The Art and Science of Clinical Medicine Faculty Guide Year 1 2013–2014
MSK 1 till End of year Jean Hudson 5/16/2014
Table of Contents: Session MSK 1 Physical exam review Portfolio 3 Sexual history, substance Use and Medication history Approach to common Neurological symptoms Neuro 1 Neuro 2 Neuro 3 MSK 2 Practice Exam Ophthalmology Final OSCE
Date February 21 2014 February 28 2014 March 7 2014 March 21 2014
Page 2 13 17 27
March 28 2014 April 4 2014 April 11 2014 April 25 2014 May 2 2014 May 9 2014 May 16 2014
February 21, 2014 -‐ Session 23 REMINDERS FOR THIS SESSION Watch videos on Portal
OBJECTIVES By the end of this session, the student should be able to: • List the key questions that distinguish inflammatory from non-‐inflammatory arthritis • Describe an approach to the patient with joint pain • Describe an approach to examination of the joints • Describe and perform an MSK screening examination: the “GALS” examination • Perform a detailed examination of an individual joint: the knee
AGENDA 8:00 Students to demonstrate GALS and knee exam, tutors to correct Some sites may have Rheumatologists co-‐teaching 9:30 Students practice on each other 10:00 Students interview and practice with volunteer patients 11:30 Feedback on Case Report #4 Recap/Reminders for Session 24
NOTES FOR FACULTY This session will introduce students to the MSK history and examination.
VIDEOS: Students (and tutors) are asked to watch a video in advance of the session, which will review the approach to the history and examination of a patient with joint pain. http://admin.med.utoronto.ca/streamer/index.cfm?code=K36UeRHm2Z0Ce70 Students (and tutors) will also be asked to watch videos that introduce the GALS screening, Dr Lori Albert created the following video: https://docs.google.com/file/d/0B1T8cW4mxZCmT3UzT1ZoN09RazA/edit?pli=1 Mississauga students created the following fun GALS video: http://www.youtube.com/watch?v=2kzeMR67Mgc The following videos are of the focused knee exam (Dr. Lori Alberts) http://admin.med.utoronto.ca/streamer/index.cfm?code=OjuA9yRFizCVl1u Bulge sign in the knee exam: http://media1.med.utoronto.ca/umevideos/2012_2013/ForBB/ASCM1/IMG_0080.mov http://media1.med.utoronto.ca/umevideos/2012_2013/ForBB/ASCM1/IMG_0243.mov The medial fossa of the knee appears full, suggesting the presence of an effusion. The examiner sweeps the hand up the medial side of the knee, from inferior to superior, sweeping the fluid into the suprapatellar pouch. After a brief pause, the hand is brought down along the lateral side of the knee, from the suprapatellar pouch downwards (being careful to avoid pressing on the patella itself).A small wave of fluid, or bulging is seen in the medial fossa as fluid moves back into the joint The focus of the ASCM 1 session with the tutor will be to practice skills learned in the video. Thus, it is expected that students will have watched the videos before coming to the session. Tutors are welcome to demonstrate parts of the exam where needed, but should avoid teaching the entire examination from the start, so that students have maximal time available for practice.
There may be a rheumatology “guest expert” available as a resource for each group. This person can help with observing and correcting students’ performance of the physical exam components during the session. Students will be examining each other, and should come prepared with shorts. Patients or simulated patients may also be available at some academies for additional practice.
BACKGROUND Review the basic anatomy of the joint. There are two main categories of pathology that affect joints causing what we see clinically as “arthritis”. Inflammatory and Non-‐inflammatory Inflammatory arthritis can be acute or chronic. Acute Inflammation in the joint E.g. Infectious arthritis, occurring secondary to bacterial infection in the joint (Other infections such as fungal may be more subacute or chronic) E.g. Acute inflammation due to deposition of crystalline products in the joint such as monosodium urate (gout) and calcium pyrophosphate (“pseudogout”) Chronic inflammation in the joint E.g. Rheumatoid arthritis: an autoimmune disease affecting the joints (there are other autoimmune diseases that also affect the joints) E.g. Chronic infections: tuberculosis, fungal, Lyme disease Non-‐inflammatory joint disease Osteoarthritis is a process of breakdown of cartilage and bone due to failed repair of joint damage resulting from stresses that may be initiated by an abnormality in any of the joint tissues. It can occur as a primary process or secondary to a long-‐standing inflammatory process that caused damage in the joint. This is the most commonest non-‐inflammatory arthritis. Why does it matter? There are different treatments for different forms of arthritis. Most importantly, chronic inflammatory arthritis can lead to permanent joint damage and loss of function. Outcomes are much better with early recognition and optimal treatment of the arthritis.
ASSESSING THE PATIENT WITH A JOINT PROBLEM People generally recognize that there is a problem with the joints because of PAIN and sometimes SWELLING. There are over 100 kinds of arthritis, so it is important to have a framework for assessing people with possible arthritis or related conditions. Is this problem in the joint, or coming from somewhere else? A joint problem will present with limitation and/or pain on movement in most planes of movement of that joint. There may be swelling when the problem is in the joint. There will be no discomfort or limitation when moving the patient’s symptomatic joint when the pain is referred from another joint or structure. If a structure immediately outside of the joint (ie. tendon, bursa) is the source of pain, movement of the symptomatic joint will usually cause pain only with certain movements, that stress the involved structure (this is a PERI-‐ARTICULAR problem). Is this problem acute or chronic? What is the time course of the problem? Is it continuing to worsen? Is it waxing and waning? Is the joint problem inflammatory or non-‐inflammatory? Are joints damaged? Inflammatory problems cause PAIN, SWELLING, WARMTH, LIMITATION OF MOVEMENT and STIFFNESS upon first movements of the day, that typically lasts one hour or more. “Morning Stiffness”. ASK: Do you have stiffness in your joints in the morning? How long does it take you to get going? How long until you’re as good as you’re going to get for the rest of the day? Are you able to dress yourself in the morning? Non-‐inflammatory problems can produce transient stiffness after prolonged sitting in a chair or car “post-‐rest GELLING”. When damage has occurred, people may hear or feel CREPITUS (and you will on exam). Are there clues in the non-‐MSK history (important review of systems questions)? So-‐called “extra-‐articular” symptoms are evidence of systemic involvement by a process that also affects the joints. Examples include certain skin rashes, eye problems, mucosal ulcers, pleuritis or other lung problems, and many others. Discovering that a person has these symptoms (or findings on examination) provides clues as to the type of arthritis the person might have. For example, a young woman with polyarthritis in the small joints and a facial rash might have systemic lupus erythematosus.
What is the impact on the patient? People with arthritis experience varying degrees of disability, and it is important to find out how patient are managing with activities of daily living, work-‐related activities, hobbies, sexual function, childcare etc. ASK: How has your life been affected by this joint problem? TAKING THE HISTORY All elements of the history are important and relevant to assessing a patient with possible arthritis because of the systemic nature of many of the diseases. The important questions are evident in the approach shown above. In addition, a thorough functional inquiry/review of systems will capture many of the associated extra-‐articular manifestations. As you learn more about the rheumatic diseases in Year 2, the specific questions to elicit these problems will become easier to understand. Look Feel Move Periarticular Is there Is there FOCAL Is there PAIN with movement ONLY IN problem focal TENDERNESS at a CERTAIN DIRECTIONS (vs pain through the swelling or peri-‐articular whole range of motion with an articular redness? structure (bursa, problem) tendon or Is there REDUCED pain when you move the tendon/ligament joint PASSIVELY (so the inflamed/irritated insertion) peri-‐articular structure is not engaged) Inflammation Is the joint Is the joint WARM? Is there PAIN THROUGH THE RANGE OF SWOLLEN? Is there MOTION, BOTH ACTIVE AND PASSIVE Is the joint TENDERNESS AT Is there STRESS PAIN (pain when you take RED (or THE JOINT LINE? the joint a little beyond the normal range purpley-‐ Is there FOCAL of motion-‐characteristic of inflammatory bluey) TENDERNESS at a problems) peri-‐articular structure? Can you demonstrate the presence of an EFFUSION? Damage Is the joint Is there Is there CREPITUS with range of motion? showing TENDERNESS at the Is there INSTABILITY or ABNORMAL DEFORMITY joint line? MOVEMENT in the joint? ? Is there LIMITATION of RANGE OF MOTION?
EXAMINING THE PATIENT The physical exam in rheumatology will complement what you learned upon taking the patient’s history. As with the history, a complete physical examination is essential to diagnosing many rheumatic diseases. Your examination should also be geared to addressing the issues outlined above. NOTE: you will learn more about how to identify some of the extra-‐ articular manifestations of rheumatic diseases over time. Right now, you should focus your efforts on deciding if the problem is articular or non-‐articular, inflammatory or non-‐ inflammatory and if there is damage to the joint. How do you operationalize this? LOOK (Inspection) FEEL (Palpation) MOVE (and check for abnormal movements) FINAL STEPS What is the distribution of joints involved, if it involves more than one joint? Certain patterns of joint involvement are typical of certain diseases. You will learn more about this in ASCM 2. What extra-‐articular manifestations are present? You will learn more about this in ASCM 2.
GALS MSK SCREENING EXAMINATION-‐ STUDENTS MUST KNOW THIS EXAM FOR THEIR OSCES Gait, Arms, Legs, Spine Sometimes the setting is not appropriate for a full history and physical exam relevant to the rheumatic diseases. The presence or absence of joint disease may need to be determined quickly in the context of the patient’s history. In this case, a screening tool can be very effective. The GALS screening exam is a validated screen for musculoskeletal disease. This can also be included as part of your regular history and physical examination to screen for musculoskeletal problems in every patient you see. SCREENING QUESTIONS › Do you have any pain or stiffness in your muscles, joints or back? › Can you dress yourself completely without any difficulty? › Can you walk up and down stairs without any difficulty? Record for a normal GALS screening exam. Record for an abnormal exam. Limb Appearance Movement Limb Appearance Movement ! ! Gait Gait ! ! ! ! Arms Arms ! ! Legs Legs Knee Swelling Flexion 90° only ! ! ! ! Spine Spine
SCREENING EXAMINATION Positioning and draping Make sure both legs are exposed in order to compare each side. There are three positions for the exam: walking, standing (back, side, front), and supine. Examination Individual Components of GALS exam (see attached article, Doherty et al, 1992) GAIT • Symmetry & smoothness of movement • Stride length & mechanics • Ability to turn normally & quickly ARMS (Hands) • Wrist/finger swelling/deformity • Squeeze across 2nd to 5th metacarpals for tenderness (indicates synovitis) • Turn hands over, inspect muscle wasting & forearm pronation/supination ARMS (Grip Strength) • Power grip (tight fist) • Precision grip (oppose each finger to thumb) ARMS (Elbows) • Full extension ARMS (Shoulders) • Abduction & external rotation of shoulders LEGS (Feet) • Squeeze across metatarsals for tenderness (indicates synovitis) • Calluses LEGS (Knees) • Knee swelling/deformity, effusion • Quadriceps muscle bulk • Crepitus during passive knee flexion
LEGS (Hips) • Check internal rotation of hips SPINE (Inspection from behind) • Shoulders & iliac crest height symmetry • Scoliosis • Paraspinal, shoulder, buttocks, thighs & calves muscles normal • Popliteal or hind foot swelling or deformity SPINE (Inspection from front) • Quadriceps normal in bulk & symmetry • Swelling or at varus or valgus deformity at knee • Forefoot of midfoot deformity, action normal • Ear against shoulder on either side to check lateral cervical spine flexion • Hands behind head with elbows back (check rotator cuff muscles, acromioclavicular, sternoclavicular & elbow joints) SPINE (Inspection from side) • Normal thoracic & lumbar lordosis • Normal cervical kyphosis • Normal flexion (lumbosacral rhythm from lumbar lordosis to kyphosis) while touching toes SPINE (Trigger point tenderness) • Supraspinatus muscle tenderness (exaggerated response)
EXAMINATION OF THE KNEE ANATOMY The knee is a synovial hinge joint, composed of the femur, tibia, and patella (knee cap). It is stabilized by four ligaments: the medial collateral (MCL), lateral collateral (LCL), anterior cruciate (ACL), and posterior cruciate (PCL). A fifth ligament, the patellar ligament, is a continuation of the quadriceps femoris tendon. It attaches superiorly to the apex and margins of the patella and inferiorly to the tibial tuberosity. Ligaments are illustrated in FIGURE 23.2. Two menisci (lateral and medial) cushion the action of the femur on the tibia (FIGURE 23.3). The synovial cavity of the knee occupies the concavities lateral and medial to the patella and also the suprapatellar pouch, which extends approximately six centimeters above the upper border of the patella, deep to the quadriceps muscle. The synovium is not normally detectable on physical exam.2,3 EXAMINATION As a general rule, it is a good idea to observe gait to inspect weight-‐bearing joints at the start of the examination. For convenience, this can be deferred to the end of the examination. Draping The patient is supine and exposed from mid-‐thighs downward to feet. Place a sheet between the patient’s legs to cover the groin. Inspection Gait: An antalgic (i.e. “against pain”) gait reflects pain anywhere from the pelvis to the foot. The stance phase on the affected side is briefer and the swing phase on the contralateral side is shorter, as the patient avoids bearing weight on the painful side.8 An arthrogenic gait indicates a stiff knee or hip. It is not necessarily painful. The affected side is circumducted during the swing phase because hip or knee flexion is limited.8 Symmetry: As the knee is examined, it is compared to ‘normal’ joints above and below, as well as to the same joint on the contralateral side.8 Alignment: Inspect when the patient is supine and in the standing position. Examine the patient’s anatomy for genu valgus (‘knock-‐knee’ deformity), genu varus (‘bow-‐leg’ deformity), or genu recurvatum (hyperextension of the knee). Also examine for a fixed flexion deformity (inability to fully extend the knee).8
Swelling: Joint fluid tends to accumulate in the suprapatellar pouch and the medial and lateral parapatellar fossae.8 Look for joint enlargement, as compared to the contralateral side. Colour changes: Erythema (abnormal redness) may be indicative of inflammation. Proximal muscle atrophy: Examine the quadriceps muscle for evidence of atrophy, as compared to the contralateral side. Palpation Effusion: There are three basic methods to test for an effusion: the bulge test is used to detect a minor effusion, while ballottement and the patellar tap are used to detect a large effusion. Bulge test (minor effusions): the patient is supine with the knee extended. The examiner uses his/her hand to milk fluid along the medial aspect of the knee joint upward into the suprapatellar pouch. The examiner then runs his/her hand down the lateral side of the knee while observing the medial aspect of the knee joint. A bulge will appear on the medial aspect if a small amount of fluid is present. However, if there is a large effusion, a bulge may not be seen.8 Ballottement (large effusions): the examiner uses one hand to press down on the suprapatellar pouch, forcing fluid downward. The index finger and thumb of the other hand is used to attempt to push fluid (if present) back and forth between the medial and lateral fossae or up toward the hand compressing the suprapatellar pouch.4 Patellar tap (large effusions): the examiner uses one hand to compress the suprapatellar pouch. With the other hand, he/she places the tips of the fingers on the patella and thrusts down firmly. Normally there is no patellar movement. In the presence of a large effusion, the patella will float up out of its normal position. As the examiner presses on the patella, downward movement will be detected, often with a palpable tap or click as the patella strikes the femoral condyles.8 Baker’s cyst: In approximately one-‐third of patients, there is a communication between the knee joint space and the popliteal bursa, which can result in a bursal swelling at the posterior aspect of the knee. This is known as a Baker’s cyst.8 Palpate the posterior aspect of the knee for the presence of a Baker’s cyst. If the cyst is very large, it may also be detected visually when the patient is standing. Warmth: The kneecap should be the coolest part of the joint. Use the dorsum of the hand and feel the temperature from the distal thigh, over the kneecap, and down the shin, comparing
the kneecap with the rest of the leg, and one knee with that of the other. Joint warmth can indicate inflammation.8 In individuals with fatty tissue around the knees, effusions may not be detectable and prepatellar warmth may be the only indication of inflammation.8 Joint line tenderness/bony tenderness: Flex the knee to 90°. Locate the tibial tuberosity and patellar tendon and palpate upward along the patellar tendon to find the joint line on either side. Feel along the joint line, one side at a time, and ask the patient to report if he/she feels tenderness. Tenderness can be indicative of meniscal damage.7 Stress pain. The valgus and varus stress tests assess for laxity of the MCL and LCL respectively. Valgus/abduction stress test (FIGURE 23.4): the patient is supine with the knee slightly flexed. The examiner places one hand against the lateral aspect of the knee to stabilize the femur; the other hand is placed on the medial aspect of the ankle. Stress is applied, pushing medially against the knee and pulling laterally at the ankle, in an attempt to open the knee joint on the medial side (valgus stress). Pain or a palpable gap in the medial joint line is indicative of an MCL tear.2 The MCL is a more common site of injury than the LCL. Varus/adduction stress test (FIGURE 23.5): the patient is supine with the knee slightly flexed. The examiner places one hand against the medial aspect of the knee and the other on the lateral aspect of the ankle. The examiner then pulls laterally at the knee and pushes medially against the ankle, in an attempt to open the knee joint on the lateral side (varus stress). Pain or a palpable gap in the lateral joint line is indicative of an LCL tear.2 Crepitus. To assess for crepitus, place one hand over the medial and lateral joint line and patella, and with the other hand move the knee through its full range of motion. A grinding or crackling sensation (audible or palpable) indicates crepitus.8 Crepitus may occur in normal joints, but may be significant if accompanied by other symptoms and signs.2 Range of motion Active and passive range of motion (ROM) should be compared to determine if the patient has restricted range of flexion. Normal range for flexion is 120˚. Active flexion: the patient is asked to touch the heel to the buttock (flexion of the knee) and then to straighten the leg (extension). Passive flexion: one hand is placed over the medial and lateral joint line and patella to palpate for crepitus while the other hand grasps the heel and moves the knee through its full extension and flexion.6
Special Manoeuvres Note that for all maneuvers, it is best to interpret a finding (e.g. ACL laxity by anterior drawer) than to state whether a particular test is positive or negative. Anterior drawer test for stability of ACL(FIGURE 23.6). The patient is supine and the knee is flexed to 90° with the sole of the foot flat on the table and hamstrings relaxed. The examiner uses his/her forearm to stabilize the tibia. The examiner cups his/her hands around the back of the tibia and places his/her thumbs on the medial and lateral joint line or the tibial tuberosity. The examiner then pulls tibia anteriorly. The test is positive if the tibia can be pulled away from the femur.2,3 Lachman’s test for stability of ACL (FIGURE 23.7). The patient is supine with the knee flexed to 20° and the hip externally rotated. The examiner uses one hand to hold the distal femur, and the other hand to hold the upper tibia, placing the thumb on the joint line. The tibia is pulled anteriorly and the femur pushed back simultaneously. If the tibia can be pulled anteriorly from the femur, an ACL tear is implicated.2,3 Posterior drawer test for stability of PCL (FIGURE 23.8). The patient is supine and the knee is flexed to 90° with the sole of the foot flat on the table and hamstrings relaxed. The examiner uses his/her forearm to stabilize the tibia. The examiner cups his/her hands around the back of the tibia and places his/her thumbs on the medial and lateral joint line or the tibial tuberosity. The examiner then pushes the tibia posteriorly. The test is positive if the tibia can be pushed posteriorly with respect to the femur.2,3
REFERENCES 1. Albert, L. Personal communication, July 22, 2008. 2. Bickley, L. S., Szilagyi, P. G. (2007). Bates’ Guide to Physical Examination & History Taking (9th ed.). Philadelphia: Lippincott Williams & Wilkins. 3. Drake R.L., Vogl W., Mitchell A.W.M. (2005). Gray’s Anatomy for Students. Toronto: Elsevier. 4. Golman, G. et al. (2003). Locomotor System. Toronto: Healthcare and Financial Publishing. 5. Gross, G., Fetto, J., Rosen, E. (2002). Musculoskeletal Examination. Malden: Blackwell. 6. Klippel, J. (2008). Primer on the Rheumatic Diseases (13th ed). New York: Springer. 7. Malanga G.A., Nadler S.F. (2006). Musculoskeletal Physical Examination: an Evidence-‐ Based Approach. Philadelphia: Elsevier. 8. Thompson J.M., Walton A. (1998). The Musculoskeletal Screening Examination. London: University of Western Ontario. 9. Doherty, M., Dacre, J., Dieppe, P., Snaith, M. (1992). The GALS locomotor screen. Annals of the Rheumatic Disease, 51, 1165-‐9. 10.Beattie et al. (2008). Validation of the GALS musculoskeletal screening exam for use in primary care: a pilot study. BMC Musculoskeletal Disorders. 9:115.
REMINDERS FOR SESSION 24 Review physical exams learned to date. Next session is a review session. Students are to take brief focused histories and spend the time on reviewing physical exam skills learned to date.
Physical Exam Review February 28, 2014 -‐ Session 24 REMINDERS FOR THIS SESSION Review physical exams learned to date.
OBJECTIVES By the end of this session, students should be able to: Demonstrate all physical exam skills learned to date.
AGENDA 8:00 Tutors and students to briefly review physical examination skills learned to date. 8:30 Examine real patients. Obtain a very brief focused history and practice the following physical exam skills: Vital signs Cardiovascular exam, including JVP and peripheral vascular exam Respiratory exam Head and Neck exam Abdominal exam Knee exam GALS screening exam 10:45 Break 11:00 Oral Reports: Present real patient cases seen today 11:30
NOTES FOR FACULTY Please find real patients prior to session if possible, so as to maximize the time students spend with patients reviewing their physical exam skills. Students should be encouraged to complete all physical exam skills listed below while being periodically observed by all available tutors. Feedback and demonstration, when needed, during physical exam practice is encouraged.
PRINCIPLES OF ORAL PRESENTATION FOR AN EXAMPLE SEE: Dr James providing an oral presentation regarding the thyroid assessment HTTPS://PORTAL.UTORONTO.CA/BBCSWEBDAV/PID-‐3792252-‐DT-‐CONTENT-‐RID-‐18740166_4/XID-‐ 18740166_4 BASIC GUIDELINES: 1. The oral presentation is brief. Its length is always <5 minutes, and ideally <3 minutes. 2. The oral presentation is delivered from memory. Try to make eye contact with your listeners during the presentation. 3. The oral presentation differs from the written presentation. The written presentation contains all the facts; the oral presentation contains only those few facts essential to understanding the current issue(s). 4. The oral presentation emphasizes History of Presenting Illness (HPI), and Summary and Impression. CONTENT: Identifying Data (ID) Age Sex Initials Chief Complaint (CC) Reason for presentation Duration History of Presenting Illness (HPI) All “positive” elements (i.e., what occurred) should precede “negative” elements (what was absent) “Positive” statements: should be in chronological order and attentive to detail (i.e., duration, frequency, progression over time, aggravating/alleviating features, associated symptoms, prior episodes, attribution and, if pain, quality, location, depth, radiation, severity) “Negative” statements: findings that although absent are important to mention (i.e., signs, symptoms and important risk factors) Past Medical History (PMH), Medications, Allergies and Habits Should be quite brief Physical Examination (PEx) Begin with “general description and vital signs” Include all abnormal findings Among normal findings, include only those essential to the understanding of the Chief Complaint Summary and Impression Provide a brief summary of the most important points, and offer your impression of the nature of the problem. This will be discussed in more detail in ASCM II. Adapted from “Oral Presentation Guidelines” by Steve McGee, M.D. University of Washington. https://catalyst.uw.edu/workspace/medsp/30311/202905
Portfolio III March 7, 2014 -‐ Session 25 OBJECTIVES By the end of this session, you should be able to: Share a story that has a personal meaning with trusted peers and colleagues and to listen to others’ stories respectfully Begin developing a reflection on what happened in your story as an introduction to reflective practice
AGENDA 8:00 Portfolio III 10:0 Interview patients for Case Report #5 0 11:4 Recap/Reminders for next session 5 Complete evaluation of the Portfolio sessions
NOTES FOR FACULTY INTRODUCTION: This two hour segment of an ASCM 1 session is designed to accomplish three things: Help students learn from their experiences as they continually improve their skills in communicating with patients and colleagues, by talking as a group about what they have seen and done, and what was important to them.
Develop students’ ability to share a potentially sensitive story that has a personal meaning to them with trusted peers and colleagues and to listen to others’ stories respectfully. Give the students a second experience with developing a reflection on what happened in their story as an introduction to reflective practice. BACKGROUND: The development of reflective practitioners is an overarching goal in medical education. Practitioners who can interpret the meaning of events around them, and adjust their practice accordingly, may have fewer difficulties in their careers with patients, colleagues, and regulatory bodies. The UME curriculum is promoting the development of reflective skills alongside all the other elements to be learned across four years. In first year, ASCM 1 is the first chance most students have to interact with patients. These are very important moments for all students, and the three Portfolio sessions are designed to give the students space and time to focus on how they are starting to develop their identity as doctors. Interspersed among the knowledge-‐based and skill-‐based sessions, these reflective sessions redirect students’ attention to their ultimate goal—being a skilled and caring practitioner. ACTIVITIES: The session format is outlined here: BEFORE THE SESSION: Students prepare ahead of time by deciding on ONE Central Story, based upon what they have seen and done relating to communicating with patients and others so far, using the prompts found on the next few pages. We tell them how to structure the story so that listeners have a clear idea of what happened. Students also prepare a statement, or Reflection, on how this experience has influenced their ideas of themselves as doctors. DURING THE SESSION: Intro: Tutor should introduce the process as outlined below. Students have this outline in their notes, but this brief review will ensure mutual understanding. (approx. 5 minutes) Activity: Students read and receive the group’s comments on their stories and reflections in the following format: Student A reads story and reflection to the group. Other students listen attentively. (approx. 5 minutes) Student A listens while other students share their thoughts, reactions and questions. Student A can respond where appropriate, but doesn’t have to -‐ s/he may wish to think about what was said. (approx. 10 minutes) Student B then starts his/her story and reflection, followed by group discussion and reaction to the story. (approx. 15 minutes) Process continues until all students have had a chance to participate. (Total 1.5 hours) Tutor’s role: In this format, you are acting more as a facilitator than a teacher. The goal is to have increasingly open and free discussion by all students about the stories and reflections. You will help the group towards this goal by doing the following: Solicit volunteers to tell their stories first, second, etc., rather than assigning an order. Let each student tell the story and reflection without interruption, and remind the other students not to interrupt if they do so. When the discussion is to begin, make sure the first people to participate are the students. Avoid giving your own views until the end, and even then make sure you are not providing the “definitive answer”. This exercise is about
students expressing their experiences learning about communicating in a clinical context. There cannot be one right interpretation, but students may look to you to provide “expertise”. If this occurs, we suggest redirecting questions back to the group, such as “What does that sound like/remind you of/make you feel/mean to you?” It is often best to put questions to the whole group rather than the initial speaker. Keep an eye on the time! If the discussion is moving along, and time is about to run out, gently interrupt and suggest that a few final points be made, so the next student can begin. If discussion stalls, try asking the group open ended questions that bring out their perspectives. Examples: “What surprised you (the group) in that story?” “How did you feel about (event) that happened, or the way (student) described it?” “Did any of you notice (tension/happiness/pride/fear/other notable emotion) in the way the story was told? Why do you think that was?” Wrap Up: Use the final minutes of the session to promote discussion of overall themes that you and the group heard. Here you can give your overview, but invite the students to provide theirs. (approx. 10-‐20 minutes) Send Off: Students have been given a worksheet to record what happened in the session. Remind them to fill it out, because these notes will be needed for their Reflection Assignment at the end of the year. Finally, remind them that the discussions in this group are not to be repeated elsewhere. We treat the thoughts and disclosures in this session as privileged, confidential information. AFTER THE SESSION: You will receive a link to a short questionnaire to record your reaction to the session and how it went. FAQ Why are we doing the group discussion of stories? We are using the power of group discussion to deepen each student’s own thought process about their own story. This format has worked successfully in the 3rd and 4th year Portfolio courses. Over the three Portfolio sessions, a climate of mutual support should emerge. Why is this considered a component of a clinical skills course? As outlined in the Background above, we use the setting of ASCM 1 because this is when students first “act like doctors”. Learning about “becoming a doctor” is a parallel process to learning clinical skills. As facilitators, you are helping students learn to talk about what is influencing them in their day-‐to-‐day experiences. We believe that this is a fundamental part of becoming a professional. What are my responsibilities about assessing (marking) the students? There is no separate mark or assessment for this activity. However, if you find that a student is rude, belittling of colleagues, argumentative, or extremely disengaged, you should consider speaking with the student after the session or assigning that student a minor lapse in professionalism, depending on the extent of your concern. You should also report absences from this session. The student materials for Portfolio Session 3 follow. Please read them to ensure you understand what students are to do.
PORTFOLIO III The History / Communication The history is one of the most essential skills that you will learn in medicine. In ASCM 1, you have spent a great deal of time learning how to take a proper history and how to develop a rapport with patients. Your ability to communicate well with you patients is vital to your ability to be a successful doctor. In addition, having the skills to communicate well with your colleagues, allied healthcare professionals, and patients’ families is also incredibly important. Purpose: To reflect on the issues and challenges that arise when taking a history, listening to patients’ stories, and otherwise learning to communicate in the clinical environment. BEFORE PORTFOLIO SESSION 3: Task: Think about one central story that highlights what you learned about the importance of strong communication skills. Alternatively, tell one central story which shows what you learned about the consequences of poor communication. The story can be from a time that you took a patient history in ASCM, an experience that you had in communicating with another medical student or staff physician, or a communication issue that came up before you even started medical school. Your task during the session will be to explain what happened in the story and what you learned about how you communicate. How could you be better at communicating? What went well and why? What would you do differently in the future? As a future physician, what do you want to keep in mind as you communicate with your patients and your colleagues? Taking a history could involve covering sensitive topics with a patient such as their sexual orientation. It also requires that you be culturally sensitive to people from different backgrounds, such as Indigenous Canadians, socially or financially disadvantaged people, and people of various faiths. If you have had an experience in which understanding a patient’s culture, religion, language, or beliefs was important in taking a history, then you could reflect on that experience and what you learned as a result. IN PORTFOLIO SESSION 3: Tasks: Explain what happened in the central story, what you learned about how you communicate, and what you thought the significance of the events were to you, in influencing how you see yourself as a doctor. Format: Tell the one central story -‐ where were you, who was there, and what happened? Lead the rest of the group through your “history”, and please include any feelings or thoughts that came to you as part of the story. (If it helps, think of this as telling the HPI of you, the “patient”.) The self-‐reflection is meant to be highly personal, and there can be no “right answer”. You’re on the right track if you can say “The thing I learned about myself as a future doctor from this experience was...” and state something that you feel is authentic and true to you. After you have finished, the rest of the group will be invited to comment on what they heard. Comments should focus on what listeners appreciated in the story, and interesting ideas that came to them while listening. Questions may be asked to clarify the story, and you may have new ideas during the discussion. Time per student: 15 minutes total.
After this, it will be time to move to the next student’s story. At this point, you will listen attentively and provide your own thoughts and reactions to the stories you hear. At the end of the entire session, the facilitator and the whole group will discuss general themes that came out of this activity. The facilitator is there to help guide the discussion, and to pose questions, but not to provide “answers”. Everyone shares responsibility for keeping the discussion on track, and within the time allotted for this activity. AFTER THE SESSION: Task: Consolidate your ideas about your story, using the points brought up by your classmates, and any other ideas you had. You will need this for your final reflection later in the year. Format: To be done as soon as you can after the session. Use whatever format will be easiest for you to follow later. We suggest using the following sheet to organize your observations and ideas. REFLECTION WORKSHEET FOR HISTORY-‐TAKING AND COMMUNICATION The Central Story I told in this session was: The key things I learned about the way that I want to practice medicine from the Central Story were: Ideas and feelings that came to me during the group discussion of my story:
Other ideas and feelings that came to me from listening to other students’ stories:
FINAL PORTFOLIO ASSIGNMENT The Written Reflection The final part of the Portfolio portion of the course is to create a short written reflection about how you see your own development as a physician at the end of the year. PURPOSE: To develop students’ skills in creating a structured written reflection which will be submitted for feedback. These skills will help students with reflections to be written in the future Portfolio components and courses in their UME training. Finally, these skills will enable students to develop their reflective practice further than the informal discussions allow. BACKGROUND: At the end of your first year of medical school, you have already mastered a large body of knowledge, both in the classroom and in the clinical world. You have also developed a solid foundation in the skills of being a clinician—meeting patients, speaking to them about their lives while taking a history, and examining them, all of which are unique professional skills that you didn’t have at the beginning of the year. You have reached an important milestone in your development as a clinician. Your discussions with classmates about your reflections in the three portfolio sessions within ASCM 1 gave you a chance to explore the impact of all this learning on how you see yourself as a clinician. Now, you will develop these ideas further by putting together a more formal reflection, using the structure specified below. Creating a written reflection is a form of explanation and analysis of your thoughts, feelings and ideas about a personal subject -‐ in this case, you as a developing clinician. You will be doing this in future Portfolio components in Year 2, and in the Portfolio Courses in Years 3 and 4, so this is a chance to develop your skills in this activity. In addition, we find that students gain greater insight into their own self-‐reflections through the process of formalizing them, and often find themselves taking their ideas further than they had before when they are preparing something to be read by another person. It is important to stress that the PROCESS of reflection is what we are looking for in these submissions. Your work will not be evaluated based upon the ideas you express, nor upon any conclusions you come to. Rather, we will focus on encouraging you to explore these ideas and conclusions further. The way in which these reflections will be assessed is explained in the “Task” section below.
TASK: Preparation: Go back to your notes from the three Portfolio discussions. Remind yourself of the encounters you described in your Central Stories, and read over the ideas you documented afterward. Choose one of the Central Stories to act as the “base” for your reflection on the question: “How did this story influence my development as a doctor over this year?” If you don’t feel that any of the stories are appropriate for this question, you can choose another Central Story to act as the “base” for this reflection. Consider the ways in which you might explain your perspective on the Central Story and its influence on your development. Here are some possible prompts to get you started: What surprised you about the situation in the Central Story? Were you shocked? Startled? Impressed? Disappointed? How did you process or understand the situation at the time, and has that changed since then? What did you change because of the situation you experienced in the Central Story? Has that change been maintained? Has it developed further? Why or why not? How do you plan to build on the lessons you learned? How will it affect the way that you practice? How has it affected your behavior, your attitude or your perspective on the way that you want to practice medicine? And most fundamentally: Why do you believe this story is the best one to tell about how you see yourself developing as a doctor? Make rough notes -‐ jot down any ideas you have, in whatever format works for you -‐ lists, diagrams, word clouds, etc. In doing so, create the relationships between the ideas in some way that will help you to write the reflection. Write the reflection: Start with your Central Story: This must have a beginning, which sets the scene. Where did this take place, who was there, and what else was going on? There must be a middle, which explains what happened, and MUST tell the reader how this involved or affected you. What did you do or say? What were your feelings when this happened? Both the “external story” and the “internal story” are part of the overall Central Story.The Central Story must end by describing how the situation ended, including what you did, and felt, at the end. Move on to your Reflection: The Reflection is fundamentally based upon answering the question, “How did this Story influence my development as a doctor over this year?” If you are thinking about whether the answers you come to are the “right” or “acceptable” ones, STOP RIGHT NOW. The process of describing your perspectives is what we focus on. The actual perspectives are uniquely yours, and should not be judged. Go back to the rough notes you prepared and outline, in paragraph form, the ideas you worked out. Be sure to explain why you see one idea leading to another. Create a summary statement about where you think you will go from here -‐ how you will carry the lessons forward into second year. Above all, make sure that the focus is on YOU, the developing doctor. Submit the Reflection using the online submission system, which will be explained to you closer to the time.
STRUCTURE: Your submission must follow this structure: Start with a Central Story, with beginning, middle, and end, described above. Move to the Reflection, focusing on the question, “How did this story influence my development as a doctor over this year?” End with a summary statement that explains how you will take the lessons learned into second year. Suggested length is 250 -‐ 500 words. CRITERIA: Your submission will be graded on a Credit/No Credit basis. The following are the standards we will use to evaluate it: No Credit if: You do not submit anything; or There is no Central Story, containing a beginning, middle and end; or There is no Reflection; or The Reflection does not address the question: “How did this story influence my development as a doctor over this year?” Credit: will be given to all submissions not described above. In addition, you will be given feedback in all cases. For those who receive No Credit, direction will be given as to how to improve the submission, which you must redo and send to the Portfolio Course directors for review. For those who receive Credit, feedback will emphasize how you can take your ideas further. Please read the feedback as this will help you in the coming years of the Portfolio course. The written Reflection is a required component of the ASCM 1 course, and students must obtain Credit status in order to achieve the ASCM 1 Course Credit. The Reflection is due on March 21, 2014.
REMINDERS FOR SESSION 26 Remind students to bring all five case reports to Session 26. They should print and bring hard copies to be able participate fully in this session.
Sexual History, Substance Use, Medication History March 21, 2014 -‐ Session 26 REMINDERS FOR THIS SESSION Students to bring all five case reports for Session 26
OBJECTIVES By the end of this session, the student should be able to: Know the types of questions to ask to document adequate Sexual History and strategies to adapt language depending on patient Identify and understand the fundamental terms related to substance use and substance-‐induced disorders Be familiar with stages of change Review the approach and specific questions that should be included when taking a medication history Develop a useful table format to summarize drug information from the medication history Use their personal five ASCM case reports to discuss and identify the challenges involved in medication history-‐taking Briefly describe the concept of medication reconciliation
AGENDA 8:00 Sexual History Substance Use 9:00 Role plays: Sexual History, Substance Use 10:00 Discussion of Medication History 11:00 Role-‐play: Medication History 11:55 Complete evaluation of the Advanced Interviewing and Substance Use/Sexual Hx/Medications Hx sessions
SEXUAL HISTORY TAKING Taking a sexual history should be part of the comprehensive health assessment for every patient, regardless of educational, marital, and socioeconomic status. Importance of taking a sexual history1 26% revealed new information 16% led to a change in treatment 39% felt it led to a better understanding of the patient WHEN IS IT APPROPRIATE TO ASK ABOUT THE SEXUAL HISTORY? ID CC HPI ROS General/Constitutional Skin/Breast Eyes/Ears/Nose/Throat Cardiovascular Respiratory Gastrointestinal Genitourinary ****SYMPTOMS**** Musculoskeletal Neurologic/Psychiatric Allergic/Immunologic/Lymphatic/Endocrine PMH Allergies and Reactions to Drugs Current Medications Medical/Psychiatric Illnesses Surgeries/Injuries/Hospitalizations Immunizations Tobacco/Alcohol/Drug Use Reproductive Status for Females *****BEHAVIOURS**** Birth History/Developmental Milestones for Children Marital/Relationship/Family Status ***** SEXUALITY ***** Occupation/Exposures SOME WAYS TO ASK ABOUT SEX “Are you sexually active?” “Are you sexually active with men, women, or both? “Tell me about your current sexual activities? “What types of sex do you engage in?”
“Do you engage in vaginal/anal/oral/digital…sex?” “How many sexual partners do you (currently) have?” “How many lifetime sexual partners have you had?” “Do you have any sexual concerns that you would like to discuss?” “Do you/your partner have other sex partners/outside sexual partners?” “Do you have a regular partner(s), casual partner(s), or both?” “Have you ever had sex under the influence of alcohol/drugs?” “Are you satisfied with your sex life?” ADAPTING LANGUAGE TO FIT YOUR PATIENT The way you phrase a question may be different with a young adult, versus someone older, or someone younger When in doubt, start with more formal terms, and adjust accordingly—always check in with the patient to make sure they are understanding your question There may be situations when the use of more slang terms are appropriate and necessary, just as more formal terms have their role in sexual history taking SOME COMPONENTS OF AN ADEQUATE SEXUAL HISTORY Start with less threatening open-‐ended questions, before progressing to more specific, sensitive questions Start of sexual activity Number of sexual partners Gender of sexual partners Partner(s) risks (sexual, other -‐ including IV drug use) Survival sex or prostitution Specific sexual activities Symptoms Condom use and consistency; history of condom-‐breaks Use of contraception Sexual abuse/violence Patient’s level of education Patient’s ideas about sexual risk Addressing confidentiality; reportable STIs Providing a safe environment Avoiding judgement Knowing one’s limitations and knowledge Awareness of responses, body language, and non-‐verbal communication—both yours and the patient’s Demonstrate interest, understanding, and respect
ADOLESCENT/TEEN HISTORY-‐TAKING Interviewing Adolescents/Teens: HEADSS2 H Home and Environment E Education and Employment A Activities D Drugs S Sexuality S Suicide/Depression
SUBSTANCE USE AND DEPENDANCE HISTORY FUNDAMENTAL TERMS USED IN ADDICTION—FROM DSM IV SUBSTANCE USE DISORDERS Substance Dependence A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-‐month period: Tolerance, as defined by either of the following: A need for markedly increased amounts of the substance to achieve intoxication or desired effect. Markedly diminished effect with continued use of the same amount of the substance. Withdrawal, as manifested by either of the following: The characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for withdrawal from the specific substances). The same (or a closely related) substance is taken to relieve or avoid symptoms. The substance is often taken in larger amounts or over a longer period than was intended. There is a persistent desire or unsuccessful efforts to cut down or control substance use. A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance, or recover from its effects. Important social, occupational, or recreational activities are given up or reduced because of substance use. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-‐induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption). Specify if: With Physiological Dependence: evidence of tolerance or withdrawal (i.e., either Item 1 or 2 is present) Without Physiological Dependence: no evidence of tolerance or withdrawal (i.e., neither Item 1 nor 2 is present) Substance Abuse A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-‐month period:
Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-‐related absences, suspensions, or expulsions from school; neglect of children or household) Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) Recurrent substance-‐related legal problems (e.g., arrests for substance-‐related disorderly conduct) Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights) b. The symptoms have never met the criteria for Substance Dependence for this class of substance. SUBSTANCE-‐INDUCED DISORDERS Substance Intoxication The development of a reversible substance-‐specific syndrome due to recent ingestion of (or exposure to) a substance. Note: Different substances may produce similar or identical syndromes. Clinically significant maladaptive behavioral or psychological changes that are due to the effect of the substance on the central nervous system (e.g., belligerence, mood lability, cognitive impairment, impaired judgement, impaired social or occupational functioning) and develop during or shortly after use of the substance. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder. Substance Withdrawal The development of a substance-‐specific syndrome due to the cessation of (or reduction in) substance use that has been heavy and prolonged. The substance-‐specific syndrome causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder. TAKING A HISTORY Taking a substance use history may be challenging. Factors can involve: Physician’s comfort and knowledge with the topic Patients may find it offensive to be asked, or may be in denial of it The following approach has been suggested by the American Society of Addiction Medicine (ASAM): How to start the conversation -‐ normalize the question: I ask all my patients about alcohol use and other substances... Get consent to talk about this: Is it ok to talk about this? Ask if they consume alcohol: Do you sometimes drink beer, wine, or other alcoholic beverages? If yes, quantify and screen: On average, how many days a week do you have an alcoholic drink? On a typical drinking day, how many drinks do you have? *For men: In the past year, how many times have you had 5 or more drinks in a day? *For women: In the past year, how many times have you had 4 or more drinks in a day? Ask if they consume other substances:
In the past year have you used an illegal drug or used a prescription medication for non-‐medical reasons? Or That was not prescribed to you? If yes, ask what substances, frequency of use, and quantities of use, and route taken (IV, PO, etc.). *These questions have been shown to have the best overall sensitivity for diagnosing substance use disorders. ALCOHOL HISTORY CAGE Questionnaire: Have you ever felt a need to Cut down on your drinking or other drug use? Have you ever been Annoyed at criticism of your drinking or other drug use? Have you ever felt Guilty about your drinking or other drug use? Have you ever had an Eye-‐opener, i.e., taken a drink or used drugs to get going in the morning? STAGES OF CHANGE: Stages of change, also known as the Transtheoretical Model (TTM) of Behaviour Change, assesses ones readiness to change to a healthier behavior. This model also provides strategies, to guide one through the stages of change above, to Action and Maintenance.
CASES FOR ROLE PLAY-‐ STUDENTS TO TAKE TURNS PLAYING PATIENT CASES for SEXUAL HISTORY TAKING and SUBSTANCE/ADDICTIONS HISTORY 1. “The Worried Traveller” 2. “ Don’t Tell Mommy” 3. “ A Hidden Agenda” 4. “The Big City” 1. “ The Worried Traveller” Mr. Smith is a 50-‐year-‐old executive who has just transferred to your practice one month ago. He comes to your office for a Periodic Health Exam (PHE)—his first one with you. He has no specific concerns. He has been married for over 20 years to a woman who is also your patient. As part of a ��thorough assessment, you review Mr. Smith’s lifestyle. You are at the point in your interview when you ask about his relationship and sexuality.
NOTES FOR FACULTY-‐ COPY THIS ROLE FOR STUDENTS TO PLAY PATIENT appears uncomfortable when asked questions about sexual history married for 20 years sexually active with wife, about once weekly – vaginal and oral sex, no condoms, no contraception (wife post-‐ menopausal); he’s curious about anal sex and asked for it, but wife is uninterested sexually active with casual female partners, usually when on business – two in the last 6 months – attends massage parlors – has received oral sex (he calls it a “blow job”), no condom use – wife unaware of this attendants he has had contact with with at this massage parlor have tattoos unaware of risk of STIs with oral sex no symptoms now; had dysuria x 1 week after an oral sex encounter at the massage parlor cannot recall last STI screen, but it was with his last family doctor “years ago” if offered an STI screen, would like one, but did not think he was at risk for STIs with his casual partners and says he’s in a “monogamous” relationship with his wife has occasional difficulty with erections but embarrassed to bring up the topic unless directly asked has had one male sexual partner in his lifetime-‐ occurred when “experimenting” in University; mutual masturbation occurred; identifies as being heterosexual total number of lifetime sexual partners about 20 2. “ A Headss-‐Up” Tracy is a 16-‐year-‐old female presenting to your office with her mother for a concern about a rash. A longer appointment was booked for a “general check-‐up”. You haven’t seen Tracy for a few years. You have been the family’s doctor since Tracy was an infant. She has been healthy overall and up-‐to-‐date with her immunizations. NOTES FOR FACULTY-‐ PLEASE COPY THIS ROLE FOR THE STUDENT WHO IS PLAYING THE PATIENT if asked about whether she prefers to be interviewed alone, Tracy says “I don’t care” – assert an individual interview, followed by one where her Mother is in the room she previously had a pruritic rash on her leg, but it has resolved – she really wants to ask you about a pruritic rash on her vagina rash has been in the same area three times, but it has resolved after days each time – it “scabbed” all those times rash on vagina started days after having sex (for the first time) with her boyfriend 6 months ago boyfriend, David, 16 years old, is only sexual partner; sex about once or twice a month, consensual condoms sometimes – twice not used when her boyfriend was using marijuana – she declined and does not use any other drugs has tried alcohol (beer) but doesn’t like the taste lives with brother and 2 mothers: has a younger brother Tim, 10 years old; has 2 mothers, Jenn and Florence – gets along well with both – thinks biological mother is more “nosy” lately but close with Florence and confides in her parents divorced when she was 10 – does see biological father Seth once a month grade 10 in school, doing well with good grades; few close friends has a part-‐time job on weekend at ice-‐cream parlor – this is where she met her boyfriend David likes volleyball and most sports mood is “good” 3. “ A Hidden Agenda”
Peter is a 35-‐year-‐old male whom you have known now for about a year. You see him infrequently—once as a new patient, once for what sounded like reflux, and another time for counseling around anxiety. He is seeing you in follow-‐up because he was seen in the ER over the weekend for abdominal pain. He was diagnosed with “gastritis”. Some baseline bloodwork shows that his liver enzymes are elevated, particularly his GGT. NOTES FOR FACULTY-‐ PLEASE COPY THIS ROLE FOR THE STUDENT WHO IS PLAYING THE PATIENT abdominal pain settled from weekend – was epigastric, “burning”, nausea, no vomiting, partially relieved by meals now on a PPI for his symptoms, improved; has a gastroscopy scheduled by ER in 2 weeks day before abdominal pain, consumed alcohol, mostly beer and hard liquor, about 15 drinks usually 2-‐4 beer per day, but more on weekends alcohol helps him to “relax” – has been anxious in the past and this helps “take the edge off” has missed work on occasion, because he was “hung over” – works in tech support at a hospital occasional guilt around drinking; friends are annoyed by him because he “flakes out” on them when get-‐ togethers are planned (usually because of feeling “hung over”; other CAGE questions negative finances: “getting by” but has used credit card to buy alcohol even when he has no money lives alone sexually active, with males only; casual partners, unprotected oral sex (performs and receives), no anal sex but has been thinking about it; usually meets partners online family in Vancouver, parents “religious” – unaware of sexuality unaware he has a “problem” with drinking, but open to treating his “anxiety” with either medications or counseling drugs used in the past: ecstasy, GHB, tried crystal meth once, no IVDU no tattoos or piercings 4. “ The Big City”
THE BIG CITY-‐ ROLE PLAY FOR STUDENTS STUDENTS TO TAKE TURNS INTERVIEWING EACH OTHER By Anthony Mak & Ayesha Malik(1T6) Jamie is a 25 year old male/female who has come to you for the first time requesting tests for sexually transmitted infections. He/she is currently single and is concerned that he/she may be at increased risk for STIs. Background: Born in small town Ontario Bad relationship with parents since coming out as gay/lesbian. Parents are not accepting of his/her sexual orientation. He/she is not “out” to the extended family. Was severely bullied throughout middle school and high school for being “queer” (called names, socially isolated) This resulted in him/her feeling the need to Toronto/Mississauga to be in the “big city” and be with people “like himself/herself” He/she works at a call center and is out at work. His/her co-‐workers are accepting of his/her sexual orientation. Habits: Smokes a pack of cigarettes a day. Started smoking at 19.
Drinks alcohol (when going out clubbing or partying with his/her LGBTQ friends). However, when drinking alcohol, he/she often gets “wasted” and can’t remember the night before. Recreational drugs: Smokes marijuana on occasion with friends. Sometimes takes ecstasy at raves (late night clubs). Sexual/relationship history: First sexual experience was at age 20 when he/she first moved to Toronto Has never had a serious romantic relationship. He/she “picks up” at bars and clubs. Currently has several sex partners. Sometimes engages in sexual activity without using any protection (e.g. condoms). Reason for the visit: Does not have any specific symptoms. Has never had a STI test before. He/she is concerned because his/her friend was recently diagnosed as HIV positive. He/she had unprotected sexual intercourse with this friend.
MEDICATION HISTORY The young physician starts life with 20 drugs for each disease, and the old physician ends life with one drug for 20 diseases. -‐William Osler Students to bring their case reports and review the medication history section with their ASCM tutor in small groups. Students to consider the following: Context of looking back over case reports with emphasis on medication history. Looking at case reports—would student have done anything differently knowing what he/she knows now? REMINDERS TO STUDENTS ON TAKING A PATIENT MEDICATION HISTORY To obtain a list of the patient’s current medications, you should ask about1: prescription medications non-‐prescription drugs i.e., over-‐the-‐counter (OTC) drugs oral contraceptives vitamins and minerals herbal supplements e.g., St. John’s wort, glucosamine N.B.: ear/eye drops, inhalers or nasal sprays medicated patches or creams injectable medications e.g., insulin medication samples from a doctor Full dosing information for each medication should be gathered, such as1: name (generic names, trade names) dose frequency of use duration of use
route of administration last dose taken for what reason (if not known or obvious) N.B.: previous medications reason(s) for medication changes Tips on asking questions to help patients remember what medications they are currently taking2: Use both open-‐ended questions (e.g., “What do you take for your high cholesterol?”) and closed-‐ended questions (e.g., “Do you take medication for your high cholesterol?”). Ask patients about routes of administration other than oral medications (e.g., “Do you put any medications on your skin?”). Patients often forget to mention creams, ointments, lotions, patches, eye drops, ear drops, nebulizers and inhalers. Ask patients about what medications they take for their medical condition(s) (e.g., “What do you take for your diabetes?”). Ask patients about the types of physicians that prescribe medications for them (e.g., “Does your “arthritis doctor” prescribe any medications for you?”). Be careful to differentiate different medications that sound similar (e.g., Xanax vs. Zantac) Ask patients if their doctor recently started them on any new medicines, stopped medications they were taking or made any changes to their medications. For inquiring about over-‐the-‐counter medications, additional prompts may include: What do you take for allergies? Do you take anything to help you fall asleep? What do you take when you get a cold? Do you take anything for heartburn? Explore vague responses (non-‐compliance with medications). Top 10 Reasons* for Physician Visits in Canada 20113 Hypertension Health check-‐up Diabetes Depression Acute upper respiratory infection Anxiety Normal pregnancy supervision Hyperlipidemia Esophagitis Otitis
ROLE-‐PLAY SCENARIOS FOR STUDENTS:
There are two patient scenarios. Students should take turns in pairs interviewing and being interviewed for each scenario. Then the group should discuss as a whole. Tutors to copy role plays for the students during the session.
ROLE-‐PLAY SCENARIO 1 By Pavan Gill1T6 Patricia Edwards is a 64-‐year-‐old female. She was born in Kingston, Jamaica and immigrated to Canada eight years ago. Her only child, Maria, sponsored her after Patricia’s husband, Michael Edwards passed away from a stroke. They had been married for 41 years. Patricia is currently living in Toronto with her daughter, son-‐in-‐law and three grandchildren. Patricia has three younger siblings, two sisters and a brother. Her sisters live in Jamaica and her brother lives in France. She is not aware of any health problems they may have. Patricia’s parents passed away when she was very young in a car accident. Being the eldest child, she took care of her siblings growing up. Patricia has multiple health conditions, including diabetes type II, hypertension and high cholesterol. Two years ago she had a myocardial infarction. Her current medications include Glyburide, Hydrochlorothiazide, Atorvastatin, Ramipril and Warfarin. If you ask Patricia to name her meds, she can only tell you the shape and color of each pill, but she knows what each pill is for. Patricia also takes a multivitamin and vitamin D daily. Patricia often finds it difficult to remember to take all of her medications daily and sometimes she ends up forgetting to take them. Usually, this happens on days when she doesn’t feel as sick and thinks therefore she doesn’t need to take her medication. She is also often worried about the costs of the medications and rations the pills so that her daughter does not have another expense to take care of. Patricia’s daughter tries to help her mother manage her medications, but is very busy herself working full time and taking care of her three children. During the day, when Patricia’s family is at work or school, Patricia often visits the local senior centre a few blocks away from their home. She has made a few friends there, and meets with them regularly to socialize. Lately Patricia has been feeling sad and lonely. She has been really missing her husband. One of her friends, Jacky, at the Senior Centre gives Patricia a half-‐used bottle of St. John’s Wort tablets and tells her that it will make her feel better. Patricia starts taking St. John’s Wort daily alongside her other medications. She decides not to tell her daughter, Maria, about the St. John’s Wort because she doesn’t want to burden her daughter with her sadness. A month later, Patricia is feeling unwell and goes to visit the local walk-‐in clinic. Begin the role-‐play with one student playing Patricia Edwards and another student playing the physician is who currently taking Mrs. Edwards’ medication history. DISCUSSION QUESTIONS: Are there any interactions you may be concerned about with Patricia’s medication regimen? Is Patricia’s concern about the cost of her medications warranted? Is she covered by the ODB (Ontario Drug Benefit program)? What options are available if she is not covered by ODB? What are some potential strategies to avoid drug interactions? Many elder patients like Patricia take multiple medications daily (polypharmacy). What tips can you offer Patricia in helping her to remember to take her medications?
ROLE-‐PLAY SCENARIO 2 By Susan Truong 1T6 Mr. Jacopo Perfetti is a 32-‐year-‐old male and is married with no children. He was born in Bergamo, a small town in Italy, and grew up in Milan. Jacopo is an art curator and consultant and has worked for museums and events such as P.A.C. in Milan, ArteMas Festival in Havana, Cuba, and Faqra Fair in Faqra, Lebanon. He moves around a lot for his job and currently , he is working at the Art Gallery of Ontario and has been living in Toronto for 2 months. His wife, Caterina, is still living in Milan and is a high school art teacher. Jacopo has one older sister Angela (41) and two older brothers, Giovanni (39) and Franco (36). They are all married and have children. They are all generally healthy as far as Jacopo knows. However, their mother, Rosa (61) was diagnosed with degenerative scoliosis 2 years ago and their father, Vincenzo (65) developed shingles 3 months ago. They both live with Angela, their eldest daughter, and from phone conversations Jacopo had with her, it seems their father Vincenzo is still in a lot of pain even though the shingles has passed. Jacopo also has an uncle on his mother’s side who was diagnosed with schizophrenia when the uncle was 19. Jacopo himself was also diagnosed with schizophrenia 4 years ago. Jacopo is currently taking olanzapine (20 mg/day, oral, yellow pill, round-‐shaped) for his schizophrenia, though inconsistently. He also keeps mixing up its name with lorazepam (a benzodiazepine). When asked for the name of the medication, Jacopo would say lorazepam, but he would admit he is uncertain of the name. As well, 6 months ago, Jacopo was diagnosed with hypothyroidism. He takes levothyroxine but he does not remember the name of the drug. All he remembers is that he takes “about 100 mcg” a day (oral, blue pill). Unlike the world of art, of which he is passionate about, Jacopo does not pay much attention to what medications he is taking. He has no allergies and but was hospitalized 7 years ago due to a tibial fracture from skiing. Two days ago, while lifting and admiring a large beautiful vase from Ancient China at the AGO, Jacopo felt a twinge in his lower back. Over the next 12 hours, he developed low back spasms and the severity of the pain increased from a 4 to an 8 on a 10-‐point scale. Jacopo took a couple of “back pain pills” from his coworker, but he is unsure whether it was Aspirin, Advil, Tylenol or even over the counter Tylenol #1. Jacopo felt it was irrelevant anyhow because the pills did nothing to relieve the pain. Because he was still relatively new to the country, Jacopo did not want to go to the hospital if he did not have to. Soon after however, the pain radiated down both legs. Jacopo tried a couple of home remedies to relieve the pain, such as using cold compresses and taking a bath with epsom salts. Nothing made much of a difference. What Jacopo found to be relieving was resting or slow controlled movements. Any sudden movements aggravated the pain. Jacopo has had no changes in bladder or bowel function since the pain started and he has not experienced this kind of pain before. Seeing that the pain was not going away, and it even appeared to be getting worse, Jacopo finally visits a walk-‐in clinic/ER. Jacopo was still experiencing severe pain, limitation of movement and antalgia, though bending forward relieves the pain somewhat. (Having grown up immersed in Italian culture), Jacopo was very vocal and expressive upon seeing the physician. Jacopo would describe his physical complains in a dramatic manner and is very emotional in his responses to pain. His suffering is shown by groaning and moaning and he is not ashamed of his expression. He is particularly emotional because this pain experience is keeping him from doing his job properly at the AGO. Begin the role-‐play with one student playing Jacopo Perfetti and another student playing the physician who is currently taking Mr. Perfetti’s medication history. DISCUSSION QUESTIONS: 1. Similar sounding names of medications often get mixed up. What was the example in this case? What kinds of questions could you ask the patient to help you distinguish what medications the patient is taking? 2. What are some sources or strategies to help you identify what medications a patient is taking if the patient forgets the name of them?
3. Is medication compliance an issue in this case? What are some things you can do to increase medication compliance? 4. Different cultures have different ways of dealing with illnesses. For example, some may turn to homeopathy before seeing a physician. What is your approach when speaking with these kinds of patients? What are some things you can do to become culturally competent?
REFERENCES Ende J, Rockwell S, Glasgow M. (1984). The Sexual History in General Medicine Practice. Arch Intern Med. 144(3):558-‐ 561. Adapted from Contemporary Pediatrics, Getting into Adolescent Heads (July 1988), by John M. Goldenring, MD, MPH, & Eric Cohen, MD IMS Health. (2012). Top 10 Reasons for Physician Visits in Canada 2011. Retrieved from http://www.imshealth.com/cds/ims/Global/North%20America/Canada/Home%20Page%20Content/Pharma%20Tren ds/Top10ReasonsPhysicianVisits_En_11.pdf
REMINDERS FOR SESSION 27, 28 AND 29 Review the section on “Approach to Common Neurological Symptoms” Watch the videos on “Cranial Nerves” on The Neurological Exam website (neuroexam.med.utoronto.ca) Review the “Introduction to the Neurological Examination” lecture in Brain and Behaviour http://media1.med.utoronto.ca/neuroexam/ neuro exam videos on portal
Approach to Common Neurological Symptoms Required Reading for Sessions 27-‐29
This section provides a guide to neurological history-‐taking and should be re-‐ viewed before Neurology Session I. The content of this section is also closely linked to the content introduced throughout Brain and Behaviour (e.g. vision loss and diplopia in Week 6, headache and seizures in Week 5), with the latter providing further clinical and disease-‐related context. After reviewing this section, you should be able to apply an approach to history-‐taking in patients presenting with the following common neurological complaints: › Vision loss › Diplopia › Dysarthria and aphasia › Headache › Memory loss › Weakness › Tremor › Numbness and tingling › Ataxia › Dizziness › Loss of consciousness
VISION LOSS Common eye complaints can be due to either neurological or ophthalmo-‐ logical causes. Neurological causes of unilateral visual loss are due to lesions of the optic nerve, such as ischemia or demyelination. The possibility of an ophthalmological cause, such as acute glaucoma or retinal detachment, should not be overlooked. Patients with a homonymous hemianopia (due to a post-‐ chiasmal lesion in the optic pathways) may only complain about the eye with the temporal field loss (e.g. bumping into objects frequently on the right side with a right homonymous hemianopia), when in fact the field loss is present in both. It is also important to distinguish between reduced or blurry vision and double vision (the latter symptom, properly known as diplopia, will be discussed in a separate section in the syllabus). Ocular symptoms such as conjunctival injection (red eye) and eyelid swelling are most commonly due to
ophthalmological conditions (e.g. eye infections), but they can also rarely be associated with neurological causes such as a cavernous-‐carotid fistula. It is also important to determine the mode of onset and the presence or absence of pain. Sudden onset of unilateral visual loss suggests a possible ischemic cause, and the presence or absence of pain may further delineate the etiology (e.g. non-‐arteritic anterior ischemic optic neuropathy and reti-‐ nal transient ischemic attack are typically painless, while anterior ischemic optic neuropathy secondary to temporal arteritis is typically associated with headache, scalp tenderness, and jaw or tongue claudication). Visual loss that comes on gradually, worsens over days and subsequently improves after weeks suggests a possible inflammatory etiology (e.g. optic neuritis). Unilateral eye pain that is exacerbated by eye movements is also typical of optic neuritis. A chronic, progressive loss of vision suggests a possible compressive lesion of the optic nerve (e.g. tumour). In addition to the above, the following questions should also be included in the history: › Location: Which eye is affected? Is the entire field of vision in that eye affected, or only part of it (e.g. superior vs. inferior, temporal vs. nasal)? › Associated symptoms (in the HPI): » GI: Have you experienced any nausea or vomiting with eye pain? » HEENT: Is the loss of vision accompanied by any pain or headache? Have you seen halos around lights, or noticed any redness of your eye? Have you seen any floaters, flashes of light, or a curtain or shadow that obscures part of your vision in one or both eyes? » NEURO: Do you have any other neurological symptoms apart from the loss of vision, such as focal numbness or weakness, speech or swallowing difficulties, difficulty with balance, dizziness or vertigo, hearing problems, or double vision? › Past medical history: Has there been any previous injury to your head or eye? Has a health care provider told you that your blood pressure or cholesterol is elevated? Do you have diabetes? Do you smoke? › Family history: Is there any family member who has lost his or her vision, particularly at a young age?
DIPLOPIA Patients with diplopia typically present with a history of ‘seeing double,’ such that single objects in their field of view appear twice. Diplopia has a wide range of neurological causes, including central lesions of the brainstem or cerebellum, weakness of one or more of the extraocular muscles (either due to a lesion in the peripheral nerves innervating them, a disease of the muscles themselves), or diseases affecting neuromuscular transmission (e.g. myasthenia gravis). Generally, the presence of diplopia essentially negates the possibility of a lesion in the supratentorial compartment.
A comprehensive history is an important evaluation of diplopia for diagnosis and subsequent investigations and management. Important questions that should be asked include: › Does the diplopia resolve or persist when the patient closes one eye (bin-‐ ocular versus monocular diplopia). Neurological lesions cause binocular diplopia, while monocular diplopia is typically due to an ocular/ophthal-‐ mologic cause (e.g. corneal deformities). Monocular diplopia may also be psychogenic. › Are the two images lined up side-‐by-‐side (horizontal diplopia) or are they lined up on top of each other (vertical diplopia)? If the patient has hori-‐ zontal diplopia, ask whether the diplopia worsens (i.e. the image separation increases) when viewing near objects (suggests medial rectus paresis) or those at a distance (suggests lateral rectus paresis). › Is the double vision worse when looking to the left or right? Binocular horizontal diplopia that is worse when looking to the right and when view-‐ ing objects at a distance suggests a right CN VI palsy (lateral rectus muscle). › Is the diplopia worse when looking downward and inward, like when walk-‐ ing down stairs? Vertical diplopia that is made apparent or worse when walking downstairs is suggestive of CN IV palsy (superior oblique muscle). › Does a specific head posture or a gaze direction eliminate the diplopia? For example, a patient with a CN IV palsy will tilt their head away from the lesion to eliminate or reduce the diplopia. › Is there any significant fluctuation of the double vision? Does the double vision tend to worsen towards the end of the day or after prolonged use of the eyes? Dramatic fluctuations or fatigability, especially when ptosis is also present, suggests the possibility of a neuromuscular junction disorder like myasthenia gravis. › Finally, ask specifically about whether the patient has suffered any recent or remote head trauma. Fracture of the orbital floor can occur from a blunt impact to the cheek causing hematoma and/or entrapment of the soft tis-‐ sue and extraocular muscles—thereby restricting downward movement of the eyes. Head trauma is also a common cause of CN IV palsy. Vascular risk factors are also important, as microvascular ischemia is a common mechanism of isolated ocular motor nerve palsies in older patients (e.g. ischemic CN VI palsy).
APHASIA AND DYSARTHRIA Before attempting to distinguish aphasia from dysarthria, understanding how speech is produced is paramount. When a person wants to speak, the words for speech are selected in Broca’s area and surrounding regions in the frontal lobe. This is one of the language centres in the brain. Conversely, the signal to actually articulate the selected words using the muscles of the speech ap-‐ paratus (lips, tongue, palate or pharynx) comes from the primary motor area in the posterior portion of the frontal lobe. Thus, the speech apparatus itself, and the nerves that control it, are physically separate from the language centres of the brain (i.e. deficits in each implicate a different anatomical localization). Hence, when seeing a patient with speech difficulties, differentiating aphasia from dysarthria is a first priority. Dysarthria can result from damage to the muscles of the speech apparatus, the axons (central or peripheral) that con-‐ trol those muscles, or a problem in the communication between nerve and muscle (i.e. neuromuscular transmission defect). In dysarthria, speech is nasal or slurred, but the language centres in the brain are spared. In other words, dysarthria represents a problem with articulation or mechanical production of speech. On the other hand, in aphasia, the muscles that control speech and the nerves that control those muscles are spared. Instead, it represents lesions affecting the higher cortical centres subserving language functions in the brain, such as Broca’s or Wernicke’s area.
Aphasia refers to a disturbance in the expression or understanding of language, while dysarthria refers to an impairment in the mechanical production of speech, like slurring.
A P H A SI A
Fluency refers to the number of words that can be produced in a given period of time.
Aphasic patients present with a deficit in producing and/or understanding speech caused by a lesion in the dominant cerebral hemisphere. The most common cause of aphasia is a stroke due to an occlusion of the left middle cerebral artery or its branches. There are two broad categories of aphasia: mo-‐ tor and sensory. › Motor aphasia is the result of a lesion in Broca’s area, or surrounding regions, in the frontal lobe. This lesion produces very slow, laborious, non-‐fluent speech characterized by only nouns and verbs with omission of prepositions or conjunctions (e.g. of, to, in, for, and, but, or). Comprehension is spared. › Sensory aphasia is the result of a lesion in Wernicke’s area, or surrounding regions, in the temporal lobe. This lesion produces very poor comprehen-‐ sion, and while speech remains fluent it may be void of meaning or out of context. Paraphasic errors are also commonly seen in aphasic patients. There are two types: semantic paraphasias where words of similar meaning are substituted (e.g. ‘knife’ instead of ‘fork’) and phonemic paraphasias where similar sounds are substituted (e.g. ‘pork’ instead of ‘fork’). Repetition may or may not be af-‐ fected depending on the type of aphasia. Refer to TABLE 27.1. Within these two broad categories, there are several different types of aphasia. Aphasias are distinguished and characterized according to four major criteria: › Fluency › Comprehension › Repetition › Naming Clinically, aphasias may not neatly fall into one specific type, which is why most are characterized under motor, sensory, or mixed aphasia. Characteristics of specific aphasias are provided in TABLE 27.1. TABLE 27.1.
Deficits by type of aphasia.
Type of aphasia
Fluency Comp. Rep.
Broca Transcortical motor Sensory
Wernicke Transcortical sensory Mixed
Global Transcortical mixed Other
IN V E STIGATION OF L A N GUAGE DIFFICU LT Y
To clinically test for aphasia and rule out dysarthria, asking the patient the following questions is a good start: › Spontaneous speech: Can you tell me what brings you to the hospital? › Comprehension: Can you point to the floor?, Can you point to the entrance of this room?, Can you take this piece of paper with your right hand, fold it in half, and place it on the floor? › Repetition: Can you repeat the phrase ‘No ifs, ands, or buts?’ Can you repeat the phrase ‘The Prime Minister lives in Ottawa.’
› Naming: Can you name this object? (e.g. point to a pair of eyeglasses, then specifically point to one of the lenses. This tests both high-‐ and low-‐fre-‐ quency words).
HEADACHE Headache is a common neurological complaint. Even though most commonly one will be encountering patients with primary headache disorders (e.g. ten-‐ sion-‐type headache, migraine), the most important task on taking the history is to identify red flags that may suggest a dangerous secondary headache (e.g. headache secondary to a space-‐occupying lesion or aneurysmal bleed). Ask the patient to describe the headache, capturing the typical qualities that one enquires about for any symptom: › Have you had headaches before? Is this one the worst headaches of your life? › Location: Where is the pain located (e.g. front. back, unilateral, bilateral)?
› Severity. How would you rate the intensity of the pain on a scale from 1 to 10? Are your daily activities (e.g. school, work) significantly disrupted by your headaches? › Sudden onset of headache suggests the possibility of an intracranial hemorrhage.
› Onset: Does the pain come on gradually? Or does it come on suddenly Early morning headache with and reach maximum intensity within seconds? space-‐occupying lesions, › Relieving factors: What makes the headaches better (e.g. lying down, including intracranial sleep-‐ ing, turning off lights and TV)? Do you take any over-‐the-‐counter neoplasms. or pre-‐ scription medications for your headache? If so, how much of each do you take with each headache? › Aggravating factors: What makes the pain worse (e.g. physical activity, coughing, sneezing, straining, bending over)? Do bright lights or loud noises bother you when you have a headache or make the Fever with stiff neck, headache or altered mental status in acute headache worse? › Triggers: Can you identify any triggers for your headache (e.g. certain foods, weather change, wine)?
› Quality: How would you describe the pain (e.g. throbbing, stabbing, tight-‐ band around the head, steady pressure)?
Timing: When are your headaches worst? Do your headaches wake you up from sleep, or are they the worst first thing in the morning? › Auras: Are your headaches preceded by any symptoms such as changes in vision (e.g. flashing lights, zig-‐zag lines, central scotoma)?
› Frequency: How frequent are you headaches? How long do they typically last? Is there a change in the pattern or characteristics compared to your usual headaches? (i.e. Has the severity increased? Has the frequency increased? Has the quality or character of the pain changed?)
› Associated symptoms (in the HPI) » Do you have a fever or stiff neck? Do you feel nauseous or vomit with your headaches? NEURO: do you have any other neurological symptoms accompanying the headache, such as double vision, dizziness, gait imbalance, numbness or tingling or weakness?
For patients above the age of 55 who present with new-‐onset headaches, one must also include questions specifically for symptoms of temporal arteritis and polymyalgia rheumatica. Any focal neurological sign that is present on the neurological examination suggests a secondary cause for a patient’s headache.
MEMORY LOSS Memory lapses and general absent-‐mindedness tend to increase with age. However, this normal age-‐related process needs to be differentiated from the type of memory loss associated with neurodegenerative conditions such as Alzheimer’s disease. Dementia is defined as an impairment in two or more cognitive domains (most commonly memory plus another domain, such as visuospatial function) that is significant enough to cause an impairment in the patient’s daily functioning. Patients with memory loss are most commonly brought in by their family members who have noticed deterioration in their memory or a change in their behaviour (e.g. asking the same questions repeatedly, getting lost in familiar surroundings). Patients themselves may deny the problem or minimize its significance due to a lack of insight. For example, they may say that they for-‐ get certain things because they are simply ‘not important.’ On the other hand, younger patients are usually more aware of their cognitive deficits, possibly because these difficulties are more likely to affect their work performance, and therefore they typically present to a physician at their own initiative. Information about memory loss can be gleaned during the course of your interview with the patient. As you are speaking with the patient, listen to the story and assess his or her ability to maintain attention and to remember. Are they unable to recall recent events with ease? Are they repeating the same things over and over? In particular, you can ask questions such as: › You mentioned that you had been having difficulties with your memory. Can you give me some specific examples? › What is today’s date? › What did you have for dinner last night? › Do you have difficulty with your concentration, such as following a conversa-‐ tion or the plot of a movie or TV program? › Did you ever get lost in your neighbourhood or places that you are familiar with? The severity of memory impairment can also be gauged by the type of lapses (e.g. forgetting appointments versus forgetting to turn off the stove after cook-‐ ing). Finally, if you do suspect that the patient is suffering from memory loss, inquire about their ability to continue carrying out their Instrumental Activi-‐ ties of Daily Living (IADLs). IADLs are a set of complex skills necessary to live independently in the community. Common IADLs to ask about include:
› Completing household chores (e.g. preparing meals) › Shopping for groceries or clothes › Managing personal finances › Driving
WEAKNESS Weakness denotes a demonstrable loss of muscle power. It is a common com-‐ plaint and can be non-‐specific at times (e.g. some patients with musculoskeletal conditions such as rheumatoid arthritis may complain of ‘weakness’ in their hands, but what they truly refer to is difficulty using their hands due to the joint deformities and pain, rather than weakness due to a neurological lesion). Patients may also use the term ‘weakness’ to mean ‘clumsiness,’ when in fact they are having a problem with coordination rather than a reduction in muscle strength. Weakness must also be distinguished from fatigue that is a relatively non-‐specific symptom with many causes and refers to sense of weariness or loss of energy. Weakness can be due to various lesions located in both central and pe-‐ ripheral nervous system, although a thorough history will typically help to narrow down the possible localization(s). Sudden onset of unilateral weakness affecting the right arm and leg associated with slurred speech is suggestive of a central cause such as stroke. Bilateral proximal weakness suggests myopa-‐ thy, while bilateral, predominantly distal weakness associated with numbness and tingling suggests the possibility of a peripheral neuropathy. Progressive weakness and wasting of muscles in an asymmetrical fashion associated with bulbar symptoms but no sensory symptoms raises the possibility of an anterior horn cell disease. When a patient complains of weakness, one should probe for exactly what it means to the patient. Patients should be able to tell you which limb(s) is/are affected. Try to gauge the severity of weakness (e.g. does the weakness affect the daily functioning of the patient, did it ever result in paralysis?) Ask about the onset of the weakness. Was it sudden onset or did the weakness comes on gradually? Is it intermittent or slowly progressive? Did the weakness start in one limb and then spread to involve others, or did it remain localized? Is one half of the body affected (e.g. hemiparetic pattern)? Are there any accompany-‐ ing sensory symptoms (i.e. try to determine if this is a pure motor syndrome or not), or any other neurological symptoms (e.g. visual, bulbar)? Also, ask whether or not the weakness worsens with repeated effort and improves after rest (fatigability). If the fluctuations in weakness are dramatic, this may be indicative of diseases of the neuromuscular junction, the classic one being myasthenia gravis. Try to distinguish between proximal and distal weakness. For proximal weakness, ask about difficulty combing hair, brushing teeth, getting out of a chair, reaching for objects above head and going up stairs. For distal weakness, ask about difficulty opening a jar, using tools (e.g. keys, scissors, screwdriver), picking up small objects (e.g. coins) and frequent tripping on the toes.
Bulbar symptoms include dysarthria and dysphagia (difficulty swallowing).
TREMOR An exaggerated physiologic tremor may become visible under the influence of medications such as beta-‐ agonists (e.g. bronchodilators), lithium, amphetamines, and caffeine.
Patients may complain about trembling or shaking movements that they are un-‐ able to control. A tremor is an involuntary, rhythmic oscillatory movement of body parts, most commonly seen distally in the hands, although the head (neck), legs, or voice can also be affected. The first question is to determine whether the tremor is exclusively or predominantly seen at rest (i.e. when the affected body part is completely supported against gravity). This is suspicious for idiopathic Parkinson’s disease, particularly if it is unilateral. A parkinsonian tremor is classically characterized by ‘pill-‐rolling’ rhythmic oscillations of the hand that significantly diminishes or disappears with voluntary movement. On the other hand, tremor that is exclusively or predominantly seen when muscles are voluntary contracted is called action tremor, which can be further subdivided into postural tremor (when patient is assuming a posture) or kinetic tremor (when patient is performing a specific task). Intention (ataxic) tremor is a subtype of kinetic tremor in which the tremor is significantly worse on approach-‐ ing the target (e.g. during finger-‐to-‐nose testing), often in a contra-‐axial fashion (i.e. perpendicular to the plane of movement). Intention tremor is characteristic of cerebellar disease, and it is often associated with other cerebellar symptoms or signs (e.g. gait ataxia). To identify and classify the tremor, a thorough patient history and physical examination is paramount. A detailed medication history is necessary, since many drugs have tremor as a potential side-‐effect. It is also important to determine the degree of functional impairment resulting from the tremor. The following contains a list of important questions to ask a patient who presents with tremors. Please note, this list is not exhaustive and the clinician should tailor the questioning depending on the patient’s history and responses. › Location: Where is the tremor and how long have you noticed it for? Do you notice the tremor in both hands, or just on one side? Did you notice a similar tremor affecting your head (head bobbing) or your voice? › Aggravating and relieving factors: What makes the tremor worse and what makes it better? Specifically, do you notice the tremor when you are doing something with your hands, or do you mainly notice it when your hands are at rest (e.g. resting on your lap while watching TV)? › Associated symptoms (in the HPI) » NEURO: Have you noticed any changes in your walking, your movements slowing down, or stiffness in your limbs? › Family history: Is there a family history of a similar tremor or Parkinson’s disease? › Past medical history: Do you have a history of thyroid disease or disorders of the liver or kidney? › Medications: Have you recently started or stopped taking any medications or illicit drugs? › Social history: How has the tremor affected your work, social life and activities of daily living (e.g. writing, signing cheques, playing the piano, social embarrassment)? › Diet: How many cups of coffee and tea do you drink on an average day? Do you drink any other caffeinated beverages (e.g. cola) › Medications: Have you recently started or stopped taking any medications or illicit drugs? › Social history: How has the tremor affected your work, social life and activities of daily living (e.g. writing, signing cheques, playing the piano, social embarrassment)? 1
› Diet: How many cups of coffee and tea do you drink on an average day? Do you drink any other caffeinated beverages (e.g. cola)? › Alcohol consumption: How often do you drink alcohol? Have you noticed whether alcohol improves or worsens your tremor?
NUMBNESS AND TINGLING
Numbness is a loss of or reduced sensation. When a patient complains of numbness, one must clarify its meaning and location. For example, some patients use the term “numbness”, when in fact what they are referring to is weakness. If possible, try to determine whether the numbness conforms to a dermatomal or peripheral nerve distribution, and whether it is unilateral or bilateral. In questioning patients with numbness, ask about the mode of onset (e.g. sudden vs. gradual). Is the numbness constant or intermittent? What brings it on? Does it progress or spread to involve a larger area over time? Which body parts are involved? Does it involve the face or the trunk? Paresthesia describes the feeling of a limb “falling asleep”, often referred to as tingling or “pins and needles”. Dysesthesia is paresthesia that is unpleasant as perceived by the patient. One type of dysesthesia is allodynia, where a patient perceives pain from a normally non-‐noxious stimulus. For example, the patient may perceive light touch as a burning or tingling sensation that is irritating or painful. This can be distinguished from another type of altered sensation, hyperalgesia, which is a simply a heightened sensation or hypersensitivity. Numbness, paresthesia, and dysesthesia may be indicative of central lesions in the brain and spinal cord, as well as disorders of the peripheral nerves or nerves roots. The presence of other accompanying symptoms will help to narrow down the potential localization(s) while taking the history. Finally, paresthesia in the hands and around the mouth that lasts for several minutes can result from hyperventilation (e.g. in panic attacks).
ATAXIA Ataxia refers to an inability to coordinate voluntary muscle movements, typically not due to muscle weakness. Diseases affecting the cerebellum are common causes of ataxia (cerebellar ataxia), although a significant loss of joint position sense (e.g. from a polyneuropathy, or from a spinal cord lesion affecting the posterior columns) can also render a patient ataxic (sensory ataxia). Such lesions can cause ataxia affect-‐ ing the limbs or the trunk, and can result in an unsteady gait (i.e. wide-‐based, stag-‐ gering gait). However, patients with limb weakness may also sometimes describe their difficulty in using the limb as ‘clumsiness,’ or if it affects the legs, a ‘difficulty with balance.’ It is therefore very important to try separate out these different causes of a patient’s incoordination by a good history, but occasionally this distinction can only be made with confidence after a detailed neurological examination. One should ask about specific tasks that the patient has difficulty with (e.g. writing, feeding). Also, a detailed drug history (prescription and recreational) and history regarding alcohol use should be elicited. Ataxia that is present exclusively or is significantly worse when the patient is navigating in the dark (e.g. getting up in the middle of the night) may suggest a sensory ataxia (analogous to Romberg’s sign). The presence of sensory symptoms (numbness, tingling) also raises the suspicion of sensory impairment as a cause of a patient’s incoordination. Another clue is that patients with sensory ataxia often watch their limbs closely when us-‐ ing them, as they are trying to use the visual cues to compensate for the lack of proprioception. A history of falling consistently towards one side may suggest a lesion in the ipsilateral cerebellum.
Dizziness is a common complaint that can mean different things to different people. The first step is therefore to ask the patient to elaborate on what they are referring to as dizziness. The three common types of ‘dizziness’ are: vertigo, light-‐headedness or presyncope, and gait unsteadiness. The key element in tak-‐ ing a history of a patient presenting with dizziness is to figure out which one of these is the patient referring to and particularly, if the dizziness described is that of true vertigo. Vertigo can be described as an illusion of movement. This movement is classically ‘spinning’ (most typical of peripheral causes of vertigo). However, central vertigo tends to be more subtle and the classical spinning character is often absent. For example, the patient may feel like he or she is rocking on a boat, or that the floor is moving up and down. The following is a list of important questions to ask when someone presents with dizziness. This list is not exhaustive and the clinician should try to steer away from any leading questions, particularly during the initial part of the interview (i.e. start with open questions). › Quality: Can you describe what you mean by dizziness?
› Onset: Does it come on suddenly? Is it constant, or does it come and go? How long does it last?
Common triggers include turning in bed or sudden head movements (benign
› Provoking factors: Can you think of any triggers for your dizziness? Was there a preceding trigger of your current dizziness (e.g. viral infection, trauma)?
paroxysmal positional vertigo)
› Timing: Have you had this feeling of dizziness before? How often does it occur?
or getting up quickly from a supine position (postural hypotension).
› Associated symptoms (in the HPI) » GI: Did you feel nauseous at the same time as you feel dizzy? Is there any associated vomiting?
» HEENT: Have you noticed any changes in your hearing, ringing in your ears, or a sensation that the ears are plugged?
Change in hearing or the sensation of plugged ears, together with vertigo, are classic symptoms of Meniere’s disease.
» NEURO: Do you have any other neurological symptoms, such as slurred speech, facial weakness, facial numbness, ataxia or diplopia? » CARDIOVASC: Is your dizziness associated with any chest pain, palpitations, or shortness of breath?
Vertigo associated with facial weakness and/or numbness can be symptoms of a cerebellopontine angle lesion. The presence of ataxia and diplopia with vertigo suggests the possibility of a brainstem/ cerebellar lesion (e.g. tumour, stroke).
LOSS OF CONSCIOUSNESS Syncope (fainting) means loss of consciousness. The most common cause of syncope is vasovagal, although cardiogenic causes (e.g. arrhythmia) must be considered because of their potential life-‐threatening nature. It is therefore important to inquire about the presence of cardiac symptoms as
well (e.g. chest pain, palpitations, shortness of breath). Syncope is caused by a transient global reduction in cerebral perfusion, so patients often regain consciousness quickly once they have fainted and have come to rest on the floor. As opposed to a seizure, which also causes a loss of consciousness, patients with syncope typically do not have a post-‐ictal phase (e.g. a period of lethargy or confusion). An epileptic aura (essentially a simple partial seizure, such as a rising epigastric sensation) may precede a complex partial or generalized seizure, but should not occur in syncope. On
the other hand, patients with syncope will often have premonitory symptoms (i.e. darkening of vision, ‘seeing stars,’ sensation of light-‐headedness). In order to obtain a thorough clinical history of a patient who presents with a history of loss of consciousness, the following questions, amongst others, should be considered. Be sure to avoid leading questions. Collateral history, if available, is always extremely helpful. › What body position were you in just before the attack? › Was there a witness or someone with you during the time that you had passed out? If so, did that person observe any jerking or seizure-‐like movements in your limbs? How long were you unconscious for? › Did you recall what happened during the attack? › Were you confused or disoriented when you regained consciousness? Did you bite your tongue or become incontinent? › Provoking factors: Was there a trigger to your attack that you can think of (e.g. seeing blood, skipping meals, sudden change in body position)? › Timing: Has this happened before? If so, how frequent are the attacks? › Aura: Do you have any warning or sensation that something is going to hap-‐ pen before you lose consciousness? › Family history: Is there a family history of seizure disorders? › Medications: What medications are you taking (e.g. diuretics)?
Neurology I: Overview of the Neurological Examination and the Cranial Nerve Exam March 28, 2014 -‐ Week 27 OBJECTIVES WATCH VIDEO http://media1.med.utoronto.ca/neuroexam/ By the end of this session, you should be able to: articulate the goal of performing the neurological examination. apply an approach to history-‐taking in patients presenting with common neurological symptoms. recognize the basic framework in organizing the different components of the neurological examination (i.e. mental status, cranial nerves, motor, sensory, coordination, and gait). demonstrate the correct techniques in examining the cranial nerves. recognize the common abnormal findings on the cranial nerve exam (see list below). With respect to the cranial nerve exam, you should also be able to: use the appropriate stimulus to test cranial nerve I. perform the swinging flashlight test and recognize the significance of the finding of a Relative Afferent Pupillary Defect (RAPD). describe the clinical signs of a cranial nerve III palsy and its common causes. differentiate ptosis that results from a cranial nerve III lesion versus Horner’s syndrome. describe the clinical signs of a cranial nerve VI palsy and its common causes. differentiate between an Upper Motor Neuron (UMN) and a Lower Motor Neuron (LMN) facial nerve lesion, including the anatomical basis that allows for this distinction. describe the clinical signs of an unilateral lesion affecting cranial nerves IX and X.
describe the clinical signs of an unilateral lesion affecting cranial nerve XII, including both UMN and LMN lesions.
AGENDA 8:00 Review common symptoms pertinent to the neurological system (see section on “Approach to Common Neurological Symptoms”) Review an approach to the neurological exam and discuss its purpose 9:30 Break 9:45 Instructor to demonstrate cranial nerve exam on a student (fundoscopy will be reinforced during Session 28) 11:15 Students to practice cranial nerve exam on each other. Students may practice the cranial nerve exam on a real patient or they may continue to practice the exam with each other Students to hand in Case Report #5 today BEFORE COMING TO THIS SESSION, YOU SHOULD HAVE REVIEWED THE FOLLOWING: The section on “Approach to Common Neurological Symptoms” The videos on “Cranial Nerves” on The Neurological Exam website (neuroexam.med.utoronto.ca) The “Introduction to the Neurological Examination” lecture in Brain and Behaviour
REMINDERS FOR SESSION 28 Review the section on “Weakness” in the “Approach to Common Neurological Symptoms” Watch the videos on “Motor Examination” on The Neurological Exam website (neuroexam.med.utoronto.ca) Review the features of upper and lower motor neuron lesions (Lecture on “Motor Pathways”, Week 1 of Brain and Behaviour)
Neurology II: The Motor Exam April 4, 2014 -‐ Session 28 OBJECTIVES WATCH VIDEO http://media1.med.utoronto.ca/neuroexam/ By the end of this session, you should be able to: Demonstrate the approach and correct techniques involved in examining the motor system, including: Inspection: involuntary movements, fasciculations, muscle bulk (looking for atrophy) Tone: spasticity and rigidity Power: maneuvers for testing major muscle groups, using the Medical Research Council (MRC) grading system Reflexes: deep tendon reflexes and their grading, eliciting ankle clonus, plantar response Differentiate an upper motor neuron from a lower motor neuron lesion as a cause of weakness. Apply an approach to describing and classifying tremor (e.g. rest tremor, action tremor, intention tremor) and cite the most common cause for each of them. Define spasticity and rigidity, recognize the different clinical settings where these two types of increased tone are seen (i.e. lesions affecting the pyramidal versus the extrapyramidal system), and the difference in examination techniques required to properly elicit these two types of increased tone (including “activated” rigidity). Cite the spinal level responsible for the common deep tendon reflexes: biceps, brachioradialis, triceps, knee and ankle. Describe specific features and patterns of weakness that may suggest a myopathy, peripheral neuropathy, neuromuscular junction disorder, or anterior horn cell disease as a cause of weakness. 3
AGENDA 8:00 Review common symptoms pertinent to the motor system (see section on “Approach to Common Neurological Symptoms”) 8:30 Instructor to demonstrate the motor exam, including inspection, tone, power and reflexes on a normal patient or a student Students to practice the motor exam on each other 9:30 Break 9:45 Working in pairs, students are to interview and practice the neurological exam learned to date (cranial nerves and motor exam) on real patients Instructor to rotate amongst the pairs to observe
11:1 Review patients seen 5 Feedback on Case Report #5 BEFORE COMING TO THIS SESSION, YOU SHOULD HAVE REVIEWED THE FOLLOWING: The section on “Weakness” in the “Approach to Common Neurological Symptoms” The videos on “Motor Examination” on The Neurological Exam website (neuroexam.med.utoronto.ca) Features of upper and lower motor neuron lesions (Lecture on “Motor Pathways”, Week 1 of Brain and Behaviour)
REMINDERS FOR SESSION 29 Review the sections on “Numbness and Tingling” and “Ataxia” in the “Approach to Common Neurological Symptoms” Watch the videos on “Coordination” (within the “Motor Exam” section), “Sensory Exam”, and “Stance & Gait” on The Neurological Exam website (neuroexam.med.utoronto.ca) 4
Neurology III : The Sensory Exam, Coordination Testing and Gait April 11, 2014 -‐ Session 29 OBJECTIVES WATCH VIDEO http://media1.med.utoronto.ca/neuroexam/ By the end of this session, you should be able to: Demonstrate the correct techniques in examining the sensory system, including: Primary modalities: pain, temperature, light touch, joint position, vibration Cortical modalities: stereognosis, graphesthesia, two–point discrimination and sensory extinction Recognize that the proper interpretation of abnormalities on cortical sensory testing is contingent upon the presence of normal primary sensation. Demonstrate the correct techniques in examining coordination in the extremities: finger-‐to-‐nose testing, heel-‐to-‐shin testing rapid alternating movements fine motor movements (e.g. finger and foot tapping) Recognize the importance to interpret abnormalities on coordination testing in light of the whole neurological examination, since difficulties in performing these maneuvers are not always the result of a cerebellar lesion. Demonstrate the correct techniques in assessing a patient’s stance and gait. Recognize and describe the features of common, abnormal gait patterns: spastic, cerebellar, parkinsonian, and sensory ataxic gait.
AGENDA 8:00 Instructor to demonstrate sensory exam (both primary and cortical modalities) on a student Review common symptoms pertinent to the neurological system (see section on “Approach to Common Neurological Symptoms”) 8:45 Instructor to demonstrate techniques for examining coordination on a student Students to practice examination of coordination on each other Review types of gait 9:30 Break 9:45 Working in pairs, students to interview and examine real patients emphasizing neurological exam learned to date Instructor to rotate amongst the pairs to observe 11:15 Review patients seen BEFORE COMING TO THIS SESSION, YOU SHOULD HAVE REVIEWED THE FOLLOWING: The sections on “Numbness and Tingling” and “Ataxia” in the “Approach to Common Neurological Symptoms” The videos on “Coordination” (within the “Motor Exam” section), “Sensory Exam”, and “Stance & Gait” on The Neurological Exam website (neuroexam.med.utoronto.ca)
REMINDERS FOR SESSION 30 Watch the back pain videos on Portal 7
Musculoskeletal II April 25, 2014 -‐ Session 30 REMINDERS FOR THIS SESSION Watch the back pain videos on Portal
OBJECTIVES By the end of this session, you should be able to: Perform a clinical assessment (interview and physical assessment) of a patient with mechanical back pain Explain why a given clinical scenario fits one of the four pattern of back pain as described by Hamilton Hall Identify clinical situations when back pain does not fit one of the four mechanical patterns (syndromes) of back pain Describe red flags to watch for that imply a non-‐mechanical back pain related diagnosis such as cancer (in ASCM 2 students will learn about assessment of inflammatory back pain)
AGENDA 8:00 Discuss the history and physical examination of a patient with back pain. Review the four syndromes of back pain and complete the provided table illustrating the four types of back pain. 9:00 Students break into pairs and practice each of the four role-‐play scenarios (answers in tutor guide) 10:00 Group discussion: Identify which pattern fits each scenario and explain rationale for the choice. Planning for a patient clinical assessment: What are some key points to remember when interviewing patients with back pain? When doing a physical assessment of a patient with back pain?
10:30 Interview and examine patients—all content learned to date. 11:30 Recap/Reminders for next sessions.
NOTES FOR FACULTY •
Please also refer to Dr. Hamilton Hall’s video on the portal:
A Syndrome (Pattern) Approach to Low Back Pain (Powerpoint Video, 11 minutes): View Here • • •
Demonstration of taking (and teaching how to do) a Screening History Interview for "A Syndrome (Pattern) Approach to Low Back Pain" (Video, 10 minutes): View Here Demonstration of doing (and teaching how to do) a Physical Exam after having completed a Screen History for "A Syndrome (Pattern) Approach to Low Back Pain" (Video, 9 minutes): View Here Demonstration of the Femoral Stretch Exam (video, 2 minutes): View Here In ASCM 1, there are two MSK sessions. MSK 1 teaches an approach to the musculoskeletal history and physical and GALS. MSK 2 teaches an approach to the basic back exam. The approach for the back exam utilizes the four patterns of back pain. These patterns have been used for back pain categorization within the CBI Health Group for nearly forty years. They are the basis of the spine triage system in Saskatchewan and the key element in the Ontario Ministry of Health and Long Term Care’s low back pain initiative for family physicians. They are contained within the CORE (Clinically Organized Relevant Exam) back tool being promoted by the Ontario MHLOC and the Ontario College of Family Practice. They have been accepted by the B.C. Ministry of Health. This syndrome-‐specific (pain pattern) approach to mechanical back pain is a validated technique and is gaining acceptance as both a method of surgical screening and as means of directing rehabilitation. The purpose of pattern recognition is to clarify the apparent complexity of back pain and to offer the non-‐specialist a comfortable and secure starting point. The system is balanced on three essential components: history, concordant physical examination, and response to pattern-‐specific mechanical treatment. This introductory session is intended to provide the student with an approach to the four syndromes of back pain. The focus is on the history and physical exam for each syndrome. In ASCM 2, an approach to inflammatory back pain will be introduced. BACK PAIN SYNDROMES: 10
Pattern 1—Pain is back dominant, which includes pain felt most intensely in the back, buttocks, coccyx, over the greater trochanters, and into the groin. The pain is increased with back flexion and can be constant or intermittent, normal neurological exam Pattern 1 is subdivided on the basis of the physical examination. The patient performs five prone extensions, passively extending the lumbar spine by using the arms to raise the shoulders while keeping the front of the pelvis down. If completing these movements reduces the pain the patient is Prone Extension Positive (PEP). If there is no change or a worsening of the back pain the patient is Prone Extension Negative (PEN). Pattern 2—Pain is back dominant and increased with back extension, pain is never increased with back flexion, pain is always intermittent, neurological exam is normal Pattern 3—Pain is leg dominant, including pain around and below the gluteal fold in the thigh, calf, ankle or foot. Leg pain is affected by back movement or position. The leg pain is always constant and there must be positive neurological findings: a positive irritative test and/or a conduction loss. Pattern 4—Pain is leg dominant, leg pain is increased with activity in extension and relieved with rest in flexion. The leg pain is intermittent. Irritative tests are always negative. There may be a conduction loss in long standing cases. Patterns 1 and 2 are mechanical back pain that is pain aggravated or relieved by movement or position and directly related to a physical structure within the spine. The description of Pattern 1 is in keeping with the literature describing the clinical picture of discogenic pain and that is the presumed pathology that fits it the best. It is important for the student to remember that Pattern 1 is the description of a clinical syndrome and not a definitive diagnosis. Seeing a “black disc” on an MRI does not automatically equate with Pattern 1. Determining the putative source of Pattern 2 is harder. Because the pain is increased only with extension it makes sense to suppose that the physical structure is somewhere in the back of the spine. That would include the facet joints, joint capsules, ligaments and so forth. The phrase, “posterior element back pain” would be acceptable. There is, in fact, little consensus about the sources of mechanical back pain outside the intervertebral disc so Pattern 2 by any name cannot be specific; one more reason why the pattern/syndrome recognition approach makes sense. And again, it is a clinical presentation, not the diagnosis of an image. Pattern 3 is sciatica as it should be described. In common usage, sciatica has come to mean merely “leg pain” and so its diagnostic precision has been lost. By returning to a sharply focused clinical scenario Pattern 3 avoids this problem. Its translation as sciatica (constant leg dominant pain caused by acute nerve root inflammation and irritation secondary to a newly herniated disc) is accurate. Pattern 4 is the syndrome of neurogenic claudication. In clinical practice, this presentation is often confused or misnamed “spinal stenosis”. Spinal stenosis is, in fact, only an anatomical description and not a clinical picture and a narrow spinal canal can exist without symptoms. Once more, the use of a clear clinical pattern focuses attention on the patient and not on a dispute about an image. Students are expected to come to the session prepared. They have pre-‐assigned homework. They should be able to present the four patterns and do the role plays.
BASIC BACK EXAM PREAMBLE More than 90% of back pain seen in family practice is the result of minor alterations in spinal mechanics. It is rarely the result of malignancy, infection, systemic illness, or major trauma. Most back pain is mechanical, that is, pain directly related to movement or position. It arises from a structural element or elements within the spine, which in the overwhelming majority of cases cannot be precisely identified. “Distinct patterns of reliable clinical findings are the only logical basis for back pain categorization and subsequent treatment.” Quebec Task Force 1987 HISTORY There are five core questions The two essential questions: 1. “Where is your pain the worst?” You must determine if it is back or leg dominant. Back symptoms usually involve both the back and the leg, but in almost every case one site will predominate. That distinction is essential for pattern recognition. The pain is considered back dominant if it is worst in the low back, buttocks, coccyx, or over the outer aspects of the hips. The pain is considered leg dominant if it is worst around and below the lower gluteal fold, in the thigh, calf, or foot. 2. “Is your pain constant or intermittent?” This question must be very clear and specific. It is best asked in two parts: “Is there ever a time during the day when your pain stops, even for a brief moment and even though it may quickly return?” “When your pain stops does it disappear completely; is it totally gone?” The pattern question: 3. Does bending forward make your typical pain worse? What are the aggravating movements and positions? The mandatory question: 4. “Since the start of your back trouble has there been a change in your bladder or bowel function?” The functional limitation question: 5.What can’t you do now that you could do before you got the pain?” The other questions: “What are the relieving movements or positions?” “Have you had this same pain before?” 12
“What treatment have you had before?” Questions to consider when the pain is constant and non-‐mechanical: Pain unaffected by movement or position Widespread neurological findings Unexplained weight loss Recent or ongoing infection Failure to respond predictably to the appropriate mechanical treatment within days/weeks Disproportionate night pain Constitutional symptoms History of malignancy, particularly in the past five years PHYSICAL EXAMINATION The physical examination is not an independent event. It should be designed to verify or refute the history. The examination should be carried out in a series of positions, usually starting with the patient standing and finishing with the patient lying down, to minimize the patient’s movements. Each test is performed in the optimum position. Observation: General activity and behaviour Back specific: Gait Contour—subtle malalignments are not relevant. Colour—areas of obvious inflammation Scars Palpation: Of very limited value—palpate quickly for tenderness and gross deformity. Movement: Flexion—rhythm of movement and reproduction of the typical pain Extension—rhythm of movement and reproduction of the typical pain Other spinal movements—when suggested by the history Nerve root irritation tests: Straight leg raise test—patient supine with the contralateral leg flexed Passive test -‐ the examiner lifts the leg to be tested Positive test is reproduction or exacerbation of the typical leg pain reproduction of back pain is not relevant Pain produced at any degree of leg elevation Femoral stretch test—when suggested by the history, with patient prone and both legs extended Passive test -‐ the examiner lifts the leg and extends the hip Positive test is reproduction or exacerbation of the anterior thigh pain Back pain is common and not relevant 13
Nerve root conduction tests: L4 Knee reflex (also tests L3) Patient is seated with the lower legs hanging free L5 Hip abduction Trendelenburg test—the examiner stands behind the patient with examiner’s hands on the patient’s iliac crests. The patient stands on one leg and then on the other. The hip abductors are tested for the leg on which the patient is standing. The movement of the contralateral crest is the marker. A normal test is symmetrical. Ankle dorsiflexion (also tests L4) Tested with the patient seated, foot on floor—hold the forefoot elevated against resistance Extensor hallucis longus Tested separately and together S1 Gluteus maximus muscle tone Patient prone, palpate buttocks as patient tenses and relaxes Flexor hallucis longus Tested separately and together Ankle reflex Tested with the patient kneeling Ankle plantar flexion Tested separately and together—examiner supplies balance as needed Sensory testing: Optional—for confirmation of root level when suggested by the history The mandatory tests: Upper motor test: Planter response, clonus—there is never an upper motor finding in mechanical low back pain Saddle sensation Lower sacral (S2, 3, 4) nerve root test—the same roots that supply saddle sensation supply bowel and bladder function.
THE F OUR PATTERNS O F M ECHANICAL B ACK P AIN PREAMBLE Distinct patterns of reliable clinical findings are syndromes. A syndrome is a constellation of symptoms and signs that appear together in a consistent manner and respond to treatment in a predictable fashion. A syndrome differs from a disease in the fact that the etiology of a syndrome has yet to be established. The key to the initial treatment is identifying the correct syndrome and identifying the correct syndrome requires a precise history and concordant physical examination. Unfortunately imaging the spine doesn’t help. There is no correlation between the degenerative changes seen on plain x-‐ray and the presence of back pain. CT has a 30% false positive rate. MRI has a 14
60-‐90% false positive rate. Even identified pathology has a weak correlation to the clinical response to treatment. This approach identifies four discrete patterns (syndromes) of back pain from findings in the history and physical. PATTERN 1 History: Pain is back dominant—pain is felt most intensely in or over the: Back Buttock Coccyx Greater trochanters Groin Pain is increased with back flexion Pain may be constant or intermittent Physical Examination: Back dominant pain—the location on examination matches the location on history Pain is increased with back flexion The neurological examination is normal or unrelated to the pattern PATTERN 2 History: Pain is back dominant Pain is increased with back extension Pain is never increased with back flexion Pain is always intermittent Physical Examination: Back dominant pain—the location on examination matched the location on history The pain is increased with back extension The pain is unchanged or reduced with back flexion The neurological examination is normal or unrelated to the pattern PATTERN 3 History: Pain is leg dominant—around and below the gluteal fold in the thigh, calf, ankle, or foot Leg pain is affected by back movement or position The leg pain is constant Physical Examination: 15
Leg dominant pain—the location on examination matches the location on history Leg pain is affected by back movement or position There are always positive neurological findings: A positive irritative test and/or a conduction loss PATTERN 4 History: Pain is leg dominant Leg pain is increased with activity in extension Leg pain is relieved with rest in flexion The leg pain is intermittent Physical Examination: The irritative tests are always negative There may be a conduction loss in long-‐standing cases
Students break into pairs and take turns role-‐playing the patient and the examiner. Figure out what type of pattern goes with each scenario. [Answers are in square brackets in the faculty version of the syllabus.] SCENARIO 1 [PATTERN 1 PRONE EXTENSION POSITIVE] A 44-‐year-‐old bank teller presents with pain in the right low back and buttock. He notes that the worst pain is in the right upper buttock. Symptoms started after he went jogging for five kilometres and have been present for five weeks. The pain has been constant and is increased with sitting and lifting. The pain is reduced but not abolished with slow walking. On examination, the back and buttock pain are increased with repetitive flexion and extension in standing but are decreased with repetitive passive extensions in prone lying. A right straight leg raise of 60 degrees reproduces the typical buttock pain. There is an inconsistent slight decrease in the left ankle reflex. The remaining examination is normal. SCENARIO 2 [PATTERN 3] A homemaker, 36 years old, complains of severe, constant left calf pain after she painted her kitchen ceiling about three weeks ago. She gives a history of left-‐sided low back pain starting two weeks before that but the calf pain is now more painful than the back. Both symptoms are increased with a single back flexion. On examination, repetitive lumbar extension increases the back and calf pain. Straight leg raising on the right increases the low back pain. Straight leg raising on the left at 40 degrees increases the left calf pain. The remaining neurological exam is negative. 16
SCENARIO 3 [PATTERN 1 PRONE EXTENSION NEGATIVE] A fashion designer complains of two years of central low back pain radiating around his left hip and into his left groin. He is 56 years old. The back pain increases with standing still for more than 30 minutes and after sitting for more than 15 minutes. The patient describes several episodes per year, each lasting between six and eight weeks. Between attacks he is completely pain free. During the attacks, the back pain fluctuates but is never completely absent. The frequency of attacks is increasing. On examination, the back pain is aggravated by repeated standing back extensions. There is pain on forward bending but it is less intense. Repeated prone passive extensions slightly increase the symptoms but not to the same degree as standing extensions. There is a slight asymmetry of the knee reflexes. All other physical findings are normal. SCENARIO 4 [PATTERN 2] A 48-‐year-‐old contractor reports two weeks of low back pain spreading across the top of both buttocks. The pain began while he was installing ceiling tiles and was severe enough to make him stop. He has had only brief periods of complete pain relief, usually when he lies curled up on his left side or when he sits and bends forward to put his head between his knees. On examination, standing flexion seems to have no effect on the symptoms. Standing extension increases the back pain as does 80 degrees of straight leg raising of either leg. The plantar responses are down going and saddle sensation is normal. SCENARIO 5 [PATTERN 4] A 64-‐year-‐old chef finds that walking for more than 15 minutes produces bilateral posterior thigh pain, worse in the right leg. She works in the kitchen of an exclusive French restaurant. When the leg pain occurs, it is sufficient to force her to stop working for a short while. She has a 10 year history of low back pain that is troublesome but which has never compromised her job. Her leg symptoms have been present for three years. Once the leg pain has started, she can gain relief only by sitting down and drawing up her right knee. The pain usually disappears completely within five minutes. On examination, the range of back movement is moderately reduced in both flexion and extension. The neurological exam is normal. Straight leg raising is unrestricted.
ROLE-‐PLAY SCENARIOS (ADDED IN FEBRUARY 2014, WONT BE IN STUDENT GUIDE-‐ THESE ARE A BIT MORE STRAIGHTFORWARD AND TUTORS MAY WISH TO INCORPORATE.
Students break into pairs and take turns role-‐playing the patient and the examiner. Figure out what type of pattern goes with each scenario. [Answers are in square brackets in the faculty version of the syllabus.]
SCENARIO 1 [PATTERN 3] A 41 year-‐old electrician develops acute, constant left leg pain radiating from his upper thigh to his left great toe. He had a couple of weeks of low back pain before the leg pain started but his leg pain is clearly dominant. The pain is increased with any back movement, particularly bending forward. On examination, the patient stands with the left knee slightly bent and refuses to sit down because of increased leg pain. Twenty degrees of left leg straight leg raising exacerbates the left leg pain. There is weakness of hip abduction and ankle dorsiflexion. The remaining neurological exam is normal. SCENARIO 2 [PATTERN 2] A 37 year-‐old chef experiences two weeks of low back pain spreading into both buttocks. The pain is increased when she tries to reach up to a high shelf. She gains complete pain relief when she sits and bends forward. On examination, repeated standing flexion seems to reduce her symptoms while standing extension aggravates the back pain. The neurological exam including the plantar responses and saddle sensation is normal. SCENARIO 3 [PATTERN 1 PRONE EXTENSION POSITIVE] A 46-‐year-‐old clerical worker presents with pain in the right low back radiating into the right buttock and around the right hip. The pain has been present for about three weeks but she is aware that it disappears for a short time if she lies down on her stomach. It is aggravated by sitting and is significantly interfering with her job. On examination, the back and buttock pain is increased with flexion and extension in standing but is substantially decreased with repeated extensions in prone lying using her arms to elevate her upper body. Straight leg raising on the right reproduces the typical back pain but causes no pain in the leg. The remaining neurological examination is normal. SCENARIO 4 [PATTERN 4] A 68 year-‐old retired banker finds that walking quickly for more than 20 minutes produces aching pain in the back of the right thigh. The pain is sufficient to force her to stop. Once the leg pain has started, she can gain relief only by sitting down and bending forward. The pain usually disappears completely within five minutes. On examination, the range of back movement is moderately reduced in both flexion and extension. The neurological exam, including the straight leg raise, is normal. SCENARIO 5 [PATTERN 1 PRONE EXTENSION NEGATIVE] A 39 year-‐old fashion designer complains of low back pain, which has been present for over a month. It is aggravated by all back movement especially by bending forward to pick something up. The severity of the pain fluctuates but it is never completely absent. On examination in standing, the back pain is aggravated by bending forward but is much worse on arching backwards. The neurological exam is normal. Having the patient repeatedly perform prone extensions using the arms and not the back muscles does not have any effect on the back pain. 18
REFERENCES Hall H, McIntosh G, Boyle C: Effectiveness of a Low Back Pain Classification System. The Spine Journal: 2009: 9: pp 648-‐657 Fourney DR, Dettori JR, Hall H, Hartl R, McGirt MJ, Daubs MD: A Systematic Review of Clinical Pathways for Lower Back Pain and Introduction of the Saskatchewan Spine Pathway. Spine: 2011: 36: pp S164-‐ S171 Donelson R, McIntosh G, Hall H: Is it Time to Rethink the Typical Course of Low Back Pain? PM&R: 2012: 4:6: pp 394-‐401
REMINDERS FOR SESSION 31
Prepare to do a practice OSCE-‐ Formative OSCE is session 31. Information will be sent out in advance of this session.
Ophthalmology May 9, 2013 -‐ Week 32 OBJECTIVES By the end of this session, you should be able to: Obtain a medical history as it pertains to the visual system Perform a basic ophthalmological examination, including: Visual acuity Confrontational visual fields Pupillary reflexes and the swinging flashlight test Anterior segment screening with slit lamp biomicroscopy Fundoscopy with direct ophthalmoscopy TENTATIVE TEACHING SITES AND TIMES The Ophthalmology session is organized through each Medical Education Office and may be scheduled outside of regular ASCM 1 hours. As well, teaching sites and times are subject to change, so please confirm your final schedule for this session with your Medical Education Office. CURRICULUM DVD on the ocular examination – approximately one hour Visual acuity testing Confrontation visual fields assessment Pupillary testing Slit lamp biomicroscopy Direct ophthalmoscopy REQUIRED PREPARATION Brain and Behaviour lectures. The Vision Week lectures have been fully integrated with the aims of this ASCM teaching session. The Ophthalmology lectures, in particular, will reinforce ocular anatomy and the causes of visual loss. These lectures will facilitate discussion of the PBL case and of the ASCM clinical skills objectives/homework exercises. Recommended reading. Bradford, C.A. 2004. Basic Ophthalmology. 8th ed. American Academy of Ophthalmology. The first two chapters contain an excellent summary of ocular anatomy and clinical examination techniques; the neuro-‐ophthalmology section complements issues
raised in your ASCM and PBL sessions. This is also the recommended text for your Ophthalmology rotation in clerkship.
EXERCISES These exercises are for discussion with your regular ASCM tutor. Your Vision Week ophthalmology instructor is available to you as a resource to review any questions you may have. 1)
What are 4 clinical techniques used to assess CN II
Techniques for evaluation of CN II:
pupil reflexes and RAPD
fundoscopic examination of disc
Draw the fundoscopic view of a right eye and label:
a) nasal and temporal retinal blood vessels
b) macula, fovea
c) optic nerve head-‐disc
d) optic cup, cup/disc ratio
PERIPHERAL RETINA NASAL RETINAL
VESSELS OPTIC DISC
OPTIC NERVE HEAD
RATIO BY AREA
FOVEA TEMPORAL VESSELS
A patient is referred to you for assessment of optic disc swelling.
If the patient had a right optic neuritis, what would be three significant responses in the history and three clinical findings on examination that would help support this diagnosis?
Right Optic Neuritis
pain with eye movement
sudden visual loss
other neurologic symptoms of MS
previous Hx MS or ON
visual field defect e.g. central scotoma
disc swelling with hemorrhages
may be normal if retrobulbar ON 22
If the patient had papilledema, what would be three significant responses in the history, and three clinical findings on examination that would help support this diagnosis?
other disc may be pale if a previous ON
headache on awakening
nausea and projectile vomiting
mass lesion effects
PeEx: NORMAL vision until very late
enlarged blind spot on VF testing
BILATERAL optic disc swelling with dilated blood
vessels and hemorrhages
VF otherwise normal unless chronic
Final Exam May 16, 2014 -‐ Session 33 ABOUT THE EXAMINATION The OSCE (Objective Structured Clinical Examination) is used widely throughout medical school and is very similar to the bell-‐ringer examination in Structure and Function. This exam counts for 30% of the final mark. EXAM LOCATIONS For overall fairness, no student will be examined at his/her home-‐base hospital. Please note that no requests for a preferred site will be accepted. Assignments will be made through the University Medical Education Office. More details will follow closer to the examination date. PROCESS History Outside each station is a stem. The student have one to two minutes to study it. You are only to obtain a chief complaint and do the HPI. BUT “pull into the HPI” any parts of the functional inquiry (or other history components) that you feel are pertinent to the HPI Be complete AND organized. Physical Describe what you are doing. Do it. Tell the examiner what you find. Be complete AND organized. SCORING Scored on checklists and global evalutions.
RESULTS Written feedback posted on MedSIS Marks posted on MEDSIS Students in difficulty will be provided additional mentoring