43 Ankle Swelling

43 Ankle swelling

Checklist / P / MP / F /
Appropriate introduction
Confirms patient’s name and age
Explains reason for consultation
Obtains consent
Open question to elicit presenting complaint
Allows patient to open up, listens carefully, remains silent and does not interrupt the patient
Signposts: e.g. ‘Mr Gregory, thank you for telling me about this problem. I would like to ask a few more detailed questions. Is that all right?’
History of presenting complaint:
• Details about swelling:
• Duration, extent (e.g. mid-shins, knees), changes since onset, presence of erythema/pain/itching, previous episodes of swelling
• Change in relation to time of day
• Associated symptoms:
• Related to heart failure: shortness of breath, paroxysmal nocturnal dyspnoea, orthopnoea, past medical history of ischaemic heart disease or chronic lung disease
• Related to chronic liver disease: abdominal distension, jaundice, changes to sleep–wake cycle
• Related to kidney disease: swelling of face, haematuria, frothy urine, oliguria
• Related to venous insufficiency: eczema, ulceration, pigmentation, risk factors, e.g. prolonged standing, high heels
• Related to hypothyroidism: decreased tolerance of cold, weight gain, mood changes
• Related to a pelvic mass: abdominal distension, constipation
• Related to a deep vein thrombosis: severe pain
• Asks in a sensitive manner about the possibility of being pregnant
• Asks about risk factors for deep vein thrombosis: recent surgery, past deep vein thrombosis, immobility, thrombophilia, cancer
Asks about constitutional symptoms: fever, weight change
• Asks if patient is suffering from any other symptoms
• Asks about any recent illnesses
• Previous episodes of ankle swelling
• Family members/contacts with similar symptoms
‘Red flags’:
• Weight loss, loss of appetite, night sweats (malignancy)
Review of systems
Past medical history:
• Ischaemic heart disease and heart failure
• Liver disease
• Diabetes
• Hypertension
• Cancer
• Pelvic surgery
Family history:
• Ischaemic heart disease
Drug history:
• Current medication
• Recent changes to dose
• Over-the-counter drugs
• Intravenous drug use
Allergies
Social history:
• Smoking
• Alcohol
• Illicit drug use (especially intravenous drug abuse – hepatitis B/C)
• Occupation
• Activities of daily living
• Effect of ankle swelling on patient’s mobility
Use of non-verbal cues, e.g. good eye contact, nodding head and good body posture
Systematic approach
Explores and responds to ICE:
• Ideas
• Concerns
• Expectations
Shows empathy
Non-verbal skills
Avoids technical jargon
Devises holistic management plan and addresses psychosocial issues as well as medical problems
Summarises
Offers to answer any questions
Thanks patient

OSCEs for Medical Finals, First Edition. Hamed Khan, Iqbal Khan, Akhil Gupta, Nazmul Hussain, and Sathiji Nageshwaran.