Professional Documents
Culture Documents
MRCGP-INT OSCE
DR.ABDELNASIR ELSHEIKH
MRCGP-INT-UK
0202
NASSIR1970@GMAIL.COM
اهداء
في ذكسى وفاة اخي حسام الدين عباس عبداهلل لكن هرا
الكتاب الرى ازجو هن اهلل ان يتقبله صدقت جازيه في
هيزان حسناته وانا اهلل وانا اليه زاجعون
MRCGP OSCE
2010
DR.ABDELNASIR
ELSHEIKH
MRCGP-INT-UK
MFFP-UK
DTP-KSU-KSA
OSCE INSTRUCTOR
NGHA-RIYADH-KSA
0
taking history in G.P 4
insomnia 13
alcoholism 19
chronic fatigue 23
COPD 25
chest pain 26
tennis elbow 31
TIA 37
postnatal depression 45
asthma 47
syncope 50
dementia 51
contraceptive pill 57
headache 59
angery patient 62
TMN 66
POST -mi 70
herpes zoster 76
prediabetic 78
index
3
HOW TO
OBTAINE
MEDICAL
HISTORY
IN GENERAL
PRACTICE
Obtaining the Medical History
PATIENT ICE
Ideas (beliefs)
5
“ok” MR.B
“I’d like to get this clear….............am I right?”
“so...... there’s.........
“Tell me if I’ve got this clear......”
“Let me take a moment to check that I’ve got it right.........”
“Can I put it into my words..........?”
“Let’s just recap............”
“You said/you mentioned .......”
WHEN SHORT OF TIME AND RUNNING LATE
6
Character-Tell me how would describe this pain, how
do you feel it? .
Severity-if I give you scale 1-9 one is mild 9 is intense
how you will score this pain.
Site, where exactly do you feel the pain.
Radiation, does this pain go any where else.
Duration, for how long does it stay with you when ever
you have it.
Periodicity. How frequent do you feel it through out the
day., it continues or periodic
Provoking factors what usually brings up your pain.
Relieving factors ,what help this pain
Associated factors. are there any symptoms come with
this pain.
Duration of chief complain usually missed
"So you have this pain for three days now?… How did you
feel three days ago before this?".
Why now
If the duration is long, what made him decide to seek help
now?
Regardless what is the chief complaint even if seems silly,
you have to show respect and empathy for the patient's chief
complaint verbally and non verbally like saying empathic
statements or sounds "OH.., that must be difficult for you."
Social History:
alcohol.
Whether drinking alcohol or not.
If drinking know whether it is healthy or not.
Healthy alcohol use:
Men: 21 units/week, .
Women: 14units/week, not > 2 units/session.
Don’t forget that healthy alcohol use is associated with less
IHD & Ischemic CVA.
Unhealthy alcohol use is associated with cardiomyopathy,
CVA, Myopathies, liver cirrhosis & CPNS dysfunction.
smoking
7
The most important cause of preventable diseases.
Smoking history - amount, duration & type.
Amount: pack Duration: continuous or interrupted.
Any trials of quitting & how many.
Deep inhalation or superficial.
Active or passive smoker.
Type: packs, self-made, Cigars, Shesha , chewing etc.
Social History: smoking
Ask the smoker whether he is willing to quit or not.
Do not forget to encourage the smoker to quit whenever
contacting a smoker as it is proved to increase quitting rate.
If he is willing to quit, but can not, help him by referral to
smoking cessation clinic.
Sexual history
Factors to be noted during the interview include
The patient's marital state.
any extra marital relation
How many previous sexual partners there have been
Who the current partner is and for how long
How many children the patient has
Which of them lives with the patient
Whether there is obvious stress in the family
Whether there are financial worries
Questions to be asked in sexual history
The problem as the patient sees it
How long has the problem been present?
Is the problem related to the time, place, or partner?
Is there a loss of sex drive, dislike of sexual contact?
Are there problems in the relationship?
What are the stress factors as seen by the patient and
by the partner?
Is there other anxiety, guilt, or anger not expressed?
Are there physical problems such as pain felt by either
partner?
8
Abbreviated Mental test Score (AMTS) or Mini-Mental State
examination
Challenging cases
• elderly
• child
• Difficult( angry, talkative, silent )
• teenage
• BBN
• Presence of 3rd party.
Teenage issues
consider certain issues in your history
SMOKING
ALCOHOL
DRUG ABUSE
UNSAFE SEX(self damaging behaviors)
ABORTION
TEENAGE PRGNANCY
SCHOOLING
CONFIDENTIALITY(PRIVACY)
9
Be teenage friendly .
COMPTENCE(pt aware of his medical problem,
understand the nature and implication of the proposed
treatment including risks and alternative options.
Elderly issues
End of life issues
Fall risk
Dementia
Driving safety
Poly pharmacy
Chronic diseases( co morbid ).
No discrimination.
Respect and dignity.
Promote health and independent
Child issues
Developmental history( sit, say mam,walk)
Vaccination
School performance.
Child abuse( child protection act)
Parental smoking, alcohol and drug abuse
Nutritional history
Parental work and finance, and support
Siblings.
Exam cases
Full history ,exam and management
Counsel( smoking,pills,lab result, patient request
Counseling skills
o START FROM THE STATION QUESTION.
o Ask early ABOUT THE ICE.
o Opportunity for health promotion and summarizing(less
time consuming)
o Through explanation discussion about management
options.
o Checking patient understanding frequently
o Otherwise you will doctor’s centered.
Common pit falls among candidate
Mechanical rapport.
02
jargon
Miss to explore the ICE
In effective listening
Being doctor centered (giving options inform of lecture
with out involving the patient).
Not considering patient believes during expiation.
Mal management of time.
00
75 suggested exam topics
00
INSOMNIA
Diagnosis and management of chronic insomnia in primary
care
Initial assessment
03
drinking more than six caffeinated
drinks a day
going to sleep hungry
consuming a significant volume of fluid near
to bedtime
having a late, heavy (sugary/fatty) meal
drinking alcohol late in the evening
carrying out stimulating activities late or
close to bedtime, such as working, texting or
using bedroom as an office, watching
exciting TV while in bed
worrying over events when you can not sleep
having a clock visible
getting up, having caffeine or smoking
if awoken
Causes of insomnia
Physical
Environmental
04
o bed partner moving or snoring
Psychological
Psychological, e.g.:
o bereavement
o relationship problems
o exam stress
o work worries
Psychiatric
Psychiatric, e.g.:
o depression
o dementia
o anxiety
o bipolar disorder
o schizophrenia
o substance/alcohol misuse
Pharmacological
Pharmacological, e.g.:
o some antidepressants, anxiolytics and
antipsychotics
o appetite suppressants
o decongestants
o beta-blockers
o corticosteroids
o caffeine
o drug/substance withdrawal
Follow up
05
o advise and help the patient plan for better sleep
hygiene
o further consideration of co-morbid causes
o manage appropriate co-morbid cases in primary
care
o refer suspected co-morbid cases to an appropriate
specialist if necessary
o manage primary insomnia in primary care (e.g.
behavioural and psychological advice) or refer
suspected primary sleep disorder to specialist
o advise continuation of sleep diary
Non-pharmacological management
Main interventions
Pharmacological treatment
Hypnotics
06
Hypnotics provide symptomatic relief and a number are
licensed to treat insomnia, including the
benzodiazepines and the Z-hypnotics. They should be
prescribed for short-term use and intermittent dosage
is often preferred
Benzodiazepine hypnotics
Z-hypnotics
07
Prolonged-release melatonin
Other medicines
When to refer
08
ALCOHOLISM
Sp Mr.XB 45 years, talks to him, exam normal
Alcohol dependence:5
o Strong desire to drink
o Difficulty controlling alcohol intake
o Physiological withdrawal when intake is reduced
o Tolerance, such that increasing amounts are
required to produce the same effect
o Harm resulting from alcohol use, e.g. work,
relationships6
09
CAGE Questionnaire
No
Have you ever felt you should Cut down on your Yes
drinking?
No
Have people Annoyed you by criticizing your Yes
drinking?
No
Have you ever felt bad or Guilty about your Yes
drinking?
Social drinking
drive,
operate machinery,
Some types of medication.
02
Heavy (hazardous) drinking
Developing diseases
MANAGMENT
Self help
00
thought that about 1 in 3 people who have a problem
with alcohol return to sensible
of resources.
Talking treatments
Detoxification ('detox')
What is detoxification?
00
CHRONIC FATIGUE SYNDROME
Mr. B has come to see you. 30 years
ch occurs in
people who are depressed.
1) Take a history about his symptoms.
How long have you been feeling tired for?
Are you tired all the time, or does it follow some pattern?
Do you have any other symptoms with the tiredness, like
muscle aches?
Are you normally well?
Do you take any medications?
Do you smoke? Do you take alcohol?
Have you had a cold recently?
2) Ask specific questions about causes of tiredness:
Thyroid: Have you been putting weight on recently? Do you
feel cold when others in the room feel warm? How are your
bowels? How are your periods? (if patient is a woman).
Anaemia: Have you been losing any blood from anywhere -
such as your bowels, vomiting or waterworks?
Renal Problems: Are your waterworks normal? Have you
been feeling sick?
Malignancy: Have you lost any weight or been having any
03
night-sweats?
Depression: How has your mood been recently? Have you
been sleeping and eating properly?
3) Explain the diagnosis to the patient.
Well, chronic fatigue syndrome is a condition in which you
can feel extremely tired and also have aches and pains. It is
quite common nowadays. We don’t know exactly what causes
it but it may be related to an infection. Unfortunately, there is
no blood test to diagnose it and there is no cure. But the
good news is that it gets better itself over time in most
people. There are some treatments that can help some. I will
explain them to you.
4) Explain management to patient.
As I have said earlier there is no cure but some treatments
can help. There are mainly a few options:(a) Cognitive
Behavioural Therapy - I can refer you to a specialist
counsellor who will talk to you and try and help you. He will
help you modify your thinking and help you think more
positively about your condition.
(b) Pacing - here we will teach you to adjust your activity
depending on how you feel. For example if you feel very well
one day then you can increase your activity. If on the other
hand you feel tired, then take it easy that day.
(c) Graded Exercises - here you try to increase your activity
slowly over days. That is everyday you try and do slightly
more than the previous day. Once you feel tired just stop and
rest.
(d) Antidepressants - in some people antidepressant tablets
help. I am not saying that you are depressed but these
tablets can sometimes help. They are not addictive but take a
few weeks to start working.
04
COPD
How I can help you today ---Dr I have cough
Would you please tell me more about your cough
Does the weather affect your cough? Yes/no
Do you ever cough up phlegm (sputum) from your chest
when you don’t have a cold? Yes/no
Do you usually cough up phlegm (sputum) from your
chest first thing in the morning? Yes/no
How frequently do you wheeze? Occasionally or more
often/never
Do you have or have you had any allergies? Yes/no
Differential diagnosis questionnaire
Smoking intensity, pack-years
Have you coughed more in the past few years? Yes/no
During the past 3 yr have you had any breathing
problems that have kept you off work?
Indoors, at home, or in bed?
Yes/no
Have you ever been admitted to hospital with breathing
problems? Yes/no
Have you been short of breath more often in the past
few years? Yes/no
On average, how much phlegm (sputum) do you cough
up most days? None, or _ 15 mL/d/_ 15 mL/d
If you get a cold, does it usually go to your chest?
Yes/no
Are you taking any treatment to help your breathing?
05
Chest pain
Stable angina
06
Also examine the abdomen (possible gastrointestinal cause),
legs (oedema or possible deep vein thrombosis) and skin
(rashchest pain is relatively unlikely to represent a
dangerous cardiac disorder if either of the following are true:
07
pain, and patients who answer yes to only 1 or none of the
questions have
History
Associated symptoms
o Excessive sweating
08
Exclude thrombolysis contra-indications if ACS is
suspected
09
Response to nitrates or antacids does not prove the
diagnosis as angina and gastro-oesophageal reflux
disease (GORD) may appear to be relieved by both.
32
TENNIS Elbow
History taking
Pain [when,where,how,radiation,helps,worst,other
joint-shoulder ]
Sleep
trauma recent
weakness
fever
Patient ICE
WORK
HOME ACTIVITY
COPING
PMS-ARTHIRITIS,DM
30
Tennis elbow most commonly affects patients in their
dominant arm (a right handed patient would experience
pain in the right arm), but it can also occur in the non-
dominant arm or on both arms.
DIAGNOSIS CHECKLIST
Questions Your Doctor May Ask - and Why!
Relieving factors?
History of trauma?
History of arthritis?
Alcohol history
30
Is the pain tender to touch?
33
Although tennis elbow commonly affects tennis players, it
also affects other athletes and workers who participate in
activities that require repetitive arm, elbow and wrist work.
Examples;Golfers,Baseball players,Bowlers,Garden and lawn
workers,Jobs that require vacuuming, sweeping, or scrubbing
Carpenters and mechanics and Assembly line workers
eliminated. It involves:
34
3. Decreasing stress and abuse on the elbow --This part of
the treatment process includes:
35
TIA
Take history
Risk communication
dizziness,
communication problems, difficulty talking and difficulty
understanding what others are saying,
problems with balance and coordination,
difficulty swallowing,
severe headaches,
numbness/weakness resulting in complete paralysis of
one side of the body, and
loss of consciousness (in severe cases).
explanation
36
Blood is supplied to your brain by two main blood vessels
called the carotid arteries. These arteries branch off into a
series of smaller blood vessels which help provide blood to
every part of your brain.
Atherosclerosis
Risk factors
Age
Gender
37
Men have a greater risk of having a TIA compared with pre-
menopausal women. However, the risk of TIA and stroke
increases in postmenopausal women.
Ethnicity
Family history
Smoking
38
cause the lining in the arteries to thicken, making your blood
more likely to clot.
Medical conditions
Referral
Testing
39
Blood tests
Electrocardiogram (ECG)
Echocardiogram.
Chest X-ray
managment
Weight reduction
Exercise
42
Healthy eating
Alcohol
Stop smoking
Management of TIA
40
endarterectomy.10 Therefore, responsive specialist services
that can deliver such treatments as quickly as possible need
to be available to all patients. The NICE guideline includes an
algorithm for the assessment and treatment of TIA.
40
People who have had a TIA but who present late (more
than 1 week after their last symptom has resolved)
should be treated as though they are at lower risk of
stroke using the low risk pathway.1
B — blood pressure at
presentation (≥140/90 mmHg = 1
point)
43
Postnataldepression
Clinical features:
- Similar to those of depression, but
o Suicidal thoughts less common – but must still ask about
them in OSCE
o Tend to have feelings of guilt or inadequacy towards the
baby
Management:
- Get senior help – consider getting psychiatrist involved
- Make assessment of severity:
o Use Edinburgh PND Scale – is important to recognise
early on that there might be severe depression
o Make social assessment, including possible risk to the
baby
- Options:
o Psychological – need to explore feelings w mother, and
reassure her. Can go further, and refer for counselling or
consultation w a psychiatrist
o Medical – eg fluoxitine – should observe baby if breast
feeding, and may need to stop breast feeding if need large
doses
o If severe, might need ECT or lithium, or transdermal
oestrogens
History;
1)Introduce yourself
2)Explain that you would like to talk about how things have
been going, and ask permission
44
o Blaming yourself unnecessarily when things have gone
wrong
o Getting anxious/worried for no good reason
o Feeling scared/panicky for no good reason
o Thoughts of self-harm
o Thoughts of harming your baby
- Ask about problems/support at home
4)Advice for mother:
- Is common – many mothers have “blues”, but sometimes
mothers get a more severe depression, in which case it is
important to help you through
- Will usually improve w treatment
- Is helpful to discuss your fears and feelings
- Would like to involve a psychiatrist, and might benefit
from counselling
- May also be helpful to try an antidepressant – are you
breastfeeding – will not harm baby if use small doses to
start with – if use larger dose, might need to stop
breastfeeding
45
Asthma
TAKE HISTORY FOR ASTHMA PATIENT
Cardinal symptoms
Cough
Wheezes
Triggers
Dust
Exercise
Colds
Infections
Stress
Risk factors
Smoking
Family history
Occupational factor
Home environment
Atopic
46
Low probability symptoms (excluded)
Dizziness
Voice change
Numbness
Light headedness
SYMTOMS OF CONTROL
Night awakening
Limitation of activity
Exacerbations (frequency)
Patient ICE
EXAMINE
PFM INSTRUCTIONS
Explain
NON-PHARMACOLOGICAL
Wt reduction
47
Smoking cessations
Avoid allergens
PHARMACOLOGICAL
USE OF INHAERS
4. Exhale comfortably.
48
SYNCOPE
49
DEMENTIA
Michael Foster came to your office to talk about his father,
Frank Foster, who is 78 year old. He think he has got
forgetfulness. Please talk to him in the next 5/10/15 minutes
concerning his father and your possible plan.------------
-----------------------------------------------
----------
-----------------------------------------------
----------------------
52
Change in the person's ability to perform daily tasks. The
person or relative may be asked whether the person can:
MEMORY ASSESSMENT
50
The most common signs and symptoms of Alzheimer’s
disease are below. Usually a person will display a
number of these signs:
VASCULAR DEMENTIA
50
Stage 2: Moderate Alzheimer’s Disease
The moderate stage of Alzheimer’s Disease is often the
longest, lasting from 2 to 10 years.
53
BREAKING BAD NEWS
The ABCDE Mnemonic for Breaking Bad News
Communicate well
Ask what the patient or family already knows.
Be frank but compassionate; avoid euphemisms and medical
jargon.
Allow for silence and tears; proceed at the patient’s pace.
Have the patient describe his or her understanding of the
news; repeat this information at subsequent visits.
Allow time to answer questions; write things down and
provide
written information.
Conclude each visit with a summary and follow-up plan.
Deal with patient and family reactions
Assess and respond to the patient and the family’s emotional
reaction; repeat at each visit.
Be empathetic.
Do not argue with or criticize colleagues.
Encourage and validate emotions
Explore what the news means to the patient.
Offer realistic hope according to the patient’s goals.
Use interdisciplinary resources.
Take care of your own needs; be attuned to the needs of
involved house staff and office or hospital personnel.
PATIENT NAME; XY
54
AGE 39 YEARS
DATE 30/6/2010
-----------------------------------------------
----------------------------
PATIENT NAME XX
AGE 35 YEARS
MRN 12345
DATE 30/6/2
55
ORAL CONTRACEPTIVES (“The Pill”)
56
• Do you have sex frequently or not very often? If not very
often, do you want to take a pill
every day?
• Are there some medical problems that prevent you from
taking the pill? Do you have liver
disease, breast cancer and/or blood clots in lungs, legs, or
arms?
• Does this method fit with your religious or moral beliefs?
• Is the pill the best method for you?
Do you want to discuss this method with your clinician,
family planning clinic staff, husband,
partner, friend, or family member? In the Philadelphia area,
click here for a list of local
family planning clinics. Outside of Philadelphia, please click
here for a clinic near you
www.plannedparenthood.org.
REMINDER: This method does not provide any protection
against sexually transmitted diseases
(STD’s) including HIV and Hepatitis B. Using a condom
consistently can help to protect you
from STD’s.
57
HEADACHE
Screening/diagnosis
Almost all headaches are benign and should be managed in general practice.*
Use questions / a questionnaire assessing impact on daily living for diagnostic
screening and to aid management decisions. (Any episodic, high impact
headache should be given a default diagnosis of migraine.)
Management
Share migraine management between the doctor and patient. (The patient taking
control of their management and the doctor providing education and guidance.)
Provide individualised care for migraine and encourage patients to treat
themselves. (Migraine attacks are highly variable in frequency, duration,
symptomatology and impact.)
Follow-up patients, preferably with migraine diaries. (Invite the patient to
return for further management and apply a proactive policy.)
Adapt migraine management to changes that occur in the illness and its
presentation over the years. (For example, migraine may change to chronic daily
headache over time.)
Treatments
Positional component
Nausea, vomiting, photophobia, sonophobia
58
Neurological phenomena
Previous headaches (is this similar)
Migraine:
Triggers
o Stress
o Food (nitrates, chocolate, caffeine)
o EtOH
o Smoking
o Menses
o Weather
o Allergies
o Lack of sleep
Tension:
59
Positional component (worse with head/neck movement)
Treatment:
o Antiinflammatories
o Muscle relaxants (Flexeril)
Cluster:
Acute onset
Male, young
Retro-ocular
Multiple/day
May have red, watery eye
Treatment: CCB (but difficult)
Meningitis:
Subarachnoid hemorrhage:
Sudden onset
Worst headache of life
Risk factor: HTN!
Nausea (blood is an irritant to brain, meninges)
Vomiting
Isolated neurological symptoms (i.e. anterior inferior surface – 3rd CN palsy)
Positional (better sitting b/c of increased ICP from blood)
Treatment: admit and do serial CT scans; control BP <180/110
62
ANGERY PATIENT
No matter what field you work in, these tips will help you
keep your cool when patients take their frustrations out on
you.
Even patients who are normally calm may quickly reach the
boiling point when illness threatens their health, mobility, and
independence. Pain and fear can lead to increased stress,
anxiety, and frustration, which can result in anger and even
loss of control. But do you know how to spot your patient's
anger early and defuse it?
For guidance, read on. These tips will help you get control of
the situation and hopefully reduce the likelihood of legal
action down the road.
60
complaints or, say, rushing him may prove detrimental to his
care. And if something goes wrong, dissatisfied patients are
more likely to sue.
Show empathy
60
-speak to the appropriate person about scheduling a time
that's less likely to involve a wait.
63
explode, maintain eye contact with the patient and just listen.
Try to understand the event that triggered the angry
outburst.
64
Trigeminal Neuralgia (TMG)
Diagnosis
History
Duration of pain
Quality of pain
Triggers of pain
65
Location of pain
Frequency of pain
Severity of pain
66
Highly predictive of trigeminal neuralgia; a person with this
refractory period of pain is ~9 times more likely to have
trigeminal neuralgia than irreversible plupitis
Rash
Skin vesicles suggest herpetic infection, which may
result in postherpetic neuralgia
Nasal discharge
Foul odor may indicate sinus disease
Other neurologic symptoms
Numbness or weakness of arms or legs may be present
with MS
Brief loss of vision in one eye may occur with optic
neuritis and MS
Impaired balance may suggest MS or possibly a brain
tumor
Decreased hearing or facial weakness on the side of
face, pain may occur with a brain tumor,
such as acoustic neurinoma
Consider the diagnosis of vagoglossopharyngeal
neuralgia when unilateral paroxysmal pain involves the
throat, back of the tongue, ear, or anterior aspect of the
neck .
Consider the diagnosis of MS (Multiple Sclerosis) if the
patient is under age 45 and has bilateral trigeminal
neuralgia or other neurologic abnormalities .
Consider the possibility of a brain tumor in a patient
with trigeminal neuralgia if there are abnormalities in
function of the fifth, seventh, or eighth cranial nerves .
Consider atypical trigeminal neuralgia in a patient with
paroxysmal triggered face pain and constant,
nontriggered face pain .
67
Consider atypical facial pain when pain is constant, not
triggered, often bilateral, and is not trigeminally
distributed in a patient who claims to have severe pain
but does not appear to be in severe pain .
Physical Exam
MRI
Consider obtaining an MRI head scan to identify another
condition causing trigeminal neuralgia, such as a brain
tumor, MS, or vascular compression
Avoid situations that may trigger face pain, and try certain
. .maneuvers that may provide temporary relief
Drug treatment
Carbamazepine
GABAPINTIN
AMITRIPTALINE
SURGERY .
68
POST-MI
MR. b 50 YEARS BP 130/75
TALK TO HIM
I am glad that you have recovered quite well after the heart
attack
How do you feel now.
69
Perform a cardiac exam including auscultation looking
for new arrhythmias at every visit.
Look for new murmurs or gallops and signs of
congestive heart failure at every visit
COUNSELLING
Cardiac rehabilitation.
Include the following components in comprehensive
cardiac rehabilitation:
72
exercise (reduces total mortality), health
education.
stress management (reduces anxiety, depression
and the risk of non-fatal myocardial infarction).
Involve partners or carers, if the patient wishes.*
Include advice on return to work and to activities
of daily living, taking into account the patient's
physical and psychological status, the nature of the
activity or work proposed, and the work
environment.*
Reassure patients that after recovery from a
heart attack, sexual activity presents no greater
risk of triggering a subsequent attack than if the
patient had never had one.
Cardiological assessment
• Offer cardiological assessment, taking account of
comorbidity, to all patients so that those who will
benefit from coronary revascularisation for secondary
prevention (reduces the risk of myocardial infarction
and total mortality in appropriately selected patients) or
from other cardiological interventions9 can be identified.
1. ASPIRIN
70
This is a Blood Thinner and decreases the chance of
developing a block in your blood vessel.
You need to take one of this tablet everyday along with your
food.
Do you suffer from Asthma or Do you have a history of
stomach ulcers?
IF NO –
Like any other tablet, it has a few side effects like irritation
of the tummy and increased risk of bleeding – nose .
If you develop irritation of the tummy, please let us know. It
can be controlled by adding an antacid along with it.
IF YES –
Then we cannot give you Aspirin. But we will give you
another blood thinner – CLOPIDOGREL.
It generally doesn’t cause tummy irritation and can be used
by patients who cannot tolerate on Aspirin.
70
risk of bleeding, consider treatment with aspirin and
moderate intensity warfarin combined.
73
You should take one tablet of this at night.
This can cause a dry cough or dizziness.
We will also have to monitor your kidney function while
you are taking this tablet.
5. SIMVASTATIN
Special issues
Sex
Flying
Driving
74
HERPES ZOSTER
Pain - the pain in the affected area tends to be
continuous. Some describe it as a dull pain, while others
experience a burning sensation. There may also be
occasional stabbing pains. The affected area will nearly
always be tender.
Confusion
Fatigue
Fever
Headache
Memory loss
75
Risk factors for shingles
More questions
Treatment
PHN
Anticonvulsant
antidepressant
76
Prediabetic
History
Present symptoms.
Risk factors.
Symptoms of complications.
Life style and habits
77
.You have high blood pressure or you've had a heart
attack or a stroke
The more risk factors that apply, the greater the risk of
prediabetes. If a person has one or more of these risk factors
Diabetes UK recommends they consult their GP or healthcare
team. The progression from prediabetes to Type 2 diabetes
may be up to two to three times greater in South Asians
compared to white people
Triggers of prediabetics
Sedentary lifestyle
High BMI.
Visceral fat.
+ve FH
78
Challenging
Metformine
Diabetes complications risk
Driving
ASP / STATIN
Diagnosis of Prediabetes
79
Oral glucose tolerance test 2-hour plasma glucose: 140
mg/dL to 199 mg/dL
HbA1c
82
The following initial approaches are recommended for people
with prediabetes:
References
NICE
SIGN
Patient .uk
MIPCA
80