginal discharge and Sexual History (Estimated time: 75
minutes)
The second part of this tutorial introduces the students to the skill of interviewing a woman about a presenting
problem of vaginal discharge. It also provides an opportunity to introduce the principles of obtaining a sexual
history from a patient.

Using the tutorial notes, talk about the features of a normal physiological vaginal discharge. Then discuss
the concept of a pathological discharge. Highlight that the most common cause of a pathological vaginal
discharge is an infection. Using the notes, talk about the common infectious causes of vaginal discharge.

Then talk about applying the cardinal features framework to vaginal discharge as a presenting symptom. Play
Case Study 5.02 and ask your students to identify the cardinal features of the patient’s presenting problem.
Tutor Note

The rest of the tutorial focuses on the principles of taking a sexual history. Use the student notes to guide
your discussion. Start by talking about the reasons that a doctor might want to talk with a patient about sexual
matters. Emphasise that at this stage of their training, students are only expected to be able to know how to
ask a patient if he or she is sexually active, specifically in the context of a history of vaginal discharge, and
to interview a patient about a sexual problem as a presenting symptom. The latter will be addressed in the
next tutorial.

Spend some time talking about barriers to communication with respect to sexual issues. See if the students
can think of other barriers apart from those in the tutorial notes. Then work through the principles of taking
a sexual history with emphasis on sign-posting. Link this with the case study. Then spend time talking about
language, both verbal and non-verbal, that can optimise communication in this setting. The tutorial should
also include a discussion about not making assumptions about a patient and their sexuality.

The next part of this tutorial focuses on vaginal discharge as a presenting symptom. It also

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provides an introduction to the principles of obtaining a sexual history from a patient.
Vaginal discharge
A small amount of vaginal discharge is a normal physiological phenomenon. Most women
produce between 1 and 4 mL of vaginal fluid each day. This fluid is composed of secretions
from the cervix, vaginal walls and the glands at the entrance to the vagina, as well as
exfoliated epithelial cells and bacteria. The amount of fluid discharged can vary, depending
on the phase of the woman’s menstrual cycle or whether she is pre- or post-menopausal. It
can also be influenced by medications, such as the oral contraceptive pill.

A physiological vaginal discharge is usually colourless although it can be white or pale


yellow. It
can have a mild odour, depending on the microbiological balance of the woman’s vagina but
it is
unusual for a physiological vaginal discharge to have an unpleasant odour. The consistency
of the discharge can vary, typically becoming thicker at mid-cycle during ovulation.

A vaginal discharge can also be due to a pathological cause, most commonly an infection.
This
can result from an overgrowth of the bacteria normally present in the vagina, such as in
bacterial vaginosis or candidiasis (thrush), or from sexually transmitted diseases, such as
trichomonas or occasionally chlamydia. Less commonly, a vaginal discharge can be due to a
local dermatological condition or a foreign body, such as a retained tampon.

When gathering information from a woman presenting with a vaginal discharge, establish the
amount of discharge and how this varies from her normal pattern. Ask about the quality of
the
discharge, including colour, odour and consistency. Candidiasis typically produces a white
discharge that is clumped, similar to curd or cottage cheese. Bacterial vaginosis usually
causes
a whitish-grey discharge that has an unpleasant fishy smell, whereas trichomonas produces
a
frothy discharge which is usually green or yellow in colour.

Ask about the context of the discharge. It may, for example, be related to recent antibiotic
use. It
is also important to find out if the woman is sexually active and to establish her risk of having
a
sexual transmitted infection. Find out about the time course and enquire if the woman has
tried
any specific remedies, such as over-the-counter antimicrobial agents.

Also ask about whether there is any associated vulvovaginal discomfort, such as irritation or
pruritus (itch) or dysuria. At this stage of your training, you do not need to be able to ask
about
other associated features that might help to point to a precise diagnosis.

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Applying the cardinal features framework to vaginal discharge
Cardinal Feature Notes

Site This is usually apparent from the patient’s presenting problem.

Quality Establish the colour, odour and consistency of the discharge.

Severity The severity of the discharge can be quantified by asking the woman
to estimate the volume. She may say whether she needs to wear pads
or panty liners because of the discharge.

Time Course Ask about how long the discharge has been present and if it is changing
over time. Find out if the woman has had the symptom previously.

Context Ask about the context in which the discharge has occurred. It may be
in relation to, for example, taking antibiotics. It is also important to find
out whether the woman is sexually active.

Aggravating Factors Ask about any factors that make the discharge worse. A physiological
discharge, for example, may be affected by the use of the contraceptive
pill.

Relieving Factors Ask the woman if she has tried any treatment for the discharge and
establish how effective this has been.

Associated Features At this stage of your training, you could ask whether the woman has
pruritus or dysuria.
As you learn more about the conditions that can cause vaginal
discharge, you will be able to ask more specific questions that help to
point to a diagnosis or that can help to establish whether the infection
is associated with systemic illness.

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Case Study 5.02

Emma Vaughn, a 24-year-old university student, has presented


to her general practitioner with a problem of vaginal discharge.
She has a history of migraines and was recently treated with
antibiotics for a urinary tract infection.

She is being interviewed by Marissa Zenetta, a second year


medical student. Watch the interview and write down the
cardinal features of her presenting problem.

Building your communication skills


Being able to talk with patients about sexual issues is a skill that many students find difficult,
often because they feel embarrassed or poorly trained for the task. Like many other skills in
medicine, taking a sexual history is easier to learn if the underlying principles are made
explicit
and introduced in a step-wise fashion.

During this part of the tutorial, you will have the opportunity to discuss with your tutor the
circumstances in which a sexual history might be helpful as well as some of the barriers that
can
interfere with communication about sexual issues. You will also have an opportunity to
explore the basic principles of taking a sensitive sexual history.
When to take a sexual history
There are many situations in clinical practice when taking a sexual history is relevant. It may,
for example, be important when a sexually-related condition is one of the potential diagnoses
for a presenting symptom, such as when a woman has developed a vaginal discharge. In
other
situations, a specific sexual problem, such as erectile dysfunction, loss of libido or
dyspareunia,
may itself be the presenting symptom.

A sexual history may also be appropriate in the presence of physiological changes relating to
the reproductive system, such as menopause, or when the patient has a medical condition
that
can impact on sexual function, such as diabetes, depression or infertility. Medical treatments
can also have an adverse effect on a person’s sexual well-being. These include certain
medications, such as anti-depressants and anti-hypertensive agents, as well as surgical
procedures such as prostate or breast cancer surgery.

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Taking a sexual history is also an important component of health promotion. An example of
this
would be talking with an adolescent patient about prevention of unwanted pregnancy and
sexually transmitted infections. A sexual history may also be an effective way of identifying
whether a patient is in an abusive relationship or is the victim of other sexual, emotional or
physical abuse.

What are the barriers to taking a good sexual history?


There are a number of potential barriers to communication about sexual matters in the
clinical
setting. Embarrassment or lack of knowledge on the part of either the doctor or the patient
may
inhibit open discussion about a sexual issue. Differences in age, gender or socioeconomic
status between the interviewer and patient may also impact on how information is
exchanged, as may cultural or religious factors.

Lack of awareness of the possibility of underlying sexual issues can mean that patient
concerns
remain unexplored. A doctor may also not recognise verbal and non-verbal cues from the
patient signalling that he or she is wishing to discuss a sensitive issue. Pressure of time may
deter a doctor from raising such issues in a consultation. Lack of privacy can provide a
significant barrier in the ward situation.

Principles of taking a sexual history


When interviewing a patient about sexual issues, it is essential that the physical environment
is comfortable and affords adequate privacy for the patient. As a student, you also need to
feel
comfortable that the task that you are undertaking matches your level of training.

If you need to ask about sexual issues as part of the diagnostic reasoning process, it is
important that you signpost this to the patient. Tell him or her that you would like to discuss
matters of a sexual nature and provide a rationale for doing so. It can be helpful to reinforce
the notion of confidentiality, especially with adolescent patients. Ask for permission to
proceed, especially at this level of your training. Marissa Zenetta used these techniques
during her interview with Emma Vaughn:

MARISSA ZENETTA: “OK … well, Emma, I agree with you that it sounds like thrush
… but I’d like to ask some more questions. First of all, I’d like
to find out whether you are sexually active at present. This is
a routine question that is asked when a woman has a vaginal
discharge. It can sometimes be important in helping to find
out about the cause … and of course, what you tell me is
confidential … between you, me and Dr Tan. Is it OK with
you if we talk about this?”

EMMA VAUGHN: “Sure … and yes, I’m sexually active. I’ve been with Jamie, my
boyfriend, for about six months now … “

Basic communication skills, such as active listening, clarification and effective questioning,
are
essential when taking a sexual history. Ensure that the patient knows you are listening
carefully
as they describe their symptoms and concerns. Use a balance of open and focused
questions

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but always start with an open question. This allows the patient to start with issues that he or
she
feels most comfortable about. In addition, information that is spontaneously volunteered is
usually more accurate than that elicited in response to a closed question. Be sure to clarify
the meaning of what the patient is telling you. Patients often use euphemisms or colloquial
terms when talking about sexual matters. Make sure that you ask questions using simple
and appropriate language. Avoid using medical terminology and slang terms. If asking about
a person’s relationship, use neutral language such as “partner”.

Observe the patient’s body language carefully during the interaction. If the patient seems
embarrassed talking about sexual matters, try to put them at ease. Reassure them that
many people find talking about sex with their doctor difficult. If you sense that the patient
does not want to discuss the matter further, do not pursue it, especially if you, and not they,
have broached it in the first place. Many people do not like discussing their sex lives with
their doctor.

One of the most important principles of taking a good sexual history is not to make
assumptions
about people. Do not, for example, take for granted that someone is not sexually active. This
particularly applies if the patient is an adolescent or an older person or comes from a
particular
religious or cultural group. Likewise, do not assume that a person is sexually active. Instead,
approach the interview in a manner that allows the person to describe their own situation
freely.
It is particularly important not to make assumptions about a person’s sexual orientation or
behaviour based on their appearance. Be non-judgmental and do not impose your own
values on the patient. Finally, do not assume that a person who is having sexual problems
has an underlying psychological problem. All presenting symptoms of a sexual nature need
to be fully evaluated, just like any other symptom.

Role Play
Practise interviewing a patient about dysuria and vaginal discharge and practise introducing
a
sexual history during your interview.

Glossary of sexual terms

Sexual term - medical Colloquial term Meaning


Penetration of the anus by penis, fingers, or
Anal Sex
other object during sexual intercourse
Anilingus Rimming Licking or sucking around the anus
Bisexual Bi Sexual and/or emotional attraction to both genders
Clitoris Clit Highly innervated area of the female genitalia
Condom Rubber Latex sheath worn on the penis during sexual
Cunnilingus Going down intercourse
Oral stimulation of clitoris/vulva
Rectangular piece of thin latex, applied of the vulva
Dam Dental Dam
and/or anus during oral sex
Ejaculation Cum Release of semen during orgasm
Fellatio Head job, blow Mouth to penis contact
job

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Fisting Fisting Whole hand inserted into the vagina or anus
Rubbing genitals together for sexual pleasure or
Frottage or Dry Humping
genital region against any part of the other person’s
Tribadism
body
An area of tissue surrounding the female urethra and
G-Spot
running along the roof of the vagina, postulated to be
erectile
Externaland to enhance
sexual organs sexual
of the arousal.
male (penis, scrotum)
Genitals
or female (clitoris, vulva, introitus of the vagina)
Homosexual Gay (man or Sexual/emotional attraction of a man to men
Lesbian woman)
Dyke Sexual/emotional attraction of a woman to women
Masturbation Wanking Stimulation of one’s own clitoris/vagina/penis
Sexual and emotional relationship with one person
Monogamy
only, being married to one person at a time
Mutual Stimulation of each other’s clitoris/vagina/penis
masturbation “an explosive discharge of neuromuscular tension”
Orgasm-female or Come
Kinsey, 1953. Culmination of sexual excitement
male
Penis Dick, Cock Male sexual organ
Polygamy Having more than one husband/wife
Sex Aids Sex toy, dildo, Items for stimulation through vaginal or anal
vibrator
Sex, Bang, penetration
Broad definition - any form of physical contact
Sexual intercourse
Bonk, involving the genital area of at least one partner
Shagging
Unsafe sex, Sex where transmission of body fluids can occur
Unprotected sex
Bare-backing including vaginal fluid, semen, saliva, faeces,
Vagina (anal)
Cunt, Pussy blood
Canal between the cervix (opening of the uterus) and
the vulva
Penetration of the vagina by penis, fingers, or
Vaginal sex
other object during sexual intercourse
Vulva or labia
Lips External female genital area, external orifice of the
majora and
vagina
minora

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Tutorial 2

Obstructive Voiding Symptoms (Estimated time: 30


minutes)
Tutor Note

The first part of this tutorial focuses on obstructive voiding symptoms, again involving the notion of a
symptom cluster. Work through the notes with your students, making sure that they understand all
the concepts. Play Case Study 5.03. Ask the students to identify the obstructive and irritative
symptoms that the patient has been experiencing. Use this to prompt a discussion about the
mechanical component of bladder neck obstruction compared with the dynamic component (smooth
muscle irritability secondary to the obstruction).

Tutorial Two
In the last tutorial, you learned about grouping or categorising symptoms, using irritative
voiding
symptoms as the example. During the first part of this tutorial, you will learn about
obstructive voiding symptoms, another group of symptoms relating to the urinary tract that
can be clustered together to help provide a framework for the patient’s presenting problem.
You will also be provided with an opportunity to practise your physical examination skills.

Obstructive voiding symptoms


Bladder outlet obstruction is a condition where the flow of urine out of the bladder into the
urethra is impaired because the neck of the bladder does not open properly during voiding.
This may occur due to a mechanical blockage or because there is a neuromuscular disorder
that prevents the outlet from functioning. The most common cause of bladder outlet
obstruction is enlargement of the prostate gland, called benign prostatic hyperplasia (BPH).
This is a condition that occurs in men as they grow older. Almost 50% of men aged 80 years
have symptoms of BPH. Other causes of bladder outlet obstruction include scar tissue,
bladder stones and tumours.

Bladder outlet obstruction produces a cluster of symptoms called obstructive voiding


symptoms.
These symptoms include hesitancy, straining and dribbling. Hesitancy refers to the difficulty
that a patient has with initiating the urinary stream. The patient may also notice a weak and
trickling stream due to a decreased force during micturition and may need to strain to pass
the urine. There may also be dribbling at the end of the stream. Incomplete emptying can
lead to a sensation of fullness in the bladder. It may be helpful to think of how water flows
through a blocked hose in order to understand these symptoms.

As a consequence of outlet obstruction, the detrusor muscle of the bladder can become
hypertrophied and irritable. This can lead to irritative voiding symptoms such as dysuria,
frequency and urgency. Thus a person with bladder outlet obstruction can experience both
irritative and obstructive voiding symptoms. If severe blockage occurs, damage to the ureter
and kidneys can occur. In extreme cases, the patient may not be able to void at all. This is
called urinary retention.

Another symptom that patients with urinary problems often describe is nocturia, which
means the urge to urinate at night. Nocturia can occur with problems that cause either
irritative or obstructive voiding symptoms. In the case of irritation of the urinary tract, the
patient may have urinary frequency that occurs during the night as well as during the day. In
the case of outlet obstruction, urine may remain in the bladder after micturition and this can

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lead to frequent voiding, especially at night. Nocturia can also be caused by conditions that
cause polyuria, such as diabetes, or by the consumption of excessive amounts of coffee,
tea or alcohol, especially before bedtime. It can also be an early symptom of chronic renal
failure. Nocturia leads to sleep deprivation and can place people, especially the elderly, at
risk of falls and injury.

Case Study 5.03

Tony Failla, a 56-year-old fruiterer with a history of


dysphagia due to a peptic stricture, has
presented with urinary symptoms. He is being
interviewed by Dr Shayan.
Watch the interview between Mr Failla and
Dr Shayan. Write down the obstructive and
irritative voiding symptoms that Mr Failla
describes. Comment on the cardinal features of his
presenting problem.

Obstructive voiding symptoms Irritative voiding symptoms

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Medical interviewing component: Erectile dysfunction (Estimated time: 45 minutes)
This part of the tutorial introduces students to the skill of interviewing a man about his
erectile function. It provides an opportunity to discuss the normal physiology of erectile
function and to further discuss the principles of obtaining a sexual history from a patient.

Using the tutorial notes, discuss the normal physiology of erectile function. It may be helpful
to have a diagram available to assist with the discussion.

Outline the common causes of erectile dysfunction using the notes. Link these with the
underlying physiology. Students are not expected to know about the causes of erectile
dysfunction in detail at this stage of their training.

Talk about using the cardinal features framework to gather information from a man who
presents with erectile dysfunction. Play Case Study 5.04 and ask your students to identify the
cardinal features of the patient’s symptom. Ask them to estimate the relative contribution
of physical and psychological factors to his presenting problem.

Revisit the principles of taking a sexual history that were introduced in the last tutorial.
Focus on the barriers that may prevent a patient from broaching a sexual problem with a
doctor. In Case Study 5.04, the patient knows his doctor and feels comfortable discussing
his sexual problem, despite some initial uneasiness. Discuss how some patients may not
wish to discuss matters of a sexual nature with their routine doctor. Also discuss how the
gender of the patient’s partner might impact on communication.

Use role plays to give students the opportunity to practise interviewing men about their
erectile
function.

This part of the tutorial focuses on erectile dysfunction as a presenting problem. It outlines
the mechanism of normal erectile function and the pathological processes that can interfere
with it. It also provides you with an opportunity to further discuss the principles of taking a
sexual history.

Erectile dysfunction
Erectile dysfunction is defined as the inability to achieve or maintain an erection that enables
sexual activity with penetration. It can be a symptom of a wide range of physical and
psychological conditions. Erectile dysfunction is a common problem that becomes more
prevalent with age. At least 1 in 5 men over 40 has some degree of erectile dysfunction,
while about 10% of men in this age group are completely unable to have an erection.

Normal erectile function


Normal erectile function, or tumescence, is a complex process, requiring the co-ordination of
a series of physiological events. It involves the redirection of blood from the pelvic vascular
bed into the erectile tissue of the penis. This process is triggered by neurological stimuli and
is mediated by an array of hormonal, chemical and psychological factors.

The erectile tissue of the male penis consists predominantly of two spongy cigar-shaped
structures called the corpora cavernosae that are composed of a network of sinusoids made
up of trabecular smooth muscle and lined by endothelial cells. During an erection, the
trabecular smooth muscle relaxes, allowing blood to flow into the sinusoidal spaces. The
expansion of erectile tissue that occurs is limited by the tunica albuginea, the strong fibro-
elastic casing that envelops the corpora cavernosae. This leads to increased pressure in the

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sinusoidal spaces that blocks the outflow of venous blood from the penis. Blood is thus
trapped within the penis, resulting in rigidity.

The flow of blood into the penis during an erection is activated by signals from the nervous
system. This can occur by two different mechanisms. The first is mediated through central or
psychogenic sensory inputs generated by erotic stimuli and relayed to the lower spinal cord
through the limbic system in the brain. The second occurs through peripheral or reflexogenic
sensory inputs produced in response to tactile stimulation of the genital region that are
relayed through a reflex arc to the sacral nerve roots. These neural signals are transmitted
through parasympathetic nerve fibres to the penis where they produce vasodilatation of the
sinusoidal blood vessels and relaxation of the trabecular smooth muscle.

Local factors also play an integral role in the regulation of erectile function. One of the most
important of these is nitric oxide, a neurotransmitter produced by the vascular endothelium. It
acts by increasing the production of cyclic 3’, 5’ guanosine monophosphate (GMP), a
chemical that augments vascular dilatation and smooth muscle relaxation. The hormone
testosterone plays a role by helping to maintain levels of the enzyme that catalyses the
production of nitric oxide. Testosterone is also important for maintaining libido.

An erection weakens when cyclic GMP is metabolised by a group of chemicals called


phosphodiesterases and when sympathetic nerve activity increases during ejaculation. As a
result of these chemical and neurological changes, the trabecular smooth muscle in erectile
tissue contracts, allowing blood to flow out of the penis and back into the pelvic vascular
bed. This process is called detumescence.

What causes erectile dysfunction?


Erectile dysfunction can be caused by any condition that interferes with the normal
mechanism of penile tumescence. Often more than one underlying cause is present. It is
important to make a full medical assessment when a man presents with erectile dysfunction
as it can be the first symptom of an underlying physical disease.

Atherosclerosis and its risk factors cause endothelial dysfunction and thus can impact on
blood flow during tumescence. Common conditions associated with vascular causes of
erectile dysfunction include diabetes, renal failure, peripheral vascular disease and sleep
apnoea. Erectile dysfunction can also be caused by neurological conditions, such as spinal
cord disease, stroke and dementia, as well as by local interruption in nerve supply to the
penis by pelvic surgery or trauma.

An estimated 25% of cases of erectile dysfunction are caused by prescribed medications.


Antidepressant and anti-hypertensive drugs account for most of these cases. Alcohol and
recreational drugs can also impact negatively on sexual function in men. Hormonal
conditions such as testosterone deficiency or high prolactin levels less commonly cause
erectile dysfunction.

Psychological factors, such as anxiety, depression or relationship problems, play a


prominent role in about 10% of cases of erectile dysfunction. Anxiety can lead to impaired
sexual function by increasing sympathetic tone, resulting in impaired smooth muscle
relaxation during tumescence. Depression may cause erectile dysfunction directly or through
the medications used for its treatment. Many men who have a physical cause for their
erectile dysfunction also have a psychological component because of the anxiety that it
generates. An inability to achieve tumescence can occur in men with normal erectile function
due to alcohol intake or lack of sleep.

Gathering information about erectile dysfunction

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The interview needs to be approached in a sensitive manner using the principles of effective
communication discussed in the last tutorial. Start by asking an open question. This allows
the man to describe the problem in his own words. Be sure to clarify the exact nature of the
presenting problem before embarking on the rest of the interview. Specifically, erectile
dysfunction needs to be differentiated from loss of libido, the inability to reach orgasm or
difficulties with ejaculation.

Apply the cardinal features framework to your information gathering. Find out about the
severity of the presenting problem. How rigid are the man’s erections? Does it take him
longer to achieve them than usual? Are the erections of a shorter duration than usual?
Establish whether the man is able to have penetrative sex. Also determine the time course of
the problem. Erectile dysfunction that has a gradual onset is likely to have a physical cause.
An acute onset suggests a psychogenic cause. Erectile dysfunction that occurs intermittently
is also likely to have a psychogenic basis or be due to alcohol or lack of sleep.

The context in which erectile dysfunction occurs may be helpful in distinguishing between
physical and psychogenic causes. If the man has more than one sexual partner, ask if the
problem occurs with one and not another. Find out if an erection can be achieved with
masturbation and whether the man has nocturnal or early morning erections.

Establish if there are any particular precipitating or aggravating factors. Also enquire about
any treatments that have been tried and how effective these have been. Ask about
associated features such as loss of libido or problems with orgasm and ejaculation if these
have not already been discussed during the interview. At this stage of your training, you are
not expected to be able to ask questions to establish the possible underlying causes of a
patient’s erectile dysfunction. You are also not expected to be able to explore complex
psychological or relationship issues with a patient.

Applying the cardinal features framework to erectile dysfunction


Cardinal Feature Notes

Site Not applicable.

Quality This is linked with the severity of the problem.

Severity Ask about the degree of rigidity of erections.


Does it take longer to achieve an erection?
Are erections of shorter duration than previously?
Is the problem severe enough to prevent intercourse?

Time Course How long has the erectile dysfunction been present?
Was the onset sudden or was it gradual?
Does it occur intermittently or is it present on every occasion?

Context Explore the context in which the erectile dysfunction occurs.


If a man has more than one sexual partner, does it occur with one and
not another?
Is the man able to achieve an erection with masturbation? Do nocturnal
or early morning erections occur?

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Aggravating Factors Does anything seem to have precipitated the erectile dysfunction?
Does anything seem to make it worse?
Does anxiety impact on the man’s ability to achieve an erection?

Relieving Factors What has been tried to help with the problem?
If medication has been tried, how effective was it?

Associated Features Ask whether there have been any difficulties with libido, orgasm and
ejaculation in association with the erectile dysfunction.
At this stage of your training, you are not expected to be able to ask
questions to establish the possible underlying causes of a patient’s
erectile dysfunction. You are also not expected to be able to explore
complex psychological or relationship issues with a patient.

Case Study 5.04

Warren Humphries, a 54-year-old accountant, has


presented to his general practitioner, Dr Steve
Trumble, with a problem of erectile dysfunction.
He has a history of SLE, hip replacement and
frozen shoulder.

Watch the interview between Mr Humphries and


Dr Trumble and write down the cardinal features of
Mr Humphries’s presenting problem. Discuss the
relative contribution of physical and psychological
factors to his presenting problem.

Role play
Using role plays, practise interviewing men about their erectile function and obstructive
voiding
symptoms.

Physical examination practice


Use the remainder of time in this tutorial to revise your physical examination
skills. Use the list of learning objectives for ICM 5 and the ICM portfolio to
identify which physical examinations you need to review.

Physical examination component


(Estimated time: 45 minutes)
Tutor Note

Use the remainder of time in this tutorial to revise physical examination skills. Ask
students to use the list of learning objectives for ICM 5 and the ICM portfolio to
identify which physical examinations they feel they need to revise. You may choose
to revise these examinations in a large group, or allow the students to split into
small groups and circulate to provide feedback.

14
Tutorial 3

This tutorial introduces students to taking a menstrual history. You may wish to have a diagram
available for the tutorial that illustrates the menstrual cycle.

Medical interviewing component: Menstrual history (Estimated time: 1 hour)


Using the tutorial notes, talk with your students about the basic physiology of the menstrual cycle.
Then talk about the principles of interviewing a woman about her menstrual history.

Discuss the normal variation of frequency and duration, emphasising that establishing if there has
been a change from a woman’s normal pattern is important. Talk about the definitions of amenorrhoea
and oligomenorrhoea. Students do not need to know details about the cause of these symptoms at
this stage of their training.

Then talk about finding out about the amount of blood lost during menstruation. Emphasise that
Tutor Note

this can be challenging as it is difficult for women to quantify this. Estimating blood loss in any
situation is a very subjective exercise. One way is to ask the woman about the number and size of the
pads and/or tampons that she needs to use. This might also involve finding out about how soaked
these products are when they are changed. Again, establishing that there has been a change from the
normal pattern may be more helpful. Discuss the definition of menorrhagia.

Then use the cardinal features framework to talk about how the students might approach a menstrual
history. Play Case Study 5.05 and ask your students to use the cardinal features framework to document
the patient’s menstrual history.

Using role plays, provide the opportunity for your students to interview women about their menstrual
histories. Be aware that students may find this process challenging due to the nature of the topic. It
will be important to discuss any issues that the students have with this. Male students, for example,
may feel uncomfortable talking to women about the use of feminine hygiene products.
Tutorial Three
Normal physiology of the menstrual cycle
Learning Sessions
The menstrual cycle involves a complex series of events under hormonal control that occurs
throughout a woman’s reproductive years. It is typically divided into three main physiological
phases: (i) the follicular phase, (ii) ovulation and (iii) the luteal phase.

During the follicular phase, follicle stimulating hormone (FSH) is released from the pituitary
gland under the control of the hypothalamus. Under its influence, a cluster of ovarian follicles
is recruited. Usually only one of these follicles fully matures (the dominant follicle) and the
other non-dominant follicles die away. During this phase, oestrogen is produced by the
ovary, leading to thickening of the endometrium.

Hormonal events at mid-cycle trigger the release of the ovum from the dominant follicle
(ovulation). The residual follicle becomes the corpus luteum, which produces the hormone
progesterone that primes the endometrium in readiness for implantation of the fertilised
ovum. If the egg has not been fertilised, the corpus luteum dies off, leading to a fall in levels
of oestrogen and progesterone. As a result, the lining of the uterus is sloughed off resulting
in menstruation.

15
Interviewing a woman about her menstrual cycle
When interviewing a woman about her menstrual cycle, it is important to establish frequency
and duration as well as the amount of blood loss.

Frequency and duration of menstruation


To establish the frequency of a woman’s menstrual cycle, ask about the time between the
first day of one period and the first day of the next period . Make sure that the woman is not
describing the time between the end of one period and the beginning of the next. The normal
duration of a menstrual cycle is between 21 and 42 days, with the typical cycle being 28
days. In most women, there is a variation of one to two days from one cycle to the next. If a
woman has greater variation than this, document the shortest and the longest times between
cycles. Also determine the length of the woman’s menstruation, which is typically about 4 - 5
days. It is also important to establish if there has been any recent change in the woman’s
menstrual cycle.

One of the most common disturbances of the menstrual cycle is amenorrhoea, which is
defined as an absence of menstruation during the reproductive years. It usually applies if a
woman has not menstruated for more than six months. The term primary amenorrhoea is
applied when a woman has never had a period whereas secondary amenorrhoea is used
when a woman has established cycles and then ceases menstruation. The most common
cause of amenorrhoea is pregnancy. Amenorrhoea can also be caused by a wide range of
pathological conditions that affect various components of the female reproductive system.

The term oligomenorrhoea is used when a woman who has previously had regular cycles
has infrequent menstruation. It usually means that the woman is having only 4 – 9 periods
per year. It is also used to describe when the flow of a woman’s period becomes lighter. The
term polymenorrhoea is used when the interval between menstrual periods is less than 21
days.

Menstrual flow
The amount of blood lost during menstruation is typically between 20 and 60 mL, with the
average being 40 mL. Blood loss during menstruation greater than 80 mL is considered to
be abnormal. It is usually difficult to obtain an accurate estimate of the amount of blood lost
during menstruation but one way to quantify it is to ask about the number and size of the
pads or tampons that the woman needs to use. It is also important to find out if there has
been any change from the normal pattern.

The term menorrhagia is used to describe abnormally heavy menstruation over at least
several
consecutive cycles. This condition affects up to 30% of women at some time during their
reproductive life. It usually occurs in the years just before menopause. Menorrhagia can lead
to iron deficiency anaemia and can have a significant impact on a woman’s quality of life.

Applying the cardinal features framework to menstrual history


Cardinal Feature Notes

Site This cardinal feature is usually not helpful. Rarely, vaginal bleeding
needs to be distinguished from rectal bleeding.

Quality Find out about the nature of the woman’s menstrual loss. It may be
bright red or brown and may vary during the period. Ask whether the
blood loss contain clots.

16
Severity Determine the amount of blood loss. It may be helpful to ask about the
number and size (regular or super) of the pads and/or tampons that
the woman needs to use and whether these are soaked through each
time.

Time Course Establish the frequency and duration of menstruation. If it is irregular,


document the shortest and longest cycle lengths. Ask about the date
of the last menstrual period (LMP). In younger women, ask about the
age at onset of menstruation (menarche).

Context Ask about circumstances that may relate to changes in the menstrual
cycle. For example, consider whether the woman might be peri-
menopausal.

Aggravating Factors Ask if there is anything that directly impacts on the woman’s menstrual
cycle. For example, stressful events or significant weight loss can lead
to amenorrhoea.

Relieving Factors Ask about what treatments have been tried for any menstrual irregularity
and how effective they have been.

Associated Features Ask if menstruation is associated with pelvic pain. This pain is called
dysmenorrhoea.
As you learn more about specific disorders of the female reproductive
system, you will be able to ask questions that help to point to potential
underlying diagnoses.

Case Study 5.05

Judith Patterson, 52, has come to see her general practitioner


because she is concerned about the pattern of her menstrual
cycle.
She is being interviewed by Tess McClure, a second year
medical student.
Watch the interview and write down the cardinal features of
Mrs Patterson’s presenting problem.

Role Play
Using role play, practise interviewing women about their menstrual cycles.

17
Tutorial Four
This tutorial provides you an opportunity to learn how to perform a breast examination with
the help of a clinical teaching associate. You will also learn the principles of communicating
appropriately with a patient during a sensitive examination.

You will revisit the principles of taking a family history from a patient and will get to practice
locating and characterising lumps using a breast model.

Through discussion with an advocate from the Breast Cancer Network Australia
(www.bcna.org. au) you will have an opportunity to learn about the issues faced by a woman
with breast cancer.

Introduction to CTAs
During this session you will be working with Clinical Teaching Associates (CTAs). The CTAs
are women from the community with a strong interest in improving the health of women.
They have had extensive training in the best practice technique of breast examination. They
will demonstrate this technique, explaining what they are doing. They will discuss with you
the best way to communicate with women while performing this examination. After this you
will be divided into groups of 2 or 3 and you will each have a turn at performing a breast
examination on a CTA. The CTAs have also been trained in feedback skills. After the
examination, each student will be given feedback on their technique and communiation
skills. The aim is that by the end of this session each student will have a greater
understanding not only of the technique for performing a breast examination but also the
principles of communicating with women while performing a sensitive examination.

Reasons why doctor may perform a breast examination


There are three main reasons. The patient may initiate a consultation because of a concern
about a breast symptom such as a lump or pain, the patient or clinician may initiate the
examination as part of a ‘Well Woman’s’ check or the doctor may initiate the
examination as part of a problemorientated examination (for example, a woman
presenting with back pain where the doctor is concerned that she has breast cancer).

Guidelines for performing a sensitive examination


• Obtain informed consent. This involves:
» an explanation of the procedure
» an opportunity for the patient to ask any questions
» an explanation that the patient can ask for the examination to stop at any time
» checking that the patient is willing to proceed.
• Ensure that the patient has a full understanding of why the examination is taking
place.
• Be sensitive to cultural or gender issues.
• Use signposting and explanation when appropriate.
• Understand your patient’s concerns, including issues relating to body image, current
pain or discomfort she is experiencing and past experiences of breast examinations.
• Use appropriate terminology and language. Avoid technical jargon, slang and
sexual connotations. For example, when checking the breasts for symmetry it is
better to say “I am inspecting / checking the breast tissue” rather that “I am looking
at your breasts”. Similarly when palpating the breast tissue,explain that you are
examining/ palpating the breast tissue rather that feeling the breasts.
• Provide clear instructions for what clothing to remove during examination and
provide a gown.

18
• Include an appropriate conclusion to the examination. At this stage of your
training this may be thanking the patient for their time and for allowing you to
examine them.

In sensitive examinations, communication skills are very important. As well as the verbal
skills mentioned above, nonverbal skills are also very important.

Nonverbal skills include:


• The manner of speech used - the tone of voice, the rate of speech, the volume of
speech. Speak clearly, at a volume the patient can hear and at a rate the patient
finds easy to understand what you are saying.
• The position in which you stand. You must respect the patient’s private space. In
Western culture it is best to be about an arm’s length from the patient and not
directly in front of her but slightly to one side. This will allow her some personal space
and will avoid directly staring at her. Only move directly in front of the patient when it
is essential for the examination.
• Appropriate eye contact. While examining a patient it is important to visually check
for any pain or discomfort but again not to stare at the patient. The rule of thirds is a
guide to eye contact - one third of the time looking at the breast, one third looking at
the patient and one third looking in the distance.
• Maintain a professional manner. This includes both facial expression and general
body language. Be aware of inappropriate mannerisms that can manifest
themselves when you are nervous such as a fixed grin, rubbing your hands
together all the time or an inability to stand still.
• Consider the patient’s comfort and privacy.
• Respect the patient’s dignity.

Remember that sexual contact between a doctor and his/her patient is not allowed and that
you
Must act at all times to ensure that the doctor-patient interaction is not ‘sexualised’. It is
important that the student/doctor does not act in such a manner so as to cause
unnecessary anxiety in the patient.

It may be appropriate for male clinicians to have a female chaperone present during the
examination (students at this stage are not permitted to perform a breast examination in a
clinical setting unless they are supervised by a tutor).

19
Introduction and Demonstration
Watch the demonstration of the breast examination by the Clinical Teaching Associate. The
sequence of the examination is outlined below.
1. Prepare the patient. Explain what you are going to do. Check that the patient
understands and gives consent. Establish a ‘stop’ signal with the patient.
2. Ask her to remove all clothing from the upper half of her body, including the bra.
Provide her with a sheet or a gown to cover herself and a private area where she
can change.
3. Wash your hands.
4. Confirm with the patient the site of her breast symptom and enquire about the
presence of any significant breast discomfort.
5. Ask the patient to sit on the examination couch and to remove the sheet or gown.
6. Conduct a detailed systematic visual examination of the patient’s breasts. This
may involve asking the woman to lift the breasts if they are large or pendulous.
7. Check for any differences in size, any differences in the shape of the breast
(asymmetry), any obvious skin changes such as dimpling or retraction or change
in colour of the skin of the breast (particularly red or erythematous changes). The
nipples should be carefully inspected and any inversion should be noted (check if
any of these changes are recent).
8. Ask the patient to raise her arms slowly above her head. This manoeuvre may
highlight subtle changes in breast symmetry or skin dimpling.
9. Ask the patient to place her hands on her hips and role her shoulders forward.
10. Ask the patient to lie down for breast palpation. For women with large or pendulous
breasts, placing a pillow under the shoulder of the side to be examined, so that the
breast mound is pointing upwards, facilitates the examination.
11. The woman’s arms should rest by her side except when the lateral breast axillary
tails are being examined.
12. The breast tissue is palpated with the flats of the fingers, moving the hands in
a circular motion. This circular motion should slowly increase in pressure, ensuring
that the superficial and deep breast tissue is examined. Always be alert to the
patient’s comfort as you are palpating the breast.
13. The breast is examined in strips in an area bounded by the midline to the mid
axillary line, and from the clavicle to the rib margin. After the first area has been
examined the hand is moved to the next area in the strip and the process
repeated until the breast has been completely examined. The nipple should be
included in the routine breast examination. Pay particular attention to the area of
the woman’s concern.

20
14. Ask the patient to sit up for the examination of the axillary lymph glands. The left
axilla is examined by supporting the patient’s left arm with the examiner’s right
arm and palpating the axilla with the right hand. The tips of the fingers are
placed gently but firmly at the top of the axilla and pressed against the chest
wall and then dragged slowly downwards. Particular attention is paid to the areas
behind the pectoralis major and adjacent to the latissimus dorsi. The other
axilla should then be examined.
15. The supraclavicular lymph glands are examined by palpating the supraclavicular
fossae.

16. Close the examination and leave the patient in private to dress.
17. Remember to look at the patient during the examination and enquire about
discomfort. Be alert for any signs of distress or discomfort.

Activity 1: Clinical Teaching Associates

21
Work with the Clinical Teaching Associates (CTAs) to practise performing a breast
examination. The CTAs will provide feedback to you about your examination technique and
talk about communication skills that are effective during a sensitive examination.

Activity 2: Breast Model and Family History


Breast Model
In pairs, use the model of the breast to practice palpating for lumps. Characterise the
lumps and describe them to your colleague.

Two breast models will be provided for each group. Each breast model contains three lumps. Ask the
students to locate the lumps and describe their features: site, shape, consistency, tenderness,
Tutor Note

mobility, associated skin changes.


(10 minutes)

Using the tutorial notes, revise the principles of taking a family history.

Play Case Study 5.06 and ask your students to write down the patient’s family history. Discuss how her
family history has influenced her attitude to her current problem. Ask your students to construct a
genogram with respect to the family history of breast and ovarian cancer. This could form the focus
for a brief discussion about the genetic inheritance of breast and ovarian cancer (BRCA1 and BRCA2
Tutor Note

genes) and about predictive genetic testing.

Encourage your students with the opportunity to practise taking family histories on their clinical
placements. It is best to avoid using a fellow student for practice as there is the potential for difficult
issues to arise. The same applies to asking students to write down their own family history of illness
during the tutorial.

(20 minutes)

Family History
Asking a patient about the family history of illness is a key component of the medical history
as
There is a genetic element to many diseases. Sometimes there is a well-defined inheritance,
such as in cystic fibrosis or Huntington’s disease. In other conditions, such as type 1
diabetes, genetic as well as environmental factors play a role.

Finding out about a specific family history of illness can be an important part of the
diagnostic
reasoning process. It can be helpful in estimating the probability that a patient has a
particular
condition. For example, if a person presents with chest pain, you are more likely to think that
they have ischaemic heart disease if they have a strong family history of this condition.

A family history is also a routine part of the medical history. It helps to establish the patient’s
risk of having conditions other than those relating to the presenting problem. For example,
the patient presenting with chest pain may have a family history of bowel cancer. When the
presenting problem has been diagnosed and treated, attention can then be given to the
person’s other health issues. In this case, it would be important to make sure that the
patient is being screened appropriately for bowel cancer.

22
Knowing about family history is also important for understanding how a patient perceives a
symptom or condition. If, for example, a patient with diabetes has family members with the
same condition who have had serious complications, then the patient’s attitude to their
own disease may be heavily influenced by this. Finally, knowing about the family history
of illness can also help you understand the stresses that a person may be
experiencing, especially if they are the primary carer for a person who is significantly
unwell.

Asking about family history


At this stage of your training, you are not expected to be able to ask specifically about
family history as part of the diagnostic process, although the patient may provide
this information in response to an open question. The focus at this level, instead, is on taking
a routine family history.

It is usually best to start by signposting that you wish to talk about the patient’s family history
of
Illness and then asking an open question such as: “Could you tell me something about the
health of your immediate family members?” Follow this with focused questions so that you
find out about the health of all first degree relatives.

Do not assume that older family members are still alive. Rather, start by establishing
whether they are alive or dead and then ask about their current age, if alive, or the age at
which they died. For significant illnesses, find out the age at which the relative developed
the condition as this may have important implications for the patient. For example, the
age at which a patient’s
parent developed bowel cancer can help determine when the person should start having
regular
screening colonoscopies. Also ask if there are any medical conditions that run in the wider
family. A patient may be unable to provide a family history if he or she was adopted.

It is important to use effective communication skills when asking about family history.
Talking with a patient about his or her family can be helpful in establishing rapport, but be
aware that it
can be a sensitive area of enquiry. A patient may, for example, find it distressing to talk
about a relative who has recently died. It is important in such circumstances to identify and
respond to the patient’s distress.

A patient may sometimes find it uncomfortable to talk about a particular medical proble
affecting
a family member, especially in the setting of problems such as illicit drug use or alcoholism.
A patient’s comfort with respect to this line of questioning may be culturally
determined.

Be aware that privacy and confidentiality issues may arise when recording the health issues
of a third person in a patient’s medical record.

Recording a family history


Write down each family member with their age now, or their age at death, and list their
medical conditions. A pedigree chart, or genogram, can be a useful way of recording this
information, especially if you are recording information about autosomal, dominant or
recessive conditions.

23
Revise the main symbols that are used to construct a genogram and record them in the table
below:

Meaning Symbol

Male

Female

Deceased

Affected with genetic


condition

Mating

Separated or divorced

More than one mating

Children

Twins

Index case

Adopted

24
Case Study 5.06

Sally Lewis, 32, has a lump in her left breast that has been
diagnosed as being a benign lesion called a fibroadenoma.
She is, however, anxious about it and has decided to have it
removed. She has come to the day surgery ward of her local
hospital for admission.

Sally is being interviewed by Sarah Blake, a second year


medical student. Watch the interview and record Sally’s
family history of illness. Discuss the interview with your
tutor.

Activity 3: Breast Cancer Network Australia consumer advocate


visit
Your group will meet with a BCNA consumer advocate. These women have personally
experienced breast cancer. You will have the opportunity to discuss their experiences from
the time they felt something was wrong, through the pathway of diagnosis and then
treatment. They may discuss what happened, how they felt, how other people reacted to
them when the diagnosis was made and how they coped. You will have the opportunity to
ask questions.

You will have one hour with the BCNA representative to facilitate discussion. Some
useful closing questions may be to ask: What would you like the students to learn
from their experience? What could have been done better? What did you really
Tutor Note

appreciate in your medical care?

If there is still time remaining, you may like to lead a discussion on other aspects of
breast cancer, such as risk factors for breast cancer or genetic factors involved in
breast cancer.

25
Tutorial 5
This tutorial introduces students to the principles of taking a medication history and also
provides an introduction to the principles of obtaining a history of illicit drug use from a patient.
It may be helpful to have ready access to a drug formulary for reference.

Medical interviewing component (Estimated time: 30 minutes)


Using the tutorial notes, discuss the principles of taking a medication history. You may wish to
Tutor Note

select a particular drug to use as an example as you work through the notes.

Talk about adverse drug reactions. Also introduce your students to the concept of adherence,
although they are not expected to be able to ask questions to explore it at this level of their
training. Be sure to talk about over the counter medications (OTC) and complementary and
alternative medications (CAMs).

Play Case Study 5.07 and ask your students to write down a list of the patient’s medications.
Use the case study to discuss other aspects of a medication history.

Encourage your students to take the opportunity to take medication histories from patients that
they meet on their clinical placements.

Tutorial Five
This first part of this tutorial provides an introduction to the principles of obtaining a
medication
history. It discusses asking patients about prescribed medications, as well as over-the-
counter
medications (OTC) and complementary or alternative medications (CAMs). It also involves
asking patients about any adverse reactions they may have had to medications.

Medication history
Most patients that you will meet will be taking some type of prescribed medication on a daily
basis. It is important to ask about the use of medications. A medication might, for example,
be the cause of a presenting symptom. Headaches, diarrhoea and rashes are just some of
the common symptoms that can be caused by medications. In addition, finding out about
medications that exacerbate or relieve a symptom can often help to point to a potential
underlying cause. Knowing about a patient’s medications is also important when developing
or monitoring a plan of management for a particular medical condition and for writing up
hospital drug charts or prescriptions.

Asking a patient about medications


At this stage of your training, you are not expected to be able to ask about specific
medications
when characterising a presenting symptom, although the patient may provide this
information in
response to an open question. The focus at this level instead is on taking a routine
medication
history.

To do this, start by signposting to the patient that you’d like to ask about their medications.
Find out what medications he or she is taking as well as the reason each has been
prescribed. Include all medications, whether taken regularly or intermittently, and any that
have recently been ceased. You may need to specifically enquire about the oral
contraceptive pill or laxatives as many patients do not think of these as being medications.

26
Most medications have a generic name as well as a trade name. As a general principle, you
should use generic names when recording a medication history, except in the case of a
combination preparation. Knowing about a corresponding trade name, however, may be
useful if this is how the medication is known by the patient. When writing down medication
names, the convention is to use a lower case letter at the start of a generic drug name and
an upper case letter in the case of a trade name. Some medications come in a slow release
preparation and this is usually included in the name.

For each medication, find out about the dose. This is recorded as an Arabic numeral plus the
corresponding metric unit. The following table shows the abbreviations of common units.

Metric unit Abbreviation

gram g

milligram mg

microgram microgram

millilitre ml

units units
Note that microgram is best written out in full. This is because using the abbreviations “µg”
or “mcg” can lead to confusion with the abbreviation mg for milligram. “Units” should always
be
written in full, as abbreviations such as U or θ can be confused with zero.

Find out about and record the route by which each medication is taken. The following table
includes some commonly used abbreviations for routes of administration. You are not
expected to know these at this level of your training. It is sufficient to write down the route in
complete words, although you can use abbreviations if you wish.

Route Abbreviation

Per oral PO

subcutaneous subcutaneous

sublingual sublingual

intramuscular injection IM

intravenous IV

per vagina PV

per rectum PR

Find out about and record the frequency with which each medication is taken. The table
below
contains abbreviations that are commonly used in Australia to describe the frequency that a
medication is taken. You are not expected to know these at this level of your training. It is
sufficient to write down the frequency in complete words, although you can use
abbreviations if you wish.

27
Frequency Abbreviation

Daily daily3

Twice daily bd

Three times a day tds

Four times a day qid4

Morning mane

Night nocte

Weekly weekly

When required prn5

Try to corroborate the information you obtain about a patient’s medications if possible. The
patient may have with them a written list, the medication packets, their prescriptions or a
dosette box. A third party history may be required if the patient is not able to tell you about
their medications. Most importantly, always check the identity of the patient.
5
Finding out about adverse drug reactions
An adverse drug reaction (ADR) is an unwanted problem that occurs as a result of taking a
particular medication. There are many types of adverse drug reactions. They can, for
example,
be due to an extension of the usual effect of a medication, such as a low blood sugar level
as a
result of an insulin injection. They can also be due to an allergic or hypersensitivity reaction,
such as rash, oedema, bronchospasm or anaphylaxis due to penicillin.

It is important to ask the patient if they have ever had an unwanted reaction to a medication.
Carefully find out details about the nature of any reactions. Patients may use the word
“allergy” when what they are actually describing is an unpleasant side-effect, such as
vomiting related to morphine or pethidine. Be aware that people may attribute a symptom to
a medication when in fact the relationship is a co-incidence. Always explore the association
and keep in mind other diagnostic possibilities.

Adherence to medications
A medication history also involves obtaining some idea of how often the patient is taking
their
medications. This is usually called “adherence”, which is defined as “the extent to which a
person’s behaviour coincides with medical or health advice”. This term is generally preferred
to “compliance”, which implies a more passive role by the patient. There are many reasons
why patients do not take their medications on a regular basis. These include cost, adverse
drug reactions, difficulty accepting the illness, inadequate instructions from the doctor,
lifestyle factors and mental health issues. At this stage of your training, it is important that
you are aware of the issue of adherence, but you do not need to be able to ask questions
about it.

Asking about other types of medicines


A medication history also involves asking the patient about over-the-counter (OTC)
medications, such as cough syrups, laxatives, paracetamol and non-steroidal anti-
inflammatory drugs, as these can also cause adverse drug reactions. Finding out about the

28
use of this type of medication can also alert you to other symptoms that the patient may be
experiencing.

Many patients also use complementary and alternative medicines (CAMS). It is important to
ask about these types of medicines, as many have pharmacologically active components
that can interact with prescription drugs. It is essential that you approach this in a non-
judgmental manner.

Case Study 5.07

Johnny Darby, 42, has type 2 diabetes that was


diagnosed after he presented with polyuria.

He has come to see his general practitioner for


review. He is being interviewed by Tess McClure, a
second year medical student.

Watch the interview and make a list of Mr Darby’s


medications. Discuss other aspects of his
medication history.

Disclaimer: The references made to specific brands of drugs in this case study are
illustrative for
educational purposes only and in no way imply any endorsement by The University of
Melbourne of these products nor any affiliation or sponsorship arrangement by the University
in relation to this tutorial.

The next part of this tutorial introduces students to the principles of taking a history of illicit drug use.

Medical interviewing component (Estimated time 30 minutes)


Using the tutorial notes, discuss the principles of taking a history of illicit drug use. There will be many

circumstances where this will not be indicated but emphasise to students that they will miss important

information if they make too many assumptions about who does and who doesn’t use illicit drugs. Work

through the basic communication skills that promote the gathering of accurate information about illicit
drug use. Also discuss thecontent of a drug history starting with the most commonly used illicit drugs
and including prescription drugs. You may wish to discuss street terms for various drugs with you
students. Play Case Study 5.08 and ask your students to identify and discuss the key features of the
patient’s history.

The next part of this tutorial provides an introduction to the principles of obtaining a history of
illicit drug use from a patient.

29
Illicit drugs
Up to 50% of Australian adults have used an illicit substance at least once in their lives. The
most commonly used illicit drug in our community is cannabis, with the prevalence of its use
approaching that of tobacco. The prevalence of use in Australia of other illicit drugs, such as
amphetamines, methamphetamines, ecstasy, hallucinogens, cocaine and heroin, is relatively
low in comparison. Use of these drugs, however, can cause a range of social, psychological
and
physical problems. Taking a history of illicit drug use is therefore an important component of
the
medical interview.

Illicit drugs history


There are two main reasons for asking a patient about the use of illicit drugs. Firstly, it may
be indicated as part of the diagnostic reasoning process when a patient presents with a
symptom
or is diagnosed with a medical condition where illicit drug use is a risk factor. Illicit drugs
when
used intravenously, for example, can be a risk factor for developing infectious diseases such
as
Hepatitis B or C, HIV or bacterial endocarditis. They can also be implicated in a range of
other
medical problems such as stroke, psychosis, cardiac arrhythmias and coma. Secondly, an
illicit
drug history is an important part of the routine medical history as a screening tool. It is
especially important if the patient has other substance abuse issues or has an erratic
lifestyle.

Principles of taking an illicit drugs history


Many of the basic skills that you have acquired so far in ICM can be applied to interviewing a
patient about the use of illicit drugs. Start by ensuring that the physical environment is
comfortable and affords adequate privacy for the patient because of the potentially sensitive
nature of the history. It is usually helpful to reinforce the notion of confidentiality, especially
with adolescent patients.

If you are asking about drug use as part of the diagnostic reasoning process, it is important
that
you signpost this to the patient and provide a rationale for your line of questioning. If the
history is being taken as part of the routine interview, it is usually best to introduce it after
you have asked about alcohol and tobacco use. By this time, the patient is more likely to feel
comfortable talking about drug use with you.

Basic communication skills, such as active listening, clarification and effective questioning,
are
essential when taking an illicit drugs history. Use a balance of open and focused questions
and, above all, be careful not to ask leading questions. Saying: “You don’t use illicit drugs,
do you?” is likely to deter the patient from giving you an honest answer.

Be careful about the language that you use. Although “illicit drugs” is the accepted technical
term, it may sound judgmental to the patient. You may find it more helpful to ask about
specific drugs directly. In general, it is preferable to use the proper names of drugs, rather
than their street names. This is because street names can vary from city to city and with
time, but also because it may also sound false to the patient if you adopt their language. If
the patient describes a drug using a street name with which you are not familiar, be sure to
clarify the exact meaning.

30
The content of an illicit drugs history
It is usually best to start by asking about cannabis as it is the most commonly used illicit
drug. Next ask about methamphetamine, the second most widely used illicit drug, with an
estimated 9.1% of the Australian population having tried this drug at some time in their
lifetime. Enquire about use of ecstasy, cocaine and heroin. It is also important to ask about
the use of prescription drugs in amounts in excess of that prescribed or in ways other than
the person is meant to. Commonly abused prescription drugs include benzodiazepines and
painkillers. Remember that polydrug use is common.

For each substance, gather detailed information about its use. The cardinal features
framework can help to provide structure to this line of questioning. Find out the route by
which the person takes the particular drug. This may be oral, intravenous, smoking,
intranasal or by subcutaneous injection (“skin popping”). If the person has used intravenous
drugs, ask whether they ever shared needles or equipment as this can help to assess their
risk of having a blood-borne infection. Try to quantify the amount of drug use. The patient
may use a slang term for this, so be sure to clarify the information provided.

Ask about the duration and frequency of drug use. It is important to establish whether the
person is an occasional user or whether there is evidence of dependence or addiction. The
context in which the person takes illicit drugs is also an important feature to explore. Find out
about what attempts the person has made to stop using drugs. Ask about associated
features, especially those that might indicate evidence of harmful drug use.

One of the most important principles of taking a good drugs history is not to make
assumptions
about people. Do not assume that an adolescent or an older person or a person who comes
from a particular religious or cultural group does not use illicit drugs. It is particularly
important not to make assumptions about a person’s drug use based on their appearance.

Case Study 5.08

Jodie Russell, 31, works as a supermarket cashier


and has an 8-year old daughter. She has recently
been diagnosed as having Hepatitis C and has
been referred to a Drug and Alcohol Service by
her infectious diseases physician.
She is being interviewed by Dr Ramin Shayan about
her use of illicit drugs. Watch the interview and
write down the key points of the history.

Physical examination practice


Use the remainder of time in this tutorial to revise your physical examination skills. Use the
list of learning objectives for ICM 5 and the ICM portfolio to identify which physical
examinations you need to review.

31
Physical examination component (Estimated time: one hour)
Use the remainder of this tutorial to revise physical examination skills, using the ICM 5 learning
objectives and learning portfolio as a guide. Emphasise to students that the physical examination station
of the ICM 5 OSCE is a hurdle requirement and they may be examined on any of the physical
examinations that they have learned in ICM 1-5.

32
Medical Interview Assessment Form
Opening segment of interview Yes No

Greets the patient


Introduces self
Explains status
Uses an open-ended question
Allows patient to complete opening statement

Exploration of the presenting problem Yes No N/A

Site
Location
Radiation
Quality
Severity
Time course
Onset
Offset
Duration
Temporal profile
Periodicity
Context
Relieving factors
Aggravating or precipitating factors
Associated features

Communication Skills Done Well Adequate Needs


improvement
Demonstrates active listening skills
Allows patient to speak without interruption
Clarifies information with patient
Uses questions effectively
Does not use jargon or technical language
Uses open questions before moving on to more
focussed questions

Interview Management Done well Adequate Needs


Improvement
Is systematic with questioning
Directs the interview effectively
Uses restatement and/or paraphrasing
Helps the patient stay relevant
Uses internal summaries
Conducts interview fluently

33
Medical Interview Assessment Form
Opening segment of interview Yes No

Greets the patient


Introduces self
Explains status
Uses an open-ended question
Allows patient to complete opening statement

Exploration of the presenting problem Yes No N/A

Site
Location
Radiation
Quality
Severity
Time course
Onset
Offset
Duration
Temporal profile
Periodicity
Context
Relieving factors
Aggravating or precipitating factors
Associated features

Communication Skills Done Well Adequate Needs


improvement
Demonstrates active listening skills
Allows patient to speak without interruption
Clarifies information with patient
Uses questions effectively
Does not use jargon or technical language
Uses open questions before moving on to more
focussed questions

Interview Management Done well Adequate Needs


Improvement
Is systematic with questioning
Directs the interview effectively
Uses restatement and/or paraphrasing
Helps the patient stay relevant
Uses internal summaries
Conducts interview fluently

34
ICM Portofolio
1. Communication, consultation and professional skills

Learning Objective Confidence Level Notes

Open an interview with a


patient

Discuss confidentiality with a


patient

Demonstrate a non-
judgemental approach to
patients

Demonstrate active listening


skills

Use clarification skills

Use effective questioning skills

Use repetition, restatement


and paraphrasing to
facilitate the interview

Use signposting in an
interview

Help a patient to stay relevant

Use summarising in an
interview

35
Learning Objective Confidence Level Notes

Take a witness account from a


third person

Communicate effectively with


a patient who has hearing
impairment

Communicate effectively with


a patient who has cognitive
impairment

Talk with a patient about sensitive


issues

Demonstrate respect for a


patient’s comfort and dignity
during a physical
examination

Demonstrate respect to all


patients regardless of gender,
ethnicity, cultural background
and sexual orientation

Identify and respond to a


patient’s emotional
distress

Give constructive feedback to


your peers about their clinical
performance

Apply basic clinical reasoning


skills during a medical interview

36
2. History and examination skills
2.1: Gastrointestinal system

2.2: Cardiovascular system

Learning Objective Confidence Level Notes

Interview a patient
presenting with chest pain in
order to identify the cardinal
features
Interview a patient
presenting with syncope in
order to identify the
cardinal features
Interview a patient
presenting with
claudication in order to
identify the cardinal
features
Interview a patient
presenting with oedema in
order to identify the
cardinal features

Measure a patient’s blood


pressure

Perform a basic
examination of the
cardiovascular system

37
2.3: Respiratory system

Learning Objective Confidence Level Notes

Interview a patient presenting


with cough/sputum production
in order to identify the cardinal
features (including history of
sputum production)
Interview a patient presenting
with shortness of breath in order
to identify the cardinal features

Interview a patient presenting


with wheeze in order to
identify the cardinal features

Interview a patient
presenting with
haemoptysis to identify the
cardinal features

Interview a patient about


his or her smoking
behaviour

Perform a basic
examination of the
respiratory system

Measure peak expiratory flow

38
2.4: Musculoskeletal system

Learning Objective Confidence Level Notes

Interview a patient
presenting with knee pain
and relate the presentation
to the underlying anatomy
Interview a patient
presenting with shoulder
pain in order to identify
the cardinal features
Interview a patient presenting
with back pain in order to
identify the cardinal features
and recognise the presence
of red flags for a serious
underlying cause
Perform a basic examination
of the knee

Perform a basic
examination of the
shoulder

Perform a basic examination


of the lumbar spine

39
2.5: Neurological system

Learning Objective Confidence Level Notes

Interview a patient presenting


with muscle weakness and
identify the pattern of weakness

Interview a patient presenting


with sensory disturbance and
identify the presence or
absence of positive and
negative symptoms as well
as the distribution of the
sensory
Interviewdisturbance
a patient presenting
with headache in order to
identify the cardinal features
and differentiate between acute
and chronic presentations
Interview a patient
presenting with chronic
headache in order to identify
the cardinal features and
differentiate
between migraine
Interview a patient and tension
presenting
headache
with transient loss of
consciousness and differentiate
between vasovagal or cardiac
syncope and seizure
Interview a patient presenting
with dizziness and
differentiate between the main
types

Interview a patient presenting


with memory loss in order to
elicit the cardinal features

Perform a basic neurological


examination of the lower limbs

Perform a basic neurological


examination of the upper limbs

Perform a basic
ophthalmological
examination

40