TÍTULO IX. Del profesorado
Artículo 93. De la cultura universitaria
ACE Tips
The patient may not know the name of the drugs they take, however always be suspicious of drug induced hepatitis in rheumatology and TB patients as the main drugs used within treatment of these conditions are toxic to the liver.
Pay attention to the young ‘gap year’ traveller who presents with jaundice. It is less likely to be alcohol and more likely to be viral especially Hepatitis A or EBV.
Do not be shy to ask personal questions regarding sexual lifestyle and recreational drug use – as a doctor you are there to find the answer and offer medical help, not to judge social habits.
Don’t miss Ace the OSCE: Video Training Series at www.AceMedicine.com 34
11) Weight Gain
Instructions given by examiner to candidate: You are a junior doctor working in a GP surgery. Mrs
Davidson a young aged female presents with weight gain. Please take an appropriate history from her and summarise your findings at the end with likely differential diagnoses.
Information provided to Examiner for History Dialogue with Candidate
You are a 34 year-old single medical typist concerned about weight gain over the past 3 months. You have gained 12kg despite no change in diet, exercise or other aspects of your lifestyle. You do have ‘naughty food’ like fish and chips once a week, but this is unchanged. You walk to work each day and play badminton once a week. You are not on any prescribed of over the counter medications. You have no medical history. You are not sexually active.
You do not freely offer it, but on direct questioning from the doctor you reveal a number of associated symptoms, including fatigue, irregular periods and dry hair/skin.
You are sure this is not purely down to diet.
Common differentials
Dietary/ lack of exercise Cushing’s syndrome/ disease Drugs e.g. HRT or OCP Hypothyroidism Depression
Undiagnosed Pregnancy
Features of the history associated with common differentials
Dietary/ lack of exercise: Look out for recent change in lifestyle, social or work habits that have led to change in diet/ exercise whether the patient is aware of these dietary changes or not.
Cushing’s syndrome/ disease: Specific Cushingoid features include; weight gain distributed mainly on face, neck, abdomen and back to give features such as “moon face” and “buffalo hump”. Thick purple striae, mood change (low mood, irritability), muscle weakness,
impotence, oligomenorrhoea, acne, hirsutism, easy bruising and thin skin.
Drugs: look out for use of drugs such as HRT, OCP, antidepressants, anti-psychotics preceding the weight gain by a few weeks.
Hypothyroidism: Look out for weight gain despite decreased appetite, dry hair and skin, complaint of neck swelling (goitre), swollen legs, hands and eyelids), cold intolerance, constipation.
Depression: Look out for low mood, anhedonia, sleep disturbance, change in appetite and weight, loss of libido, social withdrawal. There may be a history of life change prior to onset of symptoms that hints towards cause for a reactive depression.
Pregnancy: Look out for the young female of childbearing age, sexually active, amenorrhoea with insufficient contraceptive use.
Don’t miss Ace the OSCE: Video Training Series at www.AceMedicine.com 35 Introduce
Check name, age, occupation and marital status. Permission
Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?”
Presenting complaint
“Why have you come here today”? History of presenting complaint
Open question: “tell me a bit more about it” and then allow the patient to talk. Specifically ask about:
o When weight gain was first noticed and if any lifestyle, social or family circumstances changed at that time.
o Food intake, exercise and dietary supplements. o How much weight gained over how long?
o Associated symptoms e.g. low mood, sleep disturbance, abdominal pain, change in bowel habit, abdominal bloating, cold intolerance, irregular menstruation, hair or skin changes, and muscle weakness.
o Has this happened before? o Any new drugs started recently. Ideas, Concerns and expectations
“Do you have any idea what is causing your weight gain, or any concerns about it?” Past Medical History
Ask about: thyroid disease, psychiatric history including mood disorders and eating disorders, conditions treated with steroids e.g. rheumatoid, sarcoidosis, asthma etc. Drug History
Any medications they have recently started or stopped taking. Any including over the counter medications.
Drug allergies Family History
Ask about: Psychiatric illness, thyroid disease, endocrine disorders especially adrenal or pituitary tumours, and obesity.
Social History
Social stressors including work, diet, smoking and alcohol. Systems review
General overview of all systems, especially GI. Present case to patient (and examiner)
Summarise findings and finish with “the most likely cause of the presenting complaint is... However important differentials to consider would include...”
Don’t miss Ace the OSCE: Video Training Series at www.AceMedicine.com 36 Summary
This 34 year-old single women with no previous medical history admits to a significant weight gain of 12kgs over the past three months which she does not relate to changes in lifestyle. This is
accompanied by fatigue, oligomenorrhoea, dry skin and dry hair. The most likely diagnosis is hypothyroidism.
ACE Tips
Remember some drugs can cause an increase in appetite which leads to weight gain. In these cases both diet and the drug need to be addressed, especially if the drug is one that cannot be substituted for another.
Be specific when asking about diet and exercise. Patients have a varying opinion of what a healthy diet is and what constitutes adequate exercise. Ideals are 30 minutes of exercise 5 times a week and a diet high in fresh fruit, vegetables and complex carbohydrates whilst low in salt, saturated fats, simple carbohydrates and alcohol.
If you have concerns over whether the patient really is telling the truth with food intake and exercise, provide them with a food diary to bring completed to their next appointment Marking Sheet: Weight Gain Station
Not
attempted Attempted inadequate Attempted adequate 1 Introduces self and position 0 1 2
2 Obtains consent via an open question 0 1 2 3 Establishes the name, age, occupation and marital
status of patient 0 1 2 4 Open question to commence history establishing
initial understanding of why you are speaking with them
0 1 2 5
Explains the diagnosis of epilepsy and checks patient’s understanding of disease (0=none, 1 = 2-3
factors, 2 = 4 or more factors)
0 1 2 6 Enquires regarding patient’s knowledge of how
epilepsy will effect his/her activities (0=none, 1 = 2-3 factors, 2 = 4 or more factors)
0 1 2 7 Explains need and why DVLA must be informed. 0 1 2 8 Deals with the patient’s distress and concerns with
empathy
0 1 2 9
Explains other activities which need to be stop or
changed (eg, shower not bath) 0 1 2 10 Allows patient to raise concerns and questions 0 1 2 11 Summary 0 1 2 12 Rapport with patient 0 1 2 13 Thank the patient 0 1 2
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12) Weight Loss
Instructions given by examiner to candidate:
You are a junior doctor working in a GP surgery. Miss Rivers, a young female attends with her mother. She presents with weight loss. Please take an appropriate history from her mother and summarise your findings at the end with likely differential diagnoses.
Information provided to Patient for History Dialogue with Candidate
You are a 24 year-old woman and attend with your mother as you still live at home and are ot particularly fond of hospitals. You and your family are concerned about how thin you have become over the past 3 months. You are now a size 0 dress. You have lost 13kgs in total.The weight loss is not intentional having been only a size 8 before. You flatly deny any suggestions of an eating
disorder and you mum supports you in that you eat the same if not more than normal presently. You are happy, but feel anxious at times with reduced sleep requirements. Your mum adds you keep opening the windows at home, when the others feel it’s cold. You have not had a period for 4 months.
Your family, medical, social and drug history are all unremarkable.
Common differentials
Type 1 diabetes mellitus Malignancy
Intentional weight loss Depression
Thyrotoxicosis
Malnutrition & malabsorption disorders
Featuresof the history associated with common differentials
Type 1 diabetes mellitus: increased thirst, frequent urination and fatigue generally accompany weight loss as presenting symptoms of IDDM. The patient is also likely to be in their teens or younger.
Intentional weight loss: Look out for an initially overweight patient or increase in exercise and decreased/ healthier food consumption. Warning signs of eating disorders include pre- occupation with weight and appearance, also look out for the patient who is of normal/ underweight but insists they need to lose weight.
Depression:Features to look out for include low mood, loss of appetite and libido, insomnia, low self esteem, feelings of guilt and suicidal ideation.
Thyrotoxicosis:Look out for typical hyperthyroidism symptoms e.g. heat intolerance, palpitations, increased appetite, irregular periods and hand tremor.
Malnutrition/ malabsorption e.g. IBD or coeliac’s disease: Look out for (bloody) diarrhoea, mouth ulcers, peri anal disease, abdominal pain, bloating and general discomfort.
Don’t miss Ace the OSCE: Video Training Series at www.AceMedicine.com 38 History Dialogue
Introduce
Check name, age, occupation and marital status. Permission
Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?”
Presenting complaint
“Why have you come here today”? History of presenting complaint
Open question: “tell me a bit more about it” and then allow the patient to talk. Specifically ask about:
o When weight loss was first noticed and if any lifestyle, social or family circumstances changed at that time.
o Food intake, exercise and dietary supplements. o How much weight lost over how long ?
o Associated symptoms e.g. low mood, sleep disturbance, abdominal pain, change in bowel habit, abdominal bloating, thirst, polyuria or frequency, heat intolerance, irregular menstruation or palpitations.
o Has this happened before?
o Patient’s body image- do they think they need to lose weight and how does this relate to their true size.
Ideas, Concerns and expectations
“Do you have any idea what is causing your weight loss, or any concerns about it?” Past Medical History
Ask about: thyroid disease, psychiatric history including mood disorders and eating disorders, GI disease.
Drug History
Any medications they have recently started or stopped taking. Any over the counter remedies or nutritional products. Drug allergies
Family History
Ask about: Psychiatric illness, thyroid disease, IBD, coeliacs disease and other malabsorption states and weight loss in general.
Social History
Social stressors including work, diet, smoking and alcohol. Systems review
General overview of all systems, especially GI/ GU . Present case to patient (and examiner)
Summarise findings and finish with “the most likely cause of the presenting complaint is... However important differentials to consider would include...”
Don’t miss Ace the OSCE: Video Training Series at www.AceMedicine.com 39 Summary
This 24 year-old female has unintentionally loss 13kg in the past 3 months. There has been no reduction in food intake supported by a collaborative history from her mother. The weight loss have been accompanied with heat intolerance and amenorrhoea.
The most likely diagnosis is thyrotoxicosis. ACE Tips
Eating disorder is less likely if the patient presents on his/her own, but explore if patient is brought in by a parent against their own wishes, even if they deny intentional weight loss. Tread carefully and take the history from the patient away from the parent in order to get a true picture of their eating habits.
A depressed patient may be truly oblivious to the fact that they are depressed and unwilling to accept they have a low mood despite having all the core and biological symptoms of depression. It is common for a depressed patient to “not believe” in depression or have been depressed for so long they feel it is normal.
If the patient is unable to quantify their weight loss ask about change in dress sizes, trouser size or number of belt holes used to do up belt.
Remember weight loss may be the presenting complaint of an undiagnosed malignancy Marking Sheet: Weight Loss History
Not attempted Attempted inadequate Attempted adequate 1 Introduces self and position 0 1 2 2 Obtains consent via an open question 0 1 2 3 Establishes the name, age, occupation and marital
status of patient
0 1 2 4 Open question to commence history establishing
initial details of problem 0 1 2 5 Enquires in depth in about nature of the abdominal
pain 0 1 2 6 Enquires into other additional symptoms, in altered
bowel habit
0 1 2 7 Asks regarding severity of pain in an objective
fasion (scale 1 -10)
0 1
8 Past Medical History (especially surgery) 0 1 2 9 Family History
(For 2 marks must include specific enquiry on GIT pathology)
0 1 2 10 Social and Drug History
(alcohol and OTC drugs must be specifically questioned for 2 marks)
0 1 2
11 Concerns and Ideas of patient considered 0 1 2 12 Presentation and Summary 0 1 2 13 Differential Diagnoses Provided 0 1 2
Don’t miss Ace the OSCE: Video Training Series at www.AceMedicine.com 40 13) Confusion/ memory loss station
Instructions given by examiner to candidate:
You are a junior doctor working in an acute medical unit. It’s around 10pm and an elderly lady was found wandering the street on her own and was brought into hospital by police.
Please take an appropriate history from her, and summarise your findings at the end with likely differential diagnoses, with the most likely offered first.
Time Allowed: 8 minutes
Information provided to Patient for History Dialogue with Candidate
This 84 year-old lady lives alone in her bungalow, with minimal input 3 times a week from her family with no outside assistance. She has a history of hypertension and sinusitis for which she is taking limited medication. Her last admission to hospital was 20 years ago with a chest infection. She regularly plays bingo at her local church hall and is involved with matters in the local church. Over the past 48 hours her neighbour noticed he been muddled and she is now out rightly confused, being unaware of the day of the week or her pet dog’s name. Her neighbour indicates she did complain of some lower abdominal comfort prior the confusion. She is teetotal and has not recently suffered and injury.
Common differentials
Dementia - Alzheimer’s type Dementia – Multi-infarct type Delirium
Alcohol intoxication/ withdrawal Hypoglycaemic episode
Head injury
Drug side effect/Poly-pharmacy Infection – low grade UTI or LRTI
Features of the history associated with common differentials
Dementia: gradual worsening over a long period of time with Alzheimer’s or a sudden
“stepwise” deterioration in memory with multi-infarct(vascular) dementia. Activities of daily
living are compromised, loss of orientation to time, person and place occurs. Patient presents in old age. Risk factors for vascular dementia, such as hypertension, diabetes, previous strokes provide clues.
Delirium: look out for fluctuating confusion and behaviour change. Sleep wake pattern reversal, decreased consciousness, visual and tactile hallucinations and inattention are Alcohol intoxication/ withdrawal: tremors, seizures, history of chronic alcohol use and smell of alcohol are features to watch out for. Visual and tactile hallucinations can also feature in alcohol withdrawal.
Hypoglycaemic episode: check for mention of diabetes, use of insulin, oral hypoglycaemics, alcohol, quinine and beta blockers as these can cause hypoglycaemia. History typically reveals autonomic symptoms e.g. sweating, anxiety, hunger and tremors before confusion and drowsiness sets in.
Head injury: watch out for apparently unimportant incidents where the patient could have
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Drug side effect: e.g. opiates, BDZs and recreational drugs.
Infection: The patient may complain of a cough or dysuria or fever. The exclusion of other causes on history taking may lead to this diagnosis.
History Dialogue Introduce
Check name, age, occupation and marital status. Permission
Explain who you are and why you are there e.g. I am a final year medical student, I would like to ask you questions about how you are feeling at the moment, is that OK?”
Presenting complaint
“You were found wandering in the street and looking a bit lost, do you remember what you were doing?”
History of presenting complaint
Open question: “tell me a bit more about it” and then allow the patient to talk. Specifically ask about:
o How aware are they of their confusion o How much it is impacting on their daily life
o Do an AMT to check level of cognitive impairment.
o If anyone they see frequently has commented on a change o If any medications, drugs, alcohol, or acute illnesses recently. Ideas, Concerns and expectations
“Do you have any idea what is causing your headache, or any concerns about it?” Past Medical History
Ask about: Diabetes, high blood pressure, CVA, or depression. Drug History
Especially BDZs, opiates. Drug allergies
Family History
Ask about: Alzheimer’s, high blood pressure and strokes. Social History
Ask about risk factors for vascular disease: Smoking and alcohol. Systems review
Ask especially about signs of systemic illness like fevers, headaches, coughs, cold and urinary symptoms as these could cause delirium.
Present case to patient (and examiner) Summary
This 84 year-old female has been confused for the past 48 hours, with an otherwise limited medical history. There is no history of trauma, alcohol ingestion or poly-pharmacy. She is normally
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independent of her daily tasks of living, with no recent hospital admissions. The only positive other symptom is of lower abdominal discomfort via a collateral history from her neighbour.
Given the patient’s background history and absence of trauma an infection, such as a UTI is the most likely cause. I would do simple laboratory tests to confirm this.
ACE Tips:
o Try to obtain collateral history. If the patient attends with a relative, be sure to ask the relative about the history of the presenting complaint. Alternatively neighbours or carers may offer assistance. During working hours the patient’s GP may be able to assist.
o For short (5-7 minute stations), do not attempt to do a 30 point MMSE as it will be hard to complete it. Do the AMT as it will provide a rough idea of cognitive state and show your awareness that a formal test needs to be done in addition to the history.
o Don’t forget hypoglycaemia is a common cause of confusion preceding coma. If your patient is young remember to first exclude hypoglycaemia.
o Ensure that simple causes of confusion in the elderly are excluded first, such as a UTI. o Polypharmacy is a significant and easily corrected cause of confusion so be sure to take an
accurate drug history.
Marking Sheet: Confusion/Memory Loss History
Not attempted Attempted inadequate Attempted adequate 1 Introduces self and position 0 1 2 2 Obtains consent via an open question 0 1 2 3 Establishes the name, age, occupation and marital
status of patient
0 1 2 4 Open question to commence history establishing
initial details of problem
0 1 2 5 Enquires in depth in about the length and nature of
the confusion
0 1 2 6
Enquires into other additional symptoms, in
particular regarding fever, dysuria and cough 0 1 2 7
Past Medical History (especially memory problems*)
* Essential to score 2 marks
0 1 2 8 Asks regarding diabetic history 0 1 2 9 Asks regarding recent head trauma 0 1 2 10 Family History 0 1 2