Communication Skills MRCS

Communica
tion Skills
Introductio
n
Communication Skills = Sharing information
With whom you share information?

1- Patient/ Relative 2- Medical Colleagues
Giving Vs Getting (Gathering) ( introduce & greeting Open Interview - Close)
INFORMATION GIVING INFORMATION GATHERING

- Both = 1. Give & take information but
- Giving > Gathering - Gathering > Giving
2. Should give information in simple
language no medical terms
3. A fetal mistake = To give wrong medical
information
4. Should Cover The following 3 items:
. Medical .Social .Psychological
Event 1. Waiting area ( 5min),To read scenario 1. Waiting area ( 5min),To read the scenario
description 2. Actor Interview ( 10 min) 2. Actor Interview ( 10 min)= 1st bay
The examiners will not talk to or discuss you The examiners will not talk to or discuss you only they will
only they will assess your communication assess your communication skills
skills that should cover critical items within - you are allowed to write notes regarding H/o of the
the interview, & how you Begin & end the condition as you will present Later after taking The patient (=
interview Actor)
3. 2nd bay ( 10 min) = Present the case for the Examiners
& They will discuss you about the future plan for the case
- Marks 2 examiners assess you 4 4 1st bay the 2 examiners assess you 4 4
2nd bay the 2 examiners assess you 4 4
Introduction - Same important as clinical examination

- Tested between actor playing (patient / relative) & you
- Based on ( Information giving & Information gathering followed by presentation to a consultant)
- Should give accurate clinical information + good communication skills
Objectives - Assessment of communication skills
- Competent performance within time given
- Skills to recognize situations (or knowledge) outside personal experience but ability to act appropriately
Ask consultant to provide further details
Assistance from other members of the team
General skills - Introduction (Name - Explain role - Checks patients name - Appropriate greetings - Non-verbal
behaviour appropriate to culture
- Establishes purpose of interview ( Clarify why interview is taking place (patient perspective, own
perspective - Check patient happy to proceed - Establish outcome of interview
- Establish baseline knowledge / understanding ( Open questions Listens - Confirms what learned
-Signals to move to information giving at the end
General Manner 1. Picks up& responds to the patient concerns, anxieties and doubts
2. Listens actively
3. empathy
4. Offers support
5. Presents information non-judgmentally
6. Uses language patient understands
7. Uses appropriate body language
Questioning style - Open/closed questions used appropriately
Control of interview - Allows control of interview to: - alternate between doctor and patient
- Signposts change of direction
Information giving - Give the information & ensure that pt understanding
Summarizing - Summaries / next steps
The rules of preferred body language:
1. Sitting while speaking, + open posture + eye contact apply
2. Privacy may be less than optimal, in a busy clinic. Every attempt should be made to
provide a separate, quiet space. Asking the patient to quiet their personal communication
technology prior to the conversation can also minimize distraction.
3. Reducing or eliminating body signals that illustrate nervousness is very important in
establishing rapport with the patient. Simply placing your feet flat on the floor with your ankles
together and putting your hands, palms downward, on your lap is a successful neutral
position. Maintaining eye contact with your patient will help ensure your attentiveness.
Assessment of candidates:
1- Sensitivity to - Great & respect the patient , smile , be gentle & be polite
needs to patient / - Empathize & sympathize but be clear, honest & Professional
relative - Taking into account ethnicity, cultural, age & disability factors
- Responding appropriately to verbal and non-verbal ( body) language
- Listen to patients account
2- Professional Emotion/ social element
Dealing With - Variable emotional responses by the patient / relatives
- Variable cultural / religious backgrounds and ethnic backgrounds
Medical element
- Complaints appropriately
- Variable questions& situations that are beyond level of competence of candiciate
Time element - Time constraints
3- communication accurate information in an appropriate manner
Ability Informatio - To the patient / relatives
n Giving 1. Obtaining informed consent
2. Breaking bad news
3. Explain risk/benefits& possible impact of investigations in clinical situation
4. Explaining diagnosis or differential diagnosis
5. Explain options available and option not to treat
6. Explain uncertain diagnosis, outcome or prognosis
Ability to use background information to formulate an appropriate
response
- Checking for understanding and summarizing at appropriate intervals
- Involving the patient in decision making to the level that they wish
- Offer opportunities available for further information e.g. 2nd opinion
- Using feedback to regulate pace and content of consultation
- To colleagues/ other Healthcare professionals
1. Verbal communications
2. Written communications
- Clinical letters to medical colleagues - Investigation request forms
3. Telephone communication
Informatio - To the patient / relatives
n - Brief H/O from patient in OPD / ward
Gathering - Consultation with relative of patient
Ability to use background information& that gathered to formulate an
appropriate response
Discussion of management plan
Ability to summarize information appropriately
) ( ) (

Information Giving
Information Gathering
(
.1 = Breaking bad news
- Brief H/O from patient in Dealing with .2 = Angery patient or relative
OPD / ward
- Consultation with relative of .3 Explaining diagnosis or differential diagnosis
patient Explain risk/benefits& possible impact of investigations
.4 Explain options available of treatment
Explain outcome or prognosis
.5 + Obtaining informed consent
.6 + Organ transplant consent
(
- = Verbal communications
-2 = Written communications
Clinical letters to medical colleagues - Investigation request forms -
-2 Telephone communication
) (

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) = offer contact e.g social worker specialized care
)nurse(cancer, stoma amputation
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offer contact (bleep, office or telephone) +
(OPD appointment

=Verbal communications
Presentation of H/o taking

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Verbal communications
I- In The waiting area (5 min) ( Read, Record data & Mapping)
I- Read the scenario > time
II- Record Data important Items
You Name if given , & Job position (CT , SHO, Registrar).
Patient Name , Age , Venue ( hospital/ department, ER, OPD, Ward )
Consultant name if given/ specialty

Find & Record Medical problem, Social points to be covered, Psychological element
the 3 Items
II- Mapping
Medical prepare yourself about points to be covered
prepare A diagram about the medical problem
.Social prepare yourself about The Social point/s you should offer help for it
offer this in a question Ex:-
.Psychological prepare yourself about the Psychological points you should offer help for it
offer this in a question Ex:-
II- In Actor Area (10 min)= Actor Interview ( introduce & greeting Open Interview - Close)
INTERODUCE 1. Greeting the patient, smile, check hands
2. Introduce yourself - Same
3. Check patient identity
Is it Mr. / Mrs..?
OPEN INTERVIEW OPEN Differ according each situation
QUESTION
THE INTERVIEW Actor Interview ( 10 min), 1. Actor Interview ( 10 min)= 1st bay
- Task - Take H/O & Systemic review is focused on
- Scenario may go beyond - you are not allowed to write notes important points
scope of junior doctor, you The examiners will not talk to or discuss you - you are allowed to write notes regarding H/o
must recognize & should only they will assess your communication skills of the condition as you will present Later after
refer matter upwards; that should cover critical items within the taking The patient (= Actor) but take
. Ask consultant to provide interview, & how you Begin & end the interview permission.
further details The examiners will not talk to or discuss you
. Assistance from other only they will assess your communication skills
members of the team Rules :-
- You Should Cover The following items: Rules :- - Same
- Should deal with aspects 1. Medical - You should say that you will now speak to
of situation of patients 2. Social your consultant
condition as they emerge in 3. Psychological
conversation 3. Present the case ( 5 min) = 2nd bay
1. Medical Should be logical, structured,& in clinical
- Simple language (no medical terms, language
& no abbreviations) Presentation Skills
- Simple sentence & in a small chunk. - Simple language
- A fetal mistake = To give wrong medical - Methodical approach
information - Comprehensive
+ Ensure that the patient under standing you. - Succinct (keep to 5 minute limit)
Do you have any questions? - Emphasis and significance - keep appropriate
- Medical plan. to surgical context
2. Social:- offer help for it - Interpretation of ideas and concerns
3. Psychological:- The examiners will discuss you about
- empathize & sympathy but be 1. What DD would you suggest at this stage
honest & tell the truth .e.g. cancer based on the history?
- Listen to his concern & dont interrupt 2. What signs would you look for specifically in
offer help for it the examination
- Smile & use body language( nodding the 3. What investigations would you request for
head), this patient?
END INTERVIEW= - Close appropriately (check if has no further - Same
questions, and knows what will happen next)
- Summary all these in simple sentences
- End Question
Do you have any questions? Before we end
- Thanks & smile
Medical Terms & ABBREVIATIONS VS Simple Language

Medical Terms Simple Language
& Abbreviations
C/O Concern/ problem
Investigations Some tests to do
Body regions/Organs
Thorax Chest
Abdomen Tummy/ belly
Gluteal region/ buttock bottom
Anus Your back passage
Testis Your balls
Scrotum Skin contains your balls
Vessels/ Nerves/ LNs
Axillary a Artery in your armpit
Axillary Glands in your armpit
Optic N The nerve of vision
Occulomotor N A nerve that control the muscles move you eye
Coronary a Artery that supply/ feed your heart
Pathology
Congenital Disease born with it
Atherosclerosis Narrowing or occlusion to artery that supply..
Ischaemic Heart disease Narrowing or occlusion to artery that supply / feed your heart
(IHD) never said that
Angina Pain in your chest as a result of Narrowing or occlusion to artery that supply / feed your
heart
Myocardial Infarction Pain in your chest and part of your heart muscle dead as a result occlusion to artery
that supply / feed your heart
Diabetes mellitus High blood sugar
HTN High blood pressure
Shock Low blood pressure
Mass Lump
Malignant tumour cancer
Biopsy Cells we take out
Recurrence Come back
ulcer ulcer
Operative surgery
Incision Cut
Scalpel Knife
Excision = .ectomy Remove or take (The Lump or your organ) out
Drain Tube take fluid out
Ryle/ NGT Tube take fluid & content of your stomach out
Urinary catheter Tube take Urine out
Clostoma/ stoma A bag take content of your bowel out
Haemorrhage Bleeding
Haematoma Bruises
Haematemsis Blood come back from your stomach
Melena Dark blood from your back passage
Endoscope A special tube with a camera connected to a special monitor
We enter it through your .. ..So we can see the problem Inside/
take some cells/ or others for diagnose
& we can do some surgery through
Laparoscope - A special tube with a camera connected to a special monitor
- We enter it in your tummy through a small 1cm cut So we can see the problem
Inside/ take some cells/ or others for diagnose
- We can also do surgery through another small cuts with entering special tubes for
knife/ scissors & so on
Difficult situations VS Solutions

Difficult situations Solutions
If patient( actor) plays as he is
In pain - Ok I will give you a pain killer play as you call a sister to give him it
Dyspneic - Ok I will give you oxygen play as you call a sister for help ,
- sister we need oxygen & mask here hurry please
Depressed - Speak about the future plan
Anxious - Be calm & explain
Talkative - Summarize what they told you & give him the information
Uncooperative - Use closed questions
Angry - I am sorry, I understand why you are angry, I have to tell you ..e.g. your
Operation/ tests have been postponed and give the cause for postpone.
Aggressive - If stand stand ( Be at same level of his eye)
- If shout Be firm , polite , raise your voice but not shout
- Last solution leave the room & call the security
Saying "I will kill my self if - Offer postpone
test is positive" - Offer to call one of his close relatives
Suicide Trial - As Above + offer contact to psychiatrist
after bad news - dont discharge
Patient questions
Cancer biopsy test:- - I am afraid to tell you, that the cells taken from you are positive for cancer.
Is it cancer?
It will kill me? - Still early to decide before we do some tests to role out spreading of the
cancer cells in other body system
It kill my mother, it may kill I am afraid to tell you, yes
me?
How long I will life? Dont tell, why all asking this Q ?
Relatives
- Ask about the relative degree? What is your relative degree?
- Did Mr. / Mrs. Know that you are here today? Is it Mr. / Mrs. Know what we
are going to talk about today? If No dont give any information
Consent Deal with consent for surgery & organ transplants
Angry relative deal with him as angry pt. ,offer to speak in office not the patient area
Social help offer
Psychological offers
Information
Giving

Explaining diagnosis or DD Explaining Treatment options
Introduce
Raise your voice 1. Introduce yourself Hello, I am .
to make all listen Name if given , & Job position (CT , SHO, Registrar)
Be self confident Check hand & Smile, eye contact
Be warm/&sympathy 2. Check patient identity Is it Mr. / Mrs..( Family name of the patient)?
- Offer a chair...Do you have a chair Mr./ ?
If he has a chair Ask him to sit. .. Sit down please?
If no offer a chair
- Sit infront look at his face (don't give him your side), But dont give your back to the
examiners. stay calm relaxed
Explain why interview I am asked by Dr/.( Explain why interview I am asked by Dr/.( or
or team) to come to talk to you about you concern team) to come to talk to you about you concern and the
Open questions treatment options
1- Would you like someone to be with us in this Open questions
consultation? 1- Would you like someone to be with us in this
2- I would like to ask you, what do you know about consultation?
the problem? 2- I would like to ask you, what do you know about the
problem?
Medical:- = . Medical:- =
Inform the patient directly ( be clear & Inform the patient directly ( be clear & honest) - Scenario
honest) - Do you know what the treatment options for your may go
- Do you know Why this Diagnosis? concern mean? beyond
- Ok I will start to explain & if anything isnt - Ok I will start to explain & if anything isnt clear or scope of
junior
clear or if you have any Question please stop if you have any Question please stop me to re- doctor, you
me to re-explain clearly& answer your explain clearly& answer your questions. must
questions. recognize &
Social /psychological =Sympathy:- Social /psychological =Sympathy:- should refer
matter
upwards;
Medical:- = Medical:- = . Ask
Explain in brief(No much technical Explain in brief(No much technical information) consultant to
information) what is the diagnosis mean provide
further
What is this diagnosis mean What are the treatment options mean? details
what are possible other diagnosis what is What are the available a treatment options? . Assistance
the next plan in management = test or And indication for each from other
therapy What are the risks without treatment = members of
During the discussion Frequently establish complications of the disease the team
That the pt understands. Is it ok? Do you What are the risks/ benefits with each treatment
have any question? option what is the outcome = prognosis - Should
Social/psychological =Sympathy:- During the discussion Frequently establish That deal with
the pt understands. Is it ok? Do you have any aspects of
situation of
Listen to concern, idea& fear + offer question? patients
(Answer, sympathize & offer solving for any Social/psychological =Sympathy:- condition as
social Q). they emerge
Listen to concern, idea& fear + offer (Answer, in
sympathize & offer solving for any social Q). conversatio
n
Same - Summary all these in simple
sentences..
- End Question. Do you have any question, Before
we end?
- Offer contact?
- Thanks the patient ..Thank you Mr. /
Mrs..? & smile/ greeting/ check hand
Angry patient Breaking bad news

Ex: postponed surgery bec busy OR ex FNAC is positive
due to RTA
Same with all

Explain why interview I am asked by Dr/ Explain why interview I am asked by Dr/.( or team)
.( or team) to come to talk to you to come to talk to you about you concern
about you concern Open questions
Open questions 1- Would you like someone to be with us in this
Social /psychological I am Sorry I consultation?
understand why you are angry, (but dont 2- I would like to ask you, what do you know about the
blame others or yourself or talk instead of problem? Or I would like to ask you, if you expect the
others; take a neutral position; I am Sorry I result?
am afraid I am not allowed to talk about that). Social =Sympathy:-
If pt said that:- " I dont want to know the result of test
offer postpone.
I "ll kill myself if the test is +ve offer
postpone + offer a Relative call
Try to suicide offer postpone + offer a
Relative call+ offer psychiatrist
contact + dont discharge
-:Medical Social/psychological =Sympathy:-
Inform the patient directly ( be clear & =
honest) Warn"Fire a Warning Shot" =incoming news is not
I am Sorry I am afraid that I have to tell good. - Scenario
you your OR is postponed/ cancelled "Unfortunately I have some bad news to tell you," or "I may go
am sorry to tell you," beyond
Medical:- scope of
junior
Diffuse the situation = offer a solution - = doctor, you
Defusing negative circumstances & allowing Shot I am afraid that , the result of test is positive must
everybody to focus instead on good for cancer recognize &
medicine. Inform the patient directly ( be clear & honest) = no should refer
(A) Social/ emotion reaction= sympathize:- false hope matter
be gentle, polite, but firmly & Apologize Social /psychological =Sympathy:- upwards;
Listen = the main bulk to solve the problem . Ask
Listen to concern, idea& fear + offer
=
Wait & check for the patient response+ react with him/ her consultant
(Answer, sympathize & offer solving for emotion ( use both verbal& body language + always your to provide
any social Q). Listen to concerns & eyes contact with pt's eyes) further
Understand: - Empathize: - Ex; "I Range of normal reaction is wide details
understand," "I can see why you're 1. If the patient keep silent you should be silent for a . Assistance
concerned," or "I can see why you feel that moment, dont interrupt & give a chance to take the shock of from other
way", - Body language; According to this bad news. members of
Mehrabian, communication consists of: - 55% 2. If cry offer tissue the team
body language, 38% tone of voice, & 7%talk. Social =Sympathy:-Break this silence, I am sorry Mr. / Mrs.
So, mirror the angry patient's, body I understand it is difficult to you. Would you like to call - Should
language& tone of voice. So, move closer to someone to be with us? Are you ok? if Ok, go on to the deal with
them, tilt your head forward, and speak in Next step. aspects of
similar volume. Move to Medical plan:-= future plan for treatment situation of
- Agree: "The problem is with the , Before discussing a treatment plan, it is important to ask patients
right? Is that correct?" yes I agree you your patients if they are ready for such condition as
- Problem Do I understand correctly? Is this a discussion. they emerge
the problem?" it involves the patient in - I would like to Ask you, do you want to tell you more about in
problem-solving. your concern? conversatio
- Address a problem & not include him in the - Would you like to start from the result of the test? n
process ("Please tell me one more about - Ok I will start to explain & if anything isnt clear or if you
your concern.") have any Question please stop me to re-explain clearly&
- Provide confirmation repeat what he said answer your questions.
("Just to be sure I understand correctly...").
- Summarize c/o = concerns:-
Start discussion:- (No much technical information)
- Release fear, tell him Ex: your concern is Share information with the patient & involve him/ her in
important to our team & you still have the the plan and prepare a patient for participation in
priority treatment decisions + respect the level of information
(B) Medical:. Last is to move the patient/ desired.
relative to future plans with hopefulness Start by aligning with what patient knows
1- The result of test is positive
2. Diagnosis, are some tests still to do? Explain
3. Treatment options, Surgery/Radiotherapy /
chemotherapy or palliative
4. Prognosis, 3. If the patient said that is the cancer
will kill me? I am afraid to tell you; yes
4 .If the patient how long I live dont tell , still early to
tell you we have some tests to do & this including
analysis of the tissue/ & or glands we will remove.
5.support Including :- cancer care Nurse
During the discussion of the treatment plan
Frequently establish That the pt understands. Is it ok?
Do you have any question?
Listen to concern, idea& fear + offer (Answer,
sympathize & offer solving for any social Q)
Same Summary all these in simple sentences ..
- End Question. Do you have any thing to tell it to me or any Summarize
question, Before we end? Any Q
- Offer contact? To you / team/ consultant Offer
Thanks the patient ..Thank you Mr. / Mrs..? & -
smile/ greeting/ check hand
contact
Thanks
Informed Medical Consent
.Know the medical facts and their implication before initiating the conversation -
:Stick to basic rules of interview: question-listen-hear-respond -
Informed consent= -Sufficient information giving to a patient (patient's right), by either the physician or their
representative, to allow the patient to make an informed decision regarding whether or
not to consent to a treatment or procedure.
(patient's right) -Sufficient information giving to allow the patient to make an informed decision
- To refuse medical care for any reason e.g. religious grounds any other personal, even if you
as physician consider their grounds to be in poor judgment.
Who give Consent - Adult> 16y ( organ donation >18y) Responsible with complete mental capacity
- If children or not fill that ( parent or legally responsible relative or persons)
Who Obtain Consent A health care provider who is reasonably involved with the patient's care.
Validity time 30 days. In cases where planned treatments in advance .e.g. chemotherapy 6 mo
If consent is not The patient has the right to sue for medical malpractice.
obtained Informed consent is necessary any time the physician is going to either touch the patient or
perform an invasive procedure
Type Consent? Written consent All cases performed in OR / invasive procedures/ Contrast Rad.
Oral consent Clinical exam/ simple treatment requirements e.g. canula/ Injections/ NGT
No Consent Only in life saving + pt unable to give (whatever the cause) or refuse.
What is Sufficient 1. Diagnosis 2. Treatment / procedure
information to be 3. Risks &benefits of treatment/ procedure. 4. Alternatives to treatment / procedure
giving 5. Risks of not receiving treatment / procedure
Informed Medical Consent
Discussion all ( in brief) Sympathize

1. Diagnosis = why - Ensure patient Understand
Establish What 2.Treatment/ = procedure - Listen to concerns/ Answer Q
The patient 3.Risks &benefits of treatment/ - Offer contact:-
Know procedure. Breast Care Nurse
4. Alternatives to treatment / Prosthetics Nurse
procedure End
5.Risks of not receiving treatment / - Summarize
procedure - Ensure patient Understand
-Offer contact
+
Obtaining Informed Medical Consent
Same with all
Explain why interview I am asked by Dr/..( or team) To come & talk to you about your
operation that is planned tomorrow / next week ?
Open questions 1st establish what he Know
- Do you know Why this operation/ surgery are planned for you?
-Ok I will start to explain some of the aims, benefits, risks and alternatives to this procedure
(operation/treatment). We want you to be informed about your choices to help you to be fully involved
in making any decisions and at the end if you are satisfied you will sign an informed consent for the
surgery.
- Please ask about anything you do not fully understand or wish to have explained in more detail -
Remember, you can change your mind about having the procedure at any time
Medical:- =
Inform the patient directly ( be clear & honest)
- Do you know Why this Operation? (= bec the Diagnosis)
- Ok I will start to explain & if anything isnt clear or if you have any Question please stop me to re-
explain clearly& answer your questions.
Social/psychological =Sympathy:-
Medical:- =
Explain in brief(No much technical information)
Discussion all ( in brief)
During the discussion
Frequently establish That the pt understands. Is it ok? Do you have any question?
Listen to concern, idea& fear + offer (Answer, sympathize & offer solving for any social Q).
Social =Sympathy:-
5.support Including :- cancer care Nurse
- Summary all these in simple sentences..
- End Question. Do you have any question, Before we end? - Offer contact?
- Thanks the patient ..Thank you Mr. / Mrs..? & smile/ greeting/ check hand
:Discussion EX: a mastectomy & Axillary Clearance

Name of & Why this Ok, You have been recommended to have a mastectomy and removal of lymph glands in the armpit
Operation (axilla) as the surgical treatment for your breast cancer.
benefits of Aim of Cure
procedure
Who perform It will be performed by a breast surgeon who is a member of the Breast Team.
Hospital stay Normally; - You will be admitted to hospital on the day of surgery.
& OP Time - OP Time generally lasts 1- 2 hrs. - You will a stay in hospital of up to 5 days.
Anaesthesia It will be performed GA (which means you will not be conscious during the surgery).
The anaesthetist will see you before the procedure to assess your state of health&
discuss the details with you.
During the Anaesthetic and/or sedation will be given to you
procedure Mastectomy: This involves making incisions (cuts) around the breast, removing most of breast tissue,
including nipple & areola (dark skin around the nipple), + some of breast skin, which leaves a scar that
is flat against the chest wall.
Axillary Clearance: Lymph glands under the arm (armpit) drain lymphatic fluid from breast & arm.
Sometimes the cancer spread to these glands. The procedure = removal of these glands (if present) as
far as surgically possible). This wills possibility of a recurrence of the cancer under the arm, +
informing us whether the glands are involved by the cancer, which helps us plan the next treatment.
After the procedure Recovery: - After your operation You will wake up in the recovery room You may feeling sleepy. - You
may have an oxygen mask on your face to help you breathe.
- You will have an intravenous line (called a drip) in your arm. This may be attached to a bag of fluid
(called a drip), which provides fluid until you are well enough to eat and drink by yourself. - A nurse
will check your pulse & blood pressure regularly.
- When you are well enough to be moved, you will be taken to the ward.
Drain - You may have a plastic tube coming from your wound collects tissue fluid in a small
collecting chamber, which is measured daily. When there is fluid collected < 50ml/d the tube will
be removed, which is a simple procedure. It will be possible for you to go home with the drain in place.
Eating and drinking: you will be able to drink & eat (usually 2-4 hrs.
Mobilization: You will be encouraged to get out of bed as soon as possible and move around, this is to
help prevent blood clots forming in your legs.
We will arrange for a physiotherapist visit you on the ward to give advice exercises.
Before you leave the ward, you will be given two temporary prostheses comfies. Fitting the
permanent one will be about six to eight weeks after your operation and the service is provided free of
charge.
Leave hospital: if you are well enough. you may go home the day of or day after your surgery
Begin gentle work within 1- 2w, but a little longer( 6w) for more vigorous activity.
Special measures to take after procedure: You will be given more detailed information about any
special measures & about things to watch out for that might be early signs of problems (e.g., infection).
The skin stitches are dissolvable and will not need to be removed. You will have a light dressing
covering your wound to keep it clean, and this will usually be in place for the first day or so. These will
gradually come off in the bath or the shower.
Check-ups and results: You will be given a date to return to clinic for the results of your surgery. By
then the tissue removed at the operation will have examined and your results discussed by the Breast
Care Team. Any further treatment, if recommended, will be discussed with you then.
Post surgical Plan the next stage of treatment (adjuvant therapy) to help prevent recurrence of cancer &improve
treatment your outcome. When deciding if you need post-surgical treatment (called adjuvant therapy), your team
will assess several factors, including: the risk of cancer recurring, characteristics of the cancer,& how
much the treatment will benefit you. This will be discussed with you by a member of the Breast Team.
Information and support. Additional information will be given to you in the form of a Patient
Information Breast Care Pack.
Social/psychological =Sympathy:- Do feel free to speak to a member of staff if you have any questions
or anxieties. Breast Care Nurses Prosthetics Nurse
Alternative Mastectomy In some cases it is possible to treat cancer by removing part of the breast only.
procedures that are When surgery is inappropriate, the cancer can be treated by radiotherapy or medication alone.
available Axillary clearance Radiotherapy to the axilla. However, the present recommendation by the Breast
Team is that in your case, mastectomy and axillary clearance is the best form of treatment at this stage.
Other forms of treatment may be utilized in the treatment of cancer such as radiation therapy (using
high-dose x-rays to kill cancer cells), chemotherapy (drugs kill cancer cells), and hormone therapy
(hormones to stop the cells from growing)..These will be discussed with you if and when appropriate.
Complications/ risks Surgery: All operations have a small risk of side effects, such as pain, bleeding and infection. The risks
associated with general anaesthesia include potential breathing and heart problems, as well as
Very common possible reactions to medications will be discussed by The anaesthetist .
= 10 % Serious or frequently occurring risks
Mastectomy: Altered sensation: You might have tingly feelings or shooting pain where the breast was
common= removed, this can last for six months or longer. Additionally, some women notice a change in their
1% balance due to the loss of the breast weight. Wearing a prosthesis helps with this problem.
Seroma; is a collection of fluid under your chest scar after surgery. It is relatively common, but is easily
Uncommon treated by simple procedure = drainage through a small needle..
(1 /1000 ) Axillary clearance:
Numbness: You may experience numbness and discomfort in the armpit and upper arm. The
Rare= numbness usually lessens slowly, after treatment, but might not resolve completely
(1/ 10,000) Shoulder stiffness: The shoulder may become stiff and painful after your operation. Performing shoulder
exercises (taught to you after the operation) improves mobility.
very rare= Lymphoedema is a swelling in the tissue below the skin caused by lymph fluid which cannot drain
(1/100,000) away. This can occur when the lymph glands are removed (by surgery) or blocked (by radiotherapy)
secondary to scar tissue formation. The hand and or arm may swell at any time after the surgery. It can
affect about 15 to 20% of women but only around 5% to a significant degree. There are certain
precautions you need to take to prevent lymphoedema, these will be discussed with you by the Breast
Care Nurse.

( 5 )
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Thyroidectomy
= + ) 10 (

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-: /)........ = ( ) (

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-: ) (

Explain why interview I am asked by Dr/..( or team) To come & talk to you about your
? operation that is planned tomorrow / next week
Open questions 1st establish what he Know
?- Do you know Why this operation/ surgery are planned for you
-Ok I will start to explain some of the aims, benefits, risks and alternatives to this procedure
(operation/treatment). We want you to be informed about your choices to help you to be fully involved
in making any decisions and at the end if you are satisfied you will sign an informed consent for the
surgery.
- Please ask about anything you do not fully understand or wish to have explained in more detail -
Remember, you can change your mind about having the procedure at any time
Preoperative What is a thyroidectomy?
Before Surgery A thyroidectomy is the removal of all (total) or part (partial) of the thyroid gland.
Explain; Why is a thyroidectomy?
Simply You may need to have this operation because you have a swelling which could be cancerous or because
your gland is overactive. If you do not understand any of the information please ask, since it is importan
that you make the right decision.
When will the operation be done?
Time in Preoperative= OPD Admission/ Fitness Assessments:- Attend OPD before surgery( 1- 2w
before surgery = assess fitness for sugery &1day for Admission)
1day before You will be admitted through the outpatient clinic
your operation
one or two You will be invited to attend a pre-admission assessment clinic to assess your health
weeks before needs and carry out routine tests which may be required prior to surgery such as
your operation blood tests, a heart tracing also known as electrocardiogram (ECG), or a chest X-ray
+ Ear/ose/ larynx physician will assess the normal function of the nerve that controls
your voice-box
Operative
Surgery OR Time 1-2 hours.
Name of Surgeon Consultant/or Team( name if given in scenario)
Anaesthesia GA/ -position Supine with head lower 20o & sandbags between shoulder/ skin prepared +draped
Steps (simple) Through an 8 cm transverse skin cut in lower neck then layers opened in .. .. . The
surgeon will either remove one half of the thyroid (called a thyroid lobectomy) or remove the whole thyroid
(called a total thyroidectomy), depending on the abnormality of the thyroid gland. ( ectomy =excision
=Removal of the organ out = + after control of blood supply + ensuring stop bleeding)
Post operative Time in Post operative + Treatment
After surgery
General Any operation can have potential risks ( bleeding, infections( chest, UTI , wound), Clots in
leg veins lung vessels ( & special precaution will be taken according to patient risks), othe
cosmetic of scar problem( hypertophic / Keloid)
Specific - Damage to the nerve that controls your voice-box (0.5 -1% chance), this can
few
Day risks
of leave you hoarse.
Recovery.. Most patients
Following are ayou
the operation little husky
are after
kept in the operation,
the theatre recoverybut
areathis
for is
Surgery caused
aroundby 3-4having
hours andan operation
then returnedon your
to theneck
ward.and having a tube placed down your
Drip for
throat When you wake
breathing andup,usually
there will be a drip
settles afterin a
your
fewarm Through which fluids+ Antibiotics
weeks.
+pain killer
- Damage togiven
your to you.
parathyroid glands (5% chance). These are four little glands
Drain:
next Also,thyroid,
to your a little drain(
whichplastic
control tube
theconnected to a small
blood calcium. Weplastic bag to remove
will perform routineanyblood
remaining blood out) in your neck with a dressing around it.
tests after your operation to make sure that the blood calcium level is normal. If the
Drink You will be allowed to drink the same night + Walk You are encouraged to be as
blood
activecalcium level is low, then we will start you on calcium tablets. The chance of
as possible.
needing calciumtest
Daily calcium tablets at one
in blood year after
to check the operation
Hypofunction of otherisnearby
aboutgland
1%. called
- Significant
parathyroid wound bruising
gland ( control (3% chance)
calcium that blood)that
() in your need returnmytobeoperation
damaged room again to
or removed
1st Day evacuate
Day nextclotdrip
+control bleeding
and the drain(1- 2d or output < 100cc for 2 d) will be removed.
after Depending on the type of operation that was done on your thyroid, you may be started
Surgery on thyroxine therapy this is a natural hormone that replaces the job of the thyroid gland
And If your gland has been over-active, then the anti-thyroid medication is stopped.
2nd Day Discharge Usually on the 2nd day after you surgery you will allowed to go home
after
Surgery
5th Day There will be one stitch under the skin, which will be removed by your GPs nurse, five
Complications
after days after the operation.
Very common
Surgery
= 10 %
1- 2w after You can return to work
common= Surgery
1% 6-8w after You will attend OPD to assess thyroid function by doing hormone tests (TFTs)
Surgery
Uncommon
(1 /1000 ) Complications General Specific
In OR - Death/ bleeding - injury of the nearby structures
Rare= Post operative - Pain - Effects of the nearby structures injury)
(1/ 10,000) Immediate ( 1st - Bleeding / haematoma - wound blood clot may need push to
day ) - Those of Anaesthesia lung collapse operation room again to evacuate clot
very rare= due air passage block +control bleeding
(1/100,000)
Early ( 2nd d - Bleeding , bruises, infections( wound, - Wound Abscess) wound open
1st 2 w) UTI Respiratory) wound open effects of the nearby structures injury)
DVT/ PE ( clots in leg/ lung vs) - Effects of the nearby structures injury)
Late (after 2 w) - Effects of the nearby structures injury)
Delayed ( after Scar ( Keloid/Hypertrophic) - Effects of the nearby structures injury)

2 mo), Effects of organ removal ( hypofunction
- Recurrence
Problem = Refusing surgery = Complication of the disease + inform him that you have all rights to refuse surgery
And a 2nd surgical opinion is available for but should know what the benefit of surgery ( cure) and what is
the risks of refusing surgery= Progression +Complications of the disease
Other Treatment options if pt Afraid of Complications give him what other option if available for his case
indications+ benefit &risks for each e.g. medical /radiotherapy radioactive iodine,/ radiation/ chemotherap
As
( =) = II
) = ( ) = ( ) .
= (
-1 -:
-3 ..... -2 ...
-4 ....

...........

+
Common surgery consent
( 10 ) + =

Same in all OR Consent
Preoperative What is? Surgery definition

Before Surgery Why is.? = treatment option Diagnosis
Explain; If you do not understand any of the information please ask, since it is important that you make the right
Simply decision.
When will the operation be done? Day case or otherwise same in all elective
Operative
Surgery OR Time .hours.
Name of Surgeon Consultant/or Team( name if given in scenario)
Anaesthesia GA/ -position skin prepared +draped
Steps (simple) Through Acm skin cut in then other layers opened in .. .. . The surgeon will
remove. . ( ectomy =excision =Removal of the organ out = +
after control of blood supply + ensuring stop bleeding) to be sent for analysis
Post operative Time in Post operative + Treatment Same as before Unless A day case surgery (discharge in same da
After surgery and some few specific Postoperative follow up (Drain removal stitch removal
Complications General Any operation can have potential risks ( bleeding, infections( chest, UTI , wound), Clots in
Very common leg veins lung vessels ( & special precaution will be taken according to patient risks),
= 10 % other cosmetic of scar problem( hypertophic / Keloid)
Specific
common= few risks
1%
Uncommon
(1 /1000 )
Rare=
(1/ 10,000) Complications General Specific
In OR - Death/ bleeding - injury of the nearby structures
very rare= Post operative - Pain - Effects of the nearby structures injury)
(1/100,000) Immediate ( 1st - Bleeding / haematoma - wound blood clot may need push to
day ) - Those of Anaesthesia lung collapse operation room again to evacuate clot
due air passage block +control bleeding
Early ( 2nd d - Bleeding , bruises, infections( wound, - Wound Abscess) wound open
1st 2 w) UTI Respiratory) wound open effects of the nearby structures injury)
DVT/ PE ( clots in leg/ lung vs) - Effects of the nearby structures injury)
- Effects of the nearby structures injury)

Late (after 2 w) Scar ( Keloid/Hypertrophic)
- Effects of the nearby structures injury)
Delayed ( after Effects of organ removal ( hypofunction
2 mo), - Recurrence
Problem = Refusing surgery = Complication of the disease + inform him that you have all rights to refuse surgery
And a 2nd surgical opinion is available for but should know what the benefit of surgery ( cure) and what is
the risks of refusing surgery= Progression +Complications of the disease
Other Treatment options if pt Afraid of Complications give him what other option if available for his case
indications+ benefit &risks for each e.g. medical /radiotherapy radioactive iodine,/ radiation/ chemotherap
As
( =) = II
) = ( ) = ( ) .
= (
-1 -:
-3 ..... -2 ...
-4 ....

...........

+
Obtaining Organ transplant consent
Obtaining Organ transplant consent +

I- Breaking bad news
II- Informed Organ transplant Consent
Same as with all
I- Breaking bad news
Explain why interview I am asked by Dr/.( or team) to come to talk to you about you concern
Open questions
1- I would like to ask you, what is your relation to the patient ?
2- Would you like someone to be with us in this consultation?
3- I would like to ask you, what do you know about the problem?
If pt said that:- " I dont want to know offer postpone.
I- Breaking bad news Inform death ( warn / Shot ) (wait & Listen react)
Then cut the silence Explain ( Brain death)
=
Warn"Fire a Warning Shot" =incoming news is not good.
"Unfortunately I have some bad news to tell you," or "I am sorry to tell you,"
Medical:-
, Shot I am afraid to tell you =
Inform the relative t directly ( be clear & honest) = no false hope
Social /psychological =Sympathy:-
=
Wait & check for the patient response+ react with him/ her emotion ( use both verbal& body language
+ always your eyes contact with pt's eyes)
Range of normal reaction is wide
1. If the patient keep silent you should be silent for a moment, dont interrupt & give a chance to
take the shock of this bad news.
2. If cry offer tissue
Social =Sympathy:-Break this silence, I am sorry Mr. / Mrs. I understand it is difficult to you. Would
you like to call someone to be with us? Are you ok? if Ok, go on to the Next step.
Move to Medical plan:-= Explain brain death + Possibility to Disconect breating machine
Before discussing
, it is important to ask the relative if they are ready for such discussion.
- I would like to Ask you, do you want to tell you more about this?
- Ok I will start to explain what does the brain death mean? & if anything isnt clear or if you have any
Question please stop me to re-explain clearly& answer your questions.
Start discussion: Explain ( Brain death)
discussPossibility to Disconect breathing machine it is the breathing machine that make him
lives and without it he cannot take his breath
During the discussion Frequently establish That the pt understands. Is it ok? Do you have any
question?
Listen to concern, idea& fear + offer (Answer, sympathize & offer solving for social Q).
II- Informed Organ transplant Consent
Medical:- = Explain Organ transplants

-

Explain in brief(No much technical information)
- Do you know What this mean?
- Ok I will start to explain & if anything isnt clear or if you have any Question please stop me to re-
explain clearly& answer your questions.

Medical:- =
During the discussion establish That pt understands. Is it ok? Do you have any question?
Listen to concern, idea& fear + offer (Answer, sympathize & offer solving for social Q).
- Summary all these in simple sentences..
- End Question. Do you have any question, Before we end?
- Offer contact?
Thanks the patient ..Thank you Mr. / Mrs..? & smile/ greeting/ check hand -
Information
Gathering
Information gathering
History (H/O) Taking
The history of the present illness (HPI) includes all of the patient's history, both recent and
remote, that is pertinent to understanding the current illness
Complete present history (= you will have collected a great deal of data)
the remaining medical history = past medical history+ family history+ social history/patient
profile ( sympathy ), and + review of systems.
Of course, new information may appear at any time. During the remainder of the interview, the
physician directs the patient to fill in the blanks, completing the rest of the history.
Each new piece of information is assessed for reliability, completeness, and relevance to the
patient's problem. The physician should repeatedly scan the information already gathered
looking for symptom complexes or diagnostic patterns. For example, the physician
interviewing a 30-year-old woman with fever, back pain, and urinary frequency would
immediately consider the possibility of a urinary tract infection. With increasing knowledge of
clinical syndromes, the clinician's ability to form more complex diagnostic hypotheses
improves. Each hypothesis is tested for validity with further specific questions such as, "Have
you ever had a bladder or kidney infection? Any kidney stones? Are you sexually active?"
Through this process, speculations are tested against objective reality and accurate
hypotheses are generated.
Social /psychological =Sympathy:-= Frequently, problems in the interview. Patients often

have specific, perhaps unrealistic, fantasies about what the physician will or can do. The
interviewer should try to identify these. The patient's explanatory model of illness, differing
with each patient and with each cultural group, may significantly determine an individual's
behavior during an illness and affect compliance with medical therapy. Negotiation may bring
doctor and patient closer together
1- Patient's emotional reactions = (anxiety, fear anger or helplessness) Pick up during

the interview Listening=physician's interest and concern + encourages the patient
to go on talking. React = Responses vary with the severity of illness, past
experiences, personality, current stresses and supports. Reassurance may be
provided an attempt to reduce the patient's anxiety but avoid false reassurance the
unrealistic promise of a happy outcome. Statements such as "Anyone would be upset
if they didn't know what caused their pain" or "Waiting for biopsy results is pretty
tough for most patients" may increase the patient's self esteem and let him or her
know that it is all right to share experiences with the physician .
2- + Social history. Sex During the sexual history, patient's often respond more candidly
to the statement "Some patients with heart problems find that they have difficulties
with sexual function . Has this been a problem for you?" rather than "How is your sex
life?" Social history Patients often respond defensively to questions such as "How
much do you drink?" minimizing the quantity to please the interviewer. Smoking,
Alcohol, Living (who is living with youcare you at home is it away from
hospital is there telephone
3- Empathy is closely related to reassurance . Empathic statements communicate the

physician's recognition of the patient's feelings and provide feedback that the
interviewer understands . Empathy begins with the interviewer identifying the patient's
emotional state . The following statement communicates the physician's recognition
and acceptance of the patient's feelings and encourages further exploration of what is
going on : "You look sad when you talk about your son Can you tell me more about
him?" Pointing out the patient's emotion is a form of gentle confrontation . It focuses
attention on an aspect of the patient's feelings that has been communicated through
statements or behaviors .
Communication problems Example; Patients cry peace= best to let the storm pass.
Then gently resume "You seem angry about that . Can you tell me more about what has been
going on?"
patient does not want to talk about issues that seem important. "You seem reluctant to talk
with me about your problems. I wonder if you may be uncertain about whether or not you can
trust me . .. For me to be able to help you I need to know as much as possible about your
problems . . . . How do you think we should proceed?" These statements identify the problem
with a confrontation, suggest a possible cause for the problem (distrust), establish the
physician's need to know more, and invite patient participation in deciding what course the
interview will take .
Type of Questions Begin each line of inquiry with an open-ended question and proceed to
more specific questions to fill in the gaps.
Effective questions are usually simple. Avoid double-barreled questions, such as "Are you
having any stomach pains or bladder problems?"
To do a complete ROS, however, would take forever. Look in any good history and physical
examination book and see the list that they dedicate to ROS. Impossible.
LIST of RoS questions from the Schwarz physical exam book onto a cheat sheet.
who on earth asks about exposure to diethylstilbestrol?!
I don't ask about this on all of my patients especially if I think I know what is going on or the
patient has a specific organ system complaint. I also occasionally ask more if I have no idea
what is going on. What the other poster said about a focused ROS is acutally called
associated symptoms which should be part of your HPI. Usually when I see a patient I will
tailor my ROS to areas that are appropriate to the pts age. I usually always ask about the
lungs, heart and abdomen.
You'd be surprised how much of this is positive. Most of it is just passing annoyances, but you
never want to miss a red flag or a collection of positives that may indicate an underlying
syndrome (such as cold intolerance, recent weight gain, and thinning hair possibly indicating
a thyroid abnormality).
A Review of Common Problems

1 . Confusing the traditional, rigid order of the written medical history with the actual process
by which information emerges during the medical interview.
2. Relying too heavily on directed, closed questions . This style discourages the patient's
associations and spontaneous report of symptoms .
3. Ignoring the patient's emotional responses and concerns during the interview process .
4. Narrowing the scope of inquiry too early in the interview.
5 . Failure to clarify the seven dimensions of a symptom in the patient's own words .
6 . Insisting that the interview must be accomplished in one session . (Experienced clinicians
return to the patient again and again to clarify the history .)
7 . Limiting the list of diagnostic hypotheses before adequate data has been collected .
8. Using questions that are leading, too complex, double barreled, or unclear .
9. Failure to follow basic courtesies in the interview : lack of clear introductions, ignoring the
patient's comfort, and failure to establish an atmosphere of trust and confidentiality .
10. Failure to elicit the patient's own ideas about the cause of the problem and the patient's
fantasies about what the doctor will do .11 . Note taking that interrupts the flow of the
interview .
REVIEW OF SYSTEMS (ROS):- If positive analysis as usual ( OCD + what you think it
cause this Site Quantity/ Quality what & what.
History (H/O) Taking Never to use medical term use simple language if you cannot know just
simplify the term by defining it. as we call it.OR Ask patient to describe what he feels.
How you feel during he pass urine Is there any trouble ?
History (H/O) Taking

Same as with all

Explain why interview:- I am asked by Dr/.( or team) to come to talk to you about you concern
Social /psychological =Sympathy:- I will ask you some questions about your concern that are very
important in assessment of your diseases and so its management
Take a permission to write these notes: 1st please I would like to ask you a permission to write these notes
bec I will present these information to my consultants at the end of the interview Is it ok?
I am going to star now is it ok?
Medical:- = Social /psychological =
Social /psychological =Sympathy:- =
SOCIAL POINTS, Offer help in a question
PSYCHOLOGICAL POINTS, Offer help this in a question
Medical:-
PERSONAL Your name is Mr. / Mrs.,(Family Name) ., Age.y, work as .
H/O: - So I am right?
Are you having kids? if yes how many..
+ Social H/O :- (Sexual H/O :- HIV risk, married/kids/)
& , special habits Are you Smoking? if yes how much /day? For how long?
Are you alcohol? if yes how much
C/O= What is the problem What is you concern? .
concern / Pain Swelling Dysfunction Others ( in patient wards)
problem
PRESENT
H/O:- Analysis - ex ( pain..) Should mention (OCD) onset, course and duration.
the main What & What .
symptom You Should Ask Aboutas follow..
s - Duration:- when The condition start what happen 1st (H/O of
main symptoms) is it sudden/ acute/
insidious(Onset ) What do you think it cause this? ( cause/ ppt
factors)
(Following H/O of cause)
- With........................................... ex ( pain) how is pain severity/ 10(
is it slight moderate or sharp and severe ....is it constant or coming
and going...character ((what does it feel like? is it / burn/ can
you describe it .where is it ?.. referred to ( is it go
to another site? ..

What ..& What
..
- Course :- ( progressive/ regressive/ stationary)

ASSOCIATED SYMPTOMS (Other related) symptoms Same disease

& organ ( system ) You Should Ask Aboutas follow.. Do you have
any ..
............................................
............................................
A REVIEW - Start with related system then nearby then away
OF - Aiming to elicit what can cause this problem Effects and complications
SYSTEMS of the disease & to differentiate other diseases that may be similar &
(ROS):- mistaken for your disease
- This to make sure we do not mess anything that may be important.
- If positive analysis as usual ( OCD + what you think it cause this
Site Quantity/ Quality what & what).
-You Should Ask About as follow.. Do you have any..
1. Cause and risk factors............................................
2. Complications symptoms = Effects of the disease

Local =
Regional = LNs= other swellings/ or their effects e.g. pressure symptoms
General e.g. Constituational ..
Systemic effects
..
3. DD symptoms
Systems You Should Ask Aboutas follow.. Do you have any

trouble with. Systematic direct questions
-I'm now going to ask you a series of questions about common
medical problems. This to make sure we do not mess anything that
may be important.
System review
CVS Do you have any trouble with your heart, chest pain or
palpitation?
Respiratory Do you have any trouble with your lungs, shortness of
breath, coughing or sputum?
GIT Do you have problem in digestion, lose weight, difficulty in
swallowing, heart burn, nausea/vomiting, abdominal pain, swelling,
change of bowel habits, rectal bleeding?
Genitourinary Do you have any problems passing urine, change of
color, pain, smell?
Female Do you have problems in menstruation? Do you have
children? How many? How old is the youngest? (Female)
H/o of You Should Ask Aboutas follow.. Do you receive or treatment or Do
present any test for this proble
invest/ ttt
PAST H/O Transitional statements prepare the patient for what is coming next
Now I would like to ask you some questions about your past health.".
(SURGICAL):- Do you have any
1- Surgery Past history Did you have any operation before?
Have you been admitted to any hospital before?
2 - Previous evaluation of or (treatment for) a disease (e.g., medications, injections,
surgery, compression). Did you have any
3 - Other diseases:- Did you have any
Related disease/ Associated.
(MEDICAL)
1- Medical Systemic disease (affect outcome) (e.g. DM, HTN, CHD, CVA)
2- Medications Do you take any medication or contraceptive pills (Female)?
4- Allergy ( food, Drugs) Do you have any allergy?
FAMILY H/O = (Genetic) H/O of disease ( 1st relatives).
Transitional statements prepare the patient for what is coming next
Now I would like to ask you some questions about
Do you have any similar problem in your family (children, parents, brothers,
sisters)?
Does anyone of your family have a heart disease, DM, blood pressure, tumor or any
chronic disease?
Social /psychological =Sympathy:- Patient concern
"Before we go on, let's see if I understand your history. I am going to summarize what you told me to be
sure that I am not missimg any thing important Ok.
- Summary all these in simple sentences (+ve. findings)
- Last March you first noticed .." This summary gives the patient a chance to
check the accuracy of the history and gives the physician a chance to review the history for
gaps or lack of clarity ..
?Is It ok? Is this all things? Are you concerned about anything else -
Do you have any question,?
Offer opportunities available for further information
Offer contact?
. So I am going to present these information to my consultants is it -
- Thank you Mr. / Mrs..? & smile/ greeting/ check hand
Again General sheet (H/O Taking)
Hello I am (position) Is it Mr. . Sit down please. (Smile with eyes

contact)
Explain why interview:- I am asked by Dr/.( or team) to come to talk to you about you concern
Social /psychological =Sympathy:- I will ask you some questions about your concern that are
very important in assessment of your diseases and so its management
Take a permission to write these notes: 1st please I would like to ask you a permission to write these
notes bec I will present these information to my consultants at the end of the interview Is it ok?
I am going to star now is it ok?
Medical:- = Social /psychological =

The main task

Medical:-
Personal history Name - Age Occupation (Already known from scenario)
Social history Sex ( active or not / married or not ) have kids or not
Smoking (how much / d X how long) Alcoholic ( How much / w X how long)
Complaint Pain Swelling Dysfunction Others ( in patient wards)
Present History
I- Present History Analysis
II- A Review of Systems ( mainly that related to disease) Aiming to elicit
( Causes & Risk factors / complications /D.D/ fitness for surgery)
III- H/ O of Present Investigation & treatment
Past History
Surgery (any surgery if yes( what when & complications including
anaesthesia)
Medical (diseases/ drugs/ allergy last meal in emergency surgery)
Family History
Social /psychological =Sympathy:- =
SOCIAL POINTS, Offer help in a question
PSYCHOLOGICAL POINTS, Offer help this in a question
During H/ O Taking frequently establish that the pt any question. Do you have any question?
Is it ok? Or something to added or explain Anything else or any thing to explain

"Before we go on, let's see if I understand your history. I am going to summarize what you told me
to be sure that I am not missimg any thing important Ok.
- Summary all these in simple sentences (+ve. findings)
- Last March you first noticed .." This summary gives the patient a chance to
check the accuracy of the history and gives the physician a chance to review the
history for gaps or lack of clarity ..
?Is It ok? Is this all things? Are you concerned about anything else -
Do you have any question,?
Offer opportunities available for further information
Offer contact?
. So I am going to present these information to my consultants is it -
- Thank you Mr. / Mrs..? & smile/ greeting/ check hand
(Verbal) PRESENTATION of History (H/O) Taking ( 5min) (+ve. findings)

- Simple language - Methodical approach - Comprehensive
- Succinct (keep to 5 minute limit)
- Emphasis and significance - keep appropriate to surgical context
- Interpretation of ideas and concerns
PERSONAL H/O: -Mr. / Mrs.,(Family Name) ., Age.y, work as
Social H/O :- (Sexual H/O) :- ..married/ kids/) .Smoking / day.. alcohol /w
C/O= concern / problem
PRESENT H/O:- = Main Bulk
I- Analysis the main symptoms:- The condition start since with.
of sudden/ acute/ gradual( onset).. of ..= main symptoms)
(Following H/O of cause)
- The .= main symptoms).......................................... ex ( pain) how is pain severity/
10( is it slight moderate or sharp and severe ....is it constant or coming and going.
..character ((what does it feel like? is it / burn/ can you describe it .where is it ?
.. referred to ( is it go to another site? ..

What ..& What ..

- Course :- ( progressive/ regressive/ stationary)
............................................
ASSOCIATED SYMPTOMS (Other related) symptoms Same disease & organ ( system )
............................................
............................................
II- A REVIEW OF SYSTEMS (ROS):- If positive analysis as usual ( OCD + what you
think it cause this Site Quantity/ Quality what & what.
1. Cause and risk factors............................................
2. Complications symptoms = Effects of the disease

Local =
Regional = LNs= other swellings/ or their effects e.g. pressure symptoms

General e.g. Constituational ..
Systemic effects
..
3. DD symptoms
Systems
CVS
Respiratory
GIT
Genitourinary
Female
III- H/o of present invest/ ttt
PAST H/O
(SURGICAL):-
1- Surgery Past history
admitted to any hospital at / /
2 - Previous evaluation of or (treatment for) a disease (e.g., medications , surgery, compression).
3 - Other diseases:-
Related disease.
Associated.
(MEDICAL)
1- Medical Systemic disease (affect outcome) (e.g. DM, HTN, CHD, CVA)
2- Medications Do you take any medication or contraceptive pills (Female)?
4- Allergy ( food, Drugs) Do you have any allergy?
FAMILY H/O
The examiners will discuss you about ( 5 min)

1. What DD would you suggest at this stage based on the history?
2. What signs would you look for specifically in the examination
3. What investigations would you request for this patient?
- Thanks all examiners
Main Present History Analysis Questions

sympto You should know what you Ask about
ms
Pain Analysis of The Main Symptoms

Site & referral Where is it? Where it goes?
OCD Onset Is it sudden or gradual?
Course by time Is it or no change constant? How often does it happen?
Duration When did it start?
Severity How bad is it? 1/10
Character (Burning, throbbing, stabbing, constricting, tightness, What does it feel like?
colicky or just a pain)
Relation to act (= meal / effort (walking exercise elevation
Relation to rest ( rest/ sleep) & position stand/ lying flat )
Exacerbating factors What brings it? Or
Relieving factors What eases it? Or
A Review of Systems ( mainly that related to

disease)
Aiming to elicit ( Causes & Risk factors /
complications /D.D/ fitness for surgery)
ROS = Other associated /Symptoms or H/O of the
1- Cause like trauma,infection, inflammation, PVD, Venous, Why do you think you've got it?
Neuropathy, cancer
2- Complications
Local ( same organ/ system of the main complain + nearby) Do you have trouble with ..
(swelling/ disturbed function)
Regional LNs Ask about Swellings ( Associated/ Do you have any lumps?
complication local or regional e.g. LNs) or DD
General Constitutional symptoms Did you become feverish?
Systemic symptoms (cause/ complication/ DD/ surgery

fitness ( Heart, breathing, Neurology, GIT, GUT, PVD, Ortho) ) Do you have trouble with ..
other body system quick direct Questions & if any +ve
analysis
3- DD ( could be local causes/ referred/ same system or
other system) Do you receive any recent treat
or have any test for your problem
H/ O of Present Investigation & treatment
Swellings Analysis of The Main Symptoms

Lumps Site Where is it?
Course By time Is it or no change
constant?
Duration When did it start?
Ass symptoms ( Painful/ painless) ( cause / complication/ DD)

Is it painful?
disease)
ROS = Other associated /Symptoms or H/O of the.
1- Cause congenital (dating since birth or shortly) trauma, Why do you think you've got it?
infection, inflammation, PVD, Venous, Neuropathy, cancer
2- Complications
Local ( same organ/ system of the main complain + nearby) Do you have.
(swelling/ disturbed function) = pressure or difficulty in
(function)
Regional LNs Ask about other Swellings ( Associated/ Do you have any other lumps?
complication local or regional e.g. LNs) or DD
General Constitutional symptoms Did you become feverish?
Systemic symptoms (cause/ complication/ DD/ surgery

fitness ( Heart, breathing, Neurology, GIT, GUT, PVD, Ortho) ) Do you have trouble with ..
analysis
3- DD ( could be local causes/ referred/ same system or
other system)
Do you receive any recent treat
Ulcer Analysis of The Main Symptoms

Site Where did it start?
By time Is it or no change
Course constant?
When did it start?
Duration
Is it painful?
Ass symptoms ( Painful/ painless) ( cause/ complication/ DD)

disease)
Aiming to elicit ( Causes & Risk factors /
complications /D.D/ fitness for surgery)
ROS = Other associated /Symptoms or H/O of the. Why do you think you've got it?
1- Cause congenital (dating since birth or shortly) trauma,
infection, inflammation, PVD, Venous, Neuropathy, TB,
malignancy, SCC, BCC/ Marjolin) Do you have.
2- Complications
Local ( same organ/ system of the main complain + nearby) Do you have other ulcers?
(damage & spread /swelling/ disturbed function) = other ulcer/
swelling/ or difficulty in (function) + Ask about other ulcer Do you have any lump?
Regional LNs Ask about other Swellings ( Associated/

complication local or regional e.g. LNs) or DD Did you become feverish?)
General Constitutional symptoms
Systemic symptoms( cause/ complication/ DD/ surgery Do you have trouble with ..
fitness ( Heart, breathing, Neurology, GIT, GUT, PVD, Ortho) )
analysis
3- DD ( could be local causes/ referred) Do you receive any recent treat
.
SYSTEMS Do you have Ask about Do you have? Do you feel..?

any trouble with.
General/Constitutional o Fevers? o Chills? o Sweats?

o Weight changes?
o Weakness? o Fatigue?
o Heat/cold intolerance? ..Do you prefer cold/ hot weather
o Bleeding? o Blood transfusions/possible reactions?
Skin o Rashes? o Itching? o Easy bruising? o Dryness?

o Changes in skin/hair/nails?
Head o Headaches o dizziness o Fainting?

o H/o of head injury?
Eyes o Use of glasses/contacts o Change in vision?

o Double vision? o Pain when looking at light?
o Pain? o Redness? o Discharge? o Infections?
o Excessive tearing? o Recent eye exams? o H/o of eye Injuries?
Ears o Hearing difficulty ? o Use of hearing aid?

o Discharge? o Pain? o Ringing in ears? o Infections?
Nose o Nosebleeds? o Infections? o Discharge? o change in smell

o Frequency of colds? o Nasal obstruction? o History of injury?
Mouth/Throat Mouth o Pain o Discharge o Lump o change in Taste

o Condition of teeth o Condition of gums o Bleeding gums
Throat o Frequent sore throats o Hoarseness
o Voice changes o Past nasal discharge
Neck o Pain o Pain on mvmt o Discharge o Lump/ Lumps o Goiter
Breasts o Lumps o Discharge o Pain swollen glands in armpit
Chest Respiratory o Pain o Shortness of breath o Cough o Sputum (quantity, appearance) o Coughing up blood o
Wheezing
o Last x-ray
Heart o Chest pain o High blood pressure o Palpitations

o Shortness of breath with exertion/ when lying flat/ or Sudden While sleeping? o History of heart
attack
Vascular o Pain in hips, legs, calves, thigh while walking o Coolness of extremity o Loss of hair on legs o
Discoloration of extremity o Swelling of legs o Varicose veins o Ulcers
GIT o Appetite (is the desire to eat or is to cause discomfort )

o Excessive hunger o Excessive thirst
o Nausea o Vomiting ( OCD amount color relation to meal + what & what. + pain/associated
Symptoms) o Vomiting blood
Oesophagus o Difficulty in Swallowing( OCD site, relation to meal fluid vs. solid what & what. +
pain/associated Symptoms) o Heartburn
o Excessive belching Abdominal pain ( OCD site,
radiation severity 1/10, type can you describe how you feel it , relation to meal + what & what. + Ass
symptoms) Colorectal & anal Change in bowel movements o Laxative or antacid use o
Constipation
o Diarrhea( OCD amount consistency, color odor, mucus blood what & what. + pain/ass symptom)
o Hemorrhoids o Rectal pain o Rectal bleeding o Black, tarry stools

Liver disease o Ascites (do you have any Change in abdominal size + wt gain o Jaundice (do you have
any yellow change in your eye colour) abd pain/ fever/ chills
o Hepatitis o Gallbladder disease( OCD site, radiation severity 1/10, type can you describe how you
feel it , relation to meal + what & what. + associated Symptoms Jaundice / fever )
You going to the bathroom okay? Anything hurting you?
Frequent Urgent do you pass too much
o Awakening at night to urinate o H/O of retention o Incontinence o Bed-wetting
o Urine color o Urine odor o Infections o Stones o Flank pain
Male genitalia o Pain o Discharge o Lump o Sexual Activities o Frequency of intercourse o Infections o Fertility
Female genitalia o Pain o itching o Discharge o Lump o lump/ passing gush of small amount of urine (on straining)
o Sexual Activities oCarotid
Frequency Artery disease o pain on intercourse o Infections
of intercourse o Fertility
problems Contraception H/o o birth control methods o OCP exposure
Extracranial arterial periods
diseaseH/ois aocommon
age at menarche(
disorder 1st period) + ( interval
characterized between periods
by atherosclerosis of theo carotid
durationoro amount o date of
vertebral arteries last period o bleeding between periods o menstrual pain
cerebral-ocular (stroke, TIA, amaurosis fugax) or
Obstetric H/o o number of pregnancies o abortions
Vertebrobasilar symptoms: Cerebellar
o term deliveries (vertigo,ofataxia,
o number dizziness,osyncope,
living children bilateral
complications paraesthesia,
of pregnancies visual
o description of labor
hallucinations). o age at menopause o menopausal symptoms o post menopausal bleeding
A cerebrovascular accident (CVA) or stroke is a sudden onset of irreversible neurological deficit.
A transient ischaemic attack (TIA) is a sudden onset of neurological deficit that resolves within 24h
musculoskeletal
INCEDENCE:- CVA is the 3 rdo most
weakness o paralysis o muscle stiffness o limitation of movement o joint pain o joint stiffness o
common cause of death in the UK after coronary heart disease and cancer.
arthritis
CVA has an incidence of 2 /1000. 15% of these
o gout o back are due
problems to atherosclerotic
o muscle disease of the carotid arteries.
cramps o deformities
-:Risk factors Same as Atherosclerosis
-:Causes
neurologic
Complications o fainting
cerebral-ocular o dizziness
(stroke, o blackouts
TIA, amaurosis o paralysis o strokes
fugax)
o numbness o tingling o burning o tremors o unsteadiness of gait o loss of memory o loss
PATHOPHYSIOLOGY of consciousness o psychiatric disorders o
Mechanisms:- Atherosclerosis and thrombosis. Thromboemboli. Fibromuscular dysplasia.
general behavioral change o mood changes o nervousness o depression o speech disorders o
Atheromatous plaques form athallucinations
the bifurcationoofdisorientation
the common carotid artery and progress into the external and internal carotid
vessels.
CVA or TIA arise from disease and may be due to:
Pathophysiology
Ocular or cerebral symptoms: an atherosclerotic plaque (commonest extracranial lesion) at the carotid bifurcation (origin of the
internal carotid artery). Platelet aggregation from the surface of the plaque (usually after an acute rupture or opening of the
plaque surface); embolization of atheromatous material from the plaque& platelet embolization. CVA or TIA or Ocular
symptoms.
Symptoms due to flow reduction are rare in the carotid territory, but vertebrobasilar symptoms are usually flow related.
Reversed flow in the vertebral artery in the presence of ipsilateral subclavian occlusion leads to cerebral symptoms as the arm
steals blood from the cerebellum subclavian steal syndrome.
H/O Usually male >65y smoking , HTN, DM, with other risk factors of atherosclerosis & associated atherosclerosis
Ask diseases IHD, AAA, PVD (( should ask about)
Symptoms ( should ask about & analysis onset/ duration)
Several clinical variants of a classic CVA are recognized.

Stroke in evolution. Progressive neurological deficit occurring over hours/days
Completed stroke. The stable end result of an acute stroke lasting over 24h.
Crescendo TIAs. Rapidly recurring TIAs with increasing frequency, suggesting an unstable plaque
with ongoing platelet aggregation and small emboli.
Neurological features:- These depend on:- the territory supplied by the vessel affected by the embolism. -
the degree of collateral circulation to that territory. - and the size/resolution of the embolism.
Cerebral (or ocular) Transient or permanent
Cerebral symptoms motor (weakness, clumsiness or paralysis of a limb);
(contralateral) sensory (numbness, paraesthesia); speech related (receptive or expressive
dysphasia).
Ocular symptoms amaurosis fugax (transient loss of vision described as a veil coming down
(ipsilateral): over the visual field).
Amaurosis fugax. Transient monocular visual loss (described as a curtain coming down across the eye)
lasting for a few seconds or minutes central retinal artery.
Hemianopia. loss of vision in one half of the visual field.
Internal capsular stroke. Dense hemiplegia usually including the face striate branches of the middle cerebral
artery.
Mapping 1- Pathology = Carotid Atherosclerosis

2- Complication = Cerebral-ocular (stroke, TIA, amaurosis fugax)
3- Causes/ Risk factors( DM, HTN, OBESITY, smoking)
4- Associated other arterial atherosclerosis( CHD, AAA, PVD)
Environment - Introduce - Expose neck Proceed as for neck examination. - Wash your hand
Inspect Look for Pulsatile swelling noted in line of carotid artery at base of neck or scar.
Look Look for neurological associations
Palpate For Artery itself may be firm due to calcified plaque - Expansile Mass
Feel pulse ( one by one from behind)
Auscultation - Bruit over carotid arteries, best heard over course of common carotid artery (anterior triangle)
Both side & in expiration. Tell the examiner you will hear /Listen over praecordium to ensure not transmitted aortic
stenosis( ejection systolic murmur at Right 2nd intercostal space, parasternal)
- Carotid bruits are detectable in over 10% of patients > 60 years of age and do not correlate well with the
degree of stenosis or risk of CVA. So it is an unreliable indicator of pathology.
Patients with a significant stenosis may have no audible bruit.
Completing Neurological Examination ; Previous CVA ; focal neurological signs, ipsilateral Horner's syn.,)
Examine for cardiovascular associations (BP, peripheral pulses, heart) Check for signs of atherosclerosis
elsewhere
Investigations All patients with transient neurological symptoms should undergo screening for carotid disease clinical
examination is not accurate. In addition to those in general with atheroscelrosis; CBC, FBS, Urine, RFTs.
Carotid colour duplex scan: B-mode scan and Doppler ultrasonic velocitometry: method of choice for assessing degree of
carotid stenosis. all patients who have had a TIA or stroke within the last 6 months. 95% accuracy for assessment of degree
of stenosis.
CT or MRI brain scan: demonstrate the presence of a cerebral infarct.
Carotid angiography: no longer essential prior to surgery( itself risk of stroke = 2%).
MRA is reserved for those patients in whom duplex are inconclusive or difficult due to calcified vessels.
Treatment:-
Conservative Medical management; Same as Atherosclerosis
Best medical therapy is an antiplatelet agent (e.g. aspirin, dipyridamole), smoking cessation, optimization of BP
and diabetes control, and a statin for cholesterol lowering.
Anticoagulation is indicated in patients with cardiac embolic disease.
Surgery Carotid endarterectomy (CEA):- Targeted carotid endarterectomy offers optimal risk benefit in stroke
prevention. 6-fold reduction in stroke / 3 years
Offered to patients with symptomatic > 70% stenosis of the internal carotid artery.
ECST (Europe) and NASCET (North America) have both demonstrated a reduction in stroke in the first year
following CEA, from 18% with best medical treatment to 3-5% with surgery and best medical therapy. There is
no significant benefit to symptomatic patients with < 70% stenoses.
ACST (UK) and ACAS (North American) trials have shown some benefit of CEA to asymptomatic patients with
> 70% stenosis but the number needed to prevent one stroke is 22 patients treated.
Indication Carotid distribution TIA or stroke with good recovery after 1-month delay:
70% ipsilateral stenosis;
50% ipsilateral stenosis with ulceration.
Asymptomatic carotid stenosis >80% (controversial).
Carotid endarterectomy has about 5% morbidity and mortality.
stenting Carotid angioplasty - controversial
Technical Increasingly undertaken under regional (LA) block.
details Oblique incision anterior to sternomastoid.
Carotid vessels controlled after dissection.
IV heparin prior to trial clamp (if patient awake).
Cerebral circulation protected in 10% of awake patients without an intact circle of Willis
with a shunt (Pruitt/Javed).
Shunt in GA patients depending on surgeon preference and cerebral monitoring (stump
pressure of 50mmHg or transcranial Doppler monitoring of middle cerebral artery blood
flow).
Patch closure with Dacron if small vessel.
Postoperative Close monitoring of BP and neurological state.

Complications Death or major disabling stroke, 1-2%.
Minor stroke with recovery, 3-6%.
Myocardial infarction.
Wound haematoma.
Damage to hypoglossal nerve, ansa cervicalis, vagus.
Prognosis Prognosis of patients with TIAs
80% of TIA's are in the carotid territory and the risk of stroke following a TIA is around 18% in the first year,
20% of which may occur in the first month of the TIA. The overall risk is 7x the risk of stroke for an agematched
population.
Carotid artery aneurysm Normally unilateral

Causes/ & risk = Symptoms of Atherosclerosis associations (HTN, IHD, CVA, PVD, AAA,& Aortic
Dissection) H/o of (Trauma &Previous carotid surgery)
Complications neurological (ipsilateral horner's syndrome; focal neurological signs)
Previous carotid - Investigations ( Duplex scan / Digital subtraction angiography) - Surgery
Peripheral Vascular system history
Vital points:- Name/ Age/ Occupation
C/O ( in pt wards) -Present H/O:- + analysis OCD of the C/O& risk factors
Vascular symptoms Risk factors Fitness for surgery
Smoking
Diabetes
Previous medical history
Intermittent claudication Hypertension
Anaesthetic history
Rest pain Cholesterol
Drug history and allergies
Critical ischaemia Previous history
Social history (related to post-operative rehabilitation)
Family history
IHD, CVA
What you should Ask About:- .. + Analysis of each OCD

1. Symptoms Pain of intermittent claudication
Site
Stenosis of lower aorta & common iliac arteries: buttock claudication + impotence
External iliac artery: thigh claudication
Superficial femoral artery: calf claudication
Intensity
Felt in muscles due to increased oxygen demand
Lactic acidosis occurs when insufficient oxygen demands are met
Pain due to anoxia, acidosis and build-up of metabolites
Precipitating and relieving factors
Exercise after a fixed distance
Comes on more rapidly walking uphill
Relieved by a few minutes of resting
Rest Pain
Site : Occurs in the least perfused area of the leg (toes and forefoot)
Intensity :- Severe, Wakes patient up from sleeping
Precipitating and relieving factors
Comes on at night (lying flat in bed loss of gravity, reduced cardiac output at rest, relative
dilation of skin vessels due to warmth of bedclothes)
Relieved by getting up and walking on a cold floor
Pain relieved by hanging leg off bed
Critical Ischaemia
Ulcers or gangrene
Rest pain for >2w weeks
ABPI <50mmHg
2. Systems Risk factors:- Smoking, DM, HTN, Cholesterol, Previous history, Family history
Review Complications
- Risk factors Functional impact; Life, work, sleep - Going to shops - Walking aids Limp
- - Associated diseases
Complications
- Associated
3. Differential Calf pain due to
diagnosis Musculoskeletal: knee, ankle, hip pathology
Neurological: spinal stenosis
Vascular: intermittent claudication, deep vein thrombosis
4.Fitness for Previous medical history
surgery Anaesthetic history
Drug history and allergies
Social history (related to post-operative rehabilitation
Dysphagia
INCEDENCE:-
Risk factors:-
Causes:- Mechanical Within the lumen
Obstruction - FB - Oesophageal web (scleroderma) - Plummer-Vinson syndrome
In the wall
Congenital:- web, OA &TOF, Dysphagia Lusoria
Traumatic ( FB, Corrosive, Iatrogenic instrumentation, Violent vomiting,/ rupture)
Oesophagitis (Candida, corrosive, or chronic reflux)
Strictures:- Benign (Post-radiation/ corrosive /or chronic reflux) - Malignant Cancer
Tumours benign malignant
Outside the wall = compression:- Neck ( Goitre/ Pharyngeal pouch)
in chest (mediastinal syndrome, Retrosternal goitre, LN, Lung carcinoma)
Co-ordination Motility disorders :- Oesophageal spasm - Achalasia
abnormalities Neurological disease :- Myasthenia gravis, Bulbar palsy (including MND), CVA
Complications Weight loss & Cachexia ( Cancer)
Regurgitation & Aspiration pneumonia
Stasis infection ulceration, He
Metastasis ( cancer)
PATHOPHYSIOLOGY
Mapping Pathology= Difficulty swallowing . Be conscious of the possible serious pathologies

Causes/ ppt/ risk factors
Complications
H/O Vital = The main task + Risk ( Age/ smoking, family + precancerous diseases)
Ask Medical:-
PERSONAL / patient or Mr. / Mrs.,(Family Name) ., Age.y, work as .
H/O: - + Social h/o married/kids/ special habits
C/O= concern / Dysphagia = difficulty in swallowing
problem
PRESENT Present History Analysis
H/O:- - Should mention onset, course and duration. What & What .
You Should Ask About..
1 - Duration& Onset:- The condition start since of sudden/ acute/ insidious( onset)
2 - Following H/O of (cause):-
"At what level does the food appear to stick?"
"What is causing difficulty: solids, liquids, or both?" solids often first in strictures whereas
liquids first in neurological
3- With (H/O of symptoms) ...........................................

What ..& What ..
4 - Course :- ( progressive/ regressive/ intermittent/ stationary)
A Review of Systems ( mainly that related to disease) Aiming to elicit ( Causes

& Risk factors / complications /D.D/ fitness for surgery)
H/O of Causes/ Risk factors / DD
H/O of Complications Weight loss? Can you eat a full meal?

Regurgitation:- "Does the food come back up or eventually goes down?"
- System review
Systemic symptoms:- weight gain or loss, altered appetite, fever
Respiratory symptoms:- shortness of breath, stridor, cough
Gastrointestinal symptoms
Neurological
Associated: Lump in throat (globus), neck bulge (pouch), pain on swallowing (odynophagia),
heartburn( reflux)
PAST H/O Past History ( fitness & risks)
(MEDICAL Surgery (any surgery if yes( what when & complications including
&SURGICAL):- anaesthesia)
- Past evaluation of or (treatment for) a disease (e.g., medications, injections, surgery,
compression). diseases
Medical (diseases/ drugs/ allergy last meal in emergency surgery)
Other diseases:- Related disease/ Associated Previous dysphagia, reflux, or known
ulcer disease Stroke, neurological disorders (bulbar palsy, myasthenia)
Systemic disease (affect outcome) (e.g. DM, HTN, coronary artery disease, CVA)
3- Medications:-NSAIDs, steroid inhalers
4- Allergy ( food, Drugs)
FAMILY H/O = (Genetic) H/O of disease ( 1st relatives). Cancers
DD= causes
Investigations Barium swallow / Endoscopy (+ biopsies) / 24 hrs PH monitoring (for reflux),

Oesph. Manometry (Motility disorders). Staging cancer:- CT chest/ Endoscopic US/ Abd US& LFTs
Treatment:- Conservative
Surgery
Prognosis
Lumps & ulcers history

Listen carefully to the instructions
Establish the patient's details - name, age, occupation
Introduce yourself
Question:- Straight questions about the

Lump / ulcer Symptoms
Onset How does it bother you?
What made you notice the lump? Has it changed?
When did you notice it? Are there any other lumps?
Were there any predisposing events? Has it ever healed?
Relevant surgical questions - fitness for anaesthesia
What treatments have you had in the past for this lump?
What do you think is the cause of the lump?
Orthopaedic history taking

Key elements in H/O:- Deformity/ Swelling + Pain/ Loss of function/ Stiffness/ (OCD)+ Associated
Thyroid History
Approach
I- Analysis of Main Symptoms Neck Lump
Site
OCD Onset
Course; change in size - suddenly increased (haemorrhage into necrotic nodule,
subacute thyroiditis, rapidly growing carcinoma)
Duration
Cosmetic symptoms
Ass symptoms ( Painful/ painless) ( cause / complication/ DD)
pain other associated ( Causes/ complications Symptoms from the swelling)
II- A Review of Systems (ROS) ( mainly that related to disease)

mainly to elicit Causes/ DD/ complications Ask for
A Review of Systems ROS = other associated /Symptoms or H/O of the.
1- Cause congenital (dating since birth or shortly) trauma, infection, inflammation, PVD, Venous,
Neuropathy, Tumour (compress or / infiltrate nearby structures/ LNS, Distant metastasis)
2- Complications Symptoms= effect of disease
(local regional & general constuitional fever anorexia wt loss) + systemic metastasis
Benign Goitre (Cosmetic/ compress nearby structures)

Malignant r Goitre (infiltrate nearby structures/ LNS, Distant metastasis) Discomfort during
Goitrogenic Goitre (Cosmetic/ compress nearby structures + Hypo Thyroid hormones Function)
Toxic Goitre (Cosmetic/ compress nearby structures + Exaggerated Thyroid hormones Function)
Thyroid status
Hyperthyroidism Hypothyroidism
Decreased appetite, weight
General Increased appetite, loss of weight
gain, lethargy
Thermogregulatory Preference for cold weather Preference for hot weather
Dry skin, "peaches and cream"
Dermatological Increased sweating
complexion,
Proximal myopathy (autoimmune)
Musculoskeletal Muscle fatigue
with wasting and weakness
Change in bowel habit - diarrhoea,
Gastrointestinal Constipation
frequent defecation
Cardiovascular Tachycardia, atrial fibrillation Bradycardia
Gynaecological Oligomenorrhoea, amenorrhoea Menorrhagia
Nervousness, easy irritability, Slow thought, speech, action,
Psychiatric
emotional lability, insomnia, psychosis
depression, dementia
Symptoms of carpal tunnel
Neurological Fine tremor
syndrome
Other associated symptoms Eye symptoms - protruding / staring eyes, difficulty closing eyelids,
double vision (secondary to ophthalmoplegia) and pain in eye (secondary to corneal ulceration)
Local swallowing/dysphagia - oesophageal compression Dyspnoea (tracheal compression)

Hoarseness - recurrent laryngeal nerve paralysis secondary to malignant infiltration Pain
Regional LNs Ask about other Swellings ( Associated/ complication local or regional e.g. LNs) or
DD
General Constitutional symptoms ( fever wt loss) + General weakness any yellowish colour change of
eye+ preference to hot cold & dry or sweaty skin
Systemic symptoms (cause/ complication/ DD/ surgery fitness ( Heart, breathing, Neurology, GIT,
GUT, PVD, Ortho) ) other body system quick direct Questions & if any +ve analysis
3- DD ( could be local causes/ referred/ same system or other system)

Past H/O Surgical; Previous operations on thyroid gland
Medical history Medications - antithyroid drugs, thyroxine, iodine-containing medications
Radioiodine therapy for previous Grave's disease
Fitness for surgery ( DM, HTN IHD, CRF, CVAetc) , allergies & other drugs
Family H/O of similar thyroid diseases
Trauma history
Vital points = AMPLE (Allergies; Medications; Past illness ( quick Not detailed); Last Meal; Events or
Environment related to injury= History of mechanism of trauma + Symptoms of trauma;)
Tumour / cancer history = Main Bulk
I- Analysis of Main Symptoms pain/ Lump/ Ulcer + associated
II- A Review of Systems (ROS) Ask for
Causes Risk factors DD
Complications ( local regional & general constuitional fever anorexia wt loss) + systemic metastasis
III- H/ O of Present Investigation & treatment
Urinary tract calculi

Type Prevalen Composition
ce
Calcium oxalate 75% Spiky / mulberry shaped
Caused by hypercalciuria (moans, stones, psychic groans)
Rare enzyme deficiency
Increased oxalate absorption: coeliac, diverticulae of bowel, chronic
pancreatitis
Ammonium 15% Associated with proteus infection
phosphate "Staghorn calculi" (from urease)
Urate 5% Primary gout: HGPRT deficiency (Leesh-Nyhan)
Secondary gout: increased purine breakdown - tumours, RT, chemo,
psoriasis...
Cysteine 3% Results from primary cysteinuria, inborn error of metabolism
Management
1. History: precipitants, family history, personal history

2. Examination
3. Investigations
o Urine dipstick - blood, nitrates (UTI cause)
o U/Es, serum electrolytes, WCC, CRP
o KUB - 90% renal tract stones are radio-opaque (calcium, ammonium , cysteine) -
urate/xanthine stones radiolucent
o IVU: determines degree / level of obstruction (hydronephrosis) - sites for blockage: (1)
renal pelvis (2) pelvic brim (3) insertion into bladder - contrast contraindicated in
pregnancy, allergy, anaphylaxis, raised serum creatinine
o USS: - no contrast, detects stones >5mm, determines hydronephrosis and obstruction
o CT Abdo: identifies radio-opaque and lucent stones, secondary signs of obstruction
4. Analgesia - morphine, pethidine, NSAIDs
5. Hydration
Definitive treatment
<4mm 4-6mm 6mm - 2cm > 2cm

Watch and wait 60% pass 1- Upper or lower 1/3 (middle 1-in renal pelvis - Percutaneous
90% pass spontaneousl difficult to visualise apparently) nephrolithotomy tract made
spontaneously y Extra-corporeal shockwave percutaneously into renal
lithotripsy (ESWL): - collecting system and stone
contraindicated in pregnancy, extracted (large stones can be
aneurysms, pacemakers broken up first).
2- lower 1/3 Ureteroscopy 2-obstructed - percutaneous

+lithotripsy: stones in lower 1/3 decompression + JJ stenting
collected using stone basket or
fragmented and pieces collected 3- Open surgery (less than 1%
patients) - for stones that just are
bad to the bone
UTI :- Organisms:- Enterococci: E.coli, proteus, pseudomonas, klebsiella, staph aureus

Infection of bladder, ureter, kidney (via renal pelvis) NB. Urethral infection is considered a STD
Predisposition :-
Anatomy : Female anatomy: proximity of urethra to anus
Congenital abnormalities affecting flow: ectopic vesicae, ureteric duplication, urethral valves,
congenital stricture, VUJ reflux
Urine stasis
Mechanical obstruction: hydronephrosis, stricture, stone, neurogenic bladder, prostatic hypertrophy
Prostatic enlargement
Instrumentation Indwelling catheters
Systemic disease Diabetes Immune deficiencies
Diagnosis:- Urine dipstick: RBCS, WCC, nitrates/ Microscopy/ Culture

Communication Skills MRCS

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Communication Skills MRCS

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INFORMATION GIVING INFORMATION GATHERING

2nd bay the 2 examiners assess you 4 4

Introduction - Same important as clinical examination

Consultant name if given/ specialty

Medical Terms & ABBREVIATIONS VS Simple Language

Difficult situations VS Solutions

Angry patient Breaking bad news

Informed Medical Consent

Informed Medical Consent

Discussion all ( in brief) Sympathize

:Discussion EX: a mastectomy & Axillary Clearance

Late (after 2 w) - Effects of the nearby structures injury)

Delayed ( after Scar ( Keloid/Hypertrophic) - Effects of the nearby structures injury)

Common surgery consent

Preoperative What is? Surgery definition

- Effects of the nearby structures injury)

Obtaining Organ transplant consent

Obtaining Organ transplant consent +

History (H/O) Taking

Social /psychological =Sympathy:-= Frequently, problems in the interview. Patients often

1- Patient's emotional reactions = (anxiety, fear anger or helplessness) Pick up during

3- Empathy is closely related to reassurance . Empathic statements communicate the

A Review of Common Problems

History (H/O) Taking

ASSOCIATED SYMPTOMS (Other related) symptoms Same disease

2. Complications symptoms = Effects of the disease

Systems You Should Ask Aboutas follow.. Do you have any

Again General sheet (H/O Taking)

Hello I am (position) Is it Mr. . Sit down please. (Smile with eyes

Medical:- = Social /psychological =

The main task

Social /psychological =Sympathy:- Patient concern

(Verbal) PRESENTATION of History (H/O) Taking ( 5min) (+ve. findings)

What ..& What ..

1. Cause and risk factors............................................

2. Complications symptoms = Effects of the disease

Regional = LNs= other swellings/ or their effects e.g. pressure symptoms

The examiners will discuss you about ( 5 min)

- Thanks all examiners

Main Present History Analysis Questions

Pain Analysis of The Main Symptoms

A Review of Systems ( mainly that related to

General Constitutional symptoms Did you become feverish?

Systemic symptoms (cause/ complication/ DD/ surgery

Swellings Analysis of The Main Symptoms

Ass symptoms ( Painful/ painless) ( cause / complication/ DD)

General Constitutional symptoms Did you become feverish?

Systemic symptoms (cause/ complication/ DD/ surgery

Ulcer Analysis of The Main Symptoms

A Review of Systems ( mainly that related to

Regional LNs Ask about other Swellings ( Associated/

General Constitutional symptoms

SYSTEMS Do you have Ask about Do you have? Do you feel..?

General/Constitutional o Fevers? o Chills? o Sweats?

Skin o Rashes? o Itching? o Easy bruising? o Dryness?

Head o Headaches o dizziness o Fainting?

Eyes o Use of glasses/contacts o Change in vision?

Ears o Hearing difficulty ? o Use of hearing aid?

Nose o Nosebleeds? o Infections? o Discharge? o change in smell

Mouth/Throat Mouth o Pain o Discharge o Lump o change in Taste

Neck o Pain o Pain on mvmt o Discharge o Lump/ Lumps o Goiter