HISTORY

MRCS Part B Notes by Mo

CONTENTS

Example Station .................................................................................................................................................................... 3

Knee pain: (OA)..................................................................................................................................................................... 4
Back pain (Functional Back Pain) / Cauda Equina ................................................................................................................ 4
Lower Limb Claudication ...................................................................................................................................................... 5
Hematuria (Bladder Cancer)................................................................................................................................................. 8
Urine retention: (BPH) .......................................................................................................................................................... 9
Preoperative Confusion / Dementia .................................................................................................................................... 9
Bleeding Per Rectum .......................................................................................................................................................... 12
Dysphagia ........................................................................................................................................................................... 14
Change in Bowel Habits (IBD) ............................................................................................................................................. 16
Thyroid status (Female with Hyperthyroidism) ................................................................................................................. 17
Abdominal Pain (IBS) .......................................................................................................................................................... 18
Abdominal Pain (Acute Pancreatitis).................................................................................................................................. 19
Abdominal Pain (Chronic Pancreatitis)............................................................................................................................... 20
Anxious Patient (SOB) In Pre-admission clinic ................................................................................................................... 21
Headache (Subarachnoid Hemorrhage)............................................................................................................................. 22
Seizures (Brain Tumor) Right Arm Seizures........................................................................................................................ 24
Unilateral tonsillar enlargement: (Neoplastic) ................................................................................................................... 26
Depression: (Reactive Depression Post-operative on Discharging)................................................................................... 27
Impotence .......................................................................................................................................................................... 28
Chest Pain (PE).................................................................................................................................................................... 30
Inguinal Hernia ................................................................................................................................................................... 31
Groin Swelling (Infected Femoral Pseudoaneurysm) ........................................................................................................ 32

HISTORY MO’s MRCS B NOTES (Previously called Reda’s Notes) 1

THE SOURCES OF THIS SHEET:
❖ Mr Salah’s notes [MRCS Part B Notes by Mo].
❖ Mr Salah’s Mocks [JULY 2023].
❖ Mr Salah’s history lectures.
❖ Dr Turkey’s notes.
❖ Dr Bazeed’s notes.

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 History taking

Approach to History Taking

You will have pencil and paper
A. Greet the patient and introduce yourself (Hello. I am Mahmoud Bazeed one
of the exam candidate).
B. Confirm patient name and age (May I confirm your name and age) except for
hospitalized persons like confusion and depression.
C. Get verbal consent (Today I’ve been asked to ask you few questions regarding
your condition, are you OK with this?).
D. Ask for chaperon in impotence station, offer analgesia and switch off light in
Headache station.
E. Open Question, Patient statement: How can I help you today? What seems
to be your problem? (Don’t interrupt the patient).
F. Analysis of patient complain: onset, course, duration, severity, aggravating
and relieving factors and associated factors (for differential diagnosis most
important). (Interrupt the patient if you have to).
G. Past medical or surgical history
1. Have you ever visited your GP for any other medical problems?
2. Have you ever had surgeries?
H. Drug history: Doses and allergy.
1. Do you take any prescribed or over the counter medications?
2. Do you have any allergy against any drug?
I. Family history.
Is there anyone else in the family has had a similar problem?
J. Social history (May I ask personal question?)
1. Occupation
2. Home situation (Who is at home with you?).
3. Mobility (do you have any difficulties using stairs?).

HISTORY TAKING
 History taking

4. Smoking (do you smoke? How many packets per day? Have you
considered quitting? ).
5. Alcohol (Do you drink Alcohol? How many units per week? Have you
considered quitting?).
K. Ideas, concerns and expectations: Before I go any further could I ask
1. Idea: What do you think the cause is?
2. Concern: What are you the most concerned about?
3. Expectations: What are you hoping us to do for you?
L. Other system review.
Respiratory: cough Dyspnea wheezes
Cardiovascular: chest pain, orthopnea
Urinary: Dysuria
M. Anything else you want to add.
N. Thank the patient.
O. Present your case including provisional and differential diagnosis and
investigations.
P. Answer the examiner questions.

Try to practice history taking at least four times.

HISTORY TAKING
 History taking

HISTORY TAKING
 History taking

 Two history stations in the exam.

HISTORY TAKING
 History taking

 Each station is 20 marks station.

 Each station lasts for ten minutes.
 You will have one minute to read the stem on the door of
station.
 Six minutes to take history from the patient.
 Three minutes to present your case and answer the
examiner questions.
 The patient is always an actor.
 Two examiners present in each history station:
1. Surgeon examiner responsible for 15 of 20marks and he will
evaluate you on three main items history taking from the
patient, presentation and knowledge.
2. Layman examiner responsible for 5 of 20 marks and he will
evaluate you on the following items body language including
head nodding and eye to eye contact, rapport to the patient
(how can I help you sir, so sorry to hear that), use of layman
language not medical one (tummy for abdomen, bleeding for
hemorrhage) and end of conversation (answer patient
questions, anything else I have missed and thank your patient)

HISTORY TAKING
 Knee pain: (OA)
Normal history taking scheme…
Stem: Footballer, had right
Differential Diagnosis knee injury 30 years ago, had
• Traumatic knee operation that he has no
o Ligaments - Do you experience giving away when walking? (Q2) idea about, developed
o Menisci - Do you experience locking of your knee? (Q2) worsening right knee pain 4
• Infection months ago
o Fever (Q2)
o Swelling, redness, hotness (Q2)
• Inflammatory
o Stiffness – Have you noticed any stiffness in your joint(s) when you wake up in the morning? How long
does that last for? (Q2)
• Spine Pathology
o Back pain (Q2)
o Do you have any numbness / weakness? (neurology) (Q2)
• Extra-intestinal IBS
o Rashes – Have you noticed any rashes anywhere on your body? (Q2)
o Enteropathy – Have you had any diarrhea? (Q2)
o Uveitis/iritis – Have you had painful or red eyes? (Q2)
o Spondyloarthropathy – Have you had any back pain? (Q2)

DISCUSSION

Mr... is a ... year-old gentleman who has been referred with increasing pain from his right knee. This started
approximately … years ago and has been increasing in severity over the past 4 months. He is experiencing a dull constant
ache that is increased on exertion and at the end of the day. However, the joint does not swell, lock or become unsteady
on walking. The pain is limiting his daily routine. The patient has a past history of knee trauma and surgery
My main differentials will be:
• OA (traumatic)
• RA
• Meniscal injury
• Referred pain from hip or spine pathology

Investigations?
Knee x-ray (standing and weight bearing), AP and lateral views

Treatment:
Conservative
• Maintain or achieve a healthy weight i.e. aim to decrease weight, and therefore force, going through a joint
• Regular exercise, with particular attention to strengthening the muscles around the joint.
• Analgesia: care to be taken with NSAIDs with relation to gastric irritation
• Heat application to the joint may offer relief
• Physiotherapy
• Intra-articular steroids
Surgical:
• Arthroscopy and arthrocentesis
• Realignment osteotomy
• Total or partial knee replacement

Causes of failure of TKR

• Aseptic loosening
• Infection
• Wear
• Periprosthetic fractures

Will the patient be likely to play soccer in 9 months?

No

Stem Scenario Diagnosis

4 MO’s MRCS B NOTES (Previously Reda’s called Notes) HISTORY

 Back pain (Functional Back Pain) / Cauda Equina
Female with a 5-year history of back pain, worse in the last 3 years, MRI 4 years Mechanical back pain
1 ago showed mild degenerative change, no neurological symptoms, no trauma,
disabled husband, work commitment.
Cauda equina compression /
2 Male with leg weakness, urine and fecal incontinence, erectile dysfunction
syndrome

Normal history taking scheme…

Differential Diagnosis
• Intervertebral disc protrusion, prolapse or herniation. – weakness, numbness
• Spinal canal stenosis – weakness, numbness
• Cauda equina syndrome / compression – Have you had any problems with your waterworks? Bowels? Have you
had any difficulty in gaining an erection?
• Spinal metastasis, malignancy – constitutional symptoms
• Spondylitis, Ankylosing spondylitis – stiffness
• Infection / TB – night sweats, weight loss, feeling unwell, fever, etc
• Spondylolysis / Spondylolisthesis
• Spondylosis / OA
• Non-spinal causes of back pain (AAA, fibromyalgia, pancreatitis, renal calculi)

DISCUSSION

Diagnosis?
• My main differential diagnosis will be functional back pain (mechanical lower-back pain) 4 features
o Localised pain that worsens with movement and changes in posture
o History of heavy lifting
o History of previous similar episodes over several years
o No features of systemic illness, nor neurological symptoms

Cauda Equina syndrome? surgical emergency

Cauda equina syndrome is a rare and severe type of spinal stenosis causing compression of the cauda equina roots.
Symptoms include:
• Bladder and bowel dysfunction urine retention > incontinence
• Bilateral sciatica
• Numbness around genitals / anus

Investigations?
• A full examination is required, particularly looking for perianal sensory loss and anal tone. I would carefully
check for a reduction in power and decreased reflexes. Back examination and lower-limb neurological
examination
• Bloods: FBC, LFTs, U&Es, CRP and ESR ASIA chart
• X-ray lumbosacral
• Urgent MRI scan if cord compression or cauda equina is suspected. MRI is not needed if the history suggests
if suspected
uncomplicated mechanical back pain
• Consider DEXA scan if a crush fracture is suspected
• Consider chest X-ray and QuantiFERON-TB Gold (QFT) if TB suspected

Management?
Simple back pain (including prolapsed intervertebral disc): (5)
• Advise to stay active and avoid prolonged bed rest Physiotherapy, regular analgesia and consider short-course
muscle relaxants
• Serious pathology or red-flag symptoms: Cord compression –dexamethasone and urgent surgery; radiotherapy
in malignancy
• Cauda equina syndrome – urgent surgery
• Refer to social worker (most important) Decompression
laminectomy from back
disctectomy from front

HISTORY MO’s MRCS B NOTES (Previously called Reda’s Notes) 5

 Stem:
Claudication calf pain increase by cold
weather and walking and decrease by rest Lower Limb Claudication
Normal history taking scheme…
Differential Diagnosis
• Vascular VNDAM (pain on Action!!) How far can you walk before stopping because of pain?
Do you notice any breach in skin of your legs or feet?
o Pain increases in cold weather (SOCRATES) Do you feel coldness in your legs or feet?
o Pain going uphill (SOCRATES) Is walking up a hill or upstairs affect this pain?
o Skin changes (thin skin, tissue loss, ulcer, color changes, temperature) (Q2)
o Pain after exercise, relieved by rest (Q2)
• Neurological (Disc, spinal canal stenosis) Uphill
o Pain relieved by bending forward or going downhill (SOCRATES)
o Back pain (Q2)
o Tingling or numbness (Q2)
o Weakness in lower limb (Q2)
o Problems with pee or poo (Q2)
• DVT
o Calf pain(Q2)
o Calf swelling (Q2)
o Calf redness (Q2)
o Chest pain, SOB (Q2)
• Musculoskeletal injury
o History of trauma (Q2)
• OA do you notice any stiffness at your joints in the morning?

6 MO’s MRCS B NOTES (Previously Reda’s called Notes) HISTORY

 DISCUSSION

My main diagnosis will be chronic lower limb ischemia causing vascular claudication I will also consider:
• Spinal canal stenosis
• DVT
• Disc lesion causing spinal claudication
• Osteoarthritis
• Musculoskeletal injury

How to differentiate between spinal and vascular claudication?

Peripheral vascular disease
• Skin changes
• Temperature
• Claudication pain is a cramping pain in the calf, thigh or buttocks
• Brought on by exercise and relieved by rest
• Exacerbated by walking faster or uphill and by cold weather
• Risk factors/associated factors for atherosclerosis: Diabetes Hypercholesterolemia Stroke
• Rest pain may indicate critical limb ischemia
Spinal claudication
• Often relieved when walking up a hill
• Often has associated limb numbness
• Weakness
• Back pain
Sciatica
• Shooting pain down the back of a leg to the feet
• History of lower-back pain

Investigations?
• Full peripheral vascular, cardiovascular and neurological examination
• Assess gait and balance
• Arterial duplex + Lipid profile + ESR
• CT angiography (if surgical intervention was needed)
• MR angiography
If suspected spinal claudication >> lumbosscral X-Ray +- lumbosacral MRI
Treatment? If vascular:
• Optimize blood sugar, cholesterol, blood pressure
• Antiplatelet agents: aspirin, clopidogrel
• Antilipemic agents: simvastatin
• Surgical treatment: endovascular stenting, surgical bypass, amputation

HISTORY MO’s MRCS B NOTES (Previously called Reda’s Notes) 7

Stem:
- painless total hematuria
- associated with weight loss, anorexia
- patient works dye factory
Hematuria (Bladder Cancer)

Normal history taking scheme… ODIPARA severity

Sx of anemia/clots
Differential Diagnosis
• Cancer (Bladder, Renal, Prostate cancer) – constitutional symptoms (Q2)
• Calculi (Renal, Ureteric, Bladder) – dysuria (Q2)
• Benign
o BPH – frequency, hesitancy, poor stream, drippling, etc., see BPH station (Q2)
o UTI – fever feeling, unwell, etc (Q2)
o PKD – family history – (Q8)
• General
o Bleeding disorder – (Q3)
o Blood thinner – (Q5)
o Instrumentation – (Q6)
o Trauma – history of trauma (Q2)

Don’t forget to ask about…

• Back pain (Q2)
• Beetroot and certain medications (Q5)
• Job (Social)

DISCUSSION

Mr. … is a … year-old male, presented by painless hematuria one month ago, with associated weight loss over the last …,
there is no any abdominal or loin pain, there is no problems in urine stream, he is concerned about the possibility of
having cancer

Differentials?
• My main ∆∆ will be bladder cancer, renal cell carcinoma considering (his hemorrhage, weight loss, occupation)
• Stone kidney, bladder, ureter
• Infection
• Trauma
• Bleeding tendency

Types of Bladder cancer? (4)

• Transitional (Urothelial) cell carcinomas (90% of bladder cancers in developed countries)
• Squamous cell carcinoma – associated with chronic bladder irritation and infection, risk factor: schistosomiasis
• Adenocarcinoma: rare
• Small-cell carcinoma

Investigations?
• Urine dipstick to confirm hematuria, assess infection, send a sample for cytology bedside
• Bloods: FBC, U&E, clotting screen, PSA
• Cystoscopy and biopsy
• U/S, CT

Treatment
Depends on the stage and the grade of the tumor
• Surgical:
o TURBT, often followed by instillation of chemotherapy or vaccine‑based therapy into the bladder.
Cystoscopy as a follow-up
o Radical cystectomy
• Non-surgical: Chemotherapy and radiotherapy and immunotherapy

Why does patient have trouble passing urine?

• Bleeding → clot → retention
• Obstruction from the cancer itself

8 MO’s MRCS B NOTES (Previously Reda’s called Notes) HISTORY

Stem:

- Urine retention
- and use of nasal spray containing alpha blocker

Urine retention: (BPH)

Normal history taking scheme…

BPH
• Urgency: Do you have to rush to the loo?
• Incontinence: Are you able to hold your urine?
• Hesitancy: When you go to the loo, do you have to wait until your urine starts to go?
• Frequency: Do you go to the loo more often?
• Drippling: Does a bit of urine drop and stain your underwear soon after going to the loo?
• Poor stream: Does it take longer to empty your bladder?
• Nocturia: Do you have to wake at night to go to the loo?
• Incomplete evacuation: Do you have a feeling of not emptying your bladder completely?

Don’t forget to ask about… Is it Painful to pass urine?

• Bone pain? Change in urine color?
• Problems with erections
• Neurological symptoms
• Drug history: patient takes nasal sprays containing phenylephrine (α agonist) which may counteract the effect of
tamsulosin (α blocker)

DISCUSSION

Mr. … is a … year-old male, presenting with difficulty in initiating urination, slow stream, hesitancy, urgency and
increased frequency. He does not have dysuria, hematuria, bone pains, weight loss or neurological symptoms.

Differentials? If the patient is taking phenylephrine will that affect

• Benign prostatic hyperplasia your management? What about salbutamol?
• Overactive bladder Salbutamol (selective β2 agonist) will not affect our
• Prostatic cancer management.
• Obstructive bladder pathology (malignancy or But phenylephrine (α agonist) will affect / antagonize
calculi) effect of tamsulosin

Investigations? Causes of increased PSA?

• Full clinical examination including DRE • Age
• Urinary frequency-volume chart, International • BPH
prostate scoring system (IPSS) • Prostatitis or prostate infection
• Bloods: • UTI
o CBC • Perineal trauma
o PSA • Sexual activity
o U&E Assess renal function • Prostate cancer
• Urine analysis
• Imaging: What to do if the PSA is increased?
o Abdominal USS
o Transrectal USS (TRUS) What is free PSA?
Amount of PSA that is floating freely in the
Treatment? bloodstream, without being bound to a protein
Medical:
• Tamsulosin (1-α adrenergic blocker) Prostate cancer is associated with a lower percentage of
• Finasteride (5-α reductase inhibitor) free PSA in the serum as compared with benign conditions
Surgical:
• TURP The percentage of free PSA (free/total PSA ratio [f/t PSA])
has been used to improve the sensitivity of cancer
How do these medications act? detection when total PSA is in the normal range (<4
• Tamsulosin – Alpha Blocker ng/mL) and to increase the specificity of cancer detection
when total PSA in the "gray zone" (4.1 to 10 ng/mL). In
works by relaxing bladder and prostate
this latter group, the lower the value of f/t PSA, the
muscles
greater the likelihood that an elevated PSA represents
• Finasteride – 5-Alpha Reductase Inhibitor
cancer and not BPH.
causes prostate to shrink prevents growth

HISTORY MO’s MRCS B NOTES (Previously called Reda’s Notes) 9

 Preoperative Confusion / Dementia Stem: pt was scheduled for THR ,found confused in the
ward assess his/her mental state and TAKE CONSENT

Introduction… am going to ask you some questions and give you some problems to solve. Please try to answer as best you can.
“Would you mind if I asked you some questions to test your memory?”

Abbreviated mental test scoring:

1. What is the name of this place? / Do you know where you are right now?
2. What time is it to the nearest hour? / What time of day is it, roughly?
3. What year is it? (4) Names
4. What is your date of birth? / Can you tell me your date of birth? -place
5. How old are you? -job
-Name of prime
6. What is my job? And what is the job of this person (e.g. a nurse)? minister
7. Can you count backwards from 20-1? -Name of adress
Can you remember this address? 24 West St. I will ask you this at the end
8. When did WW2 end? (6) Numbers
9. Who is the current prime minister? or What’s the name of the Queen? -Time
-year
10. What was that address I asked you to remember? -DOB
-Age
AMTS score < 6 suggests dementia or delirium -count number backward
-Date of WW2

To complete my assessment of the patient i will do MMSE (mini mental state examination)
MMSE: A 30-point questionnaire that is used to measure cognitive impairment.
I am going to ask you some questions and give you some problems to solve to assess your memory, please try to answer as much as you can,
are you Okey with this?
MMSE
Questions Max Score
“What is the year? Season? Month? Date? Day of the week?” 5
“Where are we now: Country? County? Town/City? Hospital? Floor?” 5
Examiner names three objects (e.g. apple, table, penny) and asks the patient to repeat
3
(1 point for each correct. THEN the patient learns the 3 names repeating until correct). Ball, Car, Pen
Subtract 7 from 100, then repeat from result. Continue five times: 100, 93, 86, 79, 65.
5
(Alternative: spell “WORLD” backwards: DLROW).
Ask for the names of the three objects learned earlier 3
Name two objects (e.g. pen, watch). 2
Repeat “No ifs, ands, or buts”. 1
Give a three-stage command. Score 1 for each stage.
3
(e.g. “Take a paper in your hand, fold it in half, and put it on the floor.”).
Ask the patient to read and obey a written command on a piece of paper.
1
The written instruction is: “Close your eyes”.
Ask the patient to write a sentence. Score 1 if it is sensible and has subject and a verb. 1
“Please copy this picture.” (The examiner gives the patient a blank piece of paper and asks him/her to
draw the symbol below. All 10 angles must be present and two must intersect.)

24-30: no cognitive impairment

18-23: mild cognitive impairment
0-17: severe cognitive impairment
Q:tell me 2 tests to be done on paper?
-Ask pt to draw intersecting pentagon
-Ask pt to read and obey a written command

10 MO’s MRCS B NOTES (Previously Reda’s called Notes) HISTORY

 DISCUSSION

The patient has acute confusion with het AMTS SCORE of 2/10 Which suggests delirium or dementia

What is your differential diagnosis? + senile dementia

• Hypoxemia / hypercarbia
• Hypoglycemia / hyperglycemia
• Hypotension and hypoperfusion
• Dehydration
• Electrolyte disturbance (sodium, calcium, magnesium, phosphorus)
• Infection / Sepsis (pneumonia, urinary tract infection_ meningitis
• Alcohol and drug toxicity or withdrawal
• Medication / Vitamin deficiencies (Wernicke’s)
• CNS lesion, injury, infection (CVA, subdural hematoma, meningitis, encephalitis)
• Endocrinopathies (thyroid, adrenal)
• Cardiac disease (myocardial infarction, congestive heart failure, arrhythmia)
• Hyperthermia or hypothermia

Management Do Full clinical examination first

• Observations:
look for o National Early Warning Scores (NEWS) can be useful
o BP / Pulse – ↓BP ↑Pulse may indicate sepsis / dehydration + level of consciousness
o Temperature, respiratory rate and oxygen saturation are all important diagnostic clues.
• CT head:
o Ischaemic stroke
o Intracranial bleeds (from trauma or spontaneous)
o Space occupying lesions
• Bloods:
(8) o FBC – white cells for signs of infection, anaemia, increased MCV (macrocytic anaemia can be caused by
B12 or folate deficiency which can have a variety of origins: leukemias, alcohol use, lack of intake, lack
of absorption (i.e. post-gastrectomy), pernicious anaemia; hypothyroidism, liver disease.) (7) causes
o U&E – deranged electrolytes can cause confusion (consider sodium, but relative to what is normal for
the patient).
o LFTs – confusion can be caused by liver failure, malnutrition or be based on the background of alcohol
abuse.
o INR – can be useful to know if the patient is on Warfarin & you are concerned about intracranial
bleeding
o TFTs – confusion is more common in hypothyroid states.
o Calcium – Hypercalcemia often causes confusion/delirium – Bones, moans, psychotic groans
o B12 + folate / hematinics – macrocytic anaemia, and B12/folate deficiency can compound confusion
o Glucose – hypoglycaemia is a common cause of confusion
• CXR – As part of a sepsis screen to identify infection source –? Pneumonia
• Blood cultures if appropriate – as part of sepsis screen
• Urine dipstick/culture – UTI is a very common cause of delirium in the elderly History: take history from the
patient (if possible), from the notes, from her relatives
Q: will you allow her to ho for surgery?
Fitness for the operation? (1) (2)
Not fit for giving a consent, as she cannot retain information and she cannot make an informed decision

Should the operation go ahead? (THR)

No. The operation is non-urgent. Therefore, it can be postponed until the cause of the confusion has resolved. I would
talk to my consultant and the anaesthetist in charge of the case to inform them of the confusion and ask their advice
before cancelling it.
Q: Examiner asked here if the surgery was emergency?
If the cause of confusion was only senile dementia, how you will consent for the operation?
As the patient lack capacity, consent should be recorded using consent form 4 with 2 consultant signatures

Q:what is capacity?
capacity means competent (understand and retain information,belief information to be true,pt able to take decision according to what he has)

HISTORY MO’s MRCS B NOTES (Previously called Reda’s Notes) 11

 Bleeding Per Rectum
Normal history taking scheme…

Don’t forget to ask about…

• Color of blood
• Amount of blood
• Blood clots, mucous, etc.
• Pain, frequency

Differential Diagnosis
• Cancer colon
o Constitutional manifestations (anorexia, weight loss, tiredness) (Q2)
o Disturbed bowel habits (Q2) – POSITIVE
o Mucous/slime discharge or blood (Q2) – POSITIVE
o Family history (Q8) – POSITIVE
• IBD
o Abdominal pain (Q2)
o Extra-intestinal manifestations
▪ Joint pain, back pain (Q2)
▪ Skin changes (Q2)
▪ Eye changes (Q2)
o Mucous discharge (Q2)
• Local causes (fissure, piles, etc.)
o Swelling, itching, pain (Q2)
• Bleeding tendency
o Bleeding from any other sites (Q2)
o Blood thinners (Q5)
• Upper GI bleeding
o Vomiting (Q2)
o Heartburn (Q2)
o Reflux, acid taste (Q2)
• Gastroenteritis
o Fever (Q2)
o History of travel (Social)
o Tenesmus (Q2)

12 MO’s MRCS B NOTES (Previously Reda’s called Notes) HISTORY

 DISCUSSION

What is your differential diagnosis?

The weight loss, the change in bowel habit and PR bleeding are concerning. My main differential is colorectal cancer,
which would need thorough investigation. Other differentials for PR bleeding include
• Hemorrhoids
• Inflammatory bowel disease
• Angiodysplasia
• Diverticular disease
• Benign polyp
• Anal fissure mesenteric ischemia
It may also be secondary to medication or a hematological condition.

What is the most important investigation to carry out?

As I am suspecting colorectal cancer, the most important investigation is a colonoscopy +/- biopsy to examine the whole
colon.
If immediately available in clinic, a rigid sigmoidoscopy may be carried out in the first instance
Other investigations:
• Hematology:
o FBC: anaemia, leukocytosis (infective colitis, inflammatory bowel disease, ischaemic colitis), low
platelets (bleeding disorder)
o Clotting screen
o Group and save / cross match for transfusion.
• Biochemistry:
o U&Es, LFTs (hepatic failure with variceal bleed, malignancy)
• ABG: Raised lactate (ischemia), metabolic acidosis.
• ECG: Mesenteric ischemia, atrial fibrillation (emboli).
• Endoscopy:
o OGD (to exclude upper gastrointestinal cause)
o Sigmoidoscopy / proctoscopy (hemorrhoids, anorectal lesion, distal colitis, rectal ulcer)
o Colonoscopy (malignancy, diverticular disease, colitis, angiodysplasia).
• Radiology:
o Mesenteric angiography (CT or invasive) / Technetium scan / Labelled red cell scan, if source not
identified by endoscopy (looking for angiodysplasia / Meckel’s diverticulum).
o AXR (obstruction, toxic megacolon of inflammatory bowel disease)
o US scan / CT (if suspected malignancy, for liver metastases and staging).
• Microbiology:
o Stool cultures (infective colitis).

What is your management?

HISTORY MO’s MRCS B NOTES (Previously called Reda’s Notes) 13

 Dysphagia

Normal history taking scheme…

Don’t forget to ask about…

• Solids or liquids? –Do you have difficulty swallowing solids, fluids or both?
• Timing –Is it there all the time or does it come and go?
• Onset –When did this start? Progression –Has it worsened over time?
• Pain –Is there any pain when swallowing? Any chest pain?

Differential Diagnosis
• Cancer Esophagus
o Have you had any unintentional weight loss? If so, how much have you lost and over how long?
o Have you vomited at all? If so, was there any blood?
• Achalasia
o Dysphagia more to liquids
• GORD / Dyspepsia
o Do you ever taste acid at the back of your mouth?
o Heartburn? Pain in your tummy?
o Vomiting
• Pharyngeal pouch
o Have you noticed having bad-smelling breath recently?
o Do you ever notice gurgling or a wet voice after swallowing?
o Regurgitation of food while lying down?
• Goiter
o Neck swelling, Do you ever feel a lump in your throat?
• Neuro / Bulbar palsy
o Have you noticed any weakness anywhere? Any problems walking?
• Autoimmune, myasthenia, scleroderma
o Do you suffer with painfully cold hands?
o Dry eyes or mouth?
• Esophagitis
o Painful swallowing

14 MO’s MRCS B NOTES (Previously Reda’s called Notes) HISTORY

 DISCUSSION

Considering difficulty in swallowing, weight loss, heavy smoking, alcohol drinking, hematemesis my main diagnosis will be
esophageal carcinoma causing mechanical obstruction of the esophagus
I also have to consider:
• Lung cancer, pharyngeal pouch, retrosternal goiter (compression from outside)
• Esophageal web, Plummer-Vinson syndrome
• Achalasia (motility disorder) Differential diagnosis
• Myasthenia gravis Mechanical
• Esophageal carcinoma
Investigations: • Gastric carcinoma
• Full clinical examination checking for lymphadenopathy • Pharyngeal pouch (regurgitation of
• Bloods –FBC, U&Es, LFTs and clotting and bone profile food when lying down / on pillow)
• Chest X-ray • Stricture
• Esophageal manometry: achalasia, GORD o Corrosive burn
• Barium swallow o GORD
• Endoscopy and biopsy with biopsy

gold standard • Esophageal endoluminal US, also for staging of carcinoma. Motility
• Videofluoroscopy –assessing for aspiration • Achalasia cardia (liquid > solid)
• Staging CT scan, depending on what the previous
PET scan+ • Esophageal spasm (intermittent)
investigations reveal • Bulbar palsy (difficulty initiating
MRI for primary tumor and lymph nodes swallowing)
Treatment • Myasthenia gravis (difficulty in
• Operable cases: if carcinoma insitu: endoscopic mucosal resection swallowing ↑ as the day progresses)
o Esophagectomy + chemoradiotherapy
• Non-operable cases: if positive lymph node or mets
Palliation:
o Self-expanding metallic stent
o Palliative chemotherapy and radiotherapy
o Feeding jejunostomy

HISTORY MO’s MRCS B NOTES (Previously called Reda’s Notes) 15

 Change in Bowel Habits (IBD)

Normal history taking scheme…

BOWELS
Don’t forget to ask about…

• Specify –When you say constipation/diarrhoea, what do you mean exactly? Do you mean you are going
more/less often, or the consistency has changed?
• What about before?
• Onset COCA:
• Character (watery, semi-solid or solid?) Color
• Blood or mucus in the stools Odor
Character
• Color Amount
• Dark, foul-smelling stools?
• Associated features: Bloating, Pain, Weight loss, Exhaustion, Lasting urge (Tenesmus),
• Swallowing/upper-GIT symptoms –Any vomiting? (If so, ask about hematemesis), Heartburn
• Extra-intestinal features IBD – Have you had any mouth ulcers? Fever? Painful red eye? Joint or back pain?
• Foreign travel – Have you been abroad anywhere recently?
• Timing – How many times a day do you go to the toilet to pass feces now? How often do you normally go? What
are your stools normally like? Have you ever suffered from the opposite? (i.e. constipation/diarrhoea)
• Exacerbating/relieving factors –Does anything relieve the constipation/diarrhoea? Does anything make it
worse?
• Severity –How badly is this affecting your day-to-day life

DISCUSSION

Considering weight loss, diarrhea, PR bleeding, mucous discharge, extra-intestinal manifestations, my main diagnosis will
be Crohn’s disease or ulcerative colitis
I will also consider:
• Infective gastroenteritis
• Colorectal cancer
• Diverticular disease

Investigations?
• Abdominal examination including DRE
• Routine bloods: FBC, U&E, CRP, LFTs, calcium, magnesium, phosphate, coagulation screen, - group and save.
(Looking for raised inflammatory markers, dehydration, electrolyte disturbance secondary to diarrhoea, albumin
as a guide of nutritional status, coagulation defects.)
• Stool sample
• Fecal occult blood test
• Abdominal Radiograph - assess for toxic megacolon
• CT or MRI abdomen and pelvis if concerning features on examination and for pre-operative planning if surgery is
indicated
• Colonoscopy Q: in UK?

Treatment? features UC chrons

• Conservative: after conservative ttt say i will consult gastroentrologist crypt
Macro abssess transmural inflamm
o Dietary control (low residue diet) pseudopolyps non cas granuloma
mucosal ulceration
• Medical:
o Mesalazine Micro
o Prednisolone Q:what is this drug?
o Immunomodulators (infliximab) -monoclonal Ab against TNF
• Surgical:(Failure of medical treatment or complications)
In toxic megacolon, IO, malignant transformation, fistulation, refractory cases
Q:Extra intestinal manifestation? complication
-Eye:iritis,episcleritis,conjuctivitis
-Skin:pyoderma gangrenosum,erythema nodosum

complete discussion by pathology

16 MO’s MRCS B NOTES (Previously Reda’s called Notes) HISTORY

 Thyroid status (Female with Hyperthyroidism)

Normal history taking scheme… stem

- 45 female
- her aunt died of thyroid CA
Don’t forget to ask about… - has neck swelling since 13 YO
- started to increase Rapidly over last 3 months
Associated features: - complain of stucking of food in her throat.
Compressive symptoms:
• Changes in voice
• Difficulty in swallowing
• Difficulty in breathing
Toxic symptoms:
• Changes in vision or difference in eyes
• Diarrhea
P.S
• Menstruation (do you menstruate regularly)
for any lump ask about
• Sleep disturbances -trauma
• Hot or cold intolerance -other lumps
• Weight loss despite good appetite (pattern in thyroid)
• Mood or behavioral changes
• Appetite

DISCUSSION

Mrs. ... Is ... year-old woman, previously fit and well, presents with a lump in her neck, the lump has grown over the past
... years, in addition she has symptoms indicating hyperthyroidism such as … She has also compressive symptoms such as
… My main differentials will be:
• Toxic MNG if features of hyperthyroidism
• Simple MNG
• Thyroid neoplasm if(compressive sx)
• Thyroiditis

Management?
Triple assessment:
• Full clinical examination
• Ultrasound imaging
• FNAC
Other investigations:
• Radioisotope scan
• TSH, T4 ,T3
• Calcitonin, ESR
Possible causes of sudden enlargement?
• Hemorrhage inside a cyst
• Malignancy transformation
o Papillary carcinoma
o Follicular carcinoma
o Medullary carcinoma

Treatment?
Medical: Antithyroid drugs carbimazole,propylthiouracil, beta blocker
Radioactive iodine
Surgical: Thyroidectomy (hemi, near total or total) with such compressive symptoms

What possible complications of surgery do you advise this patient about?

• Risk of RLN injury: hoarseness of voice, aphonia, stridor and possibility of tracheostomy
• Risk of hypocalcemia
• Lifelong thyroxine replacement

HISTORY MO’s MRCS B NOTES (Previously called Reda’s Notes) 17

 Abdominal Pain (IBS) diffuse pain

Female referred by her GP for chronic calculous cholecystitis

Normal history taking scheme…

Don’t forget to ask about…

• Pain increases with fatty meal? (-ve)
• Yellowish discoloration of your eyes? (-ve)
• Discoloration of your urine or stool? (-ve)
• Pain referred to right shoulder? (-ve)
• Is the pain relieved by passing stool or flatus? (+ve)
• Bloating? (+ve)
• Change of bowel habits (+ve)
• Social history / stress? (+ve)

Differential diagnosis
• IBS
• IBD
• Biliary Colic
• Gastritis
• Cancer colon

DISCUSSION

Mrs. .... is a … year-old woman, presented by abdominal pain, the pain is colicky in nature, it is not related to meals, she
experiences it in the middle of her abdomen, has no special timing, no aggravating or relieving factors. Ir associated with
disturbed bowel habits, she also has some social stress
My main diagnosis will br IBS, I will also consider
• IBD
• Colon cancer,
• Chronic calculous cholecystitis

Investigations? start by Abdominal Examination with DRE

S
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o
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a
n
a
l
y
s
i
s
Abdominal ultrasound
F
B
C
!
AXR
•
!
Colonoscope
•
•
Treatment
(say this first)
Fiber diet
R
e
f
e
r
p
a
t
i
e
n
t
t
o
a
s
o
c
i
a
l
w
o
r
k
e
r
!
Antispasmodics >> (Symptomatic treatment)
•
Antidepressants
•
•
18 MO’s MRCS B NOTES (Previously Reda’s called Notes) HISTORY
 Common station in the exam

Abdominal Pain (Acute Pancreatitis)

Stem:
First stem 45-year-old female, presenting with acute onset epigastric pain. Known smoker and alcoholic. History of previous
gastric ulcer (used to take PPI) Pt is lying on the bed holding her abdomen from pain (offer analgesia first !!!)

Second stem 45-year-old male/female, alcoholic, vomiting and collapse at a party (Exclude MI first)

Normal history taking scheme…

Upper and central abdominal pain, sudden, dull aching, radiating to the back

Don’t forget to ask about… (Exclude MI first)

• Acute pancreatitis
o Site (epigastric)
o Referred to the back
o Difficulty in leaning backwards
o Diarrhea and repeated vomiting
• Acute cholecystitis (-ve)
o Jaundice, yellowish discoloration of eyes or stools
o Fatty meal intolerance
o Fever
• Gastritis / Perforated peptic ulcer (-ve)
o Hematemesis
o Heart burn
• MI (-ve)
o Chest pain
o SOB
o Palpitations
o Referred pain

DISCUSSION

See questions from Applied Knowledge Section

What’s the immediate investigations? (to exclude MI)

• ECG
• Cardiac enzymes

Differenital diagnosis?
• Acute pancreatitis
• MI
• Acute cholecystitis
• Gastritis, Perforated peptic ulcer

Management? chest x-ray with Abdominal view

HISTORY MO’s MRCS B NOTES (Previously called Reda’s Notes) 19

 Abdominal Pain (Chronic Pancreatitis)
after defecation is your stool easily flushed?
Old station, unlikely to face in the exam…
40-year-old divorced male with chronic epigastric pain radiating to the back for the past year, with steatorrhea. Drinks 5
pints of beer per day, previously admitted for acute pancreatitis. Takes 30 mg of morphine / day to numb the pain,
depressed

Normal history taking scheme…

DISCUSSION

Differentials?
• Chronic pancreatitis (epigastric pain, steatorrhea, previous attack of acute pancreatitis, alcoholic)
• Pancreatic pseudocyst
• PUD

What do you think about the history of taking 30 mg of morphine, what should be the normal dose?
15-30 mg /4hours as needed # to prescribe morphine accurately :
regular dose of morphine should be every 4 hours
1-calculate all doses in day then divide it by 6
breakthrough doses = PRN 2-Alnateg should be taken every 4 hours also it will be the dose of breakthrough
Investigations:
• Secretin stimulation test
• Serum amylase and lipase (elevated)
• Serum trypsinogen
• CT scan (pancreatic calcifications)and necrosis and pseudo cyst
• MRCP: identify the presence of biliary obstruction and the state of the pancreatic duct
• Endoscopic ultrasound
+ CBC and inflammatory markers
Treatment:
Medical treatment of chronic pancreatitis:
• Treat the addiction:
o Help the patient to stop alcohol consumption and tobacco smoking
o Involve a dependency counsellor or a psychologist
• Alleviate abdominal pain:
o Eliminate obstructive factors (duodenum, bile duct, pancreatic duct)
o Escalate analgesia in a stepwise fashion
o Refer to a pain management specialist
o For intractable pain, consider CT/EUS-guided coeliac axis block
• Nutritional and digestive measures:
o Diet: low in fat and high in protein and carbohydrates
o Pancreatic enzyme supplementation with meals
o Correct malabsorption of the fat-soluble vitamins (A, D, E, K) and vitamin B12
o Medium-chain triglycerides in patients with severe fat malabsorption (they are directly absorbed by the
small intestine without the need for digestion)
o Reducing gastric secretions may help treat diabetes mellitus
• Treat DM
The role of surgery is to overcome obstruction and remove mass lesions

20 MO’s MRCS B NOTES (Previously Reda’s called Notes) HISTORY

 Anxious Patient (SOB) In Pre-admission clinic offer oxygen

Stem:
Lady planning for cholecystectomy, since 10 years , SOB for few minutes, increasing in frequency 6 weeks after being
scheduled for operation

Normal history taking scheme…

Main DDx:
- Anxiety related
Don’t forget to ask about… - followed by interstitial lung fibrosis
• Cough - Bronchial Asthma
- pneumonia
• Have you noticed any blood? - PE
• Wheeze – “Do you get wheezy? Is it worse at any time of the day?” - Bronchogenic CA
- Cardiac
• Fever
• Constitutional, weight loss?
• Chest pain? If so, SOCRATES
• Palpitations
• Anxiety – If relevant, do you only get breathless when you are anxious?

Exclude
• MI / Heart failure (paroxysmal dyspnea? Increase SOB on lying flat?)
• PE (recent surgery? recent flight? calf swelling? haemoptysis? SOB?)
• Chest infection important to ask about Residency
• Bronchogenic carcinoma -pt is resident beside factories so Interstitial lung fibrosis will be one of DDx
don't forget: did you went to your GP recently and investigate about that?

DISCUSSION

The SOB described does not fit with cardiac or pleuritic chest problem, and the patient tells me that she has been
investigated and ruled out. My top differential would therefore be anxiety related to her impending operation.
I will also consider: anginal pain, pneumonia, pleurisy. Main DDx:
-Anxiety related
-followed by interstitial lung fibrosis
Management?
• I should contact the GP to get hold of all the notes regarding investigation of the patient’s chest pain.
• I would examine the patient and ensure that we repeat the patient’s bloods, ECG, CXR and get a baseline ABG
on room air. I will request pulmonary function test also
• I would want to ensure she had a recent echo and angiogram and discuss these with a cardiologist.
• I would reassure the patient that she is going to be well looked after and ask her if there’s anything we could do
to allay her fears.
• I would also suggest that we involve her close relatives or friends so that she has an adequate support network
in place before and after the operation
Q:this lady is 35yo medically free,her ECG is normal do you want to request echo?
-No i will not
Can the operation go ahead?
Since we have no documented evidence that there is no cardiac or respiratory illness, the operation should go ahead

FEV1?
because Volume that has been exhaled at the end of the first second of forced expiration (measurement shows the amount of air
your 2nd a person can forcefully exhale in one second of the FVC test)
DDx is
ILDs
FVC?
The amount of air which can be forcibly exhaled from the lungs after taking the deepest breath possible

FEV1/FVC ratio?
Represents the proportion of a person's vital capacity that they are able to expire in the first second of forced expiration
In obstructive lung disease, the FEV1 is reduced due to an obstruction of air escaping from the lungs. Thus, the FEV1/FVC
ratio will be reduced
In restrictive lung disease, the FEV1 and FVC are equally reduced due to fibrosis or other lung pathology (not obstructive
pathology). Thus, the FEV1/FVC ratio should be approximately normal

HISTORY MO’s MRCS B NOTES (Previously called Reda’s Notes) 21


Headache (Subarachnoid Hemorrhage)
Stem:
- female, developed severe headache and
the collapsed and brought to hospital
- has no problems before
- Past medical history: Polycystic kidney
- Family history: My aunt died suddenly of
an aneurysm in the brain

Normal history taking scheme… Possible symptoms

Do you want me to turn off the lights for you?
Headache (occipital, sudden onset,
Differential Diagnosis Do you want me to give you some pain killers?
severe) thunder clamp headache
• SAH Neck stiffness
o Injury or trauma Sickness
o Are you sensitive to light? Photophobia
o Meningism (see below) Visual problems (blurry vision,
• Infection, meningitis, encephalitis double vision)
o Have you been feeling ill or had a fever?
o Do you have any neck stiffness? Weakness to one side of the body
o Have you noticed a rash anywhere? Speech problems
• Brain tumor Facial problems
o Have you ever had seizures or blacked out? Have you ever lost
consciousness? Loss of consciousness
o Have you had any arm or leg weakness? Fits / convulsions
o Any other sensory disturbance?
o Any visual disturbances?
• Migraine
• Visual problems
o Any eye pain? Visual disturbances? Nausea or vomiting
• Trauma
o Have you banged your head, had a fall recently?

Don’t forget to ask about…

• Timing – When can you remember this starting? Was it continuous or intermittent? How long do they last?
When was the last time you had a headache?
• Past medical history: Polycystic kidney (relevant history)
• Family history: My aunt died suddenly of an aneurysm in the brain

22 MO’s MRCS B NOTES (Previously Reda’s called Notes) HISTORY

 DISCUSSION

My main differential is a subarachnoid hemorrhage, but I would also consider other causes of an acute severe headache
including:
• Meningitis
• Encephalitis
• Migraine
• Increased ICP due to brain tumor
• GCA

Management?
I would manage him in an ABC manner, ensuring that he is stable and arrange appropriate bloods and a plain CT head.

Investigations?
• CT brain
• CSF tapping
mainly decrease ICP
Treatment?
discuss in MDT
• I would refer this patient to a neurosurgical unit.
• Bed rest, 3L of IV fluids /24h.
• Oral nimodipine 60mg every 4 hours, and laxatives mannitol (nimodipine is calcium channel blocker prevent vasospasm)
• Attempt to coil the aneurysm is made
• Burr holes endovascular ttt of aneurysm and bleeding,reducing blood circulation to aneurysm
using microsurgical platineum wires inserted into aneurysm until determine blood
• Craniotomy flow not occurring in this space
• Discuss in neurovascular MDT
Q:what are signs of increased intracranial pressure?
-morning headache
-Nausea
-projectile vomiting
-focal neurological deficit
-seizures
-cushing triad
-papilledema

HISTORY MO’s MRCS B NOTES (Previously called Reda’s Notes) 23

pt have Rt arm fits and headache for longer time
Seizures (Brain Tumor) Right Arm Seizures With headache

1st date
Normal history taking scheme… Description
Frequency: how frequent do you experience your seizures?
Don’t forget to ask about… Witness
• Before (aura) experience some kind of warnings or unusual feelings at the onset or immediately preceding the seizures?
• During (loss of consciousness, eye rolling, tongue biting, incontinence)
• After (weakness, parasthesia, speech problems) Drowsy, muscle pain.
Triggering factors: did you notice any triggers to seizures like not having a good sleep, alcohol consumption,
Differential Diagnosis stress, fever ,exercises, any medications?
• Brain Tumor
o ICP – vomiting, headache, weakness, bluring of vision
• Infections, encephalitis, meningitis
o Fever, meningism, neck stiffness, photophobia
• Traumatic
o History of trauma to your head
• Epilepsy
o Past history of epilepsy or fits
• TIA, Strokes
o Weakness
o Speech disturbance
• Metabolic in PMH
o ETOH excess
o Hypoglycemia
o Hypoxia
• Sleep disorder
o Change in sleep pattern
• Migraine
o Headache
• Psychological
Stress
Associated upper or lower limb weakness or paralysis

Before during after

A: A: A:
-what happened exactly? -How did you fall? -post ictal (drowsy,muscle ache)
-where? when? -did you hit your head?
-what you were doing? B:
B: -recurrent attack
B: -did you shake your body?
Aura or only part of body?
-warning signs(fear,chest pain)
C:
C: -did you bite your tongue?
-LOC? and for How long?
D:
-witnessed ?

Deferential diagnosis:
1- brain tumor
2- epilepsy
3- paroxysmal dyskinesia
4- myoclonus
5- metabolic disorders (hypo, hyper glycemia, electrolyte imbalances)

24 MO’s MRCS B NOTES (Previously Reda’s called Notes) HISTORY

 DISCUSSION

Investigations?
• Blood glucose
• CBCD
• Electrolytes, BUN, creatinine, calcium, magnesium, anion gap, lactate, prolactin (will be elevated after seizure,
sometimes used if not sure if event was a seizure)
• ABG, U/A, LP
• CT head if trauma, suspected intracranial hemorrhage, suspected structural lesion in first time seizure,
prolonged altered mental status, focal neurological deficit, anticoagulated patient, HIV/Cancer patients
• If infection – may require full septic w/u (LP, cultures, etc.)
• EEG – most likely to be done as an outpatient (electro encephalogram)
• MRI – in consultation with neurology with gadolineum

Treatment?
If the patient is seizing
• Move to safe place
• Turn to side (recovery position) if possible
• Observation for specific activity and progression and duration Prepare to assess/monitor once seizure
subsides (ABC’s) Consider treatment if patient is in status
Postictal
• Seizure precautions ABC’s and monitors, O2
• Benzodiazepines may be used to prevent further seizures. Consider anticonvulsant therapy
• Phenytoin (Dilantin®) 300-600mg PO TDS
• Phenobarbital 60-200mg PO daily
• Valproic acid (Epival®) 15-60mg/kg daily divided BD or TDS
• Carbamazepine (Tegretol®) 400-1200mg daily divided TDS/QDS
Status epilepticus (≥ 30 min of active seizing or no recovery/consciousness between)
• IV line
• O2
• Monitors
• Consider intubation
• Benzodiazepines (diazepam 10-20mg IV, or lorazepam 4-8mg IV)
• Phenytoin 18-20mg/kg IV @ 25mg/min
Stereotactic biopsy and resection or debulking of brain tumors (gamma knife)

HISTORY MO’s MRCS B NOTES (Previously called Reda’s Notes) 25

 Unilateral tonsillar enlargement: (Neoplastic)
stem - 50 years old, smoker man who is urgently referred
Normal history taking scheme… - 55 yo male by his GP with two week history of throat swelling
- has unilateral tonsilar swelling two month ago not responding to antibiotics , and has left
- lost 10 kg in 6 months unilateral tonsillar mass.
Don’t forget to ask about… - Take history from this patient.
• Rapid increase in size, respiratory difficulties
• Change in voice
• New onset snoring
• Dysphagia
• Odynophagia
• Neck swelling
• Night fever
• Manifestations of infection
• Abdominal swelling (hepatosplenomegaly in glandular fever)
• Constitutional symptoms (weight loss, etc.)

DISCUSSION

Mr. … is a year-old male, previously fit and well gentleman, presents with a 2-month history of an enlarging left tonsil. He
has lost approximately half a stone in weight and has increasing discomfort on swallowing, with no other symptoms.

Differentials?
• Neoplastic:
2\ o Lymphoma (non-Hodgkin’s) 3\ small cell CA
4\ mets from primary sites like merkel cells from:
1\ o SCC -Renal cell CA
• Infective: -Rectal adenoCA
o Acute infection: peritonsillar abscess
o Chronic infection: mycobacteria, fungi, actinomycosis, infection mononucleosis (glandular fever)
• Asymmetric anatomical positions

Investigations?
• Bloods
o FBC: looking for raised WCC associated with infection
o U&Es: looking for renal impairment if patient has had decreased oral intake
o LFT’s: derangement may indicate glandular fever or metastasis
• Tonsillectomy for biopsy
• Biopsy with flow cytometry
• CT or PET-CT to rule out lymphoma
• Panendoscopy: examination of the upper aerodigestive tract (pharynx, larynx, upper trachea and esophagus).
• Monospot test (detecting glandular fever)
Staging: MRI neck, CT neck (for primary tumor), U/S liver + CT chest and Abd (for mets)
Treatment?
• Staging: MRI neck, CT neck, U/S liver + CT chest and Abd
• Discuss in MDT Remove all levels +(SCM muscle + IJV + accessory nerve)

• Block neck dissection (radical, modified radical, selective)

• Radiotherapy
select some levels +preserve structures

7 levels:
-level 1 for submental and submandibular
-level 2 (IJV) "upper" from hyoid to skull
-level 3(IJV) "middle" from hyoid to cricoid
-level 4(IJV) "lower" from cricoid to clavicle
-level 5 in posterior triangle
-level 6 Ant compartment from hyoid to suprasternal notch
-level 7 at superior mediastinal

Q:who to involve ?
-surgeon,pathologist,oncologist,dietician,speech and language consultant

26 MO’s MRCS B NOTES (Previously Reda’s called Notes) HISTORY

 Stem:
- pt had gastrectomy pod8
- nurse said pt has low mood

Depression: (Reactive Depression Post-operative on Discharging)

Developing a rapport:
• “How have you been feeling recently?”
Screening for core symptoms:
Screen for core symptoms of depression – feelings of depression, anhedonia and fatigue. “In the past days during your
hospital stay have you…”
• Felt down, depressed or hopeless?
• Found that you no longer enjoy, or find little pleasure in life? Been feeling overly tired?
Sleep cycle:
• “How has your sleep pattern been recently?”
• “Have you had any difficulties in getting to sleep?”
• “Do you find you wake up early, and find it difficult to get back to sleep?”
Mood:
• “Are there any particular times of day that you notice your mood is worse?”
• “Does your mood vary throughout the day?”
• “Do you find that your mood gradually worsens throughout a day?”
Appetite:
• “Have you noticed a change in your appetite?”
• “What is your diet like at the moment?”
• “What are you eating in a typical day?”
Libido:
• “Have you noticed a change in your libido?”
• “Since you have been feeling this way, have you noticed a difference in your sex drive?”
Past psychiatric history, previous episodes of depression or dysthymia: depression for longer time > 2 years
• “Have you ever felt like this before?”
• “Have you ever had any other periods of feeling particularly low?”
• “In the past, have you had any problems with your mental health?”
• “Have you had any counselling for any issues before?”
• “Have you ever been admitted to hospital because of your mental health?” If so, obtain details – time, method of
admission, result.
do you have feeling to harm yourself or another body?

DISCUSSION
DDx:
Management? -reactive depression
Mild: -Anxiety
-Bipolar
• Regular exercise -Thyroid disorder(hypothyroidism)
• Advice on sleep hygiene (regular sleep times, appropriate environment) -drug
-chronic physical illness
• Psychosocial therapy –CBT -schezhrenia
Moderate to severe:
• Regular exercise, advice on sleep hygiene,
• CBT
• Medication –SSRIs
• High-intensity psychosocial intervention (CBT or interpersonal therapy)
• Immediate and considerable high risk to themselves or others: Admit to psychiatric ward (use Mental
Health Act if necessary)

HISTORY MO’s MRCS B NOTES (Previously called Reda’s Notes) 27

 Impotence
Normal history taking scheme…
Do you mind if I ask you some questions regarding your sexual life that will help us to figure out the problem?
Don’t forget to ask about… Do you have a partner?
• Difficulty obtaining an erection?
• Is the erection suitable for penetration?
• Can the penetration be maintained until partner has achieved orgasm?
• Does ejaculation occur and if yes, is it premature?
• Do both partners experience sexual satisfaction?
• Experience nocturnal/morning erections?
• Is there associated pain/discomfort - if yes, where?
peyroni disease • Penile curvature? last sexual contact - when, who (gender & relationship), type,
• Sexual History questions contraceptive use?
• Psychological history: Previous sexual contacts in 3 months.
4 o Any episodes of ↓ mood, insomnia, lethargy, moodiness? loss of libido (depression)
o Problems/ tension in sexual relationship?
1 o Any stress from work/ other sources?
‫من مشاكل عامه‬ o Any symptoms or signs of depression –insomnia, lethargy, low mood.
‫لي خاصه‬ 3 o Difficulties within a relationship.
2 o Family or social pressures.
6 o Any changes to sexual desire.
5 o Any anxiety related to performance.
• Any systemic features: SOB, ↑°c, night sweats, Kg ↓, loss of appetite?
• Cardiovascular: Chest pain, SOB, orthopnea, palpitations, dizziness, ankle swelling
• Respiratory: SOB, exercise tolerance, PND, wheeze, chest pain, cough, hemoptyses, hoarseness
• Gastrointestinal: Change in appetite/diet, Kg loss, dysphagia, odynophagia, change in bowels
• Urogenital: abdominal pain, micturition, dysuria, urgency, polyuria, hematuria
• CNS & PNS: fits, faints, headache, LoC, tremor, m. weakness, paralysis, sensory changes
• MSK: muscle/bone/joint pain, deformity, swelling, stiffness, limb weakness
• Metabolic system: change in BMI/ appetite, alteration in build/ appearance
• Past Medical History (Cardiovascular risk factors)
o Any history of spine or pelvic surgery/ trauma, previous prostate surgery, irradiation to prostate, CV RFx?
• Thyroid dysfunction, Hypertension, Rheumatic, Epilepsy, Asthma, Diabetes, Stroke, MI, Jaundice
• Specific drugs: Antihypertensives, anti-ulcer (e.g. PPI), lipid lowering, 5α-reductase inhibitors, antidepressants,
anti- ψ, testosterone anabolic steroids

International index of erectile function

1. How often were you able to get an erection during sexual activity?
2. How often were you able to get an erection during sexual activity?
3. When you attempted intercourse, how often were you able to penetrate (enter) your partner?
4. During sexual intercourse, how often were you able to maintain your erection after you had penetrated
(entered) your partner?
5. During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
6. How many times have you attempted sexual intercourse?
7. When you attempted sexual intercourse, how often was it satisfactory for you?
8. How much have you enjoyed sexual intercourse?
9. When you had sexual stimulation or intercourse, how often did you ejaculate?
10. When you had sexual stimulation or intercourse, how often did you have the feeling of orgasm or climax?
11. How often have you felt sexual desire?
12. How would you rate your level of sexual desire?
13. How satisfied have you been with your overall sex life?
14. How satisfied have you been with your sexual relationship with your partner?
15. How do you rate your confidence that you could get and keep an erection?

28 MO’s MRCS B NOTES (Previously Reda’s called Notes) HISTORY

 DISCUSSION

Differentials? Psycholgical organic

• Atherosclerotic vascular disease (smoker) -social event no social event

-no erection at all -weak erection but
• Drug induced (antihypertensive drugs; Atenolol) but pt have morning erection No morning erection
• Psychological -suddenly -gradually
inflammatory,mechanical,pelvic trauma,Spinal cord injury/stroke,DM
Investigations?
• Hematology:
o FBC, ESR, hematinics, clotting screen, group & save.
o Glycated hemoglobin (cardiovascular risk assessment).
o Biochemistry: U&Es, LFTs, CRP, lipid profile.
o Prostate specific antigen (if relevant history).
o Serum free testosterone.
o Serum prolactin.
o Serum FSH / LH.
o ACTH (synanche) stimulation test.
• Urinalysis: Microscopy to exclude a genitourinary cause.
• Radiology:
o Duplex ultrasonography to assess vascular function of the penis.
o Ultrasonography of the testes to exclude any abnormality.
o Transrectal ultrasonography to exclude any pelvic or prostatic abnormality.
o Angiography: It can be useful for planning vascular procedures / reconstruction, particularly following
trauma.
• Injection of prostaglandin E1: This outpatient investigation includes the injection of prostaglandin E1 directly
into the corpora cavernosa and to assess rigidity after ten minutes. While it can help to evaluate the
vasculature, a positive result may still be found with mild vascular disease. It can also be utilized to assess penile
deformities to aid planning of surgical correction.

Treatment? Reassurance of the patient

• Risk factor modification by controlling lipidemia and diabetes, weight loss, smoking cessation, increase exercise.
Cognative Behavioral Therapy (CBT) , solve social issues.
• CVS specialist to change BP medication
•
•
Phosphodiesterase-5 inhibitor therapy (sildenafil)
• Intercavernous injection therapy (alprostadil)
• Placement of a penile prosthesis which may take the form of either a semirigid or inflatable implant.
Q:give me vascular syndrome that can cause impotence?
- Leirch syndrome (claudication,impotence,femoral artery aneurysm)
Q: one test only to differentiate is this vascular disease or something else?
-check peripheral pulse

HISTORY MO’s MRCS B NOTES (Previously called Reda’s Notes) 29

 Stem:
Chest Pain (PE) - THR on Rt
- now pt have chest pain and cough
Normal history taking scheme… - he is smoker and alcoholic

offer oxygen and pain killers

Don’t forget to ask about…
• Associated symptoms
• Breathlessness –Do you get breathless?
• Orthopnea –Do you ever get breathless when lying flat? How many pillows do you sleep with at night?
• Paroxysmal nocturnal dyspnea –Do you ever wake up gasping for breath?
• Cough –Have you noticed a cough? Do you bring anything up? Any blood?
• Musculoskeletal –Is the pain worse on movement? Does it hurt to press on the area?
• Do you have any lower limb pain or swelling?

DISCUSSION

Diagnosis?
Considering pleuritic chest pain, acute onset of SOB, hemoptysis, my main diagnosis will be pulmonary embolism
I will also consider:
• Pneumonia
• Basal atelectasis
• MI
GERD
Investigations? - Do full cardiovascular and respiratory examinations
Specific Invx to - General invx to assess general condition of the patient: CBC, RFT, LFT, ABG
know the cause:
• CTPA
• V/Q scan Q:what you look for?
-for mismatch look for area of perfusion
• CXR
• ECG
• ABG
• Duplex LL

Treatment?
• ABC PROTOCOL
• Non-massive: heparin until APTT 50-60 sec. UFH 80 IU/kg bolus and 18 IU/kg maintenance
• Massive: thrombolysis/ embolectomy
Q:How to prevent?
- early mobilization
- mechanical prophylaxis by Thromboembolic deterrent stocking (TED) or Intermittent pneumatic compression device
- pharmacological giving pt (heparin or clecxane)

30 MO’s MRCS B NOTES (Previously Reda’s called Notes) HISTORY

 Hx of trauma

ask about
other lumps
Inguinal Hernia stem
- 30 yo male work as gym coach
- has inguinal swelling for 3 months
Normal history taking scheme… - he went for Estonia and returned back
- he developed urethral discharge
- invesx done which was free
Don’t forget to ask about…
• Is the bulge always present or does it appear and disappear?
• Is there pain on the swelling? (uncomplicated hernia is classically painless)
• Is there change in the overlying skin, wound or sore over the bulge? Is there discharge?
o Change in overlying skin and discharge may suggest strangulation or inflammation
• Ask for other GIT symptoms
o Is there straining at defecation?
o Is there abdominal mass or distension?
• Meds / Supplements pt took tonics
• Sexual Hx did you investigate for HIV? did you repeat it?

Exclude
• Abscess
• LN
• Femoral pseudoaneurysm

Review of other systems:

All other systems must be reviewed starting from the nervous system. But the clinician should pay attention to symptoms
of chronic obstructive airway disease and obstructive uropathy such as chronic cough and straining at micturition
respectively

DISCUSSION

ICE: Ideas, Concerns, Expectations

How does a hernia happen?

With straining like you do, there will be muscle tearing, and some gut will protrude through the defect
because of holding heavy objects
Could it be better?
It usually needs a surgical operation for repair, the operation may be in open fashion or key hole surgery

Where to get back to work?

Few weeks you can back about 2-3 weeks
but don't carry heavy objects at all for 3-6 months

Indications of laparoscopic repair?

• Recurrent
• Bilateral

Steps of hernia repair?

Discussion with examiner like in inguinal examination.

HISTORY MO’s MRCS B NOTES (Previously called Reda’s Notes) 31

 Groin Swelling (Infected Femoral Pseudoaneurysm)

Stem:
Patient referred from his GP due to the presence of groin abscess

Normal history taking scheme…

Don’t forget to ask about…

• Injection: “Did you have any recent injection or trauma in your groin?”
• Pulsatility: “Do you feel that this swelling is having pulses?”
• Ischemic manifestations: “Do you feel any limb pain or coldness or colour changes or limb swelling?”
• Neurologic manifestations: “Do you have any limb numbness?”

DISCUSSION

Differential diagnosis?
• Infected femoral pseudo aneurysm
• Groin abscess
• Infected hematoma
• Inguinal lymphadenopathy

Investigations?
• Duplex ultrasonography
• CT angiography

Treatment?
Ligation of the involved artery with delayed revascularization.

32 MO’s MRCS B NOTES (Previously Reda’s called Notes) HISTORY

Pre-operative assessment