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Musculoskeletal I   February  21,  2014  –  Session  23    

REMINDERS FOR  THIS  SESSION     Watch  videos  on  Portal  


By  the  end  of  this  session,  you  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  


8:00 Students  to  demonstrate  GALS  and  knee  exam,  tutors  to  correct   Some  sites  may  have  rheumatologists  co-­‐teaching   9:30   Students  practice  on  each  other   10:00   Students  interview  and  practice  with  volunteer  patients   11:30   Feedback  on  Case  Report  #4   Recap/Reminders  for  Session  24        

NOTES FOR  FACULTY     This  session  will  introduce  students  to  the  MSK  history  and  examination.     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.     Students  (and  tutors)  will  also  be  asked  to  watch  videos  that  introduce  the  GALS  screening,  Dr.   Lori  Albert  created  the  following  video:     Mississauga  students  created  the  following  fun  GALS  video:       The  following  videos  are  of  the  focused  knee  exam  (Dr.  Lori  Alberts)     Bulge  sign  in  the  knee  exam:     Notes  for  the  bulge  video:  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.  Specifically,  there  should  be  “no”  hour-­‐long  didactic  session  at  the  beginning  of   this  session.     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.  


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  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.    


People generally  recognize  that  there  is  a  problem  with  the  joints  because  of  PAIN  and   sometimes  SWELLING.  There  are  over  100  kinds  of  arthritis,  so  it  is  important  to  have  a   framework  for  assessing  people  with  possible  arthritis  or  related  conditions.     Is  this  problem  in  the  joint,  or  coming  from  somewhere  else?   • A  joint  problem  will  present  with  limitation  and/or  pain  on  movement  in  most  planes  of   movement  of  that  joint.   • There  may  be  swelling  when  the  problem  is  in  the  joint.   • There  will  be  no  discomfort  or  limitation  when  moving  the  patient’s  symptomatic  joint   when  the  pain  is  referred  from  another  joint  or  structure.  If  a  structure  immediately   outside  of  the  joint  (ie.  tendon,  bursa)  is  the  source  of  pain,  movement  of  the  symptomatic   joint  will  usually  cause  pain  only  with  certain  movements  that  stress  the  involved  structure   (this  is  a  PERI-­‐ARTICULAR  problem).     Is  this  problem  acute  or  chronic?   • What  is  the  time  course  of  the  problem?  Is  it  continuing  to  worsen?  Is  it  waxing  and   waning?     Is  the  joint  problem  inflammatory  or  non-­‐inflammatory?  Are  joints  damaged?   • Inflammatory  problems  cause  PAIN,  SWELLING,  WARMTH,  LIMITATION  OF  MOVEMENT  and   STIFFNESS  upon  first  movements  of  the  day  that  typically  lasts  one  hour  or  more.  “Morning   Stiffness”.  ASK:  Do  you  have  stiffness  in  your  joints  in  the  morning?  How  long  does  it  take   you  to  get  going?  How  long  until  you’re  as  good  as  you’re  going  to  get  for  the  rest  of  the   day?  Are  you  able  to  dress  yourself  in  the  morning?   • Non-­‐inflammatory  problems  can  produce  transient  stiffness  after  prolonged  sitting  in  a   chair  or  car  “post-­‐rest  GELLING”.   • When  damage  has  occurred,  people  may  hear  or  feel  CREPITUS  (and  you  will  on  exam).     Are  there  clues  in  the  non-­‐MSK  history  (important  review  of  systems  questions)?   • So-­‐called  “extra-­‐articular”  symptoms  are  evidence  of  systemic  involvement  by  a  process   that  also  affects  the  joints.  Examples  include  certain  skin  rashes,  eye  problems,  mucosal   ulcers,  pleuritis  or  other  lung  problems,  and  many  others.  Discovering  that  a  person  has   these  symptoms  (or  findings  on  examination)  provides  clues  as  to  the  type  of  arthritis  the   person  might  have.  For  example,  a  young  woman  with  polyarthritis  in  the  small  joints  and  a   facial  rash  might  have  systemic  lupus  erythematosus.     What  is  the  impact  on  the  patient?  

• People with  arthritis  experience  varying  degrees  of  disability,  and  it  is  important  to  find  out   how  patient  are  managing  with  activities  of  daily  living,  work-­‐related  activities,  hobbies,   sexual  function,  childcare  etc.  ASK:  How  has  your  life  been  affected  by  this  joint  problem?     TAKING  THE  HISTORY     All  elements  of  the  history  are  important  and  relevant  to  assessing  a  patient  with  possible   arthritis  because  of  the  systemic  nature  of  many  of  the  diseases.  The  important  questions  are   evident  in  the  approach  shown  above.  In  addition,  a  thorough  functional  inquiry/review  of   systems  will  capture  many  of  the  associated  extra-­‐articular  manifestations.  As  you  learn  more   about  the  rheumatic  diseases  in  Year  2,  the  specific  questions  to  elicit  these  problems  will   become  easier  to  understand.       Look   Feel   Move   Periarticular   Is  there   Is  there  FOCAL   Is  there  PAIN  with  movement  ONLY  IN   problem   focal   TENDERNESS  at  a   CERTAIN  DIRECTIONS  (vs  pain  through  the   swelling  or   peri-­‐articular   whole  range  of  motion  with  an  articular   redness?   structure  (bursa,   problem)   tendon  or   Is  there  REDUCED  pain  when  you  move  the   tendon/ligament   joint  PASSIVELY  (so  the  inflamed/irritated   insertion)   peri-­‐articular  structure  is  not  engaged)   Inflammation   Is  the  joint   Is  the  joint  WARM?   Is  there  PAIN  THROUGH  THE  RANGE  OF   SWOLLEN?   Is  there   MOTION,  BOTH  ACTIVE  AND  PASSIVE     Is  the  joint   TENDERNESS  AT   Is  there  STRESS  PAIN  (pain  when  you  take   RED  (or   THE  JOINT  LINE?   the  joint  a  little  beyond  the  normal  range   purpley-­‐ Is  there  FOCAL   of  motion-­‐characteristic  of  inflammatory   bluey)   TENDERNESS  at  a   problems)     peri-­‐articular     structure?   Can  you   demonstrate  the   presence  of  an   EFFUSION?   Damage   Is  the  joint   Is  there   Is  there  CREPITUS  with  range  of  motion?   showing   TENDERNESS  at  the   Is  there  INSTABILITY  or  ABNORMAL   DEFORMITY joint  line?   MOVEMENT  in  the  joint?   ?   Is  there  LIMITATION  of  RANGE  OF   MOTION?        

EXAMINING THE  PATIENT     The  physical  exam  in  rheumatology  will  complement  what  you  learned  upon  taking  the   patient’s  history.  As  with  the  history,  a  complete  physical  examination  is  essential  to   diagnosing  many  rheumatic  diseases.  Your  examination  should  also  be  geared  to  addressing   the  issues  outlined  above.  NOTE:  you  will  learn  more  about  how  to  identify  some  of  the  extra-­‐ articular  manifestations  of  rheumatic  diseases  over  time.  Right  now,  you  should  focus  your   efforts  on  deciding  if  the  problem  is  articular  or  non-­‐articular,  inflammatory  or  non-­‐ inflammatory  and  if  there  is  damage  to  the  joint.     How  do  you  operationalize  this?     • LOOK  (Inspection)   • FEEL  (Palpation)   • MOVE  (and  check  for  abnormal  movements)     FINAL  STEPS     • What  is  the  distribution  of  joints  involved,  if  it  involves  more  than  one  joint?  Certain   patterns  of  joint  involvement  are  typical  of  certain  diseases.  You  will  learn  more  about  this   in  ASCM  2.   • What  extra-­‐articular  manifestations  are  present?  You  will  learn  more  about  this  in  ASCM  2.      

GALS MSK  SCREENING  EXAMINATION     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.     Limb   Appearance   Movement       Gait   !       Arms   !   !       Legs   !   !       Spine   !   !       Record  for  an  abnormal  exam.  




Movement !  





Knee Swelling  

Flexion 90°  only  




SCREENING EXAMINATION     Positioning  and  draping     Make  sure  both  legs  are  exposed  in  order  to  compare  each  side.  There  are  three  positions  for   the  exam:  walking,  standing  (back,  side,  front),  and  supine.     Examination     Individual  Components  of  GALS  exam  (see  attached  article,  Doherty  et  al,  1992)     GAIT   • Symmetry  &  smoothness  of  movement   • Stride  length  &  mechanics   • Ability  to  turn  normally  &  quickly     ARMS  (Hands)   • Wrist/finger  swelling/deformity   • Squeeze  across  2nd  to  5th  metacarpals  for  tenderness  (indicates  synovitis)     • Turn  hands  over,  inspect  muscle  wasting  &  forearm  pronation/supination     ARMS  (Grip  Strength)   • Power  grip  (tight  fist)   • Precision  grip  (oppose  each  finger  to  thumb)     ARMS  (Elbows)   • Full  extension     ARMS  (Shoulders)   • Abduction  &  external  rotation  of  shoulders     LEGS  (Feet)   • Squeeze  across  metatarsals  for  tenderness  (indicates  synovitis)   • Calluses     LEGS  (Knees)   • Knee  swelling/deformity,  effusion   • Quadriceps  muscle  bulk   • Crepitus  during  passive  knee  flexion        

LEGS (Hips)   • Check  internal  rotation  of  hips     SPINE  (Inspection  from  behind)   • Shoulders  &  iliac  crest  height  symmetry   • Scoliosis   • Paraspinal,  shoulder,  buttocks,  thighs  &  calves  muscles  normal   • Popliteal  or  hind  foot  swelling  or  deformity     SPINE  (Inspection  from  front)   • Quadriceps  normal  in  bulk  &  symmetry   • Swelling  or  at  varus  or  valgus  deformity  at  knee   • Forefoot  of  midfoot  deformity,  action  normal   • Ear  against  shoulder  on  either  side  to  check  lateral  cervical  spine  flexion   • Hands  behind  head  with  elbows  back  (check  rotator  cuff  muscles,  acromioclavicular,   sternoclavicular  &  elbow  joints)       SPINE  (Inspection  from  side)   • Normal  thoracic  &  lumbar  lordosis   • Normal  cervical  kyphosis   • Normal  flexion  (lumbosacral  rhythm  from  lumbar  lordosis  to  kyphosis)  while  touching  toes       SPINE  (Trigger  point  tenderness)   • Supraspinatus  muscle  tenderness  (exaggerated  response)      

EXAMINATION OF  THE  KNEE     ANATOMY     The  knee  is  a  synovial  hinge  joint,  composed  of  the  femur,  tibia,  and  patella  (knee  cap).  It  is   stabilized  by  four  ligaments:  the  medial  collateral  (MCL),  lateral  collateral  (LCL),  anterior   cruciate  (ACL),  and  posterior  cruciate  (PCL).  A  fifth  ligament,  the  patellar  ligament,  is  a   continuation  of  the  quadriceps  femoris  tendon.  It  attaches  superiorly  to  the  apex  and  margins   of  the  patella  and  inferiorly  to  the  tibial  tuberosity.  Ligaments  are  illustrated  in  FIGURE  23.2.   Two  menisci  (lateral  and  medial)  cushion  the  action  of  the  femur  on  the  tibia  (FIGURE  23.3).   The  synovial  cavity  of  the  knee  occupies  the  concavities  lateral  and  medial  to  the  patella  and   also  the  suprapatellar  pouch,  which  extends  approximately  six  centimeters  above  the  upper   border  of  the  patella,  deep  to  the  quadriceps  muscle.  The  synovium  is  not  normally  detectable   on  physical  exam.2,3     EXAMINATION     As  a  general  rule,  it  is  a  good  idea  to  observe  gait  to  inspect  weight-­‐bearing  joints  at  the  start   of  the  examination.  For  convenience,  this  can  be  deferred  to  the  end  of  the  examination.       Draping     The  patient  is  supine  and  exposed  from  mid-­‐thighs  downward  to  feet.  Place  a  sheet  between   the  patient’s  legs  to  cover  the  groin.     Inspection     Gait:  An  antalgic  (i.e.  “against  pain”)  gait  reflects  pain  anywhere  from  the  pelvis  to  the  foot.   The  stance  phase  on  the  affected  side  is  briefer  and  the  swing  phase  on  the  contralateral  side   is  shorter,  as  the  patient  avoids  bearing  weight  on  the  painful  side.8  An  arthrogenic  gait   indicates  a  stiff  knee  or  hip.  It  is  not  necessarily  painful.  The  affected  side  is  circumducted   during  the  swing  phase  because  hip  or  knee  flexion  is  limited.8     Symmetry:  As  the  knee  is  examined,  it  is  compared  to  ‘normal’  joints  above  and  below,  as  well   as  to  the  same  joint  on  the  contralateral  side.8     Alignment:  Inspect  when  the  patient  is  supine  and  in  the  standing  position.  Examine  the   patient’s  anatomy  for  genu  valgus  (‘knock-­‐knee’  deformity),  genu  varus  (‘bow-­‐leg’  deformity),   or  genu  recurvatum  (hyperextension  of  the  knee).  Also  examine  for  a  fixed  flexion  deformity   (inability  to  fully  extend  the  knee).8    

Swelling: Joint  fluid  tends  to  accumulate  in  the  suprapatellar  pouch  and  the  medial  and  lateral   parapatellar  fossae.8  Look  for  joint  enlargement,  as  compared  to  the  contralateral  side.       Colour  changes:  Erythema  (abnormal  redness)  may  be  indicative  of  inflammation.       Proximal  muscle  atrophy:  Examine  the  quadriceps  muscle  for  evidence  of  atrophy,  as   compared  to  the  contralateral  side.       Palpation     Effusion:  There  are  three  basic  methods  to  test  for  an  effusion:  the  bulge  test  is  used  to  detect   a  minor  effusion,  while  ballottement  and  the  patellar  tap  are  used  to  detect  a  large  effusion.     • Bulge  test  (minor  effusions):  the  patient  is  supine  with  the  knee  extended.  The  examiner   uses  his/her  hand  to  milk  fluid  along  the  medial  aspect  of  the  knee  joint  upward  into  the   suprapatellar  pouch.  The  examiner  then  runs  his/her  hand  down  the  lateral  side  of  the   knee  while  observing  the  medial  aspect  of  the  knee  joint.  A  bulge  will  appear  on  the  medial   aspect  if  a  small  amount  of  fluid  is  present.  However,  if  there  is  a  large  effusion,  a  bulge   may  not  be  seen.8     • Ballottement  (large  effusions):  the  examiner  uses  one  hand  to  press  down  on  the   suprapatellar  pouch,  forcing  fluid  downward.  The  index  finger  and  thumb  of  the  other  hand   is  used  to  attempt  to  push  fluid  (if  present)  back  and  forth  between  the  medial  and  lateral   fossae  or  up  toward  the  hand  compressing  the  suprapatellar  pouch.4     • Patellar  tap  (large  effusions):  the  examiner  uses  one  hand  to  compress  the  suprapatellar   pouch.  With  the  other  hand,  he/she  places  the  tips  of  the  fingers  on  the  patella  and  thrusts   down  firmly.  Normally  there  is  no  patellar  movement.  In  the  presence  of  a  large  effusion,   the  patella  will  float  up  out  of  its  normal  position.  As  the  examiner  presses  on  the  patella,   downward  movement  will  be  detected,  often  with  a  palpable  tap  or  click  as  the  patella   strikes  the  femoral  condyles.8     Baker’s  cyst:  In  approximately  one-­‐third  of  patients,  there  is  a  communication  between  the   knee  joint  space  and  the  popliteal  bursa,  which  can  result  in  a  bursal  swelling  at  the  posterior   aspect  of  the  knee.  This  is  known  as  a  Baker’s  cyst.8  Palpate  the  posterior  aspect  of  the  knee   for  the  presence  of  a  Baker’s  cyst.  If  the  cyst  is  very  large,  it  may  also  be  detected  visually   when  the  patient  is  standing.     Warmth:  The  kneecap  should  be  the  coolest  part  of  the  joint.  Use  the  dorsum  of  the  hand  and   feel  the  temperature  from  the  distal  thigh,  over  the  kneecap,  and  down  the  shin,  comparing   the  kneecap  with  the  rest  of  the  leg,  and  one  knee  with  that  of  the  other.  Joint  warmth  can  

indicate inflammation.8  In  individuals  with  fatty  tissue  around  the  knees,  effusions  may  not  be   detectable  and  prepatellar  warmth  may  be  the  only  indication  of  inflammation.8     Joint  line  tenderness/bony  tenderness:  Flex  the  knee  to  90°.  Locate  the  tibial  tuberosity  and   patellar  tendon  and  palpate  upward  along  the  patellar  tendon  to  find  the  joint  line  on  either   side.  Feel  along  the  joint  line,  one  side  at  a  time,  and  ask  the  patient  to  report  if  he/she  feels   tenderness.  Tenderness  can  be  indicative  of  meniscal  damage.7     Stress  pain.  The  valgus  and  varus  stress  tests  assess  for  laxity  of  the  MCL  and  LCL  respectively.     • Valgus/abduction  stress  test  (FIGURE  23.4):  the  patient  is  supine  with  the  knee  slightly   flexed.  The  examiner  places  one  hand  against  the  lateral  aspect  of  the  knee  to  stabilize  the   femur;  the  other  hand  is  placed  on  the  medial  aspect  of  the  ankle.  Stress  is  applied,  pushing   medially  against  the  knee  and  pulling  laterally  at  the  ankle,  in  an  attempt  to  open  the  knee   joint  on  the  medial  side  (valgus  stress).  Pain  or  a  palpable  gap  in  the  medial  joint  line  is   indicative  of  an  MCL  tear.2  The  MCL  is  a  more  common  site  of  injury  than  the  LCL.     • Varus/adduction  stress  test  (FIGURE  23.5):  the  patient  is  supine  with  the  knee  slightly   flexed.  The  examiner  places  one  hand  against  the  medial  aspect  of  the  knee  and  the  other   on  the  lateral  aspect  of  the  ankle.  The  examiner  then  pulls  laterally  at  the  knee  and  pushes   medially  against  the  ankle,  in  an  attempt  to  open  the  knee  joint  on  the  lateral  side  (varus   stress).  Pain  or  a  palpable  gap  in  the  lateral  joint  line  is  indicative  of  an  LCL  tear.2     Crepitus.  To  assess  for  crepitus,  place  one  hand  over  the  medial  and  lateral  joint  line  and   patella,  and  with  the  other  hand  move  the  knee  through  its  full  range  of  motion.  A  grinding  or   crackling  sensation  (audible  or  palpable)  indicates  crepitus.8  Crepitus  may  occur  in  normal   joints,  but  may  be  significant  if  accompanied  by  other  symptoms  and  signs.2     Range  of  motion     Active  and  passive  range  of  motion  (ROM)  should  be  compared  to  determine  if  the  patient  has   restricted  range  of  flexion.  Normal  range  for  flexion  is  120˚.     • Active  flexion:  the  patient  is  asked  to  touch  the  heel  to  the  buttock  (flexion  of  the  knee)   and  then  to  straighten  the  leg  (extension).     • Passive  flexion:  one  hand  is  placed  over  the  medial  and  lateral  joint  line  and  patella  to   palpate  for  crepitus  while  the  other  hand  grasps  the  heel  and  moves  the  knee  through  its   full  extension  and  flexion.6        

Special Manoeuvres     Note  that  for  all  maneuvers,  it  is  best  to  interpret  a  finding  (e.g.  ACL  laxity  by  anterior  drawer)   than  to  state  whether  a  particular  test  is  positive  or  negative.     Anterior  drawer  test  for  stability  of  ACL(FIGURE  23.6).  The  patient  is  supine  and  the  knee  is   flexed  to  90°  with  the  sole  of  the  foot  flat  on  the  table  and  hamstrings  relaxed.  The  examiner   uses  his/her  forearm  to  stabilize  the  tibia.  The  examiner  cups  his/her  hands  around  the  back  of   the  tibia  and  places  his/her  thumbs  on  the  medial  and  lateral  joint  line  or  the  tibial  tuberosity.   The  examiner  then  pulls  tibia  anteriorly.  The  test  is  positive  if  the  tibia  can  be  pulled  away   from  the  femur.2,3     Lachman’s  test  for  stability  of  ACL  (FIGURE  23.7).  The  patient  is  supine  with  the  knee  flexed  to   20°  and  the  hip  externally  rotated.  The  examiner  uses  one  hand  to  hold  the  distal  femur,  and   the  other  hand  to  hold  the  upper  tibia,  placing  the  thumb  on  the  joint  line.  The  tibia  is  pulled   anteriorly  and  the  femur  pushed  back  simultaneously.  If  the  tibia  can  be  pulled  anteriorly  from   the  femur,  an  ACL  tear  is  implicated.2,3     Posterior  drawer  test  for  stability  of  PCL  (FIGURE  23.8).  The  patient  is  supine  and  the  knee  is   flexed  to  90°  with  the  sole  of  the  foot  flat  on  the  table  and  hamstrings  relaxed.  The  examiner   uses  his/her  forearm  to  stabilize  the  tibia.  The  examiner  cups  his/her  hands  around  the  back  of   the  tibia  and  places  his/her  thumbs  on  the  medial  and  lateral  joint  line  or  the  tibial  tuberosity.   The  examiner  then  pushes  the  tibia  posteriorly.  The  test  is  positive  if  the  tibia  can  be  pushed   posteriorly  with  respect  to  the  femur.2,3            


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.  


Review  physical  exams  learned  to  date.    Next  session  is  a  review  session.  Students  are  to  take   brief  focused  histories  and  spend  the  time  on  reviewing  physical  exam  skills  learned  to  date.      

Physical Exam  Review   February  28,  2014  -­‐  Session  24    

REMINDERS FOR  THIS  SESSION     Students  to  review  physical  exams  learned  to  date.  


By  the  end  of  this  session,  you  should  be  able  to:   • Demonstrate  all  physical  exam  skills  learned  to  date   • Faculty  to  observe  students  and  provide  specific  feedback  


8:00 Tutors  and  students  to  briefly  review  physical  examination  skills  learned  to  date.   8:30   Examine  real  patients.  Obtain  a  very  brief  focused  history  and  practice  the  following   physical  exam  skills:   Vital  signs   Cardiovascular  exam,  including  JVP  and  peripheral  vascular  exam   Respiratory  exam   Head  and  Neck  exam   Abdominal  exam   Knee  exam   GALS  screening  exam   10:45   Break   11:00   Oral  Reports:  Present  real  patient  cases  seen  today   11:30          

NOTES FOR  FACULTY     Please  find  real  patients  prior  to  session  if  possible,  so  as  to  maximize  the  time  students  spend   with  patients  reviewing  their  physical  exam  skills.  Students  should  be  encouraged  to  complete   all  physical  exam  skills  listed  below  while  being  periodically  observed  by  all  available  tutors.   Feedback  and  demonstration,  when  needed,  during  physical  exam  practice  is  encouraged.    


EXAMPLE       Dr.  James  providing  an  oral  presentation  regarding  the  thyroid  assessment     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.      

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  


8:00 Portfolio  III   10:00   Interview  patients  for  Case  Report  #5   11:45   Recap/Reminders  for  next  session     Complete  evaluation  of  the  Portfolio  sessions          


INTRODUCTION   This  two-­‐hour  segment  of  an  ASCM  1  session  is  designed  to  accomplish  three  things:   1. 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.   2. 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.   3. Give  the  students  a  second  experience  with  developing  a  reflection  on  what  happened  in   their  story  as  an  introduction  to  reflective  practice.     BACKGROUND     The  development  of  reflective  practitioners  is  an  overarching  goal  in  medical  education.   Practitioners  who  can  interpret  the  meaning  of  events  around  them,  and  adjust  their  practice   accordingly,  may  have  fewer  difficulties  in  their  careers  with  patients,  colleagues,  and   regulatory  bodies.  The  UME  curriculum  is  promoting  the  development  of  reflective  skills   alongside  all  the  other  elements  to  be  learned  across  four  years.       In  first  year,  ASCM  1  is  the  first  chance  most  students  have  to  interact  with  patients.  These  are   very  important  moments  for  all  students,  and  the  three  Portfolio  sessions  are  designed  to  give   the  students  space  and  time  to  focus  on  how  they  are  starting  to  develop  their  identity  as   doctors.  Interspersed  among  the  knowledge-­‐based  and  skill-­‐based  sessions,  these  reflective   sessions  redirect  students’  attention  to  their  ultimate  goal—being  a  skilled  and  caring   practitioner.     ACTIVITIES     The  session  format  is  outlined  here:     Before  the  session     • Students  prepare  ahead  of  time  by  deciding  on  ONE  Central  Story,  based  upon  what  they   have  seen  and  done  relating  to  communicating  with  patients  and  others  so  far,  using  the   prompts  found  on  the  next  few  pages.  We  tell  them  how  to  structure  the  story  so  that   listeners  have  a  clear  idea  of  what  happened.     • Students  also  prepare  a  statement,  or  Reflection,  on  how  this  experience  has  influenced   their  ideas  of  themselves  as  doctors.      

During the  session     Intro:    Tutor  should  introduce  the  process  as  outlined  below.  Students  have  this  outline  in  their   notes,  but  this  brief  review  will  ensure  mutual  understanding.  (approx.  5  minutes)     Activity:  Students  read  and  receive  the  group’s  comments  on  their  stories  and  reflections  in   the  following  format:   • Student  A  reads  story  and  reflection  to  the  group.  Other  students  listen  attentively.   (approx.  5  minutes)   • Student  A  listens  while  other  students  share  their  thoughts,  reactions  and  questions.   Student  A  can  respond  where  appropriate,  but  doesn’t  have  to  -­‐  s/he  may  wish  to  think   about  what  was  said.  (approx.  10  minutes)   • Student  B  then  starts  his/her  story  and  reflection,  followed  by  group  discussion  and   reaction  to  the  story.  (approx.  15  minutes)   • Process  continues  until  all  students  have  had  a  chance  to  participate.  (Total  1.5  hours)     Tutor’s  role:  In  this  format,  you  are  acting  more  as  a  facilitator  than  a  teacher.  The  goal  is  to   have  increasingly  open  and  free  discussion  by  all  students  about  the  stories  and  reflections.   You  will  help  the  group  towards  this  goal  by  doing  the  following:   • Solicit  volunteers  to  tell  their  stories  first,  second,  etc.,  rather  than  assigning  an  order.     • Let  each  student  tell  the  story  and  reflection  without  interruption,  and  remind  the  other   students  not  to  interrupt  if  they  do  so.   • When  the  discussion  is  to  begin,  make  sure  the  first  people  to  participate  are  the  students.   Avoid  giving  your  own  views  until  the  end,  and  even  then  make  sure  you  are  not  providing   the  “definitive  answer”.  This  exercise  is  about  students  expressing  their  experiences   learning  about  communicating  in  a  clinical  context.  There  cannot  be  one  right   interpretation,  but  students  may  look  to  you  to  provide  “expertise”.  If  this  occurs,  we   suggest  redirecting  questions  back  to  the  group,  such  as  “What  does  that  sound   like/remind  you  of/make  you  feel/mean  to  you?”  It  is  often  best  to  put  questions  to  the   whole  group  rather  than  the  initial  speaker.   • Keep  an  eye  on  the  time!  If  the  discussion  is  moving  along,  and  time  is  about  to  run  out,   gently  interrupt  and  suggest  that  a  few  final  points  be  made,  so  the  next  student  can  begin.   • If  discussion  stalls,  try  asking  the  group  open-­‐ended  questions  that  bring  out  their   perspectives.  Examples:   o “What  surprised  you  (the  group)  in  that  story?”   o “How  did  you  feel  about  (event)  that  happened,  or  the  way  (student)  described  it?”   o “Did  any  of  you  notice  (tension/happiness/pride/fear/other  notable  emotion)  in  the   way  the  story  was  told?  Why  do  you  think  that  was?”    

Wrap Up:  Use  the  final  minutes  of  the  session  to  promote  discussion  of  overall  themes  that   you  and  the  group  heard.  Here  you  can  give  your  overview,  but  invite  the  students  to  provide   theirs.  (approx.  10-­‐20  minutes)     Send  Off:  Students  have  been  given  a  worksheet  to  record  what  happened  in  the  session.   Remind  them  to  fill  it  out,  because  these  notes  will  be  needed  for  their  Reflection  Assignment   at  the  end  of  the  year.  Finally,  remind  them  that  the  discussions  in  this  group  are  not  to  be   repeated  elsewhere.  We  treat  the  thoughts  and  disclosures  in  this  session  as  privileged,   confidential  information.     After  the  Session:       You  will  receive  a  link  to  a  short  questionnaire  to  record  your  reaction  to  the  session  and  how   it  went.     FAQ     Why  are  we  doing  the  group  discussion  of  stories?   We  are  using  the  power  of  group  discussion  to  deepen  each  student’s  own  thought  process   about  their  own  story.  This  format  has  worked  successfully  in  the  3rd  and  4th  year  Portfolio   courses.  Over  the  three  Portfolio  sessions,  a  climate  of  mutual  support  should  emerge.     Why  is  this  considered  a  component  of  a  clinical  skills  course?   As  outlined  in  the  Background  above,  we  use  the  setting  of  ASCM  1  because  this  is  when   students  first  “act  like  doctors”.  Learning  about  “becoming  a  doctor”  is  a  parallel  process  to   learning  clinical  skills.  As  facilitators,  you  are  helping  students  learn  to  talk  about  what  is   influencing  them  in  their  day-­‐to-­‐day  experiences.  We  believe  that  this  is  a  fundamental  part  of   becoming  a  professional.     What  are  my  responsibilities  about  assessing  (marking)  the  students?   There  is  no  separate  mark  or  assessment  for  this  activity.  However,  if  you  find  that  a  student  is   rude,  belittling  of  colleagues,  argumentative,  or  extremely  disengaged,  you  should  consider   speaking  with  the  student  after  the  session  or  assigning  that  student  a  minor  lapse  in   professionalism,  depending  on  the  extent  of  your  concern.  You  should  also  report  absences   from  this  session.     The  student  materials  for  Portfolio  Session  3  follow.  Please  read  them  to  ensure  you   understand  what  students  are  to  do.          

PORTFOLIO III   The  History  /  Communication     The  history  is  one  of  the  most  essential  skills  that  you  will  learn  in  medicine.  In  ASCM  1,  you   have  spent  a  great  deal  of  time  learning  how  to  take  a  proper  history  and  how  to  develop  a   rapport  with  patients.  Your  ability  to  communicate  well  with  you  patients  is  vital  to  your  ability   to  be  a  successful  doctor.  In  addition,  having  the  skills  to  communicate  well  with  your   colleagues,  allied  healthcare  professionals,  and  patients’  families  is  also  incredibly  important.     Purpose:  To  reflect  on  the  issues  and  challenges  that  arise  when  taking  a  history,  listening  to   patients’  stories,  and  otherwise  learning  to  communicate  in  the  clinical  environment.     BEFORE  PORTFOLIO  SESSION  3     Task:  Think  about  one  central  story  that  highlights  what  you  learned  about  the  importance  of   strong  communication  skills.  Alternatively,  tell  one  central  story  which  shows  what  you   learned  about  the  consequences  of  poor  communication.  The  story  can  be  from  a  time  that   you  took  a  patient  history  in  ASCM,  an  experience  that  you  had  in  communicating  with   another  medical  student  or  staff  physician,  or  a  communication  issue  that  came  up  before  you   even  started  medical  school.  Your  task  during  the  session  will  be  to  explain  what  happened  in   the  story  and  what  you  learned  about  how  you  communicate.   • How  could  you  be  better  at  communicating?     • What  went  well  and  why?   • What  would  you  do  differently  in  the  future?     • As  a  future  physician,  what  do  you  want  to  keep  in  mind  as  you  communicate  with  your   patients  and  your  colleagues?       Taking  a  history  could  involve  covering  sensitive  topics  with  a  patient  such  as  their  sexual   orientation.  It  also  requires  that  you  be  culturally  sensitive  to  people  from  different   backgrounds,  such  as  Indigenous  Canadians,  socially  or  financially  disadvantaged  people,  and   people  of  various  faiths.  If  you  have  had  an  experience  in  which  understanding  a  patient’s   culture,  religion,  language,  or  beliefs  was  important  in  taking  a  history,  then  you  could  reflect   on  that  experience  and  what  you  learned  as  a  result.     IN  PORTFOLIO  SESSION  3     Task:  Explain  what  happened  in  the  central  story,  what  you  learned  about  how  you   communicate,  and  what  you  thought  the  significance  of  the  events  were  to  you,  in  influencing   how  you  see  yourself  as  a  doctor.        

Format: • Tell  the  one  central  story  -­‐  where  were  you,  who  was  there,  and  what  happened?  Lead  the   rest  of  the  group  through  your  “history”,  and  please  include  any  feelings  or  thoughts  that   came  to  you  as  part  of  the  story.  (If  it  helps,  think  of  this  as  telling  the  HPI  of  you,  the   “patient”.)   • The  self-­‐reflection  is  meant  to  be  highly  personal,  and  there  can  be  no  “right  answer”.   You’re  on  the  right  track  if  you  can  say  “The  thing  I  learned  about  myself  as  a  future  doctor   from  this  experience  was...”  and  state  something  that  you  feel  is  authentic  and  true  to  you.   • After  you  have  finished,  the  rest  of  the  group  will  be  invited  to  comment  on  what  they   heard.  Comments  should  focus  on  what  listeners  appreciated  in  the  story,  and  interesting   ideas  that  came  to  them  while  listening.  Questions  may  be  asked  to  clarify  the  story,  and   you  may  have  new  ideas  during  the  discussion.     • Time  per  student:  15  minutes  total.     • After  this,  it  will  be  time  to  move  to  the  next  student’s  story.  At  this  point,  you  will  listen   attentively  and  provide  your  own  thoughts  and  reactions  to  the  stories  you  hear.     • At  the  end  of  the  entire  session,  the  facilitator  and  the  whole  group  will  discuss  general   themes  that  came  out  of  this  activity.   • The  facilitator  is  there  to  help  guide  the  discussion,  and  to  pose  questions,  but  not  to   provide  “answers”.     • Everyone  shares  responsibility  for  keeping  the  discussion  on  track,  and  within  the  time   allotted  for  this  activity.     AFTER  THE  SESSION     Task:  Consolidate  your  ideas  about  your  story,  using  the  points  brought  up  by  your  classmates,   and  any  other  ideas  you  had.  You  will  need  this  for  your  final  reflection  later  in  the  year.       Format:  To  be  done  as  soon  as  you  can  after  the  session.  Use  whatever  format  will  be  easiest   for  you  to  follow  later.  We  suggest  using  the  following  sheet  to  organize  your  observations  and   ideas.              

REFLECTION WORKSHEET  FOR  HISTORY-­‐TAKING  AND  COMMUNICATION     The  Central  Story  I  told  in  this  session  was:                 The  key  things  I  learned  about  the  way  that  I  want  to  practice  medicine  from  the  Central  Story   were:                   Ideas  and  feelings  that  came  to  me  during  the  group  discussion  of  my  story:                     Other  ideas  and  feelings  that  came  to  me  from  listening  to  other  students’  stories:          

FINAL PORTFOLIO  ASSIGNMENT   The  Written  Reflection     The  final  part  of  the  Portfolio  portion  of  the  course  is  to  create  a  short  written  reflection  about   how  you  see  your  own  development  as  a  physician  at  the  end  of  the  year.     PURPOSE     To  develop  students’  skills  in  creating  a  structured  written  reflection  which  will  be  submitted   for  feedback.  These  skills  will  help  students  with  reflections  to  be  written  in  the  future   Portfolio  components  and  courses  in  their  UME  training.  Finally,  these  skills  will  enable   students  to  develop  their  reflective  practice  further  than  the  informal  discussions  allow.     BACKGROUND     At  the  end  of  your  first  year  of  medical  school,  you  have  already  mastered  a  large  body  of   knowledge,  both  in  the  classroom  and  in  the  clinical  world.  You  have  also  developed  a  solid   foundation  in  the  skills  of  being  a  clinician—meeting  patients,  speaking  to  them  about  their   lives  while  taking  a  history,  and  examining  them,  all  of  which  are  unique  professional  skills  that   you  didn’t  have  at  the  beginning  of  the  year.  You  have  reached  an  important  milestone  in  your   development  as  a  clinician.     Your  discussions  with  classmates  about  your  reflections  in  the  three  portfolio  sessions  within   ASCM  1  gave  you  a  chance  to  explore  the  impact  of  all  this  learning  on  how  you  see  yourself  as   a  clinician.  Now,  you  will  develop  these  ideas  further  by  putting  together  a  more  formal   reflection,  using  the  structure  specified  below.       Creating  a  written  reflection  is  a  form  of  explanation  and  analysis  of  your  thoughts,  feelings   and  ideas  about  a  personal  subject  -­‐  in  this  case,  you  as  a  developing  clinician.  You  will  be   doing  this  in  future  Portfolio  components  in  Year  2,  and  in  the  Portfolio  Courses  in  Years  3  and   4,  so  this  is  a  chance  to  develop  your  skills  in  this  activity.  In  addition,  we  find  that  students   gain  greater  insight  into  their  own  self-­‐reflections  through  the  process  of  formalizing  them,   and  often  find  themselves  taking  their  ideas  further  than  they  had  before  when  they  are   preparing  something  to  be  read  by  another  person.     It  is  important  to  stress  that  the  PROCESS  of  reflection  is  what  we  are  looking  for  in  these   submissions.  Your  work  will  not  be  evaluated  based  upon  the  ideas  you  express,  nor  upon  any   conclusions  you  come  to.  Rather,  we  will  focus  on  encouraging  you  to  explore  these  ideas  and   conclusions  further.  The  way  in  which  these  reflections  will  be  assessed  is  explained  in  the   “Task”  section  below.    

TASK   Preparation     • Go  back  to  your  notes  from  the  three  Portfolio  discussions.  Remind  yourself  of  the   encounters  you  described  in  your  Central  Stories,  and  read  over  the  ideas  you  documented   afterward.   • Choose  one  of  the  Central  Stories  to  act  as  the  “base”  for  your  reflection  on  the  question:   “How  did  this  story  influence  my  development  as  a  doctor  over  this  year?”   • If  you  don’t  feel  that  any  of  the  stories  are  appropriate  for  this  question,  you  can  choose   another  Central  Story  to  act  as  the  “base”  for  this  reflection.   • Consider  the  ways  in  which  you  might  explain  your  perspective  on  the  Central  Story  and  its   influence  on  your  development.  Here  are  some  possible  prompts  to  get  you  started:   o What  surprised  you  about  the  situation  in  the  Central  Story?  Were  you  shocked?   Startled?  Impressed?  Disappointed?   o How  did  you  process  or  understand  the  situation  at  the  time,  and  has  that  changed   since  then?   o 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?   o How  do  you  plan  to  build  on  the  lessons  you  learned?   o 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?   o 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:   o This  must  have  a  beginning,  which  sets  the  scene.  Where  did  this  take  place,  who   was  there,  and  what  else  was  going  on?   o 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.   o 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:  

o The Reflection  is  fundamentally  based  upon  answering  the  question,  “How  did  this   Story  influence  my  development  as  a  doctor  over  this  year?”   o 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.   o 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.   o Create  a  summary  statement  about  where  you  think  you  will  go  from  here  -­‐  how  you   will  carry  the  lessons  forward  into  second  year.   o Above  all,  make  sure  that  the  focus  is  on  YOU,  the  developing  doctor.   • Submit  the  Reflection  using  the  online  submission  system,  which  will  be  explained  to  you   closer  to  the  time.     STRUCTURE     Your  submission  must  follow  this  structure:   • Start  with  a  Central  Story,  with  beginning,  middle,  and  end,  described  above.   • Move  to  the  Reflection,  focusing  on  the  question,  “How  did  this  story  influence  my   development  as  a  doctor  over  this  year?”   • End  with  a  summary  statement  that  explains  how  you  will  take  the  lessons  learned  into   second  year.   Suggested  length  is  250  -­‐  500  words.     CRITERIA     Your  submission  will  be  graded  on  a  Credit/No  Credit  basis.  The  following  are  the  standards  we   will  use  to  evaluate  it:     No  Credit  if:     • You  do  not  submit  anything;  or   • There  is  no  Central  Story,  containing  a  beginning,  middle  and  end;  or   • There  is  no  Reflection;  or   • The  Reflection  does  not  address  the  question:  “How  did  this  story  influence  my   development  as  a  doctor  over  this  year?”     Credit:  will  be  given  to  all  submissions  not  described  above.     In  addition,  you  will  be  given  feedback  in  all  cases.  For  those  who  receive  No  Credit,  direction   will  be  given  as  to  how  to  improve  the  submission,  which  you  must  redo  and  send  to  the   Portfolio  Course  directors  for  review.  For  those  who  receive  Credit,  feedback  will  emphasize  

how you  can  take  your  ideas  further.  Please  read  the  feedback  as  this  will  help  you  in  the   coming  years  of  the  Portfolio  course.     The  written  Reflection  is  a  required  component  of  the  ASCM  1  course,  and  students  must   obtain  Credit  status  in  order  to  achieve  the  ASCM  1  Course  Credit.  The  Reflection  is  due  on   March  21,  2014.    


Remind  students  to  bring  all  five  case  reports  to  Session  26.  They  should  print  and  bring  hard   copies  to  be  able  participate  fully  in  this  session.      

Sexual History,  Substance  Use,   Medication  History   March  21,  2014  -­‐  Session  26    

REMINDERS FOR  THIS  SESSION     Students  to  bring  all  five  case  reports  for  Session  26  


By  the  end  of  this  session,  you  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  


8:00 Sexual  History   Substance  Use   9:00   Role  plays:  Sexual  History,  Substance  Use   10:00   Discussion  of  Medication  History   11:00   Role-­‐play:  Medication  History   11:55   Complete  evaluation  of  the  Advanced  Interviewing  and  Substance  Use/Sexual   Hx/Medications  Hx  sessions      

SEXUAL HISTORY  TAKING     Taking  a  sexual  history  should  be  part  of  the  comprehensive  health  assessment  for  every   patient,  regardless  of  educational,  marital,  and  socioeconomic  status.     Importance  of  taking  a  sexual  history1   • 26%  revealed  new  information   • 16%  led  to  a  change  in  treatment   • 39%  felt  it  led  to  a  better  understanding  of  the  patient     WHEN  IS  IT  APPROPRIATE  TO  ASK  ABOUT  THE  SEXUAL  HISTORY?   ID   CC   HPI   ROS   General/Constitutional     Skin/Breast     Eyes/Ears/Nose/Throat     Cardiovascular     Respiratory     Gastrointestinal     Genitourinary  ****SYMPTOMS****   Musculoskeletal     Neurologic/Psychiatric     Allergic/Immunologic/Lymphatic/Endocrine     PMH   Allergies  and  Reactions  to  Drugs     Current  Medications     Medical/Psychiatric  Illnesses   Surgeries/Injuries/Hospitalizations     Immunizations     Tobacco/Alcohol/Drug  Use     Reproductive  Status  for  Females    *****BEHAVIOURS****   Birth  History/Developmental  Milestones  for  Children     Marital/Relationship/Family  Status    *****  SEXUALITY  *****   Occupation/Exposures            

SOME WAYS  TO  ASK  ABOUT  SEX       “Are  you  sexually  active?”     “Are  you  sexually  active  with  men,  women,  or  both?     “Tell  me  about  your  current  sexual  activities?     “What  types  of  sex  do  you  engage  in?”     “Do  you  engage  in  vaginal/anal/oral/digital…sex?”     “How  many  sexual  partners  do  you  (currently)  have?”     “How  many  lifetime  sexual  partners  have  you  had?”     “Do  you  have  any  sexual  concerns  that  you  would  like  to  discuss?”     “Do  you/your  partner  have  other  sex  partners/outside  sexual  partners?”     “Do  you  have  a  regular  partner(s),  casual  partner(s),  or  both?”       “Have  you  ever  had  sex  under  the  influence  of  alcohol/drugs?”     “Are  you  satisfied  with  your  sex  life?”       ADAPTING  LANGUAGE  TO  FIT  YOUR  PATIENT   • The  way  you  phrase  a  question  may  be  different  with  a  young  adult,  versus  someone  older,   or  someone  younger   • When  in  doubt,  start  with  more  formal  terms,  and  adjust  accordingly—always  check  in  with   the  patient  to  make  sure  they  are  understanding  your  question   • There  may  be  situations  when  the  use  of  more  slang  terms  are  appropriate  and  necessary,   just  as  more  formal  terms  have  their  role  in  sexual  history  taking          

SOME COMPONENTS  OF  AN  ADEQUATE  SEXUAL  HISTORY     • Start  with  less  threatening  open-­‐ended  questions,  before  progressing  to  more  specific,   sensitive  questions   • Start  of  sexual  activity   • Number  of  sexual  partners   • Gender  of  sexual  partners   • Partner(s)  risks  (sexual,  other  -­‐  including  IV  drug  use)   • Survival  sex  or  prostitution   • Specific  sexual  activities   • Symptoms   • Condom  use  and  consistency;  history  of  condom-­‐breaks   • Use  of  contraception   • Sexual  abuse/violence   • Patient’s  level  of  education   • Patient’s  ideas  about  sexual  risk   • Addressing  confidentiality;  reportable  STIs   • Providing  a  safe  environment     • Avoiding  judgement   • Knowing  one’s  limitations  and  knowledge   • Awareness  of  responses,  body  language,  and  non-­‐verbal  communication—both  yours  and   the  patient’s   • Demonstrate  interest,  understanding,  and  respect     ADOLESCENT/TEEN  HISTORY-­‐TAKING     Interviewing  Adolescents/Teens:  HEADSS2     H   Home  and  Environment   E   Education  and  Employment   A   Activities   D   Drugs   S   Sexuality   S   Suicide/Depression    


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:   1. Tolerance,  as  defined  by  either  of  the  following:   a. A  need  for  markedly  increased  amounts  of  the  substance  to  achieve  intoxication  or   desired  effect.   b. Markedly  diminished  effect  with  continued  use  of  the  same  amount  of  the  substance.   2. Withdrawal,  as  manifested  by  either  of  the  following:   a. The  characteristic  withdrawal  syndrome  for  the  substance  (refer  to  Criteria  A  and  B  of   the  criteria  sets  for  withdrawal  from  the  specific  substances).   b. The  same  (or  a  closely  related)  substance  is  taken  to  relieve  or  avoid  symptoms.   3. The  substance  is  often  taken  in  larger  amounts  or  over  a  longer  period  than  was  intended.   4. There  is  a  persistent  desire  or  unsuccessful  efforts  to  cut  down  or  control  substance  use.   5. 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.   6. Important  social,  occupational,  or  recreational  activities  are  given  up  or  reduced  because  of   substance  use.   7. 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   1. 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:  

a. 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)   b. 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)   c. Recurrent  substance-­‐related  legal  problems  (e.g.,  arrests  for  substance-­‐related   disorderly  conduct)   d. 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)   2. 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):   1. How  to  start  the  conversation  -­‐  normalize  the  question:   I  ask  all  my  patients  about  alcohol  use  and  other  substances...   2. Get  consent  to  talk  about  this:   Is  it  ok  to  talk  about  this?   3. Ask  if  they  consume  alcohol:   Do  you  sometimes  drink  beer,  wine,  or  other  alcoholic  beverages?   4. 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?   5. Ask  if  they  consume  other  substances:   In  the  past  year  have  you  used  an  illegal  drug  or  used  a  prescription  medication  for  non-­‐ medical  reasons?  Or  That  was  not  prescribed  to  you?   6. 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:   1. Have  you  ever  felt  a  need  to  Cut  down  on  your  drinking  or  other  drug  use?   2. Have  you  ever  been  Annoyed  at  criticism  of  your  drinking  or  other  drug  use?   3. Have  you  ever  felt  Guilty  about  your  drinking  or  other  drug  use?   4. 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  turn  playing  patients     CASES  for  SEXUAL  HISTORY  TAKING  and  SUBSTANCE/ADDICTIONS  HISTORY     1. “The  Worried  Traveller”   2. “  Don’t  Tell  Mommy”   3. “  A  Hidden  Agenda”   4. “The  Big  City”     1. “  The  Worried  Traveller”   Mr.  Smith  is  a  50-­‐year-­‐old  executive  who  has  just  transferred  to  your  practice  one  month  ago.   He  comes  to  your  office  for  a  Periodic  Health  Exam  (PHE)—his  first  one  with  you.  He  has  no   specific  concerns.  He  has  been  married  for  over  20  years  to  a  woman  who  is  also  your  patient.   As  part  of  a  thorough  assessment,  you  review  Mr.  Smith’s  lifestyle.  You  are  at  the  point  in  your   interview  when  you  ask  about  his  relationship  and  sexuality.     NOTES  FOR  FACULTY   COPY  THIS  ROLE  FOR  STUDENTS  TO  PLAY  PATIENT     • appears  uncomfortable  when  asked  questions  about  sexual  history   • married  for  20  years   • sexually  active  with  wife,  about  once  weekly  –  vaginal  and  oral  sex,  no  condoms,  no   contraception  (wife  post-­‐menopausal);  he’s  curious  about  anal  sex  and  asked  for  it,   but  wife  is  uninterested   • sexually  active  with  casual  female  partners,  usually  when  on  business  –  two  in  the   last  6  months  –  attends  massage  parlors  –  has  received  oral  sex  (he  calls  it  a  “blow   job”),  no  condom  use  –  wife  unaware  of  this   • attendants  he  has  had  contact  with  with  at  this  massage  parlor  have  tattoos   • unaware  of  risk  of  STIs  with  oral  sex   • no  symptoms  now;  had  dysuria  x  1  week  after  an  oral  sex  encounter  at  the  massage   parlor   • cannot  recall  last  STI  screen,  but  it  was  with  his  last  family  doctor  “years  ago”   • if  offered  an  STI  screen,  would  like  one,  but  did  not  think  he  was  at  risk  for  STIs  with   his  casual  partners  and  says  he’s  in  a  “monogamous”  relationship  with  his  wife   • has  occasional  difficulty  with  erections  but  embarrassed  to  bring  up  the  topic  unless   directly  asked   • has  had  one  male  sexual  partner  in  his  lifetime-­‐  occurred  when  “experimenting”  in   University;  mutual  masturbation  occurred;  identifies  as  being  heterosexual   • total  number  of  lifetime  sexual  partners  about  20    

2. “ A  Headss-­‐Up”   Tracy  is  a  16-­‐year-­‐old  female  presenting  to  your  office  with  her  mother  for  a  concern  about  a   rash.  A  longer  appointment  was  booked  for  a  “general  check-­‐up”.  You  haven’t  seen  Tracy  for  a   few  years.  You  have  been  the  family’s  doctor  since  Tracy  was  an  infant.  She  has  been  healthy   overall  and  up-­‐to-­‐date  with  her  immunizations.     NOTES  FOR  FACULTY   PLEASE  COPY  THIS  ROLE  FOR  THE  STUDENT  WHO  IS  PLAYING  THE  PATIENT     • if  asked  about  whether  she  prefers  to  be  interviewed  alone,  Tracy  says  “I  don’t  care”   –  assert  an  individual  interview,  followed  by  one  where  her  Mother  is  in  the  room   • she  previously  had  a  pruritic  rash  on  her  leg,  but  it  has  resolved  –  she  really  wants  to   ask  you  about  a  pruritic  rash  on  her  vagina   • rash  has  been  in  the  same  area  three  times,  but  it  has  resolved  after  days  each  time   –  it  “scabbed”    all  those  times   • rash  on  vagina  started  days  after  having  sex  (for  the  first  time)  with  her  boyfriend  6   months  ago   • boyfriend,  David,  16  years  old,  is  only  sexual  partner;  sex  about  once  or  twice  a   month,  consensual   • condoms  sometimes  –  twice  not  used  when  her  boyfriend  was  using  marijuana  –  she   declined  and  does  not  use  any  other  drugs   • has  tried  alcohol  (beer)  but  doesn’t  like  the  taste   • lives  with  brother  and  2  mothers:  has  a  younger  brother  Tim,  10  years  old;  has  2   mothers,  Jenn  and  Florence  –  gets  along  well  with  both  –  thinks  biological  mother  is   more  “nosy”  lately  but  close  with  Florence  and  confides  in  her   • parents  divorced  when  she  was  10  –  does  see  biological  father  Seth  once  a  month   • grade  10  in  school,  doing  well  with  good  grades;  few  close  friends   • has  a  part-­‐time  job  on  weekend  at  ice-­‐cream  parlor  –  this  is  where  she  met  her   boyfriend  David   • likes  volleyball  and  most  sports   • mood  is  “good”     3. “  A  Hidden  Agenda”   Peter  is  a  35-­‐year-­‐old  male  whom  you  have  known  now  for  about  a  year.  You  see  him   infrequently—once  as  a  new  patient,  once  for  what  sounded  like  reflux,  and  another  time  for   counseling  around  anxiety.  He  is  seeing  you  in  follow-­‐up  because  he  was  seen  in  the  ER  over   the  weekend  for  abdominal  pain.  He  was  diagnosed  with  “gastritis”.  Some  baseline  bloodwork   shows  that  his  liver  enzymes  are  elevated,  particularly  his  GGT.     NOTES  FOR  FACULTY   PLEASE  COPY  THIS  ROLE  FOR  THE  STUDENT  WHO  IS  PLAYING  THE  PATIENT  

• abdominal pain  settled  from  weekend  –  was  epigastric,  “burning”,  nausea,  no   vomiting,  partially  relieved  by  meals   • now  on  a  PPI  for  his  symptoms,  improved;  has  a  gastroscopy  scheduled  by  ER  in  2   weeks   • day  before  abdominal  pain,  consumed  alcohol,  mostly  beer  and  hard  liquor,  about  15   drinks   • usually  2-­‐4  beer  per  day,  but  more  on  weekends   • alcohol  helps  him  to  “relax”  –  has  been  anxious  in  the  past  and  this  helps    “take  the   edge  off”   • has  missed  work  on  occasion,  because  he  was  “hung  over”  –  works  in  tech  support  at   a  hospital   • occasional  guilt  around  drinking;  friends  are  annoyed  by  him  because  he  “flakes  out”   on  them  when  get-­‐togethers  are  planned  (usually  because  of  feeling  “hung  over”;   other  CAGE  questions  negative   • finances:  “getting  by”  but  has  used  credit  card  to  buy  alcohol  even  when  he  has  no   money   • lives  alone   • sexually  active,  with  males  only;  casual  partners,  unprotected  oral  sex  (performs  and   receives),  no  anal  sex  but  has  been  thinking  about  it;  usually  meets  partners  online   • family  in  Vancouver,    parents  “religious”  –  unaware  of  sexuality   • unaware  he  has  a  “problem”  with  drinking,  but  open  to  treating  his  “anxiety”  with   either  medications  or  counseling   • drugs  used  in  the  past:  ecstasy,  GHB,  tried  crystal  meth  once,  no  IVDU   • no  tattoos  or  piercings  

4. “  The  Big  City”   THE  BIG  CITY-­‐  ROLE  PLAY  FOR  STUDENTS   STUDENTS  TO  TAKE  TURNS  INTERVIEWING  EACH  OTHER   By  Anthony  Mak  &  Ayesha  Malik  (1T6)     Jamie  is  a  25  year  old  male/female  who  has  come  to  you  for  the  first  time  requesting  tests  for   sexually  transmitted  infections.  He/she  is  currently  single  and  is  concerned  that  he/she  may  be   at  increased  risk  for  STIs.       Background:   • Born  in  small  town  Ontario     • Bad  relationship  with  parents  since  coming  out  as  gay/lesbian.  Parents  are  not  accepting  of   his/her  sexual  orientation.  He/she  is  not  “out”  to  the  extended  family.     • Was  severely  bullied  throughout  middle  school  and  high  school  for  being  “queer”  (called   names,  socially  isolated)  

• This resulted  in  him/her  feeling  the  need  to  Toronto/Mississauga  to  be  in  the  “big  city”  and   be  with  people  “like  himself/herself”   • He/she  works  at  a  call  center  and  is  out  at  work.  His/her  co-­‐workers  are  accepting  of   his/her  sexual  orientation.       Habits:   • Smokes  a  pack  of  cigarettes  a  day.  Started  smoking  at  19.   • Drinks  alcohol  (when  going  out  clubbing  or  partying  with  his/her  LGBTQ  friends).  However,   when  drinking  alcohol,  he/she  often  gets  “wasted”  and  can’t  remember  the  night  before.       • Recreational  drugs:  Smokes  marijuana  on  occasion  with  friends.  Sometimes  takes  ecstasy   at  raves  (late  night  clubs).       Sexual/relationship  history:   • First  sexual  experience  was  at  age  20  when  he/she  first  moved  to  Toronto   • Has  never  had  a  serious  romantic  relationship.   • He/she  “picks  up”  at  bars  and  clubs.  Currently  has  several  sex  partners.     • Sometimes  engages  in  sexual  activity  without  using  any  protection  (e.g.  condoms).         Reason  for  the  visit:     • Does  not  have  any  specific  symptoms.     • Has  never  had  a  STI  test  before.     • He/she  is  concerned  because  his/her  friend  was  recently  diagnosed  as  HIV  positive.  He/she   had  unprotected  sexual  intercourse  with  this  friend.      


The young  physician  starts  life  with  20  drugs  for  each  disease,  and  the  old  physician  ends  life   with  one  drug  for  20  diseases.                 -­‐William  Osler  

Students  to  bring  their  case  reports  and  review  the  medication  history  section  with  their  ASCM   tutor  in  small  groups.       Students  to  consider  the  following:   • Context  of  looking  back  over  case  reports  with  emphasis  on  medication  history.   • Looking  at  case  reports—would  student  have  done  anything  differently  knowing  what   he/she  knows  now?     REMINDERS  TO  STUDENTS  ON  TAKING  A  PATIENT  MEDICATION  HISTORY     To  obtain  a  list  of  the  patient’s  current  medications,  you  should  ask  about1:   • prescription  medications   • non-­‐prescription  drugs  i.e.,  over-­‐the-­‐counter  (OTC)  drugs   • oral  contraceptives   • vitamins  and  minerals   • herbal  supplements  e.g.,  St.  John’s  wort,  glucosamine     N.B.:   • ear/eye  drops,  inhalers  or  nasal  sprays   • medicated  patches  or  creams   • injectable  medications  e.g.,  insulin   • medication  samples  from  a  doctor     Full  dosing  information  for  each  medication  should  be  gathered,  such  as1:   • name  (generic  names,  trade  names)   • dose   • frequency  of  use   • duration  of  use   • route  of  administration   • last  dose  taken   • for  what  reason  (if  not  known  or  obvious)     N.B.:   • previous  medications  

• reason(s) for  medication  changes     Tips  on  asking  questions  to  help  patients  remember  what  medications  they  are  currently   taking2:   • Use  both  open-­‐ended  questions  (e.g.,  “What  do  you  take  for  your  high  cholesterol?”)  and   closed-­‐ended  questions  (e.g.,  “Do  you  take  medication  for  your  high  cholesterol?”).   • Ask  patients  about  routes  of  administration  other  than  oral  medications  (e.g.,  “Do  you  put   any  medications  on  your  skin?”).  Patients  often  forget  to  mention  creams,  ointments,   lotions,  patches,  eye  drops,  ear  drops,  nebulizers  and  inhalers.   • Ask  patients  about  what  medications  they  take  for  their  medical  condition(s)  (e.g.,  “What   do  you  take  for  your  diabetes?”).   • Ask  patients  about  the  types  of  physicians  that  prescribe  medications  for  them  (e.g.,  “Does   your  “arthritis  doctor”  prescribe  any  medications  for  you?”).   • Be  careful  to  differentiate  different  medications  that  sound  similar  (e.g.,  Xanax  vs.  Zantac)   • Ask  patients  if  their  doctor  recently  started  them  on  any  new  medicines,  stopped   medications  they  were  taking  or  made  any  changes  to  their  medications.   • For  inquiring  about  over-­‐the-­‐counter  medications,  additional  prompts  may  include:   • What  do  you  take  for  allergies?   • Do  you  take  anything  to  help  you  fall  asleep?   • What  do  you  take  when  you  get  a  cold?   • Do  you  take  anything  for  heartburn?   • Explore  vague  responses  (non-­‐compliance  with  medications).     Top  10  Reasons*  for  Physician  Visits  in  Canada  20113   • Hypertension   • Health  check-­‐up   • Diabetes   • Depression   • Acute  upper  respiratory  infection   • Anxiety   • Normal  pregnancy  supervision   • Hyperlipidemia   • Esophagitis   • Otitis        

ROLE-­‐PLAY SCENARIOS  FOR  STUDENTS:     There  are  two  patient  scenarios.  Students  should  take  turns  in  pairs  interviewing  and  being   interviewed  for  each  scenario.  Then  the  group  should  discuss  as  a  whole.     Tutors  to  copy  role  plays  for  the  students  during  the  session.     ROLE-­‐PLAY  SCENARIO  1   By  Pavan  Gill  (1T6)     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   1. Are  there  any  interactions  you  may  be  concerned  about  with  Patricia’s  medication   regimen?   2. 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?     3. What  are  some  potential  strategies  to  avoid  drug  interactions?     4. Many  elder  patients  like  Patricia  take  multiple  medications  daily  (polypharmacy).  What  tips   can  you  offer  Patricia  in  helping  her  to  remember  to  take  her  medications?          

ROLE-­‐PLAY SCENARIO  2   By  Susan  Truong  (1T6)     Mr.  Jacopo  Perfetti  is  a  32-­‐year-­‐old  male  and  is  married  with  no  children.  He  was  born  in   Bergamo,  a  small  town  in  Italy,  and  grew  up  in  Milan.  Jacopo  is  an  art  curator  and  consultant   and  has  worked  for  museums  and  events  such  as  P.A.C.  in  Milan,  ArteMas  Festival  in  Havana,   Cuba,  and  Faqra  Fair  in  Faqra,  Lebanon.  He  moves  around  a  lot  for  his  job  and  currently  ,  he  is   working  at  the  Art  Gallery  of  Ontario  and  has  been  living  in  Toronto  for  2  months.  His  wife,   Caterina,  is  still  living  in  Milan  and  is  a  high  school  art  teacher.       Jacopo  has  one  older  sister  Angela  (41)  and  two  older  brothers,  Giovanni  (39)  and  Franco  (36).   They  are  all  married  and  have  children.  They  are  all  generally  healthy  as  far  as  Jacopo  knows.   However,  their  mother,  Rosa  (61)  was  diagnosed  with  degenerative  scoliosis  2  years  ago  and   their  father,  Vincenzo  (65)  developed  shingles  3  months  ago.  They  both  live  with  Angela,  their   eldest  daughter,  and  from  phone  conversations  Jacopo  had  with  her,  it  seems  their  father   Vincenzo  is  still  in  a  lot  of  pain  even  though  the  shingles  has  passed.  Jacopo  also  has  an  uncle   on  his  mother’s  side  who  was  diagnosed  with  schizophrenia  when  the  uncle  was  19.     Jacopo  himself  was  also  diagnosed  with  schizophrenia  4  years  ago.  Jacopo  is  currently  taking   olanzapine  (20  mg/day,  oral,  yellow  pill,  round-­‐shaped)  for  his  schizophrenia,  though   inconsistently.  He  also  keeps  mixing  up  its  name  with  lorazepam  (a  benzodiazepine).  When   asked  for  the  name  of  the  medication,  Jacopo  would  say  lorazepam,  but  he  would  admit  he  is   uncertain  of  the  name.  As  well,  6  months  ago,  Jacopo  was  diagnosed  with  hypothyroidism.  He   takes  levothyroxine  but  he  does  not  remember  the  name  of  the  drug.  All  he  remembers  is  that   he  takes  “about  100  mcg”  a  day  (oral,  blue  pill).  Unlike  the  world  of  art,  of  which  he  is   passionate  about,  Jacopo  does  not  pay  much  attention  to  what  medications  he  is  taking.  He   has  no  allergies  and  but  was  hospitalized  7  years  ago  due  to  a  tibial  fracture  from  skiing.       Two  days  ago,  while  lifting  and  admiring  a  large  beautiful  vase  from  Ancient  China  at  the  AGO,   Jacopo  felt  a  twinge  in  his  lower  back.  Over  the  next  12  hours,  he  developed  low  back  spasms   and  the  severity  of  the  pain  increased  from  a  4  to  an  8  on  a  10-­‐point  scale.  Jacopo  took  a   couple  of  “back  pain  pills”  from  his  coworker,  but  he  is  unsure  whether  it  was  Aspirin,  Advil,   Tylenol  or  even  over  the  counter  Tylenol  #1.  Jacopo  felt  it  was  irrelevant  anyhow  because  the   pills  did  nothing  to  relieve  the  pain.  Because  he  was  still  relatively  new  to  the  country,  Jacopo   did  not  want  to  go  to  the  hospital  if  he  did  not  have  to.  Soon  after  however,  the  pain  radiated   down  both  legs.  Jacopo  tried  a  couple  of  home  remedies  to  relieve  the  pain,  such  as  using  cold   compresses  and  taking  a  bath  with  epsom  salts.  Nothing  made  much  of  a  difference.  What   Jacopo  found  to  be  relieving  was  resting  or  slow  controlled  movements.  Any  sudden   movements  aggravated  the  pain.  Jacopo  has  had  no  changes  in  bladder  or  bowel  function   since  the  pain  started  and  he  has  not  experienced  this  kind  of  pain  before.      

Seeing that  the  pain  was  not  going  away,  and  it  even  appeared  to  be  getting  worse,  Jacopo   finally  visits  a  walk-­‐in  clinic/ER.  Jacopo  was  still  experiencing  severe  pain,  limitation  of   movement  and  antalgia,  though  bending  forward  relieves  the  pain  somewhat.  (Having  grown   up  immersed  in  Italian  culture),  Jacopo  was  very  vocal  and  expressive  upon  seeing  the   physician.  Jacopo  would  describe  his  physical  complains  in  a  dramatic  manner  and  is  very   emotional  in  his  responses  to  pain.  His  suffering  is  shown  by  groaning  and  moaning  and  he  is   not  ashamed  of  his  expression.  He  is  particularly  emotional  because  this  pain  experience  is   keeping  him  from  doing  his  job  properly  at  the  AGO.     Begin  the  role-­‐play  with  one  student  playing  Jacopo  Perfetti  and  another  student  playing  the   physician  who  is  currently  taking  Mr.  Perfetti’s  medication  history.       Discussion  Questions   1. Similar  sounding  names  of  medications  often  get  mixed  up.  What  was  the  example  in  this   case?  What  kinds  of  questions  could  you  ask  the  patient  to  help  you  distinguish  what   medications  the  patient  is  taking?   2. What  are  some  sources  or  strategies  to  help  you  identify  what  medications  a  patient  is   taking  if  the  patient  forgets  the  name  of  them?   3. Is  medication  compliance  an  issue  in  this  case?  What  are  some  things  you  can  do  to   increase  medication  compliance?   4. Different  cultures  have  different  ways  of  dealing  with  illnesses.  For  example,  some  may   turn  to  homeopathy  before  seeing  a  physician.  What  is  your  approach  when  speaking  with   these  kinds  of  patients?  What  are  some  things  you  can  do  to  become  culturally  competent?    


1. Ende J,  Rockwell  S,  Glasgow  M.  (1984).  The  Sexual  History  in  General  Medicine  Practice.   Arch  Intern  Med.  144(3):558-­‐561.   2. Adapted  from  Contemporary  Pediatrics,  Getting  into  Adolescent  Heads  (July  1988),  by  John   M.  Goldenring,  MD,  MPH,  &  Eric  Cohen,  MD   3. IMS  Health.  (2012).  Top  10  Reasons  for  Physician  Visits  in  Canada  2011.    

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   (   • Review  the  “Introduction  to  the  Neurological  Examination”  lecture  in  Brain  and  Behaviour   • Review  neuro  exam  videos  (      

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

OBJECTIVES     This  section  provides  a  guide  to  neurological  history  taking  and  should  be  reviewed  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  ophthalmological  causes.   Neurological  causes  of  unilateral  visual  loss  are  due  to  lesions  of  the  optic  nerve,  such  as   ischemia  or  demyelination.  The  possibility  of  an  ophthalmological  cause,  such  as  acute   glaucoma  or  retinal  detachment,  should  not  be  overlooked.  Patients  with  a  homonymous   hemianopia  (due  to  a  post-­‐chiasmal  lesion  in  the  optic  pathways)  may  only  complain  about  the   eye  with  the  temporal  field  loss  (e.g.  bumping  into  objects  frequently  on  the  right  side  with  a   right  homonymous  hemianopia),  when  in  fact  the  field  loss  is  present  in  both.  It  is  also   important  to  distinguish  between  reduced  or  blurry  vision  and  double  vision  (the  latter   symptom,  properly  known  as  diplopia,  will  be  discussed  in  a  separate  section  in  the  syllabus).   Ocular  symptoms  such  as  conjunctival  injection  (red  eye)  and  eyelid  swelling  are  most   commonly  due  to  ophthalmological  conditions  (e.g.  eye  infections),  but  they  can  also  rarely  be   associated  with  neurological  causes  such  as  a  cavernous-­‐carotid  fistula.     It  is  also  important  to  determine  the  mode  of  onset  and  the  presence  or  absence  of  pain.   Sudden  onset  of  unilateral  visual  loss  suggests  a  possible  ischemic  cause,  and  the  presence  or   absence  of  pain  may  further  delineate  the  etiology  (e.g.  non-­‐arteritic  anterior  ischemic  optic   neuropathy  and  retinal  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):   o GI:  Have  you  experienced  any  nausea  or  vomiting  with  eye  pain?   o 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?   o NEURO:  Do  you  have  any  other  neurological  symptoms  apart  from  the  loss  of  vision,   such  as  focal  numbness  or  weakness,  speech  or  swallowing  difficulties,  difficulty  with   balance,  dizziness  or  vertigo,  hearing  problems,  or  double  vision?   • Past  medical  history:  Has  there  been  any  previous  injury  to  your  head  or  eye?  Has  a  health   care  provider  told  you  that  your  blood  pressure  or  cholesterol  is  elevated?  Do  you  have   diabetes?  Do  you  smoke?   • Family  history:  Is  there  any  family  member  who  has  lost  his  or  her  vision,  particularly  at  a   young  age?  

DIPLOPIA   Patients  with  diplopia  typically  present  with  a  history  of  ‘seeing  double,’  such  that  single   objects  in  their  field  of  view  appear  twice.  Diplopia  has  a  wide  range  of  neurological  causes,   including  central  lesions  of  the  brainstem  or  cerebellum,  weakness  of  one  or  more  of  the   extraocular  muscles  (either  due  to  a  lesion  in  the  peripheral  nerves  innervating  them,  a   disease  of  the  muscles  themselves),  or  diseases  affecting  neuromuscular  transmission  (e.g.   myasthenia  gravis).  Generally,  the  presence  of  diplopia  essentially  negates  the  possibility  of  a   lesion  in  the  supratentorial  compartment.     A  comprehensive  history  is  an  important  evaluation  of  diplopia  for  diagnosis  and  subsequent   investigations  and  management.  Important  questions  that  should  be  asked  include:   • Does  the  diplopia  resolve  or  persist  when  the  patient  closes  one  eye  (bin-­‐  ocular  versus   monocular  diplopia).  Neurological  lesions  cause  binocular  diplopia,  while  monocular   diplopia  is  typically  due  to  an  ocular/ophthalmologic  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  horizontal  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  viewing  objects  at  a  distance  suggests  a   right  CN  VI  palsy  (lateral  rectus  muscle).   • Is  the  diplopia  worse  when  looking  downward  and  inward,  like  when  walking  down  stairs?   Vertical  diplopia  that  is  made  apparent  or  worse  when  walking  downstairs  is  suggestive  of   CN  IV  palsy  (superior  oblique  muscle).   • Does  a  specific  head  posture  or  a  gaze  direction  eliminate  the  diplopia?  For  example,  a   patient  with  a  CN  IV  palsy  will  tilt  their  head  away  from  the  lesion  to  eliminate  or  reduce   the  diplopia.   • Is  there  any  significant  fluctuation  of  the  double  vision?  Does  the  double  vision  tend  to   worsen  towards  the  end  of  the  day  or  after  prolonged  use  of  the  eyes?  Dramatic   fluctuations  or  fatigability,  especially  when  ptosis  is  also  present,  suggests  the  possibility  of   a  neuromuscular  junction  disorder  like  myasthenia  gravis.   • Finally,  ask  specifically  about  whether  the  patient  has  suffered  any  recent  or  remote  head   trauma.  Fracture  of  the  orbital  floor  can  occur  from  a  blunt  impact  to  the  cheek  causing   hematoma  and/or  entrapment  of  the  soft  tis-­‐  sue  and  extraocular  muscles—thereby   restricting  downward  movement  of  the  eyes.  Head  trauma  is  also  a  common  cause  of  CN  IV   palsy.  Vascular  risk  factors  are  also  important,  as  microvascular  ischemia  is  a  common   mechanism  of  isolated  ocular  motor  nerve  palsies  in  older  patients  (e.g.  ischemic  CN  VI   palsy).    

APHASIA AND  DYSARTHRIA     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.     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  apparatus  (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  control  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     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:  motor  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.     Fluency  refers  to  the  number  of  words  that  can  be  produced  in  a  given  period  of   time.    

• Sensory aphasia  is  the  result  of  a  lesion  in  Wernicke’s  area,  or  surrounding  regions,  in  the   temporal  lobe.  This  lesion  produces  very  poor  comprehension,  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  affected  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   Motor          Broca          Transcortical  motor   Sensory          Wernicke          Transcortical  sensory   Mixed          Global          Transcortical  mixed   Other          Conduction          Anomic        





X X     !   !     X   X     !   !  

! !     X   X     X   X     !   !  

X !     X   !     X   !     X   !  

X X     X   X     X   X     X   X  

INVESTIGATION OF  LANGUAGE  DIFFICULTY     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.  tension-­‐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?   Sudden   onset   of   a   severe   headache   suggests   the   possibility   of   an   intracranial   hemorrhage.   • Location:  Where  is  the  pain  located  (e.g.  front.  back,  unilateral,  bilateral)?   • Onset:  Does  the  pain  come  on  gradually?  Or  does  it  come  on  suddenly  and  reach  maximum   intensity  within  seconds?   • Relieving  factors:  What  makes  the  headaches  better  (e.g.  lying  down,  sleeping,  turning  off   lights  and  TV)?  Do  you  take  any  over-­‐the-­‐counter  or  prescription  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  headache  worse?   • Triggers:  Can  you  identify  any  triggers  for  your  headache  (e.g.  certain  foods,  weather   change,  wine)?   • Quality:  How  would  you  describe  the  pain  (e.g.  throbbing,  stabbing,  tight-­‐band  around  the   head,  steady  pressure)?   • 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?   • Timing:  When  are  your  headaches  worst?  Do  your  headaches  wake  you  up  from  sleep,  or   are  they  the  worst  first  thing  in  the  morning?   Early   morning   headache   with   space-­‐occupying   lesions,   including   intracranial   neoplasms.   • 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)   o Do  you  have  a  fever  or  stiff  neck?   Fever  with  stiff  neck,  headache  or  altered  mental  status  in  acute  meningitis.   o GI:  Do  you  feel  nauseous  or  vomit  with  your  headaches?   o NEURO:  Do  you  have  any  other  neurological  symptoms  accompanying  the  headache,   such  as  double  vision,  dizziness,  gait  imbalance,  numbness,  tingling  or  weakness?   • Family  history:  Is  there  a  family  history  of  similar  headaches?     For  patients  above  the  age  of  55  who  present  with  new-­‐onset  headaches,  one  must  also   include  questions  specifically  for  symptoms  of  temporal  arteritis  and  polymyalgia  rheumatica.   Any  focal  neurological  sign  that  is  present  on  the  neurological  examination  suggests  a   secondary  cause  for  a  patient’s  headache.      


Memory 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  forget  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  conversation  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  cooking).  Finally,  if  you  do  suspect   that  the  patient  is  suffering  from  memory  loss,  inquire  about  their  ability  to  continue  carrying   out  their  Instrumental  Activities  of  Daily  Living  (IADLs).  IADLs  are  a  set  of  complex  skills   necessary  to  live  independently  in  the  community.  Common  IADLs  to  ask  about  include:   • Completing  household  chores  (e.g.  preparing  meals)   • Shopping  for  groceries  or  clothes   • Managing  personal  finances   • Driving  


Weakness denotes  a  demonstrable  loss  of  muscle  power.  It  is  a  common  complaint  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  peripheral  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   myopathy,  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.     Bulbar  symptoms  include  dysarthria  and  dysphagia  (difficulty  swallowing).     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  accompanying  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.      


Patients may  complain  about  trembling  or  shaking  movements  that  they  are  unable  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.     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  approaching  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)   o 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?   An  exaggerated  physiologic  tremor  may  become  visible  under  the  influence  of   medications   such   as   beta-­‐agonists   (e.g.   bronchodilators),   lithium,   amphetamines,  and  caffeine.   • 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)?   • Alcohol  consumption:  How  often  do  you  drink  alcohol?  Have  you  noticed  whether  alcohol   improves  or  worsens  your  tremor?    


Numbness is  a  loss  of  or  reduced  sensation.  When  a  patient  complains  of  numbness,  one  must   clarify  its  meaning  and  location.  For  example,  some  patients  use  the  term  “numbness”,  when   in  fact  what  they  are  referring  to  is  weakness.  If  possible,  try  to  determine  whether  the   numbness  conforms  to  a  dermatomal  or  peripheral  nerve  distribution,  and  whether  it  is   unilateral  or  bilateral.  In  questioning  patients  with  numbness,  ask  about  the  mode  of  onset   (e.g.  sudden  vs.  gradual).  Is  the  numbness  constant  or  intermittent?  What  brings  it  on?  Does  it   progress  or  spread  to  involve  a  larger  area  over  time?  Which  body  parts  are  involved?  Does  it   involve  the  face  or  the  trunk?     Paresthesia  describes  the  feeling  of  a  limb  “falling  asleep”,  often  referred  to  as  tingling  or  “pins   and  needles”.  Dysesthesia  is  paresthesia  that  is  unpleasant  as  perceived  by  the  patient.  One   type  of  dysesthesia  is  allodynia,  where  a  patient  perceives  pain  from  a  normally  non-­‐noxious   stimulus.  For  example,  the  patient  may  perceive  light  touch  as  a  burning  or  tingling  sensation   that  is  irritating  or  painful.  This  can  be  distinguished  from  another  type  of  altered  sensation,   hyperalgesia,  which  is  a  simply  a  heightened  sensation  or  hypersensitivity.     Numbness,  paresthesia,  and  dysesthesia  may  be  indicative  of  central  lesions  in  the  brain  and   spinal  cord,  as  well  as  disorders  of  the  peripheral  nerves  or  nerves  roots.  The  presence  of   other  accompanying  symptoms  will  help  to  narrow  down  the  potential  localization(s)  while   taking  the  history.  Finally,  paresthesia  in  the  hands  and  around  the  mouth  that  lasts  for  several   minutes  can  result  from  hyperventilation  (e.g.  in  panic  attacks).    


Ataxia 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  affecting  the  limbs  or  the  trunk,  and  can  result  in  an   unsteady  gait  (i.e.  wide-­‐based,  staggering  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  using   them,  as  they  are  trying  to  use  the  visual  cues  to  compensate  for  the  lack  of  proprioception.  A   history  of  falling  consistently  towards  one  side  may  suggest  a  lesion  in  the  ipsilateral   cerebellum.        

DIZZINESS   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  taking  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).   Common   triggers   include   turning   in   bed   or   sudden   head   movements   (benign   paroxysmal   positional   vertigo)   or   getting   up   quickly   from   a   supine   position   (postural  hypotension).   • 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?   • 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)?   • Timing:  Have  you  had  this  feeling  of  dizziness  before?  How  often  does  it  occur?   • Associated  symptoms  (in  the  HPI)   o GI:  Did  you  feel  nauseous  at  the  same  time  as  you  feel  dizzy?  Is  there  any  associated   vomiting?   o 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.   o NEURO:  Do  you  have  any  other  neurological  symptoms,  such  as  slurred  speech,  facial   weakness,  facial  numbness,  ataxia  or  diplopia?   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).   o CARDIOVASC:  Is  your  dizziness  associated  with  any  chest  pain,  palpitations,  or   shortness  of  breath?  

LOSS OF  CONSCIOUSNESS     Syncope  (fainting)  means  loss  of  consciousness.  The  most  common  cause  of  syncope  is   vasovagal,  although  cardiogenic  causes  (e.g.  arrhythmia)  must  be  considered  because  of  their   potential  life-­‐threatening  nature.  It  is  therefore  important  to  inquire  about  the  presence  of   cardiac  symptoms  as  well  (e.g.  chest  pain,  palpitations,  shortness  of  breath).     Syncope  is  caused  by  a  transient  global  reduction  in  cerebral  perfusion,  so  patients  often   regain  consciousness  quickly  once  they  have  fainted  and  have  come  to  rest  on  the  floor.  As   opposed  to  a  seizure,  which  also  causes  a  loss  of  consciousness,  patients  with  syncope   typically  do  not  have  a  post-­‐ictal  phase  (e.g.  a  period  of  lethargy  or  confusion).  An  epileptic   aura  (essentially  a  simple  partial  seizure,  such  as  a  rising  epigastric  sensation)  may  precede  a   complex  partial  or  generalized  seizure,  but  should  not  occur  in  syncope.  On  the  other  hand,   patients  with  syncope  will  often  have  premonitory  symptoms  (i.e.  darkening  of  vision,  ‘seeing   stars,’  sensation  of  light-­‐headedness).  In  order  to  obtain  a  thorough  clinical  history  of  a  patient   who  presents  with  a  history  of  loss  of  consciousness,  the  following  questions,  amongst  others,   should  be  considered.  Be  sure  to  avoid  leading  questions.  Collateral  history,  if  available,  is   always  extremely  helpful.     • What  body  position  were  you  in  just  before  the  attack?   Since   vasovagal   syncope   is   due   to   a   transient   drop   in   cerebral   perfusion,   it   should  only  occur  when  patient  is  in  an  upright  position.   • 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  happen  before  you   lose  consciousness?   • Family  history:  Is  there  a  family  history  of  seizure  disorders?   • Medications:  What  medications  are  you  taking  (e.g.  diuretics)?  

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