History taking Pre- operative confusion : ~ hello, i'm... One of the surgical doctors , how are you today? = Would you mind if | asked you some questions to test your memory? Abbreviated mental test scoring “How old are you? “What time is it to the nearest hour? *Can you remember this address? 24 West St. | will ask you this at the end “What year is it? “What is the name of this place? “What is my job? And what is the job of this person (e.g. a nurse)? “What is your date of birth? “When did Ww2 end? “Who is the current prime minister? *Can you count backwards from 20-17 “What was that address | asked you to remember? Discussion: The patient has AMS SCORE 2/10 She has a short term memory loss Fitness for the operation? Not fit for giving a consent , as she can not retain informations and she can not make an informed decision Should the operation go ahead? No. The operation is non urgent, therefore it can be postponed until the cause of the confusion has resolved. | would talk to my consultant and the anaesthetist in charge of the case to inform them of the confusion and ask their advice before cancelling it. What is your differential diagnosis? - differential for this lady's acute confusion is a urinary tract infection. ~ Other causes include: . other sources of infection, metabolic abnormalities such as renal or hepatic failure, hypoglycaemia and hyperthyroidism, hypoxia, hyperthermia, vitamin deficiency such as thiamine deficiency, medication such as steroids, opiates or other sedating medication, and being in an unfamiliar environment on the background of dementia. Management: ? | would take a history from the patient, the notes, family members and her GP and perform a thorough systemic examination. My initial investigations would include a urine dip and MSU, blood tests including inflammatory markers, haematinics and thyroid function tests. Imaging should be arranged, firstly a chest X-ray and then a CT head if there are any neurological signs, or after other investigations return as negative. Page 1| would consider asking the medical registrar to see the patient to either take over care or give appropriate advice. Bleeding per rectum: ‘Scheme of history taking ~ identity your self ~ Confirm the patient name and date of birth. ~ Start by an open question: how can i help you today? Or what seems to be the proplem ? ~ History of the presenting complaint( onset , duration, course, severity, ppt factors, releving factors, associated features) - Past medical and surgical history ~ Drug history : doses, allergies ~ Social history: occupation, home situation, mobility, smoking, alcohol ~ Family history ~ ICE: ideas, concerns, expectations ~ Systems review Discussion: [History of the presenting complaint: | - onset: did this started suddenly or gradually? - duration: when did you first noted this? ~ course: does this bleeding comes and goes.? Does it get previously worse? ~ Severity:what is the colour of the blood? , how much blood you notice every time?Streaks? ‘Teaspoon? More? Is that bleeding is painful when you pass stool? = Releving factors: is there anything makes this bleeding stops ~ Ppt factors: is there any thing makes that bleeding increases? - Associated features: - do you have noticed any slime or discharge? Or pain in your tummy.? - Do you have any disturbances regarding bowel habits? - Abroad —Have you been abroad recently? if so , where? ~ Tiredness -Have you been feeling more tired than normal recently? - - Swallowing/upper-GIT symptoms —Have you been nauseous or sick? ( If 0, ask about haematemesis. ) Any difficulties swallowing? Heartburn? - Painipruritis ani - Have you had any pain in your tummy? If so, SOCRATES. Have you noticed any itching around the anus? ~ Anorexia -How has your appetite been? - Weight loss —Have you noticed any unintentional weight loss? - Systemic features Have you had any mouth ulcers? Fever? Painful red eye? Joint or back pain? [Past medical and surgical history: ] Do you have any other medical conditions, see your GP for any thing, ever had surgeries? [Drug history: ] Do you take any medications? Dose? Do you have any allergy against any drug? [Social history: ] = What is your occupation? - who is at home with you? - do you have any difficulty with the stairs - do you smoke ? How many packs/ day = do you drink alcohol? How many units/ week [Family history: ] Page 2Is there any one else in the family has had a similar problem? [Elicit ICE: ] Before i go any further, could i ask: ~ what do you think the cause is? = What are you the most concerned about? - What are you hoping us to do for you? [Systems review: ] ~ resp., cvs: is there any chest pain,SOB, cough ~ Malignancy: have you had any unintentional weight loss difficulty in swallowing, change in bowel habits, night sweats ~ Urinary: any proplems in passing urine? ~ Rheumatic : any muscle or joint pain? > Any thing i have missed? Small bowel Colon and rectum Aorto-enteric Polyps fistula Carcinoma Meckel's Diverticular disease diverticulum Ischaemic colitis Mesenteric Inflammatory bowel disease infarction Angiodysplasia Intussusception | Solitary rectal ulcer Rectal prolapse Irradiation proctitis Anus Others Haemorrhoids Significant haemorrhage from upper GI tract Anal fissure (ulcer disease) Trauma Bleeding disorder Carcinoma Anticoagulants Uraemia Discussion: What is your differential diagnosis? The weight loss, change in bowel habit and PR bleeding are concerning. My main differential is colorectal cancer, which would need thorough investigation. Other differentials for PR bleeding De a—_—s include haemorrhoids, inflammatory bowel disease, angiodysplasia, diverticular disease, benign polyp, and an anal fissure. It may also be secondary to medication or a hematological condition. What is the most important investigation to carry out? As | am suspecting colorectal cancer, the most important investigation is a colonoscopy +/- biopsy to examine the whole colon. Itimmediately available in clinic, a rigid sigmoidoscopy may be carried out in the first instance + Haematology: FBC (anaemia, leucocytosis of infective colitis, inflammatory bowel disease, ischaemic colitis), low platelets (bleeding disorder), clotting screen, group and save / cross match for transfusion. + Biochemistry: U&Es, LFTs (hepatic failure with variceal bleed, malignancy) + Arterial blood gases: Raised lactate (ischaemia), metabolic acidosis. + ECG: Mesenteric ischaemia, atrial fibrillation (emboli). + Endoscopy: OGD (to exclude upper gastrointestinal cause), sigmoidoscopy / proctoscopy (haemorthoids, anorectal lesion, distal colitis, rectal ulcer) and colonoscopy (malignancy, diverticular disease, colitis, angiodysplasia) + Mesenteric angiography (CT or invasive) / Technetium scan / Labelled red cell scan, if source not identified by endoscopy (looking for angiodysplasia / Meckel's diverticulum). + Radiology: AXR (obstruction, toxic megacolon of inflammatory bowel disease) and US scan / CT (if suspected malignancy, for liver metastases and staging). + Microbiology: Stool cultures (infective colitis). Dysphagia: ~ Solids or liquids? -Do you have difficulty swallowing solids, fluids or both? Timing —Is it there all the time or does it come and go? - Onset -When did this start? Progression —Has it worsened over time? Associated features: ~ Stuck Does the food get stuck in your throat when swallowing? ~ Halitosis -Have you noticed having bad-smelling breath recently? ~ Lump -Do you ever feel a lump in your throat? = Gurgle -Do you ever notice gurgling or a wet voice after swallowing? - Pain —Is there any pain when swallowing? Any chest pain? - GORD/dyspepsia -Do you ever taste acid at the back of your mouth? Heartburn? Pain in your tummy? - Hematemesis Have you vomited at all? If so, was there any blood? - Bowels -Have you noticed any change in your bowels? How many times a day do you go to the toilet? Has that changed at all? Have you noticed any blood in your stools? Is it darker or more smelly than usual? = Neuro -Have you noticed any weakness anywhere? Any problems walking? ~ Autoimmune -Do you suffer with painfully cold hands? Dry eyes or mouth? ~ Constitutional -Have you had any unintentional weight loss? If so , how much have you lost and over how long?Page 4 Severity: Do you experience this difficulty of swallowing to solid or to liquid foods or both? History taking as previous Discussion: Intraluminal Intramural Extrinsic Pharynx/upper oesophagus Pharyngitis/tonsillitis Moniliasis Sideropenic web Foreign body | Corrosives Carcinoma ‘Myasthenia gravis Bulbar palsy Thyroid enlargement Pharyngeal pouch Body of oesophagus Corrosives Foreign body | Peptic oesophagitis Carcinoma Mediastinal lymph nodes Aortic aneurysm, Lower oesophagus Corrosives Peptic oesophagitis Carcinoma Diffuse oesophageal spasm Systemic sclerosis Achalasia Post-vagotomy Foreign body Para-oesophageal hernia Considering : difficulty in swallowing, weight loss, heavy smoking, alcohol drinking, hematemsis my main diagnosis will be esophageal carcinoma causing mechanical obstruction of the oesophagus \ also have to consider: = lung cancer , pharyngeal pouch, retrosternal goiter ( compression from outside) ~ Oesphageal web, plumer vinson sundrome - Achalsia ( motility disorder) ~ Myathenia gravis Investigations: ~ Full clinical examination checking for lymphadenopathy - Bloods -FBC, U&Es, LFTs and clotting and bone profile = Chest X-ray > Oesophageal manometry: achalasia, GORD ~ Barium swallowEY ENS Page 5 ~ esophageal endoluminal US, also for staging of carcinoma. ~ Videofiuoroscopy —assessing for aspiration ~ Staging CT scan, depending on what the previous investigations reveal Treatment : Operable cases: oesphagectomy + chemoradiotherapy Non-operable cases: palliation: self expanding metallic stent, palliative chemotherapy and radiotherapy , feeding jeujnosomy Change in bowel habits (IBD) = Open question -Can you tell me what has been going on? ~ Specify —When you say constipation/diarthoea, what do you mean exactly? Do you mean you are going more/less often or the consistency has changed? = Onset -When did you first notice this? Has this changed recently? - Character/colour What are the stools like? Are they watery, semi-solid or solid? Is there any blood or mucus in the stools or on the tissue paper? - What colour are your stools? - Radiation (from upper GIT) -Do you get any dark, foul-smelling stools? - Associated features :(BOWELS) * Bloating -Do you tend to suffer from bloating and flatulence? * Ouch! Are you suffering from any abdominal pain? If so, SOCRATES Weight loss Have you lost any weight recently? How is your appetite? Exhaustion -How have your energy levels been? * Lasting urge -Do you feel like you always need to go to the toilet, even after you've just been? Is this despite not passing very much stool? ( Tenesmus ) * Swallowing/upper-GIT symptoms —Any vomiting? ( If so, ask about haematemesis. ) Any difficulties swallowing? Heartburn? * Extra-intestinal features IBD —Have you had any mouth ulcers? Fever? Painful red eye? Joint or back pain? * Foreign travel —Have you been abroad anywhere recently? = Timing How many times a day do you go to the toilet to pass faeces now? How often do you normally go? What are your stools normally like? Have you ever suffered from the opposite? (i.e. constipation/diarthoea) - Exacerbating/relieving factors —Does anything relieve the constipation/diarthoea? Does anything make it worse? - Severity —How badly is this affecting your day-to-day life Discussion: Considering weight loss, diahrrhea, PR bleeding, mucous discharge, extra-intetinal manifestations, my main diagnosis will be crhon's disease or ulcerative colitis | will also consider: = infective gastroenteritis > Colrectal cancer ~ Diverticular disease Manageme!aeeeieiuhel patie Abdominal examination including DRE Page 6 -Routine bloods ~ FBC, U&E, CRP, LFTs, calcium, magnesium, phophate, Coagulation screen, - Group and Save. (Looking for raised inflammatory markers, dehydration, electrolyte disturbance secondary to diarrhoea, albumin as a guide of nutritional status, coagulation defects.) -Stool sample -Faecal occult blood test Abdominal Radiograph - assess for toxic megacolon -+/-CT or MRI abdomen and pelvis if concerning features on examination and for pre-operative planning if surgery is indicated = colonscopy Treatment: Medical : mesalazine, prednisolone, immunomodualtors( intl Conservative: dietary control ( low residue diet) Surgical : in toxic megacolon, IO, maignant transformation, fistulation, refractory cases 1ab) Thyroid status: (female with hyperthyroidism) History taking as usual Assiciated features: Compressive symptoms: 1- changes in voice 2- difficulty in swallowing 3- do you breath well? Toxic symptoms: 1- changes in vision or difference in eyes 2- diarrhea 3- menstruation ( do you menstruate regularly) 4- sleep disturbances 5- hot or cold intolerance 6- weight loss 7- mood or behavioral changes 8 appetite Discussion: Mr... IS ... Y old , previously fit and well, presents with a lumb in her neck, the lumb has grown over the past .... Years, in addition she has symptoms indicating hyperthyrodism such as She has also compressive symptoms such as .. My main differentials will be: Toxic MNG simple MNG ~ thyroid neoplasm > Thyroiditis Management: Tripple assement: Full clinical examination Ultrasound imaging FNAC Other investigations: radioisotope scanFossibve Causes of sudden enlargement: ~ hemorrhage inside a cyst. Page 7 ~ Malignant: papillary, follicular , medullary carcinoma Treatment: thyroidectomy ( hemi, near total or total) with such compressive symptoms What possible complications of surgery do you advise this patient about? ~ risk of RLN injury: hoarsness of voice, aphonia, stridor and possibility of tracheostomy = Risk of hypocalcemia = life long thyroxine replacement Abdominal pain : (18s) female referred trom her GP as chronic calcular cholecystitis O’SOCRATES = Open question —| believe that you are suffering from pains in your tummy. Can you tell me a bit more about your problem? - Site -Where exactly do you get this pain? Can you point to it precisely? Where did the pain first manifest? Has it moved? - Onset -When did this pain start? Minutes, hours, days, weeks, months? - Character —What does the pain feel ike? You may need to provide examples, such as cramping, aching, sharp, knife-like, dull, twisting, excruciating, like an electric shock, etc. - Radiation -Does the pain move anywhere else? Can you show me? Does it go into your back! around the side/groinitesticles? Do you get shoulder-tip pain? ~ Associated features * Have you noticed any weight loss? How has your appetite been? * Have you had any difficulty swallowing? Any heartbum? Any voriting? If so , have you noticed any blood in the vornitus? * Any change in your bowel motions? Any blood or mucus in your stools? - Timing —Is the pain there all the time or does it come and go? What is the periodicity if any (length of time the pain is present and how long between bouts )? Is there any particular time where you have noticed you get the pain ( day, night, mealtimes, menses )? Have you ever had this pain before? If so, what happened? - Exacerbating/relieving factors -What, if anything, brings the pain on? Does anything make it worse? Does anything make it better? Have you taken anything to relieve the pain? Is it getting better/worse with time? Does body position make a difference? ~ Severity -If you had to rate the pain from 1 to 10, with 10 being the worst pain you can imagine, how would you rate it? Social history: social stress( her husband left his job with some financial problems) Discussion: Mrs... IS ..... Y old , presented by abdominal pain, the pain is colicky in nature, it is not related to meals, she experience it in the middle of her abdomen, has no special timing, no aggrevating or relieving factors, associated with disturbed bowel habits, she also has some social stress My main diagnosis will br IBS, | will also consider IBD, colon cancer, chronic calcular cholecystitis. Management: Investigations: abdominal ultrasound, AXR, colonscope, stool analysis, FBC Treatment: fiber diet, antispasmodics, antidepressants Abdominal pain (chronic pancreatitis) :PEstory Senay Page 8 40 y . Old divorced male with chronic epigastric pain radiating to the back for the past 1 year,with steatorthea, takes 5 glasses of beer/ day, previously admitted for acute pancreatitis. Takes 30 mg of morphine / day to numb the pain, depressed SOCRATES approach as usual Differentials: ~ chronic pancreatitis (in view of epigastric pain, steatorrhea, previous attack of acute pancreatitis, being an alcohol drinker) - Pancreatic pseudocyst - PUD What do you think about the history of taking 30 mg of morphine, what should be the normal dose? 15-30 mg /4hours as needed Investigations : ~ secretin stimulation test ~ Serum amylase and lipase ( elevated) = Serum trypsinogen CT scan ( pancreatic calcifications) MRCP : identify the presence of biliary obstruction and the state of the pancreatic duct Endoscopic ultrasound Treatment: Medical treatment of chronic pancreatitis: 1- Treat the addiction :IM| Help the patient to stop alcohol consumption and tobacco smoking I Involve a dependency counsellor or a psychologist 2-Allleviate abdominal pain: 1 Eliminate obstructive factors (duodenum, bile duct, pancreatic duct) Escalate analgesia in a stepwise fashion ll Refer to a pain management specialist For intractable pain, consider CT/EUS-g1 3- Nutritional and digestive measures: 1m Diet: low in fat and high in protein and carbohydrates. 1m Pancreatic enzyme supplementation with meals Correct malabsorption of the fat-soluble vitamins (A, D, E, K) and vitamin B12, 1m Medium-chain triglycerides in patients with severe fat malabsorption (they are directly absorbed by the small intestine without the need for digestion) 1m Reducing gastric secretions may help Treat diabetes mellitus 4- treat DM The role of surgery is to overcome obstruction and remove mass lesions led coeliac axis block Lower limb claudication: Analysis of pain: = Open question —Can you tell me about the pain? ~ Site -Where do you get the pain? (buttock, thigh, calf) ~ Onset —Did it come on suddenly or cradualiv?- Character —What does it feel like? (cramping, tightening of muscles) ~ Radiation —Does the pain go anywhere else? Page 9 ~ Associated factors -Do you get any pain at night? Have you noticed any ulcers in your legs or feet? If so , are they painful? , do you have any numb in your legs or feet? Do you have any back pain = Timing -Do you get the pain when walking or at rest? ~ Exacerbating & relieving factors -Is it relieved by rest? Is it made worse if you walk faster or up a hill? Does cold weather affect it? ~ Severity -How badly does it affect you? How far can you walk before stopping? Discussion : My main diagnosis will br chronic lower limb ischemia causing vascular caludication | will also consider : spinal canal stenosis, DVT, disc lesion causing spinal claudications,osteoarthritis smuskloskeletal injury How to diff. Between spinal and vascular caludications: Peripheral vascular disease : = Claudication pain is a cramping pain in the calf, thigh or buttocks ~ Brought on by exercise and relieved by rest (patients often pretend to ‘window-shop’ until the pain disappears) ~ Exacerbated by walking faster or up hills and also by cold weather ~ Risk factors/associated factors for atherosclerosis: Diabetes Hypercholesterolaemia Stroke ~ Rest pain may indicate critical limb ischaemia Spinal claudication ~ Often relieved when walking up a hill = Often has associated limb numbness Sciatica : = Shooting pain down the back of a leg to the feet ~ History of lower-back pain Management: Investigations: ~ Full peripheral vascular, cardiovascular and neurological examination ~ Assess gait and balance arterial duplex ~ ct angiography (if surgical intervention was needed) = MR Angiography Treatment: = optimise blood sugar , cholesterol, blood pressure ~ Antiplatlet agents: aspirin, clopidogrel ~ Antilipemic agents: simvastatin ~ Surgical treatment: endovascular stenting, surgical bypass, amputation Anxious patient : ( sos ) in pre-admission clinic Lady planning for chlecystectomy, SOB for few minutes, increasing in frequency 6 weeks after being scheduled for operation = Onset —How long has this been going on for? ~ Frequency —Are you always breathless or only sometimes? What sets it off? = Relieving factors —Does anything help you get your breath back? If you rest for a while, does itimprove? Do inhalers help? ~ Exacerbating factors -Does anything make it worse? Is it worse lying flat? Sleeping upright — How many pillows do you sleep with? Do you have to prop yourself up? Do you ever wake up gasping for air? Page 10 ~ Severity -How far can you walk before the breathlessness stops you? Can you climb a flight of stairs in one go? If not , how many can you manage? ~ Associated features: = Cough -Have you noticed a cough? If so , for how long? Do you bring anything up? Have you noticed any blood? ~ Wheeze -Do you get wheezy? Is it worse at any time of the day? ~ Fever -Have you recently had a cough or cold? Do you have a fever? - Constitutional Have you had any weight loss? How is your appetite? - Chest pain Do you suffer from chest pain? If so, SOCRATES ~ Palpitations -Do you get palpitations with the breathlessness - Anxiety -If relevant , do you only get breathless when you are anxious? Discussion: The SOB described does not fit with cardiac or pleuritic chest proplem , and the patient tells me that she has been investigated and ruled out. My top differential would therefore be anxiety related to her impending operation. | will also consider: anginal pain, pneumonia, pleurisy. Management: | should contact the GP to get hold of all the notes regarding investigation of the patient’s chest pain. - | would examine the patient and ensure that we repeat the patient's bloods, ECG, CXR and get a baseline ABG on room air. ~ I would want to ensure she had a recent echo and angiogram and discuss these with a cardiologist. ~ would reassure the patient that she is going to be well looked after, and ask her is there was anything we could do to allay her fears. - would also suggest that we involve her close relatives or friends so that she has an adequate support network in place before and after the operation Can the operation go ahead:? As long as we have no documented evidence that there is no cardiac or resp. Illness, the operation should go ahead - FEV1: Volume that has been exhaled at the end of the first second of forced expiration - FVC: is the amount of air which can be forcibly exhaled from the lungs after taking the deepest breath possible - FEVI/FVC ratio: It represents the proportion of a person's vital capacity that they are able to expite in the first second of forced expiration In obstructive lung disease, the FEV! is reduced due to an obstruction of air escaping from the lungs. Thus, the FEV1/FVC ratio will be reduced In restrictive lung disease, the FEV1 and FVC are equally reduced due to fibrosis or other lung(PABTOINS Y WOE QUST MINE PANNING }. ENMS, BIG PETES FANG SIO BP PIORmNaely MOEN Page 11 LUNG VOLUME iy Knee pain: (oa) Footballer, had right knee injury 30 years ago, had knee operation that he has no idea about, developed worsening right knee pain 4 months ago Analysis of pain (SOCRATES) ~ Site -Where is the pain? = Onset When did you first notice the pain? Was there any history of trauma? ~ Character -What does the pain feel like? = Radiation -Do you have pain anywhere else? (other joints) - Associated features : “Did you notice any changes in the shape of your knee?( deformity) - Did you experience lacking of your knee? menisci) - Did you experience giving away when walking? ( ACL) ~ Did you notice any numbness? neurology) ~ Stiffness —Have you noticed any stiffness in your joint(s) when you wake up in the morning? How long does that last for? ~ Swelling -Have you noticed any swelling, redness or heat in your knee ~ Extra-articular features: * Rashes —Have you noticed any rashes anywhere on your body? * Enteropathy —Have you had any diarthoea? * Uveitisfiritis Have you had painful or red eyes? - Spondyloarthropathy —Have you had any back pain? ~ Timing When do you get the pain? Is it there all the time or does it come and go? Are the symptoms worse at any particular time of the day? ~ Exacerbating/relieving factors -Does anything make it better? Does anything make it worse? Is it made better or worse by the cold? Is it made better or worse by exercise? Does resting the joint help the symptoms at all? What painkillers have you tried so far? Do they help? ~ Severity +f you had to rate the pain from 1 to 10, with 10 being the worst pain you can imagine, how would you score your pain? How do your symptoms affect your day-to-day life? Is there anything you find you cannot do now as a result of your symptoms? Discussion: Mi coo a ....year old gentleman who has been referred with increasing pain from his right knee, This started approximately ....... years ano and has been increasing in severity over the past 4months. He is experiencing a dull constant ache that is increased on exertion and at the end of the day. However, the joint does not swell, lock or become unsteady on walking. The pain is limiting his daily routine., the patient has a past history of knee trauma and surgery My main differential will be: = OA (traumatic) Page 12 - RA ~ Referred pain from hip or spine pathology Managenent: Invesigations: - knee x- ray ( standing and weight bearing) : a-p , lateral views Treatment: Conservative + Maintain or achieve a healthy weight i.e. aim to decrease weight, and therefore force, going through a joint +” Regular exercise, with particular attention to strengthening the muscles around the joint. For example in OA of the knee, cycling is beneficial + Analgesia: care to be taken with NSAID's with relation to gastric irritation + Heat application to the joint may offer relief + Physiotherapy : Intra-articular steroids Surgical: ‘Arthroscopy and arthrocentesis + Realignment osteotomy + Total or partial knee replacement Will the pi jient be likely to play soccer in 9 months? No Headache ( subarachinoid hemorhhage) = Open question -Would you please tell me about your headaches? ~ Site -ask about frontal, occipital, temporal, unilateral, all over = Onset ~Did it come on suddenly? Do you have any warnings prior to the headache? - Character —Was it one episode or multiple? Describe the pain ~ Radiation -Does the pain move anywhere else? ~ Associated symptoms : * Fever Have you been feeling ill or had a fever? * Trauma -Have you banged your head, had a fall recently? * Sensorimotor changes -Have you had any arm or leg weakness? Any visual disturbances? Any other sensory disturbance? Have you ever lost consciousness? * Meningism —Are you sensitive to light? Do you have any neck stiffness? Have you noticed a rash anywhere? * Seizures/blackouts Have you ever had seizures or blacked out? * Vision -Any eye pain? Visual disturbances? Nausea or voriting = Timing -When can you remember this starting? Was it continuous or intermittent? How long do they last? When was the last time you had a headache? = Exacerbating or relieving factors —Does it get worse on coughing? Is it worse at night or in theearly morning? Any particular activities or movements? Does anything relieve the pain? = Severity -How bad is the pain on a scale of 1-10, with 10 being the worst pain you can imagine? Has it changed over time? How is it now? Is it painful to touch or press over? Past medical history: polycystic kidney (relevant history) Page 13 Family history: My aunt died suddenly of an aneurysm in the brain Discussion : My main differential is a subarachnoid haemorrhage, but I would also consider other causes of an acute severe headache including meningitis, encephalitis, and a migraine, increased ICP due to braii tumour Management: I would manage him in an ABC manner, ensuring that he is stable and arrange appropriate bloods and a plain CT head Investigations: - CT BRAIN - CSF Tapping Treatment: ~ I would refer this patient to a neurosurgical unit. ~ bed rest, 3L of IV fluids /24h, ~ oral nimodipine 60mg every 4 hours, and laxatives = attempt to coil the aneurysm is made ~ Burr holes - Craniotomy ~ Discuss in neurovascular MDT Seizures: (brain tumour) - “Before: ~ Open question -Can you talk me through what happened exactly? Where and when? What were you doing at the time? ~ Aura How did you fee! immediately before the episode? Any aura? Chest pain, anxious or fearful? Did you have any warning that something was about to happen? = Environmental —Did you trip over anything or slip? ~ LOC —Did you lose consciousness? How long for? ~ Witness —Did anyone witness the episode? How did they describe the episode? ~ During Fall : - How did you fall exactly? Did you hit your head? ~ Seizure -Did you have a fit? Can you describe it? Did your whole body shake or only part of it? ~- Continence -Did you pass any urine or soil yourself? ~ Tongue —Did you bite your tongue? -After:POSING TET SHES STOW CN YOR TE GE PENTIC CIE GTY SEE ME TEMNNTET YOU TEGSMIEG CONSEIONSNESS Were you confused? Drowsy? Aching muscles? - Previous episodes Has something like this ever happened before? If yes , can you describe exactly what happened those times? Page 14 Discussion: Management: Investigations : CT BRAIN , MRI BRAIN, EEG Treatment: ~ start anticonvulsant therapy after discussing that with my consultant : Phenytoin ( 1g loading dose) then 300 mg once daily Ensure that the patient is on steroids( 4mg dexmethasone QDS) > disouss in neuro-oncology MDT ~ stealth guided biopsy ~ Resection and debulking Hematuria (biadder cancer) CLOTS - Clarify -When do you notice the blood? Is it only when you pass urine? Is there any chance it could be coming from elsewhere? What colour is it? Have you recently eaten any beetroot? = Onset -When did you first notice the blood? ~ Timing -Is there always blood in your urine or does it come and go? Have you had this before? Is the blood present at the start of urination, the end or throughout? ~ Severity -Do you pass any clots? = Associated symptoms: = Pain -Do you have any pain when you pass urine? Any pain in your tummy or back? If so, SOCRATES ~ Frequency —Any change in frequency? Any trouble with incontinence? Do you get sudden imepressible urges to pass water? = Nocturia -How often do you get up at night to pass urine? Urinary stream —Do you have difficulty getting the stream started? Is there prolonged dribbling at the end? Is your stream powerful or weak? ~ Constitutional -Have you been unwell recently, or had any fever or chills? How is your appetite? Have you lost any weight? > Trauma —Have you had any trauma to your stomach or groin recently? Social history: occupation? Aniline dyes and beta-naphthylamine Discussion: Mrs IS nnn Old , presented by painless hematuria one month ago, with associated weight loss over the last........, there is no any abdominal or loin pain, there is no proplems in urine stream, he is concerned about the possibility of having cancerDD: > my main dd will be bladder cancer, renal cell carcinoma considering (his hemorrhage, weight loss, occupation) ~ Stone kidney, bladder, ureter > Infection > Trauma > Bleeding tendency Page 15 Management: ~ urine dipstick to confirm hematuria, assess infection, send a sample for cytology ~ Bloods: FBC, U&€, clotting screen , PSA = Cystoscopy And biopsy > uls, CT Treatment: Depends on the stage and the grade of the tumour ~ surgical: TURBT, Radical cystectomy ~ Non- surgical: chemotherapy and radiotherapy and immunotherapy Urine retention: rx) History taking as usual Associated features: ~ do you have any pain during urination? - Any redness or blood in your urine? > Any bone pains? ~ do you have proplems in urination that awakes up from sleep ~ Do you have any hesitancy in starting micturition? = Do you have any senasation about incomplete evacuation > Do you have any proplems with erections Drug history: Patient takes nasal sprays containing phenylephrine ( which may cause additive effect to tamsulosin especially in decreasing blood pressure and postural hypotensions) Discussion: Mr... IS... ¥ old, presenting with difficulty in intiating urination, slow stream, hesitancy ,urgency and incraesed frequency. He does not have dysuria, hematuria, bone pains, or weight loss DD: = begnin prostatic hyperplasia > Overactive bladder ~ Prostatic cancer ~ Obstructive bladder pathology( malignancy or calculi) Management: Investigations: ~ full clinical examination including DRE ~ Bloods : PSA, Urine analysis, U&E ~ imaging : abdominal u/s , transrectal u/s- Treatment: Medical: = Tamsulin ( talpha adrenergic blocker) ~ Finasteride (5 alpha reductase inhibitor) Surgical: TURP Page 16 Unilateral tonsillar enlargement: ( scc tonsits) ‘Systems review: Asks specifically about the following: Weight loss Fevers Night sweats Difficulty swallowing Cough / sputum Discussion: Mra: IS... Year Old previously fit and well gentleman, has presented with a 2 month history of an enlarging left tonsil. He has lost approximately half a stone in weight and has increasing discomfort on swallowing, with no other symptoms. Dd: -Squamous cell carcinoma (SCC) tonsil -Lymphoma -Asymmetrical tonsils (unlikely) “Tuberculosis - glandular fever. Management: Investigations : -FBC: looking for raised WCC associated with infection -U+E's: looking for renal impairment if patient has had decreased oral intake -LFT's: derangement may indicate glandular fever or metastasis -Monospot test (detecting glandular fever) -Biopsy and EUA (examination under anaesthesia) -panendoscopy Treatment: > Staging: MRI neck, CT neck, u/s liver ~ Discuss in MDT ~ Block neck dissection ( radical, modi = Radiotherapy ied radical, selective)Depression : (reactive depression post operative on discharging ) pening the consultation: -Introduce yourself — name/role Developing a rapport: ~"How have you been feeling recently?” Page 17 Screening for core symptoms: Soreen for core symptoms of depression — feelings of depression, anhedonia and fatigue. “In the past days during your hospital stay have you...” Felt down, depressed or hopeless? Found that you no longer enjoy, or find lttle pleasure in lite? Been feeling overly tired? Assessing biological symptoms of depression: Soreen for the presence, and assess extent of any biological symptoms Biological symptoms Sleep cycle: “How has your sleep pattern been recently?” “Have you had any difficulties in getting to sleep?” “Do you find you wake up early, and find it difficult to get back to sleep?” Mood: “Are there any particular times of day that you notice your mood is worse?” “Does your mood vary throughout the day?” “Do you find that your mood gradually worsens throughout a day?” Appetite: “Have you noticed a change in your appetite?” “What is your diet like at the moment?” “What are you eating in a typical day?" Libido: “Have you noticed a change in your libido?” "Since you have been feeling this way, have you noticed a difference in your sex drive?” Past psychiatric History: Previous episodes of depression or dysthymia:“Have you ever felt like this before?” “Have you ever had any other periods of feeling particularly low?” “In the past, have you had any problems with your mental health?” “Have you had any counselling for any issues before?” “Have you ever been admitted to hospital because of your mental health?” f so, obtain details — time, method of admission, result. Management : Mild : ~ Regular exercise Page 18 - Advice on sleep hygiene (regular sleep times, appropriate environment) = Psychosocial therapy -CBT Moderate to severe: ~ Regular exercise, advice on sleep hygiene, - CBT ~ Medication -SSRIs ~ High-intensity psychosocial intervention (CBT or interpersonal therapy) ~ Immediate and considerable high risk to themselves or others: Admit to psychiatric ward (use Mental Health Act if necessary) Impotence: (psychological) ‘Ask about: ~ Are you ever able to obtain an erection suitable for penetration, even momentarily? - Is your ED getting worse or stable? - How long have you had trouble attaining or maintaining an erection? - How hard is the erection, on a scale of 0-100? ~ Are you able to achieve orgasm and ejaculation? - Approximately how long are able to have intercourse before ejaculating? - Do you experience nocturnal or morning erections? ~ Is penile curvature ( Peyronie disease) a problem? ~ Drug history: * Anti hypertensives, * Antiulcer drugs (eg, proton pump inhibitors [PPIs] and cimetidine) * Lipid-lowering (eg, statins and fibrates) * 5-Alpha reductase inhibitors (eg, finasteride and dutasteride) * Antidepressants * Antipsychotic drugs * Testosterone and anabolic steroids ~ Did the onset of ED coincide with a specific event ~ Do you have diminished sexual desire? If so, how long have you had this? Is your diminished sexual desire a primary symptom, or is it a reaction to poor sexual performance? ~ Do you have any feelings of performance anxiety? DD: ~ psychological impotence ( considering the presence of morning erection and the stresful conditions of his life) = Iwill also consider: ~ Venogenic erectile dysfunction = uncontrolled D.M7 ee OS = renal failure -MS - hyperprolactinemia - BPH -leriche syndrome ~ anti hypertensive drugs. Investigations: - Haematology: FBC, erythrocyte sedimentation rate, haematinics, clotting soreen, group & save. - = Glycated haemoglobin (cardiovascular risk assessment) Page 19 - + Biochemistry: U&Es, LFTS, CRP, lipid profile ~ + Prostate specific antigen (if relevant history). ~ + Serum free testosterone. ~ + Serum prolactin. - + Serum FSH / LH. - +ACTH (synacthen) stimulation test. - + Urinalysis: Microscopy to exclude a genitourinary cause. - + Radiology: —Duplex ultrasonography to assess vascular function of the penis. — Ultrasonography of the testes to exclude any abnormality. —Transrectal ultrasonography to exclude any pelvic or prostatic abnormaiity. = Angiography: It can be useful for planning vascular procedures / reconstruction, particularly following trauma. Back pain: (functional back pain ) / cauda equina 5 year history of back pain ,worse in the last 3 years, MRI 4 years ago showed mild degenerative change , no neurological symptoms , no trauma, disabled husband, work commitment. + Site -Where exactly do you feel the pain? Can you point to the area? - Onset -When did you first notice the pain? Did it come on suddenly or gradually? Was there any history of trauma? Have you had it before? If so , is it the same pain or different? - Character -What is the pain like? - Radiation -Does the pain go anywhere else? Does it travel down your legs? If so, how far? - ~ ~ Associated features : * Cord compression / cauda equina: ~Have you had any problems with your waterworks? Bowels? Have your legs been feeling weaker than usual? Have you had any strange sensations down your legs or buttocks? Have you had any difficulty in gaining an erection? * Inflammatory ~Is your back stiff in the morning? If so , how long does that last for? * * Constitutional Have you noticed any significant weight loss over the past few months? How is your appetite? Have you been feeling feverish or ill recently? How has your mood been? - Timing —Is the pain always there or does it come and go? Is it worse at any particular time of the day? - Exacerbating/relieving factors Does anything make the pain better? Anything make it worse? Is it made better or worse by movement? Is it made better or worse by rest? Is it worse when lying down or standing? Is it tender when you press on it? Have you tried taking any painkillers for it? - ‘Severity -If you had to score the pain between 1 and 10, with 10 being the worst pain you can imagine, how would you score your pain? Social history: Who is at home with you? De ceed de beccd ites eed che ee Or dnb mene ef hieDiscussion: My main differential diagnosis will be : = functional back pain (Mechanical lower-back pain) localised pain that worsens with movement and changes in posture history of heavy lifting history of previous similar episodes over a number of years No features of systemic illness, nor neurological symptoms ~ Ihave also to rule out organic pathology: Prolapsed intervertebral disc, spinal mets, ‘Seronegative spondyloarthropathy( ankylosing spondylitis) Spinal canal stenosis,Non-spinal causes of back pain( AAA, fibromyalgia, pancreatitis, renal calculi) Page 20 Cauda equina: - Urinary and faecal incontinence - Sensory numbness of buttocks and backs of thighs and weakness of legs Rea.fag symptoms (indicative of serious pathology) Progressvely worsening pan thats notrelieved by rest agrofonet = 200070 ye ‘Uinaryfecal incontinence weakness, saddle anaesthesia History of cancer, weight oss fever ‘Severe trauma or minor trauma in the presence of own ceteoporosis Investigations: ~ Aull examination is required, particularly looking for perianal sensory loss and anal tone. ~ I would carefully check for a reduction in power and decreased reflexes. ~ Back examination and lower-limb neurological examination Bloods -FBC, LFTs, U&Es, CRP and ESR Chest X-ray and QuantiFERON-TB Gold if TB suspected ‘MRI (not needed if the history suggests uncomplicated mechanical back pain) Urgent MRI/CT scan if cord compression or cauda equina is suspected X-ray and a subsequent DEXA scan if a crush fracture is suspected Management : Simple back pain (including prolapsed intervertebral disc): ~ Advise to stay active and avoid prolonged bed rest Physiotherapy, regular analgesia and consider short-course muscle relaxants ~ Serious pathology or red-fiag symptoms: Cord compression ~dexamethasone and urgent surgery; radiotherapy in malignancy > Cauda equina syndrome -urgent surgery - refer to social worker Chest pain : (re) = Site Where exactly is the pain? Can vou voint to where it is?- Onset When did it start? Did it come on suddenly or gradually? What were you doing at the time? = Character -How would you describe the pain? ~ Radiation ~Does the pain go anywhere? = Associated factors : * Breathlessness —Do you get breathless? * Orthopnoea -Do you ever get breathless when lying flat? How many pillows do you sleep with at night? + Paroxysmal nocturnal dyspnoea —Do you ever wake up gasping for breath? * Cough Have you noticed a cough? Do you bring anything up? Any blood? * Constitutional "Have you noticed any weight loss? How is your appetite? * Musculoskeletal —Is the pain worse on movement? Does it hurt to press on the area? Page 21 * Do you have any lower limb pain or swelling? ~ Timing -Is the pain always there or does it come and go? What brings the pain on? Have you ever had this pain before? ~ Exacerbating/relieving factors -Does anything make the pain better or worse? Is it worse when you walk? Does it go away with rest? Is there any relation to eating food? Is it better when you are in any particular position, e.g. sitting up? Is it worse when taking deep breaths? Severity — How bad is the pain on a scale of 1~10, with 10 being the worst pain you can imagine? How would you score it at its worst? Discussion: Considering :pleuritic chest pain, acute onset of SOB,hemoptysis, my main diagnosis will be pulmonary embolism , i will also consider: > pneumonia - Basal atelectasis - MI Manegement: Investigations - CTPA > viQ scan - CXR ECG - ABG Treatment: - ABC PROTOCOL ~ Non massive : heparin untill APTT 50-60 sec. - Massive : thromolysis/ embolectomy Inguinal her History taking as usual: -How long have you noticed this symptom? - What were you doing when you first noticed the bulge? ~ Is the bulge always present or does it appear and disappear. ~ When does it appear and when does it disappear or what do you do to make it disappear? ~ Is there pain on the swelling?( uncomplicated hernia is classically painless) - Is there change in the overlying skin? = Is there wound or sore over the bulge?~_Is there discharge ( pain, change in overlying skin and discharge may suggest strangulation or inflammation ) Ask for other GIT symptoms: Abdominal pain, abdominal rumbling, abdominal distension, vomiting or constipation (can the patient link these symptoms with the appearance of the bulge?) - Is there straining at defecation + Is there abdominal mass or distensi Review of other systems: Page 22 All other systems must be reviewed starting from the nervous system. But the clinician should pay attention to symptoms of chronic obstructive airway disease and obstructive uropathy such as chronic cough and straining at micturition respectively Special notes: ICE: How does a henia happen? With straining like you do, there will be muscle tearing , and some gut will protrude through the detect Could it be better? Itusually needs a surgical operation for repair, the operation may be in open fashion or key hole surgery Where to get back to work? Few weeks History: Stamina tonic : what are the components of it? Is it contains any steroids Visit of the GUM clinic, foreign travel: did you make test for HIV, When you came back , did you repeat it? ysrcone of Undosconded "he ox ‘este ecPage 23Page 24