Station 2: History Flashcards
1
Q
Approach to history-taking?
A
- Patient’s perception - concerns, worries
- Alarm symptoms - list of emergencies associated with disease categories
- Disease interaction - e.g COPD with new ascending weakness will warrant ICU referral
- Therapeutic success or failure - adherence, side effects, unnecessary drugs
- Risk to others - epilepsy and driving, HIV, hereditary problems
Systematic flow: HPC Systems review (constitutional/B symptoms, cardio, resp, GI, GU + period/infertility, neuro, CTD, metabolic, autoimmune) PMHx + surgery DHx Allergies FHx (genetic test where relevant) SHx (smoking, alcohol, occupation, home, independence e.g. driving/shopping/cleaning/finances) Travel Hx
2
Q
Cue words
A
Intro
- What’s the best name to call you by?
- As we’re discussing I might be writing some things down on this piece of paper, so please excuse me if I do that.
- Can I start by asking how old you are?
- I’ve had a letter from your GP and it says that you…can you tell me more about that?
HPC
- Have you managed to see if there is a pattern to this, can you think of anything that might be common amongst these events?
- Now I’m just going to ask some quick fire questions, I’m afraid they might come of as a bit thick and fast, but this is to ensure that I do not miss out anything important.
PMHx
- Have you had any illnesses in the past (apart from the ones you’ve mentioned)?
- Have you seen any specialist or been admitted to hospital for any conditions?
Fillers
- I’m just going to recap on what you’ve been talking about very briefly, if you think you can add anything or if anything is incorrect, just interrupt me.
- That’s good to know / That’s helpful, thank you.
- I can imagine that you’re worried about that, and we will talk a bit more about that in a short while.
ICE
- Do you have any ideas of what this could be?
- What about anything that you’re worried about, or any concerns you have in particular?
- What are you hoping might come out of today’s conversation?
Closing
- What I’m going to do now is talk you through the things that I think it might be
- And what we might do to investigate this further so that we can confirm and exclude a few things
- Is there anything that you would like me to explain further or anything that you are unsure about?
- Is there anything else from your side that you feel we have not talked about or we needed to mention?
3
Q
Dysphagia - approach?
A
- Determine whether oropharyngeal or oesophageal cause
- Trouble initiation or food gets stuck?
- Worse with solids or fluids?
- Progressive or comes and goes (oesophageal web/ring)?
- Location of dysphagia - pharynx or sternum?
- Associated symptoms - Odynophagia? Chest pain? Heartburn esp at night? Acid brash esp in the morning? Nasal regurgitation? Regurgitation? Neuro symptoms i.e. weakness, tremors, dysarthria, ptosis?
- PMHx - neuro disease i.e. CVA/PD/MND/MS/MG, systemic sclerosis, Sjogren’s, OA (extrinsic compression), prev radio to thorax (radiation oesophagitis), asthma/atopy (eosinophilic oesophagitis), HIV/immunosuppression
- Drugs
- Smoking and alcohol
- Social - how they maintain nutrition? Any distressing events recently (globes pharyngeus)?
4
Q
Dysphagia - features of oesophageal dysphagia?
A
- Food sticks after swallowing
- Worse with solids than liquids
- Associated with reflux and dyspepsia
- Progressive symptoms
- May be associated with alarm symptoms
5
Q
Dysphagia - causes of oesophageal dysphagia?
A
- Peptic stricture
- Oesophageal malignancy
- Oesophagitis
- Oesophageal spasm
- Oesophageal infection
- Achalasia
- Systemic sclerosis
- Extrinsic compression
6
Q
Dysphagia - features of oropharyngeal dysphagia?
A
- Trouble initiating swallowing
- Worse with fluids than solids
- Nasal regurgitation
- Associated with neurological disease or symptoms i.e. dysarthria/weakness
- History of aspiration pneumonia
- Coughing and choking
7
Q
Dysphagia - approach to oropharyngeal dysphagia?
A
- Upper GI endoscopy and possibly oesophageal manometry
- Investigation under speech therapy and ENT
- Video fluoroscopy with barium - filmed during real-time to study the mechanism of swallowing
- Treatment for neuromuscular abnormalities (found either from aspiration, pooling of barium, or muscle paralysis) - fluid thickener or swallowing manoeuvres i.e. head tilting
8
Q
Dysphagia - surveillance for Barrett’s oesophagitis?
A
- Barrett’s oesophagitis develops as a consequence of chronic GORD.
- Predisposes to the development of oesophageal adenocarcinoma.
- Rate of transformation to adenocarcinoma is 0.2-2% per year.
- Endoscopy is used as a surveillance tool - the British Society of Gastroenterology recommends endoscopic surveillance every 2-3 years for patients who would be candidates for oesophagectomy.
9
Q
Dysphagia - medications implicated in dysphagia?
A
Corrosive drugs causing injury - NSAIDs, bisphosphonates, doxycycline, iron sulphate
Drugs affecting lower oesophageal sphincter pressure - nitrates, calcium antagonists
10
Q
Risk factors for gastric cancer?
A
- H.pylori infection - atrophic gastritis, metaplasia, dysplasia, cancer
- Prev gastric surgery - hypochlorhydria or bile reflux
- Smoking
- Certain cancer syndromes e.g. hereditary non-polyposis colorectal carcinoma, familial adenomatous polyposis. Peutz-Jegher’s syndrome
11
Q
How to diagnose H.pylori infection?
A
- Non-invasive - urea breath test and H.pylori stool antigen detection (sensitivity and specificity > 95% but usage of PPI can lead to false negative)
- Rapid urease testing from endoscopic biopsy
- Routine histology from gastric antrum and body
- Bacterial C&S not routinely recommended, but may provide information in refractory disease
12
Q
H.pylori infection association?
A
- Peptic ulcer disease (95% of duodenal ulcer, 65-95% of gastric ulcers)
- Gastric adenocarcinoma (70-90%)
- Mucosal-associated lymphoid tissue (MALT) type lymphoma
13
Q
What is the role of H.pylori infection in peptic ulcer disease?
A
The mechanism of disease is thought to be due to bacterial effects on: Gastric acid secretion Gastric metaplasia Immune responses to infection Mucosal defence mechanisms
14
Q
Dyspepsia - approach?
A
- Location, duration, frequency, intensity, character
- Reflux symptoms?
- Relieved by or precipitated by meals?
- Nausea or vomiting?
- Pancreatic - radiating to back, precipitated by eating, relieved by leaning forward?
- Biliary - right side, precipitated by eating?
- Colonic - lower abdomen, colicky, relieved by defecation?
- Alarm features - LOW, LOA, early satiety, dysphagia, jaundice
- PMHx - GORD, gastric surgery, dyslipidaemia, pancreatitis, gallstones, haemoglobinopathy (pigment gallstones), FHx of gastric Ca?
- Drugs - PPI, NSAIDs, bisphosphonates, steroids, nitrates, calcium antagonists, drugs causing pancreatitis (AZA, ART, diuretics)
- Smoking and alcohol
- Social - eating late at night, affecting QoL?
15
Q
Dyspepsia - plan of action?
A
- Explain that there are many possible causes
- A trial of therapy may be the best initial strategy prior to investigation
- Arrange endoscopy if any alarm symptoms or age > 55
- If endoscopy not indicated, give trial of PPI for 4 weeks and if no improvement, arrange for H.pylori test
- Suggest abdominal ultrasound if suspicion of pancreatic or billiary cause
- If reflux - suggest elevating head and not eating so late at night
- General advise on weight loss, smoking cessation and limiting alcohol intake
