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Practice history taking

  • John 18
  • 3-4 days ago rash on foot. Itchy/uncomfortable
  • In the garden. Shoes.
  • Severity of itchiness increasing over time
  • Never stops and feels better when he thinks about something else
    • NOTE: ask more open questions e.g. "tell me a bit more about that"
  • Steroid cream makes it better
  • Worse without shoes
  • Sharp pain in groin
    • Don't just skip over the groin pain -- pay attention to associated symptoms
  • No fever
  • Itchy with throbbing, uncomfortable
    • Also the itchy foot became a painful leg -- but started off with an itchy foot.
  • Asthma - ventolin
  • Family: BP issues, heart failure, retinitis
  • Adenoids out with 7-8
  • Living with family - itchy foot not affecting him
  • Should have checked allergies - rash and history of asthma
  • Psychosocial
    • Ask about diet
    • Lifestyle
    • Alcohol, smoking
    • Drugs
    • Ask about work
    • Sex - groin issues?
  • Summary:
    • Name/age/gender
    • Presenting illness, associated information
    • At the end of the summary, say his concerns
  • OSCE: history = 7-8 minutes; exam = 5 minutes; summary = 2 minutes

Examination - ulcers, percussion and auscultation, taking temperatures

The structure of an ulcer
Ulcer types based on edge structure
  • Ulcer = loss of surface epithelium
  • More chronic and deeper than erosion
  • What to look for:
  1. Site
  2. Size
  3. Shape
  4. Base = {clean, fleshy, necrotic}
    • Clean = no discharge
    • Fleshy = granulation tissue or see underlying tissue
    • Necrotic = dead tissue - black, brown, grey
    • Edge = 1. Flat 2. Raised (above level of skin) 3. Undermined (wider as you go deeper) 4. Punched out (straight down)
  5. Surrounding tissue
    • Warmth
    • Erythema (redness)
    • Edema (swelling
    • Trophic changes (skin changes due to arterial insufficiency. Signs: 1. pale 2. shiny 3. hairless
    • Note that the first 3 above are caused by venous disease
  6. Tenderness - just ask, don't touch with bare hands
  • Note that an undermined ulcer is usually with tuberculosis. Look at an angle to visualise the base.

Description examples

Check out the powerpoint on blackboard that corresponds to the answers below.

  1. Unknown location, size
    • Irregular shape
    • Base necrotic with discharge
    • Surrounding skin normal
  2. Right lower leg
    • 10cm
    • Regular
    • Edge ?
    • Base - clean
    • Surrounding necrosis
    • Surrounding tissue: red, edema, varicose veins
  3. Left foot, ball
    • 4cm
    • Circular
    • Raised edge
    • Fleshy base, clean
    • Surrounding skin is swollen/scaly
  4. Site, size ?
    • Irregular shape (tear drop)
    • Punched out edge
    • Fleshy base
    • Shiny skin
  5. 1st toe on right foot
    • 3cm
    • Circular
    • Flat edge
    • Base - discharge, some necrosis
    • Surrounding foot - swollen, no hair
  6. Ulcer on foot
    • Diabetic ulcer - obese patient
    • 10cmx4cm on sole of right foot
    • Irregular shape
    • Necrotic base with discharge
    • Punched out edges
    • Nearby-swollen and red
    • Amputate --> impacts

Percussion and auscultation

  • Percussion - tapping with finger
    • Want to tell if it's hollow or solid
    • Hollow = resonant = air in it
    • Solid = sounds dull
    • Percuss on your hand. Third finger on third finger. Do it between ribs.
  • Auscultation
    • Narrow end of the head is called the 'bell - remove cap when using the bell. Used for low-pitched sounds e.g. murmur of mitral stenosis.
    • Broad end of the head is called the diaphragm - used for listening to high-pitched sounds e.g. heart, lungs, bruits (narrowing of arteries)
    • To select between bell and diaphragm, rotate teh hose to get the opening to point to the side you're using
  • Trachea - loud inspiration and expiration
  • Lungs - just inspiration
  • Heart
  • Stomach - gurgling

Taking temperatures

  • Axillary temperature is lower
  • Ear temperature is higher, but inaccurate
  • Axillary and auricular temperature are the two we measure at this stage (not yet rectal)
  • More accurate = oral or rectal
  • Normal temperature: 36-37C. Axillary = 38 would be too high

Axillary temperature

  1. Put cover on (do not touch the cover)
  2. Push button to turn it on
  3. Put under arm
  4. Wait for beep
  5. Check reading

Ear

  1. Push thermometer in to get cover on
  2. Turn on the thermometer
  3. Stick it in ear
  4. Press button on top
  5. Get reading

Additional resources