SURGERY HISTORY AND COUNSELLING

STATIONS

PAGE
1 UPPER ABDOMINAL PAIN (RUQ/LUQ)
2 LOWER ABDOMINAL PAIN (RIF/LIF)
3 HAEMATEMESIS
4 ANAEMIA (FIND THE CAUSE)
5 CHOLECYSTECTOMY CANCELLED
6 DYSPHAGIA
7 PERRECTAL BLEED
8 MELAENA
9 HAEMATURIA
10 TESTICULAR PAIN
11 BACK PAIN
12 KNEE PAIN
13 HAEMOPTYSIS
UPPER QUADRANT ABDOMINAL PAIN

STEP 1: P1

What brought you to the hospital today?

S Site of pain: point out with finger

O Onset: Since when, How did it start (sudden or gradual), Is it the first time?

C Character: dull, sharp, colicky

R Radiation: does it go anywhere – e.g. shoulder, back

A Associated symptoms – ask all the cardinal symptoms of GI system

T Timing: All the time? Comes and goes? Related to time of the day?

E Exacerbating & relieving factors: food, breathing, position

S Severity: Grade on a scale of 1 to 10, with 10 being the worst

STEP 2: Rule out any remaining D/Ds

Differential Diagnosis of R/L Upper Quadrant & Epigastric Pain

Imagine moving from base of lung downward.

Differentials Relevant Questions

Lungs Right basal Pneumonia Cough/sputum/fever
Hepatitis General - yellow discoloration of skin
& eye
Hepatitis A Diarrhoea/Vomiting + travel history
Hepatitis B/C Blood transfusion abroad/tattoo/drug
Liver abuse/sexual Hx
Alcoholic Hx of Alcohol
hepatitis
Autoimmune hepatitis
 Acute cholecystitis Fever. fatty food worsens the pain. Radiation
to shoulder tip
Biliary obstruction Dark urine & pale stool
Biliary Tree [gallstones/stricture/Ca head
of pancreas]
Biliary colic Pain comes and goes, radiates to back
Cholangitis Charcot’s triad: fever, jaundice, rigors

Stomach Ulcer/APD Food worse (gastric) or ease (duodenal)

& /melaena/vomit blood/NSAIDS or
duodenum Aspirin or steroid use
Pancreatitis Radiate to back/ease by leaning
Pancreas forward
Calculi Hx of passing stones / poor stream /
pinkish colour / burning / Pain while
passing urine / colicky pain
Pain of calculi:
Renal – flank
Bladder suprapubic
Urinary – 1/3 upper: loin to groin
1/3 middle: R mimics
Kidney and rest of appendicitis
urinary system L mimics
diverticulitis
1/3 lower: male – tip of
penis
female – labia
majora
Pyelonephritis All above + fever / recurrent UTI /
smelly urine

STEP 3: Complete P 2, 3-7 MAFTOSA

Task : A 25 year old lady presents with RUQ pain. Talk to the patient. Discuss D/Ds
with examiner.

Patient History

1. RUD pain radiating from loin to groin

2. +/- poor stream
3. +/- h/o passing stone
4. +/- pinkish urine
5. No fever
6. No discharge
7. No sexual history
 8. No history of excessive alcohol
9. Lying on the couch in hospital gown

Diagnosis:

Ureteric Calculi

Task : A 40 year old female/male presents with abdominal pain. Talk to the patient.
Discuss D/Ds with the examiner.

Patient History

1. RUQ pain
2. Flu like symptoms (= fever in GMC)
3. Smelly urine
4. H/o passing stone 5 years ago

Diagnosis:

Pyelonephritis

LOWER QUADRANT ABDOMINAL PAIN

STEP 1: P 1

What brought you to the hospital?

S Site of pain: point out with finger

O Onset: Since when, How did it start (sudden or gradual), Is it the first time?

C Character: dull, sharp, colicky

R Radiation: does it go anywhere – e.g. shoulder, back

A Associated symptoms – ask all the cardinal symptoms of GI system

T Timing: all the time? Comes and goes? Related to time of the day?

E Exacerbating & relieving factors: food, breathing, position

 S Severity: Grade on a scale of 1 to 10 with, 10 being the worst

STEP 2: Rule out any remaining D/Ds

Differential Diagnosis of R/L Lower Quadrant Pain

C-AUDIOS-TEMP-F

Differentials Relevant Questions

C Cancer bowel Lump, nine questions of Ca bowel*
Appendicitis Pain migrates from umbilicus to RLQ,, fever+/-vomiting,
A constipation, diarrhoea

UTI Burning, pain while passing urine, increased frequency,

U fever, smelly, pinkish urine

Diverticulitis LIF pain relieved by defecation, PR bleed, signs of

D infection

IBD (UC/CD) Diarrhoea, PR Bleed, skin, joint problem and eye problem
I Gastroenteritis / Other members of the family also affected
Colitis
O Obstruction Constipation, not passed wind, vomiting, distension
Calculi Hx of passing stones / poor stream / pinkish colour /
burning / Pain while passing urine / colicky pain
Pain of calculi:
Renal – flank
Bladder suprapubic
Urinary – 1/3 upper: loin to groin
1/3 middle: R mimics
S appendicitis
L mimics
diverticulitis
1/3 lower: male – tip of
penis
female – labia
majora

Hernia Swelling that used to go in. Now tender and doesn’t go in.
 Testicular torsion Sudden onset. Increased by lifting testes
T Torsion of ovary/ovarian Previously had U/S which showed fluid filled sac. Fullness in
cyst tummy
Epididymorchitis Gradual onset, fever, decreased by lifting testes
E Ectopic LMP => 4 wks, +ve sexual hx, pregnancy test, +/- IUCD use

M Miscarriage LMP => 4 wks, +ve sexual hx, PV bleed

P PID Fever, back pain, discharge, dyspareunia, IUCD, sexual hx

Fibroid Dull dragging sensation in abdomen, menorrhagia, anxious to
F become pregnant.

* Ten Questions for bowel cancer written under Station 3 below

STEP 3: Complete P (2,3,4,5,6,7) MAFTOSA

STEP 4: Other D/Ds if you have time

Abdominal aortic aneurysm- pain radiating towards the back.

Task : A 25 year old female presents with RIF pain. Talk to the patient and discuss
D/Ds with the examiner.

Patient History

1. RIF pain
2. LMP 5 weeks ago
3. +/- Using IUCD
4. No vomiting, fever or discharge
5. Patient lying on couch in hospital gown

Diagnosis:
Task : A 20 year old female presents with pain in the lower tummy. Talk to the patient
and discuss management with the patient.

Patient History

1. Lower tummy pain since 2 days

2. Same episode 2 weeks ago
3. Burning micturition
4. Pinkish urine
5. Flu like symptoms
6. LMP 2-3 weeks ago
7. No discharge, h/o passing stone or radiation of pain

(Diagnosis = UTI)

Management with the patient: (Note: Mx in GMC = Dx, Ix, Rx)

After speaking with you, I think you have got something called urinary tract infection. This
means that some bugs/germs are growing in your bladder and related structures/organs.

But we need to confirm this by doing some tests. We need to take a urine sample from you
(mid stream urine for C/S, dip stick for nitrates, protein and leukocytes).

We may also consider U/S. (note: U/S must in all paeds + adult male. U/S in adult female
only if = > 2 episodes in the last 3 months)

Once confirmed, we’ll give you some medications called antibiotics, which will kill those
bugs/germs. By any chance are you allergic to antibiotics? Please drink enough water. We
may also give you pain killers if needed.

Task : A 70 year old female presents with LIF pain. Talk to the patient. Discuss D/Ds
with the examiner.

Patient History

1. LLQ pain
2. Altered bowel habit
3. Weight loss (~3kg in last 2 months)
4. Family h/o bowel cancer

Diagnosis:

Ten questions of bowel cancer:

i. Weight loss (late sign of cancer so may not always be there)

ii. Loss of appetite general questions for any cancer
iii. Anaemia questions (tiredness/fatigue, heart racing, SOB, light headache)
 iv. Alternating bowel habit
v. Change in bowel habit
vi. Blood in stool
vii. Tenesmus
viii. Family h/o cancer
ix. Abdominal pain
x. Abdominal lump

HAEMATEMESIS
STEP 1: P1

What brought you to the hospital today?

O Could you tell me anything more about it?

Are you sure it is not from your lungs or mouth?
S What colour? Bright/dark? Anything else with the blood? Is it mixed with food? Or pure
blood?

O How did it start?

D Since when?

How much blood? Half a cup?

I
How often?

P Is it getting worse?

A Anything makes it worse? Like food

 Anything makes it better?
R

A Any other symptoms?

F Is it the first time you got this problem?

Ask all the cardinal symptoms of GI system

Ask questions for Anaemia.
C (tiredness/fatigue, light headedness, SOB,
heart racing) (any station with bleeding
MUST R/O anaemia)

STEP 2: Rule out any remaining D/Ds

Differential Diagnosis of Haematemesis

I-COUMB

Differentials Relevant Questions

Infection Fever? Dysphagia? Or pain on swallowing?
I Oesophagitis Heart burn while lying down

Cancer Dysphagia? Pain on swallowing? Lump? Weight loss?

C [oesophageal/stomach] Loss of appetite? Anaemia questions. Family History?
Smoking history. Also fullness (stomach Ca)

Oesophageal Varices Chronic alcohol history? Signs of portal hypertension Or

O signs of liver disease

U Ulcer[barret/gastric/duodenal] Pain related to meal, heart burn. Irregular meal. PH

Malorry-weiss tear Alcohol binge drinking?

M Were you vomiting repeatedly before the blood come?
Four D/Ds of any bleeding
B Blood thinner Are you taking any blood thinner medications? Warfarin?
Aspirin? NSAIDS or ibuprofen?
 Bleeding disorder Did you have bleeding from any part of your body? Or
have you or your family member been diagnosed with
any bleeding disorder?
Instrumentation By any chance have you gone through any procedure or
instrumentation of your gut recently?

Trauma By any chance did you get hurt on your gut? Swallowed
any object [bone]?

STEP 3: Complete P (2,3,4,5,6,7) MAFTOSA

Diagnosis:

Mostly Oesophageal Cancer

ANAEMIA: FIND THE CAUSE

Task : A 45 year old man was planned for herniorrhaphy. Lab report shows his Hb = 8.
Talk to the patient and address his concerns.

(Note: This station starts with counselling and then goes on to Hx.)

Talk to the patient:

I’m here to speak to you about the blood test we did for you. I have the result with me now
and it shows that you have anaemia. Do you know anything about it?

It means that your blood is weak. In this condition there’s not enough of haemoglobin in the
blood. Haemoglobin has the important function of carrying O2 to the body.

Because of anaemia, unfortunately we have to postpone your surgery.

Patient: why? (angry)

 Doing surgery while you are anaemic can be dangerous. When we put you to sleep,
your body may not get enough O2 from your blood because of lack of haemoglobin.
  Also, after the surgery you may face other problems like infection or delay in wound
healing.

Patient: Why didn’t you tell me before?

Apologize and tell the patient that we did some tests to check whether you are fit for the
surgery or not, and that is when we found out.

Patient: one of my friends had the same problem and during surgery he received blood
transfusion. Why can’t I have the same?

The thing is that blood transfusion has its own complications. And it is given only if it is an
emergency surgery. But your procedure is not an emergency.

Patient: when can I have the surgery?

It may take few months but as soon as your haemoglobin level returns to normal, we can have
the surgery.

(It takes 1 month to increase Hb by 1 unit. Surgery is done at Hb minimum 11)

Finding the cause of anaemia:

Explain to the patient that anaemia could be due to many reasons among which are, not
eating enough iron, or losing blood from somewhere. Then take history to find out the cause.

STEP : Rule out the D/Ds

Differential Diagnosis of Anaemia

M5 RBC

Differentials Relevant Questions

Weight loss? Bumps or lumps? FH? Dark stool? Altered bowel habit?
M Malignancy
Change in bowel habit?

M Malabsorbtion Diarrhoea? Steatorrhoea / Hard to flush? Bloating? Discomfort? Past hx

M Malnutrition Diet? How often? Diarrhoea? Food intolerance?

M Malaria Dark urine? Fever? Travel history to tropical country?
Cabamazepine? Colchicines? Clozapine? Chemotherapy?
M Medication
Also NSAIDs and other medicine which causes gastric erosion.
Rheumatoid
R Small joint pain?
Arthritis
 Blood thinners,
Bleeding disorder,
B Bleeding 4 D/Ds
instrumentation,
trauma

Chronic renal
C Bladder habit? Past Hx of kidney problem?
failure

Complete P7 MAFTOSA

Questions of symptoms of anaemia

1 Do you feel tired all the time?
2 Do you feel any racing of the heart?
3 Do you feel light headache?
4 Do you feel shortness of breath?

(*note: this station starts with counselling and then goes to history)

Patient History : Patient on aspirin since 10 years

Management: (Dx, Ix, Rx)

Diagnosis:

Aspirin happens to be one of the medications which can cause bleeding inside the
gut/tummy/stomach. Since you are taking aspirin since a long time, it may be the cause of
your anaemia due to bleeding inside.

So please stop taking Aspirin. Don’t worry we will give you some alternative which will not
cause the bleeding.

Investigations:
We need to confirm this by doing some tests. We’ll do something called endoscopy in which
a flexible tube with a camera attached is used to see inside your gut. It is inserted through the
mouth. We may also take a tissue sample.

Also, we may do some other tests (blood for IDA, scans)

Treatment:
1. Stop aspirin. We’ll give you some alternative which will not cause the bleeding
2. Iron tablets
 3. Vitamin C and give advice about orange juice. We may refer to dietician.

DYSPHAGIA
Task : A 65 year old man/lady presents with dysphagia. Patient is on H2 blocker
cimetidine, some PPI and antacid due to reflux disease since last 5 years.

Talk to the patient and discuss investigations with the examiner.

STEP 1: P1

What brought you to the hospital today?

O Could you tell me something more about it?

S Please point out with finger where exactly you feel difficulty? What sort of difficulty
occurs? Difficulty in initiating swallowing? Any discomfort? Pain? Regurgitation?
Vomiting? Coughing and choking?
O How did is it start? Gradual? Sudden? Started with solids or liquids?
D Since when?
I How often? All the time when you eat? Swallowing liquid? Saliva?
P Is it getting worse?
A Anything makes it worse? Particular food? Solid? Cold or hot food?
R Anything makes it better? Liquid? Small pieces of food?
A Any other problem?
F Is this the first time?
C Stridor? Dysphonia /hoarseness? Pain? Dysphasia? Sore throat?

STEP 2: Rule out any remaining D/Ds

Differential Diagnosis of Dysphagia

PEGG COMPASS
Differentials Relevant Questions
Palsy[Stroke/spine Difficulty in talking? Making sound?
P injury/botulism/MS/PSP/ALS/Parkinson] Other weakness?
Bulbar palsy Difficulty initiating swallowing
Did you have any procedure done
E Endoscopy/instrumentation
recently?
G GORD Belching? Heartburn, worse on lying?

Do you have a sensation of lump in your

G Globus hystericus
throat?
Starts first with solids
Weight loss? Weakness?
C Cancer Oesophagus Smoking? FH?
Steady, gradual worsening?

Oesophagitis or
O Fever, pain (odynophagia)
Infection of tonsil, larynx or epiglottis

Worse in the evening? Feel

M Myasthenia weakness in evening or after
exertion?

Bad breath? Food on pillow in morning?

P Pharyngeal pouch
Old food regurgitated?
A Achalasia Starts with liquids
Long time heart burn? Or past corrosive
ingestion?
S Stricture
Any procedures/instrumentations
done?

Intermittent? Cold or hot food

S Spasm (diffuse esophageal spasm DES)
makes it worse?

STEP 3: Complete P (2,3,4,5,6,7) MAFTOSA

Patient History : must ask about smoking

1. Difficulty started with solids

2. 2 kg weight loss in 2 months
3. Loss of appetite

Investigations with the examiner:

1. Ba swallow
2. Endoscopy
 3. CT – scan

If task says management with the patient:

After speaking with you I’m suspecting there may be an abnormal growth in your food pipe /
gullet. But we need to confirm that with some investigations.

1. We’ll do a special X-ray in which you will be asked to swallow a dye.

2. We’ll also put a flexible tube with a camera attached to it, inside the food pipe. We
may take some sample.
3. And we will also do a CT scan

If we confirm our diagnosis, the treatment will be surgery.

PER RECTAL BLEED

Task : A 70 year old female presents with bleeding PR. Lab report shows Hb = 6.7,
MCV = 65. Talk to the patient and discuss D/Ds with the examiner.

STEP 1: P1

What brought you to the hospital today?

O Could you tell me something more about it?

S What colour? Mucous? Coated on stool? Splashing? On tissue? How often?
O How did it start?
D When did you notice it first?
I How much?
P Is it getting worse?
A Anything makes it worse? Food type?
R Anything makes it better?
A Any other problem?
F Is it the first time?
C Ask all the cardinal symptoms of GI system.
Tenesmus? Lump?

STEP 2: Rule out any remaining D/Ds

 Differential Diagnosis of Per Rectal Bleed
BHF CUPPID

Differentials Relevant Questions

B Are you taking any blood thinners?
Do you have any bleeding problem?
Bleeding D/Ds
Did you have any procedure done recently via your back passage?
By any chance got hurt?
H Haemorrhoids Splashing blood on pan? Any painless mass coming out?
F Fissure Painful defecation? Blood on tissue? Visible fissure on opening?
C Cancer colon Weight loss? Altered bowel habit? Change in bowel habit? FH? Lump?
U IBD Diarrhea, tummy pain? Fever? Past history? Skin lesion?
P Polyp Family history or past history of polyp
P Prolapse Mass popping out from back passage?
I Gastroenteritis Fever? Diarrhoea? Pain? Other members of the family
D Diverticulitis LIF pain relieved on defecation? Fever? Old age?

STEP 3: Complete P (2,3,4,5,6,7) MAFTOSA

Patient History

1. Fresh bleeding
2. 2 kg weight loss in last 1-2 months.
3. SOB even while talking to you
4. Tiredness on simple activity
5. Constipation during last two months
6. Taking aspirin since 10 years after MI
7. No family h/o bowel cancer
8. No tenesmus
9. No fever
10. No tummy pain

Diagnosis:

MALAENA
Task : A 60 year old male/female presents with complain of dark stools. Talk to the
patient and give 2 D/Ds to the examiner.

STEP 1: P1

What brought you to the hospital today?

 (Same as PR bleed)
O Could you tell me something more about it?
S What colour? Mucous? Coated on stool? Splashing? On tissue? How often?
O How did it start?
D When did you notice it first?
I How much?
P Is it getting worse?
A Anything makes it worse? Food type?
R Anything makes it better?
A Any other problem?
F Is it the first time?
C Ask all the cardinal symptoms of GI system.
Tenesmus? Lump?
Ask questions for Anaemia. (tiredness/fatigue, light headedness, SOB, heart racing) (any
station with bleeding MUST R/O anaemia)

STEP 2: Rule out any remaining D/Ds

Differential Diagnosis Melaena

Differentials Relevant Questions

Alcohol binge drinking?
Mallory-Weiss Were you vomiting repeatedly before the
blood come?
Chronic alcohol history? Signs of portal
Oesophageal varices
hypertension Or signs of liver disease
Weight loss, loss of appetite, tiredness,
Gastric cancer
family history
Heart burn, pain related to meals, past
APD (+/- NSAID induced)
history, medications
Bleeding disorders, blood thinner
Four D/Ds of any Bleeding
medications, instrumentation, trauma
STEP 3: Complete P (2,3,4,5,6,7) MAFTOSA

Patient History

1. On diclofenac since 9 months for osteoarthritis

2. Feels tired with light headedness
3. +/- no weight loss
4. No family h/o bowel cancer
5. No change in bowel habit
 2 D/Ds:

1. Diclofenac induced APD

2. Gastric cancer

HAEMATURIA
Task : A 65 year old man presents with haematuria. Take history and discuss
investigations with the patient.

STEP 1: P1

What brought you to the hospital today?

O Could you tell me something more about it?

Colour of urine? Do you also get pure blood? Is it at the start of urine or at the
S end or throughout?
Is that every time when you pass urine?
O How did it start?
D Since when?
I How much blood? How bad? How pinkish?
P Is it getting worse?
A Anything makes it worse? Type of food? Sex?
R Anything makes it better?
A Any other problem?
F Is it the first time?
Ask all cardinal symptoms of Genito-urinary system and sexual function
C Ask signs of anaemia (tiredness/fatigue, heart racing, SOB, light
headache)

STEP 2: Rule out any remaining D/Ds

Differential Diagnosis of Haematuria

S-CUBBICS

Differentials Relevant Questions

Any change in diet? Does that happen only when you eat
S Substances (false)
particular food?
 Weight loss? Smoking? Exposure to aniline dye?
Cancer[renal/bladder/prost
C Note: painless haematuria = bladder cancer until R/O
ate]
otherwise
Fever? Pain on passing urine? Change in colour and smell of
U UTI
urine?
Are you taking any blood thinners? Do you have any
B Bleeding 4 D/Ds bleeding problem? Did u get hurt by any chance? Any
procedure done down below?

B BPH Dribbling, poor stream, waking up at night to go to loo

Infection[pyelonephritis,
I Fever? pain? Sexual Hx? Discharge? Recurrent UTI
prostatitis, urethritis, STI]
History of passing stone? Dehydration? Pain while
C Calculi
passing urine, colicky pain, poor stream
S Schistosomiasis Swimming lake? Travel to tropical countries? Past infection?

STEP 3: Complete P (2,3,4,5,6,7) MAFTOSA

Patient History

1. Haematuria since 2-3 weeks

2. No pain
3. 2 kg weight loss
4. +/- loss of appetite
5. Smoking since 25 years of age
6. +/- frequency, urgency & dribbling
7. No fever
8. No h/o passing stone

Diagnosis:

TESTICULAR PAIN
Task : A 30 year old man presents with pain in the private parts. Talk to the patient.
Discuss 2 D/Ds and management options with the patient.

STEP 1: P1
 What brought you to the hospital today?

Site of pain: Which side, or both? Where exactly? In a localized area? Or

S
generalized pain?

O Onset: Since when, How did it start (sudden or gradual), Is it the first time?

C Character: dull, sharp

R Radiation: does it go anywhere

Associated symptoms – ask all the signs of GU system, infertility. Take sexual
A
Hx

T Timing: all the time? Comes and goes?

E Exacerbating & relieving factors: position, lifting the testes

S Severity – grade on a scale of 1 to 10 with 10 being the worst

STEP 2: Rule out any remaining D/Ds

Differential Diagnosis of Testicular Pain

M-TESTIS

Differentials Relevant Questions

Recent (4-6 wks ago) cheek swelling, pain & flu like
M Mumps
symptoms

Sudden onset severe pain? After brisk activity?

T Testicular torsion Short duration. Upon lifting testes pain gets
even worse.

Gradual? Fever? Quite long duration. +ve sexual

E Epididymo-orchitis
history. Upon lifting testes pain gets better.
Hx of passing stones, poor stream, pinkish
colour, burning, pain while passing urine,
S Stones[referred pain]
colicky pain

T Trauma - haematoma Got hurt by any chance?

Infection [UTI, prostatitis, orchitis, skin
I Fever? Discharge? Sexual Hx? Urinary symptoms
lesion]
 Swellings [hydrocoele, varicocoele,
S Significant swelling
spermatocoele, ingiunal hernia, tumour]

STEP 3: Complete P (2,3) MAFTOSA

Patient History: ( 3 possibilities, one is given below)

1. Pain started two days ago, at which time the score was 4/10
2. Patient woke up this morning due to severe pain, now the score is 7/10
3. Pain in both testes
4. 2-3 days ago patient had flu like symptoms
5. No discharge, no redness, no hotness
6. Sexual hx: Patient says I can’t remember the last time I had sex or I’m not sexually
active or the last time I had sex was 6 months ago.
7. Any increase or decrease in pain upon lifting the testes? Patient says why should I lift
/ I didn’t think about it.

Talk to the patient about 2 D/Ds and management (Dx + Ix+ Rx):

After speaking with you, I’m suspecting two conditions.

Dx 1: The first is epididymo-orchitis. This means that there is inflammation of the testes and
surrounding structures due to some germs / bugs growing there.

Ix: But we need to confirm this by doing some tests. We need to take a urine sample from
you (dip stick + 1st catch urine culture)

We’ll also take a swab

Rx: Once we confirm the diagnosis we’ll give you medications called antibiotics that kill the
germs / bugs. By any chance are you allergic to antibiotics? (< 35 years (STI) – doxycycline
100 mg BD x 10 days. > 35 years (UTI) – ceftriaxone 300 mg BD x 10 days)

Dx 2: The second is testicular torsion. This means there is twisting of testes inside the sac
(scrotum).

Rx: This is an emergency and needs surgery right away. In the surgery we move the testes
back in the normal position and then fix both the testes so anything like this doesn’t happen
again.
Since it happened more than 6 hours ago, there may be significant damage to the twisted
testes. In that case, if there is significant damage, we may have to remove the affected testes.
(B/L orchidopexy +/- orchidectomy)
BACK PAIN
Task : A 55 year old male presents with back pain. Take history and discuss
investigations with the patient. Discuss D/Ds with the examiner.

STEP 1: P1

What brought you to the hospital today?

S Site of pain: upper or lower back

O Onset: Since when, How did it start (sudden or gradual), Is it the first time?

C Character: dull, sharp

R Radiation: does it go anywhere – to the arms / legs?

A Associated symptoms – tingling and numbness of limbs

T Timing: all the time? Comes and goes? Early morning?

E Exacerbating & relieving factors: rest, exercise

S Severity – grade on a scale of 1 to 10 with 10 being the worst

STEP 2: Rule out any remaining D/Ds

Differential Diagnosis of Back Pain

Differentials Relevant Questions

Secondary metastasis Weight loss, loss of appetite, tiredness,
SOB

Lung Chest pain, cough, haemoptysis

Breast Pain / lump in breast

Prostate Dribbling, poor stream,

Multiple myeloma Bleeding, infections, anaemia

Osteoporosis of vertebrae Loss of height over time, hx of fractures

Osteoarthritis Morning stiffness

 Trauma Did you get hurt by any chance?

Prolapse Did you do any heavy lifting?

Infection (TB/Pott’s) Fever, night sweats, anorexia, weight loss

Have you had any red eye? Has anyone in

Ankylosing spondylitis your family been diagnosed with
ankylosing spondylitis?

STEP 3: Complete P (2,3,4,5,6,7,) MAFTOSA

Patient History

1. Low back pain becoming worse in the last two months

2. Wakes up every night to go to loo since last month
3. One stone weight loss in 2 months
4. Morning stiffness
5. No haematuria
6. No heavy lifting

Diagnosis

Secondary metastasis from prostate cancer

Investigations with the patient:

After speaking with you, I’m suspecting some problem with your prostate (abnormal growth),
which is also leading to the back pain. But first I need to confirm the diagnosis by doing
some investigations.

We need to do a blood test (PSA). We will also do an U/S and take a sample (TRUS +
biopsy). And we may also do an X-ray (for bony metastasis) as well as a CT and MRI scan
(other organ metastasis)

KNEE PAIN
Task : A 28 year old male presents with complain of knee pain. Take history and discuss
D/Ds with the examiner.
STEP 1: P1

What brought you to the hospital today?

Site of pain: Which side, or both? Where exactly? In a localized area? Or

S
generalized pain?

O Onset: Since when, How did it start (sudden or gradual), Is it the first time?

C Character: dull, sharp

R Radiation: does it go anywhere

A Associated symptoms – redness, hotness, swelling

T Timing: all the time? Comes and goes?

E Exacerbating & relieving factors

S Severity – grade on a scale of 1 to 10 with 10 being the worst

STEP 2: Rule out any remaining D/Ds

Differential Diagnosis of Knee Pain

GHRRROSS

Differentials Relevant Questions

G Gout Did you have any pain in your big tow before?
Thiazide diuretics
H Haemarthrosis Bleeding, redness of joint
R Reiter’s Can’t see, can’t pee, can’t climb a tree
R Reactive arthritis Past infection
R Rheumatoid Arthritis
O Osteoarthritis Small joint pain
S Septic arthritis fever
S Sport injury Did you get hurt by any chance? Do you play a lot
of sports?

STEP 3: Complete P (2,3.4,5,6,7) MAFTOSA

Patient History

1. Knee and ankle pain since last week

2. No pain in small joints
 3. +/- morning stiffness
4. +/- calf pain
5. +/- watery eye
6. Travel history to France 2 weeks ago
7. Diarrhoea in France ruined holidays
8. No fever, or burning
9. Safe sex

Diagnosis:

HAEMOPTYSIS
Task A 65 year old female/male presents with haemoptysis. Talk to the patient. Discuss
D/Ds with the examiner.

STEP 1: P1

What brought you to the hospital today?

O Could you tell me something more about it?

Are you sure it is not from your gut or mouth? What is the colour of blood? Is there
S
anything with the blood?
O How did it start?
D Since when?
I How often? How much? Half a cup? On tissue?
F Is it the first time?
P Is it getting worse?
A Anything makes it worse? Like cough? Smoke?
R Anything makes it better? Rest /sleep
A Any other problem?
Ask cardinal symptoms of respiratory system
C Ask signs of anaemia (tiredness/fatigue,
heart racing, SOB, light headache)

STEP 2: Rule out any remaining D/Ds

Differential Diagnosis of Haemoptysis

PEP-C-BATCH
 Differentials Relevant Questions
Cough, chest pain, fever. Anyone else in your close
P Pneumonia
contacts has similar symptoms?

E Endometriosis Do you get this during your period?

Calf pain? Recent surgery? Travel history. Clotting

P Pulmonary Embolism
problem?
Cancer[Bronchogenic
carcinoma/Kaposi
Weight loss? Family history? Smoking? [In the past /
C sarcoma/carcinoid
how long? How many in a day]
tumor/metastatic
tumor]

Bleeding 4 D/Ds:
Bleeding disorder Bleeding from any other part of body? Any FH?

Blood thinners Are you taking any blood thinners?

B
Did you have any procedure or
(2) Instrumentation
instrumentation recently?

Trauma/foreign body By any chance did you hurt yourself or had choking?

Bronchiectasis Recurrent chest infections. A lot of sputum per day

A Abscess Do you have fever? Yellow smelly sputum?

Night sweats? Fever? Recent travel abroad?

Any contact with TB patient? [or any other people
T TB
have same symptoms where you live or that you
meet often?)

C COPD/Bronchiectasis Smoking? Chronic cough? SOB

STEP 3: Complete P (2,3,4,5,6,7) MAFTOSA

Patient History

1. Blood in sputum (1/2 cup) in 8 weeks OR;

 2. Had previous episode of haemoptysis within a month ago. Had seen GP who gave
antibiotics. Haemoptysis went away but had another episode again now, since last few
days.
3. Last time sputum was more yellow with specks of blood. This time it is clearer with
specks of blood.
4. Smoking history since 30 years, 20 cig per day, No history of long travel
5. No history of long travel
6. No weight loss
7. No close contact with TB patient
8. No family history of cancer

Diagnosis: