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AMC Clinical (Part 2 OSCE) study materials
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AMC Clinical (Part 2 OSCE) practice questions

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Question 1History taking

A 28-year-old woman presents with a three-day history of burning on urination. Which opening question best begins a focused history?

  1. Tell me more about the urinary symptoms you have been having. Correct answer.
  2. Are you sexually active?
  3. Do you have a fever and loin pain?
  4. Have you had this problem before?

Explanation

An open-ended invitation lets the patient describe the problem in her own words and reveals her main concern before any closed questioning. Directed questions about fever, recurrence, or sexual history are useful later but narrow the story prematurely if asked first.

Question 2History taking

Which question is most appropriate for exploring a patient's ideas about their illness?

  1. Who else in your family has this condition?
  2. When did you last see a doctor about this?
  3. How many times a day do you take the tablets?
  4. What do you think is causing your symptoms? Correct answer.

Explanation

Eliciting the patient's own explanation of their symptoms addresses the ideas component of the health-beliefs framework. This helps the clinician detect misconceptions that may affect adherence or delay presentation.

Question 3History taking

A 45-year-old man is describing chest discomfort. Which technique best encourages him to continue without interrupting his account?

  1. Summarising his story so far
  2. Repeating his last words as a question
  3. Using silence and brief facilitative nods Correct answer.
  4. Offering reassurance about the likely cause

Explanation

Silence combined with non-verbal encouragement allows the patient to complete their narrative and often yields important detail. Interrupting, even helpfully, is a common cause of missed cues in the first minute of the consultation.

Question 4History taking

During a history for headache, a patient says the pain is 'like a band around my head'. What is the most useful next step?

  1. Ask the patient to rate the pain out of ten
  2. Ask about caffeine intake only
  3. Ask the patient to describe the pain in their own words in more detail Correct answer.
  4. Ask whether anyone in the family gets migraines

Explanation

Patients often use metaphors, and asking them to elaborate on the description clarifies quality, character, and associated features. A numeric rating adds severity but does not illuminate the diagnostic character of the pain.

Question 5History taking

Which is the most appropriate way to ask about alcohol consumption?

  1. You don't drink heavily, do you?
  2. Do you have a drinking problem?
  3. Have you ever been drunk?
  4. How much alcohol do you drink in a typical week? Correct answer.

Explanation

A quantifiable, non-judgemental question about a typical week gives usable information and reduces the sense of being judged. Stigmatising or leading phrasing tends to produce under-reporting.

Question 6History taking

A patient describes several symptoms in quick succession. Which approach best ensures a complete history?

  1. Allow the patient to finish, then summarise and ask about each symptom in turn Correct answer.
  2. Focus only on the symptom that seems most serious
  3. Interrupt to take a full history of the first symptom mentioned
  4. Ask the patient to write the symptoms down and return next visit

Explanation

Letting the patient complete their account and then systematically clarifying each symptom prevents omission while preserving rapport. Interrupting early is a well-recognised cause of incomplete information and patient dissatisfaction.

Question 7History taking

Which question best screens for chest pain of possible cardiac origin?

  1. Does the pain get worse when you breathe in?
  2. Have you ever had an ECG before?
  3. Do you take any regular medications?
  4. Does the pain spread to your arm, jaw, or neck? Correct answer.

Explanation

Radiation of chest discomfort to the arm, jaw, or neck is a classic associated feature of cardiac ischaemia. Pleuritic worsening points more towards respiratory or pericardial causes.

Question 8History taking

What is the main purpose of signposting during a clinical interview?

  1. To tell the patient what topic will be covered next Correct answer.
  2. To record the patient's answers in the notes
  3. To summarise the diagnosis at the end
  4. To check the patient's understanding of treatment

Explanation

Signposting signals transitions between sections of the interview, helping the patient follow and prepare for sensitive topics. It improves the flow and perceived structure of the consultation.

Question 9History taking

A 60-year-old man reports unintentional weight loss. Which detail is most important to establish first?

  1. His preferred foods
  2. Whether his clothes feel loose
  3. Whether he has tried dieting recently
  4. The amount and time course of the weight loss Correct answer.

Explanation

Quantifying the magnitude and tempo of unintentional weight loss determines urgency and narrows the differential. Clothing fit is a subjective corroboration but does not replace measurement.

Question 10History taking

During a sexual history, which opening statement is most appropriate?

  1. You are married, so this should be straightforward.
  2. Why didn't you tell me about this earlier?
  3. Let's skip this part if it makes you uncomfortable.
  4. I ask all my patients some questions about sexual health; is that alright? Correct answer.

Explanation

Normalising the enquiry and seeking permission respects autonomy and increases the likelihood of honest disclosure. Sexual history should be framed as routine rather than exceptional.

Question 11History taking

A patient with abdominal pain reports that the pain started suddenly and was maximal at onset. Which follow-up question adds most diagnostic value?

  1. How far do you live from the hospital?
  2. Do you have any allergies?
  3. Does the pain move anywhere else? Correct answer.
  4. What did you eat for dinner last night?

Explanation

Migratory or shifting pain helps distinguish conditions such as appendicitis or biliary colic from other causes. The other questions are relevant background but do not refine the pain's diagnostic pattern.

Question 12History taking

A woman describes palpitations. Which question best distinguishes a cardiac from a non-cardiac cause?

  1. Do you feel stressed at work?
  2. Do you drink coffee in the morning?
  3. Does the sensation start and stop abruptly? Correct answer.
  4. Have you ever fainted?

Explanation

Abrupt onset and offset suggest a re-entrant tachyarrhythmia, whereas gradual onset favours sinus tachycardia or anxiety. Syncope is an important red flag but is less specific for rhythm disturbance.

Question 13History taking

Which question is most useful when taking a medication history from an older patient?

  1. Who collects your prescriptions for you?
  2. Do you take your tablets every day?
  3. Have you ever had side effects from antibiotics?
  4. Can you tell me all the medicines you take, including anything bought without a prescription? Correct answer.

Explanation

A comprehensive medication history includes prescribed, over-the-counter, and complementary products, as omissions are common. Asking about adherence or side effects alone will not capture the full list.

Question 14History taking

A patient with a chronic cough is being assessed. Which element of the history most strongly suggests gastro-oesophageal reflux as a cause?

  1. Cough with a barking quality
  2. Cough productive of green sputum
  3. Cough associated with exercise
  4. Cough worse at night and after meals Correct answer.

Explanation

Nocturnal and postprandial cough are typical of reflux-related cough because of acid exposure when supine or after eating. Purulent sputum suggests infection and barking cough suggests upper airway causes.

Question 15History taking

When assessing a patient's pain, which combination of questions gives the most complete picture?

  1. Onset and duration only
  2. Site, onset, character, radiation, associations, timing, exacerbating factors, severity Correct answer.
  3. Character and family history
  4. Site and severity only

Explanation

A structured framework covering site, onset, character, radiation, associations, timing, exacerbating and relieving factors, and severity captures the key discriminators. Using only one or two dimensions leaves important diagnostic information unrecorded.

Question 16History taking

A young man is reluctant to discuss his mood. Which response is most likely to encourage disclosure?

  1. If you don't tell me, I can't help you.
  2. You seem fine to me, so don't worry.
  3. There is nothing to be embarrassed about.
  4. Many people find it hard to talk about how they feel; take your time. Correct answer.

Explanation

Normalising the difficulty and allowing time reduces shame and pressure, which supports disclosure. Persuasive or dismissive responses tend to increase defensiveness.

Question 17History taking

A patient reports episodes of loss of consciousness. Which historical feature most strongly suggests syncope rather than seizure?

  1. A rising sensation in the stomach before the event
  2. Tongue biting during the event
  3. Post-ictal confusion lasting an hour
  4. A brief prodrome of light-headedness before falling Correct answer.

Explanation

A prodrome of presyncopal symptoms such as light-headedness or visual greying favours a vasovagal or cardiac cause. Tongue biting, prolonged confusion, and epigastric rising aura are more typical of seizures.

Question 18History taking

Which question best explores the impact of a patient's illness on daily life?

  1. How long have you had this problem?
  2. How has this problem affected your work and home life? Correct answer.
  3. What treatments have you tried so far?
  4. Do you have any family history of this illness?

Explanation

Asking about function at work and home captures the psychosocial impact of illness and informs shared management planning. Duration, treatments, and family history are important but do not address functional consequences.

Question 19History taking

A pregnant woman presents with abdominal pain and vaginal bleeding. Which question is most important to ask next?

  1. Do you have any pets at home?
  2. Have you travelled recently?
  3. What is your blood group?
  4. How many weeks pregnant are you and when was your last scan? Correct answer.

Explanation

Gestational age and scan findings determine the differential, including ectopic pregnancy, miscarriage, and placental complications. Travel and blood group are relevant but secondary to establishing gestational timing.

Question 20History taking

Which approach best elicits a family history of inherited disease?

  1. Ask about the family's country of origin only
  2. Ask about specific conditions and the ages at which relatives were affected Correct answer.
  3. Ask only whether anyone in the family is unwell
  4. Ask about the patient's own childhood illnesses

Explanation

Targeted enquiry about conditions and age of onset in relatives identifies patterns suggesting inherited risk. Generic questions about unwell relatives usually yield vague or incomplete information.

Question 21History taking

A patient with diabetes is being interviewed. Which question best assesses adherence to treatment?

  1. Do you always take your insulin?
  2. How do you manage your medicines on a typical day? Correct answer.
  3. Who supervises your diet?
  4. Are you aware that diabetes can cause complications?

Explanation

Asking about a typical day's routine yields a realistic picture of adherence without inviting a socially desirable answer. Closed or accusatory questions about always taking treatment tend to overestimate adherence.

Question 22History taking

A patient presents with a two-week history of diarrhoea. Which feature in the history most strongly warrants urgent investigation?

  1. Nocturnal diarrhoea with unintentional weight loss Correct answer.
  2. Diarrhoea that settles with fasting
  3. Diarrhoea that began after a takeaway meal
  4. Diarrhoea accompanied by a mild cold

Explanation

Nocturnal symptoms with weight loss suggest organic disease such as inflammatory bowel disease or malignancy and warrant prompt investigation. Postprandial or fasting-responsive diarrhoea is more suggestive of functional or dietary causes.

Question 23History taking

A 70-year-old woman reports recurrent falls. Which question is most likely to reveal a treatable cause?

  1. What did you eat for breakfast that day?
  2. Do you have any grandchildren at home?
  3. How often do you travel by car?
  4. What were you doing just before the fall and do you remember it? Correct answer.

Explanation

The circumstances and recall of the fall help distinguish syncope, dizziness, gait disorder, and tripping, each with different management. Recall also helps identify amnesia suggesting seizure or syncope.

Question 24History taking

A patient with suspected anxiety reports chest tightness. Which question best clarifies whether the symptom is panic-related?

  1. Does anyone in your family have heart disease?
  2. Does the tightness occur only when you exercise?
  3. Does the tightness come with a fear of dying or losing control? Correct answer.
  4. Have you had an ECG in the past year?

Explanation

Fear of dying or losing control accompanying autonomic symptoms is characteristic of panic attacks. Exertional onset and family history point towards cardiac causes rather than panic.

Question 25History taking

During a history, a patient becomes tearful and stops speaking. What is the most appropriate response?

  1. Reassure the patient that there is no need to cry
  2. Acknowledge the emotion, offer a pause, and ask if they wish to continue Correct answer.
  3. Change the subject to a less sensitive topic immediately
  4. Continue the questions so the history is completed on time

Explanation

Recognising and naming the emotion, allowing silence, and seeking consent to proceed demonstrates empathy and maintains the patient's control. Suppressing or avoiding emotion risks ending disclosure.

Question 26History taking

A patient is describing a headache. Which question best characterises the onset of the symptom?

  1. Does anyone in your family get headaches?
  2. How many hours of sleep do you usually get each night?
  3. Was the headache sudden and maximal within seconds, or did it build up gradually? Correct answer.
  4. Have you taken any pain relief for this headache today?

Explanation

Characterising onset separates thunderclap presentations, which demand urgent assessment, from gradual primary headaches. Asking whether the pain peaked within seconds gives a clear, discriminating answer rather than a vague description. The other questions explore treatment, family history and sleep, which do not define onset.

Question 27History taking

Which opening question is most appropriate when beginning the social history of a new patient?

  1. Tell me about your living situation and who supports you at home. Correct answer.
  2. Why did you stop working?
  3. Have you ever been in trouble with the police?
  4. Do you drink alcohol?

Explanation

An open, non-judgemental invitation allows the patient to describe their social circumstances in their own words. Closed or confronting questions early in the social history tend to limit disclosure and can feel intrusive. The clinician can then narrow to specific areas such as alcohol, employment and support.

Question 28History taking

A patient mentions dizziness. Which question best clarifies what the patient means by the term?

  1. Would you describe it as the room spinning, as light-headedness, or as feeling about to faint? Correct answer.
  2. Has anyone in your family had dizziness?
  3. Do you feel dizzy when you are anxious?
  4. How long have you felt this way?

Explanation

Patients use dizziness to describe vertigo, presyncope, disequilibrium or non-specific symptoms, and the meaning changes the differential. Offering distinct sensory categories lets the patient select the closest match. Duration, family history and mood are useful later but do not resolve the ambiguity of the word itself.

Question 29History taking

During a history, a patient says they have had a fever. Which detail is most useful to establish next?

  1. Whether the patient likes hot weather
  2. How the temperature was measured and what the recorded values were Correct answer.
  3. Which antibiotics the patient prefers
  4. Whether the patient has ever had a fever before

Explanation

Confirming how the temperature was measured and the actual readings distinguishes subjective chills from documented fever. This determines whether the symptom is reliable enough to drive investigation. Prior episodes, weather preference and antibiotic preference do not establish the presence of fever.

Question 30History taking

A 45-year-old woman reports fatigue. Which question best explores the functional impact of the symptom?

  1. Do you think stress is causing this?
  2. How has this changed what you can do at work and at home? Correct answer.
  3. Have you tried any supplements?
  4. What exactly do you mean by fatigue?

Explanation

Exploring functional consequences shows how the symptom interferes with work, self-care and relationships, and it helps grade severity. It also gives the patient a chance to describe the lived effect rather than a single word. Clarifying meaning, attributing cause and reviewing supplements serve different purposes.

Question 31History taking

Which question is most appropriate when screening a patient for suicidal thoughts?

  1. Is there any family history of mental illness?
  2. Do you feel sad most days?
  3. You're not thinking of doing anything silly, are you?
  4. Have you had thoughts that life is not worth living or of ending your life? Correct answer.

Explanation

Direct, non-judgemental questions using plain language are recommended when screening for suicidal ideation. Framing the question clearly gives permission to disclose without implying the thought is foolish. Asking about sadness or family history screens for other aspects of mood disorder but does not address suicide risk.

Question 32History taking

A patient is being asked about their alcohol intake. Which approach is most likely to yield an accurate answer?

  1. Ask whether alcohol has ever caused problems at work
  2. Ask how many standard drinks they have on a typical week and on their heaviest day Correct answer.
  3. Ask whether they are a heavy drinker
  4. Ask whether they prefer beer or spirits

Explanation

Quantifying intake in standard drinks on typical and heaviest days gives a concrete, comparable estimate. Framing questions around quantities rather than labels reduces social desirability bias. Judgemental labels, consequence questions and beverage preference do not measure consumption.

Question 33History taking

Which technique best ensures the patient's own agenda is addressed during the history?

  1. Following the standard template strictly from start to finish
  2. Writing notes continuously without looking up
  3. Asking at the outset what the patient most wants to discuss today Correct answer.
  4. Summarising your own hypothesis to the patient early

Explanation

Inviting the patient to state their concerns at the start allows their agenda to be identified before the clinician's. This reduces the chance that important issues are raised late or not at all. Rigid templates, premature hypotheses and inattention to the patient all undermine this goal.

Question 34History taking

A 30-year-old man reports a productive cough. Which question best characterises the sputum?

  1. What colour is the sputum, how much do you produce, and has it ever contained blood? Correct answer.
  2. Do you smoke?
  3. Does the cough keep you awake at night?
  4. Have you had a chest X-ray before?

Explanation

Colour, volume and the presence of blood are the key descriptors of sputum and influence the differential and urgency. Asking about all three in one question is efficient and specific. Sleep disturbance, prior imaging and smoking status are relevant but do not characterise the sputum.

Question 35History taking

A patient describes episodes of abdominal pain. Which question best distinguishes visceral from parietal pain?

  1. Is the pain sharp and well localised, or vague and poorly localised? Correct answer.
  2. What have you taken for the pain?
  3. Does the pain get worse after eating?
  4. Have you had this pain before?

Explanation

Visceral pain is typically dull and poorly localised, whereas parietal pain is sharp and precisely localised. Asking the patient to choose between these qualities helps localise the process. Relation to eating, recurrence and treatment are useful but do not distinguish the pain type.

Question 36History taking

A 25-year-old woman reports a headache with visual disturbance. Which question best screens for a red flag?

  1. Does the headache improve with rest?
  2. Does your mother get migraines?
  3. Is this the worst headache of your life, or does it differ from your usual headaches? Correct answer.
  4. Do you drink coffee daily?

Explanation

A thunderclap or first-ever worst headache raises concern for subarachnoid haemorrhage and needs urgent assessment. Comparing the current episode with the patient's usual headaches identifies a change in pattern. Rest, caffeine and family history are relevant to primary headache but do not screen for this red flag.

Question 37History taking

A patient reports palpitations. Which question best characterises the rhythm?

  1. Do you feel anxious during the episodes?
  2. Do you drink tea or coffee?
  3. Have you had a thyroid test before?
  4. Do the episodes start and stop suddenly, and is the beat regular or irregular? Correct answer.

Explanation

Abrupt onset and offset with a regular or irregular rhythm help distinguish re-entrant tachycardias from atrial fibrillation and from sinus tachycardia. These features guide both urgency and further testing. Anxiety, thyroid history and caffeine intake are contributory but do not describe the rhythm.

Question 38History taking

A 55-year-old man reports black stools. Which question is most important to ask next?

  1. How many times a day do you open your bowels?
  2. Do you have haemorrhoids?
  3. Do you take iron tablets or bismuth? Correct answer.
  4. What is your usual diet?

Explanation

Iron and bismuth can produce genuinely black stools without bleeding, so clarifying this avoids unnecessary urgent investigation. Once drug causes are excluded, features of true melaena such as tar-like consistency and offensive smell become relevant. Stool frequency, haemorrhoids and diet do not explain black discolouration.

Question 39History taking

Which question best assesses a patient's cardiovascular risk during the history?

  1. Do you own a pet?
  2. Have you ever been told you have high blood pressure, diabetes or high cholesterol? Correct answer.
  3. Do you have any allergies?
  4. How many siblings do you have?

Explanation

Established diagnoses of hypertension, diabetes and dyslipidaemia are major modifiable cardiovascular risk factors and are reliably recalled by patients. Asking about them directly is efficient and clinically meaningful. Allergies, sibling number and pet ownership do not assess cardiovascular risk.

Question 40History taking

A patient with known asthma reports worsening breathlessness. Which question best assesses adherence to preventer therapy?

  1. Have you ever had a spirometry test?
  2. How many days in the past week did you use your preventer inhaler, and how many puffs did you take? Correct answer.
  3. Which inhaler do you prefer?
  4. Do you take your inhaler?

Explanation

Quantifying days of use and actual doses gives a concrete measure of adherence rather than a yes or no answer. It also reveals technique problems and unintentional underuse. A general question about inhaler use, preference and prior spirometry do not measure adherence.

Question 41History taking

A 65-year-old woman reports urinary incontinence. Which question best distinguishes urge from stress incontinence?

  1. How many times do you get up at night?
  2. Do you leak when you cough, sneeze or lift, or do you get a sudden urge and leak before reaching the toilet? Correct answer.
  3. Do you drink enough water?
  4. Have you had children?

Explanation

Leakage provoked by raised intra-abdominal pressure indicates stress incontinence, whereas a sudden compelling urge with leakage indicates urge incontinence. Offering both patterns in one question lets the patient identify the relevant one. Nocturia, parity and fluid intake are contributory but do not distinguish the type.

Question 42History taking

A patient reports low back pain radiating to the leg. Which question best screens for cauda equina syndrome?

  1. Have you had any difficulty passing urine, numbness in the saddle area, or loss of bowel control? Correct answer.
  2. Have you taken anti-inflammatory tablets?
  3. How far can you walk before the pain starts?
  4. Does the pain improve when you lie down?

Explanation

Urinary retention or incontinence, saddle anaesthesia and loss of bowel control are red flags for cauda equina syndrome requiring emergency assessment. Asking about all three together is efficient and specific. Postural relief, walking distance and analgesia use describe other patterns.

Question 43History taking

A patient with type 2 diabetes reports episodes of shakiness. Which question best characterises possible hypoglycaemia?

  1. How often do you check your feet?
  2. Do you have a family history of diabetes?
  3. What were your most recent HbA1c results?
  4. When do the episodes occur in relation to meals and insulin, and what relieves them? Correct answer.

Explanation

Hypoglycaemia typically occurs in relation to missed meals or excess insulin and resolves with carbohydrate. Establishing timing relative to meals and insulin, and what relieves the symptoms, supports the diagnosis. HbA1c, family history and foot care do not characterise the episodes.

Question 44History taking

A 70-year-old man reports feeling unsteady on his feet. Which question best identifies a treatable cause?

  1. Have you fallen before?
  2. Do you use a walking stick?
  3. Do you feel unsteady when you first stand up from a chair? Correct answer.
  4. Do you live alone?

Explanation

Unsteadiness on standing suggests postural hypotension, which is common in older adults and often drug-related and treatable. Asking specifically about the timing of the symptom relative to standing links it to a mechanism. Previous falls, walking aids and living arrangements describe consequences and context.

Question 45History taking

A patient with a chronic illness is being interviewed. Which question best explores their understanding of the condition?

  1. Do you read the leaflets we give you?
  2. Would you like more information?
  3. Can you tell me in your own words what you understand about your condition and its treatment? Correct answer.
  4. Do you know what your diagnosis is?

Explanation

Asking the patient to explain their understanding in their own words reveals their explanatory model, including misconceptions. This guides education and shared decision-making more effectively than a closed check. Simple yes or no questions about diagnosis, leaflets and information do not reveal understanding.

Question 46History taking

A patient reports a two-week history of diarrhoea. Which question best explores a possible infective cause?

  1. Do you have any allergies?
  2. What is your usual bowel habit?
  3. Have you had a colonoscopy before?
  4. Have you travelled abroad recently or eaten food that may have been contaminated? Correct answer.

Explanation

Recent travel and suspect food are key exposures for infective gastroenteritis and guide stool testing. Asking about both together efficiently covers the exposure history. Allergies, prior colonoscopy and usual bowel habit are relevant but do not point to infection.

Question 47History taking

A woman reports a breast lump. Which question best assesses the risk of a hereditary breast cancer syndrome?

  1. Have you breastfed your children?
  2. Have any close relatives had breast or ovarian cancer at a young age? Correct answer.
  3. Do you perform monthly self-examination?
  4. Does the lump change with your menstrual cycle?

Explanation

Early-onset breast or ovarian cancer in close relatives raises suspicion of a pathogenic variant such as BRCA. This influences referral for genetic assessment and risk-reducing options. Cyclical change, self-examination and breastfeeding history are relevant to the lump but do not indicate hereditary risk.

Question 48History taking

A patient with known heart failure reports increasing breathlessness. Which question best explores adherence to fluid and salt restriction?

  1. How much fluid do you drink each day, and do you add salt to your food? Correct answer.
  2. Have you been admitted to hospital before?
  3. Do you weigh yourself?
  4. Do you follow a healthy diet?

Explanation

Quantifying daily fluid intake and salt use gives concrete evidence of adherence to the restrictions that influence volume status. General diet questions and weighing behaviour do not measure intake. Previous admissions describe outcome rather than current self-management.

Question 49History taking

A patient reports episodes of loss of consciousness. Which question best distinguishes seizure from syncope?

  1. Do you remember feeling unwell before the episode?
  2. Was there a warning, and did you have jerking movements, tongue biting or incontinence? Correct answer.
  3. How long did it take you to recover?
  4. Were you standing at the time?

Explanation

A prodrome with jerking, lateral tongue biting or incontinence strongly favours seizure, while provocation by standing favours syncope. Asking about all these features together gives the most discriminating information. Recovery time and posture are useful adjuncts but less specific on their own.

Question 50History taking

A 40-year-old man reports erectile dysfunction. Which question best explores a possible vascular cause?

  1. Do you smoke, and do you have high blood pressure, diabetes or high cholesterol? Correct answer.
  2. Have you ever taken sildenafil?
  3. How is your relationship with your partner?
  4. Do you feel anxious about the problem?

Explanation

Smoking, hypertension, diabetes and dyslipidaemia are established vascular risk factors for erectile dysfunction and often precede cardiac events. Asking about them together efficiently screens for a vascular mechanism. Anxiety, relationship issues and prior treatment address psychological and management aspects.