MEDICINE H&C

Read task Carefully.

HISTORY & COUNSELLING
Read task carefully.
Take history proper & discuss with patient.
Take history & No discussion.
Take History & D/D & Discuss with Examination.
Take History & Discuss management with Examiner.
HISTORY TAKING

UNCONSCIOUS
RED EYE
WEIGHT GAIN
HOARSNESS OF VOICE
DIARRHEA
LOSS OF CONSCIOUSSNESS
HAEMETEMESIS
DRY COUGH
BACK PAIN
FEVER
VOMITING
DIPLOPIA
CALF PAIN
ELDERLY CONSTIPATION
KNEE PAIN
HAEMOPTOSIS
VERTIGO
EARACHE

COUNSELLING

EPILEPSY
MULTIPLE SCLEROSIS
ASTHMA
CHRONIC RENAL FAILURE
DIABETES COUNSELLING
POST MI COUNSELLING

Unconscious:
Management:
Observe
CT Scan
4minutes History taking
Last Seconds: Differential
P3 MAFTOSA

P1 ODIPARA
O Onset
D Duration
I Intensity
P Progression
A Alleviating
R Relieving
A Associated Symptoms
Pain: Offer Painkillers.
Vomiting, Diarrhea:
Rule out dehydration:
Are you feeling excessively thirsty?
Are your lips gone dry?
Decrease urination : Passing less water than before?
Blood Loss:
Rule out Anaemia:
Always tired?
Racing of heart?
Shortness of breath?
Meningitis:
Fever, grade of fever, higher evening spikes. Vomiting. Neck stiffness.
Photophobia: Is the light bothering you?
Rash: Have you noticed any rash in your body?
Subarachnoid Haemorrhage:
Headache: Sudden, few hours.
Worst headache in my life, in the back of my head.
Associated: Vomiting, neck stiffness (is neck hurting you)
GCA:
Age: 60 years. Female usually.
Unilateral painless one side. Temporal.
When I comb, touching hair it worsens.
Have you noticed any visual problems?
Space Occupying lesion
Worsening headache over time.
Nausea, vomiting in morning, when you wake up in the morning?
Have you noticed any visual problems?
Have you noticed any numbness in your face or limbs?
Acute Glaucoma
Age Old
Headache feel it in the back of the eyes.
Have you noticed any colour haloes?
Medication: Steroids. Amytriptiline.
Migraine
Have you been diagnosed with a condition called migraine?
Have you experienced any auras before this headache coming to you?
Cluster Headache

Age Middle age.

Onset Its more in the night.
One sided.
Its comes again and again, almost 12 weeks, every 2-4 weeks.
Tension Headache
Band-like headache.
Gets worst by the end of the day.
Sinusitis
History of fever, running nose.
Trauma
IF THEY
DONT UNDERSTAND YOUR ACCENT: PATIENT SAYS: PARDON DOCTOR.

RED EYE
D/D:

Trauma
Foreign Body
Conjunctivitis
Uveitis
Acute Glaucoma
Rheumatoid Arthritis
Reiter Syndrome
Systemactic Lupus Erythemaous (SLE)
Inflammatory Bowel Disease

RULES OF ENGAGEMENT: Ruled out at least 5 differentials according to age.

D/D:
Trauma: Did you hurt yourself?
Foreign Body: Do you think something has gone into your eye by accident?
Conjunctivitis: Watering discharge from your eye? Pain in the eye in the morning?
Anyone in the family suffering from something similar.
Uveitis: Young patient, family history, back pain. Dx: Uveitis secondary to Ankylosing
Spondilantis
Acute Glaucoma: Old patient. Pain in the eye, coloured halos.
Rheumatoid Arthritis: Pain or stiffness in joints in the morning.
Reiter Syndrome: Privacy and confidentiality. Travel History Thailand. Burning
sensation when you passed urine? Joint pains.
Conjunctivitis.
Arthritis.
Urinary Tract Infection.
Diagnosis: Conjunctivitis due to Reiter syndrome. Give Dx of symptom.

SLE: Have you noticed any rash in your face? Fever, Joint Pain.
Inflammatory Bowel Disease: Altered bowel Habits.

WEIGHT GAIN

Hypothyroidism
Cushing Syndrome
PCOD
Acromegaly

Hypothyroidism: Feel cold in the same moment as others feel normal. Decreased
appetite. Tired. Dry hands. Constipation.
Cushing Syndrome:
Bluish striae.
Facial hair growth.
Medication: Steroids.
PCOD:

Trying hard to concentrate same last month.

Periods history.
Facial Hair growth.
When was your last menstrual period? Is there any chance you are
pregnant?

Hereditary: Family History

Habitual: Diet History: Carbohydrates.
Acromegaly: Male patient. Have you noticed any change in ring or shoe size.
Increased sweating.

HOARSNESS OF VOICE
Smoking. Vocal Abuse.

DIARRHEA
Young patient.
Acute: GE, Food Poisoning.

Chronic: Laxative abuse. Doxigin.

Chronic:
Malignancy

IBS (Inflammatory Bowel Syndrome)

IBD (Inflammatory Bowel Disease)
Lactose intolerance
Diabetic Neuropathy.
Malabsorption (Celiac Disease)
Hypothyroidism.
HIV

Ulcerative Colitis:
I was admitted at a hospital, they gave some medication.
Old hospital admissions for tummy. Travel/Family history.
Cancer of Colon: Loss of weight, appetite, Family history. Blood in stools.
IBD: Skin lesions. Blood in stools. Joint pain.
IBS: Alternate bowel habits. After eating a meal I have to go to a bathroom.
Malabsorption:
Have you ever been diagnosed with Celiac Disease?
Do you think that after eating a particular food you are having this problem?
Hyperthyroidism: Weight loss. Heat Intolerance. Diarrhea.
Diabetic Neuropathy : Have you ever been diagnosed with Diabetes?
Lactose Intolerance : Are you allergic to any milk products?

LOSS OF CONSCIOUSSNESS
D/D:

Subarachnoid Haemorrhage
Trauma
Meningitis
Stroke/TIA
Arrhythmias
Hypotension
Hypoglycaemia

Young patient: Trauma. Hypoglycaemia. Meningitis.

>24 Stroke
<24 TIA
Stroke/TIA: Past history of Diabetes, Hypertension.
Arrhythmias: History of heart problems.
Hypotension: Prolonged standing. Hypertension.
Hypoglycaemia: Missed the meal. Family history of Diabetes Mellitus. Alcohol (excessive).

Middel aged woman:

Have you been standing a long time? Was somebody with you (daughter)? Did you notice
pale?
Epilepsy: Have you ever been Diagnose with Epilepsy?
Third person testimony: LOC. Tongue bitting.

HAEMETEMESIS

Oesophageal varices
Oesophageal Carcinoma
Mallory Weiss Syndrome
Oesophagitis
Gastric erosion

Haemetemesis: Blood in vomiting. Rule out anaemia. Endoscopy recent.

Age factor: 20 years 40 years.
Oesophageal Varices: Alcohol >5-6 Units/day.
Have you ever been diagnosed with problems with your liver?
Carcinoma: History of weight loss and loss of appetite. Fullness in epigastrium.
Mallory Weiss Syndrome: Binge drinking.
Oesophagitis: Do you feel any heartburn? When or after lying down or after eating your meal
at night?
Gastric erosion: Painkillers. Blood thinners. Instrumentation.

CHEST PAIN
Diagnosis:

Cardiac: ACS, Pericarditis. DAA. Stable Angina.

Respiratory: Pneumonia. Costocondritis. Pneumotorax.
Pulmonary embolism.
Gastrointestinal: GERD. Gastroeosophageal reflux.
Pleural Effusion: Pain relieved by lying in opposite side.
Myocardial Infarction:
Painkillers firts.
Chest pain >30 minutes, doesnt go with rest.
Angina: Central chest pain <30 minutes, pain goes with rest. Medications:
Prescribed a GTN spray.
Pulmonary embolism: Travel history. Surgery. Family History. Sharp localized pain
in chest. Pain is aggravated by inspiration.
Pericarditis: Localized, sharped pain in chest. Pain is relieved by moving forward.

Pleural Effusion: Shortness of breath, fever, cough. Pain gradually worsens, not
sudden. Pain relieved by lying in opposite side.
Dissecting Aortic Aneurysm: Pain radiating to the back.
GERD:
Fracture rib: Trauma: Did you hurt yourself?
Herpes zoster: Have you noticed a painful rash?
Eosophageal spasm: Pain aggravates with hot or is relieved by cold drinks.

DRY COUGH
HIV: Pneumocystc carrini.
Causes:

Asthma
Pneumonia
Smoking
Occupational
Smokers Cough:

D/D:
Asthma:
Old Patient: Cardiac Asthma
Young patient: Asthma
Asthma:
Have you ever been diagnosed with a condition called asthma?
Did you noticed any wheeze with your mouth?
Upper Respiratory Infection: Fever, Cough, Running nose. Short History.
HIV:
Are you sexually active?
Are you married/ or have a partner?
Do you practice safe sex?
Do you use recreational drugs? What route?
Have you ever been diagnosed with a condition called HIV?
Atypical Pneumonia: Travel History: Spain.
Allergies: Are you allergic to anything? Peanuts, nuts?
Postnasal drip:
Have you a recent admission to a hospital?
Did doctors put instrumentation in your nose?

BACK PAIN

DISCTOMA

Disc Prolapse
Infection
Secondary
Cauda equine
Trauma
Osteoporosis
Multiple Myeloma
Ankylo Spondilosis
Pelvic Inflammatory Disease

Disc Prolapse: Numbness in your body, tingling in the back. Pain radiates from your
back to the heel?
Infection: Fever, Weight loss, Severe back pain.
Secondaries: Have you ever been diagnosed with a cancer? CA prostate.
Cauda equina: Pain in back. Numbness, weakness in lower limbs.
Trauma: Muscle spasm.
Osteoporosis: Age: female, old patient. Back pain, Joint pain, stiffness in evening.
Multiple Myeloma: 55 years old. Anaemia questions. Tired.
Ankylospondilosis: 25 year old. Young man.
Pelvic Inflammatory Disease : Back Pain, tired.

FEVER
Meningitis
Malaria
Epidemo Orquitis: Swelling. Fever. Scrotal Pain. Have you noticed
any swelling?

VOMITING
Gastroenteritis
DKA

Pregnancy
Head Injury
Medication
Accidental Injury

How many episodes?

When did it start?
With blood?
With pain?
Allergic reactions: Lactose intolerance. Celiac Disease.
DKA: Fruity smell. Pain in abdomen?
Medication: ATB, Antituberculosus, drugs.
Migraine
Pancreatitis: Multiples episodes of vomiting. Alcohol.
Vomiting: Binge drinking.

DIPLOPIA
GMC SHIRT

Giant Cell Arteritis

Multiple sclerosis, Myasthenia Gravis
Cataract
Space Occupying lesion
Hypothyroidism
Inflammatory Orbital Myositis
Refractory error
Trauma

M: Multiple Sclerosis. Myasthenia Gravis. Malignancy. Muscle Palsy.

Myasthenia Gravis: Do you feel excessively tired at the end of the
day?
Multiple Sclerosis: Weakness in limbs. Difficulty in coordinating. Loss
of bowel and bladder control.
Muscle Palsy: Do you see double in specific directions?
Malignancy: Infraorbital: Loss of weight and appetite.
Cataract: Are you diabetic? Are you taking any medication for long
term?
Hyperthyroidism: Fever, Swelling around edge. Feel pain.
Refractive error: Do you wear glasses? When was the last time you
got your eyes checked?

Trauma: Did you hurt yourself?

CALF PAIN
BBC DR SET

Burger Disease
Baker Rupture
Claudication/Cellulitis
DVT R
Sciatica
Excessive working
Trauma

Baker Rupture: Did you notice any swelling on the back of your knee
but it is no longer there?
Claudication: I have a pain only when I walk.
DVT: Recent history of travel, surgery.
Claudication: Are you able to stand in tiptoes.
Sciatica: Shooting pain. Starting from the back to the feet to the hill.
Mostly one sided.

ELDERLY CONSTIPATION
D4 HOMI2 A

D - Drugs. Diets Habits. Decreased mobility.

H Hypothyroidism.
O Instestinal Obstruction.
M Malignancy
I Fecal Impaction. Back Injury.
A Anal Fissures.
Diabetic Neuropathy.

Drugs: Codeine, Morphine.

Diet habits: Decrease fiber diet.
Decreased mobility .
Hypothyroidism: Vomiting. Constipation. Are you passing wind?
Malignancy: Decrease weight, appetite. Blood stools.

Faecal Impaction : Feel any mass in your tummy. Hard stools.

Back Injury: Trauma or History of fall.
Anal Fissures: Pain & Bleeding. Sharp, shooting pain when passing stool.

KNEE PAIN
GROSS

G - Gout
H Hemartrosis
R Reactive arthritis. Reiter syndrome.
O Osteoarthritis.
S Septic arthritis.
S Sports Injury.

Gout: Triggers. Medication: Water tablets (Diuretics).

Hemartrosis: Family history. Bleeding disorder.
Reactive arthritis: Diarrhea.
Reiter Syndrome:
Osteoarthritis: Evening stiffness. Large joints.
Septic Arthritis: Fever, sweating. Tenderness.

HAEMOPTOSIS

TB
Malignancy
PE
Pneumonia
COPD
Medications
Instrumentation

TB: Travel history. Localized pain. Loss of weight.

Malignancy: CA Bronchus. Loss of weight. Middle age.
Pulmonary Embolism:
Pneumonia: Fever, cough, pleuritic chest pain
COPD: History of smoking.
Medications: Blood thinners.

Instrumentation: Blood microscopy.

PALPITATIONS.

Anaemia
Hypothyroidism
Panic attacks.
Caffeine.
Arrhythmias.

Hyperventilation: Panic attacks. Breath in and out do they help you?

Hypoglycaemia: Proper meals.
Arrhythmias: Have you ever been diagnosed with heart problems.
Excessive alcohol: Alcohol intake.
Caffeine:
Stress, Fear, Anxiety : Special moments.
Anaemia: Cold feet.

VERTIGO
Menierre disease
Fullness in ear
Acoustic Neuroma: Numbness in face. Change in facial
features.
Benign positional vertigo.
Trauma.
Basilar insufficiency: Raise your shoulders.
Ototoxicity: Gentamicine. Anticonvulsionants.

EARACHE
Trauma
Wax impactation
Foreign Body

Mastoiditis
Otitis media
Otitis Externa
Barotrauma
Boil, Furuncle

Trauma: Did you hurt your ear by any chance?

Wax impactation: Pain starts after taking hot showers.
Foreign Body: Do you feel sometimes is crawling?
Mastoiditis: Is there any pain near the bone of back.
Otitis media: Fever, discharge, diminished hearing.
Otitis Externa: Fever.
Barotrauma: Recent flight. Diving.
Boil, Furuncle: History of diabetes.
COUNSELLING
EPILEPSY
MULTIPLE SCLEROSIS
ASTHMA
CHRONIC RENAL FAILURE
Diet
Drugs
Dyalisis
Renal transplant
Renal Transplant:
Priority list for kidney transplant in NHS. Not simple procedure. We will take kidney transplant
from a healthy donor. First have to do some extensive blood investigations for you as well as the
donor. Normally it will take till 6 months final surgery. In case situations worsens for you, we will
put you in a priority list.
DIABETES COUNSELLING
Medication will be given you in form of injections. My consultant will be prescribing it for you.
You need to take them regularly. You have to take it yourself. You will be attached to a Diabetic
nurse. Insulin requirements as well as any complications arise during treatment.
POST MI COUNSELLING
Low, fat diet.
4 weeks.
Complete rest.
No walk.
No alcohol.
No stress.