Issuu on Google+

The  Art  and  Science  of  Clinical   Medicine  Faculty  Guide  Year  1   2013–2014  

  MSK  1  till  End  of  year     Jean  Hudson   5/16/2014  

                                                                             

 

        0    


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  

             

                             

   

1  


Musculoskeletal  I

 

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  

   

 

 

2  


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.      

 

3  


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.    

 

 

 

4  


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.    

 

 

 

5  


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.          

6  


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?    

7  


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.      

 

 

 

8  


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      

 

 

9  


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      

10  


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)      

 

 

 

11  


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        

12  


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    

13  


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    

14  


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      

 

15  


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.        

 

 

16  


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  

 

 

17  


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.    

 

 

18  


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      

19  


20  


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.    

21  


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    

22  


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.    

 

 

23  


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.      

24  


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:              

25  


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.  

 

26  


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.    

 

27  


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.    

 

28  


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      

29  


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?”      

30  


“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      

31  


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:    

32  


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:  

 

33  


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.  

 

34  


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”    

35  


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.    

36  


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    

37  


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.        

38  


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?    

 

 

39  


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?    

40  


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      

 

 

41  


Approach  to  Common   Neurological  Symptoms   Required  Reading  for  Sessions  27-­‐29  

     

OBJECTIVES  

 

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    

42  


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?  

 

43  


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).  

44  


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.  

45  


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.    

Naming        

×  

ü  

×  

×  

×  

ü  

ü  

×  

ü  

×  

×  

×  

ü  

×  

ü  

×  

×  

×  

×  

×  

×  

×  

ü  

×  

ü  

ü  

×  

×  

ü  

ü  

ü  

×  

Motor  

Broca   Transcortical  motor   Sensory  

Wernicke   Transcortical  sensory   Mixed  

Global   Transcortical  mixed   Other  

Conduction        Anomic    

46  


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)?  

meningitis.  

›   Quality:   How   would   you   describe   the   pain   (e.g.   throbbing,   stabbing,   tight-­‐   band  around  the  head,  steady  pressure)?    

47  


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.    

 

 

             

 

48  


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:  

 

49  


›    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).  

50  


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).  

   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2      


3      


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.  

4      


DIZZINESS  

   

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).  

5      

 

 

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  

6      


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)?          

 

7      


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.  

1    


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)    

 

2    


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    


5    


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.  

6    


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    


8    


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?  

9    


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.    

  11  

 


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    

ROLE-­‐PLAY  SCENARIOS

 

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.]    

17    


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.      

 

19    


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  

20    


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:  

 

 

visual  acuity  

 

 

visual  fields  

 

 

pupil  reflexes  and  RAPD  

 

 

fundoscopic  examination  of  disc  

 

 

VEP  

 

 

colour  vision  

  2)  

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  

21    


PERIPHERAL RETINA NASAL RETINAL

MACULA

VESSELS OPTIC DISC

OPTIC NERVE HEAD

RATIO BY AREA

FOVEA TEMPORAL VESSELS

3)  

OPTIC CUP

=CUP/DISC RATIO

A  patient  is  referred  to  you  for  assessment  of  optic  disc  swelling.  

   

a)        

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  

 

 

Hx:  

pain  with  eye  movement  

 

 

 

sudden  visual  loss  

 

 

 

other  neurologic  symptoms  of  MS  

 

 

 

previous  Hx  MS  or  ON  

 

 

 

 

 

PEx:  

decreased  vision  

 

 

 

right  RAPD  

 

 

 

visual  field  defect  e.g.  central  scotoma  

 

 

 

disc  swelling  with  hemorrhages  

 

 

 

 

 

may  be  normal  if  retrobulbar  ON   22  

 


b)    

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  

   

Papilloedema  

 

 

Hx:  

headache  on  awakening  

 

 

 

nausea  and  projectile  vomiting  

 

 

 

mass  lesion  effects    

 

 

PeEx:   NORMAL  vision  until  very  late  

 

 

 

no  RAPD  

 

 

 

enlarged  blind  spot  on  VF  testing  

 

 

 

 

 

 

 

BILATERAL  optic  disc  swelling  with  dilated  blood  

 

 

 

vessels  and  hemorrhages  

 

     

VF  otherwise  normal  unless  chronic  

 

23    


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.      

24    


RESULTS   Written  feedback  posted  on  MedSIS   Marks  posted  on  MEDSIS   Students  in  difficulty  will  be  provided  additional  mentoring      

25    


Msk to end of year fac ascm 1 document 2014