Common histories +

RED FLAGS
GPSN Y3 OSCE NIGHT
TOPICS WE ARE COVERING
TONIGHT
• SYNCOPE
• FATIGUE
• HEADACHE
• QUESTIONS?
SYNCOPE
u What is syncope?

• Syncope
• Loss of consciousness (reversible, brief)
• Presyncope
• Feeling of lightheadedness (as though about to
pass out), but preserved consciousness)
• Vertigo
• Sensation of feeling unbalanced and dizzy
 SYNCOPE – Systems involved
1. REDUCED BLOOD SUPPLY (HEART + VESSELS)
• Orthostatic hypotension
• Vasovagal
• Structural/obstructive – ACS, AS, hypertrophy
• Arrhythmias (eg. Stokes-Adams attacks)

4. NEUROLOGICAL
2. REDUCED OXYGEN SUPPLY (LUNGS) • Stroke/TIA
• Massive PE, hypoxia/hypercapnia • Migraine
• Anaemia • Seizure
• Psychiatric – anxiety

3. REDUCED GLUCOSE SUPPLY (METABOLIC)

• Hypoglycaemia
 “FAINTING” – Differentials
Cause Patient profile Preceding events Features of episode Post
Vasovagal syncope Younger onset Emotional distress Nausea and
Previous episodes with clamminess
similar trigger
Orthostatic Hx of ↓BP or anti- Feel light-headed Brief Pale,
hypotension hypertensives Blurred/darkened vision ↑ falls forward sweating,
(dehydration, Occurs when sitting or Cold/clamm
meds, anaemia) standing y
Cardiogenic Hx of cardiac On exertion Pale Recovery in
LVOF (AS, HOCM) disease/palpitation Shortness of breath, ± few clonic jerks seconds
Cardiac s Palpitations
arrhythmia
Seizure Prodrome/aura Jerking Post-ictal
(Scotoma, smell, déjà vu) ↑ falls backward state (tired,
Occurs in any position confused)
Hypoglycaemia Diabetes Hx Low blood sugar (poor
Hypoglycaemic insulin control)
agents
Vertigo “Spinning room” No loss of
Worse when turning head consciousness
 SYNCOPE – APPROACH TO HX
1. Confirm this is syncope
• Was the room spinning? - more likely vertigo
- more likely syncope
• Did you lose consciousness?

2. Assess prior history

• Has this happened to you before?
• Any previous diagnosis?
• Similar triggers? - consider vasovagal

3. What happened during the event?

• If loss of consciousness – establish if any witnesses
• Duration
• Incontinence? - more likely seizure
• Any other injury? - i.e. head injury, possible fracture
 SYNCOPE – APPROACH TO HX
4. Establish timeline - BEFORE
• What were you doing?
• Exertion - more likely cardiogenic
• Anxiety - more likely psychogenic/vasovagal

• Any other symptoms?

• Brief systems review of neuro/cardio/resp may assist in generating differentials.

Preceding features DDx

Aura/Weakness/difficulty speaking Neurological
(TIA/Stroke/Seizure/migraine)
Chest pain Cardiogenic
(MI, pulmonary embolism)
Palpitations Cardiogenic (arrhythmia), anxiety
Dyspnoea Cardiogenic
Respiratory (pulmonary embolism)
Nausea/clamminess Vasovagal
Reduced food/water intake Hypoglycaemia
“Have you had much to eat/drink today?” Dehydration
Chronic fatigue, bowel changes Anaemia
Fever Infection
SYNCOPE – APPROACH TO HX
4. Establish timeline – AFTER
• Confusion, ↑ fatigue - more likely seizure
• Any ongoing symptoms?
• Pale, clammy - more likely cardiogenic

5. PMHx and medications: Medications to watch out for:

• Cardiac history: • Anti-hypertensives
• Murmurs, previous MI, CHF • Anti-arrhythmics (sotalol,
• HTN (?drugs) amiodarone)
• Diabetes • Diuretics
• Epilepsy • Antibiotics
• Anti-psychotics and antidepressants
• Analgesics, Alcohol
FATIGUE
• A common presentation
• Wide range of possible diagnoses

• As with other histories:

• Use an efficient approach to systems review
FATIGUE – APPROACH TO HX
1. Clarify symptom
• What does the patient mean by fatigue?
• Ddx from weakness, myalgia/arthralgia

• Impact on function and patient’s main concerns

• This may bring up other symptoms they are experiencing

2. Further explore fatigue

• Onset and duration - acute vs chronic?

• Progress - steady vs progressive?

• How has sleep been recently?
• May be that symptom such as nocturia à poor sleep à fatigue

• ?Snoring – sleep apnoea is a common and important cause of fatigue

FATIGUE – APPROACH TO HX

SYSTEM DDx Examples of review

Neurological
u 3. SYSTEMSCNS malignancy
REVIEW WITH RED FLAGSHeadache, vision change, weakness
SCREEN
Electrolyte abnormality
• Approach in systematic manner (e.g. head to toe)
Psychiatric Depression, anxiety Mood

CVS CHF, arrhythmia Chest pain, ankle oedema, dyspnoea

Resp TB, COPD Cough, sputum, haemoptysis

GI Anaemia from GI bleed Abdominal pain, bowel motion change

Coeliac, IBD
Endocrine DM, Cushing’s, thyroid, Polyuria, polydipsia, polyphagia, weight
pregnancy change (± intentional)
Infective Infection Fever, recent travel, sick contacts

Haem Anaemia, haem Pallor, bruising, recurrent illness

malignancy
MSK/rheum RA, SLE Joint pain, rash
 SOME RED FLAGS TO CONSIDER…
RED FLAG
Recent onset in elderly
Unintentional weight loss
Abnormal bleeding (e.g.
melaena)
Shortness of breath
Unexplained lymphadenopathy
DON’T FORGET TO ASK ABOUT
MEDICATIONS
*Important as ?Secondary to an underlying GI malignancy
SERIOUS DDX
Malignancy, anaemia*, cardiac
arrhythmia, diabetes
Malignancy, diabetes, hyperthyroidism
HIV infection
Anaemia*
Anaemia*, heart failure, cardiac
arrhythmia, COPD
Malignancy
Antidepressants, anti-hypertensives
Statins (inducing myopathy)
HEADACHE
• Primary vs secondary?
• Hx is important to rule out serious causes of headache!

• Diagnoses you don’t want to miss!

• Haemorrhage (SAH)
Acutely fatal
• Meningitis
• Space occupying lesion
• Giant cell arteritis – can cause irreversible vision loss
HEADACHE DDX
PRIMARY
1. Tension
DDx migraine from
• Recent stress/triggers
tension
• Neck/temporalis tenderness
Pulsatile headache
4-73hOurs duration
2. Migraine Unilateral
• “POUND” Nausea ± vomiting
Disabling
3. Cluster
• SNS activation
• Lacrimation, rhinorrhea, drooping eyelid,
facial flushing
HEADACHE DDX
SECONDARY
• Space-occupying lesions
• Tumour, bleed, abscess

• Infection
• Meningitis ± encephalitis

• Also consider:
• Giant cell arteritis
• Analgesia overuse
• CO poisoning
• Idiopathic intracranial hypertension
HEADACHE – APPROACH TO HX
uPLOTRADIO

• Preceding events
• Aura
• Triggers
• Caffeine, ↓water intake, menstruation
• Present on waking up?
• What have they tried?
• OTC medications
• Past episodes
HEADACHE – RED FLAGS

S YSTEMIC FEATURES OR ILLNESS

N EUROLOGICAL SYMPTOMS AND SIGNS

O LDER AGE (>50Y.O) AT ONSET

O NSET NEW OR SUDDEN

P ROGRESSION OR CHANGE IN PATTERN

HEADACHE RED FLAGS
SYSTEMIC SYMPTOMS OR ILLNESS
u SYMPTOMS
• Fever – meningitis
• Altered level of consciousness/confusion

u ILLNESS
• Anticoagulation – bleeding
• Cancer – metastases
• Immunosuppression – meningitis (opportunistic)
QUESTIONS?
HEADACHE RED FLAGS
NEUROLOGICAL SYMPTOMS/SIGNS
• Suggest increased likelihood of intracranial lesion/↑ ICP
• Weakness or Parasthesia
• Seizure activity
• Eye symptoms
• Meningeal signs – neck stiffness

OLDER AGE (>50y.o) ONSET

• ↑ risk of secondary causes
• Mass lesion
• Giant cell arteritis typically >50-60y.o
HEADACHE RED FLAGS
ONSET RECENT OR SUDDEN with MAXIMAL INTENSITY <1HR
• Need to rule out SAH, meningitis, cerebral venous sinus
thrombosis

PROGRESSION OF SYMPTOMS/CHANGE IN PATTERN

• May suggest lesion that is increasing in size
• CNS mass lesion, subdural haematoma

• Medication overuse headache

• Occurs when recurrent use of analgesia to treat primary headaches