History Taking Flashcards
What are the typical history taking tasks?
Take a focused history from the patient (role player)
Assess the severity of the condition based on discussion with patient/parent
Counsel the patient as to the possible causes for his/her presentation
Formulate an appropriate diagnostic workup or management/disposition/follow-up plan and communicate this to the patient
Answer the examiner’s questions regarding the differential diagnosis and further patient assessment.
Outline to the examiner the focused history you would obtain in order to diagnose a condition e.g. clinically clear the cervical spine
Give your differential diagnosis and clinical examination approach to the examiner
What are the elements of health advocacy that are assessed?
- Facilitates an adequate follow up plan
- Incorporates the patient’s chronic clinical state and their wishes when making decisions
- Implements strategies to prevent a patient ceasing their emergency care prematurely
- Provides understandable instructions for the patient on discharge, including likely progression of their clinical course, and reasons to return
- Explains to patients and/or their guardians the rationale for management decisions
- Integrates communication skills relevant to the patient’s culture to enhance delivery of health advice to patients
- Refugee Health - Identifies findings on assessment that increase the likelihood of a patient being vulnerable
- Tailors treatment and disposition decisions for a patient to account for the presence of vulnerability factors
What are some tips for history taking?
- The social history should always be explored as it often impacts the discharge advice and possible underlying cause of complaint
- Address all the tasks of the station (ie Hx, DDx, Ix and discharge)
- Pay careful attention to the role player, they will only give relevant information
- Apart from the initial open-ended question, used focused questions as the actors won’t volunteer information
Basic Psychiatric history taking? Further investigations
History
1- Explore reason/circumstances of presentation
2- Screen systemic symptoms (fevers, trauma, weight loss, infectious symptoms)
3- Past medical/Psych history
4- Illicit drug (ie meth) and medicine (ie anticholinergics) history
5- Orientation TPP
6- Basic MSE (hallucinations, delusions, homicidal/suicidal etc)
7- Social/forensic/sexual
Ix
- FBE/UEC, CK, LFT’s, ECG
- +/- CTB and CXR
- +/- LP
- +/- septic screen
- +/- drug/toxin panel (ie paracetamol level)
- +/- endocrine panel (ie TSH)
- +/- Bladder scan (ie anticholinergic delerium)
Delirium history approach and workup priorities?
Definition
- Disturbance in attention and awareness
- Develops over short period of time
- Fluctuant
- Not better explained by pre-existing pathology ie dementia, psychiatric disorder, neurocognitive disorder or coma
Causes
Substrate deficiency
- BSL, 02, CO2
- Thiamine, B12
Focal CNS pathology
- Stroke, SAH, tumour, bleed
- Hypertensive crisis
Toxidrome
- anticholinergic
- Paracetamol, salicylates, digoxin
- Psychotropics, anticonvulsants
- Diuretics
*Infectious cause
- Meningoencephalitis
- Other infections
Electrolyte derangment
- Hyponatraemia most common
- Hypernatraemia, hypercalcaemia
Metabolic/Endocrine derangment
- DKA, HHS, Uraemia, Azotaemia
- Hyper/hypothyroid
*Organ damage
- MI, PE, CCF, AKI, liver failure
Scoring Systems
MMSE
- for both delerium and dementia
- Score out of 30, needs pen and paper
- More for inpatient teams
bCAM
- Designed for ED delirium and concussion screening
- Altered mental status or fluctuating course? (yes = proceeed, no = stop)
- Innatention (name the months backwards from December to July) 2 or more errors then proceeed
- Altered level of consciousness? yes = delerium, no = proceed
- Disorganised thinking? (will a stone float on water? Are there fish in the sea? 1kg weigh more than 2kg? Does a hammer pound a nail? Hold up X fingers with each hand) If any errors then bCAM positive
General Management
Initial- Any specific antidotes and correct life threats ie low 02, hypoglycaemia, ABx etc
1- Admit to medics for further workup and psychiatric input if/when medical issue excluded
2- If patient lacks capacity then should be detained under a duty of care vs mental health act depending on scenario
3- May need 1:1 nursing +/- a nursing special dedicated to them, admit to appropriate area of hospital or ED
4- Specific workup goals ie septic and endocrine screen, CTB/LP etc
Depression History approach?
Suicide risk screening
- Determine if active Plans and the Means
- Previous Attempts
- what is the Lethality of their previous attempts and current plan
- Intoxicated, do they have capacity
- Features of psychosis, command hallucinations etc
- Detain under MHA if concerns about suicide on leaving
SAD PERSONS mnemonic for suicide
- See picture
- 0-4 is low risk
- 5-6 is medium risk
- 7-10 is high risk
SIDGECAPS for Depression
- at least 5 of the following features for > 2weeks needed to diagnose major depressive disorder (MDD
S- Sleep disturbance (insominia, excessive sleep)
I- Interest decreased (ie usual fun activities or interests)
D- Depressed mood/anhedonia
G- Guilt or worthlessness
E- Energy decreased
C- Concentration difficulties
A- Appetite disturbance or weight loss
P- Psychomotor alteration
S- Suicidal thoughts
Mental Health Act
- Appears to be mentally unwell
- This mental illness requires immediate assessment and Mx
- There is a perceived risk to the safety of the patient and others
- There is no less restrictive manner
DIfferentials
- Psychosis and mania
- Dementia
- Hypothyroidism
- CNS infection
- Autoimmune encephalitis
What is the PAIDEMS mnemonic for history taking?
Used to remember all the extra things needed to touch on apart from the presenting complaint
P- Past history (can include ante/perinatal in paeds)
A- Allergies
I- Immunisations (paeds, immunocompromised, returned traveller)
D- Developmental (growth, sleep/wake/feed cycle in paeds) Daily living (ADL’s in adults)
E- Ethanol and substances
M- Medications
S- Social (SHx in adults and NAI/depression screen in paeds)
How should a fever history be approached?
Life threats
- Meningitis, sepsis etc
- AMI, PE, ICH
- Thyroid storm, drugs, environment, NMS/SS/MH
- Seizures, transplant rejection, transfusion reaction, pancreatitis
HPC
- Onset, patterns, travel, localising symptoms
- How long for, previous infection (ie malaria)
- Weight loss, masses, input/output
- Sexual activity and STI’s, immobiliity, bed sores
PAIDEMS
- Indwelling lines, valves, joint replacements etc
- Immunocompromised, vaccination
- Medications, overdoses, chemo
- At risk populations (ATSI etc)
How should a chest pain history be approached?
Life threats
- AMI with cardiogenic shock
- Thoracic aortic dissection
- Rupturing AAA
- Pulmonary embolism
- Pneumonia
- Perforated duodenal ulcer
- Upper GI abdominal catastrophe
Red flags
- Tearing/ripping pain
- Sudden onset
-
History
- PERC/Wells/ADDRS
ECG’s
- Repeat ECG’s!!!
- Look at OLD ECG’s!!!
Investigations
- Blood gas
- Bedside CXR
- Bedside echo
- Trop and screening bloods
- Bilateral blood pressures
- radial-radial/femoral delay
Modified HEART score
- Prospectively validated in ED settings, modified has removed the troponin (ie for use before tests)
- Better validation than EDACS and not retrospective like TIMI score
H- History, high suspicion (typical symptoms) = 2 points
- Moderate suspicion (mixed atypical and typical) = 1 points
- Minimal/no suspicion (very atypical) = 0 points
E- ECG, STD = 2 points, non-specific changes = 1 point, normal = 0 points
A- Age <45 = 0 points, 45-64 = 1 point and >65 = 2 points
R- Risk factors, no RF’s = 0 points, 1-2 = 1 point, 3 or more = 2 points
- High risk if 4 or more points
T- Troponin, taken out of the modified score
- 0 points if no rise, slight to 3x rise = 1 point and >3x rise = 2 points
- Often patients with elevated troponins will be admitted anyway regardless of risk stratification
Low risk
- Discharge
- No objective testing required
Intermediate risk
- Serial ECG and troponins (3hrly)
- 2nd tropnin at at least 6hrs post pain starting
- Screen for other causes
- If normal then discharge with objective testing ie stress test
High risk
- Admit under cardiology
- DAPT +/- further therapy
Bilateral weakness DDx? How should they be addressed on history?
LOWER MOTOR NEURONE
AIDP/GBS
- Recent Gastro/virus
- Progressive ascending weakness with hypo or areflexia (diagnostic criteria)
- Hypotonia, neuropathic pain (more in kids)
- Autonomic instability, cranial nerve involvement
- Elevated CSF protein, N WCC
Botulism
- Neonates with honey, wound botulism, off canned food
- Descending flaccid paralysis
- Hypotonia, hyporeflexia
Tick Paralysis
Snake Bite
Hypokalaemic Periodic Paralysis
- PHx of HPP, unexplained weakness or hypo/hyperthyroidism
- Recent exertion or stimulant use
- Low K on blood tests
UPPER MOTOR NEURONE
Transverse Myelitis
- Recent virus/gastro
- Defined spinal cord segment with sensory/motor changes below this
- fasciculations, clonus below level
- No cranial nerve involvement
- Usually complete paralysis below level, loss bowel/bladder control
How should a travel history be approached?
Life threats
- Diving complications
- Altitude sickness
- Exotic infections
- Pulmonary embolism
History
- Pre-travel (ie Past history, meds etc)
- During travel
- Post travel
- Diving or altitude
- Exposure to animals, bug bites
- Eating
- Sexual adventure (STI’s), drug use, swimming in contaminated water
- Pre-travel vaccinations, prophylacitic medications, preventatives ie (mosquito nets)
- Exposure to animals, coral, dirty water
- Eating local food, non-bottled water
- Fever timing and severity (ie every 48hrs, 72hrs, random etc)
How should a diving history be approached?
Red flags
- Prolonged dive
- Diving to or beyond max depth
- Rapid ascent
- Inexperienced diver
- Equipment malfunction
How should a paediatric history be approached?
At least consider asking all the questions below
Birth history
- Antenatal care
- tests performed, GBS
- prematurity, PROM
- instrumentation, birth complications
- post birth NICU/special care
- vit K, baby check, heel prick testing
Development
- Ask for weight and height
- Can ask for the baby book, look at growth charts
- meeting milestones? arrest in development
Social history
- Who looks after the child
- Whos at home (parents, other children, relatives etc)
- Living environment, stressors
Meds/Allergies
PHx
What is the HEADS screening tool for adolescent/teenage social and mental health?
Social media use/abuse is another S at the end
What are some basic questions for sexual health assessment?
Key points/phrases
- This is confidential
- Give a warning shot (ie i understand these are sensitive/difficult topics)
- Follow up in sexual health clinic
- Discussion around informing the patients partner and the partners risk
- Abstinence or barrier condom while awaiting testing
Key symptoms/Signs
Gonorrhoea
- D/C, inguinal lymph nodes, rashes, joint swelling
Chlamydia
- Dysuria, dysmenorrhoea, dyspareunia, PID
Syphilis
- Chancre, rashes, soft tissue lesions
HIV
- Seroconversion illness
- On PrEP
HepB/C
- Immunized? IVDU, blood transfusion
Treatment
- Suggest treatment, shared decision making, dont force
- Gonorrhoea - Ceftriaxone
- Chlamydia - Azithromycin
- Syphilis - IM Benzathine penicillin
- Herpes - Aciclovir
Medicolegal
- If a patient knows they have HIV, and has unprotected sex with someone without informing them of this, they are liable for assault and can face jail time
Syncope history approach?
Most common (Mimics)
- Vasovagal (neurocardiogenic)
- Orthostatic hypotension, usually from dehydration
Most concerning Dx
- PE
- SAH
- Seizure
- Hypoglycaemia
- Tachydysrhythmia
- high grade AV block and sick sinus syndrome
- IHD
- Structural heart disease (HOCM, CHD, valvulopathy etc)
- Toxin/overdose induced
- Sepsis
Dysrhythmias in young people
- Brugada
- WPW
- HOCM
- ARVC
- Prolonged/shortened Qtc
Red Flags
- Exercise induced
- No prodrome (instant drop)
- Chest pain
- Sudden severe headache
- Palpitations
- Past cardiac history
- FHx sudden cardiac death or arrhythmias
History
- Previous episodes
- Tongue biting, intontinence
- seizure/myoclonic jerks/muscle soreness post event
- How long unconscious
- Precipitants (uncomfortable stimulus, dehydration etc)
- Postural symptoms
- Injury from the syncope
- Post ictal phase
- Family history and origin (ie south east asia and Brugada Syndrome)
- Nocturnal agonal breathing (brugada syndrome)
- Recent unwellness (increasing SOB, viral prodrome, intermittent chest pain etc)
- prescription meds, OTC meds, recreational drugs, overdose
San Franciscos Syncope Score
- CHESS mnemonic
- Any of the five makes patient not low risk
- C= congestive heart failure
- H= Haematocrit <30%
- E= ECG abnormal
- S= SOB
- S= SBP <90
Palpitations history approach?
Life threats
- Malignant arrhythmia
- Acute ischaemia
- Cardiac disorders (HOCM, WPW, Brugada, ARVC, MV prolapse)
- Pacemaker malfunction
- Endocrine (Hypoglycaemia, hyperthyroidism, phaeo)
- Sepsis/fever
DDx
- Psychiatric (Anxiety, stress, somatization, POTS)
- Ectopics
- Hypotension (dehydration, exercise)
- Pregnancy
- Anaemia
- Illicit drugs (cocaine, caffeine, alcohol, nicotine, ice etc)
- Medications (BB withdrawal, anticholinergics, sympathomimetics, vasodilators)
Red Flags
- Syncope
- Chest pain (particularly exertional)
- FHx cardiac disease/SCD
- Bleeding
- Oedema
Shortness of breath/Dyspnoea history?
Life threats
- Cardiac Ischaemia
- PE
- Pneumonia/Sepsis
- Heart failure with APO
- Anaphylaxis
- Airway obstruction
- Trauma/Haemorrhage
- Severe anaemia
- Pneumothorax
- Cardiac tamponade
- Status asthmaticus/COPD
- Exacerbation of bronchiectasis
- Large effusion/empyema
Common Causes
- Milder infections
- Milder heart failure
- Anxiety
- Milder respiratory disease (asthma, COPD)
Red flags
- SOB at rest
- Chest pain with SOB
- Worsening over time
- PHx severe cardiac/lung disorders and need for ICU/Ventilation
Basic History
- Duration/onset (acute vs chronic)
- Positional changes (orthopnoea and PND)
- Exertional changes
- Fevers
NYHA grading
1- no symptoms at rest/exercise
2- Dyspnoea on moderate or more exertion
3- Dypnoea on minimal exertion, asyptomatic at rest
4- Always symptomatic
Investigations
- CXR
- ECG
- VBG/ABG
- Targeted Ix (trop, septic screen, bedside echo, CT scan)
Oedema history approach?
Life Threats
- Large DVT
- Acute heart/liver/renal failure
- Severe infection (bad cellulitis, necrotizing fasciitis)
- Mass in abdomen/other cancer
- Hypothyroidism with myxoedema
Common DDx
- See pic
Drug causes DDx
- Dihydropiridine CCBs (ie Amlodipine)
- Vasodilators (alpha blockers, minoxidil, Hydralazine)
- Steroids (glucocorticoids, fludrocortisone, oestrogen, progesterone and testosterone)
- Tamoxifen
- T2DM meds (Pioglitazone)
Red Flags
- Severe SOB
- Fevers
- Weight loss with oedema
- Haemoptysis/APO
- Syncope
- Bleeding/jaundice
Basic History
- Unilateral vs bilateral
- Other sites (face, back, hands, abdomen with ascites etc)
- Painful? Erythema?
- Associated SOB, dyspnoea, PND
- Getting worse, acute vs chronic
- Inciting event (ie chest pain with AMI)
- Associated chest pain/palpitations
- B symptoms, fevers
- History of heart/renal/liver issues
- medications and illicit drugs
- Travel
- Clotting disorders, previous clots
Investigations
- CXR
- ECG
- Echocardiogram
- Ultrasound legs/pelvis
- Urine (including protein)
- UEC/LFT’s
- +/- troponin and BNP
Haematemesis history approach
Life threats
- Variceal bleed
- Acute liver failure/Liver cancer
- Duodenal/Gastric ulcer
- Boerhaves syndrome
- Trauma
- Eroding upper GI tumour
- Severe oesophagitis/Gastritis
- Aortoenteric fistula
DDx
- Epistaxis, haemoptysis, teeth
- Red coloured food/drink
- bleeding disorder (inherited or acquired)
- Anticoagulation
- Foreign body or toxin ingestion
Red Flags
- History of varices and portal HTN
- History of severe liver disease
- Cardiac failure
- Syncope
- Trauma
Basic History
- How much? How frequent? how long for? Previous episodes?
- Normal vomiting prior (Mallory-weiss tear, Boerhaves)
- Clots, coffee ground vomit
- Malaena and Haematochezia!!!
- Medications (NSAID’,s anticoagulants, beta blockers)
- Chest pain, palpitations and SOB
- Alcohol consumption
- Illicit drugs, smoking
- Cancer history
Investigations
- FBE + film, VBG for Hb
- coags
- Group and hold + cross match
- LFT’s/UEC’s (urea)
- BSL!!! (if liver failure)
- Liver ultrasound
- CXR and CT scan
- Will likely need scope
Blatchford score
- Upper GI bleeding risk stratification
- HB and Urea
- Initial SBP (<90 = 2, 90-120 = 1, >120 =0 points)
- HR >100 = 1 point
- Sex (male =1 point)
- Malaena = 1 point
- Syncope = 2 points
- Cardiac failure = 2 points
- Hepatic disease = 2 points
Headache history approach?
Critical
- SAH and Stroke
- Meningoencephalitis
- Carotid artery dissection
- Carbon monoxide poisoning
- Trauma (EDH, SAH)
Emergent
- Brain tumour
- Cerebral venous sinus thrombosis
- Head trauma (SDH)
- Hypertensive crisis (PRES, RCVS, pre-eclampsia)
- Glaucoma
- IIH
- Shunt failure
Non-Emergent DDx
- Migraines, tension and viral illnesses are the most common causes
- Non traumatic cases see pic
Red Flags
- Trauma
- Fevers, meningism
- Pregnant
- Hypercoagulability
- Known aneurysm/AVM or other anatomical concerning variant
- Previous brain surgery/shunt
History
- Worse on wakening
- Worse over time
- Morning vomiting
- PAIDEMS’s
- FHX/PHX migraines
- Precipitants/associations
Ottawa SAH Rule
Inclusion
- Age >15, alert, atraumatic
Exclusion
- Prior aneurysm or SAH, known brain tumour, new neurological deficit or chronic headache
Rule
- Age >40
- Neck pain or stiffness
- Limited neck flexion
- Witnessed LOC
- Onset during exertion
- Thunder clap headache (instant peak)
- If negative to all then essentially ruled out (100% sensitivity)
CT in SAH rule out
- Within 6hrs onset approx 98.5% sensitive and 99.5% specific
- Still very sensitive at 86% after this, and the baseline rate of people presenting with SAH after 6hrs is lower leading to a combined post test probability of 0.8%
- Small volume bleed, severe anaemia, non-neuro radiologist and increased time all decrease sensitivity
- CT angio COW is 99% sensitive/specific, but runs the risk of over diagnosing aneurysms
POUND Migraine score
- >4 features highly likely (LR 24)
- Is the headache pulsatile?
- Duration 4-72hrs?
- Is it unilateral?
- N/V associated?
- Severe/disabling headache?
Jaundice history approach?
Life threats
- Fulminant infectious liver failure (HepB, C, A)
- Acute haemolysis
- Ascending cholangitis
- Falciparum malaria
- Toxin mediated (paracetamol, valproate, mushrooms etc)
- HELLP syndrome (pregnancy)
- Acute on chronic ETOH liver failure
- Acute liver trauma
DDx
increased production
- Haemolysis (acquired vs congenital)
- Sepsis (Malaria)
- Hepatitis viruses
- Displacement from albumin
* Decreased metabolism*
- Hepatocellular dysfunction
- Autoimmune, infectious, drugs, trauma, metabolic
* Decreased Excretion*
- Biliary obstruction
- Primary biliary cirrhosis
- Sclerosing cholangitis
- Pancreatic head cancer
Red Flags
- Drug overdose/overuse
- Travel to malaria endemic region
- Mushroom consumption
- Abdominal pain
- Bleeding (malaena, haematemesis)
- Pregnancy (HELLP syndrome)
- Known liver disease or severe cardiac disease (liver congestion)
- Known cancer
History
- How long for? Preciptating event?
- Viral prodrome, fevers
- Alcohol (units per week, CAGE), IVDU and drug history
- Work history (ie occupational exposure to Hep B)
- STI and sexual history
- Medication history
- Weight loss (cancer) or weight gain (oedema, ascites)
- Screen encephalopathy (oriented, poor sleep, nightmares etc)
- Dark urine, pale stools
- Pruritus (obstructive)
- Occupational exposure and blood products received
- PHx including gallstones, recent upper abdominal surgery
Investigations
- Conjugated vs unconjugated (conjugated not neurotoxic)
- LFT’s, coags
- Ammonia level for encephalopathy
- UEC’s (hepatorenal syndrome)
- Drug levels, Alcohol level
- U/S biliary system
- BSL!!!
- TFT’s, infectious screening
- Haemolysis screen
Treatment
- Targeted to cause
- Lactulose and Rifampicin
- +/- Ceftriaxone +/- Terlipressin
Diarrhoea history approach?
Life threats?
- Abdominal sepsis
- Anaphylaxis
- Malaena
- Cholinergic agent exposure
- Ischaemic colitis
- Haemolytic Uraemic syndrome
- Toxic Megacolon
- Clostridium botulinum
DDx
- Viral gastro (most common, rota, norovirus, adenovirus etc)
- Bacterial gastro (shigella, salmonella, e. coli, clostridium, vibrio, campylobacter)
- Parasitic causes (Entamoeba, giardia, cryptosporidum etc)
- Inflammatory (Crohns, ulcerative colitis etc)
- Toxin mediated (Staph, C. botulinum and Bacillus cereus)
- Medication use
- Toxicological (colchicine, cholinergics, A. Phylloides etc)
- Surgical causes (appendicitis, diverticulitis)
- Endocrine (Pancreatic insufficiency, adrenal crisis etc)
Classification
- Acute (<14 days) vs Persistent (14-30 days) or chronic (>30 days)
- Aetiology based
- Stable vs unstable
Red Flags
- Recent travel
- Blood or mucous in stools
- Jaundice
- Severe abdominal pain
- Oligoanuria
- Syncope and dizziness
History
- Obvious precipitant?
- Recent antibiotic use or hospital admission
- Previous issues with diarrhoea (ie previous c. difficile)
- Infectious contacts/food, exposure to animals
- High fevers, abdo pain
- Other infectious symptoms
- Fluid intake, urination, weight loss
- Weakness, muscle cramps
High risk patient features
- Age >70 or very young
- Cardiac/Renal/Liver disease
- Immunocompromised (particularly undertreated HIV)
- IBD
- Pregnancy
- Public health care concerns (food workers, medical staff, day care or teaching staff)
Investigations
- VBG and electrolytes
- FBE/CRP
- Pregnancy test if female
- Stool MCS/OCP/viral PCR (+/- blood)
- +/- CT Abdomen
- Trial of fluids
Antibiotics
- Demands on likely cause
- Ciprofloxacin and Azithromycin for dysentrery
- Oral Vancomycin and Metronidazole for C. difficile
Abdominal Pain in the Young adult?
Life threats/Time urgent
- Ectopic pregnancy
- Torted testicle/ovary
- AAA/Dissection (RF’s present)
- Trauma
- Abdominal sepsis
Female Pelvic Specific
- Ovarian torsion
- Ectopic pregnancy
- Tubo-ovarian abscess/PID
- Endometriosis
- Cyst rupture
- Abdominal causes
DDx
- Appendicits
- Diverticulitis
- Pyelonephritis/UTI
- Renal/biliary colic
- Referred pain (pneumonia, AMI etc)
Red Flags
- Severe nausea and vomiting
- Infertility treatment (ovarian hyperstimulation, ovarian torsion)
- PCOS (torsion)
History
- Recent exercise or raised abdominal pressure
- PR blood
- Nature, location and time course
- Relieving and worsening
- PAIDEMS
- Point in period cycle, period heaviness, regularity and issues
- Mid cycle pain (ruptured ovarian cyst)
Ovarian torsion triad
- Pelvic pain
- Adnexal mass (of any cause)
- Severe nausea +/- vomiting
- Ultrasound about 45-70% sensitive, whirlpool sign, reduced doppler flow, discrepancy in size compared to other ovary and abnormal position
Abdominal pain in the elderly?
Life threats/Time Urgent
- Mesenteric ischaemia
- SBO/LBO
- AAA/Dissection
- AMI
- Bowel/ulcer perforation
- Sickle cell crisis
- Ascending cholangitis
- Ectopic pregnancy
- Torted ovary/testicle
- Volvulus
- Incarcerated hernia
- Trauma
- Budd-Chiari syndrome
DDx
- Infectious gastro
- Intestinal cancer
- Constipation
- Diverticulitis
- Pancreatitis, Gastritis
- Appendicitis
- DKA
- Cholecystitis, biliary colic
- Lower lobe pneumonia
- PID
- UTI, Pyelo, renal calculi
- Psoas abscess/bleed
High risk patients
- Age >60
- Previous abdo surgery
- Recent instrumentation (ie scope)
- Known abominal pathology ie IBD
- Known abdominopelvic malignancy
- Active chemotherapy or otherwise immunocompromised
- Women of childbearing age
- NESB and recent immigrants
Red flags
- Haematemesis, malaena, PR Blood
- Pregnancy
- Systemic symptoms (fevers, chills)
- Syncope, palpitations, chest pain
- Severe nausea/vomiting
History
- Migration or referral of pain
- Onset, precipitating event
- Severity and type
Investigations
- CT vs Ultrasound
- Ultrasound better for obstetric and biliary issues
- Xray has minimal utility
- inflammatory markers
- VBG for lactate and acid base
Diplopia approach?
Monocular Diplopia
- Eye trauma
- Corneal ulcer/abrasion
- cataract
- Astigmatism
Binocular Diplopia
Life threats/Critical Dx
- SAH/Aneurysm (8%)
- basilar artery thrombosis
- Meningoencephalitis
- Cavernous sinus disease or thrombosis
- Botulism
- Snake bite
- Hypoglycaemia
DDx
- Thyroid (Graves) orbitopathy
- CN3, 4, 6 lesions (most common is microvascular ischaemia ie T2DM)
- Myaesthenia gravis
- Wernickes encephalopathy
- Eye trauma
- Intracranial tumour (12%)
- Vasculitis/Autoimmune (ie multiple sclerosis) 18%
- Hyperglycaemia
- paraneoplastic (Eaton-Lambert syndrome)
- Posterior CVA (ie Wallenberg) 45%
- Vertebral artery dissection
- GBS variant miller-fisher
- PICA aneurysm (CN 6 compression)
- Orbital apex syndrome
Questions
- Sudden onset (suggests ischaemia) vs gradual onset
- Orientation/directionality of the diplopia
- Eye pain (inflammatory, trauma or infectious)
- secondary symptoms (ie fevers, headache, trauma etc)
Back pain history approach?
Life threatening/Disabling causes
Spinal
- Epidural abscess
- Discitis/osteomyelitis
- Compressive mass/Spinal tumour
- Spinal trauma
- Cauda equina
Extra Spinal
Chest
- Thoracic aortic dissection
- Large AMI
- PE/pnuemothorax
Abdomen
- Pancreatitis
- Penetrating peptic ulcer
- AAA
- Psoas abscess
- Retroperitoneal haemorrhage
Differentials
Chest
- Bacterial endocarditis
- Pneumonia
- Pleural effusion
Abdomen
- Renal colic
- Biliary colic
- Pancreatic cancer
- Pyelonephritis
MSK
- Muscle strain, Ligamentous injury
- Non-specific low back pain
- Sciatica, OA
Other
- Herpez-Zoster
- Prostatitis
- Endometriosis
- Autoimmune
Red Flags
- Trauma
- Cancer
- Fevers
- IVDU/Tattooing/Acupunture
- Meds (anticoagulants, NSAIDs and glucocorticoids)
- Immunocompromised (HIV, poorly controlled diabetes, alcoholism)
- Weight loss, night sweats and unrelenting night time pain
- Faecal incontinence and urinary retention
History
- Acute vs chronic
- Exactly where in back
- Associated symptoms
- PHx (ie AAA, osteoporosis)
- Neurological symptoms
Investigations
- CT/Xray = ? Cancer ? trauma or fracture
- MRI = ? infection, cauda equina, severe or progressive deficits
Spinal epidural abscess
- Most common is S. aureus, 2nd most common is gram negatives
- Can overlap with discitis/osteomyelitis
- Progressive pain, electrical shocks, incotninence and lastly paralysis
- Most important therapy is surgical decompression
- Empiric therapy with Flucloxacillin 2gm, Vancomycin 2gm and Ceftriaxone 2gm
- Antbiotics to cover MSSA, MRSA and gram negatives (ceftriaxone)
CCF history approach?
Life Threats
- MI, Arrhythmia
- APO, Cardiogenic shock
- Sepsis
- PE
- Aortic pathology
Precipitants
- Arrhythmias, especially AF
- Stopping meds (mostly diuretics)
- High salt diet
- Salt retaining meds (NSAID’s etc)
- MI and PE
- Anaemia/bleeding
- Infection
- Thyrotoxicosis
- Anaesthesia and surgery
- Pregnancy
- Alcohol, sympathomimetics, chemotherapy etc
LF Failure Symptoms
- Dyspnoea
- Orthopnoea/PND
RV failure symptoms
- Oedema
- Ascites/effusions
- Nausea and anorexia
PHx
- IHD and CAD
- Rheumatic fever/heart disease
- Congenital heart disease
- CAD RF’s (HTN, diabetes, smoking, high chol, obesity, FHx, menopause)
- Previous cardiac surgery
Investigations (past and future)
- Angiograms
- Echocardiography
- Stress test/nuc med test
NYHA Classification
- Grade chronic CHF
1- No limitation physical acitvity
2- Slight limitation
3- Marked limitation
4- Symptoms at rest
Killip Classification
- Used for acute heart failure due to acute coronary syndromes
- 30 day Mortality predicted based on Killip class
- Class 1-4
1- no signs of congestion (2-3%)
2- S3 and basal crackles (5-12%)
3- APO (10-20%)
4- Cardiogenic shock (20%)
Basics of treatment
*Remove Precipitant
- Revert or control arrhytmias ie AF
- Angioplasty or CABG for CAD
- Replace or fix a valve (ie AS)
Control the Failure
- Decrease physical activity
- reduce fluid/salt intake (fluid restriction, daily weights)
- Combat the RAAS system (ACE/ARB and spirinolactone)
- Oppose catecholamines (ie beta blockers
Treat severe symptoms
- NIV/intubation for severe APO
- IV frusemide for overload
- Morphine/GTN for HTN
- Inotropes for cardiogenic shock
- ECMO and IABP
Definitive treatments
- Pacemaker/defibrillator for recurrent or debillitating rhythms
- biventricular pacing for cardiac resynchronisation therapy
- Cardiac transplant
Evidence
- Only therapies with hard evidence are beta blockers, spirinolactone, CABG and stents
Takutsubos
Mayo Criteria
- Localised apical dilatation or hypokinesis on echo
- No significant CAD on angio
- No myocarditis or Phaeo
- ECG abnormality or trop rise
The swollen leg approach?
Critical Diagnoses
- Phlegmasia Alba (collaterals intact +/- arterial spasm) and Cerulea (collaterals thrombose) Dolens
- Venous gangrene (advanced phlegmasia)
- Necrotizing fasciitis
- Acute limb ischaemia (ie clot in arterial system)
- Compartment syndrome
DDx
- DVT and venous insufficiency
- Bakers cyst rupture
- Muscle tear/sprain (ie Gastrocnemius or achilles tendon)
- Cellulitis
- Fracture or haematoma
- Animal/bug/snake bite
Wells score DVT
- All score +1, except alternate diagnosis which is -2
- 0 is low risk, 1-2 is moderate and 3 or more is high risk
- Low/moderate risk and a -ve D-Dimer or U/S = rule out
- Active cancer with Mx last 6 months
- Paralysis or immobilisation of the extremity
- Previous documented VTE
- Bed ridden in last 3 days or major surgery in last 12 weeks
- Localised tenderness over deep vein
- Entire leg swollen
- Calf swelling >3cm compared to other side
- Assymetric pitting oedema
- Collateral superficial non-varicose veins
- Alternate diagnosis more or equal likelihood
Who can go home with new DVT?
- SBP >100
- No thrombolysis needed
- No active bleeding
- Not already anticoagulated
- Absence of severe pain
- Other medical or social reasons to admit
- CrCl >30
- Absence of other risks (pregnant, severe liver disease, heparin induced thrombocytopaenia)
Rectal bleeding history approach
Life Threats
- Severe infectious colitis/toxic megacolon
- Intussusception (paeds)
- Large upper GI bleed
- Aortoenteric fistula
- Ischaemic bowel
- Severe diverticulitis
- Bleeding diathesis or over anticoagulation
DDx
- Haemorrhoids
- Anal fissures
- Polyps and cancer
- proctitis
- Rectal Ulcers
- Inflammatory bowel disease
- Angiodysplasia
- Radiation enteropathy
- Meckels diverticulum (paeds)
- Anal trauma
Red Flags
- Weight loss, night sweats, bone pain, night pain
- Malaena or dark red blood
- Abnormal vital signs
- Diarrhoea with blood
- Bleeding from other sites
- Bleeding diathesis/anticoagulants
- Anaemia symptoms (headaches, palpitations, dizziness, SOBOE)
History
- Ideas, concerns and expectations “before i begin is there something forefront in your mind? Help me understand what is most important to you?”
- “would you like a male/female doctor” cultural sensitivity
- Blood on toilet paper or dripping AFTER defecation (anorectal)
- Current or associated pain vs painless bleeding
- History of constipation
- Previous episodes of bleeding and frequency
- Penetrative anal sex
- History of STD’s
- Tenesmus (proctitis)
- Change in frequency or type of stools
- PHx of IBD or cancer
- PHx of surgical or radiation
- FHx of bowel cancer/familial polyposis
- Associated abdominal pain
- PAIDEMS
- “Do you have any questions? Have I missed any of your concerns? Lets recap”
Investigations
- FBE only really required test
- Other tests as indicated
- Consider stool test for clostridium if recent hospitalisation, or other organisms if travel/contacts
- CT angio if active large bleed
Ongoing Management
- Stable then outpatient follow up for scope
- Unstable then admission for scope +/- blood products/stabilisation
Scrotal Pain history
Emergent/Urgent
- Testicular torsion
- Severe Epididymo-orchitis
- Fornieres gangrene
- testicular trauma
- Incarcerated hernia
- Post surgical complication
DDx
- Non-septic Epididymo-orchitis (STIs in younger men, E. coli and pseudomonas is older men, usually with prostatic issues)
- Testicular cancer
- Torsion of testicular or epididymus appendix
- Mumps
- Henoch-Schonlein purpura
- Acute idiopathic scrotal oedema (paeds)
Red Flags
- Abnormal vital signs
- Absent cremasteric reflex
- Abnormal (horizontal) lie of testical, high riding testicle
History
- Location of pain
- Timing (acute vs chronic) and precipitating factors (ie trauma)
- N/V (torsion)
- Fevers and chills (Epidymitis, fornieres gangrene)
- PHx of Urogenital infections, anatomical differences or surgery
- Dysuria and frequency
- STIs and unprotected sex
- Parotitis, viral symptoms (Mumps), usually unvaccinated
Exam
- Inguinal hernia while standing, coughing
- Cremasteric reflex
- Pain, tenderness, swelling
- Erythema, crepitus
- Blue dot sign and tenderness localised to the anterior-superior pole of the testis
Investigations
- Ultrasound (85% specific, 100% sensitive), will miss torsion-detorsion
- Ultrasound good test, but gold standard is surgical evaluation in theatre
- Ultrasound may delay definitive treatment
Management
- Lateral detorsion in rural setting (usually torts medially)
TWIST score
- Score 6-7 is high risk for immediate theatre, 3-5 intermediate for U/S, 1-2 low risk (not torsion)
- Testicular swelling +2
- Hard testicle +2
- High riding testis +1
- Nausea and vomiting +1
- Absent cremasteric reflex +1
Transient altered neurology (or TIA) history
Life threats
- Hypoglycaemia
- Aortic dissection
- SAH/ICH
- Meningoencephalitis
- Head trauma/SDH
DDx
- TIA
- Seizure/Todds Paresis
- Migraine
- Space occupying lesion/tumour
- Transient global amnesia
- Demyelination (ie MS)
- Myaesthenia gravis
Red Flags
- Head trauma
- Bleeding diathesis
- Severe headache/chest pain just before symptoms
History
- TIA risks (Age >60, hypertension, diabetes, duration)
- Clarify symptoms and if fits in typical stroke distribution (ie MCA etc)
- SHx: Smoking, alcohol, functional baseline
- PHx: Previous TIA/strokes, diabetes, High chol, HTN
- Transient blindness (Amaurosis fugax)
- History of migraines or seizures
- Previous similar episodes
Investigation
- BSL
- ECG (AF), basic labs
- CT vs MRI +/- US carotids
- Echo to look for cardiac thrombi
Management
- Dual antiplatelets +/- statin/antihypertensive
- Antocoagulation if AF
- Admit if high risk (use ABCD2 score to risk stratify)
- Risk factor modification (moderate exercise most days, stop smoking, better diet, weight reduction, reduce alcohol)
ABCD2 score for TIA
- 0-3 = low risk, 4-5 mod, >5 high
- Age >60 (1 point)
- BP >140/90 (1 point)
- TIA symptoms (unilateral weakness = 2, speech disturbance but no weakness = 1, other symptoms = 0)
- Duration (>60mins = 2, 10-59 = 1, <10 = 0)
- History of diabetes (1 point)
Anaesthetic risk assessment
ASA classification
- ASA 1-2 in ED
- ASA 3 consider anaesthetics
- ASA 4 or more in theatre
AMPLE
Allergies
- Particularly LOCAL ANAESTHETIC
Medications
- beta blockers, antihypertensives etc
- Illicit drug use, smoking, ETOH
Past Medical History
- Cardiorespiratory disease
- Previous anaesthetics and any complications
Last Meal
- Fasting status
Events Precipitating
- Why having anaesthetic, risks due to this ie injury arm fracture but also has head injury
Local Anaesthetic Allergy
- Clarify exactly what happened
- If has true allergy then prevents Biers block, haematoma block and regional blocks
- Essentially mandated to do some form of sedation instead
Occupational and sexual exposure history
General Approach
- Significant amounts of empathy and soft skills?
- Do you have any questions or concerns?
- Help me understand what is most important to you?
- Consider gender, sexuality, culture, language and any intellectual disability
Recipent History
- Date and time
- Type of needle used (hollow vs solid)
- Procedure being used for
- Recipient wearing gloves?
- Appropriate first aid? (soap and water for 10-20mins)
- How deep and where is the wound? direct injection into artery/vein?
- Immunised against Hep B? Known antibody titre?
- Any known blood borne viruses?
- Sexually active? Regular partner ? trying to get pregnant?
- PAIDEMS
Sexual history
- Condom use, condom failure
- Type of sexual acts being performed
- Single vs repeated sex
- Any trauma or blood, any genital piercings?
- Concomitant STI in recipient or donor
- Ejaculation? (increases risk)
- Circumcised? (insertive anal intercourse by recipient only)
- PrEP use by donor or recipient?
- Donor was sex worker? Australia (0.14%) vs overseas (varies but up to 40% in thailand)
Donor History
- Known to have bloodborne birus
- In high risk group ie IVDU or sex work
- Are they around and willing to give a blood test?
- Viral load if known (Low VL associated with almost no risk)
- On anti-HIV medications
- Human bite (very low risk)
- Highest risk group is MSM who are also IVDU (30% seroprevalence)
PEP Hep B
- No need if recipient is vaccinated with adequate antibody titre
- Non-immune and low risk then vaccinate and 6month follow up
- If non-immune and source high risk or has known chronic Hep B then vaccinate and give single dose 500IU HBIG
PEP HIV
Basics
- Needs to be started within 72hrs
- Shared decision making to prescribe PEP is needed
When to prescribe
- If Donor known to be undetectable or -ve then not recommended
- If receptive/insertive oral intercourse only with no break in skin or blood exposure then not recommended
- Any other sexual exposure or needle stick sharing/injury with source unknown or has detectable viral load then recommend PEP
Side Effects
- Nausea and vomiting + diarrhoea
- Often prescribe concomitant antiemetics
Regimens
- 2 drugs for low-mod risk, 3 drugs for high risk
- 2 drug Tenofovir/Emtricitabine 300/200mg daily 28 days
vs
- 3 drug Dolutegravir 50mg + Raltegravir 400mg + Rilpirivine 25mg for 28 days
Tests
Occupational
- HIV, HepBC serology
- LFT’s, UEC
Sexual
- Add on STI screen (chlamydia, gonorrhoea, syphillis)
- Pregnancy test if indicated
Ongoing care
- Review in 28 days with ID or occupational exposure team
- PEP as needed
- Referral for further counselling as indicated
- Consider emergency contraception if indicated
- Importance of 100% adherence to the regimen
Discussion around PEP
- High level of protection but not 100%
- Importance of adherence
- Discussion of side effects
- Importance of follow up
- Starter pack and where to get more medication
- Counsel against trying to get pregnant whilst on PEP
- If known to be pregnant then seek specialist advice
Abdominal pain in pregnancy and bleeding?
Life threats/Time Urgent
- LABOR
- Pre-eclampsia (HELLP syndrome)
- Acute fatty liver/hepatitis and cholestasis of pregnancy
- Uterine rupture
- Ectopic pregnancy
- Ovarian torsions
- PID
- Septic abortion
- Placental abruption
- Chorioamnionitis
-AAA, SBO, perforated ulcer
- Trauma/NAI
DDx
- Endometriosis
- UTI/Pyelo
- Renal/biliary colic
- Appendicitis, cholecystitis
- miscarriage
- Foetal position or movement
- Constipation
- Weird stuff (hereditary angioedema, sick cell crisis, drug overdose etc)
Gestation
T1
- Ectopic, miscarriage
T2
- Hepatitis
- Amniotic fluid embolism
- Placental abruption/praevia
T3
- Pre-eclmapsia/HELLP
- Labor
- FDIU
- Acute fatty liver/cholestasis
- Chorioamnionitis
Red Flags
- PV bleeding
- Fevers
- Hypertension
- Trauma
- Severe headaches
- Syncope
History
- Where, what time, makes worse and better?
- PHX, Surgical Hx
- Medications
Ix
- Ultrasound
- CTG
- Urinalysis
- FBE and film
- LFT’s, coags
- UEC, CRP
Ongoing Care
- Observation
- Analgesia
- Reassurance
- O/G review
Special Points
- Very difficult to exclude appendicitis, also appendix shifts and present atypically
Psychogenic Seizures History and approach?
DDx
- Actual seizure/Epilepsy
- Brain tumours
- Meningoencephalitis
- Breath holding
- Syncope
- Factitious disorder
- sydenhams chorea
Red Flags
- Severe headaches
- Trauma
- Fevers
- Headaches worse in morning
- FHx epilepsy
History
- Exact nature of events, precipitating circumstances
- Incontinence, tongue biting, injuries
- Level of awareness during episode
- Previous tests (EEG, MRI, neurologist reviews)
- Social history, stress
- Psychiatric history
- Drugs and alcohol
- Pregnancy (increases PNE)
- Menstrual cycle (associated with epilepsy
- Sleep induced (epilepsy), shortly after wakening (PNES)
- Post general anaesthesia (PNES ? disinhibition from drugs)
- Vocalisations, ictal cry vs weeping, crying, shouting etc
- Post ictal phase
Exam
- Autonomic changes during event (Absence suggests PNES)
- Writihing, thrashing, arched back, pelvic thrusting, directed movements (suggests PNES)
Diagnosis
- Not an ED diagnosis
- Needs formal diagnosis by a neurologist post extensive testing
- Relatively high associated morbidity, higher than actual epilepsy
Ongoing care
- Cannot drive, swim or operate heavy machinery until cleared by a neurologist
Assessment of the patient with Mania?
Diagnosis
- Distinct period of abnormally and persistently elevated, expansive or irritable mood (at least 1 week)
- 3 or more of the DIGFAST symptoms persist throughout this period
DIG FAST menmonic
D- Distractability
I- Irritability
G- Grandiosity
F- Flight of Ideas
A- Activity increased
S- Sleeplessness
T- Thoughtlessness (impulsivity, increased risk taking)
Further History
- PHx
- Drugs and alcohol
- Cigarettes
- Delerium features
- Suicidal, homicidal, psychotic features
- Social history, home life
- Destruction of work, social relationshops
- Gambling, high risk sexual activity, other risk taking
Assessment of the patient with Schizophrenia/Psychosis?
Diagnosis
- Symptoms over at least 1 month
- 2 or more of the following
- Delusions
- Hallucinations (largely auditory)
- Disorganised speech (Derailed or incoherent)
- Grossly disorganised or Catatonic behaviour
- Negative symptoms (avolition, diminshed emotional expression)
Haemoptysis history
Life Threats
- Massive PE
- Necrotizing pneumonia or abscess (staph, Legionella, TB and fungi ie aspergillosis)
- Bronchogenic carcinoma
- Mets, leukaemie and lymphoma
- Bronchovascular fistla or Tracheoinominate fistula
- Bleeding diathesis
- FB in airway
- Acute trauma
DDx
- SLE, Goodpastures and Wegeners (granolmatosis with polyangitis)
- Broncheictasis
- bronchitis
- Pulmonary AVM or aneurysm
- post respiratory procedure
- Cocaine use
- Pseudohaemoptysis
Investigations
- ? D-Dimer
- CTPA/CXR
- Sputum M/C/S and culture
- Bronchoscopy
- FBE + fillm, group and hold
- AFB and interferon Gamma (TB)
- ANCA, ANA, RF (autoimmune)
Seizure/Epilepsy History approach?
True Vertigo approach?
Other causes of Vertigo
Hypoglycaemia
- Sweating, anxiety, tachycardia
- AMS
- Usually diabetic, consider in children or overdose
Head Trauma
- Usually mild and self limiting
- Screen for BOS#
Neck Trauma
- Usually post whiplash injury
- Can be delayed 7-10 days
- Neck pain, often positional
Vertebrobasilar Migraine
- PHx or Fhx of migraine
- Vertigo followed by headache
- Mx as for migraine, should completely resolve
Multiple Sclerosis
- Highly variable, may be peripheral or central presentation
- Females 20-40, PHx autoimmune disease
Temporal Lobe Epilepsy
- +/- convulsions, trance like state, hallucinations
- May be post ictal
Dizziness
- Consider differentials as per syncope/pre-syncope
- Attempt to distinguish from true vertigo, but may be unable to do so
Nausea and Vomiting approach?
Wheeze and stridor approach?
Life threatening
- Anaphylaxis
- Laryngeal/tracheal FB
- Angioedema/Anaphylaxis
- Critical Asthma
- Epiglotitis
Emergent
- Cardiac wheeze (failure)
- Pulmonary embolism
- Severe Asthma/COPD
- Vocal fold swelling or dyfunction
- Tumour of upper aiway
- Tumour impinging on airway or main bronchus (thyroid, lymphoma, bronchogenic carcinoma, mets etc)
DDx
- Lower airways foreign body
- Mild-Mod Asthma/COPD
- Laryngomalacia/stenosis
- Goitre
- Bronchiolitis
