Table of Contents Golden Tips ................................................................................................................................ 4 Incontinence, ID, HPI.................................................................................................................. 6 SIM MAN .................................................................................................................................... 8 NEUROLOGICAL HAND EXAMINATION: ................................................................................... 11 SUICIDAL RISK ASSESSMENT AND MSE:................................................................................... 14 2 to 7 CRANIAL NERVE EXAMINATION: ................................................................................... 17 Insulin dose calculation............................................................................................................ 19 PRE-ECCLAMPCIA: .................................................................................................................... 20 SEXUALL HISTORY TAKING; ...................................................................................................... 23 IRREGULAR BLEEDING(POF): .................................................................................................... 28 MISCARRIAGE:.......................................................................................................................... 28 ANTEPARTUM HAEMORRHAGE: .............................................................................................. 31 AMENORRHEA: ........................................................................................................................ 31 JAUNDICE: ................................................................................................................................ 34 CONTRACEPTION: .................................................................................................................... 36 OCCUPATIONAL Needle Stick Injury: ....................................................................................... 39 INFERTILITY: ............................................................................................................................. 40 GMC Do not.............................................................................................................................. 43 UNCONCIOUS PATIENT EXAMINATION: .................................................................................. 45 PRIMARY SURVEY: .................................................................................................................... 47 CIRCULATION: .......................................................................................................................... 48 DRUG ABUSE HISTORY TAKING AND RISK ASSESSMENT: ........................................................ 50 NON OCCUPATIONAL NEEDLE STICK INJURY: .......................................................................... 53 ALCOHOLIC FOOT EXAMINATION(SENSORY AND REFLEXES) .................................................. 56 PEAK FLOW METER: ................................................................................................................. 58 LYMPHORATICULAR EXAMINATION: ....................................................................................... 59 CHRONIC KIDNEY DISEASE ....................................................................................................... 61 ECG INTERPRETATION FOR ST ELEVATION: ............................................................................. 63 GIANT CELL ARTERITIS(GCA): ................................................................................................... 65
MULTIPLE SCLEROSIS: .............................................................................................................. 67 PALPITATIONS: ......................................................................................................................... 69 WEIGHT GAIN;.......................................................................................................................... 70 WEIGHT LOSS: .......................................................................................................................... 72 DIARRHEA:................................................................................................................................ 74 SPACER EXPLANATION. ............................................................................................................ 76 DYSPHAGIA; ............................................................................................................................. 78 CONSTIPATION: ........................................................................................................................ 80 MELENA:................................................................................................................................... 82 CHANGE IN BOWEL HABIT: ...................................................................................................... 84 WHEEZE: ................................................................................................................................... 86 HEMOPTYSIS: ........................................................................................................................... 88 DRY COUGH .............................................................................................................................. 90 CHEST PAIN: ............................................................................................................................. 92 CHEST PAIN DUE TO PNEUMONIA ........................................................................................... 96 CHEST PAIN DUE TO RESPIRATORY CAUSE. ............................................................................. 97 DIZZINESS/FUNNY TURNS ........................................................................................................ 99 LOSS OF CONCIOUSNESS ....................................................................................................... 101 ANOREXIA NERVOSA: ............................................................................................................. 103 ANXIETY:................................................................................................................................. 105 MANIA(Feeling high): ............................................................................................................. 107 PSYCHOSIS: ............................................................................................................................. 109 TIP TO PASS THE URINARY CATHETER: .................................................................................. 111 ALCOHOL abuse history taking; ............................................................................................. 112
Golden Tips Dear collegues a lot of plab2 candidates asked me to explain examination.So I am going to explain few common examinations which people fail a lot. GOLDEN TIP 1:-One important thing that I would like to mention that you all know how to do examinations as you all have done in your medical school just need revision.One essential thing to pass the examination is that while you are performing the examination pt should feel respect,dignity and autonomy.This is the most important thingtopass the examination.GOLDEN TIP 2-:You must stop your examination at 4.30 bell and upto this point 70% examination must be completed.At 4.30 bell thank the pt and ask him to cover up in his/her privacy,turn to the examiner that i would like to complete my examition by doing(remaining part of examination) -My most probable dx is this(dx) GOLDEN TIP 3:-While doing examination hold the pt with confidence. GOLDEN TIP 4:-Explain every step before performing on the pt,also if he/she already has pain on examination site and ask for permission by non verbal gesture by looking into the eyes of pt with plesant smile on your face and wait for the response.If the step you are going to perform can cause pain or discomfort tell the pt and ask for co.operation.Look at the face of pt for discomfort and say sorry for this.
Golden tip 5: -If you think that pt is dx with chronic disease causing any disability or complication and sending pt back to home.ALWAYS ASK IS THERE ANYONE AT HOME WHO CAN SUPPORT YOU? GOLDEN TIP6:- MEMORIZE THESE FOUR WORDS 1-THANK YOU 2-LOVELY 3-THAT'S GREAT 4-EXCELLENT And use these words very frequently during examination and after easch step of examination. DEAR COLLEGUES:There is no trick to pass the examination station.Practice a lot and be very very gentle to the pt.
Incontinence, ID, HPI O – How long have you been incontinent for? (acute vs. chronic) P – Frequency Q – Intermittent or constant dribble S – How severe is the problem? (daily functioning, social) T – Day or night. What kind of urinary incontinence is it? Urge – larger volumes, frequency, day and night Stress – dripping with laughing,coughing ↑ intra-abdominal pressure, daytime Overflow – small, hesitancy, incomplete voiding If onset is acute . . . D delirium/dementia, stroke, Parkinson’s, cord compression – recent onset confusion, disorientation, distractibility – numbness, weakness of lower limbs – CVA, trauma, metastatic cancer Infection – history of UTIs, dysuria, changes in frequency Aatrophic vaginitis – irritation or burning in vagina, use of local estrogen cream, oral estrogen preparation P pharmaceuticals – diuretics, sedatives, anticholinergics Eendocrine – DM (polyuria, polydipsia), hyperparathyroidism R restricted mobility S stool impaction (constipation) stress – Coughing, sneezing, coughing
If onset is chronic Causes – Bladder tumor or stone – BPH – Neurological deficits (CVA, Alzheimers, neoplasms, cord compression) – Surgery – Polyuria (DM, hypercalcemia) PMHx – Surgery (vaginal, pelvic, prostate) – Childbirth
SIM MAN DO NOT MISS this station You will have three sim man stations in which you should do management 1- acute asthma 2- acute limb ischemia 3-CVS simman with preop assessment of Hystrectomy. I have seen many doctors have struggled in these three stations so I would like to talk about these three stations SHORTNESS OF BREATH IN SIMMAN: -To begin with, as you know shortness of breath in sim man has two stations: One of these is acute asthma, which involves taking history, examination and management. - The other is infective exacerbation of COPD, which involves taking history and examination, NOT management. This means before starting the station you can be sure if there is management in the task, the station is acute asthma . COMMON MISTAKES in acute asthma station; 1-Many doctors forget to fasten the mask properly, maybe they are thinking about choosing a right mask at the beginning of the station. There is usually only one mask, Hudson with reservoir, which is the right one. Therefore, it should not distract you. Please fasten the mask properly when you start your treatment in very early stage of station. Don't expect to pass if you don't fasten it properly. It is a good idea when you are putting the mask tell the examiner '' I'm giving my patient oxygen and let the examiner ask you about percentage (high flow 100%), and rate (15 L/ min). The examiner will ask you, however, if he did not so you can talk about them. 2-Many doctors could not reach to auscultation .To tackle this problem you should aim to auscultate the chest at least 90 sec before the station finishes because in this station the most important finding is on Auscultation. The best way to manage your time is you must keep looking at the monitor and as soon as oxygen saturation drops below 90%, then should start your next treatment step, so you can save time and don't let sim man to waste your time. For example, during taking history, you have to give oxygen when you come to know he has asthma. During the examination, when you see oxygen saturation drop below 90% immediately talk about nebulized salbutamol 5 mg every 15 minute. The simman may deteriorate once more, so you keep tracking the monitor and this time please talk about IV hydrocortisone 5 mg every 4-6 hours .By doing this, you don't let sim man to start showing you his shortness of breath in which you have to ask him “what is happening?” and he can't talk due to shortness of breath you have to wait and ask it again and ….
This approach not only save your time but also gives a good impression to the examiner as you keep looking at the monitor. 3-Many doctors at the end of the station when the examiner asks them a question they answer something else! -When you finishes your auscultation plz talk about your findings,which is wheez and diagnosis is Acute Asthma. -If the examiner asks you"what are you going to do now?"plz do not talk about the other options because when you finish the station simman is usually stable.The examiner does not look for other steps of treatment. -Here you should talk about the investigations,which is CXR,ABG and ECG.As you know after steroids(either IV hydrocortisone or oral prednisolon 40-50mg)If pt deteriorates you should inform ITU and your seniors so the stage after steroid should not be the examiner's concern.However if he asks "what are you doing if your pt deteriorates?"Plz tell the examiner "I informing my senior and ITU team and they may consider megnesium sulphate and intubation." BRIEF HISTORY POINTS BOTH IN ASTHMA AND COPD: -When you enterd the room pt will be gasping for air,sometime asking for help.Immidiately tell the pt I can see your oxygen saturation is low that is e,g 88%.Do you smoke?Have you ever smoked?answer would be no ar less number of cigarett not fulfilling the crieteria of copd. -Give the pt high flow oxygen. -Now introduce youself. -Take brief history.How long have you been SOB.?How did it start?What were you doing at that time?Do you have asthma?Any chest pain?Any heart problem?Any fever,cough and spotum?Any recent surgery or travel?Any Hx of Clots in lungs and legs. -In asthma keep eye on monitor while taking history as you have to manage the pt simultaneously. -On examination part directly start from percussion to save your time for auscultation which is ultimately passing point. COPD: -Approach is the same.When you ask for smoking this pt will give you hx of smoking >40 years and >30 cigretts per day.Fever,cough and green spotum +ve. -Dont give oxygen because in the question it is mentioned that take hx and do relevant examination. -Same points of Hx as in asthma. -On examination part verbalise I,ll look for clubbing,peripheral and central cyanosis.check for tracheal deviation and chest expansion,and start from percusstion and auscultation. -Tell the examiner your dx=Acute excerbation of COPD
NEUROLOGICAL HAND EXAMINATION: HI FRIENDS this station came recently in the exam and people were worried that what it was hand how to conduct this examination. -Greet the pt, introduce yourself, explain your purpose of examination, take permission and look for general risk factors (e,g pregnancy, hypothyroidism, obesity, trauma, acromegally) ... EXPOSURE: Role up your sleeves above the elbow and please place your hands on pillow(placed in the lap of pt) -INSPECTION: -Muscle wasting (thenar and hypothenar muscles) -Wrist drop -Tremor and fasciculation -Radial and ulnar deviation MOTOR POWER: Median Nerve: 1-Thumb abduction (thumbs up while both palms facing upward and thumbs up. tell the pt I am going to push it down, don't let me push it down) 2-Pincer grip: Make a perfect sign and don't let me break it. ULnar Nerve: 1-Finger abduction(spread finger against resistance)(dorsal interossei) 2-Grip card between thumb and index fingers while hands are verticals and examiner try to pull away pt will adduct his thumb to grip the card(this is to check adductor pllices, if it is affected pt will flex the hand to grip the card=Froment's sign) 3-Grip card between little finger and ring finger while hand is vertical and examiner tries to pull away(Adductor of little finger. 4-Can you please hold my index finger by making fist around it and don’t let me to pull it away (palmer interossei) Radial Nerve: 1-Wrist extension 2-finger extension (all together) 3-Thumb extension(make a fist with thumbs up and tells the pt don't let me push it down) SENSORY: Light touch +Pain: 1-Over DIPJ little and index finger while facing palm up(ulner and median) 2-Over Anatomical snuff box while palm facing down (radial nerve)
Vibration: 1-Touch the tuning fork on the fingertips of index and little finger while palm facing upward. 2-touch at tha DIPJ on thumb palm facing downward. SPECIAL TESTS: 1-Phalen's test: reverse prayer sign for 1 minut:+ve if tingling and numbness in case of carpel tunnel syndrome. 2-Tinnel sign: Tap along the course of median nerve, tingling become worse in carpel tunnel syndrome. FUNCTIONS: 1-Pincer grip 2-Squeez my fingers 3-Hold a cup 4-Undo button 5-Write a sentence THANK the pt and ask him to cover his sleeves
SUICIDAL RISK ASSESSMENT AND MSE: One of the most common question that comes in gmc exam is the suicidal risk assessment and mental state examination.ppl take this station as common psychiatric hx taking station and lat of ppl fail this station bcz you have to ask specific question for risks that can lead to depression and suicide.... Divide it into three parts1- Incident detail:i_ what was the precipetant(reason) for this Attempt.ii_ Did you plan thisiii_what methoed did you use( it could be PCM tablet..ask how many....when...was this only thing or have you taken anyother drug or anything elseIiv_did you leave any suicidal will or note?V_ were you intoxicated at that time (taken alcohol ar anyother substance of abuse)Vi_did you took any precaution against discovery(lock the door or waited untill no one at house)Vii_after the incident did you seek any help or were you found and brought to the hospital by someone elseViii_how do you feel now? Do you regret or still wish you could be succeeded.2- OTHER RISKS I- age>28 II-male>female III- are you single or in relationship? IV-are you working or unemployed? V- have you tried to take your life before? Vi-Have you ever visited mental health clinic? Vii-Do you have any physical disability? Viii-Do you drink Alcohol or anyother recreational drug? Ix-Anyone in family who tried to take his life or family hx of deppresion and drug abuse? 3 -MOOD, INSIGHT, PSYCHOSIS MOOD Core symptoms I- do you feel low and depress II- Have you lost interst in things that were enjoyable to you? III- Do feel yourself tired all the time? Mood Biological symptoms. I- have you noticed change in your sleeping pattern II-Any change in appetite? III-Any change in sex drive? Iv- How about concentration? Are you able to follow the tv program or newspaper without being distracted? INSIGHT I-Do you think you have problem and need help(if pt comes by his/her own dont ask this question) II- How do you see your future? PSYCHOSIS I-Do you belief anthing which other people dont agree with? II-Do you hear voices when nobody around you? III-Do you see images which other people cant see? Iv- Do you think that other people are stealing your thoughts or putting their thoughts into your mind?
At the end ask pt: Do you still have any thoughts of harming yourself? Any plans? Are you going back to the same environment or have you changed your mind? Thank the pt and give suicidal risk to examiner: Ms(xyz) has high/low sicidal risk because her Mood is low/high. Has no/yes insight into her problem. Has got no/yes psychosis. I will admit her/ discharge her with my senior consultation. Important points. introduction,permission,confidentiality,keep quite for few second and look at the pt for few second.This gives impression to the pt that at least someone is there to talk to her.Don't start the station with bombardment of question,otherwise she will not talk to you.If she doesn't answer you dont insist on the same question,politely and slowly move forward.
2 to 7 CRANIAL NERVE EXAMINATION: 2nd Cranial nerve; Dear friends read the question outside carefully.It is mentioned that don't do red reflex and visual acuity.So,plz dont be robotic understand the instruction.In exam you will start from inspection and directly do visual field by confrontation methoed. Tell the ex that I am going to check the 2nd cranial nerve(loudly by looking towards ex)
INSPECTION: On inspection just mention pupillary size, ptosis,strabismus,Facial muscle wasting and facial asymmitry.No need to mention discharge exophthalmosis or proptosis as nothing to do with cranial nerve . VISUAL FIELD: You and pt should be at the same level and one meter apart. -Tell the pt this is a white pin(in exam white neuropin is there for this purpose)Can you see it?yes -I'll bring it from periphery to the centre.please say yes when you see it.Is clear to you? -can you please cover your right eye with your right hand and look straight into my eye with your left open eye and please fix it.Perform this action in all four quadrants in both eyes. -Interpret findings like this.(loudly so that ex can hear) 1-If normal=2nd cranial nerve is intact 2-Mono ocular visual loss=Right/left optic nerve is affected before optic chiasma 3-Bitemporal hemianopia=2nd cranial nerve affected at the level of optic chiasma. 4-Right/left homonymus hemianopia=2nd cranial nerve is affected behind the optic chiasma 5-Tunnel vision=visual field is constricted due to 2nd cranial nerve lesion at the retinal level. BLIND SPOT: This performed with red neuro pin (bring out the pin from centre to periphery(TIP: skip this step as it will consume lot of time and you will not be able to cover 70% examination.) REFLEXES: -Accomodation reflex:Ask the pt to fix on a distant point and then at your finger which you bring infront of the pt.(if convergence and pupillary constriction occur,accomodation reflex is normal. -Direct and Indirect light reflex:mention that would like to dim the light and shine light at the angle of 45 not straight from the front.(tell your findings loudly) 3,4,6 CRANIAL NERVES: -Now vocalize loudly that I am going to check 3,4,6 cranial nerves simultaneously. -Tell the pt that I am going to move my finger infront of you in figure of H,plz follow my
finger with your eyes and dont move your head.If you see double anywhere plz let me know. -While moving your finger plz be slow in extreme quadrents and give pt time to give you findings of diplopia or strabismus. -Give your findings loudly(e,g my pt doesn't have diplopia or strabismus.so,3,4,6 cranial nerve is intact. 5th CRANIAL NERVE:Verbalise loudly I am going to check sensory component of 5th cranial nerve. -Ask the pt if he has pain or tingling anywhere on his face. -Tell the pt this is wisp of cotton,i am going to touch it on your face while your eyes will be closed.plz say yes when you feel it.It feels like this(on sternum)can you feel it?yes -Touch on ophthalic,maxillary and medibular division of nerve by comparing both sides. -Same process with neuropin for pain sensation(use the blunt end) -VERBALISE loudly that sensory component of 5th cranial nerve is intact. NOW I AM GOING TO CHECK MOTOR COMPONENT OF 5th CRANIAL NERVE. -Can you please clinch your teeth while I'll be placing my hands on your face to feel the muscle. -can you plz move your jaw side to side. -Ideally I would like to perform jaw jerk and corneal reflex VERBALISE loudly motor component of 5th cranial nerve is intact. 7th CRANIAL NERVE(Verbalize loudly) -Can you plz frown at me? -Can you plz close your eyes tightly I'll try to open them.Don't let me do it. -Can you plz puff your cheeks I 'll try to break by tapping.Don't let me do it. -Can you plz smile for me. -Do you have any problem with your taste? 7th CRANIAL NERVE IS INTACT. THANK YOU VERY MUCH
Insulin dose calculation I am going to describe insuline dose calculation because a lot of people have confusion about it. Sometime in Exam question says prepare infusion at the rate of 1 unit insuline/100ml/hr for 5 hrs and sometime it says 2 unit/100ml/hr for 5 hrs. 1-Ask the examiner I would like to do calculations in presence of witness. ... 1 unit insuline given= 1hour X units of insuline given in5 hours=1×5 X=5units Or 2 units given=1 hour X units given in 5 hrs =2×5 X= 10 units 100ml N/S in=1hour X ml N/S in 5 hours=100×5 X= 500ml 2- show your calculations to the examiner 3-Check expiry dates of insuline voil and Normal saline. 4-Clean the voil with alcohol swab. 5-Take the required dose from voil(a slightly more because you have to discard some insuline while removing the bubble) 6-Remove the needle from the syringe and put it into the sharp. 7-Place your sample on the table to show the examiner. 8-If mentioned in the question that inser into the bag than attatch a new needle on the syringe otherwise leave as it is( In exam never ask to put it into the bag.so upto point 7 ur station is complete.)
PRE-ECCLAMPCIA: It comes in two scenarios.In first scenario you will be asked to take hx and discuss anagement with the examiner.2nd scenario take brief hx and talk to the pt and adress her concern(this pt has been refered by GP with baseline investigations done.Your task at this station s to convince the pt to stay at hospital for mx and monitoing. 1St scenario; -I understand that you have been refered to us as you are having some complaints.Is that right?... -Can you plz tell me what symptoms you are experiencing?-Ask about headache,blurr vision,epigastric pain or burning,sudden onset of puffiness of face and feet.-Are you feeling the kicks of your baby?RISK factors: -Is this your first pregnancy? -have you attended all your antenatal clinics? -What was your booking BP? -Do you have any medical condition like high BP and sugar,,CKD and antiphospholipid syndrom? -Anyone in the famly who have high BP during pregnancy? -If it is not first pregnancy of pt than you can ask hx of pre-ecclampcia in previous pregnancy? Thank the pt and now tell the examiner management. MANAGEMENT. -I would like to check the BP and urinary protein. -At this point examiner will tel you that BP is 160/110 and urinary protein 3+. -Tell the examiner my most probable dx on the basis of hx and ex is pre-ecclampcia. -I will admit the pt. -Send blood for CBC,LFT,RFT,Clotting Scren. -24 hour urinary protein and monitor BP. -I will connct the pt with CTG machine. -i will give my pt antihypertensive as per hospital protocol(Methldopa,labetalol,hydralazine) -i will consider anti convulsant and steroid for lung maturation of baby after discussing with seniors. Notes
In preeclampcia you have to convince the pt for admission by telling her that condition is very dangerous for you as well as for your baby. If you throw a fit, it can cause bleeding in your brain which is very serious and life threatning condition.2ndly due to this condition afterbirth(plancenta) can be detached and can cause severe fetal distress. In PV bleeding if placenta previa and placental abruption has been ruled out.Ask the mother if she is feeling the kicks of baby. Tell the mother as you are telling me that you are feeling the kicks of baby, hopefully your child will be fine however we will connect you to the CTG machine to check the heart beat of baby and tell you finally.
SEXUALL HISTORY TAKING; Sometime this station comes as only hx taking. -Guys explanation and taking consent before hx taking is very crucial at this station -“I’ve been asked to take a sexual history from you, this is going to involve me asking some personal questions which you may find uncomfortable. Everything you tell me is confidential within the boundaries of the team looking after your care. If you would like to stop at any time, please let me know.” -So,what brought you to the hospital? -Can you plz tell me more about it? Symptoms; -For each of the symptoms below ensure you clarify duration/ severity / course (worsening vs improving) exacerbating & relieving factors / etc. -Vaginal discharge: itchy/offensive – different to normal “Have you noticed any discharge? Does it smell? What does it look like?” -Dysuria / frequency: “Do you have any pain when passing urine? Do you feel you are going more often?” -Vulval itching/soreness: “Do you have any itching/soreness down below?” -Genital skin changes: “Have you noticed any skin changes around your vagina?” “Have you noticed any blisters, spots or ulcers around your vagina or anus?” -Abdominal pain – SOCRATES is useful here “Have you had any pain in your tummy?” “Where in the tummy is the pain?” “Does it move anywhere else?” -Pain during or after intercourse – dyspareunia “Do you ever experience any pain around the time of sex?” “Does the pain feel to be within the vagina, or deep in your stomach?”
“When does it occur? How long does it last?” (before/during/after) -Systemic symptoms (which may be related) “Have you noticed any rashes elsewhere on your body?” “Do you have any pain in your joints?” “Have you had any pain in your eye?" Menstrual history:: Last menstrual period (LMP) – “When was your last period?” Regularity – monthly / unpredictable – “Do you have regular periods?” Length of cycle – “How long is your cycle? / How long do you bleed for?” Dysmenorrhoea – “Any problems with pain or heavy bleeding during periods?” (new vs longstanding) Post-coital bleeding – “Do you experience any bleeding after sexual intercourse?” (new vs longstanding) Intermenstrual bleeding – “Do you have episodes of bleeding between periods?” (new vs longstanding) -Gynae history Smears – dates / results “Have you had a smear? When? What were the results?” “Have you ever had an abnormal smear?”
Treatment – previous gynaecological treatment – e.g. Loop excision “Have you had any previous treatment to your cervix?” -Obstetric history Contraception – type of contraception, length of use, any issues, any previous contraception “What do you use for contraception at the moment?” Pregnancy:Is there any chance that you could be pregnant? SPECIFIC SEXUALL HISTORY:
Sign-posting here is of benefit to ensure the patient (and yourself!) are prepared for the nature of the questions surrounding the specific sexual health aspect. “Next, I’m going to move on to discuss your sexual history. Some of these questions are sensitive, and can make people feel embarrassed. It’s important for me to find out this information though, so we can assess the risk of you being in contact with a sexually transmitted infection, and any others involved.” -Timing of last sexual contact “When did you last have a sexual encounter?” Consensual? Partner demographics “What sex was the partner in question?” Types of sex involved – oral (genital & anal) / anal / vaginal /digital For oral/ anal sex, clarify if the patient gave or received it (or both) “What was involved in this encounter?” “Was there more than one other person involved?” -Contraception used – condoms / dental dams / etc -Clarify if contraception was used for all sexual encounters, or only a subset -Ask if there was any problems with contraception at any point – e.g. condom splitting “Was there any point at which contraception was not used during the sex?” “Was there any issues with the contraception used?” Other partners in the last 3 months “Have you had any other partners within the last 3 months?” – If so, repeat the above for each. -Past medical / Surgical history: -Drug and Allergy h -Social hx:very important to ask about occupation of the pt. HIV RISK ASSESSMENT:If asked Identify if positive risk factors are present: “Have you ever had a partner whom is known to be HIV positive?”
“Have you ever had sex with a bisexual man/engaged in male homosexual activity?” “Have you ever had sex with someone abroad, or who was born in a different country?” “Have you ever injected drugs?” “Are you aware of any of your previous partners having ever injected drugs?” “Have you ever paid someone for sex, or been paid for sex?”
IRREGULAR BLEEDING(POF): -At this station no presenting complaints in the question.when you will go inside the cabin and ask pt she will tell you I have irragular periods. -How long have you been having irragular periods? -How often are you bleeding now? --Is this heavy bleeding?clots?flooding?... -Were your periods tegular before that?-What was the length of your cycle?-After how many days did they repeat?-Do you bleed outside of your cycle?-Do you bleed after sex?-Do you feel pain during mensturation?start/throughout the mensturation?-At what age did you have your first period?-When was your first sexuall encounter?risk-Are you on any contraception?-Are you sexually active?Do you feel pain and vaginal dryness?-When was your last cervical smear?result?-Have you ever done any gynaecological procedure or operation?-Do you have childrens? ASSOCIATED SYMPTOMS:-Are you having any hot flushes,palpitations,night sweats and mood swings?-Do you feel depress and low?-Are you having difficulty sleeping?-Does the heat and cold bothers you as it does not bothers other people?-Have you gained weight and noticed any skin changes(oily,greasy and facial hair growth)?-Have you lost weight recently?-Are you doing any excessive exercise?-How much do you eat food on an average day?RISK FACTORS: -Any family history of early menopause before the age of 45. -Any parental hx of hip fracture? -Do you have any medical condition? -Are you taking any regular,Otc or herbal medication?specially steroids? SOCIAL HISTORY: -Employment -Alcohol -Drug of abuse DX in Exam= POF -Smoking-Housing
MISCARRIAGE: This is a semi breaking bad news station,so you have to follow 3 layers instead of 6 layers before breaking the news. -AT this station a lady comes with PV bleed and she is almost 10 weeks pregnant.Sometime it is incomplete miscarriage and sometime missed miscariage(baby does not have heart beat+os is closed and mother is unaware of it).In case of missed miscarriage you will not mention that it will abort naturally,you have to do something to abort the product of conception.
-HOW TO APROACH THE STATION: -Greet the pt -I unerstand that you are 10 weeks pregnant and you came to us with some complaints and we have done your USG scan.Is that right? -Can you please recap the events so far?(let the pt talk) -I have the results of the scan with me.Would you like me to discuss the result you now? -Before we go ahead,do you have an idea whats going on? -Is anyone accompnying you?Would you like me to call someone for you? -Pt becomes abxious here and ask you why? UNFORTUNATELY I have to break some difficult news to you.Your scan did not manage to detect the baby's heart beat.At this stage we should be able to pick up a heart beat if it is present.I am sorry to have to tell you,but you have had a miscarriage. -let the pt swallow the news and respond according to her emotions.If crying offer tissue.If shocked offer some water. -wait for the responce of pt.
WHY DID IT HAPPEN?DID I DO ANYTHING WRONG? -I'd like you to know that this is not your fault.This is a very common condition and every 7th pregnancy ends up in miscarriage,and in most cases it is due to a random event.There is nothing you could have done to prevent it.
WILL I GET PREGNANT AND HAVE BABY AGAIN? -Yes my dear,you can get pregnant and can have normal pregnancy and baby as like other women who does not have miscarriage.Some women are worried about future pregnancies.having a single miscarriage has no impact on your ability to get pregnant again,or your future chance of having a baby.in fact it's so common to have miscarriage that we only begin looking for a reason for the miscarriage if they happen more than 3 times.
WHAT WILL YOU DO FOR ME NOW? -There are 3 options of managing your miscarriage.There's no right or wrong choice,and you can choose whichever method suits you. 1-the first choice is to do nothing.Your body will naturally remove the miscarriage from your womb,which may take 2-3 weeks. 2-The second option is to have an operation under general anesthesia,in which a nerrow tube is inserted into the womb to remove the miscarriage.it takes about 10 minuts. 3-The 3rd option is to take some medication which will break down the lining of the womb and take the miscarriage with it.so,you avoid an operation and its quicker than letting nature take it's course
. YOU CAN EITHER DECIDE NOW,OR THINK ABOUT IT AND LET US KNOW LATER ON. WHEN I CAN GO BACK TO WORK? -You are free to get back to normal activities whenever you feel able.if you need a sick note for work I can provide you one for 2 weeks.Your GP can provide you another sick note if you still need one after 2 weeks. -Do you have anyothe concern? Thank you
ANTEPARTUM HAEMORRHAGE: -PV bleeding after 28 weeks of gestation is called antepartum haemorrhage.At this station you have to discuss mx with pt and adress her concerns.On USG placenta is normal.You have to take brief history and then management. -When did it happen? -How did it happen? -What were you doing at that time?...-how much blood have you lost?-Are you passing any clots?-How much sanitry pads have you changed?-What is the color of bleeding?-Are you running any temperature?-Any tummy pain?-Are you feeling the kicks of the baby?-Do you have any bleeding disorder?-Any hx of trauma or instrumentation?-Are you taking any medication? -SYMPTOMS of Anemia:-are you feeling weak and dizzy?-Is you heart racing?-Are passing normal amount of urine? MANAGEMENT:-Well my dear we were worried about two serious conditions that can present like this,1-when afterbirth is abnormally placed and second when afterbirth is detached from the womb wall.However, from what you are telling me and USG scan shows that you have neither of this condition.This is normal bleeding that can be in normal pregnancy.we wnant to keep you underobservation for further bleeding and to do some blood test to know how much blood have you lost and for this we need to admit you.HOW IS MY BABY:-My dear as you are feeling the kicks of your baby,hopefully your baby will be fine however we will connect you with CTG machine to check the baby heart beat.CAN I HAVE TERM BABY:-If there is no sever bleeding and your baby is growing well you can have term baby and normal delivery.Anyother concern?Thank you very much AMENORRHEA:
-How long have been having no periods? -When was your last menstural period? -Is there any chance that you could be pregnant? -Were your periods regular before that?...-What was the length of your cycle? -After how many days did they repeat? -Do you bleed outside of your cycle? -Do you bleed after sex? -Do you feel pain during mensturation?start/throughout the mensturation? -At what age did you have your first period? -When was your first sexuall encounter?risk -Are you on any contraception? -Are you sexually active?Do you feel pain and vaginal dryness? -When was your last cervical smear?result?
-Have you ever done any gynaecological procedure or operation? -Do you have childrens?
ASSOCIATED SYMPTOMS: -Are you having any hot flushes,palpitations,night sweats and mood swings? -Do you feel depress and low? -Are you having difficulty sleeping? -Does the heat and cold bothers you as it does not bothers other people? -Have you gained weight and noticed any skin changes(oily,greasy and facial hair growth)? -Have you lost weight recently? -Are you doing any excessive exercise? -How much do you eat food on an average day? -Have you noticed any headache,visual change or milky discharge from your nipple? -Have you ever been pregnent before?what was the outcome/Any history of miscarriage,any procedure down below and excessive bleeding?
RISK FACTORS: -Any family history of early menopause before the age of 45. -Any parental hx of hip fracture? -Do you have any medical condition? -Are you taking any regular,Otc or herbal medication?specially steroids? SOCIAL HISTORY: -Employment:Ask about workplace stress -Housing -Smoking -Alcohol -Drug of abuse DX IN EXAM=STRESS/PCOS
JAUNDICE: IN EXAM JAUNDICE+LFTs are given in the exam so try figure out the major causes according to the LFTs. ALT is raised=viral hepatitist... GGT is raised=Alcohlic hepatitisALP is raised=billiary obstructionSometime ALT and GGT are raised so you are not sure what it is.So at the end of hx you have to explain and council the pt for viral serology to make a clear dx. -Common differentials Hepatitis (A, B or C) Viral infections including CMV, EBV Alcoholic hepatitis Drug induced hepatitis Malaria Hepatopancreatobiliary tumour PRESENTING COMPLAINTS: Did your skin or the eyes’ white areas turn yellow or red?.. o When did you notice that your skin becoming yellow? o How did it start?all of a sudden or gradually? o Is it becoming worse or improving since started? o Any excerbating and releiving factors? o Is it contineous or intermittent? o Are you running any temperature? o Wt loss? o Do you feel sick? o Any sore throat? o Any joint and muscle pain? o Any abdominal pain? o Any flank fullness? o Change in color of urine and stool? o Have you been recently in contact with a person with jaundice? RISK FACTOR TRAVEL HISTORY:(Hep A) o Hx of eating out? o Travel abroad?exposure to suspecious source of water?
o Have you ever had blood transfusion specially abroad? o Malarial prophylaxis in case of endemic areas? SEXUAL HX o Are you sexually active? o Is your partner male or female? o Is your partner stable or unstable? o Do you practce safe sex?use condoms? o How many sex partner do you have in previous 3 months? o Any sex partner known iv drug abuser? o Do you use any recreational drud by injection? Drug HX: o Are you using any regular medication specially drus for TB and epilepsy? o Any recent hx of paracetamol overdose? o Allergy to any medication? Social Hx: o Drink alcohol?Type?How much? o Occupation o Housing and employment o smoking PAST MEDICAL HX: o Has this happened before? o Have you ever been dx with TB and Chronic liver disease. o Any recent surgery under general anesthesia? FAMILY HX: o Any family hx of CLD and liver disease and hepatitis. DX=Viral Hepatitis If ALT and GGT both are raised and question says that council the pt tell pt at that as we are not clear at the moment that what is the actual cause.you are consuming moderate amount of alcohol.so to know about exact cause we need to do another blood test to check either this is viral hepatitis or not?
CONTRACEPTION: I know about two scenario about contraception.one i got in the exam and other my friend got in the exam. 1-suitable contraception advice in 28 year old lady with history of DVT.(it is not mentioned in the question she will tell you only if you ask her the medical condition and she is on warfarin). 2-forty year old lady,smoker and has two children looking for contraception. Guys no need to diliver a lecture on all types of contraception methoeds,discuss only those options that are suitable for her because topic of contraception is so lengthy that you cant talk about all option.If you will try to do this, you will run out of time only at 2nd or 3rd type or you will have to make a speech like a robot which is not good at all. HOW TO APPROACH THE STATION; -First ask few question to assess that about which option you have to talk. 1-What do you already know about contraception? 2-Do you have any specific concern or question?? NOW ask question about sexual,menstural and medical hx before discussing about contraception. 1-Sexual Hx: -Are you currently sexually active? -Are you in a longterm relationship? -Are you using any form of contraception?reson for discontinuation? -Have you or your partner ever been diagnosed with STI?Successfully treated or not? 2-Menstural Hx: -When was your LMP? -Do you have regular periods? -Any pain or bleeding outside of your bleeding? -Any chance you could be pregnent? -Have you given birth to any child recently? 3-Medical and medication Hx: -Do you have any medical condition e,g high BP,Migrins,blood clots,liver disease, epilepsy?Any family Hx of Clots,cancer -Are you on any medication? -Do you smoke? -What is your weight and height? -And you are 28 year old?right? SUITABLE CONTRACEPTION IN A PT WITH DVT; 1-POP 2-Mirena coil 3-Sterilization.
POP: -My dear,first option that suits you is called PROGESTRON ONLY PILLS,some people call it mini pills and it contains synthetic hormone,similar to progestron which is produced by your bady. -It works by two methods 1-it thickens the mucus at the neck of the womb and make it difficult for sperm to reach the egg, 2ndly,it makes the lining of the womb thinner,so make it less likely for a fertilised egg,from implanting in the womb. -You start taking pills from 1-5 day of your cycle and continue taking 1 tablet everyday.It is very important that you need to take medication everyday on the same time otherwise its efficacy is reduced and won’t protect you properly. -If taken regularly,it is very effective almost 99% -However,it does not protect you from STI.you need to use condom to prevent STI. -Advantage of this contraception is that it makes your period lighter and painless. It also decreases the risk of ovarian and endometrial carcinoma. It carries less risk of having clots as compared to other contraception that contains estrogen hormone. -Disadvantage of these pills is that it can cause bloating, headache and wt gain. It also slightly increase the risk of breast and cervical cancer. -Do you have any question? MIRENA: -2nd option is a mirena coil, is a small T shaped plastic device that is inserted into your womb through your front passage. It also contains the synthetic progesterone hormone and acts by the same method as pop. it is also very effective almost 99%. -The advantage of mirena coil is that you need not to worry about taking any pills or injection. it'll last for 5 years. If you have heavy periods and looking for long term contraception, this best option for you as it also makes period lighter .It is very easy to insert almost in 5 minutes. -The disadvantage is that it may cause short term cramping pain after we put it also at the beginning some women experience heavy periods. It can also cause headache and breast tenderness. -Do you have any question? Sterilisation: -If you have completed your family and want permanent protection from pregnancy you can have sterilisation. Its a surgical procedure in which the tube that brings egg to the womb will be blocked by ligation. -However the disadvantage of procedure is that it is almost irreversible and NHS does not fund for reversal of procedure. -Do you have any question? Thank you very much Guys this station ends here
2ND SCENARIO: -Suitable contraception 1-pop 2-Depot injection/Implants 3-Mirena 4-Sterilization whole station will be same but you need to talk about briefly about injections and implants -Progestron injections repeated every 3 to 4 months and have the same mode of action as pop and the same side effects. -One important thing that I need to mention is that if you wish to get pregnent and stop taking injection,It takes almost 6 months to reverse your firtility. -Implants also contains progestron in a small plastic tube that is inserted under the skin.easy to insert and easy to remove and can protect you upto 3 years. Thank you very much
OCCUPATIONAL Needle Stick Injury: -In this scenario a nurse pricked herself while taking blood from an unconcious pt. HOW TO APPROACH THE STATION: -Take the incident detail as I described earlier but skip few questions which in this case obviously this incident has happened in the hospital....-The important question to ask why pt was admitted(what was the complaint).-dx is not confirmed but suspician of meningitis.-Also ask about previous plus recent invstigations of pt and also any significant hx that increases the risk of blood born viral infections.-Hospital based NSI are not tetnus pron so no need to talk about it.-Ask the pt when was your hep B vaccine booster?-Ask pt concerns?-She is worried about meningitis infection?-Tell her that we will consult the microbilogist consultant if it is meningitis l,He will prescribe you PEP antibiotics-Also take permission to take blood to check anti-Hbs antibody titer.-Tell her if anti-Hbs titer is less than 10micro liter give the her ig,if between 10 to 100 give her booster dose.-Take informed consent to check for antiHcv and HIV.(as you cant check the pt Hcv ,HIV without informed consent).-Tell her that we will fill the incident report form and refer you to occupational health department.-Tell her though the chances of pt having HIV are less and you have done a great job by squeezing and washing the wound,there are still risk of having HIV is there.There is medication for post exposure prophylaxis in this case.The best time to start this medication is within 1 hour of injury but can be taken within 72 hrs and for 28 days.This medication can cause quite serious side effeccts e,g liver and kidney damage.-Its your choice if you want to start it.-any other concer?-thank you very much
Note: anti Hbs is less than 10ug/ml she needs immunoglobulin and if more the vac booster:) if below 10 than Ig and booster if between 10 - 100.if more than 100 than no need to give anything.
INFERTILITY: At this station you have to take hx of female as well as her partner. While you are taking history plz take detail hx of menstural cycle and gynaecological history. History Taking: ... -How long have you been try to get pregnant?
Sexual Hx: -Are you in a stable relationship? -Are you practicing regular unprotected intercourse? -How often? -Do you know about your fertile days? -Are you satisfied with your relationship? -Do you feel pain while having sex? -Do you bleed after having sex? -Any discharge hx down below? -Are you on any contraception?
MENSTURAL HX: -Do you have regular periods? -What is your cycle length? -Do you pass any clots?flooding? -Do you feel pain during mensturation?at start or throughout the mensturation? -Do you bleed outside of your normal cycle? -When was your last cervical smear test. -Have you get pregnant ever before?What was the outcome?Any history of excessive bleeding or instrumentation down below? -Have you noticed any change of hair growth pattern specially on the face and weight gain? -Any milky discharge from the nipples. -Do you feel hotflushes,palpitation and night sweats. -Does the heat and cold bothers you as it does not bother other people. -Any FH of Infirtility,early menopause before age of 45. -Do you have any medical condition or on any medication? Now lets talk about your partner: -What is the age of your partner? -What is his occupation? -Does he smok?drink alcohol/ -any stress in his life? -Is there any chance that he has any previous relationship before yours?---Does he have
children from his previous relationship? -Has he suffered from STI or mumps recently? -What type of cloths he likes to wear? -Any family history of infertility on your partner side? Dds in exam:PCO/asherman syndrom/sheehan syndrom Thank you vey much.
GMC Do not
Say ‘Everything you tell me will be kept confidential’
patients can assume that doctors will keep details of the consultation confidential. You therefore do not need to say this, and indeed it could sound odd to a patient.
Say ‘May I ask you a personal question?’
Signposting when you are changing the line of questioning can sometimes be helpful; for example when moving from asking about symptoms to lifestyle habits. ‘I’d like to ask you about lifestyle habits’.
Say ‘May I ask you some questions?’; ‘Is that OK?’.
As in real life, you can assume that patients (unless detained under the Mental Health Act) have sought the consultation with you. They will expect a doctor to ask questions and they will generally wish to be cooperative. In routine consultations expressions such as ‘May I ask you some questions?’ or adding ‘Is that OK?’ to statements can sound odd coming from a doctor. It is however appropriate when examining a patient to say ‘I would like to examine you, is that OK?’ to check implied consent before proceeding.
Refer the patient to the internet.
The stations are designed to within the capability of a doctor at the level of the beginning of Foundation Year 2 in the UK, and the examiners want to hear what your advice is. There will not be any circumstances under which this is an appropriate response. Similarly, be wary of telling patients that you will discuss with a senior colleague. You will not gain any marks if this is not an appropriate response.
"How may I address you?"
This is likely to sound strange and it would be more natural to say something like "What would you like me to call you?" Prefix the given, or forename with a title. For example, if your patient's name is 'John Smith' and he has agreed that you should call him John, it would not be considered normal to address him as Mr John
Over-simplify names for parts of the body.
Most patients will know the commonly-used names for parts of the body, so there is no need to over-simplify, unless you think the patient has not understood. For example, it would be reasonable to expect most people to know the terms 'bladder', 'ovary' and 'vein'. Expressions such as 'water bag', 'eggproducing gland' and 'blood channel' are likely to sound odd. If you doubt that the patient has understood what you are saying, check.
UNCONCIOUS PATIENT EXAMINATION: -IN This station it is crucial to calculate GCS accurately. -The difference in real life and examination is that you have to give instruction to the dear simulator which means that you are requesting him to give you findings smile emoticon -Pt will not show any response on insufficient painfull stimuli.PLEASE apply painful stimulus on the nailbed of pt untill he shows response by moving his arm(might be withdrawl or localization of pain) -While applying painful stimulus look at the eyes of pt(sometime pt opens eye and close it immidiately.If you miss that thing your GCS calculation will be wrong. -GCS chatrt is available in the exam.Dont worry about it.the most important thing is that you interpret it accurately. -Eye opening response is easy to calculta(that would be 2 or 3 on verbal command or on painful stimuli) ppl make mistakes in calculation of verbal and motor respnse.So,I am going to explain these two component. VERBAL RESPONSE: -If answers you accurately regarding time place and person then score is 5 -If you ask the pt time,place and person(time morning instead of evening,home instead of hospital,some other name other than than his own).It is confused conversation....score is 4 -If pt is randomly speaking any words that does not make any sense e,g car,sky,school etc then it is counted as inappropriate words and score is 3. -If pt is just mumbling,it is counted as incomprehensible sounds and score is 2. MOTOR RESPONSE: -If obey command.....score is 6 -If try to push your hand away from painful stimulus with his other hand,it is localization of pain and scor is 5 -If flex his that arm where you applied the pain,it is withdrawl and score is 4 -If flex his both arms, it is abnormal flexion and score is 3 -If extend his both arms(moving backward),it is abnormal extension and score is 2. HOW TO APPROACH THE STATION. -After greeting the examiner look silently to the pt and check either eyes are open or not.If not than say -Hello are you ok?If noresponse...Tap on both the shoulder gently and ask again are you ok?No response -Now introduce yourself and tell the pt I am here to examine you. -can you plz open your eyes? -Can you plz tell me your name?
-Can you plz tell me where you are? -Can you plz tell me what time is now? -Can you plz raise your arm,leg,take your tongue out? Now i am going to apply some pain on your finger plz bear with me(Apply pain on index finger only and look at the face of pt for eye response if pt has not opened on verbal command.No need to give pain above the eye.Learn to calculate GCS with sigle painful stimuli. -CALCULATE YOUR GCS AND TELL THE EXAMINER LIKE THIS: -Best eye opening response is on painful stimuli that is 2 -Best verbal response is incomprehensible sounds that is 2 -Best motor response is withdrawl from the pain that is 4 -So,the GCS of my pt is 8. NOW DO THE NEUROLOGICAL EXAMINATION OF BOTH UPPER AND LOWER LIMBS. I need full exposure for the purpose of examination. I will maintain the privacy of my pt and request for chapron.(assume) 1-Bulk..pt is actually not exposed so say I'll look for muscle bulk and check it with measuring tape. 2-Tone...instruction to the pt...I am going to check some tone in your joints plz let them floppy...move the joint actively in normal direction of joints.(usually in exam there is hypotonia in upper limb and hyper tonia in lower limbs. 3-Reflexes..usually in exam hyporeflexia in upper limbs and hyer reflexia in lower limbs. 4-Ask for orange stick to check the planter and torch to check the pupillary reflex. Thank you very much
PRIMARY SURVEY: -Tell the examner i am gowned and gloved and trauma team is with me. -Proceed the pt silently with both hands in ATLS manner. -In exam collar is already applied,tell the examiner that collar has been placed,I would like to do triple immobilization. -Now introduce yourself and ask for the pt identity.Are you OK? -Guys pt is concious and talking and not in any distress plz use your common sense, no need to give oxygen. -Ask my assisstant to connect pt with all the monitor(BP,Pulse and cardiac monitor)I will also ask him to do primary series of Xrays(neck,ches,pelvis) AIRWAY: -Ask the pt to open his mouth and look for any FB or loose denture. “Mr./Ms.., Where are you now?…What day of the week is today?” To the examiner “Patient is alert, oriented, speaking, no noisy breathing, airway is patent. -If collar is applied no need to open it and check for tracheal deviation,as pt is not in any distress and breathing normally.Just mention as my pt is not in any distress so I assume his trachea is central. BREATHING: -Tell the pt that for the purpose of examination you need full exposure,I'll maintain your privacy.examiner says at this point assume you have full exposure. -Now whatever you are going to do verbalise loudly. -On inspection of chest I'll look for any chest asymmetry,swelling,bruise,open wound and flail chest. -Ask the pt if he has pain anywhere in chest as I am going to feel your chest. -On palpation I cannot appreciate any crepitus, flail segments, sucking wounds or subcutaneous emphysema. -I am going to tap on your chest plz bear with me(by comparison on both sides) -I canot appreciate any hyper resonance or dull not on percussion. -tell the pt that I am going to listen your chest plz breath in and out when i say. -Air entry is bilateral equal,I cannot appreciate any wheez,stridor or crepts.
CIRCULATION: -i cannot appreciate any blood on the cloths and bed of the pt. -I would like to check the vitals of pt(at this point examiner will show you vitals) -Tell the pt that Iam going to feel your hands and feet(to check signs of shock...cold periphres. -If hypotesion and tachcardia resussitate the pt. -1) “I want 2 wide pore gauge 14-16 IV lines established, please. 2) Start Normal Saline/ Ringer Lactate, one liter on each at 125-1000 ml/h each (choose according to the patient’s BP). 3) Take a blood sample and send for: - Blood group, Rh and cross-match, - CBC, Lytes, (ABGs, CK-MB, Tropinin) if respiratory/cardiac case - Liver function test (ALT, AST, ALP, and amylase), - Renal function tests (BUN, Cr), - Coagulation profile (INR/PTT), - Rapid bedside Blood sugar, - Toxicology screen ABDOMEN: -On inspection I'll look for bruising,swelling and distension. -Tell the pt that I am going to feel your tummy.Do you have pain anywhre in your tummy? -Do superficial palpation and look at the face of pt. -I can't appreciate any rigidity,tenderness and gaurdning -Tell pt I am going to listen your tummy.(bowel sounds)which are positive. PELVIS: -In exam findings are in pelvis. -On inspection of pelvis i'll look for perineal bruising,meatal bleeding and scrotal hematoma. -Tell the pt I am going to feel your hip,Do you have pain in your Hip.Pt replies i have taken painkiller.so,touch the pelvis with great care and look at the face of pt. -Pelvic tenderness is positive,my most probable dx is Pelvic fracture "I'll apply the pelvic strap and refer the pt to the orthopedic team(no need to say i'll resussitae or pelvic xray as you have resussitated pt earlier and sent pelvic xray with primary series of xray) LEGS: -I can't appreciate any bleeding,bruising,swelling or deformity in legs. -Palpate the legs and pulse in feet(dorsalis pedis and post tibial) Are you ok? -Cover the pt to prevent hypothermia. -I'll pass NG tube and suprapubic catheter.
Thank you very much
DRUG ABUSE HISTORY TAKING AND RISK ASSESSMENT: This station comes only as History taking and this pt reffered to psychiatric department as he has intention to quite the drug. Greet the patient and appreciate his intension.Take permission(I Understand that you are taking a recreational drug.Is that right? I am here to ask some question regarding this.Is it ok with you?and just to reassure you whatever you tell me is confidential within the boundries of team taking care of you.... Which drug are you taking? Is this the only drug or you using anyother drug also? How long are you using this drug? How do you use this drug?(route e,g by injection or sniffing) Where do you take this drug mostly?(home,street,pub) With home do you take this drug?(friends) Do you share the needle with your friend? How often do you use this drug? ASSESS THE DRUG DEPENDENCE: What happens if you do not take the drug for a day or two? Do you think that you need to take more amout of drug to get the same effect than you used to? Do you get anxious or irritable if you do not take drug? Do you feel compulsion to take the drug? Have your ever thought to cut down on the amount of drug you are taking? Do you get annoyed when other people comment on regarding drug intake? Do you feel guilty the way you are using drug? RISKS FOR DRUG ABUSE: Is there anything in life that you think has forced you to take this drug? Are you single or in relationship? Are you working or unemployed? Have you ever visited any mental health clinic? Do you have any physical problem? Do you drink alcohol? Are you taking any medication? Any family hx of drug abuse,depression,divorce and alcohol abuse? MOOD,INSIGHT,SUICIDE,PSYCHOSIS QUESTIONS: Do you feel depress and low? Have you lost interst in activities that were enjoyable to you?
Any change in your appetite,sleep and concentration level? How do you see your future? Have you ever tried to take your life?Any plans? Have you ever tried to harm anyother person?any plans? Are you sensing the things which other people think that they are not real?(it covers all type of hallucinations e,g tactile auditory and visual) How has this been affecting you,your job and relationship and how are you coping? Have you ever tried to to stop drinking?if yes then ask why it was unsuccesful?
DONT FORGET TO ASK ABOUT SOCIAL HX: Whom do you live with? Do you have any dependent children?(they are at risk) Take sexual hx to assess the risk of having HIV. Thank the pt
NON OCCUPATIONAL NEEDLE STICK INJURY: -Community acquired NSI specially in children are a cause of significant parental anxiety. -At this station pt has concern about needle acquired infection(Hep B,C,HIV) and generalised infection. -First take the detail of incident -INCIDENT DETAIL; 1-When did it happen? 2-Where did it happen? 3-What were you doing when it happened? 4-What is the site of injury on your body? 5-Do you have any idea what could be the source of needle(The person who used the needle) 6-What kind of needle was it?sewing or injection needle? 7-Was it superfecial or deep wound? 8-Have you noticed any blood on the needle? 9-What,if any,first aid has been provided? 10-Immunisation history(specifically tetnus and hepatits B) (IN THIS CASE THERE COULD BE A MOM WHOSE CHILD GOT NSI WHILE PLAYING IN THE PARK OR IT COULD BE AN ADULT)
-Now ask the pt do you have any specific concern? -Pt shows concern about Hep B,C,HIV,tetnus -If pt is child and immunised against Hep B and tetnus reassure the mother that for the bug that causes Hepatitis and HIV cant survive outside the body and secondly your child immunisation staus is up to date.It is highly unlikely that your child can contract these infection.
-If pt insists than offer blood test to check HBV and HIV(tell the pt that we will take blood and check it now and after 3 months(serum gel to store) and then we can tell you the result of blood test as this bug can take almost 6 to 8 weeks to appear in blood. -No need to offer PEP to community acquired NSI untill unless it is high risk(1.source known to be infected with a blood born virus.2.NSI from deliberate assault.3,deep large volume injection with hollow bore needle.4.personal hx of injecting drug use) or pt is non immunised. -Other concern that pt shows that will you give me antibiotics? -Needle might be contaminated so there could be chance of infection,thats why pt ask for antibiotics.
-Ask the pt generally we give antibiotics to the pt who have signs of infection.Let me check if you have redness,swelling or any discharge from injury site/no -Tell the pt you dont need any antibiotic as we want prescribe antibiotic un necssarily as it can cause resistence which means that antibiotic wont work if you need them in future. -This is the all story if pt immunisation is up to date. WHEN YOU GIVE PEP IF PT SAYS TETNUS -My tetnus booster was given >5 years than give booster dose.If < than 5 year no need to give booster. -If not immunised at all give immunoglobulin as well as vaccine and refer pt for full course of tetnus vaccination. HEP B: -If vaccinated against hep B is up to date.no need to give any tx pt will recive vaccine booster on time. -If not vaccinated;give immunoglobulin and 1st dose of vaccine and than reffer to the GP for further routine vaccination course. Note: booster is repeated normally after 10 years.but if there occurs tetnus pron injury you can repeat booster if the previous dose was given more than 5 years.
ALCOHOLIC FOOT EXAMINATION(SENSORY AND REFLEXES) -Guys at this station dont do any inspection as the task clearly ask you to do only sensory and reflexes not the routine examination. -Be very gentle with pt and dont rush him/her -Give the clear instructions to the pt before performing each step. -In alcoholic neuropathy neurological deficit occur in gloves and stocking pattern.So,start your examination from distal to proximal(do not follow the dermatoms)
-1. Light touch: S Posterior column and spinothalamic tract function. Use cotton or a tip of a tissue to touch skin. -Instructions to pt: “Mr/Ms ..,I’m going to feel your skin with this cotton on several points of your feet and legs. I want you to say ‘yes’ when you feel it just like this(touch on sternum of pt), okay.. Let us start, close your eyes. ” To the examiner “Light touch lost below the knee. TIP:Never ask the patient if he/she is feeling the touch every time you touch the skin so he wont know if you are touching or not Start with toes.If intact, stop.If not, move proximal. 2. Pain: S Spinothalamic tract function . Ask the patient to identify sensation of pain by touching his sternum.(in exam it is clearly mentioned use only blunt side,so plz dont use sharp side. “Mr/Ms .., now, I’m going to feel your skin with this paper pin. Again, say ‘yes’ when you feel it and tell me if it is dull or sharp sensation, close your eyes. ” To the examiner “Pain sensation is lost below the knee.” -Very important to check sole of the foot with monofilamens at least at 5 points shown in the fig below. 3. Vibration: Posterior column function / Peripheral neuropathy. Struck the 128 Hz tuning fork and place it on the DIP joint. Ask the patient to tell you when the vibration stops. Check the other side and both lower limbs. If it is impaired move up on bony prominences. “Mr/Ms ..,now, I’m going to place this tuning fork on your feet and then on legs. Tell me when you feel buzzing and also when it stops, close your eyes…(Also validate the sensation by touching it on the sternum) To the examiner “Vibration sensation is lost below the midshin/knee.”
4. Proprioception: S (Joint Position Sense) Posterior column function. Hold the patient’s big toe from the sides. Begin with the joint at neutral then move it up or down and ask the patient to tell you the direction. Return to neutral position before starting again. S big toes only. “Mr/Ms ..,now, I’m going to move your right big toe up or down. Tell me if I’m moving it up or down, close your eyes… now the other foot… .” To the examiner “Proprioception sensation is normal/lost below knee etc REFLEXES: Achilles tendon reflex (Ankle jerk) S1 - 2: - Dorsiflex the foot then strike the tendon. - Look for calf muscles contraction followed by planter flexion of the foot at the ankle. “Mr/Ms .., now your ankle. …. (Set the foot, strike, and watch twice). Now the other one….” To the examiner “Achilles tendon reflex is normal & symmetrical/ diminished/ increased. THANK the pt
PEAK FLOW METER: This is another common and easy station that ppl fail a lot. EXPLANATION: o Hello I am here to explain this device called peak flow meter to check how well do you breath out called peak expiratory flow rate or PEFR,to get an idea how well controlled your asthma is at this time. o You need to check your PEFR regularly, particularly if YOUR asthma is worse than usual. o Explain that the PEFR meier is to be used first thing in the morning and at any time you have symptoms of asthma o Attach a clean mouthpiece to the meier. o Slide the marker 10 the bottom of the numbered scale. o Stand or sit up straight. o Hold the peak flow meter horizontal, keeping his fingers away from the marker. o Take as deep a breath as possible and hold it. o Insert the mouthpiece into his mouth, sealing his lips around the mouthpiece. o Exhale as hard as possible inlo the meter. o Read and record the meter reading. o Repeat the procedure three to six times, keeping only the highest score. o Check this score against the peak flow chart or his previous readings. o Check the patient's understanding by asking him to carry out the procedure. o Ask him if he has any questions or concerns TIP: people fail this station because when they ask the simulator to demonstrate the procedure, pt breath out shallow and marker moves slightly. Candidate becomes happy that at least this station is pass but actually fail because Candidate could not convey the correct method to check the PEFR. Ask the pt to repeat and breathe out as hard as he can and as fast as he can untill he performs it correctly and marker moves swiftly
LYMPHORATICULAR EXAMINATION: -Greet the pt -Introduce yourself+ask the pt identity -Explain that today I am here to examine some glands in your body.For the purpose of examination you need full exposure but you can remain in your briefs,I'll ensure your privacy and request for the chaperon.Is it ok for you? -During the examination I 'll come closer for the inspection,Do some menouver and will touch you.Is it ok with you?... -If you feel uncomfortable at any point plz let me know I'll try to be as gentle as possible.Now lets start with examination.
1-Do you have pain anywhere in your head and neck? 2- I am going to feel some glands in head and neck while I 'll be standing behind you.Ask the pt to sit on the chair and ask him to slightly extend his neck.Now start palpating and vebalise loudly e,g submentle,submendibular,juglodigastric,ant auricle,post auricle,post occipital,ant post cevical(palpate on one side at a time and ask pt to look slightly on opposite side).For supraclavicular ask the pt to raise his shoulder. Findings:I cannot appreciate any enlarged lymph node in cervical and supraclavicular group of lymph nodes. AXILLARY LYMPH NODE: -Now I am going to feel some glands in your under arm.Do you have pain in your underarms.Ask the pt to stand up and can you plz place your right arm on my right shoulder.place your right arm on the right shoulder of pt(right,right)Now palpate the ant,medial and apical lymph node eith your left hand and verbalize loudly. -Repeat the same procedure for the other arm,then go behind the pt to check the ppost and lateral group of lymph nodes.(tell the pt plz to cross his arms away from chest). FINDINGS;I cannot appreciate any enlarged lymph node in axillary group of lymph nodes. ABDOMINAL LYMPH NODE. -Ask the pt to lie down on the couch and first check liver and spleen(dont start from head as if you miss liver and spleen station is gone) -Liver:ask for any abd pain and then tell the pt that I'll be feeling your tummy while you are breathing in and out. -Start from RIF toward the costal margin,feel the organ during inspiration and release your hand to move forward duting expiration. -Tell your findings loudly SPLEEN:Same method as for liver start from RIF to the left costal margin.Give your findings. -I would like to do ct abdomen and chest to check further abdominal and mediastinal lymph
node. -Ideally I 'll check the inguinal lymph nodes.
-POPLETEAL LYMPH NODES: -Tell the pt I need to check some gland in your legs while bending your knees.Do you have pain around your knee joint? After checking give your findings. -Finally now come to the head and look for alopecia,ear,nasal discharge or crusting. -Ask the pt to open his mouth and look for dental abcesses and say I would like to have torch to check the tonsils and would like to do post rhinoscopy for adenoid group of lymph nodes. Thank you very much
CHRONIC
KIDNEY
DISEASE:
EXPLAINING THE TEST RESULT AND DISCUSSING FURTHER MANAGEMENT: In this scenario test report is given already,you have to explain the report and take brief hx from the pt to find out the possible cause. (Plz look at the both sides of paper,I failed this station in my first attempt because I did not turned the page and on front side of the page there was only CBC and Urinary protein +1.I explained the whole station as anemia and also asked question regarding anemia .YOU can avoid this foolishness now. -ON test report: Hb=9 creatinin=>400 Urea=>20 K=>5 urinary protein= ++/+++ When you enter the room after greeting the examiner first read the test report and make sketch of your station in your mind and then greet the patient,introduce yourself and take permission to talk the pt. -Check the perception of patient. -Do you know why you have been asked to come here today?(pt will tell you that I am here to know about my test results) -Aask the pt can you plz tell me what has happened so far.What symptoms are you having that has made us to do these test.(Let the pt speak dont describe the background by urselflike as you know..bla bla) -Do you have any idea what could be the cause of your symptoms?(check the pt perception) -Ok I do have the test result with me and it is showing that your blood is weak,level of certain waste product that are cleared of by kidneys from our body has been raised,one more thing that we also found that some important protein is being secreted by the kidneys. -And the combination of all these things is pointing toward one thing that your kidneys are not functioning well and this condition is called Chronic kidney disease. (you can hold the test report form in your hand and bring it in front of pt and explain it.) -Why I have this condition?(pt conern) -At the moment I am not sure what is the actual cause for it.Can I ask you few questions to figure out a possible cause?yes
-Do you have any medical condition like High BP,Diabtes,Heart failure. -Are you taking any regular medication?any OTC e,gNSAIDS -Have you ever passed any stone in your urine or told that you have stones on USG. -Do you tend to suffer from recurrent water works infection? -Have you noticed any blood in your urine. -Anybody in family who have kidney disease? -Do you smoke? What you will do for me now? -This disease is chronic and progressive we cant cure it,But we can do lot of things to slow down its progression. -We also will do USG of your kidneys to check how much damge has been done. -With this condition there are certain lifestyle modification that are very important along with medication. 1-you need to avoid salty and fatty food 2-Limit your daily water intake. 3-decrease your meat and protein intake for further advice I'll refer you to the dietician -Do you smoke?yes...smoking can make this condition worse.Have you ever thought about to quite smoking? -Do you drink alcohol?yes...It is advised that you need to cut down on your drinking. MEDICAL TX: -To make your blood strong well we'll give you Iron tablet and an injetion. -Water tablet to get rid of swelling by removing extra fluid from the body. -Asprine to decrease the risk of stroke(risk of stroke increases with CKD). -ACE inhibitor to control the blood pressure and also to protect your heart and kidney. -Statin to lower the lipids in the body(in CKD hyperlipidemia is very common) -Vit.D and calcium to strengthn your bones.(when kidneys are not functioning calcium and vitamin d level becomes low and this causes weakning of bones) do you have anyother concern? thank you very much
ECG INTERPRETATION FOR ST ELEVATION: -Normally PR segment and ST segments are on the same level. -One smaal square on ECG paper is equal to 1mm.You draw a baseline from PR segment to ST segment,if both are on the same line or ST elevation is less than 1mm in limb leads(I,II,III,avF,avL) or less than 2mm in chest leads(V1 to V6) than it is normal. -If moe than 1mm in limb leads and 2mm in chest leads than label it ST elevation...-First one is normal.do comparison and you will know how to look for ST elevations.
For NSTEMI you will tell the ex that ECG is normal on the basis of hx I am suspecting ACS to confirm my dx i would like to do cardiac enzymes.
say that we will do cardiac enzymes after 6 hours of onset of pain !! If examiner says if it is clear than say ok I will repeat cardiac enzymes after 12 hours of onset of pain We are not doing any cardiac enzymes at the moment
GIANT CELL ARTERITIS(GCA): DEAR collegues GCA is an emergency,Immidiate treatment is vey important otherwise irreversible ischemic changes are inevitable. -High dose Steroid -Urgent referal(same day) to ophthalmalogist is must. -Asprin(75mg) STORE THESE THREE POINTS IN YOUR MIND AS RED FLAG -GCA has been divided futher into.... 1- Complicated GCA:Jaw and tongue claudication and visual symptoms(in this case you start the management by giving IV methypredinisolon 500mg to 1gram for 3 days before oral prednisolon....oral prednisolon should be started on 60mg daily and then tapered gradually. 2-Uncomplicated GCA:New onset of headache without jaw claudication,visual symptoms and absence of other systemic symptoms.(tx in this case is oral prednisolon 40-60mg daily and then tapred off once symptoms has been settled. IN exam Scenario:70 year old lady present with headache.Investigations including biopsy has been done.DX of GCA has been made.Talk to the pt and discuss immidiate and longterm mx. Guys now it should be cleared that this is Uncomplicated GCA.so,you dont need to give IV methylprednisolon,start with oral prednison 40 to 60 mg NOW START WITH STATION: GREET the pt,introduce yourself and explain your purpose of meeting and take permission. -How can I help ?(Either pt knows the dx or if dont know than explain that as we have done some test and result shows that you have a condition called GCA.Today I am here to discuss the immidiate and lonterm mx of the condition and will adress your concern. Would you like to know about the disease?If yes explain "Giant cell arteritis (GCA) is a condition in which medium and large arteries, usually in the head and neck, become inflamed causing swelling and narrowing of your vessels and can cause serious complications like visual loss and stroke" What will you do for me? Immidiate Management: -To traet your condition and to avoid serious complication, we need to give you high dose steroid to settle the inflamation,and for this purpose you need to stay at hospital(if pt not willing to stay at hospital tell him complication of blindness and stroke) -We will urgently refer you to the eye specialist to avoid and recognise any complication earlier. -We will also start you on low dose aspirin(have you been ever dx with peptic ulcer or do you have any bleeding disorder,anyother medication or any medical condition)
Long term management: -Once your symptoms disappear, we will slowly reduce the dose of steroids while monitoring your symptoms, to the lowest possible level which we called maintenance dose. -Low dose asprine lifelong. -How long I will take steroids? It depends upon your recovery.In some people symptoms settles quickly and in some people they persist for long time,sometime lifelong.So it is difficult to tell how long you will be on steroids. -I herd about a lot of complication of steroids.Is it safe for me? Well my dear,I can understand your concern but this medication is miracle for you.Unfortunately,steroids do have some complications but dont worry we will try to limit them as much as possible. 1-Steroids can cause osteoprosis(bone thinning):to limit this you need to take healthy balanced diet containing a lot of diary product,fruits and vegetable. -Daily walk for 20 to 30 minuts increases the bone strength. -We will start you on medication to prevent this complication called bisphosphonate. 2-Heartburn and peptic ulcer:we will start you on another medication to protect your stmach(omeprazole) 3-Wt gain,High blood pressure and high blood sugar can be controlled by diet and exercise for this i'll refer you to the dietician. VERY IMPORTANT: It is very important that you attend your follow up appointment regularly so that we can monitor your disease and steroids complication. IF you experience headache,Jaw and tongue pain,Visual problem(diplopia) or muscle pain at any time.plz come immidiately to the hospital. Thank you very much
MULTIPLE SCLEROSIS: -Greet the pt. -Introduce yourself and explain your purpose of meeting and take permission to talk. -How can I help you?(pt will tell you that i have been dx with MS because dx is made by your consultat.You have to adress the pt concern) -Would you like me to talk about MS or you have some other concern? -If yes than explain the MS -MS ,is a condition in where there is a problem in the way some of the nerves work.Nerves usually have a covering around them called myelin.It's like insulation,and makes sure the electrical impulse travels fast and accurately.In MS this outer layer is damaged by your own immune system by accident.This means electrical signals from the brain and spinal cord,to the rest of the body, don't work properly.This is the reason you been having your symptoms.Does that make sense? -Do you have any specific concern? -Why I have this disease? -Unfortunately,We don't know exactly why people get MS.We think it is related to genes or infections. I herd this is is a bad disease,will I be wheelchair bound? -.This disease generally progress in 3 patterns,most common one is RElapsing and REMITTING one in which people have normal function called remissionn period and when they have symptoms called relapse.Some people become wheelchair bound when they have symptoms.MS affects different people in different ways.so it is difficult to tell you how its gonna affect you.Everyones different,thats why we treat every pt as an individual. Is there any cure for the disease? -Unfortunately we don't have any cure for it at the moment.so,once you have MS,you have it for life.But,with the help of specialist team like the one here we can help you to manage the symptoms. I herd about canabis.Does it have some role in the treatment of this disease.? -I really appreciate your knowledge. Yes Canabis do have some role to control the stiffness. If you need at anytime my consultant will definitely prescribe it for you. What will you do for me now? Don't worry my dear we have a very good team called "Specialist neurological rehabilitation team" to look after you. So whatever the symptoms you have, we have someone here to help you.
-So, if it's a problem with muscle weakness, we have physiotherapist who can help you strengthn your muscles. -If you need any special arrangement at home we have social services to help you with it. -If you need any specific symptoms treating,specialist nurse,or myself will help you to try to get on top of it with medication. -If you suddenly get new symptoms,you need to see your GP,who will assess you.You may need steroid treatment which act as anti inflammatories and your symptoms will disappear quickly. -If the symptoms are really affecting your activities,your GP can refer you to a specialist who may consider to give you medication called interfeon to decrease the number of attacks you have.(interferon act by suppressing your immunity). -Any other concern? I have two kids what who will take care of them? -Dont worry my dear NHS will take care of you and your children? -WILL I Die doctor? My dear,there is no immidiate danger.people who have MS live almost normal life span and healthy life quite for a long time.They face problem when there is relapse of symptoms.
Notes: In BNF dose of cannabis is clearly mentioned for MS. In English culture when ppl address each other they use my dear, my love v frequently and in this culture it is not weird to call pt my dear.
PALPITATIONS: DDS: -Anemia -Anxiety...Arrythmia -Hypoglycemia -Hyperthyroidsm -Pheochromocytoma -Hypotension -IHD -Drug -Coffe HX taking: Palpitation: Have you ever felt your heart racing/ fluttering/ funny? DURATION: When did it start? ONSET:How did it start?(suddenly/gradually) SETTING: What were you doing when it started (Dusting/ Exercise)? HOW long do they last?Does it terminated spontaneously? QUALITY: How does it feel like?Can you please tap it for me? SEVERITY: How frequent?... How many times a week? IS it related to exercise? EFFECT ON PATEIENT LIFE:How has this been affecting you?What activities are you no more able to do? Do you become SOB as well? Any warning signs before this? Any hx of LOC associated with palpitations? Are you cosuming a lot of coffe? Do you use any recreational drug(cocaine)? Have you been started or stop taking any drug recently? ASSOCIATED SYMPTOMS: Chest pain,wt loss,Heat intolerance,Tremors and sweating,Headache,Pallor,weakness,feeling of anxiety/panic attack. ASK ABOUT ALCOHOL Rest of the hx as in cardiovascular system. DX IN exam= DRUG ABUSE(most of the time)
WEIGHT GAIN; DDS: 1-Lifestyle 2-Endocrine causes...-Hypothyroidsm -Cushing syndrom -Acromegally -DM type 2 -PCOs 3-Depression 4-Drug 5-Pregnency HX TAKING -Have you gained wt recently? -How much?Over how long? -Have you noticed any recent change in your appetite? -Are you gaining weight despite eating less? -Are you living a sedentry lifestyle or having any physical activity? -What type of food do you prefer to eat? -Have you noticed if certain areas of your body are getting fatter or thinner? (Redistribution)Any pigmentation or dryness of your skin? -Does the cold bother you more than you think it bothers other people?Any change in your voice?any change in your bowel habit? -Have you noticed any change in your facial features?coarsning of features or facial hair growth(female only) -Are you drinking a lot and peeing a lot? -How about your mood? -Do you feel depress and down? -Have you been started or stopped any drug recently? -Is there any chance that you could be pregnant?(female only) -Take menstural hx if pt is female. Past Medial Hx: -Do you have any medical condition like htn,DM,Thyroid problem or any other problem. -Are you on any regular or OTC drugs? -Any allergy to any medication? -Any surgry? Family HX: -Any family hx of DM,Thyroid problem,Depression,PCOs
Social Hx: -Smoking -Alcohol -drug of abuse -Housing and employment -Travel and hobbies DX IN exam=HYPOTHYROIDSM
WEIGHT LOSS: THIS station I got in my exam and one thing that irritated me was ODPARA. Dear collegues everything is not going to be fit in ODPARA.People who charged you 550 pounds or more get rid of everything in ODPARA despite the fact either it is going to fit in ODPARA or not.Think sensibly andask proper question from the pt because sometime asking in foolish manner can irritate the examiner and patient. Major DDS of weight loss: 1-Malignancy 2-HIV 3-TB 4-Lifestyle 5-GIT CAUSES -Dysphagia -APD -Malabsorption -Malnutrition -IBD -Bowel cancer 6-ENDOCRINE CAUSES -DM type 1 -Hyperthyroidsm 7-PSYCHIATRIC CAUSES -Anorexia nervosa -Bulemia Nervosa -Depression HX TAKING: -Have you lost weight recently? -How much?Over how long? -Are you losing weight intentionally? -Do you still feel yourself overweight? -Hom much food you consume on an average day? -Any recent change in lifestyle and social circumstances? -Do you tend to suffer from hearburn or indigestion?Any swallowing difficulty. -Do you tend to suffer from recurrent chest infection? - Do you fell sick?Any vomiting or dirrhea? -Any mucous or blood in your stool? -Do you feel thirsty and going to the loo more frequently? -Do you feel intolerance for heat? -Any racing of heart? -Sweating and tremors in hands? -Are you in habit of binge eating? -How is your mood? -Do you feel depress and low?
ASSOCIATED SYMPTOMS: -Mensturation?regular or irragular? -Anemia,feel weak and tired?Any SOB? -Any rash,skin and nail changes? -Any lumps and bumps in body? PAST MEDICAL HX: -Do you have any medical problem like diabetes,thyroid problem,Pepti indigestion,celiac disese or anyother IBD, TB.Depression. -Have you done any surgery ? -Any important investigation e,g Usg,ct etc SEXUAL HISTORY Are you sexually active? - Is your partner male or female? - Is your partner stable or unstable? - Do you practce safe sex?use condoms? - How many sex partner do you have in previous 3 months? - Any sex partner known iv drug abuser? - Do you use any recreational drud by injection? Drug HX: - Are you using any regular medication specially thyroxin and other laxtative,purgative and water tablets - Any recent hx of over the counter drug? - Allergy to any medication? FAMILY HISTORY: -Anyone in the family with similar symptoms? -Any family hx of bowel,breast,lung cancer? Social Hx: - Drink alcohol?Type?How much? - Occupation - Housing and employment - smoking DX IN exam=HYPERTHYROIDSM (most of the time. it could be anything else)
DIARRHEA: - ONSET: How did it start?.. Was it all of a sudden or gradually? - DURATION: When did it start? (>2 weeks: Chronic), So it is less/ more than two weeks (Chronic)? Does it come and go?… Yes How frequent does it come?.. For how long does it stay each time?.. Does it... alternate with periods of constipation? - QUALITY: Is it loose or watery?. Is it bulky shapeless? - TIMING: Is it worst in a particular time of the day? Morning: IBS. Nocturnal: Organic ARE You vomiting as well?yes How much?.. How frequent?.. any blood? Is it forceful (projectile) or with retching? ASSESSMENT OF DEHYDRATION; Do you get lightheadedness?, ...What about when you stand up or get out of bed in the morning? (pre-syncope/ Anemia),... Do you feel thirsty and your mouth dry?,... Have you ever felt your heart racing?,... Do you void less? ASSOCIATED SYMPTOMS; Are you running any temperature? Ant tummy pain? Wt loss? Recurrent chest infection? Yellow dicoloration of skin? Any joint pain and eye pain? HX OF CONTACT: Any other family member having the same symptoms? Any hx of eating out? Recent canned food? HX OF TRAVEL: Have you travelled abroad recently? Any suspecious source of water and food? PAST MEDICAL HX: Has this happend before? Any hx of IBD,Malabsorption,pancreatic insufficiency,TB.
SOCIAL HX Sexuall history in detail? IV drug abuse Alcohol Smoking Housing and employment Any drug? DX=VIRAL DIRRHEA If q says counselling. Tell the pt to drink plenty of fluid. Wash your hands after toilet use Dont share the bath towel Clean the toilet seat regularly Eat simple, palin and cold food Avoid hot ,creamy and spicy food IF you feel dizzy Not passing urine Unable to tolerate oral intake blood in stool plz come to the hospital
SPACER EXPLANATION. Counsel mum of the child who suffers with asthma about how to use the spacer. In GMC exam, Patient is a 5 years old child. Good morning I am Dr X... Ask Mum: “How is your little one doing? I have come through notes that your little one is suffering from asthma… She says: Yes Say: I am very sorry to hear that. I am here to introducing a device called spacer. Have you ever heard about it? She says: No “I am here to talk you about it. If you have any question, stop me whenever you want.” Hold the spacer in your hand and say: “Actually it is a device which contains of two ends one is called the mouthpiece and the other end is called inhaler adaptor.show the mum that end. “Do you have the medication with you?” “Do you know how many puffs you have to give?” Tip: If she doesn’t know prescription, don’t tell her on your own. I am giving you example, once you get your prescription you will find it out. If any question, come back to us we will describe it to you. Three spacers are present on the table in GMC shown below,pick up the blue one and then demonstrate it.
Demonstration how to use spacer and Inhaler; 1. Remove the protective cap from the puffer. 2. Shake the puffer and fix it firmly into the end of the spacer. 3. Make sure you little one hold the spacer horizontally, and make a tight seal with his mouth. 4. Press the puffer once to release a dose of the medicine into the spacer. Do not remove the puffer. 5. Allow your little one to breath in and out in the spacer for 5 to 7 times, then remove the spacer from the mouth of your child.if you have to repeat another puff repeat after 30 seconds. 6.“Can you please demonstrate it for me?” give the spacer to her 8. Blue capped inhaler is a reliever, a bronchodilator that may cause racing of the heart for example, palpitation. 9. Brown capped inhaler is a steroid; it is a preventer. Therefore your little one must rinse out her/his mouth after each use to prevent the growth of any bugs in the mouth called oral thrush. 10. If another puff is needed, wait for 30 seconds. How to care for your spacer “Take the spacer to bits and wash it in warm water DO NOT RINSE. Do not scrub its inside to prevent any scratches, and allow dripping dry. Do not rub dry. It should be cleaned at least once a week and more depending on frequently of use. It needs to be replaced when there is obvious breakage, any staining inside.
Ask: Does little one go to school? If yes, the school nurse should have a spacer too. 11.sometime the mum asks if my child start coughing what should i do.tell her to remove the spacer from his face and allow your child to cough.once setteled repeat the dose because the medication you have given earlier is wasted. 12.sometime she ask what should i do if my child dont like spacer.tell her that you can make it attractive by putting cartoons pictures.
REMEMBER THE YELLOW ONE Note: New guideline says thay in 5 year old child use spacer with mouthpiece to administer the inhaler. -5 year old child can understand your instruction plus some portion of drug is wasted while giving drug through facemask. -So,pick up the blue aerochamber with mouthpiece and tell the mother to ask your child to make a tight seal around the mouthpiece and breath in and out for 5 to 7 time.
Never try to disassemble it. just demonstrate as it is Blue one is for elder children above 5 years. Yellow one between 18 months to 5 years and orange one for up to children under 18 months. Never disassemble the facemask from spacer. Tell her to wash with warm soapy water.
DYSPHAGIA; DDS FOR DYSPHAGIA
1-ESOPHAGEAL CANCER 2-CARDIA ACHLASIA 3-STRICTURES SEC TO CORROSIVE...4-GORD 5-MYESTHENIA GRAVIS 6-SCLERODERMA 7-OESOPHAGITIS 8-GLOBUS HYSTERICUS 9-BULBAR PALSY 10-PHARYNGEAL POUCH 11-OESOPHAGEAL SPASM 12-SEC TO ENLARGED GOITOR HX TAKING; SWALLOWING: “What about your swallowing, any difficulty?”YES - Course: “Is it getting worse? (Progressive)” - Duration: “Does it come and go? (Intermittent)” - Quality: “Is it difficult to swallow liquids (Neuromuscular & mechanical) or solids (Mechanical)?… Do you feel a lump in your throat?” - Timing: “Do you feel the difficulty immediately at the beginning of swallowing (Oropharyngeal) or does food stop in your chest a few seconds later (Esophageal)?.. Is it followed by vomiting?.. Choking or cough?..” -Screen for: Thyroid: “Does the heat or cold bother you more than you think it bothers other people?.. How?..” Scleroderma: “Any skin tightness on your face or hands?” CNS: “Do you have Headaches?…... Do you feel lightheadedness? Do you feel any pins & needles sensations? .. Where?.. Any muscle weakness?.. Where?”
Associated symtoms: -Wt loss -Anorexia -Fever -Night sweats -Nausea/vomiting -Heartburn -Change in bowel habit -Malena+PR bleeding -Jaundice SYMPTOMS OF ANEMIA: -Tirdness+weakness -Palpitation -SOB IMPRTANT TO ASK: SOCIAL HX: -Smoking - Alcohol -Lifestyle....eat fatty,spicy pickled food+beetlenut chew -Recreational drug -Travel -Housing -Employment Rest of the history same as for other GIT hx.
DX IN EXAM= CA OESOPHAGUS INVESTIGATIONS -Blood test -Barium swallow(special xray) -Endoscopy(Camera test to look inside your food pipe and biopsy)
CONSTIPATION: Common DDs: Drugs Dietary Dehydration... IBS Anorectal disease e.g. fissure Depression Bowel Cancer Hypothyroidsm Hypercalcemia
Hx TAKING; Open question: “tell me a bit more about it” and then allow the patient to talk. Specifically ask about: o What exactly they mean by constipation- is it decreased frequency, hard consistency or difficulty in opening bowels? o How long have you had this problem? o Any noted exacerbating or alleviating factors? o Recent changes in diet and lifestyle- including new drugs? o Additional symptoms e.g. nausea and vomiting, alternating diarrhoea, abdominal bloating or pain, perianal swelling or pain, and anorexia. o Has this happened before? o Changes to mood o Do you feel cold in normal environment?Gained weight recently? o Do you feel thirsty all the time? o STOOL: Does your stool look as it was before or different? No Explore: o Shape: “Is it wider, more bulky or narrower?.. Softer or harder?.” o Content: “Is it greasy?.. Does it stick to the bowel or float?,.. Any mucus?, .. Pus?.. Undigested food?.. .” - Colour: “What colour is it?: Pale? (Fat)/ Black? (Malena)/Green? (Pus)” - Blood: “Any blood?” Yes “Is it fresh bright blood (after Splenic flexure) or altered or clots (before)? How much blood?.. A cup?.. Is it gross or only streaks on the stool surface?.. Does the blood appear at the beginning, at the end, all through the motion, or only on the toilet tissue? ” - Smell: “How does it smell?”
PAST MEDICAL HX: o Has this happened before?How often?What remedy did you take to relief the constipation? o Have you ever been told that you have kidney stone? o any past,current or childhood disease? o Any abdominal surgery? DRUG HISTORY: o Prescribed medications. Ask specifically about corticosteroids, NSAIDs, antibiotics, and the contraceptive pill. o Over·the·counter medication e,g co-codamol. o Recreational drugs. o Allergies. FAMILY HISTORY: o Parents, siblings. and children. Ask specifically about colon cancer, irritable bowel syndrome, innammatory bowel disease, jaundice, peptic ulcer, and polyps. SOCIAL HISTORY: o Detail dietry history.Do you consume fruits and vegitable in your diet? o Alcohol consumption. o Smoking. o Travel. o Employment, past and present. o HOUsing. o Contact with jaundiced patients DX IN EXAM=1 BOWEL CANCER 2 DRUG INDUCED
MELENA: Bleeding before splenic flexure present with malena(black stool) D/DS FOR BLACK STOOL. 1-APD 2-STOMACH CANCER 3-NSAIDS... 4-HEMETAMSIS 5-SMALL BOWEL CANCER 6-IRON SUPPLIMENT 7-DIETRY FACTORS HX TAKING: DURATION:How long have you been having this problem? ONSET:Did the color of your stool become black gradually or all of a sudden? PROGRESSION:IS it becoming worse or improving? IS it contineous or intermittent? HEARTBURN: Do you have water brush?.. Any burning sensation in the middle of your chest that radiates to your mouth? SWALLOWING: What about your swallowing, any difficulty? NAUSEA / Vomiting: Do you feel sick? (Nausea), Did you throw up?(vomiting) BLOATING: Any gases?YES Does the gas escape upwards or downwards?... Does it smell? GIRTH: What about your stomach girth?.. Is it bigger?.. Do you feel any lumps or bumps? Yes Where do you feel the lump? PAIN: Any stomach pain?YES - Place: Where do you feel it, point with one finger please? (Localized or generalized)? - Quality: How does it feel like?.. Is it colicky/… diffuse/… sharp/… stabbing/…dull/… tight/… cramps/… Squeezing..?…. Burning? APPETITE: Any change in your appetite recently?YES “Is it more or less than usual?” ASOCIATED SYMPTOMS:
Temperature,weight loss,Jaundice,Hemetamsis,change in bowel habit,Bleeding per rectum. SYMPTOMS OF ANEMIA: o Feel tired and weak o Palpitation o SOB on mere physical activity PAST MEDICAL HX: o Has this happened before?How often? o any past,current or childhood disease?any liver disease? o Any abdominal surgery? DRUG HISTORY: o Prescribed medications. Ask specifically about corticosteroids, NSAIDs, antibiotics, and the contraceptive pill. o Over·the·counter medication. o Recreational drugs. o Allergies. FAMILY HISTORY: o Parents, siblings. and children. Ask specifically about colon cancer, irritable bowel syndrome, innammatory bowel disease, jaundice, peptic ulcer, and polyps. SOCIAL HISTORY: o Alcohol consumption. o Smoking. o Travel. o Employment, past and present. o HOUsing. o Contact with jaundiced patients DDS IN EXAM=STOMACH CANCER,APD,NSAIDS
CHANGE IN BOWEL HABIT: Greet the pt and ask permission; Any recent change in your bowel habit?yes EXPLORE IT: - FREQUENCY:Any change in your bowel motion frequency? In what way?.. How often do you pass your bowel? Is it more or less frequent recently? (Diarrhea: > 3/day unformed/ Constipation: < 3/week hard stool with staining & sense of incomplete evacuation or blockade) - PAIN: Any pain with passing bowel motion?… Any pain in your bottom?. Yes When does it occur? - LESIONS: Any lumps, ulcers or fissures in your bottom? - TENESMUS: Any urgency to pass bowel motion but then little to pass? - CONTROL: Do you control your bowel or you soil yourself? - Stool: Does your stool look as it was before or different? No Explore: - SHAPE: Is it wider, more bulky or narrower?.. Softer or harder?. - CONTENT: Is it greasy?.. Does it stick to the bowel or float?,.. Any mucus?, .. Pus?.. Undigested food? - COLOR: What colour is it?: Pale? (Fat)/ Black? (Malena)/Green? (Pus) - BLOOD: Any blood? Yes Is it fresh bright blood (after Splenic flexure) or altered or clots (before)? How much blood?.. A cup?.. Is it gross or only streaks on the stool surface?.. Does the blood appear at the beginning, at the end, all through the motion, or only on the toilet tissue? - Smell: How does it smell? -ASSOCIATED SYMPTOMS: Any wt loss, anorexia, temperature, night sweats, dysphagia, nausea, vomiting, abdominal pain, Jaundice, pruritis. SYMPTOMS OF ANEMIA: Do you feel yoursel weak and tired? Any palpitation? Do you become SOB on minor physical activity? PAST MEDICAL HX: o Has this happened before o any past,current or childhood disease? o Any abdominal surgery?
DRUG HISTORY: o Prescribed medications. Ask specifically about corticosteroids, NSAIDs, antibiotics, and the contraceptive pill. o Over·the·counter medication. o Recreational drugs. o Allergies. FAMILY HISTORY: o Parents, siblings. and children. Ask specifically about colon cancer, irritable bowel syndrome, innammatory bowel disease, jaundice, peptic ulcer, and polyps. SOCIAL HISTORY: o Ask about lifestyle o Alcohol consumption. o Smoking. o Travel. o Employment, past and present. o HOUsing. o Contact with jaundiced patients DX IN EXAM=BOWEL CANCER
WHEEZE: ONLY HX TAKING STATION: Before starting ask the patient are you comfortable or need inhaler. D/D... Allergy URTI F.body Asthma(could be exercise induced or asthma) Copd Pneumonia GREET the pt.take permission How can I help you? WHEEZ: Do you hear noises in your chest with breathing? OR does it comes from your throat?”(Stridor?) - ONSET: How did it start? Was it all of a sudden or gradually (PE)? - SETTING: What were you doing when it started (Dusting/ Exercise)? -PROGRESSION:Is it becoming worse or improving since it started? -EXCERBATION:Anything that brings it on?(What brings it on? What makes it worse?” “Is it worse with dust?.. Pollen?.. Cold air?.. Pets? (Asthma). -RELIEVING FACTORS:Anything that relieves your symptoms?(rest,inhaler) SEVERITY:How frequent?... How many times a week? DO you become SOB as well?if yes QUALITY:How does it feel like?.. Is it like air hunger, suffocation, or heavy breathing (cardiac)?,…. Is it like rapid shallow breathing? (chest wall), Chest tightness? (Asthma), .. Increased breathing effort? (COPD/ ILS)” SEVERITY:When you get shortness of breath, are you able to speak?,… Got blue?,… Felt tired to breath?,… Blacked out?,.. Sweating? - ORTHOPNEA: Are you able to lie flat in bed without becoming short of breath?.. How many pillows do you sleep on at night?”(asthma>COPD) Do you sometimes wake up gasping for air? (Sleep apnea / Paroxysmal nocturnal dyspnea in CHF)
ASSOCIATED SYMPTOMS:(stridor, cough, sputum, haemoptysis, fever, night sweats, anorexia, loss of weight, chest pain, dizziness). PAST MEDICAL HX: Has this happened before?what did you do to relieve the symptoms. - Current, past, and childhood illnesses. Ask specifically about atopy (asthma/eczema/hay fever), pneumonia, bronchitis, and tuberculosis. - Previous investigations (e.g. bronchoscopy, chest X-ray). - Surgery. DRUG HX - Prescribed medication (especially bronchoditators, NSAIDs, ~·blockers, ACE inhibitors, amiodarone, and steroids). - Over-the·counter medication. - Recreational drugs. - Allergies. FAMILY HX: - Parents, siblings, and children. Focus especially on respiratory diseases such as atopy, cystic fibrosis. tuberculosis, and emphysema (lXt-antitrypsin deficiency). SOCIAL HX: - Employment. past and present. Ask about occupational exposure (mining, farming, asbestos). - Housing. - Travel(e,g Pakistan,India,Africa)tuberCulosis contacts. - smoking - Use of alcohol. - Hobbies (especially pigeons and budgerigars
HEMOPTYSIS: DDS IN EXAM= LUNG CANCER =COPD(pt was heavy smoker but has now stoped smoking.ask pt do you smoke=pt says no.ask him have you ever smoked=pt says yes and then ask further question. HX IS same as I described for T.B but here presenting complaint is coughing blood so you will start asking about hemoptysis. GREET the pt and take permission.... How can I help you? - BLOOD: Do you cough up blood? Yes Fresh blood or altered? How much blood? How frequent do you cough up blood? How long are you coughing blood?any previous episode? COUGH: Do you have cough? Yes: Explore: - DURATION: “You said it started … ago, does it come and go? If yes “For how long it dose stay each time?” Acute vs. chronic (>3 months for 2 years). - PLACE: Do you feel it coming from something in your throat or deep in your chest? - QUALITY: Is it dry or with sputum / phlegm? Yes - SPUTUM: How much sputum would you say?… A cup a day?.. Is it thin or thick?.. What colour is it?.. How does it smell? - TIMING:: Is it worst in a particular time of the day or season? How often does it come?” (Morning: smoking,Nocturnal: Postnasal drip, CHF, asthma.) - EXCERBATING FACTORS: What brings it on? What makes it worse? Is it worse with dust?.. Pollen?.. Cold air?.. Pets? (Asthma)..Position? (GERD). ASSOCIATED SYMPTOMS: (wheeze, stridor,fever,night sweats, anorexia, loss of weight, chest pain, dizziness). SMOKING HX: Do you smoke? Have you ever smoked?
How long? How many cigaretts a day? PAST MEDICAL HX: - Current, past, and childhood illnesses. Ask specifically about atopy (asthma/eczema/hay fever), pneumonia, bronchitis,COPD and tuberculosis. - Previous investigations (e.g. bronchoscopy, chest X-ray). - Surgery. DRUG HX - Prescribed medication (especially bronchoditators, NSAIDs, ~·blockers, ACE inhibitors, amiodarone, and steroids). - Over-the·counter medication. - Recreational drugs. - Allergies. FAMILY HX: - Parents, siblings, and children. Focus especially on respiratory diseases such as atopy, cystic fibrosis. tuberculosis, and emphysema (lXt-antitrypsin deficiency). SOCIAL HX: - Employment. past and present. Ask about occupational exposure (mining, farming, asbestos). - Housing. - Travel(e,g Pakistan,India,Africa)tuberCulosis contacts. - Use of alcohol. - Hobbies (especially pigeons and budgerigars!).
DRY COUGH DX IN EXAM=TUBERCULOSIS Greet the patient and take permission and then ask How can I help you? ... COUGH: “Do you have cough?” Yes: Explore: - DURATION: “You said it started … ago, does it come and go? If yes “For how long it dose stay each time?” Acute vs. chronic (>3 months for 2 years). - PLACE: Do you feel it coming from something in your throat or deep in your chest? - QUALITY: Is it dry or with sputum / phlegm? Yes - SPUTUM: “How much sputum would you say?… A cup a day?.. Is it thin or thick?.. What colour is it?.. How does it smell? - BLOOD: Do you cough up blood? Yes Fresh blood or altered? How much blood? How frequent do you cough up blood? - TIMING:: Is it worst in a particular time of the day or season? How often does it come?” (Morning: smoking,Nocturnal: Postnasal drip, CHF, asthma.) - EXCERBATING FACTORS: What brings it on? What makes it worse? Is it worse with dust?.. Pollen?.. Cold air?.. Pets? (Asthma)..Position? (GERD). ASSOCIATED SYMPTOMS: (wheeze, stridor,fever,night sweats, anorexia, loss of weight, chest pain, dizziness). PAST MEDICAL HX: - Current, past, and childhood illnesses. Ask specifically about atopy (asthma/eczema/hay fever), pneumonia, bronchitis, and tuberculosis. - Previous investigations (e.g. bronchoscopy, chest X-ray). - Surgery. DRUG HX
- Prescribed medication (especially bronchoditators, NSAIDs, ~·blockers, ACE inhibitors, amiodarone, and steroids). - Over-the·counter medication. - Recreational drugs. - Allergies. FAMILY HX: - Parents, siblings, and children. Focus especially on respiratory diseases such as atopy, cystic fibrosis. tuberculosis, and emphysema (lXt-antitrypsin deficiency). SOCIAL HX: - Employment. past and present. Ask about occupational exposure (mining, farming, asbestos). - Housing. - Travel(e,g Pakistan,India,Africa)tuberCulosis contacts. - smoking - Use of alcohol. - Hobbies (especially pigeons and budgerigars!). INVESTIGATION: CXR AFB(in this case no sputum so less important) BRONCHOSCOPY Bronchial lavage Blood tests
CHEST PAIN: 5 Histories comes with chest pain 1-ACS STEMI (take hx discuss mx with examiner) 2-ACS NSTEMI (take hx discuss mx with examiner) 3-PCP(pneumocystitis cranii pneumonia) (Hx and Dx) 4-CAP(community acquired pneumonia)(Hx and discuss mx with examiner) 5-Pulmonory embolism(chest pain with SOB in an air hostess on ocps) ACS: Is the major killer worldwide and purpose of this station is to assess your ability to identify it and give immidiate rescue treatment which reduces the mortality. SOCRATES will rule oute the d/ds but most important thing is to identify the risk factors(previous MI/angina,AF,Diabetes,Hypertension,Hypercholestremia,Lifestyle,smoking,Alcohol,Occupat ion and family hx) The only difference between two is that in STEMI THERE WILL BE ST elevation on ECG which will be normal in NSTEMI.thats why you need to do cardiac enzyme to make the dx. DIAGNOSTIC crieteria for ACS is based on 3 things and 2 must be presnt to make the dx. 1.Hx 2-ECG 3-Cardiac enzyme In STEMI hx plus ECG is sufficient for dx start the tx.In NSTEMI Hx is positive but ECG is normal so cardiac enzyms are necessary to make the dx. PRESENTING COMPLAINTS: o Ask about the nature of the chest pain. Use open questions and give the patient time to tell history. Also remember to be empathetic: chest pain can be a very frightening experience. o Elicit the patient'S ideas, concerns, and expectations. o For any pain. determine its: o Site and radiation:central chest pain radiating toward jaw and left arm. o Character:Heavy,squeezing,burning,sharp stabbing. o Severity (e.g. 1 to 10, sleep disturbance). o Onset and duration:How did it start?what were you doing at that time?How long did it stay? o Aggravating and alleviating factors (exercise, cold air, large meals, alcohol,movement). o Associated symptoms and signs. Ask specifically about nausea and
vomiting, shortness of breath, dizziness, cough, and palpitations,leg swelling. o Ask about any previous episodes of chest pain:what was the outcome. Past medical history: o Current, past, and childhood illnesses. o In particular, ask about coronary heart disease, myocardial infarction, rheumatic fever, stroke, intermillent claudication, hypertension, hyperlipidaemia, diabetes, smoking, and alcohol use. o Surgery. Drug history: o Prescribed medication, including the oral contraceptive pill if female. o Over-the-counter medication. o Recreational drugs. o Allergies. Family history: o Parents. siblings, and children. Ask specifically about heart disease. hypertension. and other heritable cardiovascular risk factors. Social history: o Effect of the chest pain on the patient'S life: o Employment. o Housing. o Hobbies. After taking the history Ask the patient if there is anything else that he might add that you have forgotlen to ask. This is an excellent question to ask in clinical practice. and even better one to ask in exams. Thank the patient smile emoticon ASK the examiner for ECG.....ST elevation.....Dx is ACS MX: Sit up the patient. Oxygen and pain killer(iv morphne+s/l nitrites) if needed(new guideline says if oxygen saturation is less than 94% than give oxygen) Connect with all the monitors(pulse oximeter,B.P,cardiac monitor) asprine(300mg) +clopidogral(600mg) stat S/C heparin as per hospital protocol after senior consultaion
Blood test including cardiac enzyme and lipid profile. Prepare pt for PCI otherwise inform the cardiolgy team to consider thrombolysis. IF ECG normal....I'll discuss ECG with my seniors and repeat the ECG.To make or exclude the dx i'll do cardiac enzyme at 6 hrs form onset of pain and then at 12 hrs(trop t). Rescue Mx; Oxygen and pain killer(iv morphne+s/l nitrites) if needed(new guideline says if oxygen saturation is less than 94% than give oxygen) Connect with all the monitors(pulse oximeter,B.P,cardiac monitor) asprine(300mg) +clopidogral(600mg) stat Blood test including cardiac enzyme and lipid profile. Consult seniors.
CHEST PAIN DUE TO PNEUMONIA ASK 1-SOCRATES 2-TEMPERATURE(high/low,contneous/intermittent,rigors and chills,night sweats) 3-COUGH....spotum(amount,color,consistency,blood)...4-SOB,Palpitation,leg swelling Past medical history: o Current, past, and childhood illnesses. Ask specifically about atopy (asthma/eczema/hay fever), pneumonia, bronchitis, and tuberculosis. o Previous investigations (e.g. bronchoscopy, chest X-ray). o Surgery. Drug history: o Prescribed medication (especially bronchoditators, NSAIDs, ~·blockers, ACE inhibitors, amiodarone, and steroids). o Over-the·counter medication. o Recreational drugs. o Allergies. Family history: o Parents, siblings, and children. Focus especially on respiratory diseases such as atopy, cystic fibrosis. tuberculosis, and emphysema (lXt-antitrypsin deficiency). Social history: o Employment. past and present. Ask about occupational exposure (mining, farming, asbestos). o Housing. o Travel, tubefCulosis contacts. o Use of alcohol. o Hobbies (especially pigeons and budgerigars!). DX= CAP...Community acquired pneumonia MX: Pain killer Oxygen if neede Blood test,blood cultures.cxr antibiotic as per hospital protocol
CHEST PAIN DUE TO RESPIRATORY CAUSE. 1-PCP......Young pt with chest pain and become SOB on minor walk. Ask SOCRATES and cough,spotum,and SOB(exercise tolerance.....how many blocks can you walk without being SOB),hemoptysis Are you running any temperature? Have you lost weight recently?How much?over how long period?... Have you lost your appetite? SEXUAL Hx: very important. Are you sexually active? Is your partner male or female? Do you practice anal or vaginal sex(anal sex carries more risk for HIV than vaginal sex)If anal....do you give or receive? Is your partner is stable or unstable? Do you practice safe sex?use condoms? How many sex partner do you have in the previous 3 months? Do you use any recreational drug by injection?If yes....Do you share the needle?
PAST MEDICAL HX: Has this happened before? Anyother medical condition? o Current, past, and childhood illnesses. Ask specifically about atopy (asthma/eczema/hay fever), pneumonia, bronchitis, and tuberculosis. o Previous investigations (e.g. bronchoscopy, chest X-ray). o Surgery. Drug history o Prescribed medication (especially bronchoditators, NSAIDs, ~·blockers, ACE inhibitors, amiodarone, and steroids). o Over-the·counter medication. o Recreational drugs. o Allergies. Family history: o Parents, siblings, and children. Focus especially on respiratory diseases such as atopy, cystic fibrosis. tuberculosis, and emphysema (lXt-antitrypsin deficiency).
Social history: o Employment. past and present. Ask about occupational exposure (mining, farming, asbestos). o Housing. o Travel, tubefCulosis contacts. o Use of alcohol. o Hobbies (especially pigeons and budgerigars!). THANK th Pt
DX=PCP
DIZZINESS/FUNNY TURNS DX in EXAM=BPV(Hx +Dx) If Dx and Ix to examiner than it is POSTURAL Hypotension(MX=24 hrs ambulatory B.P) D/ds Vestibular neuritis Labrynthitis BPV Menier's disease Acoustic neuroma Stroke cerbellar ataxia Vasovagal syncopy cardiac problem postural hypotension Drug induced HX Dizziness: “Have you felt unsteadiness (vertigo) or light-headedness (presyncope)?” Did you remembers falling? What were you doing before the fall? - Duration: For how long? - U: Does it change with your head movement?.. Opening or closing your eyes?.. How?(Vestibular) Does it only occur for a minute in certain head positions? (BPV, VBI) Does it change with exercise? (Cardiopulmonary) Had you just arisen from bed? (postural hypotension) Did you suffer an Intense emotion? (syncope) Had you been coughing or straining? (syncope) Had you been extending your neck? (vertebrobasilar insufficiency) Did you have any palpitations? (arrhythmia) Any loss of consciousness and its duration. Prodromal symptoms such as aura, change in mood, strange feeling in the gut, !llll5atlon of deja vu. Fitting. frothing at the mouth. tongue biting. incontinence? Headache or confusion upon recovery? Injuries sustained.? Previous episodes?
- Associated symptoms: “Have you noticed anything else that occurs with it? ... Feeling sick (nausea) or throwing up (vomiting)?…/or hearing change?(Inner ear disease),... Gait problem? (Ataxia),.. Double vision?, Difficulty speaking? (Brainstem disease) Past medical history: o Current. past, and childhood illnesses. Ask specifically about epilepsy, heart problems. stroke. diabetes (autonomic neuropathy). cervical spondylosis. and arthritis. o Surgery. Drug history: o Prescribed medication. Drugs such as anti psychotics. tricyclic antidepressants. and antihypertensives can cause postural hypotension. Insulin can cause hypoglycaemia. o Over·the-counter medication. o Recreational drugs. o Recent changes in medication. Family history: o Parents. siblings. and children. o Ask specifically about epilepsy and heart problems. Social history: o Smoking. o Alcohol use. o Employment. past and present. o Housing. o Effect of falls on patient's life. After taking the history Ask the patient if there is anything he might add that you have forgotten to ask about. Ask him if he has any questions or concerns. Thank the pt.
LOSS OF CONCIOUSNESS In EXAM young patient found unconcious outside the pub after drinking beer brought by Ambulance.While you are taking Hx ask the event before the episode,any witness during the LOC and what happened after the episode.Never forget to ask has this happend before.In this station after taking hx ask examiner I would like to know about the GCS,vitals and examination findings.EX will tell you findings. DX: LOC due to head injury+tell the management to the examiner Mx:keep under neuro observation ECG,CT scan and blood test if needed.
D/Ds Head injury. SAH Hypoglycemia Meningitis stroke/TIA Drug abuse/alcohol vasovagal syncopy arrythmias MI Aortic dissection HX TAKING: How can I help you? Ooh did you hurt yourself?(empathy) BEFORE the Incident:What were you doing before this incident? DURING the Incident: Duration: “For how long did that last?” - Completely: Did you lose consciousness completely or could voices be heard? - Body Position: What was your position during the attack? - Body Movements: Did any body movements occur? - Tongue-biting: Did any tongue-biting occur? - Confusion/ sleepiness after attack: How did you feel after the attack? - Urinary/ bowel Control: Was there any loss in bladder or bowel control? If Seizures: At what age did it start? How often dose it happen? - Warning signs: Was it preceded by warning signs?.. such us lightheadedness?
RULE OUT THE D/Ds Are you running any temperature?Rash,Neck stiffness,Photo phobia Have you noticed any facial or limb weakness/numbness. Do you have any heart problem like angina or irragular heart beat? Any medical condition e,g diabetes and high B.P When did you have your last meal? Do you drink alcohol or anyother recrational drug? Past medical history: o Current. past, and childhood illnesses. Ask specifically about epilepsy, heart problems. stroke. diabetes (autonomic neuropathy). cervical spondylosis. and arthritis. o Surgery. Drug history: o Prescribed medication. Drugs such as anti psychotics. tricyclic antidepressants. and antihypertensives can cause postural hypotension. Insulin can cause hypoglycaemia. o Over·the-counter medication. o Recreational drugs. o Recent changes in medication. Family history o Parents. siblings. and children. o Ask specifically about epilepsy and heart problems. Social history o Smoking. o Alcohol use. o Employment. past and present. o Housing. o Effect of falls on patient's life. After taking the history Ask the patient if there is anything he might add that you have forgotten to ask about. Ask him if he has any questions or concerns. Thank the pt
ANOREXIA NERVOSA: YOUNG GIRL BROUGHT BY THE MOTHER. Greet the patient and ask about do you know why you have been here? listen the pt carefully and then ask permission that i need to ask you some question regarding your weight and eating habit. WEIGHT AND PERCEPTION OF WEIGHT: Determine: can you pleaase tell me your current weight and height? How much weight have you lost? and over how long? Are you losing weight intentionally? Why? Do you still considers yourself that you are overweight? How often do you weighs yourself? How often do you looks at yourself in the mirror? Who is your role model? What type of cloths do you like to wear? DIET AND COMPENSATORY BEHAVIOURS: Ask about: Do you eat balance diet? What Amount of food do you eat in an average day? Are you in habit of Binge eating? Are you Vomiting? Are you using any laxatives, purgatives. diuretics. appetite suppressants, and stimulants to lose your weight? Are you doing physical exercise?How many times a day going to gym? OTHERS: Ask about: Menstrual periods.Do you have regular periods? Effect on patient'S life:how has this been affecting you? Relationships.Are you single or in relationship? Medical complications, e.g. anaemia, peptic ulceration, constipation. MOOD,INSIGHT,SUICIDE,PSYCHOSIS QUESTIONS: Do you feel depress and low? Have you lost interst in activities that were enjoyable to you? Any change in your appetite,sleep and concentration level? How do you see your future?
Have you ever tried to take your life?Any plans? Have you ever tried to harm anyother person?any plans? Are you sensing the things which other people think that they are not real?(it covers all type of hallucinations e,g tactile auditory and visual) Do you drink alcohol?or anyother recreational drug? Past medical. drug. and family history (briefly and only if you have time left).
ANXIETY: This station comes as only history taking. Greet the pt ask what bring you to the hospital. Listen carefully to the pt.Dont interrupt. Now start digging the History How long have you had these symptoms?(GAD>6 month) How did it start?sudden or gradual? Did anything happen just before you start feeling like this? Has it been building or remained steady state? Anything that makes this condition worse? Anything that relieve your symptoms? Is it contineous or intermittent? Are you experiencingciated symptoms?e,gSOB,muscle tightness,lump in throat,palpitation and sweating.
DIFFERENTIALS: Have you experienced tremors,change in bowl habit and feel more hot in normal temperature.? Do you experience sudden onset of intense fear and discomfort? Do you have fear of any specific thing,place or situation?e,g snake,open spaces. Do you get any thoughts over and over and feel compulsion to do certain task? Are you taking excessive amount of coffe or stimulants? How has this been affecting you?How are you coping? MOOD,INSIGHT,SUICIDE,PSYCHOSIS QUESTIONS: Do you feel depress and low? Have you lost interst in activities that were enjoyable to you? Any change in your appetite,sleep and concentration level? How do you see your future? Have you ever tried to take your life?Any plans? Have you ever tried to harm anyother person?any plans? Are you sensing the things which other people think that they are not real?(it covers all type of hallucinations e,g tactile auditory and visual) Do you drink alcohol?or anyother recreational drug? Are you working or unemployed? PAST MEDICAL PSYCHIATRIC HX: FAMILY HISTORY DRUG HX:
Are you taking any regular medication or have you stop taking any medication abruptly. DO YOU HAVE ANY CONCERN REGARDING YOUR SYMPTOMS: Reassure the pt as in question it is mentioned that all medical causes have been ruled out. Thank the pt:)
MANIA(Feeling high): This pt brought by the police as he/she was trying to enter into a closed shop by window and injured herself.Ask her why did the police bring you here?(this pt has mania and will describe the whole story as she is talkative) dont interrupt the pt.when he stop talking than start asking questions of MANIA “Have others around you noted a persistently elevated, expansive mood, energy, or self-esteem?” Mania screen. Yes: - COURSE: “Is it constantly feeling high (mania) or there are periods that you felt down (Bipolar II)?.. How often does your mood alternate in a year?.. So, it is more (Rapid cyclic)/ less than 4 times a year?” - DURATION: “….., So, you’ve been feeling down for less/ more than 1 weeks? (Manic episode)” - V: “Has it happened before? ”... When?” (Yes: Bipolar I disorder, No: Manic episode). “For how long you’ve been having these episodes on & off?... So, it is more (chronic)/ less than 2 years” BEFORE THIS EPISODE: - “How was your feeling before? Does anything happened or changed in your life? Are there any stresses at this point in your life? Were you taking any medications that you stopped recently?” - GST PAID: 3 of the 7: - Grandiosity: “Do you feel you are a very important person with special talents, power, mission, or role?” - Sleep: “How is your sleep?.. Do you feel you can get by through the day with less sleep than usual” - Talkative: “Do people say that you are more talkative than usual?” - Pleasurable activities: Painful consequences: “Do you drink & drive? Do you use a substance a lot? Do you spend more than you can afford?
Do you have inappropriate sexual behaviors?” ACTIVITY: “Do you feel you have increased energy?” Flights of ideas: “Are thoughts racing in your mind? Do people say you jump from topic to topic?” Distractibility: “Do you get distracted easily?” Organic causes: STEAM: SLE, Trauma, Endocrine, AIDS, MS INSIGHT,SUICIDE,PSYCHOSIS QUESTIONS How do you see your future? Have you ever tried to take your life?Any plans? Have you ever tried to harm anyother person?any plans? Are you sensing the things which other people think that they are not real?(it covers all type of hallucinations e,g tactile auditory and visual) How has this been affecting you,your job and relationship and how are you coping? Thank the pt
PSYCHOSIS: I am going to write about another station.This pt brought by the police as wondering in the park.This is a calm pt.Ask him do you know why you have been brought by the police here? What were you doing? I have written everything in detail.You will ask further detail if pt says yes for any question. SCHIZOPHRENIA: 2 of the followings for > 1 month active phase & residuals for > 6 months. 1. Hallucinations: Auditory, visual, tasting, olfactory. “Are you sensing things that others think they are not actually there, like seeing, hearing, or smelling things?”If yes - DURATION: “When did it start?( So it is less than a month (Brief psychosis)/ more than a month but less than 6 months (Schizophreniform)/ more than 6 months? (Schizophrenia)”. - “What?……. Where?….. When?……” - IF AUDITORY: “Are these voices familiar? Whose voices are you hearing? . Are they voices of one or more persons talking?. What do they say?” (Diagnostic if two voices conversing to each other or one commenting on his actions:) “Are they telling you to do things?... What things? Are they commenting on your actions?”. 2. DELUSIONS: “Do you believe that there are unusual things happening concerning you?”If yes - NON-BIZARRE: - Persecutory: “Are you being followed?” - Grandiosity: “Are you having special power, task, role?” - Erotamia: “Are you being loved by another person?” - Jealous: “Do you think your partner is unfaithful?” Yes: “ When did it start?” non-bizarre for > 1 month: Delusional disorder.- BIZARRE: - Reference: “Are there events having direct reference to you?” - Control: “Are you being controlled by some external sources?” - Thought broadcasting/Insertion/ withdrawal: “Do others know your thoughts?” - Religious: “Are you having a religious mission or task?” 3. Disorganized: “Do you get agitated, excited, or hostile?”
4. Thought disorder: “Are you unable to think straight?” - Loss of association. - Tangentiality: Jumping from subject to another. - Incoherence - Neologism (new words) - Though blocking. 5. NEGATIVE SYMPTOMS: - Alogia: Poverty of speech. “Do you have difficulties finding words to explain things?” - Affective flattening: “Do you have less emotional or inappropriate emotional responsiveness?”. - Avolition: “Any loss of motivation, drive, initiativeness?”. - Anhedonia: “Any loss of interest in things were enjoyable to you?”. - Apathy: Lack of interest in the surroundings: “Have you lost interest in things or activities that where interesting to you?” 6- COGNITIVE Disorders: “ Do you have memory problems or forgetfulness? (Dementia), …Do you feel agitated, irritable? (Delirium)” 7- Psychiatric VITALS: Must ask in all psychiatric cases. 1. “Do you have thoughts of hurting yourself?… Any suicide attempts?... Any plans now?” 2. “Have you ever hurt anyone? … Any plans now?” 3. “Have ever had difficulty caring for yourself?” 4. “How has this been affecting you, your relationship, your family, or your work?... What things are you no more able to do?” Marked distress needed for all psychiatric diagnoses. 8- Psychiatric Past Hx: “Any other similar complaints in the past? … Any psychiatric illnesses in the past?… How have you been before this?” “Any problems with the police or the law?” 8- Family Hx of SADDD: Suicide, Alcohol, Drugs, Depression, Divorce. “Any family history of suicide?... Alcohol abuse?... Depression?... Drugs?.... Divorce?” THANK THE PATIENT
TIP TO PASS THE URINARY CATHETER: In GMC mannikin for catheter some people are unable to pass the catheter and people face the problem when they try to push back the cover, catheter also comes back and slips down. Here is a tip that might be beneficial for some people. Tip: (the trickiest part) you won’t have problem to push the catheter inside, the difficulty is the moment you try to get cover out, catheter will come out with it. Remember you are using only your right hand, so ...push catheter inside and try to fold the bag and leave it to open carefully. Tip:If you are finding difficulty to pass the catheter slowly move the shaft ups and down or horizontally. Hopefully you'll be successful.
ALCOHOL abuse history taking; This station comes in psychiatric history taking.Patient comes with other problem like gastric erosion and ingrowing toe nail.Investigation has been done and shows alcohol related abnormalities.Pt is reffered by medica/emergency to the psychiatric department for Alcohol abuse asessment. Greet the pt and describe the brief story that I came to know that you came to hospital because of(name of problem).My collegue has done some test and found some ...abnormality that could be due to alcohol intake. I am here to ask you some question regarding your alcohol intake.Is it ok with you? and just to reassure you whatever you tell me is confidential within the boundries of team taking care of you. QUESTION ABOUT THE AMOUNT AND PATTERN OF DRINKING: Do you drink alcohol? How long have you been drinking? What type of alcohol do you drink?(bear,spirit,whisky) How much do you drink at one time? Do you drink on the weekends or throughout the week? What time do you drink?(morning/evening or throughout the day) Where do you tend to drink?(home,pub) Whom do you drink with? Is there anything that makes you to drink more or less? How much do you spend on alcohol? QUESTIONS ABOUT DEPENDENCE OF ALCOHOL: Have you ever thought that you need to cut down on your drinking? Do you get annoyed when othe people comment on the amout you drinking? Have you ever felt guilty the way you are drinking? Have you ever used alcohol as eye opener? Do you feel sick,shaky and sweaty if you do not drink alcohol? Do you need to drink mare amount of alcohol than you used to get the same effect? Do you feel compulsion for drinking?How important is drinking for you? EFFECTS OF ALCOHOL ABUSE ON LIFE: Do you think that you are eating balance diet? Are you single or in relationship? Do you work or unemployed? Are you able to maintain your social life? Have you ever been in contact with police regarding alcohol related crimes? Do you use anyother recreational drug?
MOOD,INSIGHT,SUICIDE,PSYCHOSIS QUESTIONS: Do you feel depress and low? Have you lost interst in activities that were enjoyable to you? Any change in your appetite,sleep and concentration level? Do you think that you have problem with Alcohol and you need help? Have you ever tried to take your life?Any plans? Have you ever tried to harm anyother person?any plans(bcz in alcohol abuse persecutory delusions are very common) Are you sensing the things which other people think that they are not real?(it covers all type of hallucinations e,g tactile auditory and visual) How has this been affecting you,your job and relationship and how are you coping? Have you ever tried to to stop drinking?if yes then ask why it was unsuccesful? ASK FOR FAMILY HX OF ALCOHOL ABUSE, DEPRESSION,DEVORCE AND DRUG ABUSE Thanks the patient
