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TOPICS COLLECTION 2010 2ND EDITION

MRCGP-INT OSCE
DR.ABDELNASIR ELSHEIKH
MRCGP-INT-UK

0202

NASSIR1970@GMAIL.COM

MRCGP OSCE

2010
DR.ABDELNASIR
ELSHEIKH
MRCGP-INT-UK
MFFP-UK
DTP-KSU-KSA
OSCE INSTRUCTOR
NGHA-RIYADH-KSA

taking history in G.P

common osce cases

12

insomnia

13

alcoholism

19

chronic fatigue

23

COPD

25

chest pain

tennis elbow

26

31

TIA

37

postnatal depression

45

asthma

47

syncope

50

dementia

51

breaking bad news

55

contraceptive pill

57

headache

59

angery patient

62

TMN

66

POST -mi

70

herpes zoster

76

prediabetic

78

index

HOW TO
OBTAINE
MEDICAL
HISTORY
IN GENERAL
PRACTICE
Obtaining the Medical History
THE CALSSIC STRUCTURE OF A MEDICAL HISTORY
The presenting complaint(s).
The history of the presenting complaint(s)
Past medical history
Drug/allergy history
Family medical history
Personal and social history
Systems review
Rapport
How I can help you?

Tell me, what is bothering you the most?


Would you please tell me more about that?
Is there anything else
Cues
Doctor, I think I need a checkup
Yes, of course. It's quite a time since the last one. Let me
start with
your blood pressure. . . .
Compare this with
Doctor, I think I need a check up
4

Check up?
Yes, I'm not performing as well as I used to
Performing?
Yes, well, you know, I think I'm impotent. My wife is very
good about
it and doesn't complain, but I feel so guilty and ashamed
Ashamed?
I feel terrible. I don't feel a man any more, especially as we
used to
have such a good sex life . . . .
PATIENT ICE
Ideas (beliefs)
Tell me about what you think is causing it.
What do you think might be happening?
Have you any ideas about it yourself?
Do you have any clues; any theories?
Youve obviously given this some thought; it would help me
to know what you were thinking it might be.
Concerns
What are you concerned that it might be.
Is there anything particular or specific that you were
concerned about?
What was the worst thing you were thinking it might be?
In your darkest moments ...
Expectations
What were you hoping we might be able to do for this?
What do you think might be the best plan of action?
How might I best help you with this?
Youve obviously given this some thought, what you were
thinking would be the best way of tackling this?
SUMMARISING AND CHECKING
5

ok MR.B
Id like to get this clear.............am I right?
so...... theres.........
Tell me if Ive got this clear......
Let me take a moment to check that Ive got it right.........
Can I put it into my words..........?
Lets just recap............
You said/you mentioned .......
WHEN SHORT OF TIME AND RUNNING LATE
sorry I am running late (neutral tone).. and then
negotiate where you aim to go together in the rest of the
time available, as above.
Well try to deal with as many problems as
possible.depending on time/how we get on.
Well try to do justice to as many as we can.
I want to give enough time to each of these problems..
Lets get on and see how we go..
OK, lets see what we can do today
how a problem affects a persons life:
If appropriate, pick up a cue:
you said that your knee was giving you a lot of trouble, I
was wondering how that was affecting you
I know that you spend a lot of time looking after you
disabled husband..tell me how you are coping
SENSITIVE ISSUES
Introduce sensitive topics with the common concern
approach: As we age, many of us have more trouble with . .
. or Some people taking this medication have trouble with
sex .

Taking a Pain History

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.
Dont 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?

Abbreviated Mental test Score (AMTS) or Mini-Mental State


examination
What is your age?
What is your date of birth?
What is the time to the nearest hour?
Give the patient an address and ask him or her to repeat it at
the end of the test.
What is the year?
What is the name of the hospital or number of the residence
where the patient is situated?
Can the patient recognize two persons (the doctor, nurse,
home help, etc.)?
In which year did World War 1 begin?
What is the name of the present monarch?
Count backwards from 20 down to 1.
A mark less than 7/10 means the patient needs further
screening for dementia or delirium
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 doctors 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


HTN
ANGERY PATIENT
HIV REQUEST
BACK PAIN
HEARTFAILURE
STD
PILLS-MISSED
DEPRESSION
MENORRAGIA
IBD
ASTHMA
DM
COPD
CHEST PAIN
SYNCOPE
C.T.S
TENNIS ELBOW
SHOULDER PAIN
CHILD
CONSTIPATION
SMOKING
CESSATION
ADHD/AUTISM
POST-MI
POST-STROKE
INFERTILITY

GOUT
MYOPATHY
RHEUMATIOD
ETHICAL ISSUES
DOMESTIC
VIOLENCE
UTI
SORE THROAT
PARKINGNOSIM
OBESITY
EPILEPSY
MENOPAUSE
NEONATAL
JAUNDICE
INCONTENENCE
SCHEZOPHERANIA
INSOMNIA
FATIGUE
PMS
A.F
VERTIGO
DEPRESSION
HYPOTHYRIODISM
HRT counseling
HERPES ZOSTER
BED WETTING

00

PSORIASIS
URTICARIA
GENITAL HERPES
MAMOGRAPHY
SUBSTANCE MISUSE
CHILD ABUSE
DRY EYES
ERECTIL DYSFUNCTION
O.A
OCD
SOMATIZATION
POOR SCHOOLING
CHILD NOT EAT WELL
PRG HYPERTHYRIODISM
ACUTE RENAL COLIC
ACUTE PANCREATITIS
T.B
BREAKING BAD NEWS
PTSD
IBS
ALCOHLISM
OSTEOPROSIS
TRIGEMINAL NEURALGIA
SOCIAL PHOBIA

INSOMNIA
Diagnosis and management of chronic insomnia in primary
care
Initial assessment

Sleep assessment questions should include:


o how have you been sleeping lately?
o do you have difficulty falling asleep?
o do you have difficulty staying asleep?
o do you feel refreshed in the morning?
o do you feel tired during the day?
o do you feel low and/or hopeless?
o has anyone told you that you snore or stop
breathing in your sleep?
o has anyone said your legs twitch when you are
asleep?

Sleep hygiene (sleep health)

Strategies that promote sleep hygiene over 24 hours:


o regular awakening time
o take exercise (before 7pm)
o resolve daytime stresses and plan for the next day
o establish regular wind down habits before bedtime
o have a light snack and/or milky drink before
bedtime
o ensure that bed is comfortable, room temperature
is neither too cold nor too hot and the room is
quiet and dark
o go to bed when drowsy and at a regular time
o turn the light off as soon as you are in bed
o put intrusive ideas to one side until morning
o Poor sleep hygiene; factors to avoid over 24
hours:
exercising too late in the evening (after 7pm)

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

Insomnia can be caused by an underlying physical


condition such as:
o primary sleep disorder, e.g. restless legs
syndrome (RLS)
o arthritis, headaches, back pain
o menopausal symptoms
o Parkinsons disease
o gastrointestinal disorders, including acid reflux
o pregnancy

Environmental

Disruptions within the sleeping environment or to


bedtime routines can cause insomnia:
o noise
o light
o jet lag
o shift work
o uncomfortable mattress
04

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

After the initial assessment, follow up (24 weeks later)


should cover the following:
o review sleep diary, encourage and monitor
appropriate behavioural change

05

o
o

advise and help the patient plan for better sleep


hygiene
further consideration of co-morbid causes
manage appropriate co-morbid cases in primary
care
refer suspected co-morbid cases to an appropriate
specialist if necessary
manage primary insomnia in primary care (e.g.
behavioural and psychological advice) or refer
suspected primary sleep disorder to specialist
advise continuation of sleep diary

Non-pharmacological management

Advice on good sleep health is fundamental. In addition,


patient self-help intervention can be a useful and
inexpensive addition to existing treatment options,
particularly when integrated in a stepped care approach

Access to cognitive behavioural therapy (CBT), and


other non-pharmacological interventions, may be
restricted by a lack of resources such as suitably
trained providers and cost. CBT for insomnia is the gold
standard non-pharmacological intervention

Stepped non-pharmacological approach to insomnia care


Main interventions

Pharmacological treatment

None of the medicines used to treat insomnia is


licensed for children. The doses prescribed should be
those recommended within the Summary of Product
Characteristics

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

The Committee on Safety of Medicines recommends


that the use of benzodiazepines for the treatment of
insomnia should be restricted to severe insomnia.
Treatment should be at the lowest dose possible and
not continued beyond 4 weeks

Z-hypnotics

The Z-hypnotics are non-benzodiazepine compounds


with differing licensed indications and durations of
treatment:
o zaleplon is licensed for people with insomnia who
have difficulty falling asleep, and only when the
disorder is severe, disabling or subjecting the
patient to extreme distress. Treatment should be
for a few days to a maximum of 4 weeks
o zolpidem is licensed for the short-term treatment
of insomnia that is debilitating or is causing severe
distress for the patient. Treatment should be a few
days to a maximum of 4 weeks
o zopiclone is licensed for the short-term treatment
of insomnia (including difficulties falling asleep,
nocturnal awakening, early awakening, transient,
situational or chronic insomnia, and insomnia
secondary to psychiatric disturbances) and if the
insomnia is debilitating or causing severe distress
for the patient. Long-term, continuous use is not
recommended. A single period of treatment should
not exceed 4 weeks
07

Prolonged-release melatonin

Before then, melatonin was only available in unlicensed


products or imported from the US

Other medicines

Sedative antihistamines, antidepressants, and


antipsychotics are not recommended to treat primary
insomnia:
o a sedative antidepressant or antipsychotic may,
however, be useful when insomnia is related to a
psychiatric disorder
o a sedative antihistamine may be appropriate for
when insomnia is secondary to an allergy, or there
is a tolerance to or dependence on benzodiazepine
or Z-hypnotics, or when there is a history of
substance/alcohol misuse

Patients presenting with chronic insomnia may have


been taking herbal preparations, antihistamines, and
OTC medicines without prescription. It is always
prudent to ask patients about such preparations

When to refer

Referral should be considered for the following:


o suspected primary sleep disorder, such as RLS
o severe co-morbid (secondary) insomnia
o failure to improve with primary care management

The electrophysiological parameters of sleep can be


assessed objectively in specialist sleep centres using
polysomnography (PSG). Actigraphy can also be useful
to monitor movement and delineate sleep and awake
phases

08

ALCOHOLISM
Sp Mr.XB 45 years, talks to him, exam normal
I am drinking heavily am finding difficulty to cut down,

for how long


why now
what make you to drink much
what kind, amount/day,
ICE idea regarding heavy alcohol drink, concern
Symptoms pre, during, and after.
Complications assessment
Has anyone expressed concerns about your drinks?

Alcohol withdrawal symptoms


o Hyperactivity, anxiety and coarse peripheral
tremor
o tachycardia and hypertension
o Sweating,
o nausea
o Seizures
o Auditory and visual hallucinations

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

This is best used in a clinical setting as part of a general


clinical history taking, and may be phrased informally.

Have you ever felt you should Cut down on your


drinking?

No
Yes

Have people Annoyed you by criticizing your


drinking?

No
Yes

Have you ever felt bad or Guilty about your


drinking?

No
Yes

Have you ever had a drink first thing in the


morning to steady your nerves or to get rid of a
hangover (Eye opener)?

Alcoholism and Problem Drinking


Social drinking
drive,
operate machinery,
Some types of medication.

02

Heavy (hazardous) drinking


This is drinking above the recommended 'safe' limits ;

One unit of alcohol is in about


half a pint of beer,
two thirds of a small glass of wine,
Developing diseases

cirrhosis (liver damage), damage to the pancreas,


certain cancers,
heart problems,
sexual problems
problems to yourself, family, or society
Binge drink and get drunk quite often. This may
cause you to lose time off work.
Antisocial way when you drink.
Spend more money on alcohol than you can
affords

Alcohol dependence (addiction)


This is a serious situation where drinking alcohol takes
a high priority in your life. You drink
every day, and often need to drink to prevent
unpleasant withdrawal symptoms (see below).
MANAGMENT
Self help
Some people are helped by books, websites, leaflets
and their own determination. It is

00

thought that about 1 in 3 people who have a problem


with alcohol return to sensible
drinking, or stop drinking, without any professional
help. See the end of this leaflet for a list
of resources.
Talking treatments
Some people are helped by counselling and advice from
a practice nurse or doctor.
Sometimes a referral to a specially trained counsellor
may be advised. They can help you to
talk through the issues in more detail and help you to
plan how to manage your drinking. In
some cases, more intensive talking treatments such as
cognitive behaviour therapy (CBT),
Detoxification ('detox')
This is an option if you are alcohol dependent.
What is detoxification?
Detoxification or 'detox' involves taking a short course
of a medicine which helps to prevent
withdrawal symptoms when you stop drinking alcohol.
Benzodiazepine medicines such as
chlordiazepoxide are used for detox.
.

00

CHRONIC FATIGUE SYNDROME


Mr. B has come to see you. 30 years
Take a history from him and explain the management.
Sp fatigue for 2 months
It is very different to everyday tiredness (such as 'after a
day's work').

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 dont 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 dont 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
Case scenario MR.X a patient with chest pain. Take history
and examine. management
Introduction, then you may say: as far as I know, you
have pain in your chest. I would like to ask you several
questions concerning your complaint.
History taking:
How long has the pain been there? (Duration)
Is it there all the time or does it come and goes?
(Periodicity)
Can you tell me exactly where it is? (Site)
Does it spread? (Radiation)
Can you describe what it feels like? (Nature)
Does anything seem to make it worse? (Aggravating
factors like:walking in cold weather,
Heavy meal, climbing stairs or hill)
How much can you do before you have to stop?
Do you ever feel pain or discomfort at rest?
Does anything seem to make it better? (Relieving
factors)
Any shortness of breath, cough, fever?
Examination

Vital signs, including blood pressure measurement in


both arms.

Detailed cardiovascular and respiratory examinations,


looking particularly for signs of cardiac failure or
dysrhythmia.

Chest wall, looking for localised tenderness and


evidence of trauma.

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:
The pain changes with changes in body position.
The pain is momentary or fleeting.
You have had similar pains in the past, and a cardiac
disorder was ruled out.
NICE MARCH2010
To measure the pre-test probability of CAD in the patient
with stable chest
pain undergoing initial clinical assessment, this guideline has
used the
Diamond and Forrester algorithm based on age, gender and
the typicality of
symptoms assessed by the response to 3 questions: 1). Is
there constricting
discomfort in the front of the chest, or in the neck, shoulders,
jaw, or arms?
2). Is pain precipitated by physical exertion? 3). Is pain
relieved by rest or
GTN within about 5 minutes?
Patients who answer yes to all 3 questions are determined to
have typical
chest pain. Patients who answer yes to 2 of the questions
have atypical chest

07

pain, and patients who answer yes to only 1 or none of the


questions have
non-anginal chest pain
History

Pain: site, radiation, nature (type, frequency, severity),


onset, duration, variation with time, modifying factors
(e.g. exercise, rest, eating, breathing or medication) and
any previous episodes.

Visceral chest pain:


o

(heart, blood vessels, oesophagus) and is often


(but not always) described as dull, heavy or aching
in nature.

referred cardiac pain felt in the jaw or left arm.

Somatic chest pain arises in the chest wall, pericardium


and parietal pleura and is characteristically sharp in
nature and more easily localised

Associated symptoms
o

Anorexia, nausea, vomiting

Breathlessness, cough,

Excessive sweating

Palpitations, dizziness,

and

haemoptysis

syncope

Consider the presence of any risk factors for ischaemic


heart disease.

Refer to any previous ECGs for comparison and any


previous cardiac investigations (where available).

08

Exclude thrombolysis contra-indications if ACS is


suspected

Cardiac pain is often heavy, pressing and tight.


Symptoms that may indicate acute coronary syndrome
(ACS) include:6
o

Pain in the chest and/or other areas (e.g. the arms,


back or jaw) lasting longer than 15 minutes.

Chest pain with nausea and vomiting, marked


sweating and/or breathlessness, or haemodynamic
instability.

New-onset chest pain, or abrupt deterioration in


stable angina, with recurrent pain occurring
frequently with little or no exertion and often
lasting longer than 15 minutes.

However, clinical features are not completely reliable in


the diagnosis of acute, undifferentiated chest pain:
o

The site and nature of pain, the presence of


nausea and vomiting and diaphoresis were not
found to be predictive of ACS in one study.7

ACS is often atypical (without chest pain). There


is some evidence to suggest that this occurs more
frequently in women, particularly premenopausal
women.8,9

ACS pain can be intermittent and appear to 'settle',


providing false reassurance.

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.

Non-cardiac chest pain

Consider non-cardiac causes of chest pain, including


recent trauma, past medical history, and current
medications.

Pleuritic pain (pain is aggravated during inspiration and


when coughing) may indicate a respiratory or
musculoskeletal cause of pain. Musculoskeletal pain is
usually associated with tenderness of the chest wall.

Gastrointestinal chest pain may be very difficult to


distinguish from cardiac chest pain, especially in
patients with oesophageal spasm.

Screen for panic disorder:


o

A positive screen ('yes' to either question) is


highly sensitive for panic disorder but should not
preclude cardiac testing in patients with risk
factors:10

'In the past 6 months, did you ever have a


spell or an attack when you suddenly felt
anxious or frightened or very uneasy?'

'In the past 6 months, did you ever have a


spell or an attack when for no apparent
reason your heart suddenly began to race,
you felt faint or couldn't catch your breath?

32

TENNIS Elbow
History taking
Pain [when,where,how,radiation,helps,worst,other
joint-shoulder ]
What about the other ARM
Sleep
trauma recent
numbness, Loss of sensation
weakness
fever
Patient ICE
WORK
HOME ACTIVITY
COPING
PMS-ARTHIRITIS,DM
What is "tennis elbow"?
"Tennis elbow" is a general term that is usually is not
related to playing tennis. However, this term came into
use because it can be a significant problem for some
tennis players. Tennis elbow is a condition usually
caused by overuse of the arm muscles that result in
pain at the elbow.
Tennis elbow most commonly involves the area where
the muscles and tendons of the forearm attach to the
outside bony area
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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 nondominant arm or on both arms.
DIAGNOSIS CHECKLIST

Questions Your Doctor May Ask - and Why!


How long have you noticed pain in your arm?
What area(s) of the arm is affected by the pain?
Is the hand also affected by the pain?
Are both arms affected and is it symmetrical?
Is there a time of day when arm pain is worse?
Relieving factors?
History of trauma?
History of arthritis?
Past medical histor.
Occupational and sporting history?
Alcohol history
Where exactly is the pain?
When did the pain begin?
Can you describe the pain?
How intense is the pain? .
Does the pain affect your sleep?
Have you recently suffered any trauma, injuries or
surgeries?
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Is the pain tender to touch?


Do you also have any pain or problems in your
shoulder?
Have you ever been diagnosed with osteoarthritis
or rheumatoid arthritis?
Have you noticed any weakness in your arm, or
difficulties in doing anything you would otherwise
normally be able to do?
Have you ever suffered Angina, had a myocardial
infarction, or been diagnosed with heart disease?
Do you smoke cigarettes?
Have you been experiencing fevers?
Do you have any loss of sensation in your arm, arm
numbness, or "pins and needles"?
Have you got any pain or problems in other limbs,
or in other areas?
Have you ever been diagnosed with diabetes
mellitus?
Have you ever been tested for diabetes?
Who is affected by it?
Tennis elbow affects 1 to 3 percent of the population
10 to 50 percent of tennis players during their careers.
Tennis elbow affects men more than women.
It most often affects people between the ages of 30 and
50, although people of any age can be affected.

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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
What causes tennis elbow?
Tennis elbow is caused by either abrupt or subtle tearing of
the muscle/tendon area around the outside of the elbow.
How is tennis elbow treated?
The goals of treatment
1. Reduce pain or inflammation - Rest and avoiding any activity that causes pain to the
sore elbow
Apply ice to the affected area
Non-steroidal anti-inflammatory drugs (NSAIDS) such
as ibuprofen
Cortisone-type medication, provided by injection into
the sore area
2. Promote healing -- This step begins a couple of weeks
after pain has been reduced or
eliminated. It involves:
Specific physical therapy exercises t strengthen
muscles and tendons around the injured elbow.
Avoiding activities that aggravate pain.

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3. Decreasing stress and abuse on the elbow --This part of


the treatment process includes:
Use of the proper equipment in sports and on the job
Use of the proper technique in sports or on the job
Use of a "counter-force brace," an elastic band that
wraps around the forearm just below the injured elbow
(tendon) to help relieve pain
What is the outlook for people with tennis elbow?
Overall, 90 to 95 percent of patients with tennis elbow
will improve and recover with the treatment plan
described previously.
about 5 percent of patients will not get better with
"conservative" therapy and will need surgery to repair
the injured muscle-tendon unit around the elbow.
Eighty to 90 percent of patients who have surgery will
improve with pain relief and return of strength.

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TIA
Take history
The main signs and symptoms of a TIA can be remembered
by the word FAST:

Face: weakness or numbness in the face.


Arms: weakness or numbness in the arms.
Speech: slurred speech.
Test or time

If signs and symptoms last longer than 24 hours, it is


regarded as a full stroke.
Risk communication
Without treatment, there is a one in five chance that you will
have a full stroke within four weeks of having a TIA. A
stroke is a serious condition, and can cause permanent
disability. In some cases, strokes can be fatal. Approximately
11% of all deaths in the UK are caused by strokes.
Other signs and symptoms include:

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

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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.
During a transient ischaemic attack (TIA), one of the small
blood vessels that supply your brain with oxygen-rich blood
becomes clogged, or blocked.
When a blockage in a blood vessel occurs, the blood flow to
your brain is disrupted. With a TIA, the disruption passes
quickly and the blood supply to your brain soon returns to
normal. With a full stroke, the blood flow to your brain is
disrupted for much longer. Without a constant supply of
blood, your brain cells start to die.
The blockage in your blood vessels is usually caused by
stenosis (narrowing of the arteries), or as a result of the
formation of a blood clot.
Atherosclerosis
Atherosclerosis is a common condition that causes stenosis.
It occurs when plaque (fatty deposits) develop on the inner
lining of your blood vessels. This can cause your blood
vessels to become hardened, thickened, and less elastic,
making it more difficult for blood to flow through them.
Risk factors
Fixed risk factors
Age
As you get older, your arteries begin to harden and narrow,
increasing your risk of having a TIA. Most TIAs occur in
people who are over 60 years of age.
Gender

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Men have a greater risk of having a TIA compared with premenopausal women. However, the risk of TIA and stroke
increases in postmenopausal women.
Ethnicity
African and south Asian people have an increased risk of
developing high blood pressure and diabetes, and therefore
also have a greater risk of having a TIA.
Family history
If you have a history of stroke, or TIA, in your family, your
risk of having a TIA is increased. However, the risk is
relatively small, and having family members who have had a
TIA will not necessarily mean that you will have one.
Lifestyle risk factors
High blood pressure
High blood pressure, or hypertension, is one of the biggest
risk factors that is associated with TIA. Having high blood
pressure puts extra strain on your blood vessels in your
body, causing them to become narrowed or clogged.
Weight and diet
Eating a poor diet that is high in saturated fat increases your
risk of developing atherosclerosis. If there is too much salt in
your diet, it is likely that your blood pressure will be
elevated which, like atherosclerosis, is a major risk factor for
TIA. Being overweight also puts your heart under strain, and
weakens your blood vessels.
Smoking
Smoking can double your risk of having a TIA, or stroke.
This is because the harmful chemicals in cigarette smoke

38

cause the lining in the arteries to thicken, making your blood


more likely to clot.
Stopping smoking is therefore one of the main ways that you
can help to prevent a TIA, or stroke occurring. See the
prevention section for more information about how to give
up smoking.
Medical conditions
Some medical conditions, such as diabetes mellitus (type 1
diabetes) can increase your risk of having a TIA. This is
because type1 diabetes causes a high level of glucose to be
produced in the bloodstream, which increases your risk of
developing atherosclerosis (the formation of fatty deposits in
the blood vessels).
Referral
If your GP, or health professional, suspects that you have
had a TIA, you should be referred for further testing.
You may either be referred to a neurologist (a doctor who
specialises in treating conditions which affect the brain and
spine), or a consultant who specialises in strokes. Some
people may be referred to a specialist TIA clinic, which are
available at some hospitals and GP clinics.
You should be referred to a specialist, or TIA clinic, within
seven days of your TIA occurring. If you have experienced
more than one TIA in the space of seven days, you should be
seen immediately by a specialist.
Testing
Following a TIA, you may have a number of tests that are
designed to check for any underlying factors, or conditions,
which may have caused your mini-stroke. Some of the tests
you may undergo are listed below.

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Blood tests
If you have had a TIA, you might require a series of blood
tests which may include:

a blood pressure test - your blood pressure will be


checked because high blood pressure (hypertension) is
a major risk factor for TIA and stroke,
a blood clotting test - your blood clotting ability will be
tested to check how thin your blood is and how likely
it is to clot, and
a cholesterol test - a serum cholesterol test may be
used to check your cholesterol levels. If you have high
cholesterol, you are at a greater risk of having a TIA,
or stroke.

Tests and scans


Electrocardiogram (ECG)
Echocardiogram.
Chest X-ray
Computerised tomography (CT) scan
managment
Weight reduction
Exercise
Regular exercise can lower your blood pressure, helping to
prevent many potentially life-threatening conditions including
stroke, heart disease, and cancer. It is also an effective way
of maintaining a healthy weight, and can help to combat
stress and depression.
You should aim to do at least 30 minutes of exercise, five
times a week..
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Healthy eating
Eating a healthy, balanced diet will help you to lose any
excess weight, and will also help keep your arteries healthy.
Alcohol
Drinking an excessive amount of alcohol may increase you
risk of having TIA and a stroke. Therefore, you should make
sure that you stay within the recommended limits of alcohol.
These limits are:

2-3 units a day for women,


3-4 units a day for men.

Stop smoking

NICE JULY 2008


Management of TIA
Following a TIA the risk of stroke can be as high as 30%
within the first month9 and, therefore, symptoms of TIA
should not be ignored. Correct diagnosis and identification
and treatment of risk factors will reduce the stroke risk, and
about 10% of patients will benefit from carotid
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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.

Key guideline recommendations

People who have had a suspected TIA (that is, they


have no neurological symptoms at the time of
assessment [within 24 hours]) should be assessed as
soon as possible for their risk of subsequent stroke
using a validated scoring system, such as ABCD2 (see
Box 1)although scoring systems exclude high stroke
risk patients such as those with recurrent events, and
may also be irrelevant for patients presenting late1
People who have had a suspected TIA and with an
ABCD2 score of 4 or above, should have:1
o aspirin (300 mg daily) started immediately
o specialist assessment and investigation within 24
hours of onset of symptoms
o measures for secondary prevention introduced as
soon as the diagnosis is confirmed, including
discussion of individual risk factors
People with crescendo TIA (two or more TIAs in a
week) should be treated as being at high risk of stroke,
even though they may have an ABCD2 score of 3 or
below1
People who have had a suspected TIA who are at low
risk of stroke (that is, an ABCD2 score of 3 or below)
should receive:1
o aspirin (300 mg daily) started immediately
o specialist assessment and investigation as soon as
possible, but definitely within 1 week of onset of
symptoms
o measures for secondary prevention introduced as
soon as the diagnosis is confirmed, including
discussion of individual risk factors

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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

Box 1: ABCD2 score to evaluate


stroke risk
Prognostic scores to identify
people at high risk of stroke
after a transient ischaemic
attack.
It is calculated based on:
A age (60 years = 1 point)
B blood pressure at
presentation (140/90 mmHg = 1
point)
C clinical features (unilateral
weakness = 2 points, or speech
disturbance without weakness =
1 point)
D duration of symptoms (60
minutes = 2 points, or 1059
minutes = 1 point)
The calculation of ABCD2 also
includes the presence of diabetes
(1 point).
Total scores range from 0 (low
risk) to 7 (high risk).

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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
3)Start w open questions
- General depression questions
- Edinburgh PND scale:
o Mood
o Tearfulness
o Unable to laugh and see the funny side of things
o No longer look forward w enjoyment to things
o Feelings of being unable to cope/feeling inadequate/things
getting on top of you
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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
5)Do not forget to ask about whether they have had
thoughts about harming the baby will fail station if do not
do this

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Asthma
TAKE HISTORY FOR ASTHMA PATIENT
Cardinal symptoms
Cough
Breathlessness or chest tightness
Wheezes
Triggers
Dust
Exercise
Colds
Infections
Stress
Risk factors
Smoking
Family history
Occupational factor
Home environment
High probability symptoms
Early morning and night worsen
Increase with exercise and allergen
Atopic
Relation to medicine ASP,B-blocker
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Low probability symptoms (excluded)


Dizziness
Voice change
Numbness
Light headedness
SYMTOMS OF CONTROL
Day time symptoms
Night awakening
Limitation of activity
Need for rescue medicines
Exacerbations (frequency)
Patient ICE
EXAMINE
PFM (YOU MAY OFFER SPIROMETERY
PFM INSTRUCTIONS
This device used to assess your asthma control, please stand
up as you can take deep breath,assamble the device scale to
zero ,then fill your lungs and place the mouthpiece in your
mouth, then blow hard and fast as far as you can
Then record three reading, take the highest one
Explain
NON-PHARMACOLOGICAL
Wt reduction

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Smoking cessations
Avoid allergens
Home use of PFM
PHARMACOLOGICAL
Reliever and preventers inhalers
USE OF INHAERS
1.Remove the cap from the end of the inhaler device.
2. Shake the inhaler device and ensure it is "primed"
(sprays freely).
3. Hold the inhaler in front of your mouth but not inside of
your mouth. See image for correct spacing.
4. Exhale comfortably.
5. While depressing the silver canister within the inhaler
device, take as deep of a breath as possible through your
mouth.
Hold your breath for 5 to 10 seconds

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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.------------------------------------------------------------------Frank Foster, a 78 year old man came to your office because
his son, Michael, asked you to see him because he think his
father has got forgetfulness. Please talk to him in the next
5/10/15 minutes.
-------------------------------------------------------------------Ask whether there is a family history of dementia or other
illnesses. The person being treated and often a close relative
or partner will be asked about:

Current illnesses the person may have and medications


the person takes. In some cases, illnesses or
medications can cause confusion or other signs of
dementia.
Past history of illness or injury, such as cardiovascular
disease, head injury, or mental illness such as
depression.
Alcohol use.
Change in a person's moods, hallucinations, or unusual
behavior (such as excessive lack of inhibition).
Recent problems with forgetfulness.

52

Change in the person's ability to perform daily tasks. The


person or relative may be asked whether the person can:

Bathe and dress himself or herself and use the toilet.


Cook meals.
Manage money.
Perform daily household tasks.
Take medications on schedule.
Drive safely and get around in usually familiar areas.
MEMORY ASSESSMENT

Does the person often repeat themselves or ask the


same question repeatedly?
Is the person more forgetful or having difficulty with
short-term memory?
Does the person need reminders to do daily tasks, such
as shopping or taking medicine?
Does the person forget appointments, family occasions
or holidays?
Does the person seem sad, down in the dumps or cry
more often than in the past?
Is the person having trouble doing calculations or
managing their money
Has the person lost interest in their usual activities and
hobbies, i.e reading, watching/listening to the news or
other social activities?
Does the person need help eating, dressing, bathing or
using the bathroom?
Has the person become more irritable, agitated,
suspicious or started seeing, hearing or believing things
that are not real?
Do you have concerns in relation to their safety when
driving?
Does the person have trouble finding words they want
to say; do you find yourself finishing.

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The most common signs and symptoms of Alzheimers


disease are below. Usually a person will display a
number of these signs:

Memory loss, particularly for recent events


Difficulty in performing everyday tasks
Changes in mood and behaviour
Changes in personality
Disorientation in familiar surroundings
Problems with language
Poor or decreased judgement
Misplacing things regularly
Difficulty solving problems or doing puzzles
Loss of interest in starting projects or doing things
VASCULAR DEMENTIA
Symptoms can include:
- Slowness and lethargy in thinking and actions
- Difficultly walking
- Emotional ups and downs
- Loss of bladder control early in the condition
Stage 1: Mild Alzheimers Disease
The mild stage of Alzheimers Disease can last from 2
to 4 years or longer.

Say the same thing over and over


Lose interest in things they once enjoyed
Have trouble finding names for common items
Lose things more often than normal
Seem to experience personality changes
Have difficulty grasping complex ideas

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Stage 2: Moderate Alzheimers Disease


The moderate stage of Alzheimers Disease is often the
longest, lasting from 2 to 10 years.

Get lost easily, even in places they know well


Become more confused about recent events
Need assistance or supervision with tasks such as
dressing or washing
Argue more than usual
Believe things are real when they are not
Experience restlessness and agitation
Have difficulty sleeping and may wander
Stage 3: Severe Alzheimers Disease
The severe stage can last from 1 to 3 years or longer.:

Use or understand words


Recognise family members
Care for themselves
Move around independently

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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 patients 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 familys 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 patients 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

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AGE

39 YEARS

MEDICAL RECORD NUMBER 12345


DATE 30/6/2010
-------------------------------------------------------------------------HIV TEST RESULT
POSTIVE TESTS ON BOTH THE ELISA AND WESTERN
BLOT.

PATIENT NAME XX
AGE 35 YEARS
MRN 12345
DATE 30/6/2

Fine needle aspiration cytology (FNAC) was done with


standard technique that yielded adequate material easily. Air
dried Leishman stained smears were examined. The smears
were highly cellular with many cohesive clumps of epithelial
cells arranged in rounded clumps and we favoured a
diagnosis of papillary carcinoma.

55

ORAL CONTRACEPTIVES (The Pill)


Effectiveness (chances of NOT getting pregnant)
95% - 99% chance of not getting pregnant.
Between 1-5 per 100 women may become pregnant with
proper use.
What is the Pill?
Synthetic hormones (progesterone and/or estrogen) like
those produced by the body to
regulate the menstrual cycle.
Pregnancy is prevented because the pill stops ovulation
and/or thickens the cervical mucus by
stopping sperm from passing through.
Reversible method of birth control given only by
prescription.
Advantages of the Pill
Doesnt interfere with sex.
Regulates the menstrual cycle.
Reduces menstrual flow and cramping.
Decreases acne outbreaks.
Reduces the risk of ovarian and endometrial cancer.
Most popular method used.
Disadvantages of the Pill
Must be taken every day at the same time each day.
Increased risk of heart attack, stroke, or blood clots (in
lungs, legs, or arms), especially if you
smoke more than 10 cigarettes a day, or are over 35 and
smoke.
Possible mood swings or depression.
May decrease sexual desire.
Can not be used if you are 35 or older and smoke.
Does not prevent sexually transmitted diseases (see
warning below).
How Do I Decide?
Can you remember to take a pill every day?

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
(STDs) including HIV and Hepatitis B. Using a condom
consistently can help to protect you
from STDs.

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
Provide acute medication to all migraine patients and recommend it is taken as
early as possible in the attack. (Triptans are the most effective acute

medications for migraine. Avoid the use of drugs that may cause analgesicdependent headache, e.g. regular analgesics, codeine and ergotamine.)
Prescribe prophylactic medications to patients who have four or more migraine
attacks per month or who are resistant to acute medications. (First-line

prophylactic medications are beta-blockers, sodium valproate and amitriptyline.)


Monitor prophylactic therapy regularly.
Ensure that the patient is comfortable with the treatment recommended and that
it is practical for their lifestyle and headache presentation.
Is this the worst headache of your life? Onset (acute/gradual)

Positional component
Nausea, vomiting, photophobia, sonophobia
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Neurological phenomena
Previous headaches (is this similar)

Migraine:

Females biphasic onset: late teens, late 40s


Males biphasic onset: early childhood, 20s
Classic: with aura (scintillating scotoma wavy lines, flashing lights, expanding
blind spot) lasting ~30 minutes
Common: without aura
o
o
o
o
o
o

Triggers
o
o
o
o
o
o
o
o

Unilateral (sometimes bifrontal) esp. at onset


Pounding/throbbing
Photophobia and/or sonophobia
Nausea and/or vomiting
No positional component
Usually lasts until patient falls asleep (hrs day)

Stress
Food (nitrates, chocolate, caffeine)
EtOH
Smoking
Menses
Weather
Allergies
Lack of sleep

Treatment: Abortive vs Preventative


o 1st line Ibuprofen 600mg
o Triptans
o Prevent with Beta Blockers (or CCB)

Tension:

Female, mid aged


Gradual onset
Band-like, into neck and shoulders

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:

Immune-suppressed, young adults, children


Occipital and into neck
Nausea and vomiting
Fever
Positional possible
Meningismus (Kernig and Brudzinski signs)
Ask about: immunization, exposure, recent infections
LP: Rule out increased ICP (papilledema, CT head)
Treatment: antibiotics (empiric!)

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.
Look for the signs
There are signs that indicate a patient's emotional state is
deteriorating. Look for changes in body language, including a
tightened jaw, tense posture, clenched fists, fidgeting, and
any other significant change from earlier behavior. A
talkative person, for example, may suddenly become quiet.
Observe the patient for additional signs that his temper is
rising. Is his voice raised? Is he demanding excessive
attention?
If you detect any of these warning signs, you'll need to act
fast to help the patient vent his feelings in a productive
manner. Start by spending extra time with the patient.
Although you might be tempted to spend less time with him,
doing so only increases your risk of liability. Ignoring his

60

complaints or, say, rushing him may prove detrimental to his


care. And if something goes wrong, dissatisfied patients are
more likely to sue.
If, for instance, you work in a healthcare facility, take time to
ensure that he is thoroughly familiar with his plan of care and
the rationale behind it. Review the care he's received so far,
the progress he's made, and how long his recovery should
take.
Show empathy
Some patients won't be soothed by your extra attention and
may become belligerent, demanding to know such things as,
"Why can't you start my therapy now?" "Why isn't my
treatment working?" or "Why aren't my medications ready
yet?" Your calm approach in answering such obviously loaded
questions can prevent anger from turning into a behavioral
crisis.
Rather than becoming defensive, you'd be wise to respond
calmly to the patient and treat him with respect.
If a patient is uncooperative, try to identify the underlying
reason. A patient who balks, for example, when a PT
suggests replacing one exercise for low back pain with
another may actually be anxious about an upcoming
procedure or the results of tests. After you hear him out,
reassure him that you take his concerns seriously. Empathize
with him, saying something like, "I understand how upsetting
this must be for you."
Be sure, however, to calmly explain the consequences of his
refusal. In this example, the PT would need to elaborate on
the reason for the new exercise and explain that the patient's
unwillingness to cooperate will delay his recovery.
If, on the other hand, the problem is an administrative one-such as having to wait too long to see a healthcare provider60

-speak to the appropriate person about scheduling a time


that's less likely to involve a wait.
Keep your cool
If a patient is angry enough to verbally abuse you, remain
calm and professional. Keep some distance between you and
the patient and do not respond until the verbal barrage is
over. When it is, speak softly and call the patient by name.
For instance, an EMT confronted by a patient screaming that
he doesn't want to be touched should listen quietly until the
patient is done. He can then try to soothe the patient, saying
something like, "I know you're scared, Mr. Smith, but I just
want to take your blood pressure and make sure you're
okay." That approach may calm the patient enough to allow
for a more thorough examination.
Should a patient become irrational, he's likely to try to
intimidate you. He may say things like, "I'm calling my
lawyer" or "I'm going to sue."
Trying to justify the situation or defend your actions will only
make things worse. Use active listening instead: Paraphrase
back to the patient what he's already told you, while at the
same time identifying the real feelings behind the words-fear or helplessness, for instance. Keep your statements
short and simple. Continue to treat the person with respect
and show accepting body language by letting your arms hang
loosely at your sides rather than standing with your hands on
your hips or with your arms crossed.
If the patient "blows up," he has lost control and is so
irrational he will no longer hear what you say. As in dealing
with a child's temper tantrum, your reaction may determine
exactly how long the fireworks last.
Keep your cool and don't be manipulated by the patient's
anger. Never get angry yourself or try to set limits by
saying, "Calm down" or "Stop yelling." As the fireworks
63

explode, maintain eye contact with the patient and just listen.
Try to understand the event that triggered the angry
outburst.
When the person has quieted down, acknowledge his
feelings, matching your words to his level of anger. Express
regret about the situation, and let the person know you
understand. Try to find some point of agreement, perhaps
acknowledging that his complaint is a valid one.
Ask for the patient's solution to the problem. Use phrases
like, "Can you tell me what you need?" or "Do you have some
suggestions on ways to solve this problem?" End the
conversation by trying to reach an acceptable arrangement.
Offer options by saying, "Here's how we could handle this."
If the patient threatens you physically or you fear for your
safety, don't hesitate to contact security or the police. For
more immediate assistance, consider establishing a code
phrase that indicates when a staffer needs help.
Regardless of the extent of the patient's anger, documenting
complaints--as well as attempts to resolve them and the
results of each intervention--can ward off frivolous claims
or help in your defense if a lawsuit proceeds to trial. If
applicable to your line of work, note administrative
complaints in an incident report. Document clinical
complaints in the patient's chart.
Dealing with difficult patients will always be a challenge. But
your finesse in defusing and managing anger will keep the
focus on getting the patient healthy and protect you from
unwarranted legal action.

64

Trigeminal Neuralgia (TMG)


Diagnosis
Consider the diagnosis of trigeminal neuralgia in patients
with unilateral face pain of an electric shock-like or shooting
quality that lasts less than one minute, is paroxysmal with
..pain-free intervals, and is triggered by light touch
History
Duration of pain
Seconds to minutes (trigeminal neuralgia)
minutes to a few hours (migraine variants 20
Continuous (atypical facial pain
Quality of pain
Electric-like (trigeminal neuralgia
Throbbing (migraine variants
Gnawing, aching (atypical facial pain
)Crawling, itching, burning (dysesthetic pain
Triggers of pain
)Light touch, talking, or eating (trigeminal neuralgia
)Spontaneous (trigeminal neuralgia
)Coughing or swallowing (vagoglossopharyngeal neuralgia
)Light or sound (migraine variants
)Worsened by emotional stress (atypical facial pain
)Heat, coldness, or pressure on the teeth (dental pain
65

Location of pain
Distributed trigeminally (usually second or third divisions),
)either alone or in combination (trigeminal neuralgia
First division pain around the eye or forehead occurs in
10%-20% of patients, often with pain in other parts of the
face, usually mid-cheek and upper lip or teeth (trigeminal
)neuralgia
)Usually unilateral (trigeminal neuralgia
In 5%-10% of patients with trigeminal neuralgia only
(3598670), and in 11%-20% of patients with trigeminal
neuralgia and MS, pain sometimes is on the other side of the
face but it is almost never simultaneously bilateral
)(trigeminal neuralgia
)Simultaneous bilateral face pain (atypical facial pain
Distribution of the first division of the trigeminal nerve
)(postherpetic neuralgia
Back of throat, front of neck, or deep in the ear
)(vagoglossopharyngeal neuralgia
Frequency of pain
Often episodic; weeks or months of remission may be
)followed by similar periods of pain (trigeminal neuralgia
Severity of pain
)Varies from mild to severe (trigeminal neuralgia
Refractory period of pain after stimulation of the trigger area
(cannot elicit pain again by touching or pushing immediately
)after a painful attack
Likelihood ratio: positive, 9.5%; negative, 0.05%
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
Exclude other things
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
Check patient mouth-dental carries
Sinuses maxillary-frontal
Ask patient to show you his teeth,smile,look upward
wrinckles,blowing
Corneal reflex-consent
Face touches sensations 3 areas.
Clench the teeth palpate the temporalis for
asymmetry.
Chin tapping
Open and close mouth tempomandipular joint pain
MRI
Consider obtaining an MRI head scan to identify another
condition causing trigeminal neuralgia, such as a brain
tumor, MS, or vascular compression
Neurologic Non-drug Therapy
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.
What do you know about heart attack?
. Your heart is made of muscle. Its most important job is to
pump blood to all parts of your body to provide adequate
supplies of oxygen. It also supplies blood to its own muscle.
It does this through a network of very small pipes called
coronary arteries. If one of these arteries becomes partly or
completely blocked, the heart muscle is deprived of oxygen
and this causes a heart attack (you will sometimes hear this
called a myocardial infarction or an MI).
Follow-up every visit
Patients should be followed regularly following MI,
Approximately every two to three months for the first year
and then twice yearly.
History and physical exam
Ask about recurrent chest pain, dyspnea, palpitations,
and syncope. Focus on early recognition of anginal
symptoms.
Screen for depression.
Measure blood pressure at each follow-up visit and
maintain at 135/85 mm Hg .

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
o To take enough regular physical activity to
increase exercise capacity (reduces total
mortality), building this up to 20-30 minutes a day
to the point of slight breathlessness
o To quit smoking. Offer support, advice, and
pharmacotherapy to those wishing to quit4 5
o To eat a Mediterranean-style diet: more bread,
fruit, vegetables, and fish; less meat; inclusion of
products based on vegetable and plant oils rather
than butter and cheese (reduces total mortality and
the risk of myocardial infarction)
o To keep weekly alcohol consumption within safe
limits (no more than 21 units a week for men, 14
units for women) and to avoid binge drinking (more
than three drinks in 1-2 hours)*
o To achieve and maintain a healthy weight if
overweight or obese. Offer appropriate advice and
support.6
Advise patients against taking:
o Supplements containing carotene (may increase
risk of cardiovascular death)
o Vitamin E or C supplements (no evidence of
benefit)
o Folic acid supplements (no evidence of benefit).

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.
Heart failure after myocardial infarction
Treat patients with heart failure and left ventricular
systolic dysfunction with an aldosterone antagonist
licensed for this indication, preferably after treatment
with an angiotensin converting enzyme inhibitor, within
three to 14 days of the acute myocardial infarction
(reduces total mortality and the risk of hospital
admission for cardiovascular events, including heart
failure).
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.

The medicines you need to take are


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 doesnt cause tummy irritation and can be used
by patients who cannot tolerate on Aspirin.
After a non-ST elevation myocardial infarction , treat
patients with both clopidogrel and low dose aspirin for
12 months8 (reduces cardiovascular mortality and the
risk of myocardial infarction and stroke). After an ST
elevation myocardial infarction , treat patients for at
least four weeks if this combination has been started
within the first 24 hours (reduces total mortality and the
risk of myocardial infarction and stroke). Thereafter,
continue standard treatment, including low dose aspirin
without clopidogrel, unless there are other indications to
continue both.
In patients intolerant of both aspirin and clopidogrel,
consider treatment with moderate intensity warfarin
(aiming for an international normalised ratio of 2-3)
instead (reduces the risk of myocardial infarction). In
patients intolerant of clopidogrel and who have a low

70

risk of bleeding, consider treatment with aspirin and


moderate intensity warfarin combined.
In patients already taking warfarin for another
indication, continue warfarin; in those taking moderate
intensity warfarin (international normalised ratio of 2-3)
and who have a low risk of bleeding, consider adding
aspirin.
2. GTN Sublingual
This tablet helps to relieve the pain and is to be used
only if you experience any chest pain.
When you feel a pain in your chest, place one tablet
under your tongue and close your mouth.
Always take it while sitting.
If the pain doesnt subside, you can take another tablet.
You can take upto 3 tablets in 10minutes. However if
the pain persists even after taking 3 tablets please
call an Ambulance immediately.
You can develop headache or dizziness with this
medication
3. ATENOLOL
This tablet is called as a Beta- blocker. It works by
slowing down your heart and reduces the workload on
it.
Please take one tablet of this everyday.
Do you have any history of Asthma or Pheripheral
vascular disease?
If NO
It has a few side effects. It can lower your blood
pressure, cause dizziness, and may affect your sleep.
But these side effects do not occur in every person.
If YES
Then we cannot give Atenolol. But we will give you
DILTIAZEM instead. It is a Calcium Blocker and will
reduce the workload of your heart .
4. CAPTOPRIL
This tablet helps reduce your blood pressure and also
helps prevent a heart attack in future.
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
This tablet helps reduce your cholesterol level.
You should take one tablet everyday at night.
It can cause muscle weakness and cramps and jaundice.
We will be monitoring your liver functions while you are
taking this tablet.
We will also be checking your cholesterol levels after a
few months to check if it has come down.
As I mentioned earlier, not all patients have these sideeffects. Most of the patients tolerate these medicines
without any problems.
Do you have any questions about your medications?
Do you want me to repeat anything?
Special issues
Sex
Sexual activity is associated with a moderate hemodynamic
stress and increases the risk of MI but the absolute risk is
very small. Risk modification can be accomplished with
regular physical activity and possibly BB and aspirin use.
Both the Second Princeton consensus Panel and a consensus
statement from the ACC/AHA concluded that a PDE-5
inhibitor is safe for men with stable coronary artery disease
who are not taking nitrates.
Flying
data suggest that air travel 2 to 3 weeks after an acute MI .
Driving
Data suggest I month after acute MI is safe.
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.

Rash - about two to three days after the onset of pain


the rash will appear. It usually emerges on just one side
of the body, and develops at the area of the affected
nerve. It starts off as red blotches on the skin, and
rapidly develops into itchy blisters; similar to those of
chicken pox. Each blister may be there for about one
week, then they become yellowish and dry out. Some
patients may experience slight scarring of the skin.

Postherpetic neuralgia - some patients experience


severe nerve pain (neuralgia). If the nerves are
damaged (postherpetic neuralgia) the pain can last for a very
long time, even months or years after symptoms have
disappeared.

Sometimes there may be additional symptoms, although they


are nearly always mild. They might include:

Confusion

Fatigue

Fever

Headache

Memory loss

Upset stomach

or abdominal pains
75

Risk factors for shingles


Any person who has had chickenpox can potentially develop
shingles. However, it is much more common among people
over the age of 60 (over 50% of cases). The risk of shingles
is also much higher among people with weakened immune
systems, such as those with HIV/AIDS, patients receiving
steroids, radiation and chemotherapy, or those with a history
of bone or lymphatic cancer
More questions

Is this the first attack?


What about your healthDM, CANCER, DRUGS.
Chickenpox before.
Patient contacts ;pregnant,neonate,immunecomparamize

Treatment

Acyclovir 800mg five times/day for 7-10 days


Famcyclovir 250/750 mg tds for 7-10 days
Valcyclvir tds
Local cream antiviral

PHN
Anticonvulsant
antidepressant

76

Prediabetic
History

Present symptoms.
Risk factors.
Symptoms of complications.
Life style and habits

People with prediabetes, also known as Impaired Glucose


Regulation (IGR) recent research has shown prediabetes may
already be causing long-term damage to the body, especially
the heart and circulatory system6 .
Many people with prediabetes are overweight or obese at
diagnosis and 90 per cent will either have a family history of
prediabetes or have high blood pressure and high
cholesterol1,7. Crucially, prediabetes can often be reversed
and the risk of developing Type 2 diabetes reduced by 60
per cent simply through losing even just a moderate amount
of weight reduction, .
If you are white and over 40 years old, or if you're
Black or South Asian and over 25 years old and have
one or more of the following risk factors, then you may
be at risk of prediabetes :
.A close member of your family has Type 2 diabetes
(parent or sibling )
.You're overweight or your waist is 31.5 inches or over
for women; 37 inches or over for men, but 35 inches or
over for South Asian men

77

.You have high blood pressure or you've had a heart


attack or a stroke
.You're a woman with polycystic ovary syndrome and
you are overweight
.You're a woman and you've had gestational diabetes
.You have severe mental health problems .
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
Low or no fiber diet.
High BMI.
Visceral fat.
Prediabetes; gray area? Between normal blood sugar and
diabetic levels
SP CASE1

age 44 years, taxi driver

Coming with lab result FBS 117mg/dl B.P 150/90 BM33%


ICE diabetes 'high sugar', to help me
+ve FH
PMH NO BP,LIPIDS ,HEART DISEASE

78

Challenging
Metformine
Diabetes complications risk
Driving
Case 2 age 34 HA1c 5.9% F/U BP120/80 BMI 29
LIPID T.C 5.9 LDL 3.2
ASP / STATIN
NON-SMOKER, NO BP, NO HEART DISEASE,-VE FH
Physical Examination [R]
Weight, height, body mass index (BMI), blood pressure
Cardiovascular system: heart, blood pressure, peripheral
vascular including pulses and bruits (abdominal, carotid,
femoral)
Feet: nails, web spaces, ulcers, pulses, calluses, structural
deformities, protective sensation and shoes
Other examinations as guided by the patient's symptoms
and/or concerns:
Skin: infections or diseases such as acanthosis nigricans,
xanthoma
Neurological system: sensory state of hands and feet, muscle
wasting, deep tendon reflexes
Mental health: screen for depression and/or anxiety
Referral to an eye specialist to assess optic health
Diagnosis of Prediabetes
Fasting plasma glucose of 100 mg/dL to 125 mg/dL
79

Oral glucose tolerance test 2-hour plasma glucose: 140


mg/dL to 199 mg/dL
HbA1c
Treatment to Prevent or Delay Progression to Diabetes
Patients who are identified with prediabetes should be
referred for education and lifestyle interventions. Health care
providers should follow up with patients diagnosed with
prediabetes on an annual basis to monitor their progress and
review treatment goals [R].
Intensive lifestyle change programs have been proven
effective in delaying or preventing the onset of diabetes by
about 50%. Effective lifestyle changes include setting
achievable goals, obtaining weight loss when needed (ideally
at least 5% total body weight), and increasing physical
activity [A].
Lifestyle modifications, such as nutrition, exercise and even
modest weight loss, are recommended for prevention or
delayed progression of patients with prediabetes.
Pharmacotherapy, such as metformin, is effective in some
patients with prediabetes.
There are concerns that the recent modification of the
definition of impaired fasting glucose by the American
Diabetes Association has low specificity and low positive
predictive value compared to the World Health Organization
(WHO) definition.
[Conclusion Grade II: See Conclusion Grading Worksheet A
Annotation #4 (Prediabetes) in the original guideline
document]

82

The following initial approaches are recommended for people


with prediabetes:
Intensive lifestyle behavioral change including a nutrition and
activity plan by a registered dietitian, health educator or
other qualified health professional. Ongoing support of
behavioral change is necessary.
Cardiovascular risk reduction appropriate to the needs of the
individual
Patients who respond to lifestyle interventions:
Annual follow-up and reassessment of risks for developing
diabetes [A], [R]
Patients who are high risk and not responding to lifestyle
interventions:
Intensify education and counseling on lifestyle interventions.
There is some evidence of prevention of diabetes through
pharmacotherapy with biguanides and alpha glycosidase
inhibitors [A], [M]. Rosiglitazone has been shown to prevent
diabetes, but the risk of congestive heart failure was
increased [A]. Lifestyle change remains the preferred
method to prevent diabetes [A], [M].

References

NICE
SIGN
Patient .uk
MIPCA

80