Fast PACES Academy Station 5

Fast PACES
Academy for Doctors
Station 5
DR IMRAN BABAR MRCP (UK )

FAST PACES Academy
www.facebook.com/fastpaces
Contents +923004507980 mrcpfast@gmail.com
Topic Page
1 Introduction in Station 5 03
2 Scheme for Station 5 04
3 Side Effects of Medicines Frequently Asked in Station 2 & 5 05
4 Leg Ulcer 06
5 Psoriasis 16
6 Other Possible skin cases in PACES 19
7 Musculoskeletal Cases and Connective Tissue Disorders 20
8 Seronegative spondyloarthropathies 22
9 Ankylosing Spondylitis 23
10 Reactive Arthritis 27
11 Psoriatic arthritis 29
12 IBD 31
13 Rheumatoid Arthritis 35
14 Gout 40
15 Polymyositis and Dermatomyositis 44
16 Systemic Sclerosis 49
17 Anti-Phospholipid Syndrome 54
18 Polymyalgia Rheumatica 55
19 Giant Cell Arteritis (GCA) 56
20 Granulomatosis with Polyangitis 57
21 Swelling in Neck 59
22 Thyrotoxicosis 61
23 Grave’s disease 64
24 Hashitoxicosis or Silent thyroiditis 67
25 Post Viral or sub-acute (de Quervain) thyroiditis: 67
26 Postpartum Thyroiditis 68
27 Toxic Multinodular Goiter 69
28 Toxic adenoma (Plummer disease) 69
29 Medication induced Hyperthyroidism 70
30 Hypothyroidism during pregnancy 71
31 Hypothyroidism 73
32 Thyroid Eye Disease 77
33 Acromegaly 79
34 Cushing Syndrome 83
35 Addisons’s Disease 88
36 Hypopituiarism 92
37 Diabetes Mellitus And Charcot Joint 94
38 Diabetes and Foot Care 96
39 Diabetes and Foot Ulcer 97
40 Problem of Eyes encountered in PACES 99
41 Retinitis Pigmentosa 100
42 Optic Atrophy 103
43 Visual Blurriness 106
44 Double Vision 108
45 Transient Visual Loss 110
46 Cataracts 112
47 Diabetic Retinopathy 114
48 Central Retinal Artery occlusion 116
49 Other Possible cases 118
50 Anemia 119
51 Iron Deficiency Anemia 120
52 Other GI Cases 127
53 Epistaxis Because of Elevated INR (Warfarin) 135
54 Syncope 136
55 Collapse 139
56 Seizure(Fit) 140
57 Chest Pain (Angina) 145
58 Palpitations (AF) 147
59 Other Respiratory cases 149
60 Pulmonary Embolism 150
61 Headache 154
62 Left Sided Weakness in a Young Woman 156
63 Parkinson’s Disease 158
64 6th Nerve Palsy 160
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+923004507980 mrcpfast@gmail.com
65 Blackout 161
66 Tremors 164
67 Carpal Tunnel Syndrome 166
68 Peripheral Neuropathy 168
69 UTI / Male Sexual History 170
70 Swollen Calf Causes 171
71 De-Ranged RFTs 172
72 Fever /PUO 173
73 HHT (Osler Weber Rendu Syndrome) 174
74 Other important cases 176
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1.Introduction in Station 5
Hello, Good morning!
My name is Dr. Babar.
Are you Mr/Mrs.…………?
Nice to meet you!
Well!
I have been asked to talk to you and do your examination.
Is that fine?
Right!
Please tell me what brought you here today?
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2.Scheme for Station 5

Introduction
Presenting Complaint
Localization
ODPARA (History of Present Illness) OR LOQIRAA (If Pain)
Associated system OR Underlying diagnosis
Differentials (1 or 2)
Medical conditions
Medicine
Family Hx
Social history…….Driving (If required)
Examination
Targeted
General physical and underlying condition
Idea
Concern
Explain
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3.Side Effects of Medicines Frequently Asked in Station 2 & 5
Warfarin Bleeding, Interactions
Amiodarone Thyroid problem, Pulmonary fibrosis
Tetracycline Photosensitivity
NSAIDs Renal failure,APD,Upper GI Bleed
Methotrexate Pulmonary Fibrosis,Jaundice
Nitrofurantoin Pulmonary Fibrosis
Steroids Multiple especially Osteoprosis
Tamoxifen Cardiomyopathy
Dauxorubicin Cardiomyopathy
Methadon IV drug abuser
Biological agents e.g Infliximab Flare up of TB,Hepatitis,Lymphoma
Antihypertensives Multiple side effects
NSAIDs like Ibuprofen Renal failure
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4.Leg Ulcer
Where exactly the ulcer is?
Do you have Ulcer anywhere else?
Any problem with it like: Pain, Bleeding, Discharge or itching?
For how long?
Is it getting worse?
Any Injury before this?
Any Insect bite?
Any fever or chills? (Cellulitis)
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4.Pyoderma gangrenosum:
Ulcerative cutaneous condition that may start initially as small,red papule or pustule
Pain is the predominant feature
Pathergy may be present
May be associated with underlying systemic condition in 50% of cases like
Hematological malignancy,Liver disease,Rheumatological problems,IBD etc
Legs are more commonly involved but can develop anywhere on the body
Classical form is deep ulceration with a violaceous border and overhanging edge
Questions:
Any problem with it like: Pain, Bleeding, Discharge or Itching?
For how long you have this?

General (Inflammatory conditions and Hematological problems etc)

Liver (CLD)
Upper and lower Respiratory problems (Wegener’s granulomatosis)
Thyroid
Chest (Sarcoidosis)
*Any problem with bowel works (IBD)
*Joints (Seronegative and Seropositive conditions)
Others
Medical Problem
Medicine
Family Hx
Social History
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Examination
Ulcer
 Inspection
 Pulses
 Sensory
GPE
Specific System like:

 Abdomen
Concern
Explain
Investigations:
PG is a diagnosis of exclusion
General:
 CBC,ESR,LFTs,Hepatitis profile etc
Specific: e.g If suspecting Hematological condition then
 Peripheral blood smear

 Serum or Urine protein electrophoresis
 Bone marrow aspiration or biopsy
Biopsy and Tissue cultures or swab from ulcer for C/S
Imaging:
 Doppler studies to see the status of vessels
 CT angiography to rule out the vascular problem
 CT or MRI to rule out osteomyelitis
 Chest X Ray
Colonoscopy
Treatment:
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General:
 Patient’s education
 MDT care package
 Avoiding trauma
 Topical therapy like wound care,dressings,topical corticosteroids etc
 Antibiotics
Specific:
Control of underlying condition with specific therapy like IBD,RA,SLE etc
Specific treatment usually involves
 Systemic steroids
 Immunosuppressive like Cyclosporine,Azathioprine,Cyclophosphamide etc
 Biological agents like Infliximab,Adalimumab,Etanercept etc
Surgery:
Debridement and grafting should be avoided if possible because of Pathergy
Total colectomy may be helpful in Ulcerative collitis
DD:
1.Causes of Pyoderma gangrenosum e.g

 Malignancy
 Liver disease
 Thyroid disease
 Sarcoidosis
 IBD
 Rheumatological conditions etc
2.And other causes of Ulcer on the leg e.g

 Trauma
 Insect bite
 Cellulitis
 Arterial
 Venous
 Neuropathic
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5.Neuropathic Ulcer:
May develop in cases of sensory or sensorimotor neuropathy due to any cause of

neuropathy like DM,Malignancy,Vitimin B12 deficiency or others
Usually occur at the base of foot
It may progress quickly and may become enlarged
Questions:


Any Numbness or tingling in your feet?

Any weakness or cramps in feet?
Any problem with your balance especially when you close your eyes?
Do you feel dizzy when you suddenly stand up from sitting position?
Any problem with walking?
Medical Problem e.g DM
1. How Long,Last Hb A1c

2. Medicine
3. Complications
4. Check Ups
Medicine
Family Hx
Social History
Examination
Inspection
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Sensory Examination( and/or Motor)

Pulses of feet
GPE----Pin Prick Marks
Finish With
 Fundoscopy
 BP
 Urine for proteinuria
Idea
Concern
Explain
Investigations:
Usually a clinical diagnosis but investigations may be focused upon underlying cause
General:
 CBC,ESR,CRP etc
Specific: For underlying cause
 Fasting blood sugar,Hb A1c

 Vitamin B12
 Thyroid profile
 Autoimmune profile etc
Others:
 NCS and EMG etc
Treatment:
General:
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 Feet care with all the measures
 Smoking cessation
 Pain killers for neuropathic pain like Pregabalin,Duloxetine etc
 Antibiotics if infection is present
Specific:
 Treatment of underlying condition like DM
Treatment of other complications of autonomic neuropathy like Gastropresis,erectile

dysfunction etc
Surgical:
 Debridement or amputation if required
 PEG insertion if sever gastroparesis
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6.Arterial Ulcer:
Associated with atherosclerotic conditions like Stroke and IHD etc

CABAG scars may be a clue
Lateral malleolus or shin may be affected and usually deep with sharp defined edges
Questions:


Any Pain in Legs on walking?

Any chest pain?
Ever had stroke?
Medical problem e.g DM

1. How Long,Last Hb A1c
2. Medicine
3. Complications
4. Check Ups
Medicine (Beta- Blockers)
Family Hx
Social History
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Examination
Inspection….may have pale limb and deep ulcer with well defined ulcer edge and
surrounding cyanosis and loss of hair
Palpation….Pulses may be reduced and limb may be cool
Sensory
GPE
Finish With
 Fundoscopy
 BP
 Urine for proteinuria
Concern
Explain
Investigations: Clinical then following:
 Ankle Brachial Pressure Index (ABPI)

 Arterial Doppler scans
 CT angiography
Treatment:
General:
 Patient education
 Diet and exercise
 Avoiding trauma
 Antibiotics for infection
Specific:
 Treatment of underlying condition like DM,HTN,Dyslipidemia etc
 Angioplasty and/or stenting
Bypass surgery if severe ischemia
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7.Venous Ulcers:
 Develop due to venous insufficiency

 Usually painless until complicated by infections
 Usually found over the medial malleolus as irregular shaped and shallow
ulcers
 Eczema may be present at the site
 Diagnosed clinically
Management:
 Foot elevation
 Compression bandaging
 Emoliants for dryness
 Antibiotics
 Skin grafting if large ulcers
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5.Psoriasis
Benign,chronic inflammatory skin disease
It has both a genetic basis and environmental triggers
There are several variants, most common being Chronic Plaque Psoriasis
Koebner Phenomenon may be present.
More than 40 years old should also be evaluated for Metabolic Syndrome
Triggers include:
 Medicines e.g B-Blockers,ACE-inhibitors, Antimalirials, NSAIDs, Statins and
Lithium etc
 Alcohol
 Obesity
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Questions: Notes
Where exactly the Rash is?
Do you have rash anywhere else?
Any other problem with your rash like:Pain, bleeding, discharge
or itching in it?

Is it getting worse or not?
What makes it worse?
What makes it better?
Any Problem with Nails or joints?

Any problem with eyes like redness?
Any cough or difficulty in breathing?
Any backache?
Medical Problem
Medicine
 NSAIDS e.g Brufen
 ACE inhibitors, B -Blockers
 Steroids
 Anti-Malarial
 Statins
Family Hx
Social History
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Examination
Inspection
Hands
 Nails…pitting,ridging.onycholysis,hyperkeratosis,oil
droplet sign,subungual hyperkeratosis
 Fingers…dactylitis
 Joints…deformities
Rash….samlon pink plaques with with scales

Elbows
Hair Line
Behind Ears
Back of Neck & Chest
Front Of Chest
Natal cleft (Umbilicus)

Legs & Feet (Soles)
Finish by:
Looking at External Genitalia
Idea
Concern
Explain
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Psoriatic Discussed later on in detail

arthropathy
D/D of Plaque:
D/D
 Onychomycosis
D/D of cutaneous features:

 SLE
 Reactive Arthritis
 Ptyriasis Rosea etc
Investigations Diagnosis is clinical
Investigations are done to rule out other conditions e.g KOH
preparation and Fungal cultures etc.
Treatment General Measures:

 Patient’s and family Education
 Avoidance of the triggers
 Weight control
 Vaccinations
 Psychological support
 Antihistamines for itching
Specific Measures:
1. Limited Disease (Less than 10 % BSA)

a. High to ultra-potent corticosteroids
b. Phototherapy
c. Vitamin D analogues like Calcipotriol
d. Tar Shampoo if scalp is involved
e. Tacrolimus ointment if facial or genital involvement
2. Moderate Disease (10 to 30 % of BSA)

a. UV Phototherapy
b. Systemic Therapy
3.Generalized Disease (More than 30 % BSA)
a. Narrow Band Ultra-Violet B therapy (NB-UVB)

b. PUVA Photochemotherapy
c. PUVA plus Retinoids or Methotrexate
d. Others e.g Cyclosporine and Biological agents eg. Infliximab
etc
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6.Other Possible skin cases in PACES
Necrobiosis Lipoidica Diabeticorum
Lichen Planus
Eczema
Discoid Lupus Erythematosis
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7.Musculoskeletal Cases and Connective Tissue Disorders
 Sero-negative spondylo-arthropathies
 RA
 Gout
 Polymyositis and Dermatomyositis
 Scleroderma
 Antiphospholipid Syndrome
 Polymyalgia Rheumatica
 Giant Cell Areteritis (GCA)
 Granulomatosis with Polyangitis (Wegener’s Granulomatosis)
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8.Seronegative spondyloarthropathies
It includes ARPE i.e
1. Ankylosing Spondylitis
2. Reactive Arthritis
3. Psoritatic Arthritis
4. Enteropathic Arthropathy
5. Undifferentiated Spondyloarthropathy
Common Features include:
 Male predominance
 Common before age 40
 Inflammatory arthritis of the Spine and Sacroiliac joints
 Asymmetric Oligo-arthritis of the large peripheral joints
 Enthesopathy (inflammation of where Ligaments, tendons and Joint capsule
insert into bones)
 Uveitis
 Absence of Autoantibodies and RA factor in the serum
 HLA-B27 in 50% especially those with IBD and Psoriasis having Sacroilitis
 May present with backache,SOB,Redness of eyes,cough,heel pain etc
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9.Ankylosing Spondylitis
Young male usually less than 30 years old are more commonly affected
Chronic Low Backache and Stiffness worst in the morning
Transient or persistent peripheral arthritis
Extra-articular features like:
Aneterior Uveitis
Dry cough, SOB (Apical Fibrosis)
Enthesopathy (Swelling of Achille’s tendon and plantar fascitis)
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Questions: Notes
Backache? LOQIRAA
 Where exactly?
 For how long?
 Sudden or gradual…(if sudden) what were you doing
at that time?
 What type of pain it is?
 How intense it is on a scale of 1 to 10?
 Does it move anywhere else?
 What makes it better?
 What make it worse?
Any Stiffness and for how long?

Pain in any other joint?
Extra-articualr:
Problem with eyes? Like redness or grittiness?
Any pain and stiffness in neck?
Dry Cough? Any difficulty in breathing?
Any racing of heart?
Any pain in ankle?
Any heel pain?
DD of backache:
Any injury or weight lifting before this?
Any problem with legs like weakness or numbness?
DD if backache and stiffness:

Any problem with bowel works?
Or water works?
Any rash on skin and any problem with nails?
Medical Problem
Medicine
Family Hx:
Social History
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Examination
Inspection—Standing
1. Gait and examination of spine especially lower one
2. Neck Movement
3. Lumbar Movement
(Flexion,extension,abduction and lateral rotation)
4. Wall—Occiput Distance
5. Eyes
6. Examination of Chest
7. Examination of heart
8. Heel and foot
9. Finish by doing modified Schober’s test
Idea
Concern
Explain
D/D:
Other Spondylo-arthropathies especially IBD (Bilateral)
Other causes of Backache

 Trauma
 Lumbosacral strain
 Disc disease
 Degenerative arthritis etc
Investigations:
General:
 CBC, ESR
Specific:
 HLA-B27
 AR factor and Anti CCP Antibodies to rule out others
Imaging:
 X-RAY
 MRI
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Treatment:
1.General Measures:
 Physiotherapy
 Exercise
 Occupational health physician role
2. Medical treatment:
a.NSAIDs
b.Biological agents e.g
 Infliximab
 Adalimumab
 Etanercept
 Golimumab
For Peripheral disease ….Sulfasalazines
3.Treatment of complications:
 Uveitis
 Aortic Regurgitation etc
4.Surgical: Total hip replacement and spinal surgery,sometimes
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10.Reactive Arthritis
Usually follows Dysentery or a sexually transmitted infection (Chlaymydia)
Features include:
 Conjuctivitis
 Uveitis
 Oral ulcers (Painless)
 Urethritis and asymmetric Oligo-arthritis typically of lower extremities
 Enthesitis and mucocutaneous features like stomatitis
50 to 80% are HLA-B27 positive
Sacroilitis is observed in about 20%
Carditis and aortic regurgitation may occur
Arthritis may persist even after the disappearance of other feature
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D/D 1.Ankylosing spondylitis
2.Psoriatic arthritis
3.Enteropathic arthropathy
4.Others
 RA
 Behcet’s Disease (Oral ulcers are painful)
 Gonococcal Arthritis (Culture and Rapid response to

Antibiotics)
Investigations Clinical History
CBC,ESR,CRP
Urineanylysis,uretheral swab,stool cultures
Rheumatoid factors
Imaging like X Rays
Treatment  Physiotherapy
 Antibiotics if active infection
 NSAIDs
Others for chronic cases
 Sulfasalazine
 Methotrexate
 Biological agents e.g Infliximab
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11.Psoriatic arthritis
Psoriasis Precedes in 80%
Sacroiliac joint involvement is common
Occasionally just a Single Patch of Psoriasis may be present in hidden parts like
umbilicus, Scalp or gluteal cleft
Sometimes the psoriasis lesion may have cleared before the arthritis develops
Nail pitting is sometimes the only clue
It has 5 types of Joint involvement:
1. Symmetric Polyarthritis just like RA

2. Oligo-arthritis
3. DIP joint involvement with pitting of nails,sub-ungual heperkeratosis
and Onycholysis
4. Arthritis Mutilans
5. Spondylitic form (Backache with stiffness)
D/D:
Depends upon the underlying involvement like:
 Redness of eyes
 SOB (Apical Pulmonary fibrosis)
 Rash
 Joint pains
 Backache etc
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CASPAR Criteria for diagnosis: (ClASsification Criteria for Psoriatic ARthritis)
It comprises a combination of Clinical , biochemical and radiological features.
3 out of following should be present to label Psoriatic arthropathy
1. Current psoriasis OR (current psoriasis has 2 points rest of all have 1

point)
History of psoriasis OR
Family history of psoriasis
2. Dactylitis
3. Nail dystrophy
4. Juxta-articular new bone formation on radiographs
5. Rheumatoid factor negative
Investigations:
 CBC, ESR, RA Factor, Uric acid
Imaging:
 X-Rays may show Osteolysis and pencil in cup appearance

 MRI if sacroiliac involvement
Treatment:
General measures:
 MDT package like ………
Medical treatment:
 NSAIDs
 Glucocorticoids
 Methotrexate
 Biological agents like Infliximab
 Ustekinumab and PUVA therapy
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12.IBD
Chronic inflammatory conditions that include Crohn’s Disease and Ulcerative
colitis.
Genetic factors, immune dysregulation and microbial gut flora all influence the
susceptibility
Diagnosis is based on Clinical features, Labs, Endoscopic fetures, Histology and
Radiological features
Multiple conditions can mimic IBD but main Differential is Infectious conditions
Intestinal and Extra-intestinal complications can occur especially during active
disease
Long standing disease can leads to development of colorectal cancer
Fecal Cal-protectin and Stool for Lacto-ferrin can help distinguish IBD from IBS
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Questions: Notes
Loose motion (Detail)
Any tummy pain

Any problem around the back passages like ulcers etc
Any backache with stiffness
Associated questions:
 Any problem with eyes
 Ulcers in mouth
 Rash on skin
 Joint pains
General questions (Fever,weight changes etc)
Thyroid (If diarrhea)
Medical Problem
Medicine
Family Hx…Infective and autoimmune clues
Social History… Travel history
Questions to rule out other Spondyloarthropathies:
Any Problem with water works (Reactive Arthritis)
Any Rash on skin and any problem with nails (Psoriasis)
Any ulcers in Mouth or around the private area (Behcet’s

syndrome)
Other complications:
 Malabsorption syndrome
(Vitamin ADEK,Anemia,Hypalbumenimia)
 Jaundice and itching (PSC or Cholangiocarcinoma)
 Abdominal pain (IBD,Strictures,CA colon)
 Renal colic (Renal calculi)
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Examination
GPE
Abdomen
Idea
Concern
Explain
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DD Depends on the underlying features with which patient has
presented e.g
 Loose motions
 Abdominal pain
 Bloody diarrhea
 Red Eyes
 Oral ulcers
 Backache
 Arthritis
 Rash etc
Investigations General:
 CBC,ESR,CRP
 LFTs
 S/E
 RFTs
Specific:
 Stool studies especially screening for infections
including C.Difficile
 Stool for Calprotectin and Lactoferrin
Endoscopic:
 Colonoscopy and biopsy
 Enteroscopy
Imaging:
 CT enterography
 MR enterography etc
Treatment a.General measures:

 Patient’s education
 MDTC package
 Nutrition
 Vitamins and minerals replacement
b.Specific mesures:
Medical:
 5-ASA like pentasa , asacol,rovasa,lialda
 Steroids
 Immunosupprssives AZA or 6-MP etc
 Biological agents like Infliximab and adalimumab
 Antibiotics
Treatment of complications
c.Surgical measures
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13.Rheumatoid Arthritis
Chronic systemic inflammatory disease whose major manifestation is synovitis of
multiple joints
Symmetric Polyarthritis with predilection for small joints of hands and feet
Monoarticular disease is occasionally seen
Idiopathic and can begin at any age
Usually insidious but can present acutely as well
Can have Extra-articular features as well: like
 General
 Anemia
 Eyes
 Lungs
 Heart
 Kidneys
 Splenomegaly
 Sensorimotor neuropathy
 Subcutaneous nodules
 Vasculitis
Can only involve the neck but spares the rest of spine and do not cause sacroilitis
Other joints like elbows,shoulders,knees and feet can be affected as well
RA factor and Anti-CCP-antibodies can be helpful
Early aggressive treatment is the standard of care
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In which joints you have pain?Problem with any other joints? Notes
Any swelling, Redness or increased warmth in joints?
Any stiffness and for how long?
For how long you have this problem?
MCTD and Overlap Questions:

 Color change of fingers?
 Tightening of skin at the back of your hands?
 Any weakness in shoulders or thighs?
 Dryness of eyes or mouth?
 How your skin behaves to sunlight?
Extra-articular Questions:
Any fever,fatigue,Loss of appetite,rash? Any lumps or bumps?
Any problem with eyes? Like redness,pain or grittiness?
Any racing of heart of walking?
Any chest pain?
Any cough or difficulty in breathing?
Any burning sensation in chest or any tummy pain? (APD)
Any problem with water works?
Any numbness or tingling in your feet?
Any problem with your nails? (Psoriasis)
Medical Problem
Medicine: NSAIDs, Steroids, Others
Family Hx
Social History 36
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Examination (Pillow)
Inspection
 Swelling
 Wasting
 Deformities
 Carpal tunnel release Scars
 Make a fist
Palpation
 Warmth
 Tenderness
 Grip
 Power
 Sensations (Median and Ulnar)
Movements at wrist and shoulders

 Palmar flexion
 Palmar extension
 Hands at back of head
 Hands at back of chest (Bra wearing)

Arms:
 Subcutaneous nodules and bursae
Functional capacity
 Button / unbutton
 Pick up the Coin
Shoulders,cervical spine,knees,feet etc
Complete by doing associated

GPE
Eyes
Chest
Heart
Abdomen etc
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D/D
1.OA No systemic features,pattern is different
Worsens with activity and RA factor negative
2.SLE
3.Viral Parovo virus B19 and Chronic hepatitis C etc
4.Gout If chronic but RA factor negative
5.Pseudogout X-Rays are helpful and also underlying conditions
6.Seronegative Predilection for lower limbs and involvement of spine and
Spondyloarthropathies sacroiliac joints
7.chronic Lyme Usually involve only one knee
arthritis
8.Polymyalgia Age >50 years, proximal muscle pain and stiffness,RA factor
Rheumatica negative
9.Rheumatic fever Migratory arthritis,elevated ASO-titer,dramatic response to
aspirin
10.Cancers With para-neoplastic syndromes
General
Labs 38
 CBC, ESR,CRP
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 LFTs
 RFTs
Specific
 RA factor
 Anti-CCP-antibodies
 Arthrocentesis
Imaging
 X-Rays
Treatment General measures:
 Physiotherapy and rehabilitation
 Nutrition
 Vaccinations
Specific Measures
Medical:
 Corticosteroids
 DMARD e.g Methotrexate, Sulfasalazine,
Leflunamide, Antimalarials, Tofacitinib
 Biological agents: TNF-inhibitors e.g Infliximab,
Adalimumab, Certolizumab pegol, Etarencept and
Golimumab
 Otheres: e.g Rituximab, Tocilizumab
Treatment of Complications
Surgical
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14.Gout
Gout is a metabolic disease and often familial
Initially it can present with recurrent acute arthritis, usually mono-articular
Later it can present with chronic deforming arthritis sometimes like RA
Idenetification of Urate crystals in joint fluid or tophi is diagnostic
In chronic cases ,urate deposits in subcutaneous tissue, bones, cartilage, joints and
other tissues
It can be Primary and Secondary (acquired)
Secondary causes include
a.Increased Catabolism or turn over of purines: e.g
 Myeloproliferative or Lymphoproliferative disorders

 Chronic Hemolytic anemia
 Psoriasis etc
b.Decreased Renal clearance of uric acid: e.g
 Intrinsic kidney disease

 Drug induced e.g Thiazides, Low dose aspirin etc
Hospitalized patients frequently suffer attacks of gout
Uric acid kidney stones are present in 5-10 % of patients with gouty arthritis
Dramatic therapeutic Response to NSAIDs occur
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In which joint the pain is? Problem with any other joints? Notes
Any swelling, Redness, Warmth? Any discharge from swelling?
Any Stiffness? For how long?
For how long you have joint problem?
What makes it worse? And what makes it better?
General (B-Type symptoms to rule out cancer)
Heart Complications
 Any chest pain
 Difficulty in breathing
Kidneys
 Any problem with water works
 Ever passed stone
Any numbness or tingling in your hands?
Medical Problem like: DM,HTN,IHD
Medicine like: Diuretics, NSAIDs (Aspirin)
Family Hx
Social History
 Alcohol
 Diet (Meat in excess)
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Examination
Inspection
Arms,ears and feet for tophi
Palpation
Functional Capacity
GPE
 Pallor,jaundice,L.N
Abdomen (Hepatosplenomeglay)
Kidney (Renal replacement therapy)
Idea
Concern
Explain
Differential Diagnosis:
1.Pseudogout X-Ray findings are characteristic
2.Cellulitis Bacteriological studies are helpful
3.Chronic cases may resemble RA etc
Investigations:
General: CBC, ESR,CRP
Specific:
 Serum Uric Acid (Not useful in acute attack)
 Joint fluid or tophus aspirate for Urate crystals and
others like Cell count,Gram staining and C/S and for
polarized light microscopy to see negatively birefrigent
crystals
 Blood cultures to rule out septic arthritis
Imaging:
 X Rays
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Treatment:
1.Asymptomatic:
Not treated until:

 Arthritis
 Renal calculi
 Tophi become prominent
2.Acute attack:
Focus on reducing inflammation not uric acid level
 NSAIDs
 Colchicine
 Steroids
3.Between attacks:
Potentially reversible causes of Hyperuricemia should be

avoided Like:
 High purine diets

 Obesity
 Alcohol
 Use of certain medications
Colchicine Prophylaxis
Reduction of serum uric acid

 It includes Xanthine oxidase inhibitors like Allopurinol
and Febuxostat
 Uricosuric Drugs e.g Probenecid
 Uricase like Pegloticse which is given I/V
4.Chronic Tophaceous Gout

Maintain serum Uric acid below 6mg/dl and Surgical excision
of large Tophi
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15.Polymyositis and Dermatomyositis

Systemic disorders of unknown cause
Characterized by bilateral proximal muscle weakness
Can affect any age group but usually in the 5th or 6th decade
Women are affected more
They can also be associated with other connective tissue disorders like
Scleroderma, MCD or Sjogren Syndrome etc
Sometimes patients may have just skin disease without overt muscle weakness
Usually the weakness is progressive but may develop abruptly in Polymyositis
No facial or ocular muscle weakness develop but neck muscles can involve in
Polymyositis
Few patients can have Pain and Tenderness
Dysphagia especially problem with initiation of swallowing can develop
Dermatomyositits can have associated malignancy
Rashes include:
 Facial erythema in malar distribution and beyond
 Heliotrope rash
 Shawl sign
 Gottrons Papules and
 Periungual Erythema
Scalp involvement may mimic Psoriasis
Presentations include Weakness, Rash, Joint pains or Falls etc
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Where exactly the rash is? Do you have rash anywhere else? Notes
Any problem with rash like: pain, bleeding, or itching?
For how long you have this? Where did it start first?
Is it getting worse? what makes it worse?what makes it better?
Any joints pain? which joints? Any color changes of your
fingers?
Any pain in shoulders or hips?
Any weakness especially when you comb? or going upstairs?
How your skin behaves to sunlight?
Any difficulty in swallowing?
Any difficulty in breathing or cough?
General
(Fever,fatigue,appetite,weight changes,lumps or bumps)
 Chest (Lungs)
 Breast (Women)
 GIT
 Prostate (Men)
Medical Problems
Medicine
Family Hx
Social History
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Examination
Inspection
 Cushingoid appearance
 Rash
 Back of hands….Gottrons Papules
 Around eyes…….Heliotrope Rash
 Chest
 Front……………...V Sign
 Back……………….Shawl sign
Joints and hands (If involved)
Can you please standup without support?
Tenderness in shoulders and Weakness in shoulders
GPE
Relevant System
 Chest
 Breast
 Abdomen
 Prostate
Idea
Concern
Explain
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D/D Of Proximal Muscle weakness:
1.Other Connective Tissue Disorders
 SLE
 Scleroderma
 Mixed connective tissue disorders in which Muscle
inflammation can occur (Other features may help)
2.Hyperthyroidism and Cushing Syndrome
Muscle enzymes are normal
3.Hypothyroidsim
CK may be elevated, other features may help
4.Polymyalgia Rheumatica
Above 50, pain and stiffness are prominent and CK is normal
but weakness is not a prominent feature
5.Other CNS disorders MG,LEMS,MS,CIDP etc
Have other features and characteristic electromyographic
features
6.Vasculitides like:
 PAN
 Granulomatosis with Polyangitis (GCA)
 Churgh-Strauss Syndrome can present with weakness
through vasculitic neuropathy which is distal and
asymmetric
7.Drugs e.g Corticosteroids,Clofiberate,Alcohol,Statins etc
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Investigations:
General: CBC, ESR
Specific:
 CK, Aldolase
 ANA and other specific Antibodies
 Skin and Muscle biopsy
 EMG
Imaging:
 HRCT
 CT Chest,Abdomen and Pelvis
 Mammography
 MRI
Treatment:
General:
 Patient education
 MDT care package
 Limit the sun exposure
 Bed rest for severe inflammation
Specific:
 Hydroxychloroquine if skin involvement
 Corticosteroids like Prednisolone 40-60 mg/day initially
 Immunosuppressive therapy like Methotrexate and
Azathioprine
 Others like Mycophenolate Mofetil and Rituximab
 I/V Immunoglobulins if resistant to corticosteroids
 Finally treatment of malignancy if present as steroids

won’t help in such cases
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16.Systemic Sclerosis
Systemic sclerosis is a chronic disorder characterized by diffuse fibrosis of the skin
and internal organs
Two forms are recognized
a. Limited Disease or CREST Syndrome (80%) in which thickening is limited to
the face, neck and distal extremities, have better out come because ILD or
Kidney disease rarely develops but Pulmonary HTN can develop and digital
ischemia is more common
b. Diffuse Disease (20%) widespread thickening of skin and associated with
ILD, Heart involvement and Kidney disease
Raynaud and ANA are present in virtually all patients
Raynaud may be initial manifestation
Polyarthralgias and weight loss may occur in diffuse form
Cardiac abnormalities may include Pericarditis, Heart blocks, Myocardial fibrosis
and Right Heart Failure
Telangiectasia, Pigmentation and Depigmentation are common
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Which color changes you get? White, Blue or Red? Notes
In which fingers? Any other part affected like: Ears,nose or
Toes?
Is it getting worse? What makes it worse? What makes it better?
Any other problem with your hands? Like ulcer, pain or
numbness/tingling? Any problem with nails?
Any tightening of skin at the back of your hands or around your
mouth?
MCD
Any joint pains and stiffness?
Any weakness when you stand up from sitting position?
Any dryness of eyes or mouth?
How your skin behaves to sunlight?
Other Complications:
Any chest pain? Any racing of heart?
Any cough (Dry) or difficulty in breathing?
Any burning sensation in your chest?
Any difficulty in swallowing?
Any problem with water works?
Any swelling around your ankles?
Medical Problem
Medicine
Family Hx
Social History
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Examination
Inspection
Hands
 Nails…infarcts
 Fingers…Ulcer,telangicetasias,color
changes,sclerodactyli
 Joints
Palpation—Back of hands
Pulses
Shoulder weakness
Mouth
 Opening
 Telangiectsias
Lung bases (Fibrosis on Auscultation)
Heart (P2)
Pedal Edema
Finish with
 Fundoscopy
 BP
 Urine dipping for Proteinurea
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Investigations:
General:
 CBC,ESR
 RFTs
 Urine dip stick
 Urinary protein-creatinine ratio
Immunology:
 Anti-centromere antibodies
 Anti-Scl 70 antibodies
 Anti-RNP polymerse I,II and III antibodies
Tests for complications:

 Heart
 Chest
 Kidneys
 GIT
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Treatment: Depends upon underlying involvement
Raynaud’s phenomenon
 Hand warmers
 Calcium channel blockers
 Prostacycline analogues like Iloprost
 ACE-inhibitors
 Alfa blockers
 Pentoxyphylline
Renal disease:
 ACE-inhibiors
Pulmonary fibrosis
 Prednisolone
 Immunosuppressive like cyclophosphamide
Pulmonary HTN
 Bosentan
GERD:
 Prokinetics and PPI
SIBO and Malabsorption:

 Antibiotics and multivitamins
Skin sclerosis:
 D-Penicillamine
 Methotrexate
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17.Anti-Phospholipid Syndrome
Hypercoagulability with recurrent Venous or Arterial thrombosis
Pregnancy complications especially pregnancy losses after the first Trimester
Can have different presentations like BCS, Stroke, MI, DVT, Livedo Reticularis,
Skin ulcers and Adrenal insufficiency etc
Thrombocytopenia is common
May have association with migraine
Diagnostic anti-phospholipid antibodies in the absence of other features of SLE
that include:
a. Anti-cardiolipin antibodies IgG or IgM
b. Lupus anticoagulant (Paradoxical rise in aPTT)
c. Antibodies to bet -2 glycoprotein IgG or IgM
Differentials include SLE and Hypercoagulable states like Protein C, S, anti-
thrombin deficiency and Factor V Leiden deficiency
Treatment include:
Warfarin lifelong to maintain an INR between 2.0 to 3.0
In Pregnancy: LMWH and Low dose Aspirin (81mg/day)
If catastrophic APS
I/V Heparin, High doses Corticosteroids, and either I/V Immunoglobulins or
Plasmapheresis
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18.Polymyalgia Rheumatica
Usually a clinical diagnosis based on pain and stiffness of the shoulder and pelvic
girdle area in patients above 50
Fever, malaise and weight loss may be present (General symptoms)
In two third of cases GCA may be absent
Polymyalgia Rheumatica does not cause muscle weakness
Few patients have joint swelling particularly of the knees and wrists
Vasculitis may involve other structures as well like Heart etc
Differentials:
 RA
 Other Systemic Vasculitides
 Multiple Myeloma
 Malignancy
 Chronic Infections like Infective Endocarditis or Osteomyelitis
Positive Lab findings may include Anemia and Markedly elevated ESR
Prednisone 10-20 mg/day, slow tapering after 2-4 weeks, mostly for 1year minimum
and Methotrexate may be added as steroid sparing agent
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19.Giant Cell Arteritis (GCA)

GCA is a Systemic Pan-arteritis affecting medium-sized and large vessels in
patients above 50
50 % cases are associated with Polymyalgia Rheumatica
Classic features include Headache, Scalp tenderness, visual symptoms
(Particularly amaurosis fugax, blurriness or diplopia) and
Jaw claudication, or throat pain
Temporal artery may be nodular, enlarged, tender or pulseless
Blindness may develop
It may present with PUO in 15% of cases above the age 65, which may be high grade
with normal TLC if steroids not given already
It may be considered in Older patients with high grade fever, Normal TLC and
markedly elevated ESR
Unexplained Head or neck Pain in older patients could be because of GCA
Positive Labs may include:
Anemia, Thrombocytosis, Raised alkaline phosphatase, markedly elevated ESR
(Which may be above 40 or even normal)
Biopsy proven GCA, others include USG, MRA, CTA
Urgent treatment required with prednisone 60mg/day to prevent blindness

(60mg/Day for at least 1 month)
Finally, thoracic aortic aneurysms can develop that can lead to Aortic
regurgitation, Dissection and Rupture
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20.Granulomatosis with Polyangitis (Wegeners Granulomatosis)
Classic Triad of upper and Lower respiratory tract symptoms and
glomerulonephritis
Suspected if mild Upper respiratory tract symptoms like nasal congestion, sinusitis
are refractory to usual treatment
Lower respiratory tract symptoms may include cough,SOB and hemoptysis
Othere features may include fever,malaise,weight loss,migratory oilgoarthritis and
red eye like episcleritis, scleritis and anterior uveitis etc
D/D depends on the underlying features whether URT, LRT, Joint Involvement,
Glomerulonephritis or else
Labs may include CBC,ERS, CRP, Urine analysis for Proteinurea, RBCs and Red
cell casts , serum ANCA , Renal biopsy and CT-Chest
Treatment involves 2 phases i.e induction of remission and maintenance of
remission
Induction therapy includes Cyclophosphamide plus corticosteroids or Rituximab
plus corticosteroids
For maintenance of remission options include Azathioprine, Methotrexate or
Rituximab
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Endocrinology
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21.Swelling in Neck (Goiter)
Where exactly the swelling is? Do you have swelling anywhere else? Notes
Does it move when you swallow?
Any other problem with swelling like: Pain
Any difficulty in breathing or swallowing?
For how long you have this? Is it getting bigger or not?
Any problem adjusting to temperature? (Status)
Causes:
General (Fever,fatigue,weight changes,appetite)
Any problem with your eyes? (Grave’s)
Any white patches on your skin? (Autoimmune like Hashimoto’s)
Any flue like illness before this? (Viral)
Any recent Pregnancy? (If female)
Medical Problem
Medicine: Goitrogens, Amiodarone etc
Family Hx
Social History: Iodine Deficient Diet
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Examination
 Inspection
 Palpation including LN
 Percussion
 Auscultation (If Hyperthyroid)
Hands
 Clubbing (Thyroid acropachy)
 Pin Pricks marks (Type 1 DM)
 Tremors,warmth,sweating
 Pulse
 Proximal muscle weakness
 Eyes examination
 Heart
 Legs (Pretibial edema)
Idea
Concern
Explain
Causes of Thyroid Enlargement

1. Grave’s disease
2. Hashimoto’s Disease
3. Cancer
4. Viral Infections
5. Pregnancy (Post-Partum)
6. Iodine Deficiency
7. Physiological
8. Goitrogens
9. Medicines
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22.Thyrotoxicosis
1. Grave’s disease
2. Hashi-toxicosis
3. Post Viral
4. Post-Partum
5. Toxic Multi nodular goiter (TMNG)
6. Toxic adenoma
7. Medicines e.g Amiodarone, Excess Thyroxine etc
8. Cancer
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Presenting Complaints:
Notes
 Weight Loss
 Diarrhea
 Palpitations etc
ODPARA
Screening questions
 Any problem adjusting to temperatures?
 Any changes in weight?
Hands
 Shaking of hands
 Sweating
 Racing of heart
Arms
 Any weakness in shoulders
 Any weakness while standing from sitting?
CNS
 Any changes in Mood, Sleep?
Eyes
Any problem with eyes?
 Watering, Dryness?
 Pain, Redness?
 Decreased vision
 Double vision
 Color vision
Any swelling in your neck?

Any problem with periods? (Female)
Any backache? (Osteoprosis)
Causes e.g
 Autoimmune
 Viral
 Pregnancy
 Malignancy etc
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Medical Problem
Medicine: Amiodarone, Thyroxine in excess etc
Family Hx
Social Hx
Examination
Inspection
 General
 Thyroid
 Tongue Protrusion (Thyroglossal Cyst)
Swallowing
 Take a sip of water
 Hold it into your mouth
 Now plz swallow
Palpation
 Swallow
 Texture
 Extent
 Tenderness
Lymph Nodes
Percussion
Auscultation
Hands
 Tremors
 Sweating
 Acropachy
Pulse
Proximal Muscle weakness
Eyes
 Vision
 Movements
 Fundoscopy (Tell)
Heart
Legs (Rash)
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Grave’s disease
Most common cause of Thyrotoxicosis
Autoimmune condition which is much more common in women
It may be accompanied by Infiltrative Ophthalmopathy, less commonly Infiltrative

Dermopathy (pretibial myxedema) and rarely Thyroid acropachy
There may be Family history of Grave’ disease or Hashimoto thyroiditis
It can be triggered by dietary Iodine,Potassium iodide or Amiodarone
There may be increased risk of other Autoimmune disorders like Celiac disease,
Addison’s disease, Pernicious anemia, vitiligo, type1 DM, MG etc
Grave’s Eye manifestations include Lid Lag, Lid retraction and a staring Look
which can also occur with any other cause of Hyperthyroidism
Ophthalmopathy is present in 20-40% of patients with Grave’s disease and some

cases of Amiodarone induced Thyrotoxicosis and it includes Chemosis,
Conjunctivitis and Exophthalmos
Eye related symptoms may include diplopia, corneal dryness, decreased visual
acuity and color vision( optic nerve compression) and may be asymmetrical
Ocular MG may also sometimes be associated with Grave’s disease with diplopia
Exopthalmometry should be performed to check exophthalmos and its progression
Labs include:
a. Thyroid profile
b. TSI or TSHr Abs
c. RAI scan is not required with typical features but helpful if need to rule out
concomitant Strumma ovarii (rare)
d. MRI and CT scanning of the orbits are the methods of choice to visualize
Grave’s Ophthalmopathy and is required in severe or unilateral cases or in
Euthyroid exophthalmos to distinguish it from other lesions
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Treatment:
 Propranolol
 Thiourea drugs: e.g Propylthiouracil or Methimazole
 Iodinated contrast agents: e.g
 Radioactive Iodine (131I,RAI)
 Thyroid surgery
Details of treatment:
a.Propranolol:
 Given as Propranolol ER 60 mg OD or BD and may increase every 2-3 days to

maximum of 320 mg if required and may be given as OD dose once the
symptoms are controlled. It may also help Periodic paralysis
b.Thiourea drugs: e.g Propylthiouracil or Methimazole
 Which are especially useful in mild hyperthyroidism and small goiters. These
are also useful for preparing hyperthyroid patients before surgery and
elderly for RAI treatment .These drug do not permanently damage the
thyroid gland. It may be continued long term if patient is tolerating it well.
 Caution about unusual bleeding or onset of any infection (Like sore throat)
is required.
 Surveillance with WBCs may be required periodically.changing status is best
monitored clinically and with FT4 as the patient may become hypothyroid 2
weeks or more before the TSH level rise.
Methimazole:
 Avoided in first trimester

 Initially may be given 30-60 mg once or twice daily, less doses may be
required with mild symptoms
 If used in Pregnancy or Breast feeding the dose should not exceed 20mg/day
 Dose is reduced once the symptoms improve and FT4 is normalized
 For patients receiving Iodine therapy:
 Methimazole is discontinued 4 days prior to receiving the therapy and is
resumed 3 days later to avoid recurrence and may be discontinued 4 weeks
later if the patient is Euthyroid
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Propylthiouracil:
 Drug of choice during breast-feeding and pregnancy

 Initially given in doses of 300-600mg/day in 4 divided doses
 During pregnancy the dose is kept below 200mg/day to avoid Neonatl
goitrous hypothyroidism, the patient may be switched to Methimazole
during the 2nd trimester
c.Iodinated contrast agents: e.g
 Iopanoic acid or Ipodate sodium is given orally in a dosage of 500 mg twice

daily for 3 days , then 500 mg once daily for all types of hyperthyroidism and
is for temporary relief especially if symptoms are severe
 For patients with Grave’s disease, methimazole is begun first to block iodine
organification, the next day these agents may be added
 Treatment period of 8 months or more may be possible
d.Radioactive Iodine (131I,RAI)
 Excellent method of destroying overactive gland

 Should not be given to pregnant or lactating women
 All women should have a pregnancy test before starting
 Therapy in Grave’s disease is usually effective if Thiourea drugs are
discontinued 4 days before the treatment is started
 Grave’s Ophthalmopathy may worsen in 15% women and improve in none,
may improve in 2% with methimazole and with prednisolone following 131I
treatment it may improve in 67% and worsens in none

 So prophylactic Prednisone (20-40mg) may be given for 2 months
 Smoking is encouraged to quit before therapy
 Increased Risk of Hypothyroidsim and Hypo-parathyroidism, so long life
follow up with FT4, FT3,TSH and Calcium is necessary
e.Thyroid surgery:
 Total resection of one lobe and subtotal resection of other lobe

 Increase risk of Hypothyroidism and Hypo-parathyroidism
 Other Forms of Thyrotoxicosis
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Hashitoxicosis or Silent thyroiditis
 Can occur spontaneously or triggered by certain medications

 Can have Triphasic phase i.e variable Hyper, Eu and followed by
Hypothyroidism
 Initially hyperthyroid then 10-20% remain hypothyroid after one year and
can subside spontaneously within weeks to months
 May have non palpable goiter or a Small, Non-tender goiter
 About 50% have Antithyroid Antibodies
 RAI uptake is low
 Thiourea drugs are ineffective
 For symptomatic relief, patients are treated with Propranolol ER 60 mg
twice daily and increase every 3 days until the heart rate is less than 90
beats/min
 Other option includes Ipodate sodium or Iopanoic acid 500mg/day for 15-60
days until the serum FT4 normalizes
 Patient is monitored for Hypothyroidism and treated accordingly
Post Viral or sub-acute (de Quervain) thyroiditis:
 Can follow a flue like viral illness (URTI) and can develop extremely painful
thyroid that can be tender and typically enlarged 3-4 times its normal size
 There may be dysphagia and pain can radiate to jaw or ear
 Can cause hyperthyroidism for 3-6 weeks followed by hypothyroidism and
10% remain hypothyroid 1 year after
 WBC, ESR and CRP are helpful and it should be differentiated from
suppurative thyroiditis as well
 RAI uptake is low
 Thiourea drugs are ineffective Treatment is just like Hashitoxicosis but for
pain NSAIDs, Corticosteroids or Opiates may be required
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Postpartum Thyroiditis
 Hashimoto thyroiditis that occurs in the first 12 month after deliver

 It can also develop after miscarriage
 This is common especially in women with other autoimmune disorders
 The Thyrotoxic phase typically occurs 2-6 weeks postpartum and lasts 2-3
months
 Affected women may have mild symptoms like Palpitations, Anxiety Heat
intolerance etc
 Patients may have either no palpable goiter or a small, non-tender goiter
 Over 80% have anti-thyroid antibodies
 Most develop hypothyroid phase that can last a few months but can be
permanent
 Treatment includes Propranolol during Hyperthyroid phase and
Levothyroxine during the Hypothyroid phase
 Thiourea drugs are ineffective
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Toxic Multinodular Goiter
 Medical treatment incudes Propranolol and Thiourea drugs

 Surgery is the definitive treatment in patients with large toxic nodular
goiter, following therapy with a thiourea to render them Euthyroid
 Not treated Pre-operatively with Potassium iodide
 Total or near total Thyroidectomy is recommended
 Radioiodine uptake therapy may also be used to treat patients with toxic
nodular goiter and for this first Methimazole is given to render Euthyroid ,
which is stopped at least 4 days before RAI therapy
Toxic adenoma (Plummer disease)
 Usually benign but may rarely be malignant

 Non-surgically, it can be evaluated with FNA biopsy
 Medically it can be treated with Propranolol and Methimazloe and if patient
tolerates it Methimazole can be continued long term
TSH is kept slightly suppressed
 If age is under 40 or healthy older patients, surgery is usually recommended

and patients are made eutyroid with a thiouea preoperatively and given
several days of iodine, ipodate sodium or iopanoic acid before surgery
 Postop Hypothyroidism usually resolves spontaneously
 If age is over 40 or in Poor Health, may be offered 131I therapy and if
methimazole has been used preoperatively then the TSH should be slightly
suppressed and the nodule may remain palpable in 50% thereafter
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Medication induced Hyperthyroidism
a.Amiodarone is widely used anti-arrythmic which is 37% iodine by weight
 Thyroid profile can be checked after about 3 months until clinically

indicated
 Serum TSH must be suppressed to diagnose Amiodarone induced
thyrotoxicosis
 The problem can occur even several months after the treatment is stopped
 As it tends to cause Bradycardia so the signs could be missed
 Amiodarone induced thyrotoxicosis can be categorized as Type I, Type II or
mixed
Type I is caused by excessive production of thyroid hormones and thyroid color

flow Doppler shows an enlarged gland with increased vascularity, and presence of
proptosis and TSHr Ab is diagnostic
Type II is caused by thyroiditis with passive release of stored hormone and thyroid
color flow Doppler shows a normal sized gland without increased vascularity and
IL-6 levels are usually quite elevated
Treatment:
 Propranolol ER
 Methimazole 30 mg/day as its difficult to categorize thy types
 After 2 doses of methimazole, iopanoic acid or sodium ipodate 500mg orally
twice daily for 3 days, then 500mg/day until the thyrotoxicosis is resolved
 If above is not available then potassium perchlorate
 Other options include Prednisone and Subtotal Thyroidectomy
b.Iodine induced Hyperthyriodism:
 Recommended Iodine intake for non-pregnant is 150microgram/day

 Higher Iodine intake can precipitate Hyperthyroidism in patients with
nodular goiter, autonomous thyroid nodules or asymptomatic Grave’s
disease
 Urinary iodine concentration is high
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Hyperthyroidism during pregnancy
 Grave’s disease can improve during pregnancy

 Manifestations include many of the features of normal pregnancy
 Unrecognized Hyperthyroid state can lead to miscarriage, Pre-eclampsia,
eclampsia, preterm delivery, maternal heart failure and thyroid crisis etc
 Total T4 and FT4 are elevated but the TSH is suppressed, however 18%
pregnant patients have normally low TSH
 Men and women with Grave’s disease who are planning pregnancy should
not have RAI treatment within about 3 months of conception
 Women with Grave’s disease are encouraged to consider definitive treatment
with RAI or surgery well before conception and dietary iodine should not be
restricted for such women
 If Grave’s disease patient becomes pregnant, Methimazole should be
replaced with Propylthiouracil and mild state of hyperthyroidism is
maintained with use of low dose
 Both Thiourea can cross the placenta and can cause fetal Hypothyroidism
and goiter, fetal ultrasound at 20-32 weeks is recommend to visualize the
goiter
Subtotal thyroidectomy is preferred in 2nd trimester under following circumstances
1. Severe adverse reaction to thiourea

2. High dosage requirement of thiourea
3. Uncontrolled hyperthyroidism due to non-adherence
In Breast feeding low doses are recommended and are taken just after feeding the
baby
1.Cardiac complications
a.Sinus Tachycardia
Treatment of thyrotoxicosis and Beta-blockers
b.Atrial Fibrillation
Digoxin, Beta-blockers and anti-coagulatnts
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Sub-clinical Hyperthyroidism
 Asymptomatic individuals with low serum TSH but normal serum levels
of FT4 and T3
 Progression to symptomatic thyrotoxicosis can occur
Hypokalemic periodic paralysis
 Occurs in about 15% of Asian men with thyrotoxicosis

 It presents abruptly with symmetric flaccid paralysis ,often after I/V
Dextrose, oral carbohydrates, or vigorous exercise and lasts 7-72 hours
 It is more prevalent in men
 Treatment includes oral propranolol 3mg/kg in divided doses
 I/V Dextrose and oral Carbohydrtaes are avoided
Scans
a.RAI Uptake and Scanning
Should never be administered to pregnant women
It may be helpful in determining the cause
High RAI uptake is seen in conditions with increased synthesis of the hormone like
Grave’s disease, Toxic nodular goiter, Type I amiodarone induced thyrotoxicosis
Low RAI uptake is seen in conditions like subacute Thyroiditis, Iodine induced
thyrotoxicosis and Type II amiodarone induced hyperthyroidism
b.Thyroid USG
Helpful in distinguishing solid form cystic lesion ,particularly in patients with

palpable thyroid nodules
c.Colour Flow Doppler Sonography and 99m Tc-sestamibi scanning
It is helpful in distinguishing Type I from Type II amiodarone induced

hyperthyroidism
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23.Hypothyroidism
Presenting Complaints: Like
 Weight gain
 Fatigue
ODPARA
Any problem adjusting to temperatures?
Any changes in appetite or weight?
Any dryness of skin?
Numbness or tingling in hands?
Any weakness in shoulders or hips?
Changes in mood, memory, depression or changes in sleep?
Any fatigue?
Any headache? (Frontal)
Any changes in your voice?
Any swelling in neck?
Any difficulty in breathing?
Any changes in monthly periods? (If female)
D/D Or Causes:
Any problem with eyes (Grave’s)
Any white patches on the skin (Grave’s or Hashimot’s)
Any flue like illness before this? (Viral)
Any recent pregnancy? (Post Partum Thyroiditis)
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Medical problem: Previous hyperthyroidism or autoimmune

disease
Medicine: like
 Amiodarone
 Lithium
 Radioiodine therapy
 Operation on neck
Family Hx: Thyroid or autoimmune disease
Social History:
Examination
Inspection
 General
 Thyroid
 Swallowing
Palpation
Percussion
Hands
 Skin
 Temperature
 Carpal Tunnel
 Pin prick marks
 Thyroid acropachy
Pulse
Proximal Muscle weakness
Eyes
Rash on legs
Ankle reflex
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Investigations:
 fT4, fT3 and TSH (which is more sensitive)

 Fasting lipid profile and blood sugar
 CBC looking for anemia
 Serum electrlolytes to look for Hyponatremia
 Others include LFTs, serum Prolactin etc
 Imaging is usually not required
Treatment:
 Before treatment with thyroid hormone is started, clinical assessment for

angina and adrenal insufficiency is required
 Synthetic Levothyroxine may be started in a dose of 25-75 mcg orally daily
 Women who are pregnant may start with 100-150 mcg/day
 Dose may be increased to keep TSH between 0.4 – 2.0 milli units/L and
according to clinical response
 Timing should be kept constant preferably in the morning 1 hour before
breakfast
 Patients with IHD or those who are above 60 may be started with low initial
doses of about 25-50 mcg/day and dose can be increased every 1-3 weeks until
the patient is euthyroid
Monitoring and optimizing treatment of Hypothyroidism
 Same manufacturer brand should be used every time

 The goal is to keep TSH normal
 Hepatic enzymes inducer and inhibitors should be kept in mind and doses
increased or decreased accordingly
 Decreased effects can also be noted with Sertraline, Iron or other minerals
and vitamins, Antacids, GI Malabsorption, bile salt binding resins etc
 Increased doses are required with OCPs
 Pregnancy increases the requirement of Levothyroxine, so that in pregnancy
the dose is increased 20-30% from previous dose
 Post partum requirement returns to normal
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1.Elevated serum TSH
Following should be checked
1. Poor compliance
2. Under replacement
3. Malabsorption due to concurrent drugs, taking with food, GI disorders like
celiac disease etc
4. TSH can be raised by antipsychotic medications
2.Normal Serum TSH level
1. For most patients TSH is kept in the lower normal range but for patients
with AF or angina it is kept slightly above normal
2. Some patients with normal TSH continue to have Hypothyroid like
symptoms like Fatigue, lethargy, weight changes, depression etc, such
patients need to be assessed for other concurrent conditions like adverse
reaction of medicines, hypogonadism, depression, anemia, OSA ,Celiac
disease, Addison’s disease etc
3.Low or Suppressed Serum TSH
1. If serum TSH level is less than the reference range, it is considered low
(0.04-0.4 milli-units/L)
2. If serum TSH level is less than 0.03 milli-units/L , it is considered suppressed
3. If with suppressed level,patient has features of Hyperthyroidism,t he dose of
levothyroxine should be reduced
4. If with Low serum TSH, patient don’t have such hyperthyroid symptoms, it is
important to determine whether Hypopituarism or severe non-thyroidal
illness is present
5. Certain medications can also reduce TSH like: NSAIDs, Steroids, Opioids,
Nifedipine etc and if such causes are absent and patient is euthyroid
clinically, then the lower dose can be used
6. With primary hypothyroidism, there are chances of AF and osteoporosis if
the TSH is suppressed, so lower dose may be used
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24.Thyroid Eye Disease
What exactly the problem is? NOTES

In which eye?
Any other problem with your Eyes Like:
 Redness, Watering or Discharge?
 Decreased vision
 Double vision
 Color vision

Is it getting worse? What makes it worse?
Any problem adjusting to temperatures?

Any changes in appetite?
Any changes in weight? Increased or decreased?
Medical Problem
Medicine: Propylthiouracil, Methimazole or Carbimazole

Family Hx:
Social History: Driving
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Examination
Inspection
General
 Thyroid
 May be scar
Eyes
Hands
Pulse
Pretibial Myxedema
(=Legs)
1.Grave’s Orbitopathy
 Orbitopathy can be flared with 131I, smoking and Thiozolidinediones like
Pioglitazone
 Mild symptoms can be treated with Selenium 100 mcg orally twice daily
 For acute and progressive exophthalmous, I/V methylprednisolone is
preferred as 500 mg weekly for 6 weeks , and then 250 mg weekly for 6 weeks
 Patients with corticosteroid resistant acute Grave’s Orbito-pathy may also
be treated with Rituximab in the form of retro-orbital injection
 Other options include Retro-bulbar radiation and orbital decompression
surgery
o Other options related to eye problems include
 Prism in glasses if diplopia
 Artificial Tears and lubricant drops for dryness
 Tarsorraphy for corneal protection and improved appearance
2.Grave’s Dermopathy:
 Topical corticosteroids with nocturnal occlusive dressings
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25.Acromegaly
Presenting complaints like: NOTES

 Headache
 Accident while parking
 Changes in appearance etc
For how long?How did it develop?suddenly or gradually?

Is it getting worse?what makes it worse?what makes it better?
Any Changes in hand size & Feet size?
Any numbness/ Tingling in Hands?
Any Sweating in your hands?
Any weakness on standing from sitting?
Any changes in Mood? Any Headache? (Frontal)
Any problem adjusting to temperatures? (Thyroid)
Do you feel dizzy when you stand up suddenly?

(Adrenal insufficiency)
Any problem with vision? (Bitemporal Hemianopia, Diabetic

Retinopathy, Cataract, Homonymous etc)
Any Changes in facial appearance? (Previous Snaps)
Any problem with with chewing?
Do you feel increased thirst? (DM)
Any swelling on front of the neck?
Any difficulty in breathing? (CCF etc)
Any tummy pain?
Ever had blood through back passages? (Polyps or Carcinoma)
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Any problem with water works especially increased frequency?
(DM or Diabetes Inspidus)
Ever passed stone through water works?
Any problem with periods? (Pituitary suppression)
Medical problem:
Medicine:
Family Hx:
Social Hx:
Other associations:
Pituitay Apoplexy may have:
 Sudden severe headache
 Diplopia
 Ptosis
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Examination
Hands
 Large broad palms and broad fingers
 Sweating
 Carpal tunnel release scars? Carpal tunnel syndrome
 Thickness of skin
 Pin prick marks
 Numbness /Tingling
Arms
 Proximal Muscle weakness
 Under arms (Skin tags, Acanthosis Nigricans)
Face
 Prominent Supra-orbital Ridges
 Nose,Ears, Tongue and lips
 Increased interdental space
Side of face
 Proganthism
Breast (If Male)

 Gynaecomastia
 Discharge
Heart (CCF etc)
Abdomen (Including DRE)
Knee (OA)
Finish by:
 Fundoscopy
 BP
 Dip the urine for Glycosuria
Idea
Concern
Explain
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Investigations:
1. Screening is done with random IGF-I, which if normal rules out acromegaly
2. Fasting IGF-I (significant if more than 5 times normal)
3. Then Glucose syrup (100 g) is administered orally, and serum GH is
measured after 60 minutes if which is less than 1ng/ml rules out acromegaly
4. Other tests done in fasting include
 Prolactin (secreted by many GH-Secreting Tumors)
 Serum calcium (to exclude Hyperparathyroidism)
 Serum FT4 and TSH (to exclude secondary hypothyroidism)
 Glucose (DM is common)
 LFTs and RFTs (as these can misleadingly elevate GH)
Imaging
 MRI Brain
 X-Ray lateral foot to see the increased thickness of the Heel pad
Treatment
1. Pituitary Trans-sphenoidal Microsurgery
2. Medical treatment: If there is incomplete biochemical remission after
pituitary surgery, medical therapy with :
 Dopamine agonist (Cabergoline)
 Somatostatin analogues (Octreotide or Lantreotide)
 SERM (Tamoxifen)
 GH Receptor antagonist (Pegvisomant)
3. Stereotactic Radiotherapy which is administered by Gamma knife or proton
beam methods etc
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26.Cushing Syndrome
Presenting complaint like: NOTES
Weight gain etc.
ODPARA
Any thinning of skin or discoloration of skin?
Numbness or tingling in hands?
Any Bluish spot on your skin?
Any marks on skin?
Any Weakness in shoulders or hips?
Any changes in weight?
Any change in mood or sleep?
Any vision problem (what type of)

1) Any headache (Frontal For Cushing Disease)
2) Any lumps or bumps
Any cough or phlegm (Lung Cancer,Ectopic)
3) Any swelling in tummy (Adrenal Mass)
Medical Problem or any operation
Medicine:
4) Steroids
Family Hx:
Social History:
Body building
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Examination
Inspection
 Cushingoid appearance
 Centripetal obesity
Hands and Arms
 Clubbing
 Pin Prick marks
 Numbness or tingling
 Bruising
 Striae
Proximal
 Muscle weakness
Face and Neck
 Inter-scapular and Supra-clavicular fat pads
 Acne
 Excessive hair growth
Eyes
Tongue
 Candidiasis
Lymph Nodes
Chest
Abdomen
Scar at the back
Spinal Tenderness (Osteoporosis)
Broom stick appearance of legs
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1.Screening:
 Overnight Dexamethasone suppression test

 24-Hour urinary free Cortisol and Creatinine
2.Confirmatory tests:
 Mid-night Serum Cortisol

 Low dose dexamethasone suppression test
3.Etiology:
Serum or plasma ACTH level…..not raised but serum cortisol is high then
 CT of the adrenals
Serum or plasma ACTH level…..raised
 MRI of the Pituitary

 Selective catheterization of the Inferior Petrosal Sinus Veins
 CT scanning of the chest and abdomen with special attention to the lung,
thyums, pancreas and the adrenals
 OCT-Scanning can detect occult tumors if above fails
Investigations of Cushing syndrome in details (It can be difficult and conflicting)
Screening:
Screening can be done with Overnight Dexamethasone suppression test in
which 1 mg of oral dexamethasone is give at 11 PM and serum is collected for
Cortisol at 8 AM next morning. If cortisol level is less than 5mcg/dl, it
excludes Cushing syndrome with some certainty. However, if other features
suggest hyper-cortisolism, further evaluation is warranted.
24-Hour urinary free Cortisol and Creatinine is the usual confirmatory test
for patients with an abnormal dexamethasone test
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Confirmatory tests:
Mid-night Serum Cortisol (more than 7.5mcg/dl is indicative of Cushing
syndrome) and low dose dexamethasone suppression test can be used to
distinguish Cushing syndrome from Pseudo-Cushing states (like obesity,
depression and alcoholism)
Etiology:
1. Once Hyper-corticolism is confirmed next step is to find the cause that
whether it is ACTH-Dependent or ACTH-Independent , so serum or plasma
ACTH level is obtained and if level of ACTH is below 20 pg/ml, it indicates a
probable adrenal tumor whereas higher levels are produced by pituitary or
ectopic ACTH-secreting tumors
2. If ACTH-independent Cushing syndrome is suspected (ACTH less than
20pg/ml) then CT of the adrenals usually detects a mass lesion (Benign or
Malignant)
3. If ACTH-Dependent Cushing syndrome is suspected than MRI of the
pituitary can demonstrate lesion in 50% of cases. If the pituitary MRI is
normal than selective catheterization of the Inferior Petrosal Sinus Veins
draining the pituitary is performed. If the ACTH level is greater than twice
the simultaneous peripheral venous ACTH level, it indicates pituitary
disease
4. If Inferior petrosal sinus ACTH concentrations are not above the requisite
level, a search for ectopic source of ACTH is made that includes CT scanning
of the chest and abdomen with special attention to the lung, thyums,
pancreas and the adrenals
5. In about 40%, CT scanning fails to detect the ectopic source than OCT-
Scanning can detect occult tumors
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Treatment of cushing syndrome: Depends upon the underlying cause
Iatrogenic:
 Reduction of exogenous steroids or steroid sparing medicines if possible
Other causes:
Medicines:
 Metyrapone and Ketoknoazole before definitive treatment
Surgery:
 Adrenal mass or ectopic ACTH-producing tumor with or without
radiotherapy
 Cushing’s disease: Trans-sphenoidal hypophysectomy with or without
radiotherapy
 Previously it was treated with bilateral adrenalectomy
Treatment of complications like:
 DM
 HTN
 Ostroprosis etc
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27.Addisons’s Disease
Presenting complaints: Notes

 Weakness
 Fatigue etc

How did it develop,suddenly or gradually?
Is it getting worse? What makes it better?
Any darkening of skin? Which parts of body is affected?
Any Headache (Frontal)? Change in mood?
Dizziness on standing?
Nausea / vomiting?
Abdominal pain?
Problem with bowel works
DD (Causes)
General
Any white patches on the skin (Autoimmune)
Any cough or Phlegm (TB or Cancer)
If headache and vision problem (Pan-hypopituarism i.e
Secondary cause)
Medical problem: Autoimmune,TB,Cancer,HIV etc or

operation in the past like adrenalectomy or Pituitary
adenoma
Medicine: Previous or recent steroid use due to any reason
Family Hx:
Social Hx:
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Examination
General physical
Pigmentation
 Hands
 Body
 Mouth
 Pressure areas
Hair distribution (Females)
Ear auricular calcifications (Males)
Adrenalectomy scars
Postural BP
Examination related to cause if found like chest for TB etc
Polyglandular autoimmune syndromes
Type 1:
 Autosomal recessive
 Mucocutaneous candidiasis and Hypoparathyroidism in childhood
 Adrenal insufficiency and primary hypogonadism in adulthood
Type 2:
 More common than type 1

 50 % cases are familial
 Associated with Type 1 DM and Autoimmune thyroid disease
 Adrenal insufficiency is almost always present
 Not associated with hypoparathyroidism
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Investigations:
1. CBC to look for Neutropenia, Lymphocytosis and Eosinophilia
2. Serum electrolytes to look for hyponatremia and hyperkalemia
3. Fasting blood glucose to document Hypoglycemia
4. Serum calcium to check Hyper-calcemia
5. Autoantibodies
6. .Plasma cortisol (less than 83 nmol/L) and plasma ACTH (more than 200
pgm/ml) both at 8:00 AM are diagnostic
7. The diagnosis is confirmed by simplified Cosyntropin stimulation test
 Synthetic ACTH (Cosyntropin) 0.25 mg is given IM
 Serum cortisol is obtained 45 minutes after the test
 Normally it rises to more than 550 pmol/L but with adrenal
insufficiency, It fails to rise above 550 pmol/L
Imaging:
 X-Ray chest if TB or malignancy is suspected
 CT adrenals if infiltrative process is suspected
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Treatment
1. Medical alert bracelet or necklace etc

2. All infections should be treated immediately and vigorously
3. Replacement therapy includes Glucocorticoids and Mineralocorticoids
a.Glucocorticoids Replacement Therapy
 Hydrocortisone 15-30mg/day orally, with two third dose in the morning and
one third in the late afternoon or in the early evening, other options
include prednisone and methylprednisolone
 Glucocorticoid dose can be increased during stress and also in the third
trimester, the dose can be increased to 50% the usual dose and the dose is
reduced back to normal once the stress is over
b.Mineralocorticoid Replacement (Fludrocortisone acetate)
 The dose is 0.05-0.3 mg/day depending on symptoms
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28.Hypopituiarism
Features:
Frontal headache and bitemporal hemianopia if adenoma is the cause
Pale,dry,wrinkled skin
Decreased body hair
Problem adjusting to temperatures
Gynaecomastia (May be due to gonadotropin replacement)
Decreased testicular size and lack interest in sex
Postural hypotension
ODPARA
Any injury to head before these symptoms?
General Questions (Malignancy)
Liver (Hemochromatosis)
Joints (Eyes,Chest,Painful rash)
Excessive blood during pregnancy (If female for Sheehan syndrome)
Medical problem:
 Malignancy
 Pituitary surgery or radiotherapy
Medicine:
Family Hx:
Social Hx:
Examination:
Idea
Concern
Explain
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Note:
Acute disease can present with sudden loss of ACTH and hypotension e.g Pituitary
apoplexy and infarction
Others may cause gradual loss of hormones in sequence e.g
 Growth hormone followed by

 Gonadotrophins followed by
 ACTH and TSH deficiencies
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29.Diabetes Mellitus And Charcot Joint

In which joint you have problem? Notes
Do you have problem in any other joint?
Any pain, redness or problem with movement of your ankle?
ODPARA
Any injury before this? (Trauma)
Neuropathy related Questions:
 Any numbness? - ve
Any tingling? + ve
 Any weakness in feet? – ve

Any cramps? + ve
 Any problem with your balance?
 Any dizziness on standing? (Autonomic)


Any pain in your legs while walking? (PVD)
Medical problem:
I understand that you have diabetes? Please tell me for how
long?
 What was last Hb A1c?
 Which medicine you are taking?
 Any complications?
 Do you get regular check ups for your eyes, kidneys
and feet?
Medical problems:
Medicine: Any other medicine?
Family Hx:
Social History:
 Smoking
 Alcohol
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Examination:
General
Inspection
Passive movement
Palpation
 Temperature
 Sensations (Pin Prick in stocking distribution)
 Dorsalis Pedis
Gait—Balance (Romberg ‘s)
GPE
Complete by
 Fundoscopy
 Blood pressure
 Dip the Urine for glycosuria and proteinuria
Idea
Concern
Explain
Foot Care
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30.Diabetes and Foot Care

If you take care of your feet, you can avoid many complications:
1. Daily inspect your feet, including your sloe by a mirror.
2. Daily wash your feet and dry them gently but not to rub.
3. Do not walk bare foot and wear comfortable shows and socks?
4. Do not apply plaster corns on your feet?
5. Get regular visits for your feet care.
6. If you get any wound, immediately visit the doctor.
Referrals depend on the underlying problems in Diabetes Mellitus and include the
followings:
 General Physician
 Diabetes specialist
 Diabetes Foot clinic
 Clinical nurse specialist
 Foot Surgeon
 Dietion
 Physical trainer
 Physiotherapist
 Blood channels surgeon
 Eye specialist
 Kidney specialist
 Occupational health physician
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31.Diabetes and Foot Ulcer

Neuropathic
Ischemic (Arterial)
Where exactly the ulcer is? Notes

Do you have ulcer anywhere else?
How does it look like?
Any pain, bleeding or discharge?
ODPARA
Any injury before this?
Any insect bite?
Any numbness /tingling in feet?
Any pain in feet?
Any weakness in feet?
Any cramps or tremors in hands?
Any problem with your balance?
Do you feel dizzy when you stand up from sitting position?
(Neuropathy)
Any pain in your legs while walking? (PVD)

Medical problem: DM, HTN, Fat Levels
I understand you have DM
 For how long?
 What was your last Hb A1c?
 Medicine for DM?
 Any complications?
 Do you get regular check ups for your Eyes, kidney
or Feet care?
Any other health problem?
Medicine:
Are you taking any other medicine?
Social history:
 Smoking, Alcohol
 How you are affected?
Examination
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Inspection
Sensory (10 gm Monofilament)
 Pin prick
 Sensory level
 Balance
 Walk ± Power
Dorsalis Pedis
Idea
Concern
Explain
Foot Care
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32.Problem of Eyes encountered in PACES

Loss of Vision
1.Sudden
a.Sudden Permanent
 Retinal Artery Occlusion

 Retinal Vein occlusion
 GCA
 Vasculitis
 Toxins
b.Sudden Transient
 Amaurosis Fugax
 Migraine
2.Gradual
 DM
 HTN
 RP
 Others
3.Partial (Quadrants)
 Bitemporal Hemianopia
 Homonymous Hemianopia
 Quadrantanopia
 Nasal Fields loss (Tumor)
Double Vision:
 Extra ocular Muscles

 NMJ
 Nerves
 Drugs
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33.Retinitis Pigmentosa
 Young with Tunnel vision
 Night-time vision problem
 Positive Family History
What exactly the problem is? Notes
Any specific part in your vision or whole of your vision is
decreased?
Any other problem with your eyes: like
Redness, watering, discharge or pain?
Any double vision?
Problem with color vision?
ODPARA
 Any problem with hearing or water works?

(Alport Ushers,Refsums disease etc)
 Any problem with swallowing or racing of heart

(Kearns-Sayer Syndrome )
 Any numbness or tingling in feet?

 Any balance problem (Abeta-Lipoproteinemia)
Medical: DM, Hypo-gonadism (Lawrence-Moon)
Medicine:
Family Hx:
Social Hx:
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Examination
Inspection
 General
 Lawrence-moon Six fingers or Amputated fingers
Hearing device
Visual Acuity
 Finger counting
 Hand movement
 Throw light
Visual Fields (Bitemporal Loss)
Eye movements (Kearns Sayer Syndrome)
Fundoscopy
 Waxy Pallor Disc

 Bony Spiculed pigmentation (Peripheral,symmetrical
and widespread)
 Attentuation of Blood vessels
Idea
Concern
Explain Driving
DD:
 LASER scars
 Retinal trauma
Investigations:
 Tests for underlying cause
 Electro-retinogram
 Genetic testing
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Treatment:
No cure,just supportive treatment
General:
 Patient and family education
 MDT care if required like psychological support and
eye specialist involvement
 Visual impairment support like: Walking aids,Guide
dog
 Liason with DVLA
 Support groups
Medical:
 Vitamin E
New therapies underway:
 Retinal implants
 Transplants
 Stem cell therapy
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34.Optic Atrophy
Presenting Complaints: Decreased Vision etc Notes
What exactly the problem is?
Whole of your vision or any specific part of vision is affected?
In which eye you have this problem?
Any other problem with eyes: Like any pain,watering?
Any double vision, blurriness, Problem with color vision?
For how long you have these symptoms?
Was it sudden or gradual?
Any injury before this? (Trauma)
Any fever, fatigue, Lumps or bumps? (Malignancy)
CNS
Any rash, joint pains? (Vasculitis)
Cough, SOB? (Sacoidosis, TB)
Medical: DM, HTN, Congenital (DIDMOD,Leber’s Hereditary
optic neuropathy etc)
Medicine: INH, Ethambutol,Sulfonamides,Radiations
Family Hx:
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Social History
 Smoking
 Methyl alcohol
 Ethyl Alcohol
 Other toxins
 Diet- Vitamin B-12 Deficiency
Examination
Inspection
 General
 Eyes
Visual Acuity
Color vision
Field of vision
 Central Scotoma on affected side and MS is most likely
Light reflex
 RAPD (Early)
 Consenual reflex only (Advanced)
Fundoscopy
 Pale Disc with normal margins
Idea
Concern
Explain Driving
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Differential Diagnosis/ Causes of optic atrophy
1. Compression
2. Demyelination
3. Ischemia (Central retinal artery occlusion)
4. Infections
5. Vasculitis
6. Inflammation
7. BIH
8. Trauma
9. Glaucoma (cupping of Disc)
10. Hereditary conditions
11. Medicines
12. Radiation
13. Drugs
14. Toxins (Cyanide,Alcohol,Lead)
15. RP
16. Friedrich’s ataxia and MS
17. Dietary
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35.Visual Blurriness
Presenting Complaints: Notes
What exactly the problem is? In which eye?

Any other problem with you eyes lik:Pain, redness,
watering?
Any double vision, decreased vision, problem with color
vision?
For how long? Was it sudden or gradual?

Ever checked blood sugar at that time?
(Hyperglycemia,Hypoglycemia or diabetic maculopathy)
Any weakness in limbs or speech problem at that time?
(Recurrent TIAs)
Any glare in your vision especially at nighttime while
driving because of headlights of other Vehicles?
(Cataract)
Any black blobs in your vision?(Vitreous Hemorrhage)
Headache and jaw pain? (GCA)
Medical problem: DM
 Control
 Medicines
 Complications
 Check ups
Medicine:
Family Hx:
Social History: Smoking, Alcohol
Driving
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Examination
Inspection
 General
 Eyes
Visual acuity
Field of vision
Fundoscopy
Relevant Examination Like:
 Power
 Reflexes
Idea
Concern
Explain like Mini-stroke etc
Investigation:
Depends upon underlying cause of TIA :
 Fasting blood sugar
 Hb A1c
 Fasting lipid profile
 CT Brain
 MRI Brain
 4 vessels neck Doppler
 ECG and Echocardiography etc
Treatment:
ABCD score < 4 refer to TIA clinic and CT brain within 7
days
 Control of underlying risk factors
 Warfarin therapy -if contraindicated then aspirin
 Refer for Carotid end-artecrectomy within 7 days
if stenosis is > 70 %
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36.Double Vision
Presenting Complaints:
In which direction you get double vision?
 Looking straight (3rd Nerve)
 Right or Left (6th Nerve)
 Looking down (4th Nerve)
In which eye?
Any other problem with eyes like pain, redness, watering or
discharge?
Any decreased in vision, blurriness or problem with color vision?
For how long? Was it sudden or gradual?
Any flu like illness before this?(Miller Fischer)
CNS (SOL, MS, Stroke etc)
Did you take any cane food before you have this? (Botulism)
Any fatigue, When you get more fatigue? (MG)
Any lumps or bumps? (Tumors)
Any problem adjusting to temperature? (Grave ‘s Disease)
Medical:
Medicine: Aminoglycosides, Penicillamine
Family Hx:
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Examination
Inspection
General
Eyes
 Visual acuity
 Eye Movements
 Fundoscopy
Concern
Explain
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37.Transient Visual Loss

What exactly the vision problem is? Notes
Whole of vision or any specific part of your vision?
In which eye?
Any other problem with your eye? Like pain,watering etc
Any double vision, blurriness or problem with color vision?
For how long? Was it sudden or gradual? Is it getting

worse?
Any weakness in body limbs or any speech problem?
Any racing of your heart?
Any fever, rash on your hands? (IE)
Any facial pain? (If > 55 years)
Any headache?
Medical Problem: DM, HTN, Fat Levels
Medicine:
Famliy Hx:
Social History: Smoking, Alcohol, Recreational Drugs,
Cocaine
Driving
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Examination
General
Specific according to cause
Idea
Concern
Explain
CAUSES:
 Amaurosis Fugax (TIA)
 Migraine
 GCA
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38.Cataracts
Presenting complaint: Notes
Decreased vision or glare in vision during driving
What exactly the problem is? In which eye?
For how long? Was it sudden?Is it getting worse?
What else?
Associated problem like DM
Medical problem
Medicine
Family Hx:
Social History
Examination:
General
Opacity
Visual acuity
Fundoscopy
Dimunition of Red reflex (Small cataract)
Loss of red reflex (Large cataract)
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Causes:
 Senile
 DM
 Cushing syndrome
 Myotonia Dystrophica
 Hypo-parathyroidism
 Turner syndrome
 Down syndrome
 Drugs like steroids.amiodarone and tamoxifen
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39.Diabetic Retinopathy
Middle or Old aged patient with vision problem most likely decreased vision
Problem reading News Paper
For how long?Did it start suddenly or gradually?
Do you have any other problem?
Associated like DM in detail
Medical problems especially other Risk factors like HTN,Fat levels etc
Medicines
Family Hx:
Social History Especially smoking and Driving
Examination
Visual acuity
Field of vision
Fundoscopy
 Microaneurysms
 Dot and blot hemorrhages
 Flame shaped hemorrhages
 Hard exudates
 Cotton wool spots
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Idea
Concern
Explain:
Blood channels at the back of eyes are affected
Refer to eye specialist for detailed examination and LASER therapy
Control of risk factors including DM
Stop driving
DD:
Hypertensive Retinopathy
Retinal vein occlusion
 BRVO
 CRVO
LASER Therapy
Pan-retinal photocoagulation for pre-proliferative and proliferative Retinopathy
Focal Laser photocoagulation for maculopathy
Vitrectomy for sever vitreous hemorrhage
Future treatments:
 Bevacizumab
 Triamcinolone (Intravitreous Corticosteroids)
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40.Central Retinal Artery Occlusion

Patient may present with acute painless loss of vision
For how long? Was it sudden or gradual? Is it getting worse?
Associated system e.g DM
DD:
 GCA
 Heart problem like AF etc
Medical problem: DM,HTN,Dyslipidemia,AF,Infective endocarditis,Vasculitis etc
Medicine
Family Hx:
Social history
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Examination:
General
Eyes
 Visual acuity
 Color vision
 Field of vision
 Light reflex
Fundoscopy may show
 Pale edematous Retina

 Attentuation of Retinal arteries
 Cherry Red Spot at macula (May not present if few days have past)
Other
 Pulse
 Carotid
 Heart
Idea
Concern
Explain
Investigations according to cause
Treatment:
 Treatment of underlying disease

 Ocular massage
 Acetazolamide
 Carbogen therapy
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41.Other Possible cases
1. Retinal vein occlusion may have variable vision problem like gradual or
sudden vision problem or mild to sever vision problem
2. Hypertensive Retinopathy
3. Diabetic Laser Scars and Papilledema
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42.Anemia
Anemias
Hb <13.5 g/dl or Hct <41% in Men
Hb <12 g/dl or Hct <36% in Women
a. Pallor
b. Glossitis
c. Hepatosplenomegaly
d. Lymphadenopathy and
e. Bone tenderness are important Signs to Look for
Riticulocyte count and MCV are important factors in the evaluation of anemias of
all types
Bone marrow biopsy is required when:
a. Other Lab evaluation is inconclusive

b. Additional Cytopenias
c. Other primary or secondary bone marrow process is suspected
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43.Iron Deficiency Anemia

1. Iron deficiency anemia is the most common cause of anemia
2. Bleeding is the most common cause of iron loss from the body
3. Iron deficiency is present when:
Serum Ferritin is <12 ng/ml or
Serum Ferritin is < 30 ng /ml with Anemia
4. Iron absorption is good under the acidic conditions of upper GIT
5. Symptoms of Iron deficiency include:
a. Anemia related (Fatigue, Tiredness, Palpitation and SOB especially on
exertion)
b. Skin and Mucosal changes if severe deficiency
c. (Brittle Nails, Spooning of nails, Cheilosis,Smooth tongue and Esophageal
webs)
d. Pica eating
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Presenting complaints: Notes
SOB, Fatigue, Racing of heart on exertion

Sudden or gradual? Is it getting worse?
What makes it worse? What makes it better?
GIT
 Yellowness of eyes?
 Red Spots on skin or inside mouth?
 Nausea, vomiting?
 Burning sensation in your chest?
 Difficulty in swallowing?
 Tummy pain?
 Changes in bowel habits?

(Any problem with eyes, ulcers in mouth, rash,
joint pains)
 Ever had worms in bowel works?
General:
Blood Loss:
 Bleeding from any site
 Recent blood donations
 Any recent Injury or operation
 Any blood transfusion
IF female:Menorrhagia, Pregnancies, Breast Feeding etc
Medical: Liver Disease, Kidney disease etc
Medicine: NSAIDs, Heparin, Warfarin
Family Hx:Hemolytic anemia etc
Social History: Alcohol, Diet, Red Meat or not etc
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Examination
General Inspection
Hands
 Koilonychia
 Clubbing
 Pallor
Eyes
Lymph Nodes
GIT including DRE
Causes of Iron Deficiency Bleeding is the most common

cause
A.GIT Causes of Iron Deficiency
1.Dietary
 Decreased intake of Meat
 Zinc Deficiency
2.Gastritis (Causing Hypochlorhydria)

 Autoimmune
 H.Pylori
3.Malabsorption
 Celiac Disease
 IBD etc
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3.Bleeding (Upper and Lower GI causes especially with

chronic Losses)
 HHT
 Esophagitis
 APD (NSAIDs, other causes etc)
 CLD
 Malignancy
 Inflammatory conditions (IBD etc)
 Other causes including causes of occult bleeding
4.Worm Infestation
B.Non-GIT Causes of Iron deficiency
1.Increased Requirements
 Pregnancy
 Lactation
2.Blood Loss other than GI (Chronic)

 Menorrhagia
 Blood donation
3.Hemoglobinurea
4.Iron sequestration Pulmonary Hemosiderosis
5.Herediatary Iron-refractory
6.Idiopathic
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Labs
Stages of Iron Deficiency
1. Depletion of Iron stores without anemia
2. Anemia with normal MCV
3. Anemia with Low MCV
 Reticulocyte Count may be Low
 Serum Ferritin may be Low (May be elevated because of Inflammation, so
non specific)
 Serum Iron may be Low (So Transferrin Level rise to compensate)
 Transferrin saturation is Low (Serum Iron/TIBC 100)
 TIBC is Increased
 Peripheral blood picture may show different forms depending on iron
deficits
Differential Diagnosis: (Low MCV)
1.Anemia of chronic disease
 Serum Ferritin may be normal or elevated
 TIBC and Transferrin may be either Normal or Low
2.Thalassemia
 MCV may be strikingly Low as compared to degree of anemia
 Red Blood Cell count may be normal or elevated
 Reticulocytosis may be present
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Treatment:
1.Oral Iron Therapy
 Ferrous sulfate 325mg TDS on an empty stomach (Provides 180 mg/day of
which upto10mg is absorbed)
 Extended release Ferrous Sulfate with Mucoprotease (Tolerated well)
Good response within 3 to 8 weeks
 Iron therapy is continued for 3-6 months after normal Hematological values
to replenish the iron stores
Causes of failure to Response in Iron deficiency Anemia
1. Poor compliance
2. Incorrect Diagnosis (Anemia of chronic disease, Thalassemia etc)
3. Malabsorption (Celiac disease)
4. On going blood Losses that exceeds the replacement or new erythropoises
5. H.Pylori or Autoimmune Gastritis
6. Decreased stomach acidity because of certain reasons like concomitant PPI
use or above (In such case concomitant Ascorbic Acid may help)
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2.Par-enteral Iron therapy:
Indications include:
a. Intolerance to oral therapy

b. GI disease (IBD etc)
c. Continued blood loss that can not be corrected (Chronic
hemodialysis)
 Current preparations are safe and can be given in 5 minutes

 Iron deficit is calculated by determining the decrement in Red cell volume
from normal
 There is 1 mg of Iron in each I ml of Red blood cells
 Total body iron is between 2 to 4 grams
 Men have approximately 50mg/Kg and women 35mg/Kg
 Red blood cell volume in Men is about 30 ml/Kg and women 27 ml/Kg
Example: If
 Woman has Hb = 9 gm/dl (Normal for women is 12 gm/dl, which means 25%
less in this case)
 Weight = 50 kg
 Iron Deficit in this case is: 0.25  27 ml/kg  50 kg = 337.5 mL of Red blood
cells
 Which means 337.5 mg of Iron
 The parenteral dose is Iron deficit plus 1gram extra to replenish the stores
so in the above case it will be 1.4 gram
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44.Other GI Cases
Hematemesis (Young Patient) Notes
What exactly happened?
Did you get blood with vomiting i.e mixed with food or with cough
containing Phlegm?
What was the color? How much blood with vomiting?
Do you have bleeding form any other site?Any dizziness?
For how long?

How many episodes?
GIT Questions (It will rule out all the causes)
Medical problem: APD, Liver Disease etc
Medicine: e.g Aspirin, NSADs, Steroids etc
Family hx:
Social History: especially Alcohol
Examination:
GPE
Abdomen (Offer DRE)
Observation charts
Idea
Concern
Explain
Camera Test (Upper GI Endoscopy on OPD basis or in emergency

depending on the status)
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Treatment also involves ABCDE Measures
Rocall score (Mortality risk)
Blatch Ford score (Intervention required or not)
Causes or Differentials:
1. Esophagitis
2. Mallory Weiss tear
3. Acid peptic disease
4. CLD
5. Malignacny
6. Others
Old Patient
Same scheme as above
 Malignancy
 CLD
 Gastritis
 Other causes e.g APD, HHT, Drugs (NSAIDs)

Camera test (Endoscopy)
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NAFLD
Presentation may be with deranged ALT, AST with risk factors like:
Obesity, DM etc
Any symptoms? Like: Any Yellowness of eyes?

Nausea, vomiting or vomiting containing blood?
Ever lost consciousness? (Encephalopathy)
 Risk factors assessment for hepatitis B and C?
 Autoimmune causes of Liver?
 Metabolic causes?
Medical: Medical Problems e.g DM, HTN etc
Medicine: Methotrexate, Amiodarone, Phenytoin and INH or Herbal

medicines etc
Family Hx:
Social History: Alcohol
Examination:
Idea
Concern
Explain (Depending the cause like NAFLD risk factors management etc)
D/D
1. Alcohol
2. Viral (Chronic Hepatitis BV and HCV)
3. Autoimmune (PBC, PSC, AIH)
4. Metabolic (Wilson’s, Hemochromatosis, Alf-1 AT deficiency)
5. Drugs
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Elevated Liver Function Test and HBs Ag +ve after 6 Months of

Jaundice (Chronic Hepatitis)
Symptoms Assessment
Risk factors Assessment
 Piercing
 Tattooing
 Blood transfusions
 Medical or Surgical procedures
 Sexual History
 I/V Drugs
 Job risk
Crohn’s Disease
 Loose Motion detail
 Other Extra-intestinal Symptoms
 Mal-absorption related Questions
Medical problem:
Medicine:
Family Hx:
Social History:
Examination:
General physical and Abdomen
Idea
Concern
Explain: Camera Test (Colonoscopy)
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OTHER IMPORTANT CASES
Diarrhoea b/c of recent Antibiotics /Camera test (Colonoscopy)
Weight loss See History Notes for weight Loss with Good appetite and
with bad appetite
Or
Weight Loss with GI causes and Non-GI causes
Dysphagia and Weight Loss (History Notes)/Camera Test (Endoscopy)
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Platelet Type bleeding can present with superficial or mucosal-dermal

bleed like:
 Nose bleed
 Gum bleed
 Menorrhagea (Female)
 Petechiae, Purpura and Bruising etc
Factor type bleeding can present with deep bleeding Like:

 Hematoma
 Hemarthrosis etc
Platelets Like Disorders can be of 2 types
1.Thrombotic Disorders (Platelet) Further divided into 2 Types

Quantitative and Qualitative
Quantitative Platelet Disorders because of Increased Destruction:
a. ITP (May be associated with following conditions)

Drugs (Many)
Infections like HCV, HBV, HIV,Lymphoproliferative disorders and
Connective Tissue Disorders e.g SLE
b. TTP, HUS
a. Other features Like Fever, CNS and Kidney involvement
along with Thrombocytopenia and Micro-angiopathic
anemia
c. DIC
d. Hyper-Splenism
e. Heparin Induced Thrombo-cytopenia
Quantitative Platelet Disorders because of Decreased Production
Bone marrow Depression because of following conditions

 Lympho-proliferative and Myeloproliferative disorders
 Other tumors
 Infections
 B-12 and Folate Deficiency
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Qualitative Platelet Disorders:
 Uremia
 Medicines like Aspirin, Clopidogrel etc
 Congenital conditions: like Bernard Soulier Disease ,Glanzmann

Thromasthenia
2.Non-Thrombotic Disorders
 Henosch-Schonlein Purpura
 HHT
 Scury (Vitamin C deficiency)
 Senial Purpura
Where exactly the rash is? Anywhere else?

How does it look like? Can you feel it?
Does it disappear when you press it?
For how long? Sudden or gradual?

Any Bluish spots on your skin?
Bleeding from any part?
Any difficulty in breathing, Fatigue or Racing of heart on

walking (Anemia)
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DD
Any Flue like illness before this? (ITP)
General (Malignancy,Leukemias ,metastatic)
CNS (TTP)
GIT (Henosch Schonlein Purpura)
Liver (CLD)
Kidney (HUS)
Joints (SLE,RA)
R.O.S
Past Hx
Allergy
Medical problems: Liver disease, Kidney disease
Medicine: Heparin, Aspirin,Warfarin,Steroids
Hugs: Radiation exposure
Family Hx: HHT, Bleeding disorders
Ob/Gynae:
 Recurrent abortions, Periods
 Pregnancy induced Thrombocytopenia
 Pre-eclampsia
Sexual Hx: HIV, EBV
Social: Diet deficient in vitamin C
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45.Epistaxis Because of Elevated INR (Warfarin)

Presenting complaints like Nose bleed Bleeding from any other site?
How much blood?
Any SOB, Fatigue, racing of heart (Anemia status)
Any dizziness (Assess Severity)
For how long?Sudden or gradual?How frequent?
Any injury or nose picking before this? (Trauma)
I understand that your blood thinning test called INR is on higher side.
Are you taking any blood thinning medicine called Warfarin
Why you are taking this? If not told in the notes (Prosthetic valves, AF, PE or DVT)
Have you been taking it regularly?
Ever had problem with this medicine in the past?
Do you visit INR clinic regularly?
Do you have record on Yellow book? Can you please show it to me?
Triggers
 Any changes in doses recently
 Any new medicines
 Any changes in your dietary habits
 Any Alcohol intake in excess recently
Medical Problem:
Medicine:
Family Hx:
Social History:
Examination: Cardiology
Idea,Concern,Explain
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46.Syncope
May be preceded by Pre-syncope i.e Light-headedness or black out or closing in of
visula fields
Transient collapse because of Sudden transient decreased cerebral perfusion and
self limited loss of consciousness
Gets up quickly
No problem thereafter i.e Completly Normal therafter
Syncoope is of 3 types
1.Neural or Refles which has 3 sub-types
 Vasovagal
 Situationl
 Carotid sinus hypersensitivity
2.Postural
3.Caridac
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1.Neurological or Reflex syncope is due to excessive Vagal Tone
May be preceded by Autonomic Aura like:
 Blurriness
 Nausea
 Sweating
a.Vasovagal also called common faint Common in young females
Always on standing when there is:
 Frightening seen
 Fear
 Excitement
 Exercise stress
b.Situational: Men at night usually while passing water works
others include
 Laughing
 Sneezing
 Coughing
 Straining
c.Carotid Sinus Hypersensitivity usually in old age group
during
 Sudden turning of head
 Hanging of clothes
 Putting books in the shelves
 Shaving
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2.Cardiac Usually there is no prodromal features
May be preceded by or accompanied by Palpitation, SOB and
chest pain
 IHD
 Arrythmias
 Aortic Stenosis
 HOCM
Mechanical problem can cause exertional or non-exertional
syncope
Non-mechanical include arrythmias
3.Postural Elderly with DM due to autonomic neuropathy or
HTN and on treatment
Can develop after following
 Diarrhea and Vomiting
 Burns
 HTN Drugs: ACE inhibitors ,B-Blockers ,Diuretics and
Vasodilators
 DM (AutonomicNeuropathy)
 Addison’s Disease
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47.Collapse
Falls Syncope Collapse
Remembers while falling Loses of consciousness Loses consciousness with

which occurs some abnormality e.g
No Loss of consciousness transiently and
followed by complete  Focal Deficit
 Polymyositis recovery (TIA,Stroke)
 Dermatomyositis  Subarachnoid
Collapse and Syncope Hemorrhage
 Parkinson’s disease are interchangeable
terms depending upon  Maningtits/
 Old Stroke the situation Encephalitis
 Cerebellum Problem  Hypoglycemia
 Sensory Ataxia  Epilepsy
 Drugs etc
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48. Seizure (Fit)
May develop while sleeping or lying
May develop while watching TV
There could be other triggers as well
There could be
 Altered breathing
 Cyanosis
 Tonic-clonic seizures
 Urinary incontinence
 Tongue biting
Post-ictal confusion like:
 Drowsiness
 Amnesia
 Transient focal deficit
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What exactly happened? Notes
What were you doing at that time?
1.Presyncope events:
Did you remember while falling? (If patient says no then
following)
Any unusual symptoms before this? Keep following clues in mind.
Lightheadedness,generalized weakness or narrowing of vision
may favor pre-syncope state which can be seen in different types
Blurriness, nausea or sweating? (Vasovagal)
On sudden turning of head or hanging clothes etc (Carotid sinus
Hypersensitivity)
While coughing or sneezing etc (Situational)
Chest pain, racing of heart or SOB? Or there may be no
complaints at all and patient collapses suddenly (Cardiac)
Dizziness on standing quickly? (Postural)
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2.During Synope:
Did you Lose consciousness? Was it Complete or partial?
Do you have any idea about how long?
Was there anyone around you at that time?
Did any one tell you about shaking of body limbs?
Any color changes of skin?
3.After Syncope:
When you woke up, were you completely back to normal?
Medical: DM, HTN, APKD
Medicine: ACE inhibitors, Beta Blockers, Diuretics or alpha
blockers
Social History: Cocaine, Alcohol, Ecstasy,Strobing Lights in club
Examination: Neural or Cardiac depending upon the cause
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Investigations for Syncope
It depends on the clinical presentations and the underlying possibility
May be completely clinical like history and examination of following:
 Pulse
 Carotids
 Heart
 Neurological Examination
And no specific investigations are required e.g Vasovagal syncope
Following can be done:
Blood pressure measurements both in lying and standing postures
Carotid sinus massage
Tilt Table Test and Valsalva menauver for autonomic testing
Tracing of Heart to look for Blocks,arrhythmias etc
Serial Tracings of Heart, 24-hour or 7-days tracing of heart, Scan of Heart and
Angiography to look directly into the blood channels
Electrophysiological studies for suspected cardiac syncope with others
CT Scan Brain, MRI Brain, Tracing of brain (EEG)
Blood sugar levels
Drug Levels in blood and urine
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Treatment of syncope
Vasodepressor causes:
 Avoid triggers
 Adequate hydration
 Volume expanders like Fludrocortisone
 Vosconstrictors like Midodrin
 SSRI with some benefit
Permanent pace maker if carotid block
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49.Chest Pain (Angina)
L___ Where exactly the pain is?
O___ Was it sudden or gradual in onset?
If sudden then ask
What were you doing at that time?
Do you have still this pain?
If no then ask for how long it remained there?
Q___ How does it feel like? Pressure,burning,squeezing,crushing etc
I___ How intense it is on a scale of 1----10?
R___ Does it move anywhere else?
A___ what makes it worse? like
 Pressing that area or by movement (Musculoskeletal)

 Lying flat (Pericarditis)
 Eating (GERD)
 Exertion (IHD)
 Taking deep breath in (PE, Pneumonitis)
 Coughing or straining (Spinal)
A___ what makes it better? (Alleviating factors)
Associated like dizziness,nausea,vomiting,sweating,racing of heart,SOB etc
DD:
Any injury before this?
Chest
GERD
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Medical problem:
Medicine:
Family Hx:
Social History: Smoking, Alcohol, Job, How it is affecting?
Examination:
General-----Tenderness
Heart
Idea/Concern / Explain
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50.Palpitations (AF)
For how long you have this problem? Notes
How frequent you get racing of heart?
For how long an episode remains?
Do you think that it is getting worse?
Can you please tap for me that how does it feel like and
how fast it is?
Did you ever count your pulse during this?
If cannot tap then:
Do you feel any thumping in your chest?
Do you feel it regular or not? How fast it is?
Associated
Heart
Chest
GERD
Thyroroxicosis
Medical: IHD,Valvular heart disease
Medicine: Theophylline, Anti thyroid drugs, Beta agonists
Family Hx:
Social History: Smoking,Alcohol ,Cocaine
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Examination
 General
 Heart
 Chest
 Thyroid etc
Idea
Concern
Explain
Investigations:
Treatment: CHA2DS2 VASc Score
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51.Other Respiratory cases

Asthma
COPD
Pleural Effusion
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52.Pulmonary Embolism
Presenting complaint: like
Chest pain,SOB ,Dizziness especially if large embolus
Coughing up blood etc
ODPARA or LOQIRA
Any swelling in leg? Where exactly? Any pain there?
Any changes in weight? Lumps or bumps? (Malignancy)
Any joint pains, fever or rash? How your skin behaves to
sunlight? (SLE, Vasculitis)
Any problem with bowel works? (IBD)
Have you been immobile recently? (Immobility)
Past history---Previous history of blood clot in legs or lung?
Medical: Blood clotting problem , Cancer , SLE ,
Antiphospholipid antibody syndrome etc
Medicine: Warfarin, OCPs
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Hospitalization: Recent Operation
Family history: Blood clotting problem in the family
OBS History– Recent Pregnancy (Hyper-coagulable State)
Social History: Smoking, Alcohol, Travelling
Examination
 General
 Leg
 Chest
 Heart
Idea
Concern
Explain
2-level well’s score
 PE likely > 4
 PE unlikely < 4
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Investigations for pulmonary Embolism:
Treatment:
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Haemoptysis
PCP pneumonia
Mass in a ptient with RA
Breathlessness dut to ILD or

methotrexate
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53.Headache
Main cases in station 5: Notes
1. Acromegaly
GCA Questions
2. Migraine
 Fever, fatigue,
3. Subarachnoid hemorrhage
changes in
4. Exercise induced headache
appetite & weight?
5. GCA
 Problem with
6. Analgesic induced headache
memory or
7. SOL Brain
depression?
 Vision problem?
Where exactly the pain is?
 Jaw pain?
Was it sudden or gradual?
 Stiffness in
How does it feel like?
How intense it is on a scale of 1 ot 10? shoulders or hips
Does it go anywhere else?  Chest pain?
What makes it better?  Pain in legs on
What makes it worse? walking?
Any unusual symptoms before this? Like funny zig-zags,

or Flashing lights.speech prolem,weaknsess of limbs or
abnormal sensations in arms or legs? (Aura – Migraine)
Associated system like CNS or underlying diagnosis

like GCA
General Questions (Malignancy,Vasculitis etc)
Medical problem:
Medicine: Pain killers more than 12 days/month
Family Hx:
Social history
Examination:
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 General inspection
 GPE
 Specific according to cause
Idea
Concern
Explain
Investigations: according to cause
Treatment: according to cause
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54.Left Sided Weakness in a Young Woman

Where exactly the weakness is?
In which part of leg or arm?
Do you have weakness anywhere else?
For how long? Is it still there? Was it sudden or gradual to statrt

with? Is it getting worse?
CNS related questions will rule out following:

 Stroke
 Subarachnoid Hemorrhage
 Migraine
 Epilepsy
 SOL
Any pain in neck before this? (Carotid artery dissection)
Any racing of your heart? (AF, IE)
Ever had clot in the blood channels of your legs or lungs? (ASD)
Any fever, rash, joint pain? (Vasculitis)
Medical problem:
Medicine:
Family Hx:
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Examination
 General
 Specific
Idea
Concern
Explain
Causes:
Stroke / TIA due to:

 Carotid artery dissection
 AF
 Infective endocarditis
 Vasculitis
 Anti-phospholipid antibody Syndrome
 Others
Other causes:
 Todd’s Paresis
 Migraine (Complex)
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55.Parkinson’s Disease
Falls
Tremors
In which hand you feel shaking?

Do you get shaking of any other part? Like
 Head
 Jaw
 Feet
When you get more shaking?
At rest or on sustained posture or if going to hold
something?

CNS Questions or associated system
Medical problem:
Medicine: Antipsychotics, anti epileptics etc
Family Hx:
Social history
 Smoking
 Alcohol
 Cocaine
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Examination:
General
Specific according to causee e.g Parkinson’s disease
Idea
Concern
Explain
Investigations: According to cause
DAT scan using SPECT to trace dopamine transporters in

the brain to support the diagnosis when in doubt.
Treatment: According to cause
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56. 6th Nerve Palsy (Double Vision on Looking to

Left or Right)
Causes:
Presenting complaint: like Double vision  Ischemic (DM, HTN etc)
In which direction?  Vasculitis (SLE, RA)
In which eye?  Infective (TB, Viral)
Any other problem with your eyes?  Infiltrative (Sarcoidosis)
ODPARA  SOL Brain
 CNS
 Flu like illness before?
 Thyroid
 Chest
 Joints
Medical:
Medicine:
Social History:
Driving
Examination:
Concern
Explain
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57.Blackout (First Fit)

History like Collapse & Syncope
Causes: Apply VITAMINS Formula
 Vascular events
 Infections
 Trauma
 Autoimmune
 Metabolic
 Idiopathic
 Neurological malignancy
 Psychiatric
What exactly happened? What were you doing at that time?
Any unusual Symptoms before this? like abnormal smell or
ringing in your ears or seeing of unusual objects ?
Did you remember while falling? (No—Favors syncope/Collapse)
Was there any one around you?
Did you lose consciousness? For about how Long?
Did any one tell you about the color changes of your skin? Or
Any shaking of body limbs?
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When you woke up, were you completely back to normal or any
sleepiness and confusion.
Any headache,body aches, injury, tongue bite?
Did you wet yourself?
Any Weakness in body limbs or speech problem at that time?
Did any one check your blood sugar at that time?
Any injury to head before this?
Medical Problem:
Medicine:
Family Hx:
Social History:
 Alcohol
 Recreational drugs, Ecstasy, Cocaine etc

 Night club
Driving:
Examination
Idea/Concern/Explain
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Investigations for Fit/Seizures:
Treatment plan if any:
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58.Tremors
Causes:
 Resting
 Postural- Begin essential, Anxiety Induced
 Intentional – Cerebellar
 Metabolic Present all the time e.g hyperthyroid
Exactly where? On hand or both? Any other part affected or not?
For how long you have this problem? When you get this problem like at rest or
going to hold something like glass of water etc?
Is it getting worse? What makes it worse?
(Scheme for Cerebellar causes in the following way---if cerbellar)
CNS
 Posterior cranial fossa Tumor

 MS
 Friedreich’s ataxia
 Parkinsion’s disease & Parkinsons’s plus
 Stroke
Any problem adjusting to temperature? (Hypothyroid state may cause cerebellar

involvement)
Any lumps and bumps? (Paraneoplastic)
Any white patches on your skin? (Association with Autoimmune gastritis)
Any problem with Bowel works? (Malabsorption e.g Fat soluble vitamins deficiency
including vit. E and vit. B 12)
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Medical Problem: like Vitamin B 12 Deficiency
Medicine: Antiepileptics like Phenytoin etc
Family Hx:
Social History: Like Alcohol
Diet: Lack of Dairy products in diet etc
Examination:
Idea
Concern
Explain
Investigation:
Treatment:
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59.Carpal Tunnel Syndrome

Scheme: Causes:
In which hand you have this problem? Upto which Obesity

level? Do you have problem in any other part like feet?
Glands Problem
For how long? Is it getting worse? What makes it  DM
worse? What makes it better?  Hypothyroidism
 Cushing syndrome
Questions related to hands and them Relevant cause  Acromegaly
like weight gain and cause like Thyroid etc
Heart
DD  CCF
Medical problem: Liver
Medicine  CLD
Family Hx:
Kidneys
Social History like Job e.g Farmer and Tractor driving  CRF
 Nephrotic
Examination syndrome
 Dialysis
Idea
Concern Hands
Explain  Injury
 RA
DD: Occupational
1. Peripheral Neuropathy  Vibrating

tools(Tractor
2. Cervical Radiculopathy (C6, C7 and C8,T1)
driver e.g)
3. Brachial plexopathy (Lateral cord)  Typing
4. Mononeuritis Multiplex
Others
 Amyloidosis
Pregnancy
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Investigations:
Treatment:
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60.Peripheral Neuropathy
Which foot? On or both? Exactly upto which level you have this
problem? ? Any other part affected like hands?
Then following questions

Sensory
-ve Numbness
+ve Tingling
Motor
-ve Weakness
+ve Cramps
Any problem with your balance? In darkness especially?
Do you feel dizzy when you stand up quickly from sitting?
For how long you have this problem? Is it getting worse?
Underlying system causing this like DM
DD:
General: Malignancy or Multiple myeloma
Thyroid
White patches on skin or other autoimmune clues Vitamin B 12

because of Autoimmune Gastritis
Any problem with Bowel works Malabsorption e.g vitamin B 12

Deficiency
Problem with Water works CRF
Joints problem Connective tissue disorder
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M: e.g DM
Medicine : e.g INH ,Chemotherapy etc
Hugs
F HSMN
Sx HIV
Social: Exposure to Mercury or Organophosphates
Investigations:
Treatment:
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61.UTI / Male sexual history

Any pain while passing water works?
Any burning? Any Blood? Any discharge? Color?
Any problem with eyes?Any Joint pains?
Any Fever? Rash? (Reactive e,g Chlamydia or Gonococcal etc)
Permission:
Is that alright if I ask you some personal questions?
Let me assure you whatever you will tell me will be kept confidential
Are you in relationship with someone?
Regular partner or casual?
If casual then ask
How many?Men ,women or both?
When did you have last intercourse with your casual partner? (Within 3 months)
Did you use any protective measures?
Did it remain intact throughout the intercourse?
Did you know the health status of your partner?
Do you know the contact details of your partner at that time?
Does your current partner (Regular) know about your problem?
Is she with you today?Have you both ever visited sexual health clinic?
Did you both have tests for sexually transmitted infections in the past?
Did you both ever get vaccine for Hepatitis B virus?
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62.Swollen Calf Causes
1. DVT
2. Dependent edema
3. Ruptured Baker’s cyst
4. Cellulitis
5. Sprained muscle
6. Muscle Hematoma
7. Insect bite
8. Injury (Trauma)
Two level well’s score if DVT
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63.De-Ranged RFTs
Causes
 Pre Renal
 Renal
 Post renal
Complications
 Encephalopathy
 SOB (Fluid over load)
 Chest pain (Pericarditis)
 Palpitations (Hyperkalemia – Arrythmias)
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64.Fever /PUO (Traveller)

For how long? General Causes:Meningitis or
encephalitis, Malaria, Brain abscess
Is it persistent or comes and goes?
Do you check it?

ENT Ear problem like Discharge
How high does it go?
Sore throat Bacterial, HIV,CMV etc
Any chills?
Any other problem with fever?

Thyroid Like Hyperthyroidism
( To look for Focus ?)
Chest Problems like Pneumonia
Did you visit your GP before travelling?
Did you take any vaccines before travelling?

Heart Infective Endocarditis
Did you take any malarial prevented
GIT Enteric fever,Hepatis,Liver
medicine?
abscess,Intestinal TB
Did you take it regularly?
Where did you stay in Africa etc? UTI
Did you stay in Urban area or Country side?

Other causes:
Did you use any nets there?
Cancers
Did you remember any insect bite there?
Joint Problem Connective tissue
Tell me about your eating habits there?
disorders
Did any one else with you have similar
Drugs
complaints?
Factitious
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65.HHT (Osler Weber Rendu Syndrome)
1.A hereditary condition characterized by diffuse Telangiectasias and Large AV

malformations
2.Mostly Telangiectasisas are found on Lips, Oral mucosa and finger Tips
3.One third of patients have cerebral , pulmonary or hepatic AV Malformtaions
4.Patients generally present with:
a. Recurrent Nose bleed

b. GI Bleeding
c. Iron deficiency anemia
5.It can be life threatening because of embolic strokes and brain abscesses
6.Symptoms usually develop in childhood or early adulthood
7.Usually autosomal dominant
8.Diagnosis is based on 4 criteria:
a. Spontaneous and recurrent Epistaxis

b. Multiple muco-cutaneous Telangiectasias
c. Visceral AV-Malformations
d. A first degree relative with HHT
9.Family members should consider genetic testing
10.Systems to be asked
a. Bleeding
b. Anemia
c. CNS Sroke
d. Chest AV-Malformations
e. GIT CLD, PHTN
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Treatment of HHT
1.Contorl of Active bleeding e.g Nose bleed or GI bleed
a. It included Endoscopic treatment for GI bleeding e.g Coagulation (APC etc)

b. Other Local treatment options for Nose bleed
c. Hormonal Therapy
d. Biological agents like Bevacizumab
2.Prevention of Re-bleeding
3.Correction of Iron deficiency Anemia
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66.Other important cases
 Skin and hyperextended joints
 Marfan syndrome
 Other joints problems like Septic arthritis and OA etc
 SLE
 Erythema Nodosum
 Henosch Schonlein Purpura
 Hypertensive retinopathy
 Small stature
 Tall stature
 Red rashes
 Multiple Sclerosis
 Von Hippel Lindau Syndrome
 Tuberous Sclerosis
 Bruising in a patient with underlying splenectomy
 Hypokalemic Periodic paralysis
 Hyokalemia after insulin therapy
 Hyperkalemic periodic paralysis
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Fast PACES

Academy for Doctors

DR IMRAN BABAR MRCP (UK )

Hello, Good morning!

My name is Dr. Babar.

Are you Mr/Mrs.…………?

Nice to meet you!

I have been asked to talk to you and do your examination.

Please tell me what brought you here today?

2.Scheme for Station 5

ODPARA (History of Present Illness) OR LOQIRAA (If Pain)

Associated system OR Underlying diagnosis

Social history…….Driving (If required)

General physical and underlying condition

3.Side Effects of Medicines Frequently Asked in Station 2 & 5

Warfarin Bleeding, Interactions

Amiodarone Thyroid problem, Pulmonary fibrosis

NSAIDs Renal failure,APD,Upper GI Bleed

Methotrexate Pulmonary Fibrosis,Jaundice

Nitrofurantoin Pulmonary Fibrosis

Steroids Multiple especially Osteoprosis

Methadon IV drug abuser

Biological agents e.g Infliximab Flare up of TB,Hepatitis,Lymphoma

Antihypertensives Multiple side effects

NSAIDs like Ibuprofen Renal failure

Do you have Ulcer anywhere else?

Any problem with it like: Pain, Bleeding, Discharge or itching?

For how long?

Any Injury before this?

Any Insect bite?

Any fever or chills? (Cellulitis)

For how long you have this?

General (Inflammatory conditions and Hematological problems etc)

Specific System like:

 CBC,ESR,LFTs,Hepatitis profile etc

Specific: e.g If suspecting Hematological condition then

 Peripheral blood smear

Total colectomy may be helpful in Ulcerative collitis

1.Causes of Pyoderma gangrenosum e.g

2.And other causes of Ulcer on the leg e.g

May develop in cases of sensory or sensorimotor neuropathy due to any cause of

Where exactly the ulcer is?

For how long you have this?

Any Numbness or tingling in your feet?

Medical Problem e.g DM

1. How Long,Last Hb A1c

Sensory Examination( and/or Motor)

Specific: For underlying cause

 Fasting blood sugar,Hb A1c

 NCS and EMG etc

 MDT care package

Treatment of other complications of autonomic neuropathy like Gastropresis,erectile

Associated with atherosclerotic conditions like Stroke and IHD etc

Where exactly the ulcer is?

For how long you have this?

Any Pain in Legs on walking?

Medical problem e.g DM

Medicine (Beta- Blockers)

Palpation….Pulses may be reduced and limb may be cool

Investigations: Clinical then following:

 Ankle Brachial Pressure Index (ABPI)

 Angioplasty and/or stenting

Bypass surgery if severe ischemia

 Develop due to venous insufficiency