OSCE Guide, University of Queensland School of Medicine

OBJECTIVE)STRUCTURED)CLINICAL)EXAMINATION)(OSCEs))
!
There!are!5!stations:!
1.! History)Taking))
2.! Physical)Examination)
3.! Clinical)Reasoning))
4.! Clinical)Communication)Skills))
5.! Procedural)Skills))
!
How$much$time$do$I$get$at$each$station?$$
What$can$they$ask$me$about?$$
!
!
!
What$are$some$typical$presenting$complaints?$
Chest!pain,!SOB,!dizziness,!abdominal!pain,!
nausea/vomiting,!diarrhoea,!headache,!special!senses!
(hearing/vision),!joint!pain,!cough,!collapse,!tiredness,!fever!!
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STATION)1))HISTORY)TAKING)!
!
This!station!is!designed!to!allow!you!to!demonstrate!your!skills!in!taking!focused!or!systematic!medical!histories!from!patients.!!
It!will!also!test!your!ability!to!develop!rapport!with!your!patient.!!The!examiner!will!let!you!know!when!there!is!1!minute!
remaining,!and!you!must!give!the!examiner!your!provisional)diagnosis!(but!you!will!not!be!asked!to!justify!this).!
!
EXAMPLE!
Clinical'Scenario:'Christine)Black,)45yo)lady!complaining!of!urinary!frequency!and!lethargy.!She!is!seeing!you!for!the!first!time.!'
!
Candidate!Tasks!
1.! You!have!eight)(8))minutes)to)take)a)history.!You!are!to!interact!with!the!patient!as!in!a!consultation.!!
2.! The)examiner)will)observe)and)notify)you)when!there!is)one)(1))minute!remaining.!!
3.! In!the!final!minute,!you!need!to!conclude)the)consultation)and)provide)one)(1))likely)provisional)diagnosis.!You!do)not)
need)to)justify!this.!!
4.! Do!not!make!any!inferences!based!on!the!appearance!of!the!simulated!patient!
!
MARKING)SHEET!
Score)sheet))How)well)were)the)components)demonstrated?)
1.!General)
Introduces!self!to!patient!
Speaks!clearly!and!fluently!
Conveys!caring!and!empathic!manner!
Clear!communication!skills!O!verbal!and!nonOverbal!
Good!use!of!open!and!closed!questions!
2.!History)of)Presenting)Complaint)
Presenting!complaint!clearly!identified!)
NILDOCAAFIAT!specifics!
Timeline!of!symptoms!clearly!elicited!
3.)History)of)Presenting)Systems)&)Systems)Review)
Red!flags!noted!!
Systems!review!adequately!performed!in!sufficient!depth!
4.)Important)Past)History)Items)
PMHx!!
PSH!!
Medications/allergies!
Substance!Use!!
Screening/Immunization/Diet/Exercise!noted!
5.)Social)History)&)Conclusion)
Social!History!!
Provisional!Diagnosis!
Overall)impression)and)comments!
Rated!from:!!
Not!at!all!
Poorly!
Partially!!
Well!
Very!Well!
Overall:!!
Unacceptable!
Not!satisfactory!
Borderline!
Satisfactory!!
Proficient!
STATION)2))PHYSICAL)EXAMINATION)!
!
The!physical!examination!station!requires!you!to!demonstrate!focused!or!systematic!physical!examination!skills!on!a!simulated!
patient.!!You!will!be!given!a!clinical!scenario!(eg.!presenting!complaint!or!diagnosis_!and!asked!to!perform!the!appropriate!
examination!or!examination(s).!!You!may!find!your!scenario!requires!a!combined!examination!approach!(eg.!SOB!!combine!
Resp!and!CVS).!!You!will!be!required!to!explain!to!the!examiner!throughout!your!examination!what!you!are!looking!for!and!what!
you!might!expect!to!find!in!the!particular!clinical!scenario.!
!
It!is!not!expected!that!you!will!be!able!to!complete!a!comprehensive!examination!within!8!minutes.!!For!this!reason,!the!
examiner!has!been!instructed!to!politely!interrupt!you!and!ask!you!to!move!on!so!that!you!might!demonstrate!a!wide!range!of!
examination!techniques!during!the!time!frame!(eg.!you!may!be!asked!to!move!on!before!completing!your!full!peripheries!
inspection!or!your!complete!lung!auscultation.!!The!examiner!may!ask!you!to!perform!only!part!of!an!examination!(eg.!examine!
only!the!first!5!cranial!nerves).!!However,!it!is!up!to!the!examiner,!not!the!student,!to!decide!which!parts!other!examination!may!
be!omitted.!!!
!
You!must!treat!the!simulated!patient!with!the!same!respect!and!professionalism!as!a!real!patient.!
!
All!required!equipment!will!be!provided!by!the!School!of!Medicine,!but!you!are!allowed!to!bring!your!own!stethoscope,!if!
preferred.!!
!
EXAMPLE!
Clinical'Scenario:))The!patient!you!are!about!to!examine!is!Matthew)Smith,)a)68)year)old)man!who!has!presented!with!acute!left!
sided!abdominal!pain!and!recent!change!in!bowel!habit.!)
!
Candidate!Tasks:!
1.! You)have)eight)(8))minutes)to!perform!an!appropriate)examination.!!
2.! Explain)to)the)examiner)during)the)examination)the)reasoning)for)the)examination)that)you)do)and)the)specific)findings!
that!you!may!expect!in!a!patient!with!this!presentation.!!
!
MARKING)SHEET!
1.!Introduction)and)Consent)
Candidate!introduces!self!!name!and!role!
Explains!examination/s!!&!!obtains!consent!!
Washes!hands!!
Interacts!with!simulated!patient!appropriately!
Appropriate!exposure!!
2.)General)Observations))
Discusses!general!appearance!!
Dependent!on!required!examination!
3.)Appropriate))Examination))
4.)Appropriate))Examination))
5.)Appropriate)Examination)
Overall)impression)and)comments)
Rated!from:!!
Not!at!all!
Poorly!
Partially!!
Well!
Very!Well!
Overall:!!
Unacceptable!
Not!satisfactory!
Borderline!
Satisfactory!!
Proficient!
!
Notes:!
O! All!equipment!required!for!this!station!will!be!supplied!
O! You!may!bring!your!own!stethoscope!and!watch!
O! If!fundoscopy,!otoscopy!is!indicated!please!MENTION)THIS!to!the!examiner,!but!you!will!not!be!expected!to!do!it!!
!
STATION)3))CLINICAL)REASONING)!
!
The!Clinical!Reasoning!station!is!designed!to!assess!the!following!skills:!
O! !Your!ability!to!formulate!differential!diagnoses!from!a!medical!history!provided!to!you!
O! Your!ability!to!do!an!oral!presentation!of!your!clinical!reasoning!to!another!medical!professional!
O! Your!ability!to!justify!your!choices!of!differential!diagnoses!in!a!logical!manner!and!in!response!to!questioning!!
!
EXAMPLE!
Clinical'scenario:''The!patient!in!the!next!room!is!Thomas)Brown,)a)42)year)old)man!who!presents!complaining!of!rectal!
bleeding.!!You!have!been!given!this!patients!history.'
!
!
Candidate!Tasks:!
1.! You!have!a!total!of!four)(4))minutes!to!peruse!this!information!!
! two!(2)!minutes!in!the!perusal!time!and!!
! a!further!two!(2)!minutes!after!the!station!begins.!The!examiner!will!notify!you!when!you!need!to!start!talking.!
2.! You!then!have!six)(6))minutes!to!discuss!with!the!examiner!three)possible)differential)diagnoses,)starting)with)the)most)
likely)diagnosis.!
)
3.! You!should!include!positive)and)negative)features)of)this)history!which!support!or!refute!your!diagnoses.!
'
MARKING)SHEET!
'
1.)General))summary)
'
Organised!summary!of!diagnoses!
'
Logical!structure!to!presentation!
'
Appropriate!diagnoses!chosen!
Prioritises!diagnoses!
'
!
'
Rated!from:!!
Overall:!!
2.)Differential)Diagnosis)ONE)
'
Not!at!all!
Unacceptable!
Diagnosis:!
'
Appropriate!supportive!points!
Poorly!
Not!satisfactory!
'
Appropriate!negative!points!
Partially!!
Borderline!
Logical!presentation!of!reasoning!
'
Well!
Satisfactory!!
3.)Differential)Diagnosis)TWO)
'
Very!Well!
Proficient!
Diagnosis:!
'
'
'
4.)Differential)Diagnosis)THREE)
'
'
'
'
5.)Adequate)Reasoning!
Oral!presentation!O!clear!and!fluent!!
'
Appropriate!medical!terminology!used!
'
No!major!hesitation!
'
Minimal!irrelevant!material!included!
'
'
Notes:'
O! !Your!reasoning!will!be!based!on!history!alone!!including!HPC,!HPS,!systems!review!and!past!medical!history!!
O! You!will!not!be!given!examination!findings!or!investigation!results!to!interpret!!
!
STATION)4))CLINICAL)COMMUNICATION)SKILLS))!
!
This!station!will!test!your!ability!to!communicate!with!patients!in!varying!and!difficult!circumstances.!
'
EXAMPLE)
Clinical'Scenario:!You!are!a!medical!student!on!clinical!placement!in!general!practice.!!Your!next!patient!is!Grant!Writer,!a!60yo!
man.!!The!GP!is!running!late,!and!asks!you!to!interview!Graham!regarding!a!particular!health!or!behavioural!issue.!
!
Candidate!Tasks:!
1.! You!have!a!total!of!eight)(8))minutes!to!!
! Assess!Grant!
! Convey!to!the!examiner!(when!asked)!your!assessment!of!Grant!!
! Utilize!strategies!learnt!in!Clinical!Communication!Skills!to!communicate!with/counsel!the!patient!appropriately!!
)
MARKING)SHEET!
1.!General)communication)
Uses!active!listening!skills!and!open!questions!
Asks!for!clarification;!paraphrases;!summarises!to!check!
understanding!
Picks!up!cues!from!patient!
Shows!empathy!&!sensitivity!to!patients!concerns!
2.)Consultation)structure)
Logical!and!organized!structure!
!
3/4/5)Criteria)dependent)on)case)
Rated!from:!!
Not!at!all!
Poorly!
Partially!!
Well!
Very!Well!
Overall:!!
Unacceptable!
Not!satisfactory!
Borderline!
Satisfactory!!
Proficient!
STATION)5))PROCEDURAL)SKILLS))!
!
The!Procedural!Skills!station!is!designed!to!test!your!competency!in!basic!procedural!skills!learned!in!Years!1!and!2!PSWs.!!You!
ma!be!required!to!report!findings!to!the!examiner.!
!
EXAMPLE)!
Clinical'Scenario:''You!have!been!asked!to!perform!the!following!procedural!skill/s.!!The!equipment!required!for!the!task!is!
provided!at!the!station.'
!
Candidate!Tasks!
1.! You!have!seven)(7))minutes!to!do!the!following!procedural!skill/s..!
2.! After!7!minutes,!the!examiner!will!stop!you.!You!then!have!one)(1))minute)to)report)your)findings!to!the!examiner!or!
answer)the)examiners)questions.)
!
MARKING)SHEET))
Rated!from:!!
Overall:!!
Not!at!all!
Unacceptable!
1.!General)communication)
Poorly!
Not!satisfactory!
Communication!skills!
Consent!
Partially!!
Borderline!
2/3/4/5)Criteria)dependent)on)case)
Well!
Satisfactory!!
Criteria!are!taken!from!the!PSW!competency!sheets !
Very!Well!
Proficient!
)
Notes:!
O! !You!will!be!asked!to!perform!a!skill!on!either!a!simulated!patient,!partOtask!trainer!or!mannequin!
O! You!are!not!required!to!verbalise!your!actions!to!the!examiner!during!this!station,!however!they!can!ask!you!to!clarify!
technique!
O! You!will!NOT)BE)EXAMINED)ON)CANNULATION)OR)VENEPUNCTURE!
!
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YOU)MUST)PASS)ALL)5)STATIONS)TO)PASS)
GOODLUCK)!)!
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HISTORY!TAKING!
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History
Presenting Complaint & HPC
For each symptom
SOCRATES (UK) or NILDOCAAFIAT (UQ)
Site
Onset (sudden/gradual)
Character
Radiations
Associations (e.g. pain with food intake)
Timing (duration)
Exacerbating and alleviating factors
Severity (1-10)
Family History (FH)

Nature
Intensity
Location
Duration
Onset
Contributing factors
Aggravating factors
Alleviating factors
Frequency
Impact
Attribute
Treatment
Past Medical History (PMH)
Social History (SH)
Hospital visits, previous illness, previous operations
Specifically: diabetes, asthma, bronchitis, TB, jaundice, high BP (dont say

hypertension), heart disease, stroke, epilepsy, peptic ulcers
Medications - tablets, injections, prescriptions, herbal remedies, the pill
Allergies & adverse drug reaction
Vaccination history
Indications to ask urethral/vaginal discharge, genital ulcer/rash, abdominal

pain, pain on intercourse
Last date of intercourse, # partners, homosexual/bisexual, prostitutes
Type of sexual practice (vaginal, oral, anal, ano-oral)
History of sexual abuse
All women; esp. abdominal pain, ? endocrine disease, genitourinary symptoms

Date of last menstrual period, whether or not periods are regular
Age at menarche, whether menopause has occurred
Symptoms related to menstruation pain etc.
Alcohol average per day, CAGE (Cut down, Annoyed, Guilty, Eye opener)
Smoking - pack years
(= # of packs (20 cigarettes) smoked per day * # of years patient has smoked)
Recreational drugs
Systems Review
General - weight loss, night sweats, lumps, fevers, fatigue / malaise /

lethargy, appetite, sleeping (sleepiness, early waking, being woken by
pain), itch / rash, recent trauma
Cardio-respiratory - chest pain, dyspnoea (exertional, PND, orthopnoea),

oedema, palpitations, cough, wheeze sputum production, haemoptysis
Gastrointestinal abdominal pain, difficulty / pain on swallowing, indigestion,

nausea / vomiting, change in bowels (constipation / vomiting), stools (colour,
consistency, blood, slime, difficulty, urgency, tenesmus)
Genitourinary incontinence, dysuria, haematuria, nocturia, frequency, polyuria,

hesitancy, terminal dribbling
Neurological sight, hearing, smell, taste, seizures, faints, dizzy spells, headaches,
paraesthesia, limb weakness, poor balance, function
Musculoskeletal pain / stiffness / swelling of joints / muscles, changes

throughout the day, functional impact
Menstrual History
Home life marriage, children, living situation

Vocation - job, education, hobbies, spouses job
Mobility need for walking aids, stairs in home
Diet average day
Exercise
Substance History
Sexual History
Do any conditions run in the family?

Parents, siblings, grandparents etc. (pedigree)
Alive health, age, any conditions, similar presenting complaint
Dead age at death, cause of death
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SYSTEMS!SUMMARIES!
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Gastrointestinal System
Presenting Complaints
Examination
Appetite changes anorexia,

hyperphagia
Weight loss (malabsorption,

malignancy, diabetes, thyroid, IBD,
eating disorder, depression)
Weight gain
Dysphagia (oesophagus, nodes,

goitre)
Mental state alert, confused,

coma
Indigestion / heartburn reflux
Body habitus weight, wasting,

oedema, hydration
Nausea / vomiting onset,

frequency, contents (infection,
inflammation, obstruction)
Colour pallor, jaundice,

haemochromatosis
Vital signs Temp, HR, BP, RR, O2
Haematemesis frank or coffee

ground (ulcer, varices, Mallory Weiss
tear, malignancy)
Abdominal pain colicky (biliary,

GI), severe (peritonitis)
Jaundice (haemolysis, liver, biliary)
Hands leukonychia (albumin),

koilonychia (spooning, iron),
clubbing (cirrhosis, IBD), pallor in
palmar creases, palmar erythema
(oestrogen), wasting, dupuytrens
contracture
Change in bowel motions

volume, frequency, consistency,
colour, tenesmus, blood
Patient History
PMH abdominal surgery
Family colorectal cancer,

haemochromatosis, IBD, ulcers
Medications NSAIDs (ulcers),

metformin (diarrhoea), opioids
(constipation), antibiotics (bowel
changes), bisphosponates
(oesophagitis), SSRIs (nausea)
Social smoking, alcohol, IV drugs,

travel, vaccinations, birth country
Patient lying supine with one pillow

Inspection
General age, gender,
comfort/distress
Hepatic flap
Arms/shoulders spider naevi

(oestrogen), bruising, wasting,
scratch marks (?obs jaundice)
Eyes xanthelasma, icterus,

conjunctival pallor, uveitis, KayserFleisher rings (Wilsons disease)
Salivary glands parotid &

submandibular glands & ducts
Lips hydration, agular cheilitis,

ulceration, pigmentation,
telangiectasia
Mouth foetor, stomatitis,

candidiasis/leukoplakia (L wont
scrape off, C will), gums, glossitis,
central cyanosis, teeth
Red Flags
Lymph nodes cervical & axillary
Chest spider naevi (oestrogen),

loss of hair distribution,
gynaecomastia (oestrogen)
Abdomen scars, striae, bruising,

stoma, distension (8 Fs), masses,
veins, peristalsis, pulsations
Palpation
Superficial tenderness, masses
Deep masses, guarding, rigidity,

rebound tenderness, McBurneys
point,Rosvings sign
Liver & gallbladder (Murphys
sign)
Spleen
Kidneys
Abdominal aorta
Percussion
Liver
Bladder
Shifting dullness
Auscultation
Bowel sounds
Epigastric bruits
Renal bruits
Other
DRE inspection (fissure, fistula,

tags, blood, rash, ulcer, mucus);
palpation (wall consistency;
prostate size, surface, tenderness)
Urinalysis
Pregnancy test
Bowel chart
Sudden onset of pain

Increasing severity of pain
Syncope / pre-syncope
Vomiting
Haematemesis
Abdominal distension
Pallor & sweating
Tachycardia & atrial fibrillation
Hypotension
Fever
Rebound tenderness, guarding,
rigidity
Oliguria / anuria
Positive pregnancy test
Respiratory System
Cough nature, onset, wet (viral,

LRTI, COPD, bronchiectasis), dry
(viral, asthma, GI reflux, restrictive,
ACEi), night (asthma LVF, post-nasal
drip), morning (smoking),
whooping, bovine (laryngeal nerve),
croup
Sputum colour, volume, type

(purulent, mucoid), blood
Haemoptysis acute (malignancy),

chronic (bronchiectasis), pink frothy
(pulmonary oedema)
Dyspnoea / shortness of breath

onset, nocturnal (asthma/LVF), on
waking (COPD), duration, relieving
factors, severity, exertional change
Wheeze (high pitch) when,

with coughing, exercise (asthma)
Stridor (inspiratory rasp) onset

(respiratory obstruction)
Chest pain nature, intensity,

exertional change (chest wall,
pleura or mediastinal causes)
Sleep apnoea snoring or waking

up dyspnoeic (airway obstruction)
Voice change - dysphonia,

aphonia
Patient History
Examination
Patient sitting upright, general inspection
then entire back exam entire front exam
Inspection
General age, gender, body
habitus, oxygen equipment,
posture (?dyspnoeic), respiratory
distress, cough, sputum
Hands clubbing (pus in lungs),

peripheral cyanosis, wasting
(brachial plexus), pallor in creases
Asterixis (CO2 retention)
Radial pulse, respiratory rate,

breathing (Cheyne-Stokes =
alternating, Kussmaul = shallow)
Eyes conjunctival pallor, Horner

syndrome (miosis, partial ptosis,
lower lid elevation, enopthalmos,
anhydrosis)
Nose (straight in) polyps,

enlarged turbinates, displaced
septum
Mouth central cyanosis,

erythema, tonsils, exudates,
candidiasis
Voice
Sinuses frontal, ethmoidal,

maxillary
Lymph nodes cervical & axillary
PMH hay fever, eczema, HIV
Trachea cartilage, tug, deviation
Family atopy, CF, 1-antitrypsin,

TB asbestos, same symptoms
Occupation asbestos, chemicals
Meds ACEi, -blockers, NSAIDs
Chest shape, symmetry, scars,

tattoos, scoliosis, pigeon chest,
funnel chest, barrel chest,
breathing
Social smoking, travel, pets
Red Flags
Palpation
Back chest expansion,
tenderness, spring chest (front,
back, sides), tactile fremitus
Front tenderness, tactile
fremitus, apex beat (lying)
Percussion
Lungs (remember dullness over
liver & heart)
Auscultation
Breath sounds - vesicular (normal),
bronchial (hollow, consolidation)
Added sounds stridor

(inspiratory, upper airway
obstruction) wheezing (narrowed
airways), crackles (fine=fibrosis,
medium=pulmonary oedema,
coarse=pneumonia/COPD), pleural
rub (pneumonia, infarction)
Vocal resonance
Other
Temperature
Pulse oximetry
Spirometry FVC, FEV1, PEFR
Haemoptysis URTI, LRTI,

bronchiectasis, bronchial
carcinoma
Sudden onset dyspnoea ? PE or

pneumothorax
Sudden onset stridor

anaphylaxis, inhaled foreign body,
acute epiglotitis (may block
airway), gas inhalation
Cardiovascular System
Chest pain crushing (MI), angina

(tight, retrosternal, exertional),
sharp inspiratory (pericarditis,
pleuritic), interscapular (dissecting
aneurysm, back pain), acid
taste/burping (GI reflux), chest wall
(costochondritis, rib fracture, skin)
Dyspnoea precipitating factors,
exertional (CCF, angina),
orthopnoea (CCF, LVF), paroxysmal
nocturnal dyspnoea (LVF, silent MI)
Palpitations fast (SVT, heart
cond., hyperthyroid, stress, meds),
slow
Peripheral oedema where,
when, pitting (CCF), generalised
(kidney, liver), unilateral (DVT, lymph
obstr.)
Syncope / pre-syncope postural

(postural hypotension), lightheaded,
sudden collapse (arrhythmia)
Sputum pink frothy (LVF)
Leg pain calf (DVT), exertional

(intermittent claudication)
Examination
Patient sitting initially and lying at 45
(starting at neck)
Inspection
Sitting
General age, gender, comfort,
dysmorphism (Downs, Turner,
Marfan), mental state, body
habitus, oedema
Surroundings - cigarettes, O2
devices, GTN spray, holter monitor,
ECG leads
Colour pallor (anaemia/

vasoconstriction), cyanosis
Hydration status
Hands pallor of nail bed,

peripheral cyanosis, capillary refill,
clubbing (congenital heart disease,
IE), xanthomata, signs of infective
endocarditis (Janeway lesions,
splinter haemorrhages, Osler
nodes)
Patient History
PMH HTN, lipids, BMI, diabetes,

CKD, AF, previous cardiac events,
rheumatic fever, renal disease,
Marfan / Downs / Turner syndrome
Family IHD, lipids, HTN, CKD, DM,
sudden cardiac death
Meds T4 (angina), -agonists

(HR), -blockers (HR)
Social smoking, IV drugs (IE),

alcohol (AF, HTN), job (pilot / driver)
Arms - radial pulse (rate, rhythm),

radio-radial delay (aortic
coarctation, subclavian stenosis),
respiratory rate, blood pressure
(+pulsus paradoxus)
Eyes xanthelasma, conj. pallor
Mouth central cyanosis, higharched palate (Marfan), gums,

dentition (poor ?IE)
Neck (lying 45) JVP, carotid pulse

(rhythm, character)
Red Flags
Chest
Lying 45
Inspection scars, deformities,
pacemaker / defibrillator, visible
apex beat
Palpation - apex beat, thrill (LVF),

heave (palpable murmur)
Diaphragm of steth (A,P,M,T,axilla)

heart rate, heart sounds (S1, S2, S3,
S4), carotid, murmurs (intensity,
timing, location, breathing inspright, expleft)
Bell of steth mitral area
Left lateral position (MS)
Sitting forward holding breath

after expiration (AS, AR, pericardial
rub)
Abdomen
Palpate tenderness, masses,
organomegaly, AAA
Back
Sitting
Auscultate aortic, renal, iliac,

femoral bruits
Inspect scars, deformities

Palpate sacral oedema
Percuss lung bases (effusion)
Auscultate lung bases
Lower Limbs
Inspection varicose veins, colour,
trophic s (thin/dry/shiny skin, hair,
nails, ulcers), xanthomata, clubbing
Palpation temp., tenderness,
pulses (F, P, PT, DP), pitting oedema
Irregularly irregular pulse

(arrhythmia e.g. AF)
Six Ps (acute limb ischaemia)

pallor, pulseless, pain, paraesthesia,
perishing cold
Unilateral leg swelling (DVT)
Very sudden & severe tearing

pain (thoracic aortic dissection)
Musculoskeletal System
Pain site, symmetry, radiation,

mono/polyarticular, acute/chronic, bone,
nociceptive/neuropathic, inflammatory/noninflammatory
Morning joint stiffness brief & worse w/

movement (osteoarthritis) vs. prolonged &
improved with exercise (rheumatoid arthritis)
Muscle stiffness (polymyalgia rheumatica)
Joint abnormalities - locking (loose body,

meniscal tear), instability (ligamentous stretching /
rupture), triggering (tendon thickening)
Swelling location, shape, size, consistency,

surface texture, mobility, tenderness, pulsation
Tenderness (inflamm., infection)
Skin changes erythema, shiny skin, ulceration,

rash (psoriasis, SLE)
Loss of function
Other symptoms fever, weight loss, bowel

symptoms, urethritis, uveitis, conjunctivitis, dry
mouth
Red Flags
Regular night sweats

Unintentional weight loss
Constant (day & night) pain
>50 or <20 years old
Significant trauma
History of cancer or osteoporosis
IV drug user
Immunosuppressed
Knee Examination
Look
General age, gender, body habitus, comfort,

assistance devices (stick, brace, sling, cast)
Rashes, scars, erythema, swelling, gluteal folds,
popliteal folds, bursae (supra-, infra-, pre-patellar)
Muscles (wasting, spasm) esp. quadriceps
Deformities genu valgum (knock-knee), genu

varum (bow-leg), genu recurvatum (back-knee)
Gait & posture leg length, 10 steps, sitting, squat
Feel
Quadriceps - tenderness, wasting, spasm
Bursae supra-/infra-/pre-patellar, popliteal

Bony landmarks joint line, femoral condyles &
epicondyles, fibular head, Gerties tubercle, patella
Simple backache mechanical pain in 20-55 y.o.
Nerve root pain unilateral leg pain, motor /

sensory change
Ligaments & tendons M & L collateral ligaments,

biceps, semimembranosus, semitendinosus
tendons
Patella tap slide hand down thigh to upper edge

of patella, tap on patella (clunk effusion)
Bulge test stroke hand medial, up & around to

lateral patella (bulge in medial patella effusion)
Cauda equina syndrome urinary/ faecal

incontinence, perineal anaesthesia, leg weakness
Patient History
PMH joint or back problems, IBD, anterior uveitis,

urethritis, malignancy
Family RA, OA, gout, osteoporosis
Meds analgesics, NSAIDs
Loss of function brushing teeth (elbow),

buttoning shirt (wrist, hands, walking (lower limb)
Move
Supine, stabilise pelvis with other hand
Active passive (crepitus) resisted
Collateral ligament stress test supine (once 20

once straight); brace medial knee & apply varus
force (medial collateral ligament), brace lateral
knee & apply valgus force (lateral collateral
ligament)
Anterior & posterior draw test (start by looking

for posterior draw) sit on patients foot, both
hands around upper tibia, thumbs over tibial
tuberosity, pull forwards (anterior cruciate lig),
push backwards (posterior cruciate lig) (laxity/pain)
Lachmans Test (anterior cruciate ligament)

supine, 15 of flexion, examiners knee under their
knee, stabilise femur & apply pressure to posterior
upper tibia (laxity/pain)
McMurrays test valgus force on lateral knee,

flex to 90, hold sole of foot, rotate leg internally &
extend knee (lateral meniscus); varus force on
medial knee, flex to 90, hold sole of foot, rotate leg
externally & extend knee (lateral meniscus) (pain)
Applys grind test prone, knee flexed to 90;

compress knee while internally & externally
rotating (medial & lateral menisci), pull on knee
while internally & externally rotating (collateral
ligaments)
Skin temperature
Special Tests
Patella apprehension (patella dislocation) apply
laterally directed force on medial patella with
thumbs (feels like patella will dislocate)
Flexion (closing), extension (opening),

internal rotation, external rotation
Hip Examination
Ankle & Foot Examination
Spinal Examination
Look
Look
Look


Footwear abnormal, asymmetric, poor fit,
orthotic
Deformities (true/false scoliosis), swelling, scars,

gluteal folds, popliteal creases, ASIS level
Muscles (gluteus, adductors, iliopsoas, quads)

wasting, spasm
Ankles swelling, bruising, deformities, tibialis

posterior, FDL, FHL
Gait & posture walking 10 paces, sitting,

squatting
Feet posture, arch, skin changes, colour, swelling,

rashes, ulcers, infection ,calluses, plantar surface
Toes alignment (straight, hammer, claw, mallet),

nail changes, swelling, hallux valgus (bunions)
Feel
Supine
Swellings (hernia)
Landmarks greater trochanter of femur, ASIS,

PSIS, ischial tuberosity, pubic symphysis
Muscles gluteus, adductors, iliopsoas, quadriceps
Leg length true (ASIS medial malleolus) vs.

apparent (umbilicus medial malleolus)
Move
Supine, stabilise pelvis with other hand
Active passive resisted
Flexion (anterior), extension (posterior, prone),

adduction (medial), abduction (lateral),
internal rotation, external rotation
Special Tests
Thomas test (fixed flexion hip deformity) patient

supine, bring knee a to chest (leg b raises off
ground deformity in leg b)
Trendelenberg test (glut med weakness, short

femoral neck, unstable hip) hold patients hands,
ask them to stand on foot a and lift foot b off
ground (hip b falls)
Feel
Temperature
Ankle distal 1/3 of fibula, malleoli, tendons

(peroneal, tibialis posterior), joint line, PT pulse
Foot navicular bone, calcaneus (medial tubercle),

MTP & IP joints, metatarsal heads, tendons (TA,
FHL, FDL), DP pulse
Move
Tibiotalar joint dorsiflexion, plantar flexion
Subtalar joint inversion, eversion
Chopards joint toe dorsiflexion & plantar flexion
Special Tests
Thompsons test (calcaneal tendon) prone, foot
over edge of bed, squeeze calf muscles (no passive
plantar flexion)

assistance devices (stick, brace, sling, cast), gait,
cushingoid facies
Skin scars, rashes, ulcers
Muscles bulk, wasting, spasm
Joints swelling, deformities (scoliosis, thoracic

kyphosis, loss of lumbar lordosis)
Foot posture
Feel
Supine
Muscles (wasting / spasm) levator scapulae,
trapezius, semispinalis capitus, rhomboids
Prone
Move
Bones & ligaments costochondral &

sternochondral joints
Muscles (wasting / spasm) SCM, scalenes, levator
scapulae, erector spinae, gluteal, hamstrings
Bones & ligaments spinous processes,
interspinous ligaments, cervical facet joints,
costovertebral articulation, sacroiliac joint
Cervical flexion (down), extension (up), L / R
lateral flexion (tilt), L / R rotation (turn),
extension + rotation
Thoracic & lumbar extension (back), flexion
(forward), L / R rotation (sitting, turn), L / R lateral
flexion (hand down thigh)
Special Tests
Femoral nerve stretch (L3 radiculopathy) prone,
flex knee with hand on hamstring (pain in femoral
nerve distribution)
Straight leg raise (sciatic nerve) supine, flex hip

with leg straight (pain in back of leg from 30-70)
Shoulder Examination
Look
Feel
General age, gender, body habitus, comfort

Skin changes, symmetry, posture, swelling,
deformities (scoliosis, dislocation)
Muscles (wasting / spasm) deltoids, biceps,
triceps, supraspinatus, infraspinatus, trapezius,
rhomboids, pectoralis major, latissimus dorsi
Scapular winging (push against wall)
Temperature
Bony landmarks SC joint, clavicle, AC joint,
acromian, subacromial space, coracoid, scapula,
thoracic vertebrae
Muscles as above
Move
Bilaterally at the same time for comparison
Active passive restricted
Flexion (forward), extension (backward),

abduction (laterally, externally rotate at 90),
drop-arm test (internally rotate while coming
down) adduction (medial), internal rotation,
external rotation (flexed 90), push shoulders
back
Special Tests
Applys scratch test patient reaches over
opposite shoulder (adduction), behind neck
(adduction & external rotation), behind back
(internal rotation)
Supraspinatus tests resisted internal rotation

into abdomen (Napoleon test); resisted internal
rotation away from back (lift off test); resisted
abduction from 90 + resisted abduction from 30
while internally rotated (empty can test) (pain)
Hawkins-Kennedy test (impingement) flex
patients elbow & shoulder to 90, support
shoulder & forcibly internally rotate shoulder (pain)
Apprehension/relocation test (anterior stability)

supine, abduct patients arm to 90 & externally
rotate & apply posterior pressure to humerus
(apprehension of dislocation), internally rotate &
apply anterior pressure (relocation)
Neers test (subacromial impingement) flex
patients straight arm with their thumb down
(pain)
Elbow Examination
Look

Swelling, asymmetry, deformities, nodules
Rashes anterior (eczema), posterior (psoriasis)
Feel
Bony landmarks olecranon, lateral & medial

epicondyles, head of radius, radiohumeral joint
Muscles flexors & pronators (medial), extensors

& supinators (lateral), brachioradialis
Tendons (triceps, biceps), ulnar nerve
Move
Flexion, extension, pronation (palm down),
supination (palm up), flexion in semipronation
(brachioradialis)
Special Tests
Lateral epicondylitis tests resisted wrist
extension with extended elbow; resisted middle
finger extension; tight fist (pain)
Medial epicondylitis resisted wrist flexion (pain)
Valgus & varus stress tests elbow flexed to 20

and supinated, support humerus and gently stress
medial side (lateral ligaments) and then lateral side
(medial ligaments) of the elbow joint
Nerve entrapment tests extend thumb (radial),

abduct thumb (median), adduct thumb (ulnar)
Wrist Examination
Look

Scars, rashes, colour, wounds, nail changes,

wasting, swelling, ganglia, deformities, symmetry
Nerve lesions wrist drop (radial), hand of

benediction (median), claw hand (ulnar)
Feel
Dorsal wrist distal forearm, ulna, radius, lunate,

metacarpals, snuff box, PIP & DIP joints
Palmar wrist - pisiform, hook of hamate, flexor

retinaculum, Guyons canal
Hand swelling, tenderness, warmth, nodules
Move
Active passive resisted (not resisted for wrist)
Wrist flexion, extension, ulnar deviation, radial
deviation, pronation, supination
Fingers flexion, extension, abduction, adduction
Thumb opposition, abduction, adduction,

flexion, extension
Special Tests
Phalens test (median nerve compression) reverse
prayer sign (flex wrists), normal prayer sign (pain)
Tinels sign (carpel tunnel syndrome) percuss

over flexor retinaculum (paraesthesia)
Nerve entrapment tests extend thumb (radial),

abduct thumb (median), adduct thumb (ulnar)
Neurological System
Headache onset, severity,

location, aggravating factors,
relieving factors
Vision changes blurring,
diplopia, flashes
Hearing/balance changes
vertigo, tinnitus, hearing loss
Weakness in face, arms, legs
time course, generalised / specific,
unilateral / bilateral, proximal /
distal, sudden (vascular)
Burning, tingling, numbness
Fits, faints, mood changes aura,

LOC, tongue biting
Patient History
PMH neurological events, HTN,

DM, AF, CV risk factors, pregnancy
Family neurofibromatosis,
tuberose sclerosis, Hungingtons
disease, Friedrichs ataxia, DMD
Medications
Social toxin exposure, alcohol,

smoking, level of function
Cranial Nerve Examination
Upper Limb Neuro Examination
Upper Limb Neuro Examination
Patient sitting on edge of bed

Inspection craniotomy scars,
neurofibromas, facial asymmetry,
ptosis (Horners, oculomotor lesion,
myasthenia gravis), exophthalmos,
enothalmos, eye deviation, pupils
Patient supine
Inspection
Posture (decerebrate), nerve signs
(wrist drop, claw hand, hand of
benediction), muscles (wasting,
fasciculations), tremor at rest,
abnormal movements, skin change
Inspection
Gait - 10 steps
Olfactory (CN I) ask patient re:

smell, inspect nares, present smells
Optic (CN II) visual acuity, visual

fields (peripheral & central),
fundoscopy (disc, retina)
Eye reflexes (CN II, III) inspection

(shape, size, ptosis), direct response
(ipsilateral), consensual response
(contralateral), swinging light test
(partial), accommodation
Tone flaccid, decreased, normal,

increased
Power - 0 (no contraction),
1 (flicker), 2 (w/o gravity),
3 (vs. gravity), 4 (mild resistance),
5 (normal)
Reflexes 0 (absent), + (reduced),
++ (normal), +++ (~increased),
++++ (greatly increased
Trigeminal (V) sensation (light

touch, pain), corneal reflex
(opthalmicfacial), muscles of
mastication & jaw jerk (mandibular)
Facial (VII) raise eyebrows, close

eyes, smile, puff out cheeks
Vestibulocochlear (CN VIII)

otoscopt, auditory acuity (rub
fingers), Webers test (forehead),
Rinnes test (mastoidear)
Throat (IX, X) say ahh, gag reflex,

hoarseness, cough
Hypoglossal (XII) protrude

tongue, deviate each side, push vs.
cheek
Grading Guide
Eye movement (CN III, IV, VI)

modified H, asking about diplopia
Accessory (XI) torticollis (tilted

head), turn head vs. resistance
(SCM), shrug vs. resistance (traps)
Walking on heels (L4/L5), toes (L1)
Tandem walking R heel in front

of L toe etc. (cerebellar lesion)
Positional drift (arms out, eyes

closed) - down & pronation
(weakness), up & pronation
(cerebellar disease), all directions
(loss of proprioception)
Proximal myopathy sit & rise

without assistance, Trendelenberg
test (stand on one foot, supported)
Proprioception stand, feet

together, eyes open (station),
closed (Romberg test)
Motor
Tone active movement, passive
movement (elbow & wrist), grade
(flaccid, , normal, )
General inspection skin, muscles

(wasting, fasciculations)
Power movement vs. resistance
Reflexes biceps (C5, C6), triceps

(C7, C8), supinator (C5, C6)
Coordination finger-nose test

(their nose examiners finger),
rapid alternative movement
(quickly turning hand over)
Sensory
Pain dermatomes
Vibration (128Hz) pulp of middle

finger, ulnar styloid process,
olecranon, clavicle etc.
Proprioception distal IP joint
Soft touch - dermatomes
Motor
Tone active movement, passive
movement
Clonus push on superior patella,

rotate then dorsiflex ankle (UMN)
Power movement vs. resistance
Reflexes knee (L3, L4), ankle (S1,

S2), Babinski (L5, S1, S2)
Coordination drag heel down

shin & back up; toe-finger test (bed
examiners finger), rapid
alternating movement (tap foot
against palm of hand quickly)
Sensory
Pain dermatomes
Vibration (128Hz) 1st metacarpal

head, malleoli, patellae, ASIS
Proprioception distal IP joint
Soft touch - dermatomes
Haematological System
Thyroid
Presentations
Tiredness
Weakness
Dyspnoea
Fatigue
Postural dizziness
Bruising
Blood in stool
Lumps neck, armpit, groin
Hyperthyroidism - appetite, weight loss, diarrhoea, sweating, dry skin, hair thinning, preference for cold
Hypothyroidism - appetite, weight gain, constipation, lethargy, heavy periods, preference for warm weather
Thyroid Disease Examination
Hyperthyroidism
Hypothyroidism
General
Weight loss, anxiety
Mental / physical slowness, voice change
Hands
Tremor, onycholysis (nail separates from bed),

clubbing, palmar erythema, sweaty palms
Peripheral cyanosis, pigmentation, cool / dry

hands, pallor
Pulse
Sinus tachycardia / atrial fibrillation
bradycardia
Face
Exophthalmos (sclera visible below iris & eye

protruding beyond orbit Graves disease),
lid retraction (sclera visible above iris), lid lag
Skin pigmentation (hypercarotinaemia), skin

thickening, alopecia (hair loss), periorbital
oedema, xanthelasma, swelling of tongue
Patient History
PMH infections, fever, chills

Social diet (meat)
Menstrual history blood loss
Examination
General - age, gender, racial origin (thalassaemia),

pallor (anaemia), bruising (coagulopathy), jaundice
(haemolytic anaemia), scratch marks (lymphoma)
Hands koilonychias, pallor of nail beds / palmar

creases, bruising
Radial pulse (tachycardia)
Lymph nodes (site, size, fixation, consistency,

tenderness) cervical, axillary, trochlear, supraclavular
Face scleral icterus (jaundice), conjunctival pallor,

gums, oral mucosa, tongue (glossitis), tonsils
Thyroid Examination
Inspection - scars (thyroidectomy), veins (retrosternal goitre), redness (suppuratives thyroiditis), swelling
(generalised / localised), during swallowing (moves superiorly normal, goitre, thyroglossal cyst)
Palpation (from behind; lobes & isthmus) size; shape; nodules; thrill (hyperthyroidism); fixation (carcinoma);
consistency: firm (goitre), rubbery hard (Hashimotos thyroiditis), stony hard (thyroiditis), tenderness (thyroiditis)
Percussion upper part of manubrium (retrosternal goitre)
Auscultation over each lobe for bruits (hyperthyroidism, antithyroid medication)
Chest press sternum & clavicles with heel of hand,

push shoulders together
Pebertons sign (thoracic inlet obstruction e.g. retrosternal goitre) patient lifts both hands as high as possible,
look for signs of congestion / cyanosis / respiratory distress
Abdomen masses, liver, spleen, inguinal nodes
Chest (auscultate heart & lungs) systolic flow murmur, CCF, pericardial / pleural effusion (all hyperthyroidism)
Legs bruising, pigmentation, scratch marks, ulcers,

sensation, popliteal nodes
Legs pretibial myxoedema (bilateral, firm, elevated dermal nodules; Graves disease), non-pitting oedema
(hypothyroidism), reflexes ( hyperthyroidism, hypothyroidism)
Other fundoscopy (papiloedema, haemorrhage),

temperature, urinalysis, rectal / pelvic examination
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EXAMINATIONS!!MARKING!
SHEETS!
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The Gastrointestinal System
Gastrointestinal system - assessment sheet 2012

Detail
Process
Introduction
Wash hands, introduction, obtain consent.
Position/exposure
Position and expose as necessary.
General inspection
Vital signs /
Hydration
Hand and upper limb
Face
Neck and chest
General observation, mental state, body habitus, colour

Temp, PR, BP, RR (O2 sats, Wt, BSL, WTU)
Nails (leukonychia, koilonychia).
Hands (clubbing, palmar erythema, pallor, Dupuytrens
contracture).
Hepatic flap (if indicated), tremor.
Arms (spider naevi, bruising, wasting, scratch marks).
Eyes: xanthelasma, conjunctival pallor, jaundice, iritis.
Parotid glands: inspect, palpate.
Mouth: foetor, lips, oral mucosa, tongue, gums, teeth.
Inspect for spider naevi, hair distribution, gynaecomastia.
Palpate lymph nodes: submental, submandibular, jugular chain,
supraclavicular, posterior triangle, occipital, pre/post auricular,
axillary.
Mention not
performed Y1
Inspect
skin: scars, striae, bruising, pigmentation.
abdomen: distension, masses, veins, peristalsis, pulsation.
Palpate superficial (herniae) and deep (ask about tender areas)
tenderness: localised (Murphys sign, McBurneys point), referred
(Rovsings sign), and rebound (watch face)
guarding (voluntary and involuntary)
masses: describe
organs liver (gallbladder), spleen, kidneys, bladder, AAA.
Percuss
- liver span, bladder
- shifting dullness.
Auscultate
bowel sounds
bruits over renal and aortic areas.
Examination of groin region (hernias and lymphadenopathy),
genitalia, DRE +/- vaginal examination
Legs
Skin changes, sacral and leg oedema.
Discuss
WTU, urine preg test if not already done
Abdomen
Tick if
Demonstrated
Professional Behaviour (Critical Error) all the criteria below must be fulfilled to pass
confident professional approach to task / professionally dressed
treated patient and examiner with respect
clear instructions to patient. No jargon
fluid performance. Minor hesitation only
technique correct in all or most areas
able to answer questions from handbook
Overall Mark
Pass
Fail
Comments - to be recorded over page

Examiners name and signature:
Date:
University of Queensland
91
The Respiratory System
Respiratory system - assessment sheet 2012

Process
Detail
Introduction
Position and
exposure
Lying or sitting with chest exposed as necessary.
General inspection
Vital signs/hydration
Hands/upper limbs
Face/neck
Chest inspection
Palpation
Percussion
Ausculation
Further assessments
Tick if
Demonstrated
General observation, Mental state, Body Habitus, Colour

Temp, PR, BP, RR, , (O2 sats, BSL)
clubbing, cyanosis, tar staining, pallor, cyanosis, wasting

flapping tremor
radial pulse - rate, rhythm
respiratory rate, accessory muscle use
BP/pulsus paradoxus.
eyes: conjunctival pallor, Horners syndrome

nose: polyps, enlarged turbinates, displaced septum, sinus
tenderness
tongue: central cyanosis
sinus tenderness
pharynx: tonsil size/exudate oral candidiasis. leukoplakia,
teeth
palpate trachea for displacement / tug
lymphadenopathy submental, submandibular, jugular
chain, pre/post auricular, occipital, posterior triangle,
supraclavicular.
(Start posterior chest and repeat all examination below
anteriorly also)
Shape, symmetry, scars, deformities, respiratory movement
and supraclavicular, and intercostal and subcostal recession.
Measure expansion / Note asymmetry.
Position (arms crossed for posterior chest), compare
symmetry, include axillae/supraclavicular fossa/clavicles.
Compare symmetry:
breath sounds: vesicular/bronchial
added sounds
stridor
wheezes (inspiratory/expiratory)
crackles (fine, medium, coarse)
vocal resonance
observation chart
respiratory function tests (Peak flow meter, spirometry)
Professional behaviour (Critical Error) all the criteria below must be fulfilled to pass
clear instructions to patient . No jargon
Overall Mark
Pass
Fail

Date:
76
The Cardiovascular System
Cardiovascular system - assessment sheet 2012

Process
Introduction
Detail
Position/exposure
Couch raised to 3045, exposed only as necessary.
General inspection
General observation, Mental state, Body Habitus, Colour
Vital signs/hydration
Hands
Temp, PR, BP, RR, (O2 sats, BSL, urinalysis)

Pallor, cyanosis, xanthomata, clubbing, signs of endocarditis.
Radial pulse/
respiratory rate
Radial pulse: rate and rhythm

Radio-radial, radio-femoral delay, respiratory rate.
Blood pressure
Demonstrate technique and /assess for postural hypotension.
Face
Eyes: xanthelasma, conjunctival pallor, jaundice

Mouth: central cyanosis, palate, teeth, gums.
Neck
JVP
Carotid palpate pulse note character, auscultate for bruits.
Chest
Scars, deformities, apex beat, thrills, parasternal and LV heave.
Heart
Auscultate
two heart sounds
added sounds
murmurs
Listen in three positions:
lying down
left lateral position
sitting forward after full expiration and breath hold.
Back
inspect for scars, deformity

palpate for sacral oedema
percuss the lung bases looking for effusion due to pulmonary
oedema
auscultate the lung bases for crackles due to pulmonary
oedema.
Abdomen
Supine on one pillow

palpate: tenderness, masses, organomegaly, aortic aneurysm,
ascites
auscultate for bruits: aortic, renal, femoral
Legs
Further assessments
Tick if demonstrated
Look for: varicose veins, colour and temperature of legs, trophic

changes, ulceration of the skin, clubbing of toes, xanthomata,
oedema.
Compare pulses both limbs: femoral, popliteal, posterior tibial,
dorsalis pedis.
fundoscopy, ECG.
Overall Mark
Pass
Fail
Date:
63
The Neurological System
Neurological system - assessment sheet 2012

Process
Tick if
Demonstrated
Detail
CRANIAL NERVES EXAMINATION
Positioning
General inspection
CN I Olfactory
CN II Optic
CN III, IV, VI
Oculomotor,
Trochlear, Abducens
CN V Trigeminal
CN VII Facial
CN VIII Acoustic
CN IX, X
Glossopharyngeal
and Vagus
CN XI Accessory
CN XII Hypoglossal
Positioning
Inspect
Tone
Power
Reflexes
Coordination
Sensation
Functional tests
Inspect
Tone
Power
Reflexes
Coordination
Sensation
Scars, neurofibromas, facial asymmetry, ptosis, proptosis, deviation of

eyes, unequal pupils
Ask patient if they can smell normally
Visual acuity, visual fields, fundi
Inspect pupils, test pupillary reaction to light and accommodation,
assess eye movements look for failure of movement and nystagmus,
ask about diplopia
Corneal reflex, face sensation, mastication muscles, jaw jerk
Facial muscle power forehead, wrinkle eyes, grin and compare
nasolabial folds, puff out cheeks
Whisper tests, inspect auditory canals and drums if indicated, Weber +
Rinnes tests with a 256 Hz tuning fork
Inspect palate and uvula
Assess palatal movement
Assess cough and speech
Inspect for torticollis, shrug shoulders, assess sternomastoid
Inspect tongue, protrude tongue
UPPER LIMB EXAMINATION
Sitting upright
Posture, wasting, fasciculation, pronator drift
Wrist, elbow
Shoulder abduction and adduction, elbow flexion and extension, wrist
flexion and extension, finger extension, flexion and abduction
Biceps, triceps, supinator reinforce if necessary
Finger-nose test, rapidly alternating movements
Light touch, pain, vibration sense, proprioception
LOWER LIMB EXAMINATION
Observe/test gait, heel-toe, tiptoes, heels.
Observe/test proximal myopathy
Romberg test
Skin changes, muscle wasting, fasciculation
Knee, ankle
Hip flexion, extension, abduction and adduction, knee flexion and
extension, ankle plantar flexion and dorsiflexion, tarsal joint eversion
and inversion
Knee jerk, ankle jerk, plantar reflex reinforce if necessary
Observe/test for coordination
Light touch, pain, vibration sensation, proprioception
Professional Behaviour (Critical Error) all the criteria below must be fulfilled to pass:
confident, professional approach to task / professionally dressed

able to answer questions from handbook.
Overall Mark
Pass
Fail
Date
Examiners name
and signature:
141
The Musculoskeletal System
Spine examination - assessment sheet 2012

Process
Introduction
Detail
Tick if
Demonstrated
Wash hands, introduction, consent obtained.
Position/exposure
Initially upright and appropriately exposed depending on region to be

examined, then recumbent.
General inspection
Age, gender, well/unwell, mental state, body habitus, assistance devices,

general posture (check for normal spinal curvature), deformity.
Look
Look specifically at bony/muscular landmarks (assess vertebral

levels).
Check for posture, deformity, symmetry (landmarks), spasm, swelling,
skin changes, scars, and wasting.
Check skin temperature.
Feel
Palpate spine (spinous processes, interspinous ligaments, facet

joints), all bony landmarks, and surrounding muscles, note
tenderness.
Palpate paravertebral muscles for bulk, spasm, and tenderness.
Assess full range of active and passive movement.
Move
Note symmetry, restriction, pain, or neurological symptoms.

For thoracic spine sitting will fix the pelvis.
Assess how daily function is affected.
Function
Cx spine: driving, sleeping.

Thoracic spine: twisting.
Lumbar spine: bending over, tying laces.
Cervical spine: neurological assessment of arms.
Thoracic spine: Assess for scoliosis.
Special tests
Lumbar spine:
femoral nerve stretch
straight leg raise (sciatic nerve)
neurological assessment of lower limb.
Professional Behaviour (Critical Error) all the criteria below must be fulfilled to pass
Overall Mark

Pass

Fail

Examiners name
and signature:
Date:
176
Knee examination - assessment sheet 2012

Process
Introduction
Position/exposure
General inspection
Look
Detail
Tick if
Demonstrated

Begin with patient in standing position in exercise shorts or underwear.
Assess the patients age, body habitus, posture, general health, and
behaviour.
Observe gait, undressing, sitting and rising from chair, removing shoes
and socks.
Inspect for posture, deformity (genu valgum/varum), symmetry
(landmarks), spasm, swelling (joint effusion, bursae), skin changes,
scars and wasting (esp, quads).
Inspect from front, side, and behind (Bakers cyst).
Skin temperature, swellings, tenderness.
Palpate:
bony landmarks for swelling, tenderness, or deformity (patella, patella
ligament, tibial tuberosity, medial and lateral femoral and tibial
condyles and head of fibula)
Feel
joint line
muscles: quads (bulk, spasm, tenderness) and quad tendon
bursae
popliteal fossa for Bakers cyst.
Test for effusion: patella tap, bulge test.
Move
Function
Active movement.
Passive movement.
Assess symmetry, quality of movement, grade restrictions.
Flexion, extension, rotation.
Assess gait, squatting, sitting and rising from chair, removing shoes and
socks.
Patella apprehension test
Medial and lateral collateral ligament test
Special tests
Anterior draw test

Lachmans test
McMurrays test for medial/lateral meniscal tear
Overall Mark

Pass

Fail

Examiners name
and signature:
Date:
178
Shoulder examination - assessment sheet 2012

Process
Introduction
Tick if
Demonstrated
Detail
Wash hands, introduction, consent obtained
Position/exposure
Comfortable position for patient preferably standing

Both shoulders fully exposed for males, shirt off; for females,
bra/sports top.
General inspection
Assess the patients age, body habitus, posture, general health, and
behaviour.
Observe patient undress to assess functional impairment.
Look
Inspect for posture, deformity (dislocation), symmetry (landmarks),

spasm, swelling (joint effusion), skin changes, scars and wasting (esp.
deltoid).
Inspect from front, side, and behind (muscles of scapula).
Feel
Skin temperature, swellings, tenderness.

Palpate:
Bony landmarks for swelling, tenderness or deformity (sternoclavicular
joint, clavicle, acromioclavicular joint, coracoid and acromion
processes, spine, and borders of scapula)
Joint line
Muscles - deltoid, biceps, triceps
Move
Assess symmetry, quality of movement, grade restrictions of

abduction/elevation, flexion/elevation, internal rotation, external rotation,
extension, adduction
active movement: from front and back to assess symmetrical
scapulohumeral rhythm.
passive movement.
Function
Special tests
Assess brushing hair, doing up bra in women, hanging out washing

Apprehension Test - for anterior stability.
Rotator Cuff impingement tests.
Hawkins Test, Empty-can test.
Biceps tendon tests
Winged Scapular test
Overall Mark
Pass
Fail

Examiners name
and signature:
Date:
180
The Haematology System
Haematological Examination
Tick if
demonstrated
Process
Detail
Introduction
Positioning/exposure
General inspection
Hands
Palpate lymph nodes
Face
Chest
Abdominal
examination
Lower limbs
Discuss further
examination
Expose only the minimum necessary at one time.

Ask the patient to expose themselves where possible.
Look for pallor, bruising, jaundice, scratch marks, rashes.
Inspect for koilonychia, pallor of nail beds/palmar creases,
joint/connective tissue disease.
Palpate for radial pulse.
Assess lymph nodes for site, size, consistency, tenderness, fixation,
overlying skin changes.
Epitrochlear (elbow)
Axillary
Cervical/Occipital
Supraclavicular
(Inguinal with abdominal examination)
(Popliteal with leg examination).
Eyes: jaundice, haemorrhage, conjunctival pallor.
Mouth: mucosa, tongue, gums, tonsils.
Check for bony tenderness:
Tap fist over spine.
Press sternum and clavicles with heel of hand.
Push shoulders together.
Examine for:
masses
organomegaly
inguinal lymphadenopathy.
Inspect for bruising, pigmentation, scratch marks, ulceration
Palpate regional nodes.
Test for peripheral neuropathy.
Consider fundoscopy DRE and VE.
Comments
Overall Mark
Pass
Fail
Date:
Examiners name:
Examiners signature:
103
The Endocrine System
Thyroid examination
Tick if
demonstrated
Process
Detail
Introduction
Position/exposure

Offer patient sheet or modesty blanket.
General inspection
Look for:
evidence of weight loss, anxiety (hyperthyroidism)
mental or physical sluggishness (hypothyroidism)
Hands
Look for:
tremor, onycholysis, clubbing, palmar erythema, warmth/sweatiness
(hyperthyroidism)
cyanosis, swelling, cool/dry hands (hypothyroidism)
Palpate for radial pulse (tachycardia, atrial fibrillation hyperthyroidism,
bradycardia hypothyroidism).
Arms
Lift arms above head (proximal myopathy).

Reflexes.
Face
Look for:
Exophthalmos, lid retraction, lid lag (hyperthyroidism)
Thickening of skin, pigmentation, alopecia, periorbital oedema, loss of
outer one-third of eyebrows, xanthelasma, tongue swelling, voice
change (hypothyroidism).
Neck
Inspect for scars, goitre, thyroid nodules ask patient to swallow

Palpate thyroid repeat with patient swallowing
Palpate cervical lymph nodes, carotid arteries, position of trachea
Demonstrate testing for Pembertons sign
Chest
Auscultate heart for murmurs.

Auscultate lungs for signs of CCF (basal crackles) or pleural effusion.
Legs
Look for pretibial myxoedema.

Test for power (proximal myopathy).
Test reflexes.
Overall mark
0 = no skills or critical error

1 = novice
2 = more practice required
3 = competent and confident
4 = expert
Comments
Overall Mark
Pass
Fail
Date:
Examiners name:
Examiners signature:
111
The Endocrine System

Diabetic examination
Process
Detail
Introduction
Wash hands, introduction, consent/chaperone, any pain?
Positioning
Supine with pillow
General inspection
General observation (distress/discomfort), body habitus (obesity,

weight loss), mental state, hydration, signs of Cushings,
acromegaly, haemochromatosis (2 diabetes), Kussmauls
respiration (ketoacidosis)
Lower limbs
Inspection: colour, skin changes (hair loss, atrophy, dryness,

pigmentation), ulceration/infection, injection sites, muscle wasting
(quads)
Palpation: temperature, cap refill, bilateral peripheral pulses
(femoral, popliteal, post tibial, dorsalis pedis)
Neuro exam: sensation (light touch, pain, vibration, proprioception),
reflexes (knee & ankle), proximal myopathy (squat & stand), + tone,
power & coordination if indicated
Upper limbs
Inspection: nails (candida), ulceration/infection, injection sites

Radial pulse rate, rhythm
Blood pressure: lying, standing
Eyes
Visual acuity
Argyll Robertson pupils (small, irregular, unequal, brisk
accommodation, response to light)
CN III, IV, VI inspect pupils, reaction to light, accommodation, eye
movements, nystagmus, diplopia
Fundoscopy (if available) cataracts, inspect retina for proliferative
(new vessels, vitreal haemorrhage, scars, retinal detachment) and
non-proliferative change (dot/blot haemorrhages, microaneurysms,
cotton-wool spots)
Ears/Mouth
Mouth: candida
Ears: inspect for infection (if indicated only)
Neck
Carotid arteries palpate & auscultate for atherosclerosis

Examine & palpate thyroid
Chest
Signs of infection (if indicated only)
Abdomen
Hepatomegaly
Discuss
Vitals, WTU (glucose, ketones, protein, nitrites, blood )
Tick if
demonstrated
The Urinary System
Urinary system examination

Process
Detail
Tick if demonstrated
Introduction
Positioning and
exposure

Offer patient sheet or modesty blanket.
Vital Signs
Temp, PR, BP, RR, (O sats, Wt/Ht/BMI, BSL, WTU)
General inspection
Mental state, complexion, fetor, hydration.
Hands
Leukocychia, pallor, asterixis.
Arms
Face
Anaemia, jaundice, fetor, mouth ulcers, thrush, gingivitis.
Neck
Measure JVP.
Auscultate for carotic bruits.
Chest
Auscultate heart and lungs.
Abdomen
Back
Palpate for bony tenderness, renal tenderness, sacral oedema.
Legs
Inspect for oedema, purpure, pigmentation, excoriation, gouty

tophi.
Palpate for oedema, peripheral pulses.
Check sensation (peripheral neuropathy).
Discuss
Consider fundoscopy, temperature chart, urine analysis.
Inspect for AV fistulae, bruising, pigmentation, excoriation.

Test for sensation (peripheral neuropathy).
Pulse.
Measure blood pressure.
Inspect for scars, distension, catheter.

Palpate for masses, liver, kidney, bladder, aortic aneurysm.
Percuss for shifting dullness, bladder.
Auscultate for renal bruit.
(Discuss rectal examination for prostatomegaly).
Comments
Overall Mark
Pass
Fail
Date:
Examiners name:
Examiners Signature:
97
!
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CLINICAL!REASONING!
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The Unconscious Patient

Pathogenesis
Clinical Approach
OSCE Prep
General
The Unconscious Patient
Headache
Chronic Tiredness
Fever
Lymphadenopathy
Bleeding
Pelvic & Scrotal Masses
Sudden Collapse
Seizure
Cardiorespiratory
Cough
Chest Pain
Breathlessness
Hoarseness
Gastrointestinal
Abdominal Pain
Constipation
Diarrhoea
Jaundice
Upper GI Bleeding
Anorectal Symptoms
Urinary
Dysuria
Haematuria
Proteinuria
Urinary Incontinence
Musculoskeletal
Lower Back Pain
Leg Pain
Knee Pain
Reticular activating system (RAS) responsible for regulating arousal and sleep-wake transitions
Non-specific arousal of most parts of the brain in response to ascending sensory input
Made up of parts of the midbrain, mesencephalon, thalamus, hypothalamus and tegmentum
Stimulated by toxins, temperature, thyroid, too much of anything seizures
Inhibited by direct pressure tumours, bleeds, trauma
Starved hypoxia, hypoglycaemia, hypotension
Aetiology
COMA
AEIOU TIPS
Alcohol / drugs
Endocrine / electrolytes
Insulin
Oxygen
Uraemia
Trauma
Infection / intracranial pressure
Poison / porphyrins
Seizure / stroke / space-occupying lesion /
sub-arachnoid haemorrhage
Cerebral cause
Overdose / organ failure
Metabolic (glucose / urea / electrolytes)
Asphyxia
Assessment
Glasgow Coma Scale
Good for tracking progress
<9/15 consider intubation
1
Eyes
Does not
open eyes
Opens eyes to
painful stimuli
Opens eyes to
voice
Opens eyes
spontaneously
Verbal
Makes no
sounds
Incomprehensible
sounds
Inappropriate
words
Confused /
disoriented
Oriented,
converses
normally
Motor
Makes no
movements
Extension to
painful stimuli
(decerebrate)
Abnormal flexion
to painful stimuli
(decorticate)
Flexion /
withdrawal to
painful stimuli
Localizes
painful
stimuli
AVPU
A - alert
V responds to voice
P responds to pain
U unresponsive
Obeys
commands
Stages of Anaesthesia
Headache
Stage 1 amnestic but still staggering and talking, some protective reflexes
Stage 2 eyes shut, amnestic, often hyperreflexic (gag, cough), irregular RR, BP, HR
Pain or discomfort between the orbits and occiput, arising from pain sensitive structures.
Stage 3 deeply asleep, stable slow HR and RR, low but stable BP, no protective reflexes
Stage 4 HR, BP, RR not enough to maintain life
A very common presenting complaint

o 85% of the population will experience headache within 1 year
o 38% of adults will have had a headache within 2 weeks
o 40% of children will have experienced one or more headaches by the age of 7 (75% by age 15)
Needs a sound diagnostic strategy - careful history, high index of suspicion, judicious use of CT scanning
Management
CLOBBERED
Call for help
Lie on side, protecting neck
Oxygenate
Blood pressure maintain
BSL
Environment check temperature
Responsiveness GCS, AVPU, stages
Examine possible causes / associations (trauma, track marks, med alerts, organ failure)
Differential diagnosis intracranial vs. extracranial, local vs. global damage
Aetiology
Tension / combination / exertional / post-traumatic headache
Migraine
Drugs
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Alcohol
Aspirin, codeine
Antihypertensives
Oral contraceptives
Sympathomimetics
Caffeine
Corticosteroids
Cyclosporin
Dipyridamole
H2-receptor antagonists
MAO inhibitors
Nicotine
Nitrazepam
Nitrous oxide
Retinoids
Theophylline
Vasodilators
Most Probable
Respiratory infection
Tension-type headache
Combination headache
Migraine
Most Serious
Cardiovascular subarachnoid / intracranial
haemorrhage, carotid / vertebral artery dissection,
temporal arteritis, cerebral venous thrombosis
Severe infection meningitis, encephalitis,
intracranial abscess
Neoplasia cerebral, pituitary
Haematoma extradural / subdural
Glaucoma
Benign intracranial hypertension
Often Missed
Dental disorders
Refractive errors of eyes
Sinusitis
Opthalmic herpes zoster
Exertional headache
Hypoglycaemia
Post-traumatic headache
Post-spinal procedure
Sleep apnoea
Infection respiratory, meningitis, encephalitis, abscess
Haemorrhage subarachnoid / intracranial
Dissection carotid / vertebral artery
Neoplasia cerebral / pituitary
Haematoma extradural / subdural
Inflammation - temporal arteritis, sinusitis
Visual disorders refractive errors, glaucoma, opthalmic herpes zoster
Benign intracranial hypertension
Dental disorders
Hypoglycaemia
Sleep apnoea
Psychogenic depression, anxiety
Children
Infection
Psychogenic
Migraine
Meningitis
Post-traumatic
Assessment
History
SOCRATES
Frequency
Pain in back of head or neck
Diurnal variation
Associated symptoms
o Nausea, vomiting
o Dizziness, weakness
o Light sensitivity
o Blurred vision
o Watering / redness of eyes
o Pain / tenderness of scalp
o Rhinorrhoea
o Fever, sweats
Stress
Medications
Recent trauma
Examination
Temperature
Blood pressure
Fundoscopy
Inspect temporal arteries, facial / neck
muscles, sinuses, Cspine, teeth, TMJ
Mental state examination
Neurological examination visual fields,
acuity, pupillary reflexes, eye movements
Upper cervical pain sign palpate over
C2 and C3 tender headache of
cervical origin
Ewings sign for frontal sinusitis press
finger gently upwards and inwards against
the orbital roof medial to the supraorbital
nerve pain frontal sinusitis
Investigations
Haemoglobin anaemia
WCC leukocytosis (bacterial infection)
ESR temporal arteritis
Radiography
o CXR
o Cervical spine
o Skull X-ray brain tumour, Pagets
o Sinus X-ray sinusitis
o CT scan brain tumour, CVA, SAH
Lumbar puncture meningitis
Diurnal Pain Patterns
Chronic Tiredness
Normal tiredness due to increased mental/physical demands; relieved by rest

Chronic tiredness rest provides partial/no relief; present for >6 months
Causes
Common
Idiopathic life factors
Psychological stress,
anxiety, depression
Sleep disorders
Medications
Iron deficiency
Glandular fever
Infrequent
Pregnancy
Menopause
Physical disease
Domestic violence
Rare
Psych. disease e.g. eating disorder

Rheumatological disorders e.g. SLE
Lyme disease
Neurological disorders
Tuberculosis
Endocrine disorders
Narcolepsy
Chronic Fatigue Syndrome Diagnostic Criteria

1. Persistent tiredness or fatigueability that persists or relapses for >6 months
2. >4 of the following symptoms persistent for >6 months:
o Multi-joint pain
o New headaches
o memory, concentration
o Sore throat
o Unrefreshing sleep
o Tender cervical/ axillary lymph
o Muscle pain
nodes
Clinical Approach
Red Flag Symptoms

Sudden onset
Severe and debilitating pain
Fever
Vomiting
Disturbed consciousness
Worse on bending or coughing
Worst in the morning
Neurological symptoms / signs
Young obese female
New headache in elderly
Red Flag Signs
Altered consciousness
Altered cognition
Meningism
Abnormal vital signs BP, temp, RR
Focal neurological signs pupils, fundi,
eye movement
Tender, poorly pulsatile cranial arteries
History
Onset, duration, relation to other symptoms
Attributions what the patient thinks is the cause, how it is affecting them
Physical features general health, diet, appetite, systems review
Recent infection e.g. glandular fever
Investigation
Medications
Tired all the time (TATT) screen
Substance use alcohol, marijuana, other illicit drugs
Full blood count
Depression/anxiety history
Erythrocyte sedimentation rate
Sleep quality, snoring, apnoea
Urea, electrolyes, creatinine
Social history relationships, work, stress, last holiday
Urine culture and microscopy
Sexual history + HIV, Hep C
HIV, hepatitis B and C
Occupational exposure heavy metals, CO
Liver function tests
Iron studies serum iron and
Examination
Ferritin
Lymphadenopathy
Thyroid stimulating hormone
Cardiovascular signs
Glucose
Full mental state examination
Management
1. Treat the pathological condition if one is identified
2. If all tests are normal possible psychiatric disorder full psych and mental exams
o Usually only mild to moderate psychiatric disorder e.g. depressed mood or anxiety disorder
o Consider counselling and cognitive behavioural therapy before medication
3. If still complaining of fatigue despite normal results, consider more detailed tests cortisol, calcium,
magnesium, rheumatoid factor, infection screen (EBV, CMV, lyme disease, tuberculosis), chest X-ray,
echocardiogram, sleep studies
Fever
Lymphadenopathy
Aetiology
Normal body temperature: 36.8 0.4C at ~6am and is higher between 4-6pm
Fever: >37.2C (at 6am, or 37.7C at 4pm)
Pathogenesis
hypothalamic set point body temp. until affector neurons register blood temp. at new set point
Mechanism
1. Pyrogens release of prostaglandin E2 (PGE2) by hypothalamic endothelial cells
2. PGE2 release of cAMP by glial cells in the hypothalamus
o PGE2 release in peripheral cells muscle and joint pain
3. cAMP set point by neuronal cells in the thermoregulatory centre
Muscle/joint pain
Endogenous Pyrogens
IL-1, IL-6, TNF-, IFN-
PGE2
Exogenous Pyrogens
Bacteria, endotoxins,
hormones, medications
cAMP
2. Benign immune disorder

o Autoimmine - rheumatoid arthritis, systemic lupus erythematosus
o Serum sickness
o Drug reactions (e.g. to phenytoin)
o Langerhans cell histiocytosis
Vasoconstriction
Set point
Hypothalamus
Shivering
1. Infection
o Bacterial all pyogenic bacteria, syphilis
o Mycobacterial tuberculosis, leprosy
o Fungal histoplasmosis
o Chlamydial
o Parasitic toxoplasmosis, trypanosomiasis, filariasis
o Viral Epstein-Barr virus, cytomegalovirus, rubella, hepatitis, HIV
"Temperature
Liver metabolism
3. Malignant immune disorder

o Leukaemia acute/chronic, myeloid/lymphoid
o Lymphoma Hodgkins, non-Hodgkins
o Monoclonal gammopathy - multiple myeloma, Waldenstrms macroglobulinaemia
o Malignant histiocytosis
4. Other malignancies breast, lung, melanoma, head & neck, GIT, germ cell
Aetiology
1. Infections viral bacterial, malaria, syphilis etc.
2. Malignancy lymphoma, carcinoma
3. Rheumatological disorder SLE, sarcoid, rheumatoid arthritis
4. Drug fever reaction with medicine (usually accompanied by rash)
5. Pulmonary embolism (mild fever)
6. Osteomyelitis
5. Lipid storage diseases Gauchers disease, Niemann-Pick disease

6. Endocrinopathies
o Thyroid disease - hyperthyroidism; thyroiditis
o Andrenal insufficiency
7. Miscellaneous
o Sarcoidosis
o Amyloidosis
o Dermatopathic lymphadenitis
History
Age, sex, occupation

o Children usually benign e.g. viral, bacterial, toxoplasmosis
o > age 50 incidence of malignant disorders increases significantly
Localised symptoms suggests infection or malignancy
Exposure cats, undercooked meat, travel, unsafe sexual or drug activity
Indicators of systemic involvement -suggest tuberculosis, lymphoma or other malignancy

o Fever
o Night sweats
o Unexpected weight loss of >10%
Medications e.g. phenytoin
Generalised pruritis
Pain from inflammation
Bleeding
Examination
1. Location localised or generalised
2. Size
o
o
o
<1cm $benign
1+2.25$cm$$8%$malignant
>2.25$cm$$38%$malignant
3. Consistency
o Hard malignant leading to fibrosis
o Firm/rubbery lymphoma or chronic lymphocytic lymphoma
4. Fixation - chronic infection or malignancy
5. Tenderness due to inflammation
o Infection rapid growth within capsule tenderness
o Malignancy gradual expansion of entire encapsulated node no tenderness
6. Signs of inflammation over the node
7. Splenomegaly systemic illness e.g. infectious mononucleosis, lymphoma, leukaemia, SLE, sarcoidosis
Investigations
1. Observe for 3-4 weeks if there are no clues about aetiology
2. Full blood count
3. Serology EBV, CMV, toxoplasmosis, HIV, Bartonella henselae, syphilis, TB
4. Chest X-ray
5. Biopsy
Types of Biopsy
1. Excision biopsy for when malignancy is suspected and the
patient has no history of malignancy
2. Core biopsy for when lymphoma is suspected and lymph
nodes are not easily obtainable
3. Fine needle aspirate (FNA) to confirm recurrence of
malignancy, but not for diagnosis
Who to Biopsy
Patients >40 years
> 2cm in size
Abnormal chest X-ray
Supraclavicular LN
involvement
Hard consistency
Generalised pruritis
No symptoms of
local/systemic infection
Purpura: bleeding into the skin or mucous membranes

o Petechiae: smaller purpuric lesions 2mm
o Ecchymoses: purpuric lesions >2mm
Aetiology
Vessel Wall Abnormalities
Platelet count, bleeding time, PT and aPTT are usually normal
1. Infections: meningococcaemia, septicaemia, infective endocarditis, rickets
o Microbial damage to microvasculature, or DIC
2. Drug Reactions: usually vascular injury is mediated by deposition of drug-induced immune complexes
3. Scurvy & Ehlers-Danlos Syndrome: microvascular bleeding resulting from defects in collagen
Platelet Deficiency
Thrombocytopenia: reduced platelet number - <100,000 platelets/L
1. Decreased production
o Depression of bone marrow aplastic anaemia, leukaemia
o Selective depression of megakaryocytes drugs, alcohol, measles, HIV, myelodysplastic syndromes
2. Decreased survival
o Immunological platelet destruction autoimmune, alloimmune (post-transfusion), drugs, infection
o Non-immunological destruction DIC, mechanical injury
3. Sequestration splenomegaly
4. Dilution massive transfusions
Defective Platelet Function
1. Defective adhesion to subendothelial matrix e.g. Bernard-Soulier syndrome (defect in vWF receptor)
2. Defective aggregation e.g. Glanzmann thrombasthenia
3. Disorders of platelet secretion defective release of factors e.g. TXA2, ADP e.g. aspirin intake
Abnormalities in Clotting Factors
1. Hereditary deficiencies typically affect a single clotting factor
o Haemophilia A factor VIII
o Haemophilia B factor IX
o Von Willebrand disease vW factor
2. Acquired deficiencies usually involve multiple coagulation factors
o Vitamin K deficiency $ factors, II, VII, IX, X, protein C
Most Probable
Simple purpura
Senile purpura
Corticosteroid-induced purpura
Immune thrombocytopaenic purpura
Most Serious
Malignancy leukaemia, myeloma
Aplastic anaemia
Myelofibrosis
Severe infection septicaemia,
meningococcal, measles, typhoid
Disseminated intravascular coagulation
Pelvic and Scrotal Masses
Assessment
History
Trauma
General health tiredness, weight loss, fever, night sweats
Medications
o Steroids
o Cytotoxic drugs
o Gold
o
o
o
Heparin
Phenylbutazone
Sulphonamides
o
o
o
Quinine
Thiazide diuretics
Chlorampenicol
o
o
o
Aspirin
NSAIDS
Warfarin
Family history
o Sex-linked recessive haemophilia A/B
o Autosomal dominant von Willebrand disease, dysfibrinogenaemias
o Autosomal recessive coagulation facor V, VII, X deficiency
Factors suggesting a bleeding defect spontaneous haemorrhage, sever/recurrent bleeding episodes,
bleeding from multiple sites, bleeding out of proportion to trauma
o Early bleeding following trauma platelet deficiency
o Delayed bleeding after initial homeostasis coagulation factor deficiency
o Normal history of previous coagulative stresses acquired problem drugs, malignancy, liver
Examination
Nature of bleeding and rash distribution
o Senile purpura dorsum of hands, extensor surface of forearms and shins
Lips and oral mucosa telangiectasia, gum hypertrophy
Signs of malignancy sternal tenderness, lymphadenopathy, splenomegaly
Urinalysis
Investigations
Tests
Method
Normal
Platelets
An automated cut with a BP

cuff set to 40mmHg
2-8 min
Prothrombin
Time
Extrinsic &
common
pathways
Tissue factor and Ca2+ are

added to a plasma sample,
coagulation time is measured
12-15 sec
vitamin K, DIC, GIT

malabsorption,
warfarin
Activated Partial
Thromboplastin
Time (aPTT)
Intrinsic &
common
pathways
Contact activation by
phospholipid, Ca2+ added,
25-39 sec
Heparin, haemophilia
Common
pathway
An excess of thrombin is
added to a plasma sample,
12-18 sec
Can occur at any age

Usually a diagnosis can be made clinically; ultrasound can be helpful
Scrotal lump = cancer until proven otherwise
Acute, tender enlargement of testes = torsion until proven otherwise
Aetiology
Pelvic Masses
Lymphadenopathy (tender / non-tender)
Femoral hernia (painful if strangulated)
Psoas abscess (painful)
Skin lumps e.g. epidermal cyst
Testis undescended, maldescended, ectopic
Femoral artery aneurysm
Saphena varix varicosity of the saphenous vein
Scrotal Masses
Testicular torsion (very painful)
Orchitis / epididymo-orchitis (painful) Chlamydia, E. coli, mumps, N. gonorrhoea, TB
Inguinal hernia (painful if strangulated)
Hydrocoele collection of fluid within the two layers of the tunica vaginalis
Varicocoele varicosity of pampiniform plexus (bag of worms with a dull ache) reversible subfertility
Haematocoele blood within the tunica vaginalis
Spermatocoele cyst containing spermatozoa
Testicular tumour
Haematoma
Abnormal Result
Von Willebrand
disease, platelets,
DIC, aspirin
Bleeding Time
Thrombin Time
Normal
Hydrocoele
Testicular tumour
Epididymitis
Spermatocoele
Varicocoele
vitamin K, warfarin
Orchitis
Indirect inguinal hernia
Sudden Collapse
Assessment
History
Duration and onset
Change in size
Pain
Does it reduce (e.g. on lying down)
Any abdominal symptoms
o Torsion of testis may have pain referred to the abdomen
o Intestinal obstruction symptoms are likely with strangulated hernia
Occupation & hobbies
Examination
Tenderness infection, ischaemia testicular torsion, strangulated
hernia, epididymo-orchitis
Hernias
o Femoral hernias are below and lateral to the pubic tubercle
o Cannot feel the upper border of a hernia can you feel above it?
o It is not necessary to distinguish between direct and indirect
inguinal hernias
Is the lump separate from the testis?
Cough impulse hernia or saphena varix
Varicocoeles typically feel like a bag of worms and are more left-sided
Investigations
Ultrasound of scrotum and/or groin
If testicular tumour suspected blood for AFP and -HCG (tumour markers)
Aetiology
Can have syncopal or non-syncopal causes

Syncope (fainting): transient loss of consciousness due to reduced cerebral blood flow
Mechanism
Causes
Syncopal Causes
Vasovagal syncope vagal tone + sympathetic tone
Preceded by presyncope - nausea, pallor, sweating
Stimulated by pain, sight of blood etc.
Structures and
Landmarks
Inguinal ligament
Femoral artery
Pubic tubercle
Testis
Epididymis
Spermatic cord
Neurally
Mediated
PSNS (bradycardia)
& SNS (vasodilation)
Postural (orthostatic) hypotension hypovolaemia, drugs

Carotid sinus hypersensitivity
Situational reflex-mediated syncope
On coughing, exercise, micturition
Autonomic dysfunction
Cardiac
cardiac output
Tachyarhhythmias / Bradyarrythmias
abnormal impulse generation (e.g. sinoatrial arrest)
abnormal conduction (e.g. AV block)
Myocardial ischaemia
Obstructive aortic stenosis, mitral stenosis, HCM
Cerebrovascular
Cerebral ischaemia
Transient ischaemic attack

Subarachnoid haemorrhage
Non-Syncopal Causes
Epilepsy grand mal (LOC) or complex partial (impairment of consciousness) preceded by aura
Hypoglycaemia tremor, hunger and perspiration; rare in non-diabetics
Drop attacks sudden weakness of the legs, especially in older women (no LOC)
Anxiety RR, tremor, sweating, HR, light-headedness, no LOC panic attack
Choking patient may collapse, turn blue and be unable to speak
Assessment
History
1. Before the attack any warning (e.g. epileptic aura, presyncope), circumstances (watching TV)
2. During the attack ask a witness
o Loss of consciousness
o Change in complexion (white/red arrythmia)
o Injury following collapse
o Duration
o Incontinence
o Patient movement floppy or stiff
3. After the attack patients memory, patient confused/sleepy; muscle pain afterwards
(tonic/clonic seizure)
Examination cardiovascular and neurological exams; BP lying & standing
Investigations ECG, FBC, Hb, electrolytes, LFTs, echocardiogram, CT/MRI, PaCO2 (hyperventilation)
Seizure
Cough
Abnormally high frequency discharge of a neurone group motor, sensory & behavioural areas
Unconsciousness if the reticular formation is involved
Aetiology
Epilepsy
Drug withdrawal
Meningitis
Alcohol withdrawal
Head injury
Poisoning
Haemorrhage subarachnoid / cerebral
Hypercapnia
Mass-occupying lesion tumour / abscess
Hypoxia
Stroke
Encephalitis
Poisoning
Psychogenic
Classification of Seizures
I Partial (focal) seizures
A simple partial seizures (consciousness not impaired)
B complex partial seizures (consciousness impaired)
C partial seizures evolving to secondarily generalised seizures
II Generalised seizures of non-focal origin
A absence seizures (petit mal)
B myoclonic seizures / jerks (single / multiple)
C tonic-clonic seizures (grand mal)
D tonic seizures
E atonic seizures
III unclassified epileptic seizures
Diagnosis
History
Ask a friend as well patient may be confused
What drugs has she taken
Medical history epilepsy
Incontinence
Investigations
FBC especially white cells
Blood glucose and electrolytes
ABGs test for acidosis
Liver function test for toxins
CT if no history of epilepsy
Drug screen heroin, alcohol, amphetamines, cocaine
Examination
Mental confusion
GCS
Odour
Neurological signs paresis, facial symmetry, muscle tone, reflexes (Babinski is upgoing after a seizure)
Fundoscopy haemorrhage, oedema
Treatment
Protect the patient
Acute treatment benzodiazepine (PR if seizing)
Anticonvulsants carbemazepine, valproate
Aetiology
Dry Cough
Productive Cough
Infection
Chronic bronchitis
o Upper respiratory tract infection
Bronchiectasis
o Lower respiratory tract infection
Pneumonia
o Tuberculosis
Asthma
o Whooping cough
Foreign body (late response)
Inhaled irritants smoke, dust fumes
Lung abscess
Inhaled foreign body
Tuberculosis (when cavitating)
Bronchial neoplasm
Smoking morning coughs
Interstitial lung disorders
o Fibrosing alveolitis
Most Serious
Most Probable
o Extrinsic allergic alveolitis
LVF
URT infection
o Pneumoconioses
Neoplasm
Postnasal drip
o Sarcoidosis
Severe infection
Smoking
Left ventricular failure
Asthma
Acute bronchitis
GORD; hiatus hernia
CF
Chronic bronchitis
Postnasal drip
Foreign body
Pleural irritation
Pneumothorax
Assessment
History
Cough
Character
o Brassy tracheitis and bronchitis
o Barking laryngeal disorder
o Croupy laryngeal disorders
o Bovine (no power) vocal cord paralysis
o Paroxysmal with whoops whooping cough
o Painful tracheitis, left ventricular failure
Timing
o Nocturnal asthma, LVF, postnasal drip, chronic bronchitis, whooping cough
o Waking bronchiectasis, chronic bronchitis, GORD
Associations
o Changing posture bronchiectasis, lung abscess
o Meals hiatus hernia, oesophageal diverticulum, trachea-oesphageal fistula
o Wheezing asthma
o Breathlessness asthma, LVF, COPD
Sputum
Amount
Character
o Clear white normal / uninfected bronchitis
o Yellow / Green (purulent cellular material) infection, asthma, bronchiectasis
o Rusty lobar pneumonia (blood)
o Thick & sticky asthma
o Profuse, watery alveolar cell carcinoma
o Thin, clear mucoid viral infection
o Redcurrent jelly bronchial carcinoma
o Profuse & offensive bronchiectasis, lung abscess
o Thick plugs allergic bronchopulmonary aspergillosis, bronchial carcinoma
o Pink frothy sputum pulmonary oedema
Haemoptysis acute infection, chronic bronchitis, bronchiectasis, pneumonia, TB, neoplasm, PE, foreign
body, LVF, mitral stenosis, anticoagulant therapy, idiopathic
Other History
Any other symptoms chest pain, fever, shivers, sweats, leg swelling, wheeze
Family history asthma
Smoking history
Occupational history
Including exposure to asbestos
Birds as pets or near home
Inhalation of foreign body
Recent operation or confinement to bed
Examination
General examination + lung & cardiac
Enlarged cervical or axillary lymph nodes bronchial carcinoma, Horners syndrome
Fine crackles oedema of heart failure, interstitial pulmonary fibrosis, early lobar pneumonia
Coarse crackles resolving pneumonia, bronchiectasis, TB
Sputum colour, consistency, particulate matter
Investigations
Haemoglobin, blood film, white cell count
Sputum cytology and colour
ESR - bacterial infection, bronchiectasis, TB, lung abscess, bronchial carcinoma
Respiratory function tests
Radiology CXR, CT, tomography, bronchography, V/Q isotope scan
Skin tests
Lung biopsy
Bronchoscopy
Chest Pain
Causes
Cardiovascular
Myocardial Infarction
Angina Pectoris
Pericarditis
Aortic dissection
Respiratory
Pulmonary embolism
Pneumothorax
Pneumonia
Lung cancer
Functional
Anxiety
Hyperventilation
Chest Wall
Trauma
Fracture
Costochondritis
Gastrointestinal
Oesophageal reflux
Oesophageal spasm
Peptic ulcer
Aerophagy
Gall bladder disease
Most Probable
Musculoskeletal
Psychogenic
Angina
Most Serious
Cardio MI/UA, aortic
dissection, Pulm. embolism
Neoplasia lung, spinal
cord, meninges
Infection pneumonia,
mediastinitis, pericarditis
Pneumothorax
Assessment
History
SOCRATES site, onset, character, radiation, exacerbating/relieving factors, severity
Associated symptoms
o Syncope MI, pulmonary embolism, dissecting aneurysm
o Pain on inspiration pleurisy, pericarditis, pneumothorax, musculoskeletal
o Thoracic back pain spinal dysfunction, MI, angina, aortic dissection, pericarditis, GIT
Cough productive, blood in sputum, colour of sputum etc.
History of trauma
Examination
Pale and sweating AMI, dissecting aneurysm, pulmonary embolism
Blood pressure hypotension (AMI, DA), hypertension (early AMI)
Palpitation chest wall (tenderness), legs (DVT), abdomen (tenderness)
Auscultation
o Reduced breath sounds, hyper-resonant percussion, vocal fremitus pneumothorax
o Friction rub pericarditis / pleurisy
o Basal crackles heart failure
o S3 / S4 AMI
Investigations
ECG to differentiate between MI, pulmonary embolism and pericarditis
Stress ECG to diagnose myocardial ischaemia
Holter monitor silent ischaemia and arrhythmias
X-ray chest or spinal
Full blood count anaemia may be associated
Cardiac markers
Oesophageal endoscopy
Breathlessness
Differentiation of Important Causes

Myocardial Ischaemia
Typically retrosternal
Common sites of radiation neck, inside of arms,
epigastrium, interscapular
1. Stable angina lasts ~3-5 minutes, relieved by

rest and GTN; may be precipitated by arrhythmia
2. Unstable angina pain 15-20 minutes or more;
can be at rest, with effort, post infarction or post
coronary surgery
3. Myocardial infarction pain >15-20 minutes,
typically heavy & crushing, with pallor, sweating or
vomiting
Causes
Sudden (seconds to minutes)
Pneumothorax
Pulmonary embolism
Pulmonary oedema
Aspiration
Anaphylaxis
Anxiety
Chest Trauma
Aortic Dissection
Usually sudden, severe and midline
Tearing sensation retrosternally and between scapulae
Inequality of carotid, radial and femoral pulses
Most Probable
Asthma
Left heart failure
COPD
Obesity
Lack of fitness
Pulmonary Embolism
Usually retrosternal chest pain
May be associated, with syncope and breathlessness
Massive embolus hypotension, right heart failure or cardiac arrest
Pneumothorax
Acute onset of pleuritic pain and dyspnoea
Often in a patient with a history of asthma or emphysema (due to rupture or a subpleural cyst)
Gastrointestinal
Character
Site
Precipitation
Relief
Orthopnoea breathlessness when lying down lfat

Paroxysmal nocturnal dyspnoea breathlessness causing waking from sleep
Tachypnoea fast breathing
Hyperpnoea increased level of ventilation (e.g. during exertion)
Hyperventilation overbreathing
Acid reflux
Oesophageal spasm
Peptic Ulcer
Gallbladder disease
Burning
Constricting
Gnawing
Deep ache
Epigastric
Retrosternal
Retrosternal
Right hypochondrium
Heavy meals
Food and drink
Eating
Fatty food
Standing
Antacids
Antispasmodics
GTN
Antacids
Psychogenic
Can occur anywhere in the chest, but often in the left submammary region, usually without radiation
Continuous and sharp / stabbing
May mimic angina but tends to last for hours or days
Usually aggravated by tiredness or emotional tension
May be associated with shortness of breath, fatigue and palpitations
Acute (hours to days)

Asthma
Respiratory infection
Lung tumour
Pleural effusion
Metabolic acidosis
Chronic (months to years)

COPD
Cardiac failure
Anaemia
Arrhythmia
Valvular heart disease
Chest wall deformities
Cystic fibrosis
Pulmonary hypertension
Most Serious
Cardio AMI, arrhythmia, pulmonary
embolism, DA, cardiomyopathy, anaphylaxis
Neoplasia bronchial carcinoma
Infection SARS, avian flu, pneumonia
Respiratory foreign body, obstruction,
pneumothorax, pleural effusion, tuberculosis
Assessment
History
Identify what the patient means by breathlessness
Onset; provoking factors
Associated symptoms - wheeze (asthma, COPD), cough (pulmonary causes)
Examination
Inspection cyanosis, clubbing, alertness, dyspnoea at rest, use of accessory muscles, rib retraction
Tremor of outstretched hands CO poisoning
Tracheal displacement - bronchial collapse (toward affected side), pleural effusion, pneumothorax (away)
Chest expansion
Percussion
Breath sounds - vesicular / bronchial
Vocal fremitus
Crackles LVF, alveolitis, pneumonia, bronchiectasis, chronic bronchitis, asbestosis, pulmonary fibrosis
Wheeze partial obstruction, asthma, bronchitis, bronchiolitis
Investigations
Pulmonary function tests PEF, FEV1, FVC
Blood count
Arterial blood gases
Pulse oximetry
Cardio tests ECG, echo, cardiac markers

Imaging MRI, CT, V/Q scan
Bronchoscopy
Lung biopsy
Hoarseness
Abdominal Pain
Aetiology
Aetiology
Laryngitis
o Assorted viruses parainfluenza, coronavirus, influenza, rhinovirus, adenovirus
o Excessive abuse of voice
o Bacteria Moraxella catarrhalis, haemophilis influenzae
o Irritants cigarette smoke, alcohol, caustic chemicals (e.g. HCl in GORD)
Benign laryngeal growths papillomas, cysts, polyps, chondromas, lipomas, nodules
Laryngeal cancer
Compression of larynx e.g. oesophageal cancer
Thyroid disease thyroiditis, goitre
Vocal cord pathology

o Trauma blunt, penetrating, iatrogenic (intubation / surgery)
o Stenosis / calcification
Nerve pathology
o Left recurrent laryngeal nerve palsy
o Left recurrent laryngeal nerve compression apical lung cancer, oesophageal cancer
o Motor neurone disease
Foreign body
History
Nature and duration of hoarseness

History of excessive voice straining
Respiratory symptoms
Symptoms of hypothyroidism - depressed,
slow, tired, thin hair, croaky voice, heavy
periods, constipation, dry skin, prefers warm
weather
Medications corticosteroid inhalations
Recent surgery
Smoking
Exposure to environmental pollutants
Examination
Neck palpation enlargement of thyroid or

cervical nodes
Oropharyngeal examination epiglottis
Signs of hypothyroidism coarse dry hair and
skin, slow pulse, mental slowing
Investigations
Thyroid function tests

Chest x-ray (if lung carcinoma is suspected)
Indirect/direct laryngoscopy
CT if suspected neoplasia/laryngeal tumour
Management
Diagnose and treat the cause

Vocal rest and minimal usage
Avoid irritants e.g. dust, cigarettes, alcohol
Cough consider cough suppressants
Consider referral to an ENT specialist if
o Acute - unexplained, fail to respond (3-4 weeks) or recur
o Chronic (all cases)
o Presenting with strider or non-tender lymphadenopathy
o Sever vocal abuse (voice therapy is needed)
Inflammation
Inflammatory bowel disease
Appendicitis
Cholecystitis
Pancreatitis
Salpingitis
Diverticulitis
Perforation
Duodenal ulcer
Gastric ulcer
Faecal peritonitis
Biliary peritonitis
Appendicitis
Obstruction
Biliary colic
Acute small / large bowel obstruction
Ureteric colic
Acute urinary retention
Intestinal infarction
Most Probable - Acute

Gastroenteritis
Appendicitis
Dysmenorrhoea
Irritable bowel syndrome
Most Serious - Acute
Cardio MI, AAA rupture, aortic
aneurysm, mesenteric artery occlusion
Neoplasia (bowel obstruction)
Infection salpingitis, peritonitis,
cholangitis, abscess
Ectopic pregnancy
Obstruction
Sigmoid volvulus
Perforation duodenal ulcer, colonic /
Meckels diverticulum, colonic cancer
Haemorrhage
Ruptured ectopic pregnancy
Ruptured spleen / liver
Ruptured ovarian cyst
Ruptured AAA
Torsion (Ischaemia)
Sigmoid volvulus
Torsion ovarian cyst
Torsion of testes
Most Probable - Chronic

Dysmenorrhoea
Peptic ulcer / gastritis
Most Serious - Chronic
Cardio mesenteric artery
ischaemia, AAA
Neoplasia bowel, stomach,
pancreas, ovaries
Infection hepatitis, PID
Common Causes in Children
Infantile colic (2 weeks 16 weeks) regular, unexplained, inconsolable crying, usually in the afternoon
Intussusception (3 months 2 years) severe colicky abdominal pain; very serious condition
Acute appendicitis (school age / adolescence) usually occurs with vomiting (80%) or diarrhoea (20%)
Mesenteric adenitis similar Hx to appendicitis, except with high fever and preceding URTI / tonsillitis
Child abuse
Testicular Torsion
Recurrent abdominal pain three distinct episodes of abdominal pain over 3+ months occurs in 10%
of school-aged children; only 5-10% have an organic cause
Assessment
History
SOCRATES
o Constant / coming and going
o Severity (1-10)
o Contributing / relieving factors
o Response to milk, food, antacids
Previous attacks with similar pain
Associated symptoms sweats, chills,
burning urination
Bowel motions constipation, diarrhoea,
blood
Urine
Medications aspirin
Smoking, alcohol, drugs
Recent travel
Menstrual history
Past medical history e.g. appendectomy
Pain Patterns
Examination
General appearance
Oral cavity
Vital signs
Heart & lungs
Abdomen inspection, palpation, percussion,
auscultation
Inguinal region hernias
DRE
Vaginal examination for suspected
problem with fallopian tubes, uterus, ovaries
Thoracolumnar spine referred spinal pain
Urine analysis WBC, RBC, glucose, ketones,
porphyrins
Investigations
Haemoglobin - anaemia due to chronic
blood loss (peptic ulcer, carcinoma, oesophagitis
Blood film e.g. sickle cell anaemia
WCC leukocytosis appendicitis, pancreatitis,
mesenteric adenitis, cholecystitis, pyelonephritis
ESR - carcinoma, Crohns, abscess
CRP - $infection, inflammation
LFTs hepatobiliary disease
Serum
Abdominal X-ray see features
ECG
Upper GIT endoscopy
Sigmoidoscopy / colonoscopy
Acute Pain
Chronic Pain
Red Flag Features

Symptoms
Collapsing at toilet intra-abdominal bleeding
Lightheadedness
Progressive intractable vomiting
Progressive abdominal distension
Progressive intensity of pain
Prostration (appearance of praying)
Timing
Colicky pain: rhythmic pain with regular spasms
of recurring pain building to climax then fading
Usually indicative of intestinal obstruction
Signs
Pallor & sweating

Hypotension
Atrial fibrillation / tachycardia
Fever
Rebound tenderness & guarding
Decreased urine output
Constipation
Diarrhoea
Aetiology
Dietary/exercise causes
Dehydration
Faecal impaction
Intestinal obstruction
Volvulus
Depression
Anorexia nervosa
History
Ask patient what they mean by constipation

Diet
Medications
Lumps in the perianal area
Acute appendicitis
Spinal cord compression
Hypokalaemia
Hypercalcaemia
Examination
Digital rectal examiniation always

Abdominal examination
A relative increase in stool volume, frequency and/or fluidity (compared to normal)

Technically stool weight >200g / day (difficult to assess)
Consider: frequency, volume, consistency, content, colour, smell
Consequences dehydration, electrolyte loss, cardiovascular collapse, chronic malnutrition
Classification
By Time Course
Acute (<2 weeks)

o Usually caused by infection (viral, bacterial)
o Self-limiting - doesnt damage gut mucosa
Persistent (2-4 weeks)
Chronic (> 4 weeks)

o Many causes (chronic infection, hormones, enzyme dysfunction, osmosis)
o Usually watery, fatty or inflammatory
o Generally causes damage to gut mucosa
Investigations
Bowel Motions
What are they normally like?
Frequency
Consistency - bulky, hard, soft
Pain on opening bowels
Blood
Soiling in underwear (?incontinence)
Endoscopy
Stool occult blood biochemistry, culture
Radiological studies e.g. barium enema
Physiological tests
o Anal manometry testing anal tone
o Rectal sensation and compliance
Management
Advice
Adequate exercise
Plenty of fluids water, prune juice
Optimal bulk diet fruits, vegetables, cereals
Defecate as soon as possible when the need strikes
Avoid laxatives and codeine compounds
Medication
1. First line bulking agent e.g. psyllium
2. Second line osmotic laxative or fibre-based stimulant preparation (e.g. sorbitol)
3. Third line magnesium sulphate
By Location
Small Intestinal large volume; usually malabsorptive or secretory
Colonic smaller volume but frequent; usually exudative, loss of electrolytes, osmotic, nervous.
Pathogenesis
(DOMES)
Mechanism
Examples
Deranged
Motility
Dysfunction of neuromuscular control

Decreased transit time ( absorption)
Hyperthyroidism, IBS,
diabetic neuropathy
Osmotic
Osmotic pressure generated by non-absorbed

molecules draws water into lumen
Lactose intolerance, laxatives
Correlates with ingestion of food (slows with fasting)
Malabsorptive
Impaired absorption
Often fat absorption (steatorrhoea)
Slows with fasting
Physical blanketing (Giardia),

reduced surface are (coeliac
disease), mal-digestion
(pancreatic insufficiency)
Exudative
Inflammation & destruction of mucosa

Small volume, high frequency
Blood/pus/mucus in stools
Persists with fasting
Inflammatory bowel disease,

Infection (shigella/
entamoeba)
Secretory
Secretion > absorption

Large volume stools, no blood/pus/mucus
Persists with fasting
Enterotoxin-mediated
(cholera), hormonal, villous
adenoma
Aetiology
Infection bacterial, viral, parasitic
Bowel inflammation inflammatory bowel disease, appendicitis, diverticulitis, ischaemic colitis
Colorectal cancer
Drugs alcohol, antibiotics, antihypertensives, cytotoxic agents, heavy metals, H2 receptor antagonists,
iron-containing compounds, laxatives, metformin, NSAIDs, quinidine, salicylates, statins, theophylline
Malabsorption coeliac disease, lactase deficiency, tropical sprue, pancreatic insufficiency
Jaundice
Yellowish colouration of the body due to build-up of bilirubin (hyperbilirubinaemia), also known as icterus
A symptom, not a disease
Clinically noticeable (in the skin/sclera of the eyes) at plasma [bilirubin] > 50mol/L
Increased bilirubin can be from disturbance in heme catabolism or in conjugation/excretion of bilirubin
Aetiology
heme oxygenase
Macrophages
reductase
Hemoglobin
Endocrine hyperthyroidism, diabetic neuropathy
Psychogenic irritable bowel syndrome
Diagnosis
Frequency
Associated symptoms abdominal pain, fever, nausea, vomiting
Food intake in the past 72 hours chicken (Salmonella, Campylobacter), seafood (Vibrio)
Recent travel abroad
Medications antibiotics
Normal diet (if chronic) milk, alcohol, vitamin C supplementation, wheat
Examination
GIT examination especially for masses, hepatomegaly, splenomegaly, tenderness, skin changes, iritis
Stool examination - blood, mucus, steatorrhoea
Investigations
Stool microscopy, culture and sensitivity
Blood tests FBC, iron studies, folate, B12, calcium, electrolytes, thyroid function tests, HIV tests
Antibodies e.g. transglutenaminade for coeliac disease
Malabsorption studies
Endoscopy proctosigmoidoscopy, flexible sigmoidoscopy + biopsy, small bowel biopsy (coeliac)
Radiology barium enema
Unconjugated Bilirubin
pre-hepatic
Jaundice
Globin (protein)
Plasma
disturbance causes
unconjugated
hyperbilirubinaemia
(bound to albumin)
Liver
1. Uptake
History
Nature
o Amount small volume (inflammation, cancer), large volume (laxative abuse, malabsorption)
o Consistency liquid (gastroenteritis), bulky/pale (malabsorption) etc.
o Blood present (more likely to be bacterial), profuse (diverticulitis, cancer)
o Mucus inflammatory bowel disease
Biliverdin biliverdin
Heme
+ 2 glucuronic acid
UDP-glucuronyl
hepatic
Jaundice
transferase
2. Conjugation
Conjugated Bilirubin
3. Excretion
Bile.
post-hepatic
Jaundice
Duodenum
disturbance causes
conjugated
hyperbilirubinaemia
Urobilinogen
through plasma
Colon
(80-90%) Urobilinogen
Stercobilinogen
Stercobilin
(colours stools)
Kidney
Urobilinogen (10-20%)
Urobilin
(colours urine)
If there is blockage of the flow of bile

(conjugated bilirubin) then these result:
Pale stools - bile in the duodenum

stercobilin (stool pigment) excretion
Dark Urine - conjugated bilirubin

backflows into liver and is taken up by
the kidney$urobilin (urine pigment)
Upper Gastrointestinal Bleeding
Pre-Hepatic Jaundice
Excessive bilirubin production from Haemolysis, glomerular nephritis etc.
unconjugated bilirubin in blood
urobilinogen in urine & stools
Normal urine and stool colour
Hepatic Jaundice
Impaired liver function or hepatocellular damage from hepatitis, toxins, cirrhosis
Three processes that can be affected
Aetiology
1. Uptake
+ unconjugated bilirubin in blood
+ Normal urine colour, pale stools
2. Conjugation
+ unconjugated bilirubin in blood
+ Normal urine colour, pale stools
3. Excretion (hepatic cholestasis)

+ $conjugated bilirubin in blood
+ Dark urine & pale stools
Post-Hepatic Jaundice
Blockage of outflow from liver from gallstones, head of pancreas cancer
unconjugated bilirubin in blood
Dark urine & pale stools
Hepatic
Bilirubin in
Plasma
Urine
Stool
AST/ALT
ALP
Urine
Bilirubin
Urine
Urobilinogen
Unconjugated
Normal
Normal
Normal
Normal
Absent
Uptake
Unconjugated
Normal
Pale
Conjugation
Unconjugated
Normal
Pale
Conjugated
Dark
Pale
Conjugated
dark
pale
Excretion
Post-Hepatic
!
!
!
Gastritis
Ulcer gastric, duodenal, stomal (can be caused by NSAIDs, alcohol)
GORD
Oesophageal varices due to portal hypertension (usually due to cirrhosis)
Mallory-Weiss syndrome
o Tears at lower end of oesophageal mucosa due to an episode of severe vomiting / coughing
o Blood in vomitus after a bout of heavy vomiting / dry retching
o Usually seen in alcoholic patients
Carcinoma - gastric / oesophageal
Anticoagulant therapy
Vascular malformations
Hereditary haemorrhagic telangiectasia
Assessment
Differential Diagnosis
Pre-Hepatic
Haematemesis: vomiting of blood (fresh blood or coffee ground)

Melaena: black tarry stools with distinctive odour
Severe upper GI haemorrhage is life-threatening (melaena is less life-threatening than haematemesis)
Normal
Normal
Absent
History
Amount and appearance of vomit - black dots like coffee grounds?
Indigestion, heartburn, stomach pain
Appearance of stools
Medications especially aspirin and NSAIDs; also prednisolone, warfain, clopidogrel, SSRIs
Alcohol history
Previous operations on stomach especially for peptic ulcer
History of normal vomiting before blood in vomit
Examination
General state haemodynamic status (heart rate, blood pressure, postural change)
Abdominal examination including DRE looking for a mass, hepatomegaly or splenomegaly
Investigations
Upper GIT endoscopy detects cause in >80% of cases
Haemoglobin - <90 g/L transfusion
Management
1. Restore effective blood volume
o Two large-bore IV lines infusion of colloid
o Plasma expander
o NG tube to evacuate blood from the stomach and reduce vomiting
o Intubation to protect the airway and prevent aspiration of gastric contents
2. Diagnose and treat the cause
o Endoscopy to identify site, assess bleeding and give treatment
o Treatments adrenaline, sclerotherapy, variceal banding
Anorectal Symptoms
Include:
Bleeding
Pain
Lumps
Discharge
Pruritis
Anorectal Pain
Pain Without Swelling
Anal fissure
Anal herpes
Ulcerative proctitis
Solitary rectal ulcer
Pain With Swelling

Perianal haematoma
Strangulated internal haemorrhoids
Abscess perianal / ischiorectal
Pilonidal sinus
Anorectal Lumps
Prolapsing Lumps
2nd / 3rd degree haemorrhoids
Rectal prolapse
Rectal polyp
Hypertrophied anal papilla
Persistent Lumps
Skin tag
Perianal warts
Anal carcinoma
4th degree haemorrhoids
Perianal haematoma
Perianal abscess
Anal Discharge
Rectal Bleeding
Bright red blood in toilet separate from faeces internal haemorrhoids
Bright red blood on toilet paper internal haemorrhoids, fissure, anal carcinoma, pruritis, anal warts
Blood on underwear
o Mucus - 3rd/4th degree haemorrhoids, prolapsed rectum, mucosal prolapse
o No mucus ulcerated perianal haematoma
Blood in faeces
o Mucus colorectal carcinoma, proctitis, colitis, mucosal polyp, ischaemic colitits
o No mucus small colorectal polyp, small colorectal carcinoma
o With mentstruation (rare) rectal endometriosis
Melaena GIT bleeding (usually upper) with long transit time to anus
Torrential haemorrhage (rare) diverticular disorder, angiodysplasia
History
Nature of the blood bright red, dark red, black
Nature of the bleeding smear, streaked on stool, mixed with stool, massive
Smell (melaena)
Frequency of blood
o High frequency rectal tumour / proctitis
o Lower frequency proximal tumours, extensive colitis
Associated symptoms pain, diarrhoea, constipation, lumps, urgency, tenesmus, change in bowel habit
Examination
General inspection
Anal inspection
DRE
Proctosigmoidoscopy
Continent
Anal fistula
Pilonidal sinus
STIs anal warts, gonococcal ulcers, herpes
Solitary rectal ulcer
Carcinoma of anal margin
Incontinent
Minor weakness of internal sphincter
Major weakness of levator ani & puborectalis
Partially Continent
Faecal impaction
Rectal prolapse
Pruritis Ani
Aetiology
Psychological stress, anxiety, fear of cancer
Systemic / skin disorders eczema, DM, candidiasis, psoriasis, antibiotic treatment, pinworm /
threadworm, excoriation (due to diarrhoea)
Localised anorectal conditions piles, fissures, warts
Excessive hygiene
Contact dermatitis dyed / perfumed toilet paper, soap, powder, clothing
Excessive sweating
Diagnosis
Urinalyisis for diabetes
Anorectal examination
Scrapings & microscopy to detect organisms
Stool examination for parasites
Treatment
Stop scratching
Avoid hot water when bathing
Keep the area as dry and cool as possible
Keep bowel motions regular
Clean gently after bowel motions
No perfumed soaps or powders
Loose clothing & underwear
Tenesmus
Unpleasant feeling of incomplete emptying of the rectum mostly caused by irritable bowel syndrome
Also caused by rectal / anal mass carcinoma, haemorrhoids, hard faecal mass
Dysuria
Haematuria
Difficult and/or painful micturition

Due to passage of urine across inflamed mucosa of lower genitourinary tract (urethra, bladder, prostate)
Dysuria and frequency commonly coexist
Sometimes accompanied by haematuria and systemic symptoms
Presence of blood in the urine

Macroscopic haematuria - bladder, urethra, prostate, kidney
Microscopic urine - >2,000 RBCs / mL urine using light microscopy

o Glomerular (from kidney parenchyma) or non-glomerular (urinary tract)
o Athletes can develop transient microscopic haematuria following vigorous exercise
Often a sign of a serious underlying disorder
Aetiology
Infection cystitis, urethritis, vaginitis, prostatitis, urethral

syndrome (males), gonorrhea, genital herpes
Neoplasia bladder, prostate, urethra
Calculi e.g. in the bladder
Foreign body in lower urinary tract
Acidic urine
Vaginal prolapse
Obstruction BPH, urethral stricture, phimosis, meatal stenosis
Most Likely
Cystitis (females)
Urethritis
Vaginitis
Most Serious
Neoplasia
Severe infection
Reiters Syndrome
Calculi
Aetiology
Assessment
History
Description of discomfort
o Timing
i. Pain at onset of micturition urethritis
ii. Pain at end of micturition cystitis
o Location - suprapubic cystitis
Colour of urine
Discharge could it be sexually acquired
Painful intercourse (women)
Systemic features fever, sweats, chills
Examination
Vitals HR, temp, BP
Abdominal palpitation loins & suprapubic area
Vaginal, rectal, genital examination may be appropriate
Investigations
Urine dipstick
Urine microscopy & culture (midstream)
Contamination of urine specimen

Infection bladder, kidneys, urethra, epididymis, testes
Coagulopathy
Vascular endothelial injury
Necrosis
Autoimmune / inflammatory nephritic / nephrotic syndrome
Neoplasia prostate, kidney, bladder, external genitalia
Benign prostatic hyperplasia
Trauma
o Blunt abdominal trauma
o Penetrative trauma
o Iatrogenic - surgery, catheterization, self-inflicted
o Kidney stones
Fistula labour complications, Crohns disease
Non-Blood Causes of Dark Red Urine

Dietary colour beetroot, berocca, berries, confectionary
Drugs rifampicin, phenolphthalein
Porphyria
Breakdown products bilirubin, myoglobin, free haemoglobin
Most Likely
Infection cystitis,
urethritis, prostatitis
Calculi kidney, ureter,
bladder
Most Serious
Cardiovascular kidney
infarction, kidney vein
thrombosis, prostatic
varices
Neoplasia kidney,
urothelium, prostate
Severe infection IE,
kidney tuberculosis,
acute glomerulonephritis
IgA nephropathy
Kidney papillary necrosis
History
Is it really haematuria could be haemolysis / red food dye / breakdown products
Trauma to loin, pelvis, genital area
Timing
o First part of stream urethral / prostatic lesion
o Terminal bladder
Associated symptoms
o Pain infection, calculi, kidney infarction
o Painless infection, trauma, tumours, polycystic kidneys
o Frequency
o Bleeding elsewhere skin, nosebleeds
Possibility of the condition being sexually acquired
History of kidney problems
History of diabetes
Examination
Proteinuria
Can originate from the glomeruli, tubules or lower urinary tract

Healthy people excrete some protein in the urine, which can vary from day-day or hour-hour
Microalbuminuria
Macroalbuminuria
Albumin /
creatinine ratio
F: 3.6-35 mg/mmol
M: 2.6-25 mg/mmol
F: >35 mg/mmol
M: >25 mg/mmol
Dipstick
>3mg/dL (albumin)
>20mg/dL
Protein /
creatinine ratio
Proteinuria
1+ or more
>0.3 g/24 hours
Aetiology
Transient - benign
o Contamination from vaginal secretions
o Urinary tract infection
o Pre-eclampsia
Kidney disease
o Glomerulonephritis
o Nephrotic syndrome
o Congenital tubular disease polycystic kidney, kidney dysplasia
o Acute tubular damage
o Kidney papillary necrosis
o Overflow proteinuria
o Systemic diseases DM, HTN, SLE, malignancy, drugs
Non-kidney disease
o Orthostatic proteinuria
o Exercise
o Fever
o Post-operative
o Heart failure
Investigations
Urine dipstick
Urine microscopy
o Formed RBCs true haematuria
o Red cell casts glomerular bleeding
o Dysmorphic RBCs glomerular bleeding
Urine culture
Urine cytology to detect malignancies of the bladder / lower UT (not kidney)
Blood tests FBC, ESR, urea, creatinine
Radiology
o IV urography (UVI)
o Ultrasound better for kidneys than lower UT
o CT
o Kidney angiography
o Retrograde pyelography
Direct imaging urethroscopy, cystoscopy
Kidney biopsy indicated if glomerular disease is suspected
Orthostatic Proteinuria
Significant proteinuria after the patient has been standing but absent after sitting for several hours
Occurs in 5-10% of people, especially during adolescent years
Diabetic Microalbuminuria
Presence of small amounts of protein in urine is a sensitive marker of diabetic nephropathy

Dipstick is helpful, radioimmunoassay is better
Consequences of Proteinuria
>3g / 24 hours
Oedema
Intravascular volume depletion
Venous thromboembolism
Hyperlipidaemia
Malnutrition
Urinary Incontinence
Urinary incontinence: involuntary urine loss during the day / night

Nocturnal enuresis (bed-wetting): involuntary urine loss during sleep
Urge incontinence: urgent desire to void followed by involuntary urine loss
Overactive bladder (detrusor instability): involuntary bladder contractions sudden urge to urinate
Stress incontinence: involuntary urine loss on coughing, sneezing, straining, lifting
Voiding dysfunction: urinary difficulties, detrusor instability, overflow incontinence
Function incontinence: loss of urine secondary to factors outside of the urinary tract
Aetiology
DIAPPEERSS
Delerium
Infection of urinary tract
Atrophic urethritis
Pharmacological e.g. diuretics
Psychological acute distress
Endocrine e.g. hypercalcaemia
Environmental e.g. unfamiliar sounds
Restricted mobility
Stool impaction
Sphincter damage / weakness
Management
Exclude UTI & drug causes
Stress Incontinence
Weak pelvic floor exercises
Obesity weight reduction
Menopause HRT / vaginal oestrogen creams
Chronic cough physiotherapy
Urge Incontinence
Neurological signs neurologist
Abnormal voiding pattern bladder retraining
Voiding dysfunction
Neurological signs neurologist
Gynaecological cause gynaecologist
Bladder atony anticholinergics
Lower Back Pain
The most common cause of back pain in people <45 years, and the 3rd most common in those >45 years
60-80% of people will experience lower back pain in their lives
Grading:
o Acute: <4 weeks
o Subacute: 4-12 weeks
o Chronic: >12 weeks
Predisposition to lower back pain is mostly inherited
Work has been shown to contribute up to 25% of variance in lower back pain
Causes
1. IV discs
o Degeneration
o Herniation
Mechanical Bones, discs, SC, nerves

Non-mechanical inflammatory, infective,
neoplastic
Non-spinal viscerogenic, psychogenic
2. Vertebrae
o Spondylolisthesis (forward displacement of a vertebral body onto another)
o Scheuermanns kyphosis (adolescents vertebral wedging, schmorls nodes, disc degeneration)
o Fractures (may be from osteoporosis)
o Spinal stenosis
o Infection
o Tumours
o Osteomalacia
o Pagets disease
3. Spinal Cord
a. Epidural abcess
b. Intradural tumours
4. Joints
o Apophyseal osteoarthritis (facet joints)
o Rheumatoid arthritis
o Ankylosing spondylitis (chronic inflammation of spinal and sacroilial joints that leads to joint
fusion)
o Chondrocalcinosis (accumulation of calcium pyrophosphate dehydrate crystals in CT)
5. Misalignments postural, differences in leg length, misaligned pelvis, abnormal foot pronation
6. Referred Pain from pelvic or abdominal organs
7. Psychogenic/Neurogenic stress, depression
Risk Factors
Family history
Heavy manual work
Sedentary lifestyle
Obesity, tallness
Low socioeconomic status
Stress
Red Flags
Age >50 years

History of cancer
Unexplained weight loss
Unexplained fever
Steroid or IV drug use
Severe, unremitting pain at night
Significant trauma
No improvement over 1 month
Clinical Features
Treatment
Nature of Pain
Nature of Pain
Aching throbbing pain
Deep diffuse aching pain
Superficial steady diffuse pain
Boring deep pain
Intense sharp or stabbing pain
Likely Cause
Inflammation
Referred pain
Local pain
Bone disease
Radicular pain
Examples
Sacroileitis
Dysmenorrhoea
Muscular strain
Neoplasia, Pagets disease
Sciatica
Inflammatory vs. Mechanical Causes

History
Inflammation
Insidious onset
Nature
Aching, throbbing
Stiffness
Effect of rest
Effect of activity
Radiation
Intensity
Severe, prolonged morning stiffness

Exacerbates
Relieves
More localised, bilateral or alternating
Night, early morning
Major Conditions to Exclude

Can cause major morbidity or mortality
Fractures (4%)
Tumours (1%)
Infections (<1%)
Rheumatoid and other related conditions (0.1%)
Mechanical
Precipitating injury/previous episodes
Deep dull ache /
Sharp (root compression)
Moderate, transient
Relieves
Exacerbates
Tends to be diffuse, unilateral
End of day, following activity
Conditions that Masquerade as Back Pain
Depression
Diabetes
Drugs
Anaemia
Thyroid disease
Urinary tract infection
Diagnosis
Once tumours, fractures, infection, disc herniation and rheumatological conditions have been excluded,
there is no certainty about diagnosis
Spinal/Neurological Examination
Palpation checking for tenderness
Movement
o Range of movement
o Symmetry
o Power (MRC grading)
Tendon Reflexes
Special tests
o Walking on heels (L4/L5)
o Walking on toes (S1)
o Squatting (quadriceps power, femoral
nerve, L3/L4)
Imaging
Decision to perform imaging is made taking into account
findings of examination and presence of red flags
CT
MRI
Myelogram injection of contrast medium into
lumbar spine, followed by x-rays (useful when
MRI is contraindicated)
Most conditions are self-limiting and will recover with little to no treatment
1. Management: mostly conservative involving

o Heat/cold
o Physical therapy
o Avoidance of heavy manual labour
2. Mobilisation vs. bed rest: for acute cases, the priority is early mobilisation
o A brief period of rest may be necessary (<3 days)
o Prolonged immobilisation can lead to bone weakness, muscle atrophy etc.
3. Analgesics: NSAIDs can provide some pain relief
4. Surgery: patients with cauda equina syndrome or spinal abcess may require surgery
Leg Pain
Knee Pain
Aetiology
Musculoskeletal
o Cramps
o Strain
o Osteoarthritis
o Overuse injury Osgood-Schlatter
o Ruptured bakers cyst
o Pagets disease
Peripheral neural
o Nerve root pain prolapsed disc
o Sciatica (pain in sciatic nerve
distribution)
o Nerve entrapment
o Spinal canal stenosis
Vascular
o Arterial occlusion claudication,
rest pain
o Thrombosis DVT
o Varicose veins
Common presenting symptoms of the knee pain, stiffness, swelling, clicking and locking
Neoplasia
o Primary myeloma
o Secondary metastasis
Infection
o Osteomyelitis
o Septic arthritis
o Lymphangitis
o Gas gangrene
o Herpes zoster
Ligamentous conditions
o Strains & strains
o Cruciate ligament tear
Menisceal tears
Referred pain
o Spondylogenic (vertebral joints, IV discs,
ligaments, muscle attachements)
o Sacroiliac dysfunction
Arthritis
o Osteoarthritis
o Rheumatoid arthritis
o Juvenile chronic arthritis
Ruptured popliteal cyst
Osgood-Schlatter disorder
Foreign bodies
Fractures
Patellofemoral syndrome
Bursitis prepatellar / patellar
Crystals gout / pseudogout
Vascular disorders DVT, superficial

thrombophlebitis
Neoplasia primary bone, metastases
Infection septic arthritis, tuberculosis
Referred pain
o Hip joint mainly innervated by L3 pain radiates from the groin to the frontal & medial thigh
o Lumbosacral spine worse on sitting, coughing or straining; but not walking
o L3 nerve root pressure from L2-3 prolapse
Psychogenic imaginary or exaggerated pain
Most Probable
Cramps
Sciatica
Muscular injury
Osteoarthritis
Overuse injury
Most Serious
Vascular
Neoplasia
Infection
Assessment
History
Site and whether the site of pain is the same as the site of trauma
Acute / chronic (acute + no Hx of trauma vascular)
Mechanical / postural / related to walking
Arising from joint or bone
Examination
Gait & stance especially antalgic gait, symmetry
Swelling, bruising, rashes
Trophic changes colour, hair distribution, wasting, temperature, dryness, ulceration
Palpate for pain ischial tuberosity, trochanteric area, hamstrings, tendon insertions, superficial LN
Palpation of lower limb pulses
Neurological examination for nerve root lesions and entrapment neuropathies
Joint examination
Investigations
FBC + ESR
Radiology X-ray of leg, X-ray/CT/MRI of lumbosacral spine, bone scan
Vascular arteriography, duplex ultrasound, contrast venography, D-dimer
Aetiology
Most Serious
Cruciate ligament tear
Vascular disorders
Neoplasia
Infection
Rheumatoid arthritis
Most Probable
Ligament strains & sprains
Osteoarthritis
Patellofemoral syndrome
Prepatellar bursitis
Assessment
History
Related to injury
Mechanism of injury
Twisting of leg or popping sound
Swelling haemarthrosis (torn ligaments,
synovium, fractured bones)
Feeling of bones separating
Onset of pain / swelling after injury
Ability to walk afterwards
Previous knee injury / surgery
General Features
Locking torn meniscus, loose body, torn ACL,
dislocated patella, gross effusion
No history of injury
Onset with walking, jogging, other activity
Kneeling scrubbing floors, cleaning carpets
Locking or catching of the knee
Variation through the day
Catching osteochondritis dessicans,

dislodged osteophyte, osteochondral fracture
Clicking patellofemoral subluxation, loose

intra-articular body, torn meniscus
Anterior pain patellofemoral syndrome,

osteoarthritis, patellar tendonopathy,
osteonecrosis
Lateral pain osteoarthritis, lateral meniscus

lesion, patellofemoral syndrome
Medial pain osteoarthritis, medial meniscus

lesion, patellofemoral syndrome
Physical Examination
Look while the patient is walking, standing, lying supine

o Deformities genu valgum (knock-knee), genu varum (bow legs), genu recurvatum (back knee)
o Swelling
o Muscle wasting
Feel patella, patellar tendon, joint lines, tibial tubercle, bursae, popliteal fossa
o Fluid, warmth, swelling, synovial thickening, crepitus, clicking, tenderness
o Popliteal cyst
o Bulge sign (fluid effusion) compress the medial side of the joint
Move extension (0-5), flexion (135), rotation (5-10)
Special tests
o Collateral ligaments varus & valgus stresses
o Cruciate ligaments anterior draw test
o Menisci McMurrays test, Apley grind test
o Patella patellar apprehension test
Investigations
Blood tests rheumatoid factor, ESR, blood culture
Radiology plain x-ray, bone scan, MRI, arthrography, ultrasoung
Special examination under anaesthesia, arthroscopy, knee aspiration
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CLINICAL!COMMUNICATION!
SKILLS!
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MEDI2021 & MEDI2022 Clinical Communication Skills Program 2015

Module
Semester
Topic
Lecture Series
Learning Activity
4a
Breaking Bad News
Communicating in Difficult
Circumstances
1 x 2hr tutorial in groups of 12
4b
Communicating in a Palliative Care Setting
Palliative Care
Summative Assessment: Breaking Bad News

DVD Recording and review
1 x 1.5 hr tutorial in groups of 6
History Taking in a Mental Health Setting
2 x 2hr tutorials in groups of 24
Facilitating Behavioural Change/Motivational Motivational Interviewing

Interviewing
Facilitating Behavioural Change
(VOPP)
3 x 2hr tutorials in groups of 24
Sexual History Taking
Taking a Sexual History

INFORMATION SHEET 4b
COMMUNICATION WITH A PALLIATIVE CARE PATIENT
fears of the medical hierarchy. (e.g., the young intern not wanting to upset the consultant by
asking the patient the wrong thing)
(B) DEFINITIONS AND STANDARDS OF PALLIATIVE CARE

Palliative care has been defined by the World Health Organisation (WHO) as:
Effective symptom control is impossible without effective communication.
The social denial of death
an approach that improves the quality of life of individuals and their families facing the problems
associated with life-threatening illness, through the prevention and relief of suffering by means of
early identification and impeccable assessment and treatment of pain and other problems, physical,
psychosocial and spiritual.
Lack of experience of death in the family, high expectations of health and life, high value placed on
material possessions and the changing role of religion all contribute to a process where dying is
perceived as alien and fearsome.
The WHO further states that palliative care:
Patients fears of dying
provides relief from pain and other distressing symptoms
Every person dying has a unique combination of fears and concerns in facing the prospect of dying.
Some commonly expressed fears are about:
affirms life and regards dying as a normal process
intends neither to hasten nor postpone death
Physical illness (e.g., symptoms, disability, disfigurement)
integrates the psychological and spiritual aspects of care
Psychological effects (e.g., not coping, dementia)
offers a support system to help patients live as actively as possible until death
Dying (e.g., religious concerns, existential concerns)
Treatment (e.g., side effects, mutilation/change in body image)
Family and friends (e.g., being a burden, loss of family role)
Finances, social status and job
offers a support system to help the family cope during the patients illness and in their own
bereavement
uses a team approach to address the needs of patients and families, including bereavement
counselling, if indicated
will enhance quality of life, and may also positively influence the course of illness
(A) SOURCES OF DIFFICULTY IN COMMUNICATING WITH DYING PATIENTS
Factors originating in the health care professional
is applicable early in the course of illness, in conjunction with other therapies that are
intended to prolong life, such as chemotherapy or radiation therapy, and includes those
investigations needed to better understand and manage distressing complications
Results of a survey (Buckman, 1984) suggest a number of factors may be operating that contribute
to the discomfort of talking with a dying person:
Standards of palliative care
Sympathetic pain (overwhelmed by the patients distress)
Palliative Care Australia has developed national palliative care standards based on the principals of
Fear of being blamed (blaming the messenger for the message, a sense of therapeutic
failure)
Fear of the untaught. As professionals we like to follow guidelines to do things properly.
Dignity of the patient, caregiver/s and family
Empowerment of the patient, caregiver/s and family
Often there are not rigid guidelines to follow in palliative care.
Compassion towards the patient, caregiver/s and family
Fear of eliciting a reaction.
Respect for the patient, caregiver/s and family
Fear of saying I dont know.
Equity in access to palliative care services and resources
Fear of expressing emotions (while it is appropriate not to show panic or rage, a doctor who
shows no emotions when the patient is facing death is likely to be perceived as cold or
insensitive.)
ambiguity of phrase Im sorry (doctors may fear it sounds as though they are apologising b
and taking blame)
own fears of death and suffering
Advocacy on behalf of the expressed wishes of patients, families and communities
Excellence in the provision of care and support
Accountability to patients, caregivers, families and community
Putting the standards into practice.
(C) BASIC COMMUNICATION SKILLS FOR PALLIATIVE CARE
Physical context: ensure privacy wherever possible.
Introductions: ensure the patient knows who you are and what you do. You may wish to
shake hands. Offer handshake as well to spouse if present.
Sit down: conveys a willingness to listen and conveys an attitude of unhurriedness that is
helpful.
Body language. Maintain a comfortable distance and lean forward slightly. Eye contact is
important in conveying attention, understanding, and concern.
Touch: may be very helpful, but need to be sensitive to reactions of patient.
Facilitate the flow of the dialogue with general communication skills (e.g., ask open-ended
questions, dont speak on top of the patient, use minimal encouragers)
Tolerate short silences. Silences dont mean the patient has stopped thinking. S/he may be
experiencing feelings that are too intense to easily express. If you have to break the silence,
it may help to ask gently, What were you thinking about just then? or What made you
pause just then? Silence may also indicate the patient is weary or breathless and needs to
pause.
Repetition and reiteration. Use patients key words to convey that you have been listening
carefully.
Identify the patients emotion and its origin, and respond in a way that tells the patient you
have made the connection; e.g., It must be very distressing for you to know that all that
chemotherapy didnt give you a long (or any) remission. Professionals dont have to feel
the same emotion as the patient (sympathy) but it is important they convey to the patient
that they are making an effort to understand his/her experience (empathy).
Dignity offers a useful overarching framework to guide palliative care staff, patients and
significant others in defining goals and considerations at the end of life. Patients feel worthy
and esteemed when they are treated with respect and their symptoms are well managed.
Some examples of dignity-promoting questions are:
- Is there anything we can do to make you more comfortable?
- Is there anything further about your illness that you would like to know?
As death approaches, patients will communicate increasingly nonverbally. This should not
stop professionals talking to them, describing what they are doing, and treating them as
people with feelings. Patients may still hear though be unable to speak (be careful of what is
discussed around the bed). Relatives may feel tense and distressed and need to be
supported sensitively. Needs and wishes need to be regularly reviewed.
Cultural/religious practices are to be respected and should be discussed when the patient is
admitted to the palliative care unit/home visiting service.
(D) OTHER CONSIDERATIONS

As well as fear, dying patients may experience a range of other distressing emotions.
Anger: at the rest of the world; who will survive after s/he has gone; anger at God/fate; anger at any
one who is trying to help. Behind anger are often feelings of powerlessness and a desperate search
to regain some sense of control and meaning. It is often helpful for the patient/familys anger to be
acknowledged and respectfully explored. (I can understand that you feel very angry that . Would
you like to tell me more about ). Remaining calm and non defensive are key tasks for professionals
in these situations.
Denial: Denial is a useful protective mechanism in a dangerous situation. Professionals need to

understand the individuals need to protect themselves, without colluding with the denial by
pretending to share it. A supportive comment such as, When things are difficult, it helps to think
about something pleasant. recognizes the pain of the situation, but also notes the patients
avoidance. Professionals should not collude with patients denial such that key information is
withheld; for example, regarding diagnosis (ie, disseminated cancer) and prognosis (eg, not more
than a few months). However, this does not mean that every conversation between the patient and
doctor needs to involve confrontation or argument about the facts. (Over time, the inevitable
deterioration in a patients condition usually breaks down his/her initial use of denial as a coping
strategy.) Denial may need to be confronted openly (but still sensitively) in some circumstances, e.g.,
when a single parent is dying and plans are not in place for the care of young children.
Depression, sadness and despair: Sadness at the ending of ones life is a normal reaction and
patients should not be jollied out of their legitimate feelings. However, clinical depression needs to
be treated and not ignored just because the patient is terminally ill. Patients often feel lonely as they
progress toward death. Supportive communication (between patient and significant others,
including palliative care staff) will help to reduce these painful feelings of isolation.
- Is there anything in the way you are treated that is undermining your sense of dignity?
- What about yourself or your life are you most proud of?
- What are your biggest concerns for the people you will leave behind?
- How do you want to be remembered?
See Chochinov, 2002, for a discussion)
Asking for euthanasia: From time to time, patients ask to have their death actively hastened. (You
wouldnt let a dog live like this.) It is helpful to explore with the patient/carer what aspects of the
situation are most painful. Acknowledge and empathize with the emotional pain as well as the
physical suffering. Gently explore fears, maybe previously not expressed. (Im wondering what else
you may be fearful/concerned about, perhaps some things you havent mentioned yet.). Only after
exploring and hearing concerns should the professional outline the boundaries set by the law and
conscience regarding euthanasia. This needs to be done in a way that does not make the patient feel
abandoned or reproached for expressing the wish. It is usually helpful to give reassurance that life
will not be unnecessarily prolonged (e.g., through heroic, medical gestures). Furthermore, the
patient and their family need to understand that symptomatic treatment will be administered even
to the extent that the nature and dose of medication may contribute to significant side effects.
CONCLUSION
Sheldon (1993) has observed, It is not possible to be perfectly prepared for whatever comes. So
courage is needed along with a solid value base and some understanding of basic skills. Most
important though is a faith in the potential of the partner in the dialogue, whether that person is
dying or bereaved, to change and grow in response to the crisis of loss and death.
(Professionals can grow and change too!)

References
Buckman, R., (1993). Communication in palliative care: a practical guide. In D.Doyle, G.Hanks and
N.MacDonald (Eds), Oxford textbook of Palliative Medicine. (pp.47-61). Oxford University Press.
Chochinov, H.M. (2002). Dignity-conserving care: a new model for palliative care. JAMA, 287, (17)
2253-2260.
Mitchell, G. (2010). Communicating with dying patients and their families. In M.Groves and J
Fitzgerald (Eds.), Communication skills in Medicine: promoting patient-centred care (p.159170). Melbourne .IP Communications
Palliative Care Australia (2005). Standards for providing quality palliative care to all Australians,
Canberra.
Sheldon, F. (1993). Communication. In C Saunders and N.Sykes (Eds.), The management of
terminal malignant disease. (pp.15-32). London: Edward Arnold.
World Health Organisation (2002). National Cancer Control Programmes: Policy and Managerial
Guidelines (2nd Edition). Geneva: World Health Organisation.
Students are also encouraged to consult Clinical practice guidelines for the psychosocial care of
adults with cancer (2003). (Prepared by the National Breast Cancer Centre and National Cancer
Control Initiative)
CCS#Module#6#Communicating#in#Mental#Health#
Semester#1,#2013#
#
#
Semester#1,#2013#
#
#
INFORMATION(SHEET(6.1(
Impaired(attention(&(concentration(
COMMUNICATING(WITH(PATIENTS(WITH(MENTAL(ILLNESS(
Psychotic#processes#consume#a#lot#of#the#resources#of#brain#and#mind#making#people#
distracted#and#impaired#in#attention#and#concentration.##This#will#make#listening#to,#and#
answering,#questions#more#difficult#for#them.##Keeping#the#focus#of#the#question#clear#and#
concise#will#help#and#avoid#longZwinded#vague#questions.##They#can#still#be#open#questions,#
but#you#may#have#to#narrow#down#to#closed#questions#earlier#to#get#the#information#you#
need.##Sometimes#you#may#need#to#refocus#the#patient,#particularly#if#they#appear#to#be#
having#difficulty#maintaining#the#topic#of#conversation#in#working#memory.##Similarly,#sedation#
from#medication#can#produce#impairments#of#attention#and#concentration#requiring#gentle#
prompting#to#maintain#engagement.#
Building(rapport(
Patients#presenting#with#mental#health#problems#frequently#feel#apprehensive,#uncomfortable#
or#anxious.##It#may#have#taken#a#long#time#and#much#courage#to#seek#help.#The#practitioner#
needs#to#establish#rapport#to#assist#patients#to#relax#and#tell#their#stories.##Some#ways#to#do#
this:#
#
#
#
Introduce#yourself#and#find#out#how#the#patient#would#like#to#be#addressed.#
Smile#and#be#friendly,#but#take#the#patients#concerns#seriously.##
Recognise#signs#and#respond.##Attend#carefully#to#the#patients#facial#
expressions,#tone#of#voice,#body#language#and#metaphors.#You#can#respond#in#a#
range#of#different#waysP#for#example,#with#a#frown,#smile#or#raised#eyebrow#that#is#
appropriate#to#the#emotion#expressed#and#conveys#interest#and#respect.##If#the#
patient#uses#a#metaphor#such#as,#It#feels#like#there#is#no#light#at#the#end#of#the#
tunnel,#you#could#respond#by#asking,#For#how#long#has#it#felt#so#dark?#
Identify#the#patients#distress#and#empathise.##Help#the#patient#to#put#his/her#
distress#into#words#by#asking#questions#that#facilitate#the#expression#of#
experience.##E.g.,#What#is#troubling/bothering#you?,#How#did#that#make#you#
feel?#Let#the#patient#know#that#you#are#getting#a#sense#of#his#experience.##E.g.,#
That#must#be#very#hard#for#you.P#This#has#been#a#very#stressful#time#for#you.#
Endeavour#to#help#the#patient#feel#you#are#for#rather#than#against#him/her.##
Remember#an#intake#interview#does#not#usually#have#to#be#completed#in#one#
session/visit.#Assessment#is#a#process,#not#an#event.##If#the#patient#is#overly#
fatigued#or#strained,#slow#down#and#return#later#to#gather#more#information.#
Identify#what#is#important#to#the#patientwhy#is#s/he#seeking#help#at#this#time?##
What#symptom/s#causes#most#distress?##What#are#his/her#questions/fears?#
Delusions((and(other(psychotic(beliefs)(
Patients#who#are#acutely#psychotic#will#often#be#preZoccupied#with#the#delusional#content#of#
their#thoughts#and#difficult#to#steer#on#to#other#topics.##Novice#interviewers#are#often#unsure#
as#to#how#to#handle#delusional#beliefs.##The#general#rule#is#to#avoid#confirming#or#colluding#
with#these#false#beliefs.##Conversely,#attempting#to#convince#a#patient#that#their#beliefs#are#
false#is#likely#to#dissuade#them#from#talking#to#you#at#best#and#provoke#aggression#at#worst.##
Often#it#is#possible#to#agree#to#disagree#to#enable#you#to#gain#information#about#the#
delusional#beliefs#without#needing#to#collude#with#the#patient.##You#may#also#need#to#check#if#
there#is#some#psychotic#reason#why#they#may#be#reluctant#to#talk,#e.g.#the#voices#are#telling#
them#not#to#trust#you.#
Paranoia(in(particular(
#COMMUNICATION(WITH(A(PERSON(WITH(PSYCHOSIS(
When#patients#are#suffering#persecutory#delusions#(people#are#out#to#harm#them#in#some#
way)#they#can#be#particularly#difficult#to#interview.##If#they#believe#that#you#are#a#part#of#the#
conspiracy#against#them,#they#may#be#particularly#reluctant#to#discuss#anything#with#you.#
Remember:#persecutory#delusions#are#when#people#are#out#to#harm#themP#paranoid#
delusions#include#an#element#of#grandiosity,#e.g.#the#government#is#out#to#get#them#because#
they#are#important.#
Sources(of(difficulty(in(communicating(
Thought(Disorder(
Agitation#
Disorders#of#formal#thought#can#make#communication#very#difficult.##If#the#patient#is#having#
difficulty#maintaining#any#logical#train#of#thought,#then#understanding#your#questions#and#
generating#a#logical#response#may#be#dramatically#impaired.##Often#you#begin#to#feel#as#
confused#as#the#patient#by#the#conversation.##Be#prepared#to#slow#down#and#use#very#
straightforward#interviewing#questions#so#that#you#can#be#clear#where#the#confusion#is#
coming#from.#
People#suffering#acute#psychosis#are#frequently#agitated#and#aroused.##This#can#cause#
difficulties#in#communication.##First#and#foremost,#you#should#always#be#mindful#of#your#
personal#safety.##Always#be#aware#of#the#level#of#arousal#that#a#patient#is#showing.##In#
particular,#be#aware#if#this#appears#to#be#increasing#as#a#result#of#your#interview.##If#this#
happens#you#may#need#to#terminate#the#interview#and#try#again#later.#
When#people#are#agitated#or#aroused#you#often#see#problems#with#poor#concentration#and#
attention#(see#next#section).##Modelling#calm#behaviour#with#your#own#body#language#and#
verbal#communication#will#often#help#to#calm#the#situation.##Avoid#confrontational#statements#
where#possible#(see#section#on#delusions,#below).#
(
Information#Sheets#6.1#and#6.2#(Students(to(Bring(to(tutorial)##
"
COMMUNICATION(WITH(A(PERSON(WITH(SUICIDAL(SYMPTOMS(
Patients#who#are#experiencing#suicidal#thoughts#may#be#feeling#ashamed,#hopeless,#angry#
and/or#overwhelmed.#It#is#likely#that#part#of#the#patient#wants#to#keep#the#suicidal#thoughts#
and#plans#a#secret,#so#that#others#do#not#impede#the#carrying#out#of#the#plans.##On#the#other#
hand,#another#part#of#the#patient#is#likely#to#be#feeling#burdened#by#the#dark#thoughts,#
frightened#and/or#lonely.##If#the#patient#has#voiced#suicidal#thoughts#or#made#previous#
1"
"
2"
Semester#1,#2013#
#
#
Semester#1,#2013#
#
#
attempts,#s/he#may#fear,#or#have#experienced,#ridicule#from#family#members#or#health#
professionals#(Why#would#you#want#to#do#such#a#ridiculous#thing?#is#not#a#helpful#
response.)#
and#impaired#concentration#are#also#common.##It#is#important#to#record#signs#and#symptoms#
of#withdrawal,#also#try#to#differentiate#between#reported#subjective#levels#and#observed#
objective#levels.#
Suggestions(for(managing(difficulties(
Judgemental#Attitudes#
It#can#be#a#relief#for#suicidal#patients#to#talk#about#their#distress.##An#accepting#and#calm#
response#from#the#practitioner#will#contribute#to#a#problemZsolving#approach.#Enquire#(slowly#
and#patiently)#about#the#nature#of#the#suicidal#ideas,#any#plans#to#carry#out#the#ideas#and#
what#means#the#patient#may#have#to#complete#the#plans.##Further,#it#is#useful#to#establish#the#
patients#strength#of#belief#that#s/he#will#carry#out#the#plans.#It#is#usually#useful#to#refer#to#the#
patients#suicidal#ideas#in#a#matterZofZfact#manner,#noting#that#these#ideas#are#a#symptom#of#
depression/#distress#(rather#than#a#statement#of#fact#that#the#situation#is#truly#hopeless#and#
the#patients#life#is#worthless).##Realistic#hope#may#be#engendered#with#a#comment#such#as#
Symptoms#come#and#goP#with#support#and#appropriate#treatment,#this#symptom#is#likely#to#
subside.##
Patients#will#often#expect#you#to#be#judging#them#adversely#as#a#result#of#their#substance#
use.##Adopting#an#open#and#accepting#manner#will#help#to#get#more#useful#information#and#
foster#a#better#therapeutic#alliance.##Patients#will#often#volunteer#small#amounts#of#
information#to#test#the#water#and#gauge#your#response#before#deciding#how#honest#to#be#
about#their#consumption.#
#If#the#patient#is#estimated#to#be#at#risk#of#selfZharm#and#cannot#guarantee#safety#until#
another#consultation#in#the#near#future,#the#practitioner#needs#to#act#on#a#safety#plan.#This#
may#mean#(a)#contacting#next#of#kin#who#will#take#responsibility#for#supervision#of#the#patient,#
(b)#arranging#voluntary#admission#to#an#appropriate#hospital#or#(c)#arranging#involuntary#
admission.###
COMMUNICATION(WITH(A(PERSON(WITH(ALCOHOL(&/OR(DRUG(DISORDERS(
Intoxication#
Trying#to#interview#someone#acutely#intoxicated#with#one#or#more#substances#is#a#challenge.##
Blood#levels#of#drugs#&#alcohol#are#not#necessarily#a#good#guide#to#the#degree#of#impairment#
as#many#heavy#users#will#be#significantly#tolerant.##The#old#response#of#Im#not#interviewing#
them#until#their#blood#alcohol#is#less#than#0.05#is#not#good#enough#but#is#still#sometimes#
used#as#a#way#to#dismiss#patients.#
You#have#to#weigh#the#quality#of#information#gathered#against#the#level#of#functional#
impairment#demonstrated#by#an#intoxicated#person.##In#many#cases#the#best#approach#is#to#
get#what#you#need#immediately#and#then#come#back#to#get#the#rest#once#they#are#less#
impaired.#
It#is#important#to#remember#that#intoxication#often#causes#disinhibition,#which#increases#the#
risk#of#violence#to#self#and#others.##As#always,#be#aware#of#your#personal#safety#and#the#level#
of#agitation#and#arousal#being#displayed#by#the#patient.#
Try#to#avoid#labelling#statements#like#drunk#and#record#observable#signs#of#intoxication,#e.g.#
slurred#speech,#ataxia,#dilated#pupils,#etc.#
Withdrawal#
Withdrawal#is#a#significantly#unpleasant#stateP#potentially#lethal#in#the#case#of#alcohol#
withdrawal.##Irritability#is#a#common#symptom#and#can#lead#to#difficult#interviews.##Confusion#
"
Shame#&#Guilt#
For#many#patients,#these#are#common#emotions#concerning#their#substance#misuse.##In#
some#cases,#e.g.#for#Muslims,#being#a#drinker#has#significant#cultural#implications.##People#
are#often#willing#to#boast#about#excessive#consumption,#but#would#be#ashamed#to#be#
considered#alcoholic.##There#is#a#marked#stigma#attached#to#being#a#junkie.##Parents#may#
also#be#feeling#guilty#about#the#impact#of#their#substance#use#on#their#children#or#conversely#
be#blaming#themselves#for#their#childs#substance#use.#
Suggestions#for#taking#a#reliable#drug#&#alcohol#history#
This#is#always#a#challenge.##For#multiple#reasons,#patients#may#inflate#or#minimise#their#
reported#consumption.##Asking#in#different#ways#helps#to#develop#a#clearer#pictureP#for#
example,#comparing#an#estimate#of#the#amount#spent,#number#of#days#spent#usingP#weekly#
average#etc.#will#give#the#opportunity#to#explore#inconsistencies#and#arrive#at#a#more#
accurate#estimate#of#drug#use.##You#should#also#ask#about#patterns#of#use,#routes#of#
administration#and#symptoms#of#dependence#for#all#the#drugs#used.#Remember#to#ask#about#
age#of#onset,#duration#of#use,#previous#treatments#and#episodes#of#sobriety#or#abstinence.#
#
COMMUNICATION(WITH(A(PERSON(WITH(DEMENTIA(
People#with#dementia#often#have#normal#attention#but#poor#recall#and#understanding.#Some#
will#have#dysphasia#(language#difficulty),#dyspraxia#(difficulty#with#complex#motor#function)#or#
agnosia#(difficulty#recognising#objects,#including#people).#They#often#have#greatly#impaired#
insight#into#their#impairment.#As#most#people#with#dementia#are#over#the#age#of#75#years,#
many#also#have#impaired#hearing#and#eyesight.#The#interviewer#is#often#much#younger#than#
the#patient#and#has#often#had#entirely#different#life#experiences.##
It#is#often#helpful#for#the#interviewer#to#employ#greater#formality#than#usual#when#interviewing#
an#older#person#with#dementia.#It#is#important#to#look#the#part#and#take#care#in#making#
introductions.#If#the#person#with#dementia#has#severe#amnestic#difficulties,#as#is#often#the#
case,#a#formal#introduction#might#need#to#be#undertaken#each#time#the#person#is#interviewed.#
You#should#not#only#enunciate#your#name#clearly#but#also#indicate#your#role#(medical#
3"
"
4"
Semester#1,#2013#
#
#
Semester#1,#2013#
#
#
student).#It#is#often#helpful#to#indicate#that#you#are#speaking#with#them#at#the#suggestion#of#
the#consultant#or#registrar#(mention#them#by#name#as#Dr#X#or#Dr#Y).#It#is#best#to#interview#
people#with#dementia#in#an#environment#that#is#free#of#extraneous#noise#and#other#
distractions.#It#is#essential#also#to#ensure#that#they#have#their#hearing#aids#and#spectacles#
with#them.#It#may#be#advantageous#to#allow#the#older#person#to#visit#the#bathroom#before#you#
begin#an#extended#interview.#Allow#sufficient#time#to#conduct#the#interview#and#make#sure#
you#have#the#necessary#materials#with#you#before#you#start.#These#might#include#cognitive#
assessment#tools#such#as#the#MiniZMental#State#Examination#(MMSE)#and#rating#scales#for#
depression#(GDS)#and#anxiety#(GAI).##
COMMUNICATION(WITH(A(PERSON(WITH(MENTAL(HEALTH(PROBLEMS(RELATED(
TO(PHYSICAL(ILLNESS((e.g.,(cancer,(renal(failure)(
The#person#with#dementia#often#has#limited#insight#into#the#nature#and#severity#of#their#
cognitive#impairment.#They#often#provide#unreliable#historical#details#so#an#informant#should#
always#be#interviewed##preferably#alone.#Some#patients#with#dementia#have#such#poor#
recall#ability#that#psychiatric#interview#is#restricted#to#the#mental#state#examination.#Some#
patients#with#dementia#will#exhibit#pathological#crying#or#laughing.#Some#will#confabulate#
(make#up#historical#details).#Some#will#have#delusional#beliefs#or#hallucinatory#experiences.#
Occasionally,#the#person#with#dementia#will#exhibit#a#catastrophic#reaction#in#which#they#
react#dramatically#to#the#frustration#they#experience#with#their#cognitive#impairment.#Some#
will#be#so#agitated#that#they#refuse#to#be#separated#from#their#spouse#or#other#carer.#
Furthermore,#the#precise#meaning#of#the#condition#and#stage#of#life#cycle#will#affect#response#
#for#example#whilst#a#diagnosis#of#epilepsy#may#not#be#lifeZthreatening#it#represents#a#major#
threat#to#a#young#man#who#is#thus#unable#to#drive.#Past#history#will#also#influence#the#
response#to#illness##for#example#the#woman#who#has#been#diagnosed#with#early#breast#
cancer#may#appear#to#be#distressed#out#of#proportion#to#the#prognosis,#however#if#she#has#
witnessed#her#mother,#sister#and#aunt#die#from#the#disease#her#distress#becomes#more#
understandable.##
Do#not#commence#the#interview#with#an#older#person#suspected#of#having#dementia#by#
immediately#undertaking#cognitive#testing.#If#you#do#this#you#are#likely#to#get#the#interview#off#
to#a#very#poor#start.#However,#cognitive#testing#should#not#be#left#to#the#end#of#a#long#
interview#as#the#older#patient#may#by#then#be#starting#to#tire.#It#is#far#better#to#engage#them#in#
talking#about#something#they#have#no#difficulty#talking#about,#often#their#early#years#or#
wartime#experiences.#If#their#remote#memory#is#so#poor#that#they#are#unable#to#chat#about#
earlier#times,#concentrate#on#the#here#and#now.#Ask#them#how#they#are#feeling#right#now.#
Comment#on#things#that#are#happening#right#before#them#during#the#interview#(e.g.#things#
that#can#be#seen#through#the#window,#such#as#the#weather#or#passing#traffic).##
People#with#dementia#are#often#repetitive.#The#interviewer#simply#has#to#tolerate#this#
although#it#might#mean#hearing#the#same#story#several#times#during#a#relatively#brief#
encounter.#It#is#often#helpful#to#use#a#direct#and#concrete#approach#to#interviewing,#
minimising#the#use#of#jargon.#It#is#sometimes#useful#to#repeat#the#question#in#a#different#way#
if#the#patient#does#not#seem#to#understand#it#the#first#time#round.###
Nonverbal#prompts,#including#encouraging#social#gestures#and#appropriate#body#language#
are#essential#if#you#wish#to#gain#the#most#from#the#interview#with#the#person#with#dementia.#It#
is#often#necessary#to#conduct#the#interview#in#a#series#of#short#bursts#spread#over#time,#
rather#than#as#one#long#event.#
As#a#general#rule,#older#people#are#more#interesting#to#interview#than#younger#people#as#they#
have#experienced#more#of#life#and#have#often#survived#significant#challenges.#They#have#
usually#had#steady#employment#and#normal#interpersonal#relationships.#They#frequently#
have#stable#accommodation#and#a#steady#income.#They#are#much#less#likely#than#younger#
people#to#have#abused#illicit#drugs.#However,#they#almost#always#have#general#medical#
problems#that#interact#with#their#mental#health#issues.####
#
"
People#who#are#coping#with#physical#illness#have#high#rates#of#anxiety#and#distress,#including#
depression.#In#addition#to#the#obvious#impact#of#a#diagnosis#of#serious#illness,#adjustment#
can#be#influenced#directly#by#the#condition,#for#example#cerebral#metastases#from#
melanoma,#and#particular#treatments#such#as#steroids#which#powerfully#affect#mood.#There#
is#good#evidence#that#emotional#adjustment#is#also#influenced#by#physical#symptoms#such#as#
pain#and#dyspnoea.##
Times#of#especial#vulnerability#to#distress#include#the#initial#diagnosis,#completion#of#active#
treatment#(such#as#completion#of#chemotherapy#and#radiotherapy#after#surgery#for#breast#
cancer)#and#diagnosis#of#recurrent#or#progressive#disease.#
The#circumstances#of#the#diagnosis#of#the#condition#may#be#an#important#determinant#of#
adjustment#and#response#to#an#interviewer.#In#cases#where#the#person#feels#that#there#was#a#
delay#in#the#diagnosis#of#their#condition,#it#is#common#to#wonder#if#this#has#adversely#affected#
the#prognosis.#It#may#also#lead#to#problems#with#trust#with#other#health#professionals#or#even#
frank#hostility.#
Physical#incapacity#or#pain#will#affect#the#ability#or#willingness#of#the#person#to#be#
interviewed.#However#some#people#are#reluctant#to#accept#analgesia#for#fear#that#they#are#
seen#as#weak,#or#apprehension#that#the#medication#will#become#ineffective#if#their#disease#
progresses.#
Cognitive#impairment#is#common#in#many#patients#with#serious#illnesses#such#as#renal#failure#
or#brain#tumours.#This#may#be#obvious#in#terms#of#reduced#attention#and#concentration,#or#
more#subtle#in#the#form#of#mild#rigidity,#perseveration,#asking#frequently#for#questions#to#be#
repeated,#or#even#seeming#just#vague.#
Patients#who#are#facing#a#very#poor#prognosis#may#be#reluctant#to#openly#discuss#their#
feelings#because#of#their#desire#to#be#strong#or#they#may#become#very#distressed.#
Sometimes#the#interviewer#is#uncertain#about#the#patients#understanding#of#the#condition#
and#may#be#apprehensive#about#overstepping#the#mark.#Especially#in#young#patients#for#
whom#the#diagnosis#is#untimely,#or#those#who#may#die#leaving#dependent#children,#open#
expressions#of#intense#grief#may#feel#overwhelming#for#the#inexperienced#interviewer.##
It#is#tempting#to#assume#that#distress#is#natural#and#understandable#in#the#person#with#a#
serious#medical#illness#and#thus#fail#to#explore#symptoms#which#might#lead#to#a#diagnosis#of#
depression.#Even#if#sadness#seems#in#keeping#with#the#situation#it#is#important#to#explore#
5"
"
6"
Semester#1,#2013#
#
#
Semester#1,#2013#
#
#
depressive#symptoms#in#detail#as#patients#with#medical#illness#are#vulnerable#to#experiencing#
depression#and#anxiety.#Remember#that#depression#may#present#with#irritability#and#
withdrawal,#not#just#depressed#mood.##
Sources(of(difficulty(in(communicating( (
Partners#and#family#members#may#be#very#distressed,#angry#or#confused,#especially#at#the#
time#of#a#patients#initial#diagnosis,#or#suicide#attempt#or#if#the#patient#has#behaved#
aggressively#toward#them.#It#is#often#the#case#that#partners/family#members#have#ambivalent#
feelings#toward#the#patient#(that#is,#they#may#love#the#person,#but#find#the#
problems/symptoms/behaviours#very#disruptive,#upsetting#or#exhausting).##It#is#
understandable#that#partners#and#family#members#can#become#fatigued,#irritable#and#
impatient#with#the#needs#and#demands#of#the#patient.#Many#partners/family#members#feel#at#
their#wits#end.###
Ensure#that#the#person#is#comfortable,#that#if#they#require#analgesia#this#has#been#given,#and#
that#they#have#access#to#water#if#they#have#a#dry#mouth.#Always#ask#if#the#timing#is#suitable#
for#an#interview.#If#the#person#has#to#move#from#one#site#to#another#for#the#interview#(for#
example#into#an#office#off#the#ward)#check#beforehand#that#the#person#is#fully#mobile#or#if#
they#need#assistance,#such#as#a#wheelchair.##
Adopting#a#neutral#interested#style#of#questioning#initially#can#be#helpful#to#make#the#person#
feel#that#you#are#comfortable#discussing#their#condition#e.g.,#I#understand#that#you#were#
diagnosed#with#epilepsy#about#5#months#ago.#I#wonder#if#you#could#tell#me#a#little#about#how#
the#diagnosis#was#made#and#what#you#understand#about#the#condition?#If#the#person#relates#
a#series#of#complaints#about#doctors#do#not#become#defensive,#nor#agree#with#the#person#
that#they#have#been#treated#poorly,#instead#focusing#on#their#feelings:#It#seems#as#though#
this#has#been#a#really#difficult#time#for#you.#
Never#presume#to#know#how#the#diagnosis#affects#the#individual#person,#but#be#aware#that#
questions#about#adjustment#can#sometimes#seem#duh.#For#example#it#might#be#helpful#to#
ask:#Everyone#responds#differently#to#a#diagnosis#like#this.#Are#you#able#to#tell#me#how#it#has#
affected#you?#and#perhaps#clarify#with:#Whats#the#worst#thing#about#it#for#you?#It#can#
strengthen#rapport#to#make#an#educated#guess#such#as:#It#must#be#tough#if#the#doctors#say#
you#cant#drive#at#present.##
If#you#anticipate#that#the#person#may#have#some#cognitive#difficulties#such#as#due#to#cerebral#
metastases,#ask#at#the#outset#if#they#have#any#problems#with#their#memory#or#concentration.#
If#the#person#appears#to#be#struggling#to#respond#to#questions#during#the#interview,#step#back#
and#reflect#if#you#have#pushed#them#too#far#in#exploring#emotional#issues,#or#if#cognitive#
issues#are#relevant.#A#direct#question#could#be#asked#such#as:#Ive#asked#a#lot#of#questions#
and#Im#sure#it#must#be#tiring#for#you.#Do#you#find#that#focusing#on#things#is#more#difficult#now#
than#before?#
COMMUNICATION(WITH(PARTNERS(AND(NEXTROFRKIN(
Suggestions(for(managing(family(interviews((
Practitioners#need#to#maintain#a#respectful#attitude,#and#refrain#from#being#judgemental#
wherever#possible.#Aim#to#adopt#an#interested,#concerned#but#neutral#stance#when#family#
matters#are#discussed.#If#there#is#open#conflict#amongst#family#members,#politely#but#firmly#
inform#them#that#you#are#interested#to#hear#their#perspectives,#but#would#prefer#to#speak#to#
them#individually,#one#at#a#time.##(Take#individual#to#a#nearby#interview#room#if#available.)##
These#situations#often#require#empathic#containmentP#for#example,#I#understand#that#this#
has#been#a#very#stressful#time#for#you.##(empathic#reflection)P#I#would#like#to#ask#you#some#
questions,#so#I#need#you#to#stay#as#calm#as#you#can,#and#answer#as#accurately#as#possible#
(containment).#Be#careful#not#to#get#embroiled#in#family#disputes,#and#be#cautious#in#offering#
opinions#or#comments#until#a#careful#history#has#been#taken.#Willingness#to#answer#
questions#and#explain#distressing#symptoms#or#behaviours#will#be#appreciated.#
(SUMMARY(OF(BASIC(COMMUNICATION(SKILLS((
#
#
If#exploring#the#persons#prognosis#or#concerns#for#the#future#acknowledge#at#the#outset#that#
this#could#be#challenging.#Be#gentle#and#lower#your#voice#and#quietly#comment:#Youve#
been#very#generous#in#sharing#a#lot#of#information#about#your#condition,#and#I#can#see#that#it#
hasnt#been#easy.#This#is#personal#and#you#may#not#want#to#answer,#but#I#wonder#how#you#
see#things#in#the#future#with#your#condition?#
#
#
Exploring#mood#can#seem#absurd#to#the#patient#who#is#clearly#distressed,#and#is#best#
addressed#directly#with#an#explanation.#This#is#obviously#very#distressing,#and#I#imagine#
anyone#in#your#situation#would#feel#upset.#But#sometimes#being#upset#can#really#become#
quite#marked,#and#we#then#start#to#think#about#depression.#Would#it#be#OK#if#I#asked#a#little#
more#about#that?#Picking#up#on#depression#is#really#important#because#it#can#be#effectively#
treated.#
"
#
#
7"
Physical#context:#ensure#privacy#wherever#possible,#but#be#mindful#of#your#
personal#safety.#
Introductions:#ensure#the#person#knows#who#you#are#and#what#you#do.#You#may#
wish#to#shake#hands.##Offer#handshake#to#carer#as#well,#if#present.#Clarify#the#
identity#of#the#person#with#the#patient##it#may#be#a#carer#but#could#equally#be#a#
casual#visitor#
#
Sit#down:#conveys#a#willingness#to#listen#and#conveys#an#attitude#of#
unhurriedness#that#is#helpful.#
Body#language.##Maintain#a#comfortable#distance.##Eye#contact#is#important#in#
conveying#attention,#understanding,#and#concern.##Be#wary#of#appearing#to#stare#
at#selfZconscious#or#paranoid#people.#
Touch:##is#seldom#a#good#idea#unless#the#person#is#acutely#distressed,#and#even#
then#to#be#used#with#caution.#
Facilitate#the#flow#of#the#dialogue#with#general#communication#skills#(e.g.,#ask#
openZended#questions,#dont#speak#on#top#of#the#patient,#use#minimal#
encouragers).##Some#patients#may#need#help#to#refocus#on#the#topic#at#hand,#
especially#if#distracted#by#hallucinations#or#other#forms#of#interference#with#
thought#processes.#
"
8"
Semester#1,#2013#
#
#
#
#
Tolerate#short#silences.##Silences#dont#mean#the#person#has#stopped#thinking.##
S/he#may#be#experiencing#feelings#that#are#too#intense#to#easily#express,#or#their#
thinking#may#be#slowed.##Look#for#signs#that#they#may#be#responding#to#
hallucinations#and#it#may#be#prudent#to#ask#if#something#is#distracting#them,#if#
they#appear#to#have#tuned#out.#
Repetition#and#reiteration.##Use#the#persons#own#words#when#summarising#to#
convey#that#you#have#been#listening#carefully.##
Identify#the#persons#emotions#and#respond#in#a#way#that#tells#them#that#you#have#
made#the#connectionP#e.g.,#It#must#be#very#distressing#for#you.##Professionals#
dont#have#to#feel#the#same#emotion#as#the#patient#(sympathy)#but#it#is#important#
they#convey#to#the#patient#that#they#are#making#an#effort#to#understand#his/her#
experience#(empathy).#Often#this#is#where#Doctor#and#Patient#can#agree#common#
goals,#as#neither#wants#the#patient#to#feel#distressed.#
Dignity#People#are#often#resentful#at#being#detained#and#treated#against#their#will.##
Engaging#them#in#their#recovery#and#agreeing#on#common#goals#is#important#in#
building#the#therapeutic#alliance.#Simple#questions#can#help,#e.g.#
,# Is#there#anything#further#about#your#illness#that#you#would#like#to#know?#
Cultural/religious#practices#are#to#be#respected#and#it#is#important#to#check#their#
possible#impact#on#beliefs#about#the#illness,#its#cause#and#treatment.#
INFORMATION(SHEET(6.2(((
OUTLINE(OF(AN(INTERVIEW(WITH(A(PATIENT(IN(A(MENTAL(HEALTH(SETTING(
#
Presenting#complaint#and#history#of#presenting#complaint##
Past#psychiatric#history#
Past#medical#history/Medications/Allergies#
Family#historyP#family#psychiatric#history#
Personal#history#
Birth#and#early#life#
Schooling#
Higher#education/training#
Employment#history#
Psychosexual#history#(relationships)#
Forensic#history#
Further(reading(
Use#of#alcohol#and#other#drugs#
Othmer,#E.#and#Othmer,#S.#(1994).##The#clinical#interview#using#DSMZIV.##Volume#1:#
Fundamentals.##Washington:#American#Psychiatric#Association#
#
Semester#1,#2013#
#
#
Premorbid#personality#
Suicide#risk#assessment##
History#of#previous#selfZharm#
Presence#of#depression#
Suicidal#ideation#
Plans#
Means#to#carry#out#plans#
How#close#to#attempting#to#carry#out#plans#
#
#
For#more#comprehensive#risk#assessment,#see#Adult#Mental#Health#Services#Risk#Screening#
Tool.#
#
"
9"
"
10"
Semester#1,#2013#
Semester#1,#2013#
Mood(
CONDUCTING(A(MENTAL(STATUS(EXAMINATION(
Mood#refers#to#the#patients#internal#feelings#and#emotional#state,#which#the#patient#may#
verbalise#during#an#interview.#Mood#generally#remains#stable#over#time,#and#may#change#
over#days#and#weeks.#The#onset#of#the#patients#mood,#the#intensity,#and#level#of#fluctuation#
is#assessed.#Assessment#of#mood#is#subjective#as#it#is#based#on#the#patients#selfRreport.#
Rating#scales#can#be#used#to#examine#intensity#of#mood#from#1#(not#at#all#intense#to#10#
(extremely#intense).#Normal#mood#is#described#as#euthymic.#Other#mood#states#are:#
dysphoric#(sad#or#depressed),#euphoric#(elation#and#happiness),#angry#or#irritable,#and#
apprehensive.#If#a#patient#appears#to#be#experiencing#symptoms#of#depression,#it#is#
necessary#to#conduct#a#suicide#risk#assessment.##
The#mental#status#exam#(MSE)#represents#a#crucial#part#of#the#psychiatric#interview#that#is#
important#in#diagnosis,#differential#diagnosis,#and#treatment#planning.#The#aim#of#the#MSE#is#
to#provide#a#systematic#framework#for#the#evaluation#of#a#patients#current#mental#functioning#
that#also#increases#objectivity#and#reliability#of#the#information#gathered.#It#is#an#essential#tool#
for#all#medical#health#professionals.#The#role#of#the#doctor#in#conducting#a#MSE#is#to#assess#
the#patients#current#state#of#behaviour#and#cognitive#functioning.#The#MSE#consists#of#
observations#of#the#patients#verbal#and#nonverbal#behaviour.#The#majority#of#the#MSE#can#
be#conducted#informally#during#the#interview,#while#discussing#the#medical#history#and#
performing#a#physical#examination.#To#ensure#accuracy,#the#MSE#should#be#recorded#as#
soon#as#possible#following#the#end#of#the#interview.#
Appearance(and(Behaviour((
Appearance#refers#to#the#physical#features#of#the#patient.#An#individuals#appearance#should#
be#documented#in#sufficient#detail#so#that#when#another#person#reads#the#description,#they#
are#able#to#form#a#vivid#picture.#Physical#features#include:#facial#features#and#expressions,#
height,#weight,#hair#colour#and#style,#body#shape,#cleanliness,#posture,#eye#contact#and#
movements,#scars,#clothing,#tattoos,#jewellery,#actual#and#stated#age,#signs#of#intoxication,#
and#any#physical#disabilities.##
Assessing#behaviour#involves#observations#of#the#how#the#patient#acts,#both#verbally#and#
nonverbally.#Level#of#consciousness#can#be#described#on#a#continuum#from#a#low#level#of#
consciousness#to#hypervigilence.#A#patient#with#a#normal#level#of#consciousness#is#generally#
defined#as#alert,#and#provides#appropriate#responses#and#is#aware#of#internal#and#external#
stimuli.#A#patient#with#a#low#level#of#consciousness#often#has#reduced#alertness#and#may#
appear#lethargic,#while#a#hypervigilent#patient#may#appear#restless,#easily#startled,#and#wellR
attuned#to#the#environment.##
Motor#activity#is#the#type#and#quality#of#the#patients#movements.#The#patients#gait#and#
freedom#of#movement#is#observed.#It#is#also#important#to#note#the#strength#and#quality#of#the#
patients#handshake,#any#mannerisms,#which#are#exaggerated#behaviours#that#are#socially#
appropriate#but#unusual,#involuntary#and/or#repetitive#movements#such#as#tremors.#The#
patients#degree#of#agitation#is#evidenced#by#their#degree#of#pacing#and#hand#wringing.#The#
extent#to#which#the#patient#coRoperates#during#the#interview#and#can#build#rapport#with#the#
interviewer#is#also#important#to#record.#
Speech(
Listening#to#the#patients#speech#involves#observing#their#rate#of#speech,#spontaneity#of#
responses,#the#range#of#voice#intonation#patterns,#and#volume.#The#presence#of#stuttering#is#
also#notable.#A#patients#speech#can#provide#information#about#their#current#emotional#state.#
Mood#disorders#and/or#substance#use#disorders#may#affect#the#rate,#volume,#and#amount#of#
speechU#neurological#disorders#may#affect#clarity#of#speech.#Also#pay#attention#to#their#use#of#
language,#e.g.#use#of#neologisms.#
(
Information#Sheets#6.3#and#6.4#(Students(to(Bring(to(lecture#
Affect#refers#to#the#patients#external#expression#of#emotional#state,#and#is#influenced#by#
context#and#may#change#moment#to#moment.#Assessment#of#affect#is#more#objective,#as#it#
may#involve#observations#of#the#patients#body#language.#Examples#of#adjectives#to#describe#
mood#are:#anxious,#worried,#tense,#sad,#bright,#bitter,#defensive,#distant,#and#disgusted.#
Appropriateness#of#affect#involves#considering#to#what#extent#the#patients#affect#matches#
what#he#or#she#is#saying.#Patients#with#discordant#mood#and#affect#may#be#experiencing#a#
psychotic#disorder.#
Thought(and(Perception(
Assessment#of#the#patients#thoughts#involves#observations#of#how#well#they#formulate,#
organise,#and#express#the#internal#dialogue#in#their#mind.#Coherent#thought#is#clear,#easy#to#
follow,#and#logical.#Stream#of#thought#refers#to#the#quantity#and#rate#of#the#patients#thoughts,#
ranging#from#a#paucity#of#thoughts#to#a#flooding#of#thoughts.#When#a#patients#thoughts#are#at#
a#rapid#rate#and#changes#from#topic#to#topic,#this#is#referred#to#as#a#flight#of#ideas.#Other#
thought#disturbances#are:##
#
Circumstantial##a#mild#form#of#thought#disorder#that#involves#patients#providing#
detailed,#very#elaborative#responses#that#eventually#get#to#the#pointU#
#
Tangential##thoughts#move#away#from#the#topic#at#hand#and#never#returnsU#
#
Word#salad##the#most#extreme#form#of#thought#disorder#in#which#there#is#no#logical#
association#between#wordsU#
#
Neologisms##madeRup#wordsU#
#
Perseveration##repetition#of#a#word#or#phrase,#or#idea#resulting#from#an#inability#to#
inhibit#a#response#when#it#is#no#longer#appropriateU#
#
Thought#blocking##when#a#patient#loses#their#train#of#thought#midRsentence,#and#
when#they#return#to#talking,#they#have#changed#the#topic#and#cannot#remember#what#they#
were#talking#about.#
Thought#content#refers#to#what#the#patient#thinks#and#talks#about.#Assessment#of#thought#
content#begins#at#the#start#of#the#interview.#The#topic#that#the#patient#wishes#to#talk#about#first#
in#the#interview#may#indicate#what#is#important#to#the#patient.#The#presence#of#obsessions#
such#as#fear#of#contamination,#a#need#for#order,#aggressive#impulses#are#often#accompanied#
by#compulsions,#such#as#washing,#checking#and#need#for#order.#To#find#out#if#a#patient#is#
experiencing#obsessions,#you#may#ask#them:#do#you#experience#any#repetitive#thoughts#that#
you#cant#stop?#Presence#of#any#phobias#is#also#notable.#
1#
!
2#
Semester#1,#2013#
Semester#1,#2013#
#
Perception#is#the#patients#interpretation#of#external#events#and#situationsU#delusions#are#
impairments#in#this#interpretation.#Delusions#are#false,#fixed#beliefs,#out#of#keeping#with#the#
persons#culture#or#background#that#have#no#rational#basis#in#reality,#and#are#not#corrected#
by#an#appeal#to#reason#or#contradictory#evidence.#Delusions#range#from#plausible#to#bizarre.#
Some#types#of#delusions#include#those#of#persecution,#grandeur,#jealousy,#and#love.#
Paranoid#delusions#of#persecutory#type#are#the#most#common#in#psychiatric#patients.#If#
delusions#are#suspected,#you#may#wish#to#ask:#do#you#feel#that#anyone#has#it#in#for#you#or#
that#you#are#being#watched?#Or,#do#you#have#experiences#that#you#dont#think#you#could#
easily#explain#to#others?##
Perceptual#distortion#may#also#consist#of#hallucinations,#which#are#experiences#for#which#
there#are#no#external#stimulus.#Auditory#hallucinations#are#most#commonU#for#example,#
command#hallucinations,#voices#arguing#or#discussing,#and#running#commentary.#There#are#
also#other#types#of#hallucinations#such#as#visual,#tactile#(feeling#sensations#when#there#is#no#
stimulus),#gustatory#(tasting#sensations#when#there#is#no#stimulus),#and#olfactory#(smelling#
odours#that#are#not#present).#Visual#hallucinations#are#also#commonU#however,#they#often#
reflect#neurological#dysfunction.##
Primary#psychotic#disorders#such#as#schizophrenia,#substance#use,#and/or#delirium#may#
affect#thoughts#processes,#delusions,#and#hallucinations.##
Cognition(
This#is#usually#an#informal#assessment#of#orientation,#concentration,#attention#and#memory.##
Where#a#more#formal#test#is#indicated,#most#clinicians#in#routine#clinical#practice#would#use#
the#Mini#Mental#State#Examination#(MMSEU#Folstein,#Folstein#&#McHugh,#1983).##
Assessment#of#orientation#to#time,#place,#person,#and#situation#reflects#the#patients#ability#to#
know#who#they#are,#where#they#are,#what#the#date#and#time#is,#and#their#present#
circumstances.##
Concentration#refers#to#the#patients#ability#to#focus#and#maintain#attention#during#the#
interview.#Difficulties#with#concentration#may#be#evidenced#by#the#patient#asking#questions#to#
be#repeated#or#distractibility.#
The#extent#to#which#the#patient#can#recall#past#events#earlier#in#life#(from#childhood),#recent#
past#events#from#the#past#few#days,#and#shortRterm#memory#is#assessed.#Questions#to#
examine#these#aspects#of#memory#may#refer#to#the#patients#first#job#or#where#they#went#to#
school,#naming#significant#historical#people#or#events,#what#the#patient#had#for#breakfast#or#
how#they#found#their#way#to#the#appointment,#and/or#ask#the#patient#to#recall#what#has#been#
discussed#in#the#interview#thus#far.#ShortRterm#memory#can#be#examined#more#formally#by#
asking#the#patient#to#remember#three#words,#and#five#minutes#later#asking#the#patient#to#
recall#these#words.#
Delirium#may#causes#fluctuations#in#level#of#alertness,#disorientation,#and#problems#with#
concentration.#Dementia#may#reflect#memory#problems.##
#
think#you#have#been#having#these#problems?#or#even#Do#you#think#you#are#unwell#at#the#
moment?#
A#reduced#level#of#insight#is#often#associated#with#psychosis#or#cognitive#impairment.##
AGE(AND(CULTURAL(CONSIDERATIONS((
It#is#often#necessary#to#modify#the#MSE#and#the#interpretation#of#the#MSE#when#working#with#
children,#adolescents,#and#older#adults,#and#people#from#different#cultural#backgrounds.##
It#is#generally#recommended#that#clinicians#interview#young#children#in#the#presence#of#a#
caregiver,#at#least#initially,#due#to#developmental#limitations#in#social#skills#and#separation#
issues#from#their#caregiver.#For#older#children#(aged#5R11#years),#there#should#be#greater#
attempts#to#separate#a#child#from#the#caregiver,#in#order#to#interview#them#alone.#For#children#
that#are#slow#to#warm#or#may#be#showing#symptoms#of#anxiety,#time#may#be#spent#engaging#
in#play#and#building#rapport.##
With#older#adults,#the#clinician#may#need#to#speak#more#slowly#and#loudly.#Also,#there#needs#
to#be#consideration#of#the#older#patients#educational#background,#as#some#of#these#patients#
may#have#experienced#low#levels#of#education.#Also,#circumstantial#speech#is#common#
among#older#adults,#sometimes#as#a#result#of#stories#they#often#like#to#share.#Further,#older#
adults#have#higher#rates#of#depression#and#suicide.#Indicators#for#depression#are#largely#the#
same#as#younger#adultsU#however,#older#adults#tend#to#have#more#somatic#complaints,#and#
physical#symptoms#are#not#as#reliable#an#indicator#of#depression.##
When#interviewing#people#from#different#backgrounds,#special#consideration#is#given#when#
evaluating#thought#content,#perception,#and#speech.#For#example,#in#some#cultures#it#may#be#
common#for#people#to#see#visions#of#loved#ones#who#have#passed#away.##It#can#sometimes#
be#difficult#to#determine#if#the#religious#or#cultural#beliefs#of#a#person#from#another#culture#are#
appropriate#or#signs#of#psychosis.##In#difficult#cases#it#may#be#necessary#to#seek#advice#from#
others#within#the#patients#own#culture#or#religion.#
Sources:((
Daniel,#M.#&#Carothers,#T.#(2007).#Mental#status#examination.#In#M.#Hersen#&#J.#C.#Thomas##
(Eds),#Handbook#of#clinical#interviewing#with#adults.#United#States#of#America:#Sage#
Publications.##
#
Casat,#C.#D.#&#Pearson,#D.#A#(2001).#The#mental#status#exam#in#child#and#adolescent#
evaluation.#In#H.#B.#Vance#&#A.#Pumariega#(Eds),#Child#and#adolescent#behaviour.#Canada:#
John#Wiley#&#Sons.#
#
#
Insight(
The#patients#level#of#insight#is#the#patients#awareness#and#understanding#of#the#current#
problem#or#illness,#its#causes#and#possible#solutions.#Level#of#insight#can#provide#an#
indication#of#the#extent#to#which#they#may#benefit#from#treatment.#Questions#to#elicit#insight#
may#include#what#do#you#think#needs#to#happen#for#your#life#to#improve?#or#why#do#you#
3#
!
4#
Semester#1,#2013#
#
OUTLINE(OF(MENTAL(STATUS(EXAMINATION((
Appearance#and#Behaviour#
#
Eye#contact#and#Rapport#
Personal#Hygiene#
Facial#Expressions#
Motor#behaviour#
Autonomic#arousal/Level#of#consciousness##
Speech#
#
Form#
Volume#
Content##
Mood#
Affective#expression#
Appropriateness#
Presence#of#suicidal#ideation#
Thoughts#
#
Stream#of#thought#
Form##
#
Thought#content#
Perceptions##
Delusions#
Presence#of#hallucinations#
Cognition#
#
Orientation#
Concentration#and#attention#
Registration#
#
Memory#Recall#
General#knowledge# #
Insight#
#
5#
INFORMATION SHEET 8.1

COMMUNICATING ABOUT SEXUAL HEALTH AND FUNCTIONING
Communicating with patients about their sexual health and functioning requires skill and
sensitivity. Such a conversation will be required in a range of different situations; for
example, when the patient presents with explicit problems with sexual health or functioning
(such as abnormal vaginal or urethral discharge, loss of libido, erectile dysfunction, pain
associated with intercourse; concerns about sexual orientation); or when discussing
relationship distress; when providing contraceptive advice; when discussing side effects of
medications/surgery.
PROFESSIONAL DISCOMFORT
There are a number of reasons why medical students and doctors experience difficulty talking
to patients about sex. For example:
There may be embarrassment and personal unease with the subject
Students and junior doctors may feel they are too young to ask older patients about
the details of their sexual relationships
There may be concern that the patient will be offended by questions
There could be a belief that a sexual history is not relevant to the complaint
It may be assumed it is someone elses task (eg., a clinical psychologist or
genitourinary specialist)
There may be lack of skills in dealing with the complexity of patients personal
relationship problems
The medical student may feel inadequately trained for the task
STEREOTYPES
Further, stereotypes and assumptions about behaviour and lifestyle may be a barrier to open
communication. Some common assumptions and misconceptions about sexuality:
Older adults dont have sex
Gay men only have sex with men
A married person couldnt possibly have a sexually transmitted disease
Everyone understands the basics of reproduction
You can tell a persons sexual orientation by their appearance
SKILLS
Clinicians need to be sensitive to the patients embarrassment. Some suggestions for dealing
sensitively with a patients embarrassment include:
Acknowledge your own anxiety/discomfort (dont pretend it is not there)
Practise (alone or with peers) the use of questions that are comfortable for
you
Aim to use the same tone of voice and manner as you would when enquiring
about other parts or functions of the body
Where possible, it may be more comfortable to start with more general
questions first (eg, general health, general relationship functioning) before
moving to more sensitive topics.
Speak clearly and purposefully, without being apologetic.
- Example: I would like to find out something about your relationships to
help make an assessment of this problem. I need to ask you some personal
questions about your sexual relationships.
Listen respectfully to patients stories; respond non-judgmentally and
empathically to sensitive issues.
Acknowledge patients discomfort (if perceived), eg, I understand that it has
probably been quite difficult to come and talk about this problem. Some
doctors add, It might be helpful for you to know that I sometimes find it a
bit difficult to ask some of these questions!
Use concrete and specific terms.
- Example 1: For how long have you had this dull pain in your scrotum?
(NOT: For how long have you had the trouble down below?)
- Example 2: Do you ever engage in sexual activities with partners other
than your wife?
(NOT: Do you, you know, go elsewhere for it?)
Remain non-judgemental about lifestyle. Avoid stereotyping. It may be better
to ask, Was that relationship/contact with a man or a woman? rather than,
Are you gay?
Normalise as much as possible (eg, Many men when they get older
experience difficulties with erections. Can you tell me some more about the
problem that you and your partner are experiencing?)
ASSESSMENT OF SEXUAL DYSFUNCTION
For details of the categories of sexual dysfunction, see DSM IV-TR
Some patients will present with sexual difficulties and describe their symptoms quite matterof-factly. Others will need to be prompted, for example, Has your illness affected your
sexual functioning? Even when asked about any sexual concerns or problems, some patients
may answer no but appear hesitant in their denial. It can be helpful to observe, You seem
a little doubtful. Im wondering if everything is not that great? Key areas of assessment
typically include:
The nature of the problem needs to be examined
frequency (How often does this problem occur?)
intensity (How would you rate the intensity of this pain?)
duration (When did you first become aware of this problem?
Is the problem primary versus secondary?
e.g., Have you experienced this problem all your life, or just recently?
Is the problem generalised or situational, that is, is the problem present in all
relationships or only a specific one?
e.g., Do you have any partners other than your wife? Does this difficulty occur in
all/both those relation ships?
Is the sexual difficulty reported a single problem or are there multiple problems?
(Premature Ejaculation and Erectile Dysfunction; Anorgasmia and Hypo Active
Desire Disorder).
Enquire about partners perspective: How is your partner responding to this
problem?
COMMUNICATING ABOUT SEX AFTER SURGERY OR CHRONIC ILLNESS
Patients may experience a range of problems following illness/ surgery that impact on
sexual functioning. For example,
Mechanical (eg., arthritis, surgical wounds)
Physiological (eg., fatigue, shortness of breath)
Neurovascular (eg., damage to nerves to bladder, pelvis)
Psychological (eg., change to body image owing to colostomy, mastectomy,
disfigurement)
Do not assume that a person with a debilitating illness or disfigurement is not interested
in sex. Ask.
Suggested reading: Atken, S. and Pavlin, N (2010). Talking about sex. In M. Groves and J.
Fitzgerald (Eds.), Communication skills in medicine (pp75-90). Melbourne: IP Communications

STAGES OF CHANGE
The capacity to act on advice varies widely across patients. The patients willingness to
accept the need for change or responsibility for change can inform the type of approach
taken. The patient engaging in the harmful behaviour will be somewhere along the
continuum of the Stages of Change (Prochaska & DiClemente 1982). Note that a patient
might fluctuate between stages.
1. Pre-contemplation
No interest in changing their behaviour.
Unaware of or minimise health risks or harms.
Benefits of unhealthy behaviour outweigh possible concerns.
Doctors task is primarily to give information and feedback, raise awareness and
develop rapport.
2. Contemplation
Ambivalent and undecided, considering costs and benefits of unhealthy
behaviours.
Do not necessarily perceive risks and harms of unhealthy behaviour
outweighing benefits
Might accept information about change.
Not currently planning to change, but considering it in the next six months.
Might stay in contemplation for two or more years before moving to next
stage.
Doctors task is primarily to examine the pros and cons of behaviour and to help
them tip scales in favour of change.
3. Preparation
Concerns (perceived risks and harms) far outweigh the benefits of unhealthy
behaviour.
Making specific plans to undertake change within next 30 days.
Setting a date to commence change.
Doctors task is not so much motivating as matching change strategies that
are acceptable, accessible and appropriate and effective.
Doctors task is not so much motivating as matching change strategies that are
acceptable, accessible, appropriate and effective.
4. Action
Implementing new behaviour/skills.
Doctors task is to assist patient in operationalising change and to assist in
removing road blocks.
5. Maintenance
Maintaining new behaviour, including coping with temptation or minor slips.
Development of relapse prevention strategies.
Doctors role is one of reinforcement of patients self-efficacy beliefs
6. Relapse
Reverting to the previous or an earlier stage is likely when initially making
change attempts and can happen at any time.
Doctors role is to educate that relapse is not unusual and frame this experience
as an opportunity to learn
PRINCIPLES OF MOTIVATIONAL INTERVIEWING

Express Empathy Reflective listening is the fundamental clinical skill
Understanding, unconditional acceptance (not identifying with) without judging,
criticising, or blaming supports patients self-esteem and promotes an
effective relationship.
Unconditional acceptance of person does not imply agreement or approval of
specific behaviours.
Accept ambivalence as normal.
Develop Discrepancy
Facilitate patient clarification of goals and awareness of consequences of present
behaviour.
Clarify and amplify discrepancy between present behaviour and broader goals
until it overrides attachment to behaviour (ie. motivates change.)
Facilitate patient arguing for change.
Avoid Arguments
It is important for the consultation to not become adversarial.
Direct confrontation and arguing evoke defensiveness and denial, are counterproductive and do not motivate change.
Acknowledge patients decisions and feelings.
Keep the door open to future help.
Roll with Resistance
Resistance can be related to:
- Reluctance Inertia.
- Rebellion Hostility, arguing, challenging, denying, blaming.
- Resignation Hopelessness, pessimism, lack of energy.
- Rationalisation Yes but, point-counterpoint debate, minimising
adverse effects.
Reluctance, rebellion, resignation, and rationalisation are all signals to back off.
Respectfully acknowledge (reflective listening) patients personal responsibility
and choice. You cant force change.
Shift focus, move around road blocks. Okay, lets not get stuck on that point.
What about (another subject)? Can you tell me a bit about that?
Support Self-Efficacy
Patients belief in self and ability to carry out specific task (change) important
motivator.
Patient is responsible for choosing and carrying out change.
Positive expectations of outcome. Other patients have found these approaches
very effective.
Reframe self-defeating thoughts, treatment failures, relapses etc. into
opportunities to learn, overwhelming tasks into achievable step-by step
process to final goal, success stories of third-parties similar to patient. For
example, Its great that you were able to quit for two weeks. Youre almost
there.

DEALING WITH RESISTANCE
REVISION OF MICRO-SKILLS
Ask students for useful micro-skills they might remember, and examples of each. Revise
and clarify common misunderstandings. Vital skills from last year to incorporate:
Be empathic
See Principles of Motivational Interviewing.
Use open-ended questions
To establish relationship of trust and acceptance, help patient take responsibility,
and ensure the doctor doesnt funnel prematurely.
Patient should do most of the talking, particularly at the start of the consultation.
Reflective listening. (Including paraphrasing and reflection of feelings)
Means making a guess as to what the person means to say (content and feeling),
and reflecting it back as a statement. , Eg. You sound pretty fed up with
whats been happening to you.
Often the most effective way of dealing with an angry patient is with empathy,
reflective listening, and affirming so they feel acknowledged and accepted.
Ordering, warning, advice, persuasion shoulds, disagreeing, judging, labeling,
interpreting, questioning, humouring, agreeing, approving, reassuring,
sympathising are not reflective listening. They are roadblocks and can
engender resistance; particularly if there will be an ongoing clinical
relationship. There is a place for some of these responses but not at the
opening stages.
Affirm
Support in the form of compliments, appreciation, and understanding (It is
important to distinguish from agreeing, approving, reassuring etc)
Eg. That must have been hard for you, It takes a lot of courage to do what
youre doing, I can understand why you feel so frustrated, I can imagine
how difficult it must have been for you to come here, etc.
Probe:
Elaboration Can you tell me a bit more about that?
Clarification What do you mean when you say.? Or In what way?
Avoid leading and loaded questions:
Leading: Suggests how the patient should be feeling or the presence or absence
of symptoms without reasonable supporting information. (Observation as
opposed to inference) eg. So youre feeling quite depressed, are you? Was
the pain crushing? (can quickly be converted to non-leading one: Or was it
dull or burning, or would you describe it some other way?
Loaded: Extreme form of leading question with a clear social-judgmental bias,
Youre not still smoking I hope, are you?
Summarise
Should occur progressively and before terminating consultation.
To integrate key themes or issues, to allow both to review content, facilitate
further discussion or change of subject
Resistance is the hallmark of the pre-contemplation stage, but a patient can revert to this
stage at any time and resistance is what you will experience. It is imperative that the
consultation should not become an adversarial or hostile experience.
The 4 Rs
Resistance falls into four categories: Reluctance, rebellion, resignation and
rationalisation.
Reluctance
Defining features:
- Through lack of information or inertia do not want to consider change.
- Not fully aware of information or impact of behaviour.
Strategy:
- Provide feedback in an empathic manner.
Rebellion
Defining features:
- Hostile, resistant to change.
- Argumentative (challenging accuracy, expertise or integrity of doctor)
- Have heavy emotional investment in problem behaviour and in making
own decisions.
- Denying, blaming.
Strategy:
- Provide choices.
- The real task is trying to facilitate them shifting their energy in to
contemplating change.
Resignation
Defining features:
- Lack of energy and investment.
- Given up on possibility of change.
- Might feel overwhelmed by problem, having made many attempts to
quit.
- Might feel hopeless and pessimistic, that its too late for them.
Strategies:
- Instil hope (personal feedback, successful examples of change in
others.)
- Supporting self-efficacy. (See Principles of Motivational Interviewing)
- Explore barriers to change.
Rationalisation
Defining features:
- Has all the answers, blaming, yes but, minimising.
-- Consultation can turn into a debate point-counterpoint.
Strategies:
- Empathy and reflective listening.
- Extended discussion will only serve to facilitate their habit of
strengthening their argument.

MOTIVATIONAL INTERVIEWING
STAGES OF CHANGE: CONTEMPLATIVE
USING CIGARETTE SMOKING AS AN EXAMPLE
Contemplative
Always keep in mind the Principles of Motivational Interviewing. The doctors primary
task is to help tip the balance in favour of change. Depending on time, tasks may
include:
Assess behaviour
Get estimate of cumulative exposure to cigarettes
Specific tar content and number of cigarettes, years smoked.
Assess dependence severity
Assess past attempts
Withdrawal symptoms, patterns, high risk situations.
Eg. Have you ever stopped smoking before even for a few days?
How did you do it? What problems did you have?
What did you do to deal with those problems?
Elicit pros and cons of behaviour and of change
What are the good things about smoking?
What are some of the not so good things about smoking?
Probe by asking What else? and What others? (Generates more options
(more open) than Anything else? where the answer can be No).
What are the good things about giving up smoking?
What are some of the not so good things?
Develop discrepancy.
Does that concern you? What concerns you about it?
Remember useful clarification and elaboration probes: What do you mean
by? Can you tell me more about that?
Summarise pros and cons.
Verbally reinforce statements that indicate that change is being considered.
Provide information and encourage patient to interpret it.
Advantages of change.
Remember immediate, personal and concrete information is more motivating.
Identify treatment options.
Provide self-help material.
Provide objective feedback and have the patient discuss the impact of the results.
Support self-efficacy.
Highlight patients personal strengths or Ive seen other patients who feel like
you and theyve successfully..
Highlight any past successes in abstaining even for short periods of time.
Follow-up.
With agreement, negotiate at appropriate time.
Student Resources
INFORMATION SHEET 7
MOTIVATIONAL INTERVIEWING STAGES OF CHANGEPREPARATION AND ACTION
PREPARATION
The doctors primary task is facilitating patients choice of an appropriate change
strategy that is acceptable, accessible, appropriate and effective. Preparation is more a
matter of matching than motivating. Tasks to achieve:
Self-monitoring.
Encourage patient to keep diary. Direct feedback is powerful tool.
Identify high risk situations.

Elicit from patient.
Brainstorm Strategies.
Elicit from patient and suggestions from doctor I can tell you what
works for others and There are lots of options. Eg. Trans-dermal
patches are recommended for all but they are the most highly
nicotine dependent.
Help patient to develop situation-specific strategies.
Goals.
Negotiated with patient.

Small achievable steps if most suitable. Eg daily average and
weekly totals.
Set a quit date and finalise a plan.
Verbally reinforce value of any past attempts, reframe.
ACTION
The doctors primary task is to ensure that the attempt to change behaviour is more
likely to be successful.
Very important in action stage.
Focus on their successful activity, reaffirm decisions, help them
make intrinsic attributions of successes (and take the credit for
it).
Give information.
Successful models which have used a variety of action options.
Purpose of models is not to offer rigid prescription for change,
but to engender a sense that success is possible for someone
like the patient.
Follow-up.
Reinforce small gains
MOTIVATIONAL INTERVIEWING STAGES OF CHANGEMAINTENANCE/RELAPSE
MAINTENANCE
Identify support.
Successful behaviour change is more likely in supportive
environment.
Roll with resistance.
If patient responds that wont work because Thats fine, lets
not get too stuck on one idea. Lets move on, what else could you
do?
Self-help materials.
A preferred option by many patients and most successful in
preparation and action stages and answer questions.
Follow-up.
At follow-up monitor progress, reinforce small gains, review goals.
Referral.
Appropriate if brief intervention is ineffective. Evidence of
significant social disruption.
The doctors main task is to develop relapse prevention strategies with patient to
ensure long-term sustained change over several years.
Problem-solve in high-risk situations.
Recognition of problem, brainstorming strategies, assess pros and cons of each
strategy, choose suitable strategy, refine if necessary.
RELAPSE
The reasons for relapse are typically a strong, unexpected urge or temptation, relaxing
their guard or testing themselves, unexpected costs of change and commitment or
self-efficacy erodes. Return to previous behaviour usually occurs gradually after an
initial lapse (slip).
Deal with the effects of lapses.
Cognitive dissonance, goal-violation effect, low self-efficacy
Strategies: Reframe lapse from failure to learning opportunity, and focus on

what was achieved, emphasise how common lapses are, emphasise new skills
needed and discuss how to achieve them.

ADHERENCE
Adherence (formerly referred to as compliance and sometimes referred to as
concordance) is usually defined as the extent to which patients follow the treatment
plan of their health care provider (e.g. taking prescribed medications, following a
weight loss plan, completing a physiotherapy exercise schedule). Adherence rates are
typically higher among patients with acute conditions, as compared with those with
chronic conditions. Across a range of chronic conditions of varying severity,
adherence rates can be as low as 20%, with an average of 50%. Further, after the first
six months of treatment, adherence typically drops off dramatically. In some
conditions such as HIV, adherence is literally a matter of life and death. In one study
of an antiretroviral treatment regimen, > 95% adherence to treatment resulted in viral
suppression, but failure rates increased sharply with < 95% adherence (Paterson et al.,
2000). Even in a well-informed patient group, with established support networks and
no cost disincentives, antiretroviral medication adherence rates can be as low as 50%,
particularly in the maintenance stages of treatment (Descamps, et al., 2000).
There are a number of factors that influence patient adherence.
Patient factors:
- rapport with clinician
- knowledge of the disease process and treatment principles
- impact of treatment on daily life (e.g., injecting insulin at lunch time at work)
- severity of side-effects
- mood disorders, sleep deprivation, cognitive impairment, substance use
- quality of social support
Clinician factors:
- quality of patient-provider relationship
- ability to provide clear information to patient on treatment
- consistency in advice over time and across care givers
- ability of health professional to detect non-adherence and work with it
constructively
Institutional factors:
- quality of environment (e.g., culturally sensitive, respectful)
- cost of intervention/medication
- continuity of care
- availability of after-hours support for side- effects or crises
- social work support to assist with financial and logistical barriers to adherence
The World Health Care Organisation listed the physician-patient relationship as one
of the five identified factors believed to enhance adherence (Sabate, 2003). Further, a
recent meta-analysis of 127 studies examining physician communication and client
adherence, concluded that the client is more than twice as likely to adhere to treatment
recommendations if their physician has effective communication skills and improving
physician communication also led to a 12% increase in client adherence (Haskard

Zolnierek & Dimatteo, 2009)
Suggestions to increase patient adherence when starting a

new treatment
Educate patient about his/her disease process and the main principles of
treatment, using language the patient can understand. Support your words with
pictures, diagrams, written handouts. See CCS information sheet: Information
Giving
Outline the pros and cons of treatment. Discuss most likely side-effects
If similarly effective evidence-based treatments exist, engage patient in
decision- making process (eg. Nicotine replacement therapy using patches
verses gum).
Acknowledge the commitment required, the benefits of treatment and the
consequences of non-adherence
Recognise patients lifestyle and preferences (e.g. consider once a day versus
more frequent dosing, particularly for person at work or school)
Link treatment with daily routines (e.g. one tablet with breakfast and dinner;
puffers twice a day when clean teeth, practise the exercises on waking and
before going to bed)
For young patients or other patients with carers, ensure parent/carer is
informed of purpose and routine of treatment
Ask the patient if s/he expects any difficulties in adhering to the treatment
plan.
Assess motivation and behavioural stage of change. Pre-contemplators will
generally be less adherent than those in action stage. The emphasis for Precontemplators should be brief provision of clear, evidence-based information.
Involve the pharmacist, who can then reinforce the message to the patient and
informed carer.
Suggestions for dealing with suspected or confirmed noncompliance
Ask about adherence in a non-judgemental way using pleasant and relaxed

tone of voice (e.g., People in your situation often have difficulty in taking
their medicines all the time. How are you going?)
Review your relationship with this patient. Does he/she feel you are willing to
listen to concerns and difficulties? Express empathy for the difficulty
experienced in adhering to the plan (e.g., Its been hard for you to remember
the tablets each day?)
Find out about the patients experience with the treatment (e.g., Can you tell
me some more about how the tablets made you feel?)
Review the patients understanding of the function and significance of the
treatment (Lets go back to the problem you are having with.Tell me what
you understand about how these tablets are going to help you.). Build on the
patients understanding and knowledge.
Explore health beliefs with patient. (What are your thoughts on how things
are going with your health at the moment?)
Consider other barriers to adherence such as financial problems, memory
impairment, mood disorders, poor family support, lack of continuity of care.
Address/treat where possible.
Engage assistance of calendars, dosage dispensers (eg. Webster Packs), family
support.
Always anticipate relapse in adherence (particularly for chronic conditions),
even after long-term use
Selected References
Deschamps, D, et al (2000). Mechanisms of virologic failure in previously untreated
HIV-infected patients from a trial of induction-maintenance therapy. Journal
of the American Medical Association, 283, 205-211.
Haskard Zolnierek, K. B., & Dimatteo, M. R. (2009). Physician communication and
patient adherence to treatment: A meta-analysis. Medical Care, 47(8), 826834.
Ickovics, J. (1997). Adherence in AIDS clinical trials: a framework for clinical
research and clinical care. Journal of Clinical Epidemiology, 50, 385-391.
McDonald, H., Garg, A., and Haynes, R. (2002). Interventions to enhance patient
adherence to medication prescriptions. Journal of American Medical
Association, 288, 2868-2879.
Osterberg, L. and Blaschke, T. (2005). Drug therapy: Adherence to medication. New
England Journal of Medicine, 353, 487-497.
Paterson, D. Swindells, S., Mohr, J., Brester, M., Vergis, E., Squier, C., Wagener, M.,
and Singh, N. (2000). Adherence to protease inhibitor therapy and outcomes
in patients with HIV infection. Annals of Internal Medicine, 133, 21-30.
Sabate, E. (2003). Adherence to Long-Term Therapies: Evidence for Action. Geneva:
World Health Organization.
Spoont, M., et al (2005). PTSD and Treatment Adherence: The Role of Health
Beliefs. Journal of Nervous and Mental Disease,193, 515-522
Weaver, K. et al (2005). A Stress and Coping Model of Medication Adherence and
Viral Load in HIV-Positive Men and Women on Highly Active Antiretroviral
Therapy (HAART). Health Psychology, 24, 385-392.
See also School of Medicine Portal/Therapeutic Guidelines/Psychotropic/Pertinent
practical points for psychotropic drugs/Compliance
!
!
!
!
PSW!!STEPS!AND!MARKING!
SHEETS!
Steps for Routine/Social Hand wash Liquid

Soap and Water
6. Rub back of fingers with hands clasped
Hands should be washed vigorously for 15-30seconds

(Total duration of hand wash: 40-60 seconds)
1.
2.
3.
4.
Remove jewellery (may wear a plain wedding band)

Wet hands and wrists thoroughly and apply soap
Rub hands palm to palm
Rub back of hand with palm of other hand with fingers
interlaced. Repeat on other hand
7. Clasp thumb and clean in a circular motion and repeat

on other thumb
5. Rub palm to palm with fingers interlaced
8.
Rub tips of fingers into palm of one hand in a circular

motion and repeat on other hand
9.
Rub around the wrists
11. Pat hands dry with a paper towel, starting at fingers

then moving towards wrist and forearm.
(Patting the skin dry prevents chapping. Hands are
dried first because they are considered the cleanest
and least contaminated area)
12. If using a sink without an auto-sensor regulator or

elbow controls, dont touch taps with clean hands.
Use paper towel to turn off taps
10. Rinse hands under running water with fingertips

uppermost, allowing water to run down towards wrist
Competency for Routine/Social Hand wash

Liquid soap and Water
Hands should be washed vigorously for 15-30seconds
(Total duration of hand wash: 40-60 seconds)
1. Removes jewellery (may wear wedding band)
2. Wets hands thoroughly and applies soap using elbow
on soap dispenser
3. Rubs hands palm to palm
4. Rubs back of hand with palm of other hand with
fingers interlaced. Repeats on other hand
5. Rubs palm to palm with fingers interlaced
6. Rubs backs of fingers with hands clasped
7. Clasps thumb and cleans in a circular motion. Repeats
on other thumb
8. Rubs tips of fingers into palm of one hand in a circular
motion. Repeats on other hand
9. Rubs around each wrist
10. Rinses hands under running water
11. Doesnt touch taps with clean hands if elbow controls
are not available, uses paper towel to turn off taps
12. Pats hands dry using paper towel
STEPS FOR MEASURING TYMPANIC TEMPERATURE
Start Button
Probe cover
Release
button
1. Perform hand hygiene (Moment 1)

2. Remove thermometer from handheld unit
3. Place cover over probe of earpiece. The thermometer turns on
automatically
4. Wait for the ready signal beep. The display screen will show -5. Gently pull ear straight up and back for adults and back for
children
(Straightens external auditory canal, allowing maximum
exposure of the tympanic membrane)
6. Insert the probe snuggly into the auditory canal using gentle
but firm pressure
Steps for measuring tympanic temperature (2014)
7. Push and release the start button

(A green light on the top of thermometer will flash during the
measuring process)
8. Leave probe in place until audible signal occurs
(If the probe has been fitted correctly into the ear canal a long
beep will signal within 3 seconds)
9. Read temperature on display screen
10. Press release button just above display screen to discard

cover into bin
Steps for measuring tympanic temperature (2014)
STEPS FOR MEASURING PULSE AND RESPIRATION

RATE (RR):
2. Determine previous baseline pulse rate and RR from
patients notes
3. Place patients forearm straight alongside or across
lower chest or upper abdomen with wrist extended
straight
4. Place pads of the index and middle fingers at the base
of the patients thumb, and slide down about 2cms in
the groove of the inner wrist.
5. Lightly compress the artery so pulsations can be felt
(The pads of your fingers are more sensitive)
6. Assess the rhythm and amplitude/strength of the

pulse and note whether pulse is bounding, strong,
weak or thready
7. Count pulse for 30 seconds and multiply by 2. If pulse
is irregular count for 60 seconds
8. While your fingers are still in place for the pulse
measurement, observe the patients RR
9. Observe a complete respiratory cycle
(1 inspiration and 1 expiration)
10. Count the number of respirations for 30 seconds. If
respirations are abnormal in any way, count for 60
seconds
11. Record results in patients chart
Steps for measuring pulse rate and respiratory rate (2014)
1!
!
!
STEPS!FOR!MEASUREMENT!OF!A!B!RACHIAL!BLOOD!PRESSURE!(2014)!
!
!
1.! Perform!hand'hygiene'(Moment'1)'
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2.! Explain!procedure'to'patient'and'gain'verbal'consent;'Check!for'any'clinical'conditions'that'
may'prevent'taking'BP'on'a'particular'arm'(e.g.'mastectomy'etc)'
'
3.! Position'patient'correctly''Seated'with'back'supported,'legs'uncrossed,'feet'flat'on'the'floor'
and'arm'supported'so'brachial'artery'is'level'with'the'heart'
'
4.! Remove'excess'clothing'from'the'arm'that'may'interfere'with'BP'cuff'or'constrict'blood'flow'
to'the'arm'''
'''''''''''''''''''''''''''''''''''''
5.! Choose!appropriate'sized'cuff''(Measure'cuff'around'patients'arm'and'ensure'index'line'is'
within!the'range'area)'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
''''''''
'
'''''''
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6.! Palpate!the'brachial'artery'and'position'cuff'so'artery!marker'on'cuff'points'to'the'brachial'
artery''
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''''''''''''''''''
'
''''''''''''''''''Use'the'pads'of'your'fingers'
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Steps!for!Measurement!of!Blood!Pressure!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
2014!
2!
''''
'''''''
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'
'
7.! Wrap!BP'cuff'snuggly'around'the'arm.''The'bottom'edge'of'the'cuff'should'be'2.5''5'cms'
above'the'crease'of'elbow.''Ensure'you'are'directly'facing'the'pressure'manometer/gauge'
to'ensure'a'correct'reading'(avoid'parallax'error)'
'
8.! Palpate'radial'pulse'''''''''
'''''''''''''''
''''''''''''''''''''''''''''''
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9.! Close'valve'of'pressure'bulb'clockwise'until'tight'and'inflate!cuff.''Note'on'pressure'gauge'
where'the'radial'pulse'disappears'and'continue'to'inflate'a'further'30'mm'Hg'above'this'
pressure'''
'
10.! Turn'valve'anticlockwise'to'slowly'release'air'from'cuff'(maximum'rate'of'3'S'
4mmHg/second)'noting'on'the'pressure'gauge'where'radial'pulse'reappears.'(This'is'an'
estimate'of'the'patients'systolic'reading);'Rapidly!deflate'cuff''
2014!
3!
!
'
''''''''''''''''''''''''''''''''
'
'
'
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'
'
'
'
'
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'
'
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'
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11.! Wait'30'seconds!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
'
12.! Palpate'brachial'pulse'and'position'diaphragm'of'stethoscope'over'the'brachial'artery'in'the'
antecubital'fossa''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''(Make'sure'the'
diaphragm'does'not'touch'the'cuff'or'tubing'to'minimise'artifact/stray'sounds)'
'
'
''''''''''''''''''''''''''''''''''
'
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13.! Rapidly!reSinflate'cuff'30mm'Hg'above'that'at'which'radial'pulse'reappeared''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''
(This'ensures'avoiding'BP'measurement'during'any'auscultatory'gap)'
'
st
14.! Slowly!deflate'cuff'(at'a'maximum'rate'of'3'S'4mmHg/second)'and'listen'for'the'1 'of'2'
consecutive'beats'(Korotkoff,'phase'1),'even'if'the'sounds'disappear'temporarily'(the'
auscultatory'gap).'This'is'the'systolic!BP.'''The'diastolic!reading'is'recorded'at'where'sounds'
disappear'(Korotkoff,'phase'5).''
15.! !Rapidly!deflate'cuff'
16.! Record!systolic'and'diastolic'BP'to'the'nearest'2'mmHg'
17.! Wait!for'at'least'30'seconds'before'repeating'BP'on'the'same'arm'
18.! Average!the'2'readings'
19.! Perform'hand'hygiene'(Moment'4)'
2014!
STEPSFORTHECOLLAPSEDPATIENT:
ADULT BASIC LIFE SUPPORT COMPETENCY (2014)

UNIVERSITY OF QUEENSLAND
Name: ___________________________________________________________
Date: ___________________________
PERFORMANCE CRITERIA
Checks area for potential danger/hazards to self, patient and others
If danger identified, discusses management
Uses PPE if required (gloves, pocket mask) ensuring safety of self
Assesses patients response using verbal and tactile stimuli
Asks simple questions:
Can you hear me?
Whats your name?
Squeeze my hands?
Speaks into both ears (in case patient is deaf)
Gently squeeze patients shoulders
Stays with patient
Calls for help
Presses emergency buzzer
Notes time
Checks airway by opening mouth (no head tilt)
Removes foreign body by turning head gently to side (if no risk of spinal injury)
Allows drainage via gravity
Finger sweep for visible material
No blind finger sweep
Leaves well fitting dentures
Uses suction (if available)
Performs head tilt/chin lift and assesses breathing for up to 10 secs:
Looks for chest rise and fall
Listens for escape of air from the nose and mouth
Feels for movement of chest and expired air on cheek
If patient breathing rolls into the recovery position
DANGER
RESPONSE
SENDS FOR HELP
AIRWAY
BREATHING
If patient not breathing - Immediately commences 30 compressions
PBL Number: _______________

Session Time: _______________
1st
ATTEMPT
2nd
ATTEMPT
COMMENTS
COMPRESSIONS
Demonstrates:
States:
RESCUE BREATHS
DEFIBRILLATION
Perform 30 compressions: 2 rescue breaths

Perform 100 compressions/min
Rotate compressor role every 2 mins
Compressions are paused for ventilations
Demonstrates the correct technique for mouth to mask:
Mask placed in correct position with a good seal
Performs head tilt/jaw lift
Inflates lungs with enough air to achieve chest rise
Delivers each breath in 1 second
Removes mouth from mask to look, listen and feel for the escape of air and chest fall
Allows chest to fully recoil before giving next breath. Does not deliver extra breaths if
chest rise is not seen
Turns on AED and follows prompts:

States:
Correct placement for pads in Anterior/Lateral position
(L) mid-axillary line across from xiphoid process in 6th intercostal space
(R) side of upper sternum in mid-clavicular line 2nd intercostal space
No contact with patient during analyse
Calls stand clear and performs visual sweep prior to pressing SHOCK button
States safety principles:
Dont place pads over:

Implantable devices, ECG electrodes & leads
Medication patches, jewellery
Excessive chest hair/moisture
Avoid defibrillation when:

Direct/indirect contact with the patient during defibrillation
Patient in contact with metal surfaces e.g. bedrails or IV therapy poles
Responders standing in water/ urine
An explosive or flammable environment
Free flowing (move oxygen mask at least 1 meter away )
Date: ________________________
C/NYC
Correct hand position (centre of chest/lower of sternum)

Interlocks fingers or locks hand around the wrist of the compressing hand with fingers raised off
chest
Keeps compressing arm straight with shoulders vertical over sternum
Compresses chest with heel of hand 1/3 depth of chest (>5cms)
Assessors Signature: 1st attempt: _____________________________
If NYC: Students signature: ______________________________
2nd attempt ______________________________

OSCE Guide, University of Queensland School of Medicine

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OBJECTIVE)STRUCTURED)CLINICAL)EXAMINATION)(OSCEs))

Family History (FH)

Past Medical History (PMH)

Social History (SH)

Hospital visits, previous illness, previous operations

Specifically: diabetes, asthma, bronchitis, TB, jaundice, high BP (dont say

Medications - tablets, injections, prescriptions, herbal remedies, the pill

Allergies & adverse drug reaction

Indications to ask urethral/vaginal discharge, genital ulcer/rash, abdominal

All women; esp. abdominal pain, ? endocrine disease, genitourinary symptoms

General - weight loss, night sweats, lumps, fevers, fatigue / malaise /

Cardio-respiratory - chest pain, dyspnoea (exertional, PND, orthopnoea),

Gastrointestinal abdominal pain, difficulty / pain on swallowing, indigestion,

Genitourinary incontinence, dysuria, haematuria, nocturia, frequency, polyuria,

Musculoskeletal pain / stiffness / swelling of joints / muscles, changes

Home life marriage, children, living situation

Do any conditions run in the family?

Appetite changes anorexia,

Weight loss (malabsorption,

Dysphagia (oesophagus, nodes,

Mental state alert, confused,

Indigestion / heartburn reflux

Body habitus weight, wasting,

Nausea / vomiting onset,

Colour pallor, jaundice,

Vital signs Temp, HR, BP, RR, O2

Haematemesis frank or coffee

Abdominal pain colicky (biliary,

Jaundice (haemolysis, liver, biliary)

Hands leukonychia (albumin),

Change in bowel motions

PMH abdominal surgery

Family colorectal cancer,

Medications NSAIDs (ulcers),

Social smoking, alcohol, IV drugs,

Patient lying supine with one pillow

Arms/shoulders spider naevi

Eyes xanthelasma, icterus,

Salivary glands parotid &

Lips hydration, agular cheilitis,

Mouth foetor, stomatitis,

Lymph nodes cervical & axillary

Chest spider naevi (oestrogen),

Abdomen scars, striae, bruising,

Deep masses, guarding, rigidity,

DRE inspection (fissure, fistula,

Sudden onset of pain

Cough nature, onset, wet (viral,

Sputum colour, volume, type

Haemoptysis acute (malignancy),

Dyspnoea / shortness of breath

Wheeze (high pitch) when,

Stridor (inspiratory rasp) onset

Chest pain nature, intensity,

Sleep apnoea snoring or waking

Voice change - dysphonia,

Hands clubbing (pus in lungs),

Asterixis (CO2 retention)

Radial pulse, respiratory rate,

Eyes conjunctival pallor, Horner

Nose (straight in) polyps,

Mouth central cyanosis,

Sinuses frontal, ethmoidal,

Lymph nodes cervical & axillary