Al-Rokh's Pacemaker of Paces

Al-Rokh’s
Pacemaker of Paces
A simplified approach For MRCP (UK) Paces
Communication - History - Brief consultation
First Edition
By/ Dr. Sadek Al-Rokh

MBBS Mansoura University
MRCP United kingdom
International Medical Center (Jeddah)
ME
MIDDLE EAST LIBRARIES
01110150022-01001485817-01221570154
1
Pacemaker of Paces
A simplified approach - for MRCP Paces
Edited by Dr. Sadek Al-Rokh
MRCP (UK)
International Medical Center (Jeddah)
Copyright© 2017
ISBN 978-977-6551-04-6 :
2016/20959
All rights reserved
No part of thispublication may be reproduced, printed or

transmitted in any from or by any means, electronic of
mechanical, including photocopying, recording or any
information storage or retrieval system without penmission in
writing from the publisher.
Arabic
Publisher: Middle East Libraries

01110150022 - 01065351200 - 010014S5317 - 01221570154
E-mail: Me_book2010@yahoo.com
ME
MIDDLE EAST LIBRARIES
01110150022-01001485817-01221570154
2
Arabic
And of knowledge, you (mankind) have been given only a little.

DEDICATION
This book is dedicated to ray great mother who always taught me to love giving
and helping others.
And to my wonderful wife for her patience and encouragement.
And to my dear colleagues, wishing that this book could help and ease their
approach in the exam and real medical practice.
3
Contents
Station 4 Communication...1
About Communication (Station 4)…..2

Communication Scheme…..5
Counseling for chronic disease
(Pheochromocytoma) …..7
(Multiple Sclerosis) …..10
Counseling for chronic disease (Adult polycystic kidney
disease) …..13
(Addisoo disease)…..16
Counseling for chronic illness
(Celiac Disease)…..19
Counseling for chronic illness (Epilepsy) …..22
Active TB Asking for discharge…..25
Breaking bad news (Advanced cancer for palliative care)…..29
A Nurse with a needle stick injury from a patient with HIV…..32
4
Contents
(Medical error) Angry son - Father developed Allergy for codeine…..35
Complication of a procedure Angry son - Father
died after a procedure (PCI) …..38
Counseling for DNR decision…..41
Counseling for Steroid therapy Side effects…..44
Counseling for Warfarin side effects…..47
Counseling for Genetic test…..50
Counseling for a procedure (SLE for Renal biopsy) …..53
Breaking bad news Counseling for hickman line
(Hodgkin Lymphoma for hickman line) …..56
Drug incompliance…..59
Patient with Suicidal Attempt Asking For Discharge…..62
Somatization Somatoform Disorders…..66
Station 2 History...73
About station 2 (History taking) …..74
History Approach…..75
5
Microcytic Anemia in Young Female.....78
Chronic Diarrhea.....83
Jaundice.....88
Chronic Cough and Wheezy chest.....94
Chronic cough and hyponatremia.....100
Both Lower limb weakness.....105
Periodic paralysis.....110
Abnormal sensation in both Lower limbs.....115
Ataxia.....121
Tremors.....126
Low Back pain.....131
Monoarthritis.....136
Osteoporosis.....141
Hematurea in young Femate.....146
Recurrent chest pain in young mate.....151
Recurrent Sweating and Gtycosurea.....157
Skin rash and SOB.....162
Syncope.....169
6
Station 5 Cases … 175
About station 5 (Brief consuitation)….176
Vitiligo….179
Psoraisis….183
Hereditary Hemorrhagic Telangectesia (HHT) ….186
Pemphigus….190
Neurofibromatosis….195
Chronic Mouth Ulcer….199
Tuberous Sclerosis….202
Acromegaly….206
Addison Disease (Hyperpigmentation)....212
Cushing Syndrome (Weight gain) ….216
Neck lump (Graves' disease) ….220
Obstructive sleep Apnea (Hypothyroidism) ….225
Ankylosing Spondilitis….228
Psoraitic Arthropathy….233
Rheumtoid Arthritis….236
7
Systemic Lupus Erythematosus….241
Systemic scterosis ….245
Monoarthritis….251
Retinitis Pigmentosa….254
Papiiioedema….258
Optic Atrophy….262
Diabetic& hypertensive Retinopathy….266
Limb weakness in young femaie….271
Sudden paintess loss of vision….275
Both lower limb swelling….278
Chest pain (Pulmonary embolism) ….281
Hematemsis and Metena….285
Lymphadenopathy ….289
Tall Stature (Marfan Syndrome) ….292
Pruritus….297
Miscellaneous Notes….300
8
Communication
9
About Communication (Station 4)
 Communications is 20 minutes, 14 minutes with the surrogate, 1 minutes to review your ideas and 5 minutes
with the examiner.
 You are given 5 minutes before the station in which you have to read he scenario and prepare yourself. Focus on
every word in the scenario to know the patient name, your task and your position.
 These 5 minutes prior to the station are very precious to prepare yourself, organize your ideas , structure your
case and write scheme of the headlines you are going to discuss with the surrogate in a white paper to cover all
the important points in the scenario.
Golden points in communication
1. Make a good scheme in your mind and write it on your white paper in headlines to cover all the important points
in the station.
2. But a good structure and be organized in your thoughts and information during your discussion with the
surrogate.
3. Avoid jargons absolutely, try to be fluent in your discussion.
4. You have to be a good actor, with empathic body language and eye contact.
5. Don't push a lot of detailed complicated information to the surrogate.
6. Don't interrupt the surrogate when he is talking and let him to express his thoughts, feelings or queries.
7. Be interactive with the surrogate, don't talk a lot without checking his understanding and absorption saying are
you with me Mr (x)?.. Does it makes any sense for you.. Please don't hesitate to interrupt me any time for any
query.
8. If the Surrogate showed any variant emotions like anger, denial or crying, don't interrupt him and try to
understand and appreciate his feeling.
9. Show empathy and sympathy from time to the other in breaking bad news and counseling for chronic illness in
empathic body language and eye contact.
10
Ethical and legal issues in communications skills
Ethical Issues: These four are fixed for all the cases
 Autonomy: the patient has the right to know everything about his condition and share in the management pian.
 Justice: the patient has the right of management regardless his race, religion or color.
 Beneficence: to do good for the patient.
 Non malfeasance: not to harm the patient.
Other Ethical issues according to the case:
 Confidentiality: Respecting the privacy of the patient, the patient is the only one to know the results of his
investigations, results are not released by mail or telephone and to be delivered to the patient himself (In cases
of HIV and Genetic testing)
 Breaking confidentiality: if the patient is harmful for the others, and insist not to tell his partner about his
HIV status for example (Avoid confrontation and try to convince diplomatically).
11
Legal issues:
 Consent: signed consent of a procedure after detailed explanation about benefits and complications, patient has
the right to withdraw any time after his signature.
 Advanced directive and living will: If the patient is competent, he has the right to make signed informed
decision for his future treatment plan.
 DNR: The treating team has the right to make DNR decision in the best interest of the patient condition
regardless the decision of the family members (Try to convince avoiding confrontation).
 Treating life threatening condition: The treating team has the right to treat the patient in the best interest
of his condition to save his life even without consent, in case of the patient don't has advanced directive or living
will.
 Discharge against medicai advice (DAMA); the patient has the right to sign to be discharged against
medical advice after discussion of the risks of discharge.
 Admission under the common low: If the patient has active infectious disease and may infect the others,
so that this patient is not allowed to be discharged until his disease is controlled and not infectious any more
(avoid confrontation). (Active TB)
 Admission under the mental health act: If the patient has

Psychological instability, so that has to be admitted against his or her wishes of discharge until to be assessed by
a psychiatrist to evaluate her condition (Avoid confrontation). (Suicidal attempt)
 Disablement compensation: The patient has the right to claim for compensation if he developed anv disease
related to his job.
12
Communication scheme
Introduction:
– Shake hands with the surrogate.

– Introduce yourself.
– Confirm the patient identity
– Confirm agenda of meeting and take permission for discussion.
– Ask if he want anyone else to attend the discussion (if breaking bad news or counseling for chronic illness)..
Absolutely don't in cases of confidentiality like Counseling for HIV.
– Ask open question how much he know about his condition.
– Ask him about his expectation (if breaking bad news or counseling for chronic illness)
Gradual breaking of the news:
– Start breaking of the news:

The results of the blood test or imaging have been released and it's not as we hope.. Stop for a while.. They reveals
that you have disease called (...) or (cancer) stop for a while and let the patient to express his feelings..
Shwoing empathy and sympathy:

(If it is cancer, or the patient know information about the disease ): I'm really sorry, I highly appreciate your feelings
, I know how much these news are hard for you and be sure that we are here to give you the full care Give the
surrogate tissue if start crying.
Explanation of the disease:
Do you want me to explain to you more about your condition?

 Start to explain the disease simply avoiding jargons (medical terms) -
Avoid pushing a lot of complicated informrmation.
 Explain all symptoms and complications of the disease.
 Explain the management plan:
 Referral to specialized doctor or to MDT team to give him the proper care and management plan.
 Main points of management without details.
13
Social History
 What do you do for living? And how much his or her symptoms affect her or his job and usual daily activity?
(Refer the patient to a social worker if his social life is affected, and to an occupational health care worker if his
work is affected.
 With whom the patient is living? Who is supporting him or her at home?
 Financial support?
 Smoking and alcohol history?
– Emphasize again for these bad news today, I know how much it's hard for you, but be sure that we will do our
best to give you the full care and management.
Concerns" Do you have any concern? If didn't ask about the concern you may lose this station and may be the exam.
Summary: Summarize your meeting with the surrogate in brief: I'm going to summarize the important points in our
discussion today.
Check Understanding: by asking may 1 know please how much did you get from our discussion today?
Help: I'm sorry again for hard news today, I will give you some leaflets, brochures, websites to know more about
the disease.
I will give you my contact number as well to call me if you have any worries or queries any time .. Anyone to drive
you home?
– Nice to meet you - Shake hands.
14
(Pheochromocytoma)
Indroduction:
– Shake hands.
– Confirm the patient identity.
– Confirm Agenda of meeting.
– Ask if the patient need anyone else to attend the discussion (for support).
– Ask how much hr know about his condition.
– Ask about his expectation.
Breaking the news gradually:
– The resuits of biood tests and imaging have been released, and they are not as we hope.. Stop for a while.. They
reveal that you have a disease called (Pheaochromcytoma).. Stop for a while (let the patient to express his feelings
and thoughts).. Have you ever heard about this disease before?.. Do you want me to explain for you more about
it?
Explain the disease simply without jargon:
– It's a disease due to increased secretion of a special protein in the body called Adrenaline and Noradrenalin
hormone due to overgrowth of the gland located above your kidneys.
– 10% of this overgrowth may be malignant, 10% could be familial, 10% are located on both glands over your
kidneys, 10% could be located in other sites.
– Symptoms and complications of the disease: Increased level of this hormone leads to some manifestations like
loss of weight, flushing, anxiety and mood disturbance, racing of heart beats, sweating, shaking of the hands and
high blood pressure which may be difficult to control with increased risk of heart attacks and strokes.
– Treatment plan: What we are going to do is to refer you to MDT from Gland physician, surgeon,
psychotherapist; social worker to give you the full care and the proper plan of management.
– The main treatment is surgical resection of the overgrowth, you are going to receive oral medications for high
blood pressure 10 - 14 days before the operation to control your BP and ovoid sever
15
Hypertension during the operation, the details of this procedure will be discussed by the surgeon involving your
consent for agreement to do the operation.
Empathy and sympathy: I'm really sorry for these bad information today, I highly appreciate your feelings, if know
how hard these news for you, But be sure that we are going to do our best to give you the full care and management.
Social history:
 What are you doing for living?.. How much your illness impact your job and usual daily activity?.. Refer the
patient to an occupational health worker if his job is affected, Refer to a social worker if social life is affected.
 With whom you are living? Are they doing well? Who is supporting you at home?
 Are you financially supported?
 Do you smoke at all, do you drink alcohol?.. You didn't thing about giving up smoking?.. We can help you by
referring you to smoking cessation clinic if you don't mind.
Concerns: Do you have any concern?
- Is it curable condition Dr?

Mostly yes, if the operation done successfully, your hormone will return to normal range and all your symptoms will
be subsided and your blood pressure will be controlled and even you will be free from medications.. Any other
concerns?
Is it cancer Dr?
10% of this overgrowth is cancerous, so when we are going to do the operation, we are going to have a snip from
the overgrowth do to be analyzed and make sure of its nature, and we will you to screening counselling team for this
reason.
My children may have the disease Dr?

10% of the disease is familial, so we can refer you and your children to a gentic counseling team to discuss this issue
in details and for possible screening.
16
Make summery about important points of the disease and management including referral to MDT.
Check understanding: May I know how much did you get from our meeting today?
Help: I'm going to give you some leaflets, brochures, websites to read more about the disease.
i will give you my contact number as well to contact me any time if you have any worries of queries .
- Shake hands.
17
(Multiple sclerosis)
Introduction
– Shake hands.
– How much do you know about your condition?
Breaking the news gradually

– The results of blood investigation and imaging have been released, and it's not as we hope.. Stop for a while..
They reveal that you have a disease called (Multiple Sclerosis).. Stop for a while (let the patient to express his
feelings and thoughts).. Do you have any information about this disease?
– Show your empathy here if the patient know the disease or has bad family experience about the disease.
Do you want me to explain to you more about this disease?

 It's a disease due to disturbance in your defensive system which suppose to attack the bugs, in your condition
it attacks your brain and main nerve cable ip your body disturbing the electrical impulses in your nerve
cables.
 It's coming in attacks on and off with different forms and times.
Symptoms and complications:

 It can come in attacks in different forms like visual disturbance, abnormal speech, shaking of the hands,
unsteady gait, muscle weakness or sensory disturbance some symptoms together or separated.
 The majority of patients with Ms (85%) are left without major disability and can live near normal life , only
minority(15%) are left with major disability and need walking aid .
18
Management plan:
 So we are going to refer you to MDT team from nerve doctor, physiotherapist, psychologist, eye doctor (if
visual disturbance) to give you the full care and management plan
 In the sudden attacks you will be given treatment through a needle called steroids to shorten the course of
the attack.
 Some treatment is given to reduce the chance of the recurrence of the attacks but it need certain criteria to
be given and to be discussed and decided by the nerve doctor
Pregnancy:
May I ask do you have a partner, if you are planning for pregnancy, you have to inform your Obs and Nerve doctor
to make MDT to give you the full care during your pregnancy?
Empathy and sympathy:

I'm really sorry for these bad information today, I highly Appreciate your feelings , I know how much these news
are hard for you , But be sure that we are going to give you the full care and support as much as we can.
Social history:
 What are you doing for living? How much your illness impact your job and usual daily activity? Refer the
patient to an occupational health worker if job is affected, Refer to a social worker if his or her social life is
affected.
 Do you smoke at all, drink alcohol?
Concerns: Do you have any concerns?
– Is it curable condition Dr?
I'm sorry to tell you that it is not curable, but we are going to do our best to control it and give you the full care,
support and regular follow up to live near normal life and... Any other concern?
– I’m going to be wheelchair Dr?
19
Mostly no , and as I told you before the majority of patients with Ms ( 85%) are left without major disability and can
live near normal life, only minority(15%) are left with major disability and need walking aid .
– Any problem with pregnancy Dr?
You can become pregnant without complications and if you are planning for pregnancy, you have to inform your
Obs and nerve doctor to make MDT, to give you the full care during your pregnancy.
Make summary: About the important points of the disease and management.
Check understanding: Check how much the patient got from the discussion?
Help: Emphasize again.
 I'm going to give you some leaflets, brochures, websites to read more about the disease.
 I will give you my contact number as well to contact me any time if you have any worries or queries.
 I will give you also the number of MS society to share information and experience about the disease.
-Shake hands.
20
(Adult polycstic kidney disease)
Introduction:
– Shake hands.
– Ask if the patient want anyone eise to attend the discussion (for support).
– How much do you know about your condition?
Breaking the new gradually:
– The results of blood investigation and imaging have been reieased, and unfortunately they are not as we hope..
Stop for a while.. They reveals that you have a disease called (Adult polycystic kidney disease).. Stop for a while
(let the patient to express his feelings and thoughts).. Have you ever heard about this disease before?
– Do you want me to explain for you more about it?

 It's a familial disease which runs in families , in which there is enlargement of both kidneys due to multiple
sacs filled with fluid invading both kidneys , May be associated with sacs in other body organs like the liver
, spleen and balloon formation of any of blood conduit in the brain.

 The disease has some symptoms and complications like recurrent tummy pain, recurrent rupture of the sacs
causing bloody urine, recurrent infection of your kidneys, stone formation
 On the long run dctcrioration of kidney function and kidney failure and you may need kidney replacement
therapy in certain stage.. 50% of patient with APCKD may need kidney replacement therapy at the age of
60.
 Hypertension is one of the complications of the disease which need strict follow up and control.
 If there is any balloon formation of the blood conduits of the brain may rupture at any time causing serious
complications
21
Management plan:
 So we are going to refer you to MDT team from kidney doctor, brain doctor, physiotherapist, occupational
health worker to give you the full care and management plan.
 The management plan will be in the form of regular follow up of your kidney function, aspiration of the sacs
if causing pressure symptoms, and treating any recurrent infection.
 Your blood pressure needs to be strictly controlled on one drug for hypertension.
 We will do imaging to the brain to confirm any presence of balloon dilatation of blood conduit.
Special advice:
 New medications: if you are going to receive any new medication, you have to inform your kidney doctor
as many medication can affect the kidneys and may worsen your kidney function.
 Vigorous exercise: You have to avoid vigorous exercise like rugby and football to avoid rupture of the sacs.
 Pregnancy: If you are planning for pregnancy, you have to inform your kidney physician and Obs doctor to
make MDT, to give you the full care during your pregnancy to avoid any complications at all.
 How do you feel now?

 I'm really sorry for these bad information today , I highly Appreciate your feelings , i know how much these
news are hard for you ,And be sure that we are going to do our best to control your condition , and give you
the regular .. Follow up.
Social history:
patient to occupational health worker if job is affected, Refer to social worker if social life is affected.
 With whom you are living? Are they doing well? Who is supporting you at home? Do you have brothers and
sisters? Re they doing well? Any family history of sudden death?
22
 Screening: We can offer screening for your family members to confirm if they have the disease or not as it is a familial
disease to have the advantage of early detection and early treatment to avoid complications of the disease, so that we
can refer them to a genetic counseling team.
 Do you smoke, drink alcohol?
Is it curabie condition Dr?
I'm sorry to tell you that it is not curable , but we are going to do our best to control it and give you the full care and regular
follow up to avoid complications as much as we can. .. Any other concern?
I'm pregnant doctor any action can be taken to prevent the disease for my baby?
 The chance of your baby to have the disease is 50%, and I'm sorry to tell you that the disease can't be prevented, we
will refer you to genetic counseling team to discuss all the details about your baby
 Genetic testing is not of a big value as it may has false positive and flase negative results , and it will not alter the
outcome of the disease
 The disease is not prevented, the golden standard of screening is at the age of 20 by imaging for early detection and
early follow up to avoid complications.
Summary: About important points of the disease and management plan.
Check understanding: How much did you get from our meeting today?
Help:
Emphasize again , 1'rn going to give you some leaflets , brochures , websites to read more about the disease , i will give you my
contact number as well to contact me any time if you have any worries or queries .
– Shake hands.
23
(Addison disease)
Introduction:
– Shake hands.
– Ask if the patient needs anyone else to attend the discussion (for support).
Breaking the news gradnahy:
– The results of blood investigations and imaging have been released, and they are not as we hope.. Stop for a while..
They reveal that you have a disease called (Addison disease).. Stop for a while (let the patient to express his feelings
and thoughts).. Do you have any information about this disease?
Is it serious condition Dr? It can be serious if untreated, but we are going (o do our best to control your condition.
Do you want to explain to you more about the disease?

It's a disease due to diminished secretion of a special protein in the body called cortisone hormone secreted from the
glands located above your kidneys,
Mostly is due to disturbance of your defensive system which supposed to attack the bugs and viruses, in your
condition it attacks your glands.
Symptoms and complications of the disease: It is an important hormone in the body, deficiency of this hormone
leads to some complications like loss of weight, decreased blood pressure, dizziness, decreased glucose level, tanned
skin, tummy pain, feeling and getting sick, electrolyte disturbance and if the hormone severely diminished may result
in severed hydration and coma and can be life threatening at that time.
Treatment plan: What we are going to do is to refer you to MDT from Gland physician,, psychiatrist, social worker
to give you the full care and appropriate plan of management.
24
– The main treatment is replacement therapy of this hormone by orai tablets , and you have to be strictly adherent to
your medications to avoid complications of the disease and to live near normal life and we will provide you with
regular fellow up in the outpatient clinic to be sure of your hormone level and offer you the full care.
– If you felt any time that you are sick and unwell you have to seek medical emergency care at once, as your condition
may be unstable at that time and you may need urgent medical care at once.
Special circumstances: In special situations like fever, recurrent vomiting, recurrent loose motions you have to
duplicate your cortisone dose and you have to seek medical care to adjust the dose of your medications.
Medic Alert Bracelet: you have to wear Medic Alert Bracelet to make the others to know about your condition and
to carry one ampoule of cortisone to be given to you if needed in emergency situation.
If female patient: if you are planning for pregnancy, you have to inform your Obs and gland doctor to make MDT,
to give you the full care and to avoid any complications during your pregnancy.
Showing empathy and sympathy:

I'm really sorry for these bad information today, I highly Appreciate your feelings , i know how much hard these
news for you, But be sure that we are going to do our best to give you the full care and proper treatment.
Social history:
patient to an occupational health worker if his job is affected, Refer to a social worker if his social life is
affected.
 Do you smoke, drink alcohol? .. Didn’t you thing about giving up smoking? We can help you by referring
you to a smoking cessation clinic if you don't mind.
25
I'm sorry to tell you that it's not curable but it can be controlled on medication, and if you will be completely
compliant on your medications and on regular fellow up, you can live near normal life.
Any other concern?
– What about complications of steroid therapy Dr?
Steroids will be given to you as replacement therapy, to reach the normal level, So that you will not suffer from
complications of the long term use of steroids, May be some soreness of the stomach which can be managed by
simple medication.
Make summary: About important points of the disease and management
Check understamdimg: Check how much the patient got from the discussion?
Help: Emphasize again, I'm going to give you some leaflets, brochures, websites to read more about the disease,
I will give you my contact number as well to contact me any time if you have any worries or queries.
- Shake hands
26
(Celias Disease)
Introduction:
– Shake hands.
– Confirm Agenda of meeting and take permission to start the discussion (We are together today to discuss the
results of your blood tests and camera test done for you, Is it alright with you?)
– Ask if the patient want anyone else to attend the discussion (for support).
– Ask how much the patient knoe about his condition.
– The results of blood tests and camera test have been released
, and they are not as we hope.. Stop for a while.. they revealed that you have disease called (Celiac disease) .. Stop
for a while (Let the patient to express his feelings and thoughts) .. Do you have any idea about this disease?
Do you want me to explain for you more about this disease?

 It is a disease due to bowl allergy to any type of food containing gluten. Causing disturbance of the defensive
system which supposed to attack the bugs and germs, in your condition it attacks the lining of the bowls
causing mal absorption to main nutrients, minerals and vitamins.
 Gluten present in Oates, wheels, ryes, and barley involved in some types of food like bread, pasta, pizza and
biscuit.

 It has some symptoms and complications in the form of recurrent tummy pain, loose motions, loss of weight,
anemia, fatigue, fragile bone, easy bleeding due to mal absorption of certain vitamins.
 And on the long run if the condition is not controlled may lead to certain type of cancer in the gut called
lymphoma at the late stages of the disease..
 BUT.. All of these complications can be avoided and chance of cancer can be significantly reduced if you
completely avoided any type of food containing gluten.
27
Management plan:
 The comer stone of the treatment is to avoid any type of food containing giuten completely.. If you avoid
any food containing gluten completely, then you can avoid all the complications of the disease and enjoy
your life.
 We will refer you to a MDT team involving a gut physician to provide your with the essential nutrients,
minerals and vitamins, A dietitian to give you the list of types of food to avoid completely and a social
worker to support you socially.
 There are some restaurants have special partitions for food gluten.
 If you are travelling on airplanes inform the airplane stuff about your condition to give you food free gluten.
Empathy amd sympathy: How do you fee! Now? I'm really sorry for these bad information today , I highly
Appreciate your feelings , I know how much these information are hard for you, But be sure that we are going to do
our best to give you the full social and medical care as much as we can to live near normal life.
Social history:
patient to occupational health worker if job is affected, Refer to social worker if social life is affected.
 Do you smoke at all, do you drink alcohol? (If the patient drink alcohol advise him to contact the dietitian
as most types of alcohol contain gluten and mat trigger his condition.
Is it curable condition Dr?
– Unfortunately it's not curable, but it can be controlled, and if you avoided any type of food containing gluten, your
condition will be completely controlled and you can live near normal life.
– Any other concern?
May I have cancer in the future dr?

If you avoided any food containing gluten, your condition will be controlled and the chance to have cancer will be
extremely low.
28
Make sumamanry: About the important points of the disease and management pian.
Help: I'm going to give you some leaflets , brochures , websites to read more about the disease , I will give you my
contact number as well to contact me any time if you have any worries or queries .. Anyone to drive you home? (If
not admitted).
- Shake hands
29
Counseling for chronic illness
(Epik-psv)
Emtroducticm:
– Shake hands
– Ask how much the patient knows about your condition?

– The results of blood tests and imaging done for your brain have been released They are all normal.. But the nerve
doctor made a diagnosis of your condition a disease called (Epilepsy).. Stop for a while (let the patient to
Express his feelings and thoughts).. Do you have any information about this disease?

Do you want me to explain to you more about this disease?
 Epilepsy is an active focus in the brain, sending abnormal electrical impulses to the Body, causing
unpredictable shaking of the body.
 It can be precipitated by strong flashes and voices, stress and sleep deprivation.
 The underlying cause of the disease is unknown for the most cases or sometimes mat be familial.
Symptoms and complications: It can come in the form of unpredictable shaking of the body with loss of
consciousness, tongue biting, frothing from the mouth and may be uncontrolled water work.
Empathy and sympathy: How do feel now Mrs. (x) ? Tm really sorry for these bad information today, I highly
Appreciate your feelings , I know how much these news are hard for you , But be sure that we are going to do our
best to give you the full care to control your condition to live near normal life.
30
Treatment plan:
 So what we are going to do is to refer you to a MDT from a nerve doctor social worker , occupational health
care worker to give you the proper care and management plan to control your .
 Treatment of this condition is oral medications will be prescribed by the Nerve consultant, and you have to
be completely compliant on these medication to control your condition and to decrease the chance for any
further attacks.
Modification of life style:

You have to follow some life style modifications:
 Avoid percipients: like Strong flashes and voices, avoid stress and sleep deprivation and to be compliant
on medications and regular fellow up.
 Avoid life risk situations: presence in high attitudes , beside fire and sharp objects , don't lock in the door
of the bathroom as if you developed any attacks in these situations as your life may be threaten in such
situations , and if you are going to swim your should be under supervision.
OCP: May I ask if you are receiving any oral contraceptive pills , you have to inform your Obs and nerve doctor
because Anti epileptic medication can change the efficacy of OCP and you may get pregnant despite contraception.
Pregnancy:
 May I ask if you have a partner, are you planning for pregnancy?
 You have to inform your obstetrician and nerve doctor to make a MDT
to give you the full care during pregnancy as seizures and be harmful for the baby.
 Also anti epileptic Medications may be harmful to your fetus, so they may provide you with the least anti
epileptic medications that may affect your baby and some medications that will decrease the effect of anti
epileptic medications on your fetus like folic acid.
Driving: May I ask if you drive ?You have to inform DVLA about your condition , Fm sorry to tell you that you will
be banned from driving for at least 1 year until you will be completely free from attacks , as your condition is risky
on yourself and for the others during driving .
Social history:
 What are you doing for living? How much.your illness may affect your job and usual daily activity? I’m
going to refer you the to a social worker and
31
Occupational health worker to manage any social or occupational troubles could happen.

I'm sorry to tell you that it is not curable, but it can be controlled by avoiding triggers and complete compliance on
your medications and regular follow up.
Any problem if I get pregnant Dr?
If you are planning for pregnancy, you have to inform your obstetrician and nerve doctor to make a MDT to give
you the full care during pregnancy as seizures may be harmful for your baby. Anti epileptic Medications may be
harmful to your fetus as well, so they may provide you with the least anti epileptic medications that may affect your
baby and some medications that will decrease the effect of anti epileptic medications on your fetus like folic acid.
Make summary: About the important points of the disease and management plan.
Help: Emphasize again , I'm going to give you some leaflets , brochures , websites to read more about the disease, i
will give you my contact number as well to contact me any time if you have any worries or queries ..
 Anyone to drive you home? (If not admitted)
-Shake hands
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25
33
26
34
Cemcerms: Do you have any concerns?
It is a curable condition in most of the cases after the full course of Anti TB medications, within few weeks your
condition will improve and you can enjoy your life. Compliance and regular follow up is very important to guarantee
the full cure.. Any other concerns?
– I want to go home and take medications at home dr?
You: May i ask why do you want to go home? Try to solve any dilemma for the patient.
Patient: Some of the nurse stuff have bad attitude here doctor.
You: I'm sorry for that, I am going to talk to the nurse in charge and i promise to improve their attitude.
Patient: They forbidden me to drink alcohol Dr?

You: Didn't you think to give up drinking alcohol at all? Alcohol intake may worsen your condition as it worsen
your defensive system , we can help you in this issue by referring you to a specialized team to help you to give up
alcohol intake.
Patient: they forbidden to smoke doctor.

You: Didn't you think about giving up smoking before, smoking may worsen you condition, so we can help you to
give up smoking by referring you to smoking cessation if you don't min
Explain for the patient the risk of discharge:

You have to be admitted under our observation for at least 2 weeks until your sputum is free from the bugs, to be
discharged now is risky on yourself as your condition may worsen and even may be life threatening, and may be
risky for the public as you still infectious for the others.
If the patient still persist to be discharged.

You: I'm going to involve my consultant soon to solve any other worries or queries you may have.
Make summary: About the important points of discussion and management plan.
35
Check MtmderslsmdiRmg: Check how much the patient got from the discussion?
Help: Emphasize again , I'm going to give you some leaflets , brochures , websites to read more about the disease ,
I will give you my contact number as well to contact me any time if you have any worries or queries ..
- Shake hands
N.B: The main issue here is that patient is not allowed to be discharged, but avoid confrontation with the patient,
Try to convince him kindiy to stay in the hospital until his sputum will be free from the germs, showing the hazards
of being discharged in the time being on himself and for the others, involve your consultant at the end if the patient
still insisting.
-This patient has to be admitted under the common low and not allowed to be discharged against medical advice.
(Discussion with the exmanier)
36
Breaking bad news
(Advanced cancer for palliative care)
Scenario: Mr. Kamal is 65 years old has been complaining of recurrent loose motions and loss of weight for the
last 2 months.
Blood investigations and CT abdomen, chest and pelvis confirmed a diagnosis of advanced cancer colon with
metastasis to the liver and spleen, the oncologist made decision that Mr. Kamal is not fit for chemotherapy or
radiation and only for palliative treatment.
You are SHO of the medical department on call today, you are asked to discuss the condition to Mr. Ahmed the son
of Mr. Kamal.
Introduction:
– Shake hands.
– Introduce your self
– Confirm the son identity.
– Ask if he is next of kin of Mr. Kamal.
– Ask if he has permission from Mr. Kamal to discuss his condition.
– Ask if the he need anyone else from the family to attend the discussion (for support).
Breaking the mews gradually:

– The results of blood tests and imaging have been released, and they are not as we hope.. Stop for a while.. They
revealed that your father has advanced cancer in his gut.. Stop for a while (let the son to express his feelings and
thoughts).

How do you feel now Mr. Ahmed?
I'm really sorry for these bad information today, I highly Appreciate your feelings, i know how much these news are
hard for you, But be sure that we are going to give your father the full care and support.
Explain the disease simpiy without jargons:

Do you want me to explain to you more about your father's condition?
37
Unfortunately the blood tests and images done to for your father revealed the: he has advanced cancer in his gut,
which has been spread to other organs like liver and spleen.
Complications of the disease:

 I'm sorry to tell you that cancer has a lot of complications in the form of fever, loss of weight, fatigue,
decreased appetite, easy infection, lump- and bumps and may be failure of the affected organs
 And Fm sorry to tell you that your father cancer seems to be in advanced stage, Fm sorry again for these bad
information today.
Treatment pian:
 So what we are going to do is to refer your father to a MDT from a Turner physician, Macmillan nurse,
psychiatrist, social worker, and pain management doctor to give your father the full care and proper plan of
management.
 Unfortunately the cancer physician saw that the condition of your father is very advanced and he is fit for
chemotherapy nor radiation, as there is no chance to improve his condition, and only will be for palliative
care.
The son: Why doctor, please do anything to keep my father alive, why you are not going to give my father
chemotherapy doctor.
 I highly appreciate your feeling, this decision was taken by the cancer doctor in the best interest of your
father’s condition.
 Chemotherapy has a lot of side effects and your father is going to suffer from all the side effects of
chemotherapy with no chance his condition to he improved.
 But we are going to give your father the full palliative care in the form of patent pain killers to keep him pain
free all the time , providing him with th appropriate nutrients and fluids that your father needs , correction
of any electrolyte imbalance and treatment of any infection .
Social history:
 What is your father doing for living? How much illness of your father impact his life? Fm sorry for that we
will involve a social worker to solve any social trouble he has.
 With whom your father is living? Are they doing well? Is anyone in the family needs any social care?
 Is your father financially supported?
38
 Do your father has any advanced direction or iiving well? (This question is for ah cases of cancer).
There is no hope doctor?
I'm sorry to tell you that the condition of your father seems to be very advanced , But we are going to do our best
and give your father the full care and to keep him pain free ah the time.
Any other concern?
For how long my father is going to live doctor?
I'm sorry to teh you that may be not for long time as your father condition is very advanced , but be sure that we are
going to do our best and give you the full care and to keep you pain free for the rest of your life and support you
socially, psychologically
I don't want my father to know about his condition doctor?
 May ask why you don't want your father to know?

 I appreciate your feeling, But as your father has the full mental capacity so that he has the full right to know
everything about his condition and to share in the management plan.
 We will give him the information in pieces according to his worries and queries, and will involve a
psychiatrist to manage any mood disturbance.
Make summary: About the important points of meeting.
Check understanding: Check how much the son got from the discussion?
Help: Emphasize again, I'm going to give you my contact number to contact me any time if you have any worries
or queries..
- Shake hands
39
A Nurse with a needle stick injury
From a patient with HIV
Scenario: Ms. Sara is 27 years old, a nurse in your medical unite, when she tried to have a blood sample from one
patient who is known case of HIV she had a needle stick injury, she is very anxious since that event and want to
discuss with you this issue.
You are SHo of the medical department on call today, you have been asked to discuss with her this issue.
Introduction:
– Shake hands.
– Confirm agenda of meeting and take permission to start.
– Ask the patient: May i know what happened exactly?
Ask about the Circumstances of needle stick injury

 What happened before? Did you wear gloves?
 What happened during? Was it wide or narrow bored needle? Was it deep or superficial injury?
 What happened after? Did you squeeze the site of injury? Did you wash your hands with soap and alcohol?
 Did you receive immunization for Hepatitis B before?
Reassurance: I'm really sorry for what happened to you today, needle stick injury may carry a risk of HIV, HCV
and HBV as well... But i want to reassure you that the chance of HIV infection after needle stick injury is only 0.3%
, For HCV is 3% and for HBC 30%.
A large number of medical stuff had history of needle stick injury with very limited cases of infection.
Explain the plan of care:

What we are going to do is to
 Write incident report.
 Give you prophylaxis treatment soon.
 Check your blood for HCV, HBV, and for HIV now and after S months.
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 A signed consent wiH be required for agreement to do HIV test.. The resuit wiii be reieased after 24 to 48 h
and wiii be completely confidential, and will be released only to you not by email or telephone.
 We are going to refer you to MDT from an infectious disease doctor,, an occupational health care worker to
give you the proper plan of care and follow up.
 If you have any symptoms of fever, skin rash, lumps or bumps, or loss of weight you have to seek medical
care at once (Seroconversion symptoms)
 HIV is different from AIDS, AIDS is HIV plus superimposed illness or infection.
Explain the Results of the test:

The test may has false negative and false positive results.
-If the test is positive: It means that you have HIV infection, you may have anxiety and mood changes, you may
lose your future insurance, bur prior insurance will be preserved, but the advantage is that we will start early
treatment to avoid complications, you will have some life style and job modification.
- If the test is negative: you may have some relief, it has to be repeated within 3 months to be sure you are completely
free from the virus.
Modification of life style:

Until confirming that you are completely free from the virus you have to make some life style modification:
 At work you have to avoid sharing in procedures and direct contact with the patients and Fm going to involve
occupational health care worker to provide you with office work.
 You have to avoid transfusion of blood during that time, you have to keep your personal instruments like
razors, mouth brushes for only your personal use.
 Do you have a partner? Are you pregnant or plan for pregnancy soon? You have to make safe sex until
confirming that you are completely virus free.
41
Showing empathy and sympathy and Reassure again:
I'm really sorry again for what happened to you, and i want to reassure you again that the chance of catching infection
of HIV is extremely low after a needle stick injury.
Sociai History:
My I ask some social questions if you don't mind?
 With whom you are living? Are they doing well? Who is supporting your at home?
 Do you smoke? Drink alcohol?
Make summary: About important the points in the meeting.
Check understanding: May I know how much did you get from our discussion today?
Help: I will give you some leaflets and websites about needle stick injury, I'm going to give you my contact number,
if you have any worries or queries, please don't hesitate to contact me.. Anyone to drive you home?
- Shake hands.
42
(Medical error)
Angry son – Father developed Allergy for codcine
Scenario: Mr. Sami is 60 years oid, was admitted 2 days ago because of pneumonia. His condition was improving.
Yesterday night he deveioped back pain, codeine was given to him in the best interest of his condition, unfortunately
he deveioped allergy to codeine with skin rash and hypotension. He was given anti allergic medication and his
condition was stabilized and was put under close observation.
You are SHO of the medical department on call today, you have been asked to discuss this issue with his son Mr.
Amr who is very angry for what happened to his father.
Introduction
-Shake hands.
-Introduce yourself.
-Confirm the patient identity (May I confirm that you are Mr. Amr son of Mr. Sami? Are you next of kin of Mr.
Sami?
- Confirm agenda of meeting and take permission to start.
(We are together today to discuss what happened to your father, I it ok?)
-Ask the son: How much do you know about your father condition? Let the son to express his feeling and anger
without interruption.
Apologize for what happen to the father:

I'm really sorry for what happened to your father... May I explain for you more about what happened exactly?
- Expiain the incident: Your father was admitted 2 days ago because of lung infection , and he was given the
proper treatment and his condition was improving , yesterday he developed back , and he was given codeine in the
best interest of his condition. Unfortunately he developed allergy for codeine with some skin rash, and low blood
pressure, codeine was stopped and he was given Anti allergic treatment at once and his condition was stabilized and
he is under our close monitoring now.
43
Apologize again exploring the possible cause:
I’m really sorry again for what happened to your father, i know how much your father is precious for you, your
feeling is highly appreciated.
May be there was breaking of communication or missed information and we are going to investigate what happened
seriously.
Explain what actions wM be dome:

So what we are going to do is:
 To check your father tile to know what happened in details.

 Write incident report for what happened.
 Inform our consultant and nurse in charge.
 Write in clear obvious notes in your father file that he is allergic to codeine not to be given to him in the
future.
 Discuss this issue in the next morbidity and mortality meeting to avoid this to happen in the future
 Refer this issue to the risk management team to investigate what happen. Is it OK with you?
- The son might be still angry - Apologize again and clarify for him that we are here to help your father as much as
we can, and any harm for your father was not intended at all.
Soctai History:
May I ask some social questions if you don't mind?
 What is your father doing for living? Do his illness impact his job and usual daily activity? I'm sorry for that
I'm going to refer him to a social worker to solve any social troubles he has.
 With whom your father is living? Are they doing well? Who is supporting your father at home?
 Is he financially supported?
 Does he smoke? Drink alcohol?
I want to make a complain doctor?

- This is definitely your right. We will help you by referring you to the patient advice liaison office and we will
follow up the result of your complain and be sure that the plan of management of your father will not be affected at
all
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Any other concern?
I want the name of the doctor who prescribed this medication please?
- I'm not defending my colleague, but we are working here as one team, all of team members are responsible for
your father"s condition.
Make Summary: About the important points in the meeting. Apologize and emphasize again.
Help: I'm going to give you my contact number, if you have any worries or queries, please don't hesitate to contact
me any time.
- Shake hands.
45
Complication of a procedure
Angry son-father died after a procedure (PCI)
Scenario: Mr.Gamai is 65 years old. He seeked medical care today morning after complaining of chest pain, ECG
done and revealed Anterolateral MI.
PCI done for him in the best interest of his condition alter his consent, unfortunately his condition was deteriorated
after PCI and was transferred to the ICU, and had cardiac arrest, resuscitation done for him but unfortunately he
passed away.
You are SHO of cardiology department on call today, you have been asked to discuss this issue with Mr. Rami his
son who just came asking for his father condition.
Introducation:
– Shake hands.
– Confirm the son identity and ask if he is the next of kin.
– Ask if he want any one of the family members o attend the meeting.
– Ask the son: How much do you know about your father condition?
Explain to the son the condition of the father since he seeked medical care in ER and Break the news
gradually:
 Actually our father seeked medical care in our emergency department today morning complaining of chest
pain. Blood tests and heart tracing done for him and unfortunately it revealed that he had severe heart attack
with extensive blockage of the blood supplies of his heart.
 An urgent life saving procedure done for him in the best interest of his condition which is called
(Percutaneous Coronary Intervention). It is a procedure done to widen the narrowed and blocked blood
conduit and remove any blood clot of the heart.
 A consent was signed by your father after explaining the Advantage and complications of the procedure and
he agreed to do the procedure.
 Unfortunately your father condition was deteriorated after this procedure, and was transferred to Intensive
care unit to be given the best care, then he had heart arrest, Maximum efforts were done to restore his heart
beats but unfortunately... he passed away.
Stop for awhile and let the son to express his feelings.
46
(Here the son may show denial or may be anger that you have to manage)
Showing empathy and sympathy for the son: I'm really sorry for you, I appreciate your feeling , I know how much
theses news are hard for you, and be sure that we did our best to save your father's life .
The son maty have some queries and anger: Did you kill my father doctor? .. How dear you to do such procedure
without informing us?
-1 really appreciate your feeling again, be sure that we did our

Best effort to save your father's life, this procedure was done for him in the best interest of his condition.. Without
this procedure, your father would have cardiac arrest and would die at once.
- Your father was completely competent and had full mental capacity to made decision.. All the procedure
information including the advantage and complications were explained to him and he agreed.. So the procedure was
done urgently to save his heart and his life.. And like any other procedure it has its own complications that he
developed unfortunately.
Does this make any sense for you?
Show empathy and sympathy again: I'm sorry again Mr. Rami. AH the medical team members are feeling sorry for
your loss, and be sure that we did our best to save your father's condition.
Soeiai History:
 What was your father doing for living?
 With whom your father was living? Are they doing well? Any one of them need special care, social or
financial support?
Concerns:
I want the name of the doctor who did the procedure to my father?
- Your concern is highly appreciated, I'm not defending my colleague but we are working here as one team, and all
of team members are responsible for your father's condition.
47
– I Want to make a complain doctor?
Definitely this is your right, We will help you by referring you to the patient advice liaison office, and we will follow
up the result of your complain.
Any other concern?
– I want the death certificats of my father now please?
-1 appreciate your concern, the death certificate will be released by the coroner, we will contact him soon to release
it to avoid any delay of the funeral ceremony.
Help: I'm going to give you my contact number, if you have any worries or queries, please don't hesitate to contact
me
– Shake hands.
48
Counseling for DNR decision
Scenario: Mr. Salem is 65 years old Know case of advanced multiple myeloma, DM, HTN, IHD admitted last
week because of altered conscious level, His condition was deteriorated and was put on mechanical ventilation and
transferred to intensive care unit.
The treating team made decision not to resuscitate the patient in the best interest of his condition.
You are SHO of the medical department, you are asked to discuss this issue with his son Mr. Ahmed
Introduction:
– Shake hands.
– Confirm the son identity.
– Ask if he is the next of kin.
– Ask if he need any one of the family members to attend this meeting
– Ask the son: how much do you know about your father's condition?
Unitiai question: May i ask if your father has advanced directive or living will or power of Attorney?
Expiaim the condition of the father to the son:

Your father is known to have advanced multiple myeloma which is a cancer of the blood, DM, HTN, IHD admitted
last week because of altered conscious level, Unfortunately His condition was deteriorated and was transferred to
intensive care unit and was put on assessed ventilation.
Showing empathy and sympathy:

How do you feel now Mr. Ahmed? Tm really sorry for that, I highly appreciate your feeling, and be sure that we are
here to do the best for your father and to offer him the full care.
ExpMm the decision of BNR:

So according to the advanced deteriorated condition of your father, the treating team made decision in the best
interest of your father's condition not to be resuscitated if he had heart arrest.
49
Explain Resuscitation to the son:
Do you have any idea what is resuscitation?
-When any patient's heart stops beating, we start to do resuscitation to stimuiate the heart to beat again by repeated
compression on the chest, insertion of a tube through the air pipe and giving some medication through a needie to
stimuiate the heart to work again.
Explain complications of Resuscitation:

-Resuscitation has its own complications like chest bones fractures, bleeding in the iungs, deformity of the chest and
injury to the air pipe.
-The chance of your father to revive again is extremeiy iow , and even if he revived he wiii suffer a iot and will has
a very bad iife quality, So that a decision not to resuscitated was taken in the best of your father's condition ..
Outweighing the complications versus the benefits, the complications are extremely more for resuscitation.
- Showing empathy and sympathy again: How do you feel now Mr. Ahmed?
.. I really appreciate your feeling, I know how much there news are hard for you, and be sure this decision was taken
in the best interest of your father condition.
– Managing the dilemma of rejection of the son to DNR:

The son may be unsatisfied with DNR decision and may tell you: please doctor do anything to keep my father alive.
– I really appreciate your feeling, I know how much your father is precious for you and be sure that he is precious
for us as well.. As your father do not has advanced directive, living will or power of attorney so that the medical
team has the right to make medical decision in the best interest of the patient condition.
– But as long as your father heart is beating, he will be offered all the medical care and management.
– If the son still not accepting DNR decision.. Then tell him we can arrange another meeting involving anyone else
of your family members whom you can trust, we can involve our consultant as well to reply any worries or queries
you still have .
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Social History:
-May I ask some social questions if you don't mind
With whom your father was living? Are they doing well? Any one of them need any social of medical or financial
support?
-Are they financially supported?
Comcems: Do you have any concerns?
Make summary: About the important points in the meeting.
Check amderstamdtmg: May I know how much did you get from our discussion today?
– Help: I'm going to give you my contact number, if you have any
Worries or queries, please don't hesitate to contact me
– Shake hands.
51
Counseling for Steroid Therapy Side Effects
Scenario: Mrs. Mona is 23 years old was admitted 3 days back after history of recurrent loose motions for 2 months
colonoscopy done for her and a diagnosis of ulcerative colitis was confirmed, she was prescribed Steroids by the
gastroenterology consultant.
She read about steroids side effects on the internet, she is very worried about this medication.
You are SHO of the Gastroenterology clinic, you are asked to discuss this issue with Mrs. Mona.
Introduction:
- Shake hands.
- Introduce yourself.
- Confirm the patient identity.
- Ask the patient: How much do you know about your condition.
- Ask what information you read about Steroids?
Explain the condition of the patient simply without jargons:

May i explain to you more about your condition?
Ulcerative colitis is long standing soreness of the bowls due to disturbance of your defensive system. It is a long
standing disease causing recurrent loose motions, tummy pain, anemia, fatigue, electrolyte imbalance and loss of
weight.
Advantage of Steroids:
 Steroids are prescribed to you in the best interest of your condition to adjust your defensive system and
control your condition.
 Steroid is very important drug in your condition that you have to be completely compliant and adherent to
control your condition to avoid complications of the disease.
 You will receive steroids for a time will be decided by the bowl physician until your condition is controlled.
Disadvantage of Steroid:
Like any other drug steroid has its own complications , like weight gam , thin skin and linear rash, easy bleeding ,
abnormal hair growth , stomach soreness high glucose level, high blood pressure, fragile bones, diminished defensive
system, But...
52
Explain how to overcome these complication:
 But, we are going to give you reguiar follow up to check for any side effect of the drug to manage at once.
 We will check your glucose level and blood pressur, Electrolytes regularly for any disturbance.
 For fragile bone we will give you calcium to keep your bone density and we will follow up any infection to
be treated properly.
 Outweighing the risk versus the benefits of steroids, the benefits are extremely more.
- Without Steroid, your condition will be deteriorated, and you may have a lot of complications of the disease.
- With steroids your condition will be controlled, and the chance for any complication will be low, and you can
live near normal life. Is it ok with you?
Pregnancy: May I ask if you have a partner? Are you planning for pregnancy? - If you are planning for pregnancy
any time, you have to inform your Obstetrician and gut doctor to make MDT to give you the full care and proper
management during your pregnancy.
Social History:
May i ask some social questions if you don't mind?
 What are you doing for living? How much your illness may affect your work and social life? (Refer the
patient to occupational health care worker if work will be affected, and to social worker if social life will be
affected)
 With whom you are living? Are they doing well? Do they support you?
 Do you smoke at all? Do you drink alcohol?
-Concerns: Do you have any concerns?
Any other alternative doctor?
I appreciate your concern, steroid was prescribed in the best interest of your condition by the gut consultant who is
expert in such cases.
For how long I’m going to receive this medication doctor?

It varies from one patient to the other, this will be decided by the gut doctor according to the disease activity and
control.
53
Check understanding: May I know how much did you get from our meeting today?
Help:
 I hope I couid cover your worries about steroid therapy
 I'm going to give you some leaflets and websites about steroids to read more about it, I will give my contact
number, if you have any worries or queries, please don't hesitate to contact me.
- Shake hands.
54
Counseling for Warfarin side effects
Scenario: Mrs. Amira is 29 years old wad admitted 3 days ago as a case of putmonary embolism, the hematologist
prescribed warfarin for her in the best interest of her condition.
She read about warfarin side effects on the internet, and she is very worried about this drug.
You are SHO of the medical department, you are asked to discuss this issue with Mrs. Amira.
Introduction:
- Shake hands.
- Ask the patient: How much do you know about your condition?
- Ask how much information you got about warfarin?
Explain the condition of the patient simply without jargons:

You have admitted 3 days ago because of a blood clot in the blood conduit of your lungs, which is a life threading
condition.
Advantages of warfarin:
That is why the blood doctor prescribed to you warfarin as a blood thinner in the best interest of your condition to
thin your blood to prevent further extension of the clot and prevent another blood clot in the future.
Warfarin is very important drug in your condition and you have to be completely compliant and adherent to it to
control your condition.
Without warfarin your condition may deteriorate ans you may have another blood clots in the future.
Disadvantages of warfarin:
As any other drug warfarin has its own complications, like increased blood thinning and may be bleeding from
anybody orifice or even bleeding in the brain but....
55
Explain How to manage these complications:
 But, we can overcome such complications by referring you to a special clinic called (Coagulation clinic)
with a special card involving your warfarin dose and blood thinning value for regular follow up and regular
checking of your blood thinning value to keep it within target range which is (2-3).
 If we kept the range of blood thinning within (2-3) the chance of bleeding will be extremely low.
 Outweighing the risk versus benefits of warfarin, the benefits are extremely more.
- Without warfarin you will be at high risk of developing further blood clots in the future, and your life may be in
danger, Sorry to tell you that.
- On warfarin your condition will be well controlled, and the chance of blood clots will be extremely rare, and
you can live near normal life.
– New medications: If you are going to receive any new medication, you have to inform you blood physician as
many medications may interact with warfarin and may alter its efficacy.
– Diet: Some types of food may alter warfarin effect as well, so we will refer you to a dietician to write the list of
types of food you have to avoid.
– Pregnancy:
 May I ask if you have a partner? Are you planning for pregnancy? - If you are planning for pregnancy any
time, you have to inform your Obstetrician and blood doctor to make MDT to give you the full care during
your pregnancy.
 Warfarin can be harmful to the baby, so during pregnancy it will be
Exchanged with another thinner given under the skin which is safe during pregnancy.
Sociai History:
May i ask some social questions if you don't mind?
 What are you doing for living?
 How much your illness may affect your work and social life? (Refer the patiant to occupational health care
worker if work will be affected, and to social worker if social life will be affected)
 With whom you are living? Are they doing well? Do they support you?
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 Are you financially supposed?
 Do you smoke at all? Do you drink alcohol? (Alcohol may alter warfarin efficac, so this issue to be discussed
with the dietician in details).
Comcetrmg: Do you have any concerns?
Any other alternative doctor?
I appreciate your concern, warfarin was prescribed in the best interest of your condition by the blood physician who
is expert in such cases, any other alternative to be discussed with blood doctor himself.
For how long I'm going to receive this medication doctor?
It varies from one patient to the other, may be for few months or may be forever according to the underlying cause,
this will be decided by the blood doctor.
Make sttammary: About the important points in the meeting.
Check mndterstamdmg: May i know how much did you get from our discussion today?
Help: I’m going to give you some leaflets and websites about warfarin therapy, i will give my contact number, if
you have any worries or queries, please don't hesitate to contact me any time.
- Shake hands.
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Counseling for Genetic test
Scenario: Mrs. Heba is 25 years old, her father was diagnosed as Huntington disease 2 weeks ago, she read on the
internet that it has strong familial predisposition. She is very anxious since that time; she is coming to do Genetic
test for Huntington.
You are SHO of the Neurology clinic, you are asked to discuss this issue with Mrs. Heba.
Introduction:
- Shake hands.
- Ask if she want her husband to attend this meeting.
- Ask the patient: How much do you know about Huntington disease?
- How much she know about the test?
- Ask if anyone pressurized you to do the test?
Explain Huntington disease simply without jargons:
May i explain to you more about Huntington disease?
 It is a progressive condition causing Cognitive function impairment and abnormal jerky movements all over
the body.
 It is a familial condition, unfortunately the chance of every one of the offspring to have the disease is 50%.
 Unfortunately the disease in the next generation is coming in earlier age, and with more severe symptoms
(Anticipation and Expansion)
 We cannot guarantee when the symptoms will appear exactly, it varies from one to the other.
Explain the test:

- Genetic test is a blood test, the result will be released within 24 or 48 h.
You will be the only one to receive the result, it is not released by email or telephone (Confidentiality).
-This test may has false positive or false negative results.
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If the test is positive:
 Positive test will have some disadvantages: You may have a bad mood and anxiety, you may lose your future
insurance, but prior insurance will be preserved.
 Advantages: We will refer you early to MDT to give you regular follow up and management.
If the test is negative:

 Disadvantages: It may be false negative and may be repeated to confirm the result.
 Advantages: You will be relaxed, and continue your life without stress
Consent:
 If you agree to do this test, you have to sign a consent in which all the information of the test are mentioned,
if you want to withdraw any time you have completely the right for that.
 You can have some time to think about it, and you can bring your husband next time to share the information
and decision with you, postponing the test will not alter the outcome of the disease.
Social History:
May I ask some social questions if you don't mind?

 What are you doing for living?
 With whom you are living? Are they doing well? Are you supported at home?
 Do you have any sisters or brothers? Are they doing well?
 Do you smoke at all? Do you drink alcohol?
If i have the disease doctor, when will the symptoms appears?
I appreciate your concern, we cannot guarantee when the symptoms will appear exactly, it varies from one to the
other.
What about my children doctor, they may have the disease?
If you are confirmed to have the disease, I'm sorry to tell you that every one of your children have chance of 50% to
have the disease.
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What if I planned to be pregnant doctor?
If the test is positive, and you have a plan for pregnancy, at that time we will refer you to MDT invoiving genetic
counseling team to heip you in this issue to make the best of your interest.
Check understanding May I know how much did you get from our discussion today?
Help: I'm going to give you some leaflets and websites about Genetic test of Huntington, I will give my contact
number too, if you have any worries or queries, please don't hesitate to contact me
- Shake hands.
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Counseling for a procedure
(SLE for Renal biopsy)
Scenario: Mrs Hala is 35 years old has been diagnosed as a case of Systemic lupus 3 years ago , Recently she has
been complaining of morning eyes puffiness and frothy urine, 24 h urine protein done for here and a diagnosis of
nephrotic syndrome has been confirmed. The nephrology consultant decided to do renal biopsy to know the staging
of her kidney involvement to start the proper treatment.
You are SHO in nephrology department oncall today, you are asked to discuss this issue with here.
Introduction
- Shake hands.
- Confirm the patient identity
- Confirm Agenda of meeting and take permission to start.
- Ask if the patient needs anyone else to attend the meeting
- Ask open question: May I know how much do you know about your condition?
Explain the disease briefly and the decision of renal biopsy:
May I explain to you more about your condition?
 Systemic lupus is a multi system disease due to disturbance of your defensive system which supposed to
attack the germs and viruses, in your condition it attacks your own body, like the joints, lining of the heart
and lungs, the skin and kidneys.
 Blood and urine tests done for you unfortunately revealed that you have protein in urine, which means your
kidney are involved. The kidney consultant decided that a kidney snip is seriously needed to assess your
kidney condition.
 Do you have any idea about this procedure of kidney snip?
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Explain the procedure simply without jargons:
May I explain to you more about this procedure?

 It is a procedure done by an expert doctor who did such procedures hundreds of times before.
 It is inserting done by inserting a special needle into your back while you are laying on your tummy under
aseptic condition, image guided, and local anesthesia to numb the area of needle insertion to feel less pain,
the snip will be taken and will be sent to a pathologist for analysis.
 You may stay in the hospital for 24 hours after the procedure to be sure you are free from any complications
- ask if the patient has any drug thin her blood and that you will do some blood test prior to the procedure to
make sure about any bleeding tendency.
Explain Advantage:
 This procedure is very important as it will give us idea about how much your kidneys are affected and what
is the stage of your kidney disease, and according to that you will receive the proper treatment.
 Without this procedure we can't and out the stage of your kidney disease so that we can't give you the proper
treatment, and your kidney function will be deteriorated and I'm sorry to tell you that even you may have
kidney failure and need renal replacement therapy in the future.
Explain disadvantage:
 This procedure has some complications like bleeding, infection, injury to internal organ and inappropriate snip.
 But such all complications are extremely rare and outweighing the risk versus the benefits, the benefits are
extremely more.
Consent: If you accept to do the procedure, you have to sign a consent for agreement containing all the information
of the procedure, and you can withdraw any time if you changed you mind.
N.B: The patient task here is to refuse the procedure for a reason, and your task is to convince her to do the procedure
exploring the reasons of patient refusal trying to solve them.. Like needle phobia: We are going to give you local
anesthesia to numb the area of insertion so that you will feel so little pain.
If the patient is still hesitated or refusing the procedure:

I will give you some time to think about it and may be to share opinion with some one of your family members, i
will involve my consultant as well in another meeting to convince you more about the procedure.
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Treatment plan:
 What we are going to do is'to refer you to MDT from blood physician, Macmillan nurse, psycho therapist,
social worker to give you the appropriate care and plan of management.
 The main treatment plan is a course of chemotherapy (explain advantage and disadvantage of chemotherapy)
chemotherapy can destroy the nasty growth and may cure the cancer completely..
 It has some complications in the form of feeling or getting sick that can be treated by some medications,
falling of hair which will grow again, you can use a wig at that time, your defensive system may be disturbed
and you may get easy infection and we will give you a card and follow your condition and give you
antibiotics if any infection developed..
 Outweighing the risk versus the benefits of chemotherapy, the benefits are significantly more.
Hickman line explanation:

Chemotherapy has to be given though a wide bore needle called hickman line,
 It is wide bore needle will be inserted in a large blood conduit under local anesthesia to numb the area of
insertion and under aseptic condition, done by expert doctor who did such this procedure hundreds of times
before.
 This line has advantage in the form of providing easy access for the cycles of chemotherapy.
 It has some complications in the form of bleeding, infection, injury to the adjacent tissues, or may be
blockage of the line, but such complications are rare to happen.
 If you agree to do this procedure you have to sign a consent involving all the information about the procedure,
and if you want to withdraw from the consent, you have the right any time.
Social History:
 How much your illness impact your job and usual daily activity? Refer the patient to occupational health
worker if job is affected, Refer to social worker if social life is affected.
 With whom you are living? Who is supporting you at home?
 Do you smoke at all, drink alcohol?
I know that chemotherapy can cause infertility doctor?
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Infertility one of the complications of chemotherapy which can be irreversible some times , So we can overcome
this problem by saving some of your sperms in a sperm bank to be used in the future , you can bring your wife next
time to discuss this issue with both of you.
Is it curable condition doctor?
A lot of cases were completely cured after the full course of chemotherapy.
Make summary: About the important points of the disease and management plan.
Check understanding: may I ask how much did you get from our discussion today? (If you have time)
Help: I'm going to give you some leaflets, brochures, websites to read more about the disease, I will give you my
contact number as well to contact me any time if you have any worries or queries.
- Shake hands.
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Drug incompliance
Scenario: Mr. Hend is 34 years old Known case of DM on insulin, her HBA1C in the last visit is 10.5. The diabetic
nurse see that uncontrolled DM is most probably due to Mrs. Hend not compliant on her medications.
You are SHO of the diabetic clinic, you are asked to discuss this issue with her.
Introduction:
- Shake hands.
- Ask the patient: How much do you know about your condition?
Infrom the patient about the result (avoid confrontation):
 The blood result of HBA1C, Which measures DM control in the last 3 months unfortunately is high. It means
that your DM is not controlled, And mostly this is due to incompliance on your medications.. What do think
about that Mrs. Hend?
 Mrs. Hend be sure we are here not to judge you, we are here to offer you the full care and help.
Ask about reasons of incompliance:
Can I ask if you have any troubles with your medications like forgetfulness, needle phobia or bad experience?
Offer solutions to the patient:

 If forgetfulness: We can help you by giving you reminder aid device to remind you every time for your
injection.
 If needle phobia: I appreciate you feeling, the diabetic nurse can teach you or one of your family members
how to inject you in perfect way.
 Other important options to help adherence:
 Nowadays there are a lot of different advanced devices and equipment for treatment of DM, one of them
is insulin pump to avoid repeated injection, I will refer you to the diabetic nurse to explain to you the
different devices and you can choose the most suitable one for you. Is it OK with you Mrs. Hend?
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Importance of compliance to avoid complications:
Compliance on your medication is very important to control your DM and avoid complications of high glucose level,
 Short term complications: Short term complications of uncontrolled DM is Loss of weight, increased thirsty
and increased water work frequency and with very high level of glucose it can be serious and you may have
Diabetic coma, I'm sorry to tell you that.
 Long term complications: Long term complications of uncontrolled DM is visual disturbance due to impact
on the back of the eyes, deterioration of the kidney function i, pins and needles in the hands and feet due to
impact on the nerve cables, impaired healing of the wounds, easy infection due to impaired defensive system
and exposure to heart attacks in the future.
 But.. If you are completely compliant on your medications and your glucose level is well controlled, you are
going to avoid all of these complications and you can live near normal life.
Life sfyfe modification:

Beside Drug compliance, you have to make some life style modification to help your diabetes control:
 Daily Exercise is very important for DM control, we can refer you to exercise training program for more
education.
 Diet control is very important as well, and we will refer you to a dietician for more education about diet
adjustment.
Social History:
 What are you doing for living? How much your illness impacts your job and usual daily activity? Refer the
patient to an occupational health worker if her job is affected, Refer to a social worker if her social life is
affected.
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Check Mmdtersitsimditmg: Can I know how much did you get from our discussion today?
Help: I'm going to give you some leaflets, websites about DM and new devices and equipment of treatment.
I’m going to give you my contact number, if you have any worries or queries please don't hesitate to contact me any
time.
- Nice to meet you - Shake hands.
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Patient with Suicidal Attempt
Asking For Discharge
Scenario: Mrs. Liala is 23 years old was admitted 2 days ago with suicidal attempt after intake of 20 tablets of
paracetamol, with normal blood test are normal, she is asking for discharge.
You are SHO of the medical department on call today, the nurse in charge called you to talk with Mr. Laila.
Introduction
- Shake hands.
- How do you feel now Mr. Laila?
Ask abotut circumstances of the suicidal attempt:
To assess the patient liability for further suicidal attempts in the future
May I know whatt happened exactly?
 What happened before? Do you have History of similar attempt in the past? Did you write any suicidal notes?
 What happened during? How many tablets did you take, did you take any other tablets or alcohol? Did you
lock the door form inside?
 What happened after? Did you call for help? Do you still have any suicidal thoughts? Is life still precious for
you?
Ask why the paitiemt wamt to go home try to sofve her
You: May I ask why do you want to go home?

Try to solve any troubles the patient has..
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For example.
Patient: the nurse stuff have bad attitude dr.
You: I'm sorry for that, I'm going to talk to the nurse in charge and I promise they will improve their attitude.
Patient: They banned from smoking doctor?
You: Didn't you think about giving up smoking before, we can heip you by referring you to smoking cessation cfinic to
help you giving up if you don't mind .. Is it Ok with you?
Patient: The food quality is so bad here doctor?
You: I'm sorry for that, I'm going to talk to the chief in charge, and i promise to improve the food quality and provide
you with the of food you like.
Is it ok for you?
The patient stifl insists to go home.
Explain the complications of paracetamol overdose:

Paracetamol over dose may be asymptomatic with normal blood tests in the first 2 or 3 days, but it may carry high
risk later on in the form of:
 Deterioration of liver function, and may be liver failure in the late stages, and may proceed to coma, and in
advanced condition liver transplant may be needed.
 Deterioration of kidney function, and may be kidney failure in late stages.
 Increased thinning of the blood due to decrease level of clotting factors, and increase chance for bleeding.
 Increase blood acidity, and deterioration of the functions of the body organs.
Patient: Thank you doctor. I feel ok now. I just want to go home?
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Explain the risk of discharge:
 You have to be admitted under our observation for at least 5 Days to confirm that your condition is stable
and you are completely free from any complications mentioned before.
 If you developed any complications, and you did not receive the proper treatment, your life will be in serious
danger, and I'm sorry to tell that you may even die...
The surrogate task is to insist to be discharged, and may tell you i can sign any form to be discharged on my own
responsibility.
You: I'm going to involve my consultant soon to convince you more, and Psychiatrist to assess your condition before
discharge... Is Ok with you?
Social History:
 What are you doing for living? Does your mood affect your job and your social life? — Refer the patient to
occupational health care worker if her job is affected, and to a social worker if her social life is affected.
 Do you smoke? Drink alcohol?
Check understanding:
Help:
 I'm going to give you some procures about paracetamol over dose to know more about it.
 I'm going to give you my contact number, if you have any worries or queries, please don't hesitate to contact
me.
- Shake hands.
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N.B:
– The surrogate task here is to insist for discharge.
– Your task is to convince the surrogate kindly to stay for further investigations, and observation exploring the reasons
for asking for discharge, trying to solve any dilemma for him, clarifying the risk of early discharge.
– This lady is not allowed to go home before assessment by a psychiatrist, Not allowed even to sign against medical
advice, and if insist for discharge has to be kept under the mental act.
– Avoid confrontation with the patient, and try to conveinse hir kindly without judgment.
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Somatization
Somatoform Disorders
Scenario: Mrs. Mona is 40 years old has been complaining of recurrent headache, chest pain, abdominal pain for
the last 10 years.
All the blood tests done for here were normal, the consultant made decision no more investigations are needed for her.
You are SHO of the medical Outpatient clinic, you are asked to discuss this issue with her.
Indroduction:
– Shake hands.
– Ask the patient: How much do you know about your condition?
– Do you have any expectations for results of the blood test done for you?
Inform the patiemt about the resuit:
Mrs. Sarnia I have good news for you, that the results of the blood test done for you all are normal.. What do you
think about that?
The Surrogate wiil express anger:
At that point you will find the surrogate so angry.
Patient: What do mean doctor, you mean Fm medically free, do you mean Fm malingering, do you want me to go
back to my husband telling him all blood test are normal and Fm such a big liar).
- Let the surrogate to express her anger without interruption and keep calm until she end her anger, and then start to
explain her condition.
Managing auger of the surrogate and admit her suffering:

You: I really appreciate your feeling , i didn't say you lie or you are malingering at all, i admit you are suffering, and
you have something we have to manage and we are here to give you the full help and care, is that ok with you?
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Explaining the condition of the patient:
Do you want me to explain to you more about your condition?

 Your symptoms mostly due to stress being overwhelmed with responsibilities.
 When the someone is under mental stress he may express that with physical symptoms like headache, chest
pain, tummy pain, loose motions and fatigue.
 So we admit you are suffering and needs medical support and care, and we are here to help you as much as
we can and do our best to manage your condition.
Detailed Social History:
May I ask you some social questions if you don't mind?

 What are you doing for living? Any stress or troubles at work?
 With whom do you live? What your husband is doing for living?
 Does he support you at home? Does he stay away from the house for long time?
 Do you have children? Are they doing well? What about their school performance?
 What about your family Dad, Mom, brothers and sisters? Are they doing well?
 Do you think you need any social or occupational support? We can help you in this issue. As we have UN expert
teams to manage any social troubles.
 Any troubles with your neighbors?
 Do you smoke at all, do you drink alcohol?
 Do you think you are under stress or overwhelmed all the time?
Mamagememt plan:
 So what are going to do is to refer you to MDT from a social worker and a psychiatrist to give you the proper
care and support.
The surrogate may be angry again.

Patient: Psychiatrist... Do you think I'm mad doctor?
You:
 Not at all, Psychiatrist is not for mad people only... a lot of people are seeking medical care with psychiatrist
for mental support and relief when they are under a lot of stress.
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 He may, help you much a Talking therapy, such as cognitive behavioral therapy, may help you to understand
the reasons of your symptom, also may prescribe some medications which improve your mood and relieve
your stress.
 The social worker is to relieve and manage any social troubles you have.
Concerns: May I ask if you have any concerns?
I have long standing headache doctor, i want to do Imaging for myhead
 Actually your headache is one of the symptoms secondary to stress.

 We don't have any indication to do imaging for the brain in the time being.
 You are going to have all complications of exposure to radiation without benefits.
I want to be surethat my brain is ok and I don't have something serious
 Actually our consultant decided that no need for more investigations in your condition.
 Imaging has some side effects like exposure to radiation... And no need to expose you to radiation without
need or clear indication.
Please doctor I insist to do imaging to my brain
Ok, I will involve my consultant regarding this issue... Is it Ok with you?
Check understanding: May I know how much did you get from our discussion today?
Help: I'm going to give you my contact number, if you have any worries or queries any time, please don't hesitate
to contact me
- Shake hands.
N.B
 This case is one of the tricky cases in the exam.
 In this case let the patient to express her feelings and anger without interruption.
 Appreciate the feeling of the patient a lot and show a lot of empathy and sympathy.
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 Admit for her that you know she is suffering a lot and admit that she need medical care.
 Inform her what could be the reasons of her condition without confrontation.
 Try to explore her detailed social history to pick up any underlying stressful social life she might has. (Here
you are acting like a social worker).
What are the somatoform disorders?
The somatoform disorders are the extreme end of the scale of somatization. So, the physical symptoms persist long-
term, or are' severe but no physical disease can fully explain the symptoms. Somatoform disorders include:
. Somatization disorder – Hypochondriasis
 Conversion disorder
 Body dysmorphic disorder
 Pain disorder
People with somatoform disorders usually disagree that their symptoms are due to mental factors. They are
convinced that the cause of their symptoms is a physical problem.
Somatization disorder
People with this disorder have many physical symptoms from different parts of the body - for example:
 Headache
 Feeling sick (nauseated)
 Tummy (abdominal) pain
 Bowel problems
 Period problems
 Tiredness
 Sexual problems
The main symptoms may vary at different times. Affected people tend to be emotional about their symptoms. So
they may describe their symptoms as 'terrible', 'unbearable', etc and symptoms can greatly affect day-to-day life. The
disorder persists long-term although the symptoms may wax and wane in severity.
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The cause is not known. It may have something to do with an unconscious desire for help, attention or care. It runs
in some families. The disorder usually first develops between the ages of 18 and 30. More women than men are
affected.
It is difficult for a doctor to diagnose somatization disorder. This is because it is difficult to be sure that there is no
physical cause for the symptoms. So, people with this disorder tend to be referred to various specialists, and have
many tests and investigations. However, no physical disease is found to account for the symptoms.
Hypochondriasis
This is a disorder where people fear that minor symptoms may be due to a serious disease. For example, that a minor
headache may be caused by a brain tumor, or a mild rash is the start of skin cancer. Even normal bodily sensations
such as 'tummy rumbling' may be thought of as a symptom of serious illness. People with this disorder have many
such fears and spend a lot of time thinking about their symptoms.
This disorder is similar to somatization disorder. The difference is that people with hypochondriasis may accept the
symptoms are minor but believe or fear they are caused by some serious disease. Reassurance by a doctor does not
usually help, as people with hypochondriasis fear that the doctor has just not found the serious disease.
Conversion disorder
Conversion disorder is a condition where a person has symptoms which suggest a serious disease of the brain or
nerves (a neurological disease). For example, blindness (severe sight impairment), deafness, weakness, paralysis or
numbness of the arms or legs. The symptoms usually develop quickly in response to a stressful situation. Yon
unconsciously convert your mental stress into a physical symptom.
Conversion disorder tends to occur between the ages of 18 and 30. Symptoms often last no longer than a few weeks
but persist long-term in some people. In many cases there is only ever one episode and no treatment is needed once
symptoms have gone. Some people have repeated episodes of conversion disorder from time to time.
Body dysmorphic disorder

Body dysmorphic disorder is a condition where a person spends a lot of time worried and concerned about their
appearance. A person with this disorder may focus on an apparent physical defect that other people cannot see. Or,
they
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Might have a mild physical defect but the concern about it is out of proportion to the defect.
For example, a person may think that he or she has a skin blemish or an oddshaped nose. However, no one else can
see the defect, or the blemish would be considered trivial by most people. The person becomes preoccupied with the
imagined defect, or slight defect. For example, they may spend a lot of time looking in the mirror at the apparent
defect. They may wear camouflaging make-up to hide the defect. The thought of the defect is very distressing for
people with this condition.
Some people with body dysmorphic disorder consult a cosmetic surgeon to have the imagined or trivial defect
corrected.
Pain disorder
Pain disorder is a condition where a person has a persistent pain that cannot be attributed to a physical disorder.
What is the treatment for somatoform disorders?
Treatment is often difficult, as people with somatization disorders commonly do not accept that their symptoms are
due to mental (psychological) factors. They may become angry with their doctors who cannot find the cause for their
symptoms. Another difficulty is that people with somatization disorder, like everyone else, will develop physical
diseases at some point. So, every new symptom is a challenge to a doctor to know how far to investigate.
 Cognitive behavioral therapy
 Antidepressant and Anoxylitics
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History
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About Station 2 (History taking)
 Station 2 is 20 min, 14 minutes with the surrogate, 1 minute to review your ideas and 5 minutes with the
examiner.
 You are given 5 minutes before going inside to meet the surrogate, these 5 minutes are very precious in
which you have to read the scenario very carefully and put a very good differential diagnosis list.
Golden point in Station 2 (History taking)
 Put very good differential diagnosis list in your white paper (The comer stone of Station 2).
 Ask about every symptoms of every differential diagnosis.
 If you missed asking about one symptom, you may miss the case.
 After finishing symptoms of differential diagnosis list ask about the systemic review in organized pattern
(You may miss asking something in the differential diagnosis, so that you can catch it in systemic review).
 In the reply of the concern of the patient explain the most proper diagnosis simply without jargons.
 In discussion with the examiner, don't put a far differential diagnosis which is mostly excluded by history.
 Put only 3 to 4 or even 2 differential diagnosis which are strongly supported by history.
 Put your differential diagnosis in a sequence related to the positive data of the patient.. Don't put wide
differential diagnosis (will consider you a text doctor), and mention what against your 2nd and 3rd
differential diagnosis.
 In investigations, don't mention unnecessary investigations for a far differential diagnosis, which is mostly
excluded in history.
 Put your investigations in organized pattern: Basic investigations in the form of CBC, Electrolytes, RET,
LFT and specific investigations according to your diagnosis in a sequence of importance and priority (for
example: in a Case of TIA, don't mention ECG, echo and 24H holter before CT Brain).
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History Approach
Introduction
 Shake hands.
 Introduce yourself.
 Confirm the patient identity.
 Confirm Agenda of meeting and take permission to start discussion.
 Ask open question can you teli me more about your condition please.
 I'm going to write some notes will be confidential, and be sure my full attention wiH be completely with
you.
Analysis of the complain avoiding jargons:
 Onset
 Course
 Duration
 Progression
 Improving factors
 Worsening factors
 Associated symptoms.
Ask About symptoms of your differential diagnosis list:
 If you have 7 or 8 differential diagnosis, then you have to ask about symptom of every differential diagnosis.
Systemic review:
 General symptoms: Fever, ioss of weight, high temperature, fatigue, lumps or pumps.
 CNS symptoms: Headache, LOC, visual disturbance, weakness, altered sensation, abnormal gait, shaking
of the body, altered speech, uncontrolled water work or bowel motions.
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 CVS symptoms: Chest pain, racing of heart beats, SOB (If positive do analysis of SOB), Leg swelling.
 Pulmonary symptoms: Runny nose, bleeding per nose, cough, phlegm, coughing up blood, noisy chest,.
 GIT symptoms: Mouth sores, acid brush, heart bum, difficulty of swallowing, tummy pain, feeling sick,
throwing up, altered bowel motions, blood in the stool, yellow discoloration of eye balls.
 Genitourinary: Any change in your water work? Amount, color, frequency, frothy urine.
 Hematoiogy symptoms: Any bleeding from anybody orifice, bleeding under the skin (if needed)
 Musk skeietai: Any joint pain, skin rash.
 Sexual history: If needed if you are suspecting sexual transmitted disease like HIV - Take permission (I
would like to ask private questions if you don't mind: Are you sexually active, How many partners do you
have?
 Menstrual history: Last cycle, regular or irregular, amount of blood, How many pads the patient is using if
menorrhagia.
 Travelling history: If you are suspecting infectious disease - When and where, for how long, where the
patient stayed? In Urban or rural area? Any insect bite there? Any swimming in local pools there? Any
endemic disease there? Any relation with local girls there?
 Medical history: Of any medical history of long standing disease like DM, HTN, heart disease.
 Surgical history: Any history of surgical operation, blood transfusion, dental procedure, tattooing, piercing,
needle sharing (AH have to be asked earlier if suspected blood transmitted disease)
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 Family history: Of simitar condition or long standing disease.
 Drug list: What is your drug list piease? Any over the counter medications? Any recreational drugs?
 Social history:
 Patient job? How much his or her symptoms affect her or his job and usual daily activity?
 With whom the patient is living? Who supporting him or her at home?
 Financial support.
 Smoking and alcohol history.
Summary: About positive data you got from the patient, and ask do you want to add any thing more?
 Explain simply without jargons what most probably the patient has.
 Explain what you are going to do as investigations without details and referral to a MDT or a specialized
doctor.
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Microcytic Anemia in Young Female
Scenario: Mrs. Hala is 42 years old , complaining of fatigue and both lower limbs edema for the last 2 months ,
blood investigations done for her revealed microcytic hypochromic anemia for you kind care.
Make your differential diagnosis list in your paper before going inside:
 Blood loss: from anybody orifice, menorrhagia.

 GIT causes: Peptic ulcer, IBD, Angiodysplesia, Malaborbtion, Malignancy -
 Hereditary causes (Herditary hemorrhagic telangiectasia, Thalasemia)
 Drug induced peptic ulcer: NSAIDS, Steroids, Aspirin or drug induced bleeding tendency (Anticoagulant i.e
warfarin)
Introduction:
 Shake hands.
 Confirm agenda of meeting (I have a letter from your GP informing me that you have been complaining of
fatigue for 2 months , and blood test done for you revealed that you have anemia ) Are you ready to discuss
this issue today ?
 I'm going to write some notes, be sure they be confidential and my full attention will be with you.
 Can you tell more about your complaint please?
Analysis of the complaint:
Onset course, duration progression, worsening factors, improving - associated symptoms:
 When this fatigue started exactly? Suddenly or gradually? Coming on and off or all the time? Is it increasing,
decreasing or the same?
 Did you notice anything worsen your fatigue, like exertion?
 Did you notice anything improve your fatigue, like rest?
 Associated symptoms of Anemia (Any headache, dizziness, SOB, racing eart beats, being pallor than
before?)
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Ask about symptoms of djifferernttaii dtagmosas list:
Chronic biood ioss:
 Any history of bieeding from anybody orifice?

 What about your periods, when was the last one, is it regular or irregular, is it associate with excessive
bleeding, how many tampons are you using per day?
 Hypothyroidism: Any weight gain, cold intolerance, constipation, low mood
GIT causes (PUD, IBD, Malabsorption, Malignancy, Angiodysplasia)
 Any mouth sores , acid brush , difficulty of swallowing , heart bum sensation , tummy pain , tummy swelling
, feeling sick , feeling sick, vomiting , vomiting up blood , blood in stool ? Any loose motions or less Motions,
yellow discoloration of the eye balls?
 If there is loose motions take detailed history:
 When these loose motions started exactly? Suddenly or gradually? Coming on and off or all the time? Is
it increasing, decreasing or the same?
 Worsening factors: Do you notice anything worsen your condition like special type of food containing
gluten?
 Improving factors: Do you notice anything improve your condition like fasting?
 Frequency: How many times per day?
 Consistency: Is it bulky or watery - Does it contain any blood (cancer, IBD), mucus or slim?
 Volume: What about the amount, is it large, moderate, or little amount?
 Odor: Is it offensive?
 Timing: Any diurnal variation, does it awake you from sleeping?
 Is it difficult to flush away?
 Loss of weight? How much KG? For how long? Intended or not, what about your appetite?
Hereditary Causes (Hereditary hemorrhagic telangiectasia (HHT), Thalasemia):
Any history of skin rash specially around the mouse, nose and face, any hstory of recurrent nasal bleeding, family
history of anemia or sudden death?
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Drug History: Any blood thinner drug, pain painkilier or steroids? What is your drug list please?
Systemic review: Don't ask about symptoms you asked before?
General symptoms: You asked about ah before.
GIT symptoms: You asked about all before.
CNS symptoms: Any loss of consciousness, headache, visual disturbance, altered speech, weakness, altered
sensation, abnormal gait, shaking of the body, uncontrolled water work or bowl motions?
CVS symptoms: Any chest pain, racing of heart rate, SOB, leg swelling?
Pulmonary symptoms: Any cough, phlegm, coughing up blood, noisy chest, runny nose, bleeding per nose?
Genitourinary: Any change in your water work? Amount, color, frequency, frothy urine?
Musculoskeletal: Any kin rash, muscle pain, joint pain?
Sexual history May i ask some personal questions.. Are you sexually active? How many partners do you have?
Menstrual history: You asked about it before.
Hematology symptoms: You asked about all before.
Travelling history: If there take detailed travelling history.
Medical history: Of any medical history of long standing disease like DM, HTN, heart disease.
Surgical history: Any history of surgical operation, dental procedure, needle sharing, tattooing, piercing,
recreational drug?
Family history: Of similar condition or long standing disease.
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Drug list: You asked before.
Social history
 Patient job? How much her symptoms affect her job and usual daily activity? Refer the patient to an
occupational health care worker if work is affected, and to a social worker if her social life is affected.
 With whom the patient is living? Who is supporting her at home?
Summary:
 Now I'm going to summarize the positive data in our discussion today:
 You have been complaining of fatigue for the last 2 months.
 You have been complaining of loose motions for the last 6 months , 4 to 5 times per days , you are not sure
if it is related to specific type of food , you lost weight about 7 kg in the last 6 months not intended , with no
change in your appetite ,
 You have been complaining of excessive blood of your periods for the last 3 months, which is not
investigated before.
 You have been complaining of back pain for which you are receiving pain killer called Ibuprofen 3 times
daily for the last 3 months.
 You father died because of cancer colon at the age 65. Anything else you want to add?
Concerns: May i know what is your concern?
Is it cancer like my father doctor?
I appreciate your concern, we have to do full examination and investigations first to confirm our diagnosis.
 Cancer in Unlikely in your condition, but we have to exclude as well.

 You have multiple causes for your anemia, the first one is Mai abortion causing your long standing loose
motions mostly a disease called (Celiac disease) caused by disturbance of you defensive system by any type
of food containing gluten.
 Second cause may be due to long standing excessive blood loss in your periods.
 Third cause may be intake of Ibuprofen for long time causing soreness and bleeding of your stomach.
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 So what we are going to do is to do further blood test and may be camera test for your gut and may be to
take a snip after your consent to confirm our diagnosis , then we will refer you to MDT to give you the proper
care and management plan .. Is it Ok with you? Any other concerns?
Discussion with the Examiner:
What is your diagnosis and DD?

 First differential is Malabosrbtion syndrome mostly celiac disease.
 Second differential is Menorrhagia.
 Third differential is peptic ulcer disease due to long use of NS AIDS.
 In the bottom of my DD is malignancy, against that the age of the patient, but i have to rule out because of
family history.
What investigation you are going to do?

 Apart from basic investigations: CBC, RFT, LFT, Inflammatory markers.
 Specific investigations: Iron profile, stool workup (Microscopy, and culture), Autoimmune profile for Celiac
(TTG Ab, Anti endometrial Ab, Antigliadin Ab), Upper and Lower endoscopy.
What is the treatment plan?
- Non pharmacological treatment:

 Patient education and counseling
 Psychosocial support
 Occupational support
- Pharmacological treatment
 MDT Approach from a gastroenterologist, dietician, gynecologist
 Iron supplementation: Blood transfusion or Iron transfusion or oral iron according to HB level, symptoms
and patient tolerance.
 If Celiac disease is confirmed: Avoidance of any type of food containing gluten, Vitamin and calcium
supplement.
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Scenaro: Mrs. Stephanie is 27 years old, complaining of loose motions for the last 6 months , Blood investigations
done for her revealed : AST : 75 , ALT: 150 . ALP: 345. For your kind care.
Make your differential diagnosis list in your paper:
 GIT causes (IBD, IBD, Malabsorbtion, Malignency)

 Malabsorbtion Causes (Celiac the more common in exam, Short bowl, chronic pancreatitis, Bacterial
overgrowth, Wippel disease).
 Endocrinal causes (Hyperthyroidism, Addison).
 Carcinoid syndrome.
 Infectious causes (i.e. HIV, TB).
 Autonomic dysfunction (Long standing DM).
 Drug induced (Laxitive, NSAIDS, Colchicines, Metformin)
Introduction:
 Shake hands,
 Introduce yourself,
 Confirm patient identity.
 Confirm agenda of meeting (I have a letter from GB saying that you have been complaining of loose motions
for the last 6 months).
 I'm going to write some notes, be sure it will be confidential and my full attention will be with you.
 Can you tell more about your complain please?
 Onset, course, duration, progression, worsening and improving factors:

 When these loose motions started exactly? Suddenly or gradually? Coming on and off or all the time? Is it
increasing, decreasing or the same?
 Worsening factors: do you notice anything worsen your condition, special type of food containing gluten
 Improving factors: Do you notice anything improve your condition like fasting?
 Frequency: how many times per day?
 Consistency: Is it bulky or watery - Does it contain any blood (cancer, IBD), mucus, slim?
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 Volume: what about the amount, is it large, moderate, or little amount?
 Odor: Is it offensive?
 Timing: any diumal variation, does it awake you from sleeping?
 Is it difficult to flush away?
 Association: Is it associated with tummy pain? (Simple analysis of the pain)
Ask about Differential Diagnosis list:
 Malignancy: Any Loss of weight, fever, lumps or bumps, fatigue?
 IBS: There is no loss of weight, associated with abdominal flatulence relieved by defecation.
 IBD: Associated with loss of weight, mouth sores (chrohn's), usually bloody stool, not altered by fasting.
 Maiabsorbtion: Associated with loss of weight, may worsen by food containing gluten (celiac), no blood
in stool, not altered by fasting.
 Hyperthyroidism: loss of weight (asked before), hot intolerance, racing of heart rate, shaking of the hands,
sweating, anxiety.
 Carcinoid syndrome: Flushing, noisy chest?
 Infection:
Any contact with TB patient?
(Risk factors for HIV) Any surgical operations, blood transfusion, needle sharing, tattooing, piercing,
recreational drugs. May i ask personal question, are you sexually active how many partners do you have?
 Autonomic dysfunction: Diabetic nephropathy. If diabetic, for how long you have diabetes, what
medication you are on? Are you compliant on your medication, what about the last HBA1C? - Ask about
long term complications of uncontrolled DM (visual disturbance, frothy urine, chest pain, SOB, pins and
needles in feet or hands)?
 Drug induced: Are you receiving any laxatives, any regular medications?
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 General symptoms: Were asked before

 GIT symptoms: (ask about symptoms you didn't ask before) acid brush, heartburn, difficulty of swallowing,
yellow discoloration of the eye ball
 CNS symptoms: Any headache, LOC, visual disturbance, altered speech
 Weakness, altered sensation, abnormal gait, shaking of the body, uncontrolled water work or bowl habits?
 CVS symptoms: Any chest pain, SOB, leg swelling (May be because of hypoalbuminemia)?
 Pulmonary symptoms: Any cough, phlegm, coughing up blood, noisy chest, runny nose?
 Genitourinary: Any change in your water work? Amount, color, frothy urine?
 Musculoskeletal: Any joint pain, skin rash.
 Sexual history: (you asked before in risk factors for HIV)
 Menstrual history: (If female patient) Last cycle, regular or irregular, amount of blood, how many tampons
the patient is using if menorrhagia.
 Hematology symptoms: Any bleeding from anybody orifice, bleeding under the skin.
 Travelling history: If there. When and where? For how long? Where the patient stayed? In Urban or rural
area? Any insect bite there? Any swimming in local pools there? Any endemic disease there? Any relation
with local girls there?
 Medical history: Any history of any medical of long standing disease like DM, HTN, heart disease?
 Surgical history; any history of surgical operation (Short bowel).
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 Family history: of simitar condition or long standing disease.
 Drug list: What is your drug list please? Any over the counter medications? Any recreational drugs?
 Social history:
 Patient job? And how much her symptoms affect her or her job and usual daily activity? Refer the patient
to an occupational health care worker if her work is affected, and to a social worker if her social life is
affected.
 With whom the patient is living? Who is supporting her at home?
 Financial support?
 Smoking and alcohol history?
Summary:
Now I’m going to summarize the positive data in our discussion today,
You have been complaining of recurrent loose motions for the last 6 months, 6 times per day, tinged sometimes with
blood, not precipitated by any factor, with loss of weight 10 kg, not intended, with good appetite. Do you want to
add anything else?
Concerns: What is your concern please?
Is it cancer doctor?
 1 appreciate your concern, we have to do full examination and investigations first to confirm our diagnosis.
 Cancer in Unlikely in your condition, but we have to exclude as well.
 Mostly you have a condition called ulcerative colitis which is a long standing inflammation and soreness of
your gut, which is highly associated with a liver disease called primary sclerosing cholengitis that is why
you have elevated liver function.
 What we are going to do is to do further blood test and imaging and may be camera test after your consent
to take a snip and confirm your diagnosis.
 You need to be admitted now for proper management and investigations and we will refer you to a MDT to
give you the proper care and management.
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Discussion with the examiner:
What is your diagnosis and differential diagnosis?
 My first differential is uicerative colitis with primary scierosing choiingitis which are highly associated.
 My differential is infectious cause, but against that the long standing history.
What investigations you are going to do?
 Apart from basic investigations: CBC, RFT, LFT, Inflammatory markers (CRP, ESR).
 Specific investigations:
 Stool work up (Microscopy, Cytology and culture).
 Colonoscopy and biopsy.
 Abdominal US.
 MRCP
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Jaundice
Scenario: Mrs. Samia is 28 years old, complaining of jaundice and tummy pain associated with abdominal pain for
the last 5 days, for your kind care.
Pre hepatic causes: Hereditary hemolytic anemia, autoimmune hemolysis, Paroxysmal nocturnal hemoglobinurea,
Malariasis.
Hepatic causes:
 Alcoholic hepatitis
 Viral hepatitis
 Metabolic liver cirrhosis (Wilson, Hemochromatosis, alpha 1 Antitrypsin deficiency, Cystic fibrosis)
 Autoimmune (Autoimmune hepatitis, PSC, PBC)
 Malignancy (Hematoma, seconderies)
 Vascular (Bud chiari Syndrome)
 Drug induced (i.e. Isoniazid, methotrexate, Amiodarone)
Post Hepatic causes:

 Intra luminal: Calcular Obstructive jaundice.
 Luminal: Primary biliary cirrhosis, primary sclerosing cholangitis, Drug induced.
 Extra luminal: Any swelling compressing CBD i.e. Malignancy, Lymphoma.
Introduction
 Shake hands.
yellow discoloration of your eye balls and tummy pain for the last 5 days.
 I’m going to write some notes which will be completely confidential and my full attention will be with you.
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 Onset, course, duration, progression:

 When yeiiow discoloration started exactly? Suddenly or gradually is it increasing, decreasing or the same?
Coming on and off or all the time?
 When your tummy pain started exactly? Suddenly or gradually? Coming on and off or all the time? Is it
 Site: where exactly in your tummy?
 Character: What is the character of the pain (colicky, dull aching, sharp?)
 Intensity: How much grade of the pain - 0 is the minimum, 10 is the maximum?
 Radiation: -Does this pain radiate to anywhere else?
 Recurrence: Any history of similar condition before?
 Worsening factors: Do you notice anything worsen your condition, like any type of food or drugs?
 Improving factors: Do you notice anything improve your condition like fasting?
 Associated symptoms: Any Tummy swelling, distension (Acute ascites in Bud chiari syndrome, chronic
ascites in CLD), any change in water work or stool color (pale stool, dark urine in obstructive jaundice),
(coffee ground urine in PNH)
Ask about your Differential diagnosis list:

Prehepatic:
 Hemoiysis: Symptoms of anemia (Any associated fatigue, SOB, dizziness, racing of heart beats, pallor than
before).
History of recurrent yellow discoloration. Family History of similar condition - Malarias risk factors
(Travelling abroad, insect bite).
Hepatic:
 Viral hepatitis: Fever, Vomiting up blood, blood in the stool, Risk factors (surgical operations, dental
procures, blood transfusion, needle sharing, tattooing, piercing)
 Aicohoiic hepatitis: Do you drink alcohol? How many unites per week?
 MetaboYlC liver cirrhosis: (Wilson, Hemochromatosis, alpha

1Antitrypsin deficiency, cystic fibrosis): Any Family History of similar condition? Other symptoms can be
covered in Systemic review.
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 Malignancy (Hepatoma, seconderies): Loss of weight, fever, fatigue, tumps or bumps?
 Vascular (Bud chiari Syndrome): Any history or family history of btood clot, Missed abortions, oral
contraceptives pills (in female patient) -
 SLE symptoms for 2ndery APS (Falling of hair, facial rash, mouth sores, joint pain, frothy urine)?
 Drug induced hepatitis: Are you regular on any medication?
 Autoimmune Hepatitis: No specific question?
Post hepatic:
 Any History of gall stones.
 (PBS): Fatigue, itching, fat deposits around the eyes, tanned skin.
 General symptoms: Were asked before
 GIT symptoms: (Ask about symptoms you didn't ask before) acid brush, heart bum difficulty of swallowing,
feeling sick, vomiting, Loose or less motions- mouth sores or sores down below?
 CNS symptoms: Headache, LOC, visual disturbance, altered speech weakness, altered sensation, abnormal
gait, shaking of the body,
 Uncontrolled water work or bowl habits?
 CVS symptoms: Chest pain, SOB, leg swelling.
 Pulmonary symptoms: Cough, phlegm, coughing up blood, noisy chest, runny nose, bleeding from the
nose? & Genitourinary: Any change in your water work? Amount, color, frothy urine?
 MusclosReletal: Any joint pain, skin rash.
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 Sexual history: (you asked before in risk factors for viral Hepatitis and for HIV as well)
 Menstrual history: Last period, regular or irregular, amount of blood, how many tampons the patient is
using if menorrhagia.
 Hematology symptoms: Any bleeding from anybody orifice, bleeding under the skin.
 Travelling history: If there, When and where? For how long? Where the patient stayed? In urban or rural
area? Any insect bite there? Any swimming in local pools there? Any endemic disease there? Any
relationwith local girls there?
 Medical history: Of any medical hx of long standing disease like DM, HPN, heart disease.
 Surgical history: Any history of surgical operation, blood transfusion, dental procedure, tattooing, piercing,
needle sharing (were Asked before).
 Family history: Was asked before
 Drug list: What is your drug list please?
 Social history:
 Patient job? How much her symptoms affect her job and usual daily activity? Refer the patient to an
occupational health care worker if her work is affected, and to a social worker if her social life is affected.
 With whom the patient is living? Who is supporting her at home?
Summary: I'm going to summarize the positive data in our discussion today You have been complaining of yellow
discoloration of your eye balls, started suddenly 5 days ago, associated with right upper tummy pain at the same
time and gradual increase of your tummy girth.
You have history of missed abortions 2 times befhre.You ate receiving oral contraceptive pills for the last 2 months..
Do you want to add anything more?
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Concerns:
What couid be the cause ofyeHow discoloration of my eyes Dr?
 I appreciate your concern, we have to do fuli examination and investigations first to confirm your diagnosis.
 Most probably this yellow discoloration , tummy pain and increased tummy girth is due to a condition called
Budd chiari syndrome which is due to a blood clot of one of the blood conduit of your liver, may be secondary
to a disease called Anti phospholipid syndrome causing recurrent blood clots .
 So what we are going to do is to admit you and do further blood test and urgent imaging to confirm our
diagnosis then to refer you to a MDT from a blood physician, liver physician to give you the proper care and
management plan.
 In the time being you have to stop the OCP you are receiving as it precipitates blood clots and will be
exchanged with another safe contraceptive. Any other concerns?
Disscussion with the examiner:
What is you diagnosis and DD?

 My first DD is Budd chiari syndrome (hepatic vein thrombosis) supported by sudden onset of jaundice
abdominal pain.
 This could be secondary to:

 Anti-phospholipid syndrome (Hx of 2 missed abortions, OCP).
 Hereditary thrombophilia.
 Myeloproliferative disease i.e. Polycythemia rubra Vera.
 Hypercoagulable state.
 Apart from basic investigations: CBC, LFT, RFT, Electrolytes.

 Specific investigations.
 Doppler US hepatic veins -Retrograde angiography - CT Abdomen
 Ascetic fluid analysis (cell count and cytology, stain, culture)
 The serum ascites-albumin gradient (SAAG) is usually less than 1.1 (except in the acute forms of Budd-
Chian syndrome)
 Lupus anticoagulant, Anticardiolipin Ab, Thrombophilia screening.
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What is the treatment of Budd chiari syndrome?
 Non pharmacotogica):
 Patient education and counseling
 Psychosocial support
 Occupational support
 Safe OCP (Progesterone only pills)
 Pharmacotogica):
 Anticoagulant.
 Thrombolytic.
 Diuretics.
 Procedures and surgery
 Balloon angioplasty.
 Localized thrombolysis.
 Paracentesis.
 Liver transplantation.
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Chronic Cough and wheezy chest
Scenario: Mr. Sami is 32 years oid is complaining dry cough and wheezes for the iast 2 months, CXR done for him
and was normal.
He is known case of hypertension for which he is receiving, ramipril and labetalol. For your kind care.
Make your DD list in your paper:
 Asthma (Bronchial Asthma-Occupational asthma-Exercise induced asthma- Drug induced asthma).

 Post nasal drip, GRED (Common cause of dry cough, not wheezes)
 COPD.
 Extrinsic Allergic Alveolitis. (EAA).
 Allergic bronchopulmonary aspergillosis (ABPA)
 Cardiac Asthma.
 Carcinoid syndrome.
 Infectious causes (i.e. HIV, TB)
 Churg stauss syndrome.
Introduction:
 Shake hands.
dry cough and noisy chest for the last 2 months.).
 I'm going to write some notes which will be completely confidential and my full attention will be with you.

 When these symptoms started exactly? Suddenly or gradually? Is it increasing, decreasing or the same?
Coming on and off or all the time?
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 Worsening factors: Do you notice anything worsen your condition, iike exposure to pollens, dust, pets,
smoke, perfumes, cold weather, exercise.
 Improving factors: Do you notice anything improve your condition like avoidance of these factors?
 Timing: Any diumai variation, more at morning, or night?
 Association symptoms: Is cough associated with phlegm, SOB, coughing up Biood, fever?
Ask about Differential diagnosis list:
Maiignancy:-Any Loss of weight, lumps or bumps, fatigue. (Fever was asked before)?
Postnasal drip, GERD (Common causes of chronic dry cough): Any nasal drip, heart bum, acid brush sensation?
Bronchial Asthma: Any history of chiidhood eczema, hay fever, allergic rhinitis?
Occupational Asthma: What is your job? Do you feel your symptoms improve in the weekends?
Drug induced Asthma: Do you receive regular medications? For how long you are on these medications? Any new
added medication recently?
Exercise induced Asthma: You asked in triggering factors before?
COPD: Do you smoke? How many cigarette per day? For how tong?
Extrinsic Allergic Alveolitis. (EAA): Any animal or birds at home? (Bird fancier disease).
Carcinoid syndrome: Flushing, loose motions?
Allergic bronchopulmonary aspergillosis (ABPA): Is associated with wheezes, but the cough is productive.
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Infection: Any history of Contact with TB patient -
(Risk factors for HIV): Surgical operations, dental procedures, blood transfusion, needle sharing, tattooing, piercing,
recreational drugs, May i ask personal question please, are you sexually active, how many partners you have?
Cardiac Asthma: Chest pain, racing of heart beats, leg swelling?

(SOB was asked before)
Churg Strauss: Any tummy pain, joint pain, skin rash, pain and needles in feet or hands, frothy urine?
General symptoms: Were asked before.
Pulmonary symptoms: Were asked before
CVS symptoms: Were asked before.
GIT symptoms: Acid brush, heart burn, difficulty of swallowing, yellow discoloration of the eye balls, loose
motions or less motions, feeling suck or getting sick, vomiting up blood or blood in the stool?
CNS symptoms: Headache, LOC, visual disturbance, altered speech weakness, altered sensation, abnormal gait,
shaking of the body, uncontrolled water work or bowl habits?
Genitourinary: Any change in your water work? Amount, color, Frothy urine?
Musculoskeletal: Any joint pain, skin rash?
Sexual history: (You asked before in risk factors for HIV)
Menstrual history: (If female patient) Last peroid, regular or irregular, amount of blood?
Hematology symptoms: Any bleeding from anybodyorifice, bleeding under the skin?
104
Travelling history: If there, When and where? For how long stayed there? Where did he stay there? In urban or
rural area? Any insect bite there? Any swimming in local pools there? Any endemic disease there? Any relation with
local girls there?
Medicai history: Any medical history of long standing disease like DM, HNT, heart disease?
Surgicai history: Any history of surgical operation, blood transfusion, dental procedure, tattooing, piercing, needle
sharing. (Asked before).
Drug list: What is your drug list please? Any over the counter medications? Any recreational drugs?
Social history
 Patient job? And how much his symptoms affect his job and usual daily activity? Refer the patient to
occupational health care worker if hisa work is affected, and to a social worker if his social life is affected.
 With whom the patient is living? Who is supporting him or her at home?
 Smoking and alcohol?
Summary:
I'm going to summarize the positive data we discussed today.
You have been complaining of dry cough and noisy chest for 2 months, and you are working in coal mining company,
your symptoms are not relieved in the weekends and was relieved when you went to a vacation to Turkey for 1
week,.
You have history of childhood allergic rhinitis, you are smoker of 10 cigarettes per day for 10 gears. You are
receiving ramipril and labetalol for hypertension. Your father died because of a disease called cystic fibrosis, do you
want to add anything more?
105
 I appreciate your concern, we have to do for you full examination first, and full investigations to confirm our
diagnosis.
 Cancer is unlikely in your condition, as you don't have any alarming symptoms of cancer, but we have to
exclude as well.
 Mostly you have bronchial asthma due to allergy of your small air pipes to certain allergens causing
narrowing of your air pipes.
 So what we are going to do is to do further blood test and blow test to confirm our diagnosis, then we will
refer you to a lung physician to give you the proper management plan.
 Your condition is worsened by exposure to dust in your work, so we will contact occupational health worker
to provide you with another job away from allergens.
 Your antihypertensive drugs also may worsen you condition, so we will exchange these medications with
anther medications which are safe in your condition.
 Smoking can worsen your condition as well, so we can refer you to a smoking cessation clinic to help you
giving up smoking.
 My first DD is B.A supported by: History of childhood allergic Rhinitis, relieve of symptoms during
vacation to turkey.
 Second DD is occupational asthma: Against that symptoms not relieved in the weekends, but his job may
be a trigger of his BA symptoms.
 Third DD is dug induced Asthma: Against that long hx of antihypertensive treatment, it seems they are
triggers of his B.A.
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N.B: hereditary cystic fibrosjs causing bronchiectasis is mostly excluded as no history of productive cough, and
normal x ray.
COPD is mostly excluded he as here as no productive cough, normal X ray.

 Apart from basic investigations: CBC for eosinophilia, LFT, RFT,
Electrolytes, Inflammatory markers.
 Specific investigations: Spirometry - Pulmonary function test, Peak Expiratory flow rate (PEF) with a trial
of bronchodilators.
What is the treatment?
Non pharmacological:
 Avoidance of the triggers and precipitating drugs.
Pharmacological treatment:
 In the acute attack: Short acting beta agonist nebulizer, steroid nebulizer Anticholinergic nebulizer, IV
steroids , Magnesium sulphate 2 gm infusion in acute severe asthma .
 As long term therapy: Short term oral steroids, long acting beta agonist and steroid inhalers, oral leukotriene
receptor antagonist (Montelukast):
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Chronic cough and hyponatremia
Scenario: Mr. Hani is 32 years old have been complaining of Productive cough for 8 weeks , Blood investigations
revealed S.NA : 120 - S.K: 4.4 for your kind care.
Make your differential diagnosis list in your paper before going inside:
More appropriate DD:
 Small cell carcinoma associated with SIADH.

 Atypical Pneumonia (Legionnaire and mycoplasma with SIADH.
Less appropriate DD:

 Infection: HIV, TB.
 COPD, Bronchiectasis, Empyema.
Introduction
 Shake hands.
productive cough for 8 weeks).
 Pm going to write some notes, be sure it will be confidential and my full attention will be completely with
you.
 Onset, course, duration, progression, worsening and improving factors, associated symptoms:
 When the cough started exactly? Suddenly or gradually? Coming on and off or all the time? Is it increasing,
decreasing or the same?
 Is it dry or with phlegm (Amount, color, odor of phlegm)?
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 Did you notice anything worsen your condition, tike exposure to dust, pollens, smoke, cold, perfumes?
 Did you notice anything Improve your condition like avoidance of all what i mentioned before, inhalers,
drugs?
 Any associated symptoms: Fever, noisy chest, SOB, runny nose or bleeding per nose?
Ask about Differenial diagnosis list:
Small cell carcinoma associated with SIADH:
 Any loss of weight? How much KG? For how long? Intended or not? What about your appetite?
 Any fatigue, lumps or bumps, pallor than before?
Atypicai Pneumonia (Legionnaire and mycopiasma with SiADH):

 Any history of fever (If there make analysis of fever- How frequent? Grade of fever? Diumal variation?)
 Any history of travelling aboard recently? When and where? For how long? Where the patient stayed? In
urban or rural area? Any insect bite there? Any swimming in local pools there? Any endemic disease there?
Any relation with local girls there?
Infection: HIV, TB
 Any night sweats, contact with TB patient?
 Any history of surgical operations, blood transfusion, dental procedures, tattooing, piercing, needle sharing?
(Risks for HIV)
 May I ask private question? Are your sexually activ? How many partners do you have? (Risks for HIV)
COPD:
 Do you smoke? How many cigarette per day? For how long?
 Didn't you think about giving up smoking? We can help you by referring you to a smoking sensation clinic
if you don't mind.
Bronchiectasis
 Any family history of similar condition (Cystic fibrosis)
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General symptoms were asked before
GIT symptoms: Any acid brush, heart bum, difficulty of swallowing, getting sick or feeling sick, yellow
discoloration of the eye ball, Tummy pain, altered bowel habits?
CNS symptoms: Any headache, LOC, limb weakness, altered sensation, altered speech, abnormal gait, uncontrolled
water work or bowel motions?
CVS symptoms: Any chest pain, racing of heart rate, SOB, leg swelling?
Pulmonary symptoms were asked before
Genitourinary: Any change in your water work? Amount, color, frothy urine?
Muscuioskeietai: Any joint pain, muscle pain, skin rash?
Sexual history: Were asked
Menstrual history: (If female patient) Last cycle, regular or irregular, amount of blood, how many tampons the
patient is using?
Hematology symptoms: Any bleeding from anybody orifice, bleeding under the skin.
Travelling history: Was asked before
Medical history: of any medical hx of long standing disease like DM, HPN, heart disease.
Surgical history: was asked before
Drug list? What is your drug list please? Any over the counter medications? Any recreational drugs?
110
Social history:
 Patient job? How much his symptoms affect his job and usual daily activity? Refer the patient to an
occupational health care worker if his work is affected, and to a social worker if his social life is affected.
Summary:
Now I'm going to summarize the positive data in our discussion today:
You have been complaining of long standing cough associated with phlegm sometimes.
You have been lost 10 KG in the last 8 weeks which was not intended, with decreased appetite, you have history of
travelling abroad to Turkeyl month ago in which you stayed in a hotel. Do you want to add anything else?
Concerns: May I know what is your concern?
Is It cancer doctor?
 I appreciate your concern, we have to do full examination and investigations first to confirm our diagnosis.
 Unfortunately cancer may be a possibility in your condition, Also some types of infection called legionella
or mycoplasma can present with a similar pattern.
 What we are going to do is admit you to do further blood test and imaging to confirm your diagnosis.
 You need to be admitted now for proper management and investigations and we will refer you to a MDT to
give you the proper care and management.
 My first DD is small cell carcinoma of the lung associated with SLADH as a paraneoplastic syndrome
secreting Anti diuretic hormone.
 Second DD is atypical infection like Legionnaire disease or mycoplasma.
 Third DD is TB lung.
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 Apart from basic investigations CBC, LFT, RFT, Electrolytes, Inflammatory markers.
 Chest X Ray, Sputum analysis (Cytology, AFB, stain, Culture), CT with contrast.
 Urinary legionella antigen.
 Bronchoscopy for biopsy or lavage if needed
 TB workup: AFB, PCR, Quantiferon, culture and gram stain.
112
Scenario: Mr.kareem is 25 years old, complaining of both lower limb weakness started 5 days ago for your kind
care.
Make your DD list in your paper:
Differential diagnosis of Acute Flaccid paraparesis:
Infectious:
 Botulism.
 Poliomyelitis, Diphtheria - Enterovirus71, paralytic rabies.
Inflammatory:
 Guillian barre syndrome.
 Acute intermittent porphyria.
 Lead poisoning.
Spinai cord Disease:

 Spinal cord compression.
 Spinal cord infarction.
 Demylenating disease (Acute transverse myelitis).
Introduction:
 Shake hands
 Introduce your self
 Confirm patient identity
 Confirm agenda of meeting (I have a letter from GB informing me that you have been complaining of both
leg weakness for 3 days, is it right?)
 I'm going to write some notes, be sure they will be confidential and my full attention will be with you.

 Onset, course, duration, progression, worsening and improving factors, associated symptoms:
113
 When did your limb weakness start exactly? Suddenly or gradually? Coming on and off or all the time? Is it
increasing, Decreasing or the same?
 Triggering factors: Any history of recent rich carbohydrate diet, heavy exercise, stress, infection?
 Recurrence: Any history of similar problem in the past (MS, Periodic paralysis)?
 Do you feel your legs floppy or stiff?
 Is it in one limb or both limbs, is it more in one limb or the same on both limbs (symmetric weakness in
GBS)?
 Is the weakness more in your feet, or your thighs?
 What about your gait:
a. Do you drag both feed at the side? (Spastic gait).
b. Do you lift your feet high off the ground? (High steppage gait).
c. Is you gait waddling from side to side? (Waddling gait).
 Symptoms of spinal cord lesion: Any history of back trauma, back pain, altered leg sensation, abnormal gait,
uncontrolled water work or bowel habits.
 Associated symptoms (Other neurological symptoms): Headache, loss of consciousness, Seizures, visual
disturbance, altered speech, weakness of the upper limbs, altered sensation.
Infectious causes: Any history of canned food, body sores?
GBS: Any history of loose motions in the last 2 weeks (if present, take brief hx).. Hx of SOB (Respiratory muscle
weakness)... if present take brief hx of SOB( when started , suddenly or gradually, is it on rest, on laying down, on
exertion .. how many meters you can walk until developing SOB?
Acute intermittent porphyria: Any tummy pain, change in urine color, abnormal behavior, family history of
similar condition?
Spinai cord infarction: Any history of blood clot or b'ood disease or family history of blood disease?
Demyelinating disease: May be asymmetrical, can be recurrent.
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General symptoms: Fatigue, Fever, toss of weight, lumps or bumps?
GIT symptoms: Any cid brush, heart bum, difficulty of swallowing, getting sick or feeling sick, yellow
discoloration of the eye ball?
CNS symptoms: You asked about all before.
CVS symptoms: Any chest pain, racing of heart beats, shortness of breath leg swelling?
Genitourinary: Any change in your water work? Amount, color, frothy urine?
Musculoskeletal: Any joint pain, muscle pain, skin rash?
Sexual history: May I ask some personal questions... Are you sexually active? How many partners do you have?
Menstrual history: (If female patient) Last period, regular or irregular, amount of blood, how many tampons the
patient is using?
Medical history: Of long standing disease like DM, HNT, heart disease.
Surgical history: Any history of surgical operation, blood transfusion, dental procedure, tattooing, piercing, needle
sharing?
Drug list? What is your drug list please? Any over the counter medication? Any recreational drugs, any history of
drug allergy?
Social history:
Patient job? How much his or her symptoms affect his job and. asual Daily activity? Refer the patient to an
115
Summary:
Now Fm going to summarize the positive data in our discussion today:
You have been complaining of both legs weakness started 5days ago, which is increasing, preceded by history of
loose motions 2 weeks ago resolved with some anti diarrheal medications.
You have been complaining of SOB started since yesterday increased with exertion.. Do you want to add anything
else?
CONCERNS. Do you have any concerns?
What could be the cause of my limbs weakness doctor?
 I appreciate your concern, we have to do full examination and investigation first to confirm our diagnosis.
 Most probably you have a condition called Guillain-barre syndrome, § condition due to disturbance of the
defensive system causing disturbance of the nerve cables leading to weakness , may be precipitated by the
recent infection of diarrhea. Your chest muscles may be involved causing this shortness of breath.
 So we have to do urgent blood tests and to admit you in intensive care unit under close monitoring of your
vital signs and pulmonary function and to refer you urgently to a nerve doctor to give you the proper
treatment and plan of care.
Is it serious condition doctor?

 I'm sorry to tell you it can be serious if untreated, but we are going to put you under close monitoring and
refer you urgently to a nerve doctor to give you the appropriate treatment as soon as possible.
116
What is your diagnosis?
 My diagnosis is Guillain-barre syndrome supported by history of diarrhea 2 weeks ago before symptoms of
the patient, associated with respiratory muscie weakness.
 Second DD is demyelinating disease like Transverse myelitis. But against that the symmetrical distribution
of the weakens, and the progressive ascending weakness, and involvement of the respiratory muscles.
After following ABCD protocol and putting the patient under close observation of vital signs.
 Nerve conduction study - Lumber puncture, ECG (for arrythmia of autonomic dysfunction)
 MR1 brain and spinal cord to rule out demyelinating disease.
What is the treatment of GBS?
 ABCD Protocol, close monitoring of vital signs, ICU admission e
 Intravenous Immunoglobulin
 Plasmapharesis in acute severe cases
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Scenario: Mr. Kamal is 25 years old has been complaining of both lower limb weakness since today morning after
walking up for your kind care.
Make your DD list in your white paper before going inside:
 Hypokalemic (The more common), Hyperkalemic, Normokalemic periodic paralysis (Less common).
 Thyrotoxic periodic paralysis.
 Myasthenia Gravis.
 Lambert Eaton syndrome.
 Andersen-Tawil syndrome.
Introduction
 Shake hands.
both LL weakness since today morning).

 When did your limb weakness start exactly? Suddenly or gradually? Coming on and off or all the time? Is it
 Triggering factors: any history of recent eating rich carbohydrate diet, heavy exercise, stress, infection?
 Recurrence: Any history of similar problem in the past (MS, Periodic paralysis)?
 Do you feel your legs floppy or stiff?
 Is it in one limb or both limbs, is it more in one limb or the same on both limbs?
118
 Is the weakness more in your feet, or your thighs?
 What about your gait:
 Do you drag both feed at the side? (Spastic gait).
 Do you iift your feet high off the ground? (High steppage gait).
 Do your gait is waddling from side to side? (Waddling gait).
 Symptoms of spinal cord lesion (emergency): Any history of back trauma, back pain, altered leg sensation,
abnormal gait, uncontrolled water work or bowel motions.
 Associated symptoms (Other neurological symptoms): Any associated headache, loss of consciousness,
shaking of the body, visual disturbance, altered speech, weakness of the upper limbs, altered sensation.
Hypokalemic periodic paralysis: Is recurrent, more proximal, precipitated by recent rich carbohydrate diet, heavy
Exercise, stress or infection, may be associated with family history.
Thyrotoxic periodic paralysis: Any history of hot intolerance, loss of weight, anxiety, racing of heart beats,
Sweating, shaking of the hands, loose motions?
Myasthenia gravis: Any double vision, dropping of the eye lids, fatigue specially at the end of the day?
Lambert Eaton syndrome: Fever, lumps or bumps, fatigue?
Andersen-Tawil syndrome: Family history of similar condition?
General symptoms: Were asked before
CVS symptoms: Any chest pain, racing of heart beats, SOB, leg swelling,?
Pulmonary symptoms: Any cough, coughing up blood, noisy chest?
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GIT symptoms: Any mouth sores, difficulty of swatiowing, tummy pain, netting or feeling sick, yellow
discoloration of the eye ball, altered bowel habits, ?lood in the stool?
Genitourinary: Any change in your water work? Amount .Color, frequency .Frothy urine?
Musculoskeietai: Any joint pain, muscle pain, skin rash?
Sexual history: I would like to ask personal questions if you don't mind - Are you sexually active, how many
partners do you have?
patient is using per day.
Hematoiogy symptoms: Any bleeding from anybody orifice, bleeding under the skin?
Travelling history: Any history of travelling abroad recently?
Medical history: Of any medical history of long standing disease like DM, HTN, heart disease?
sharing?
Social history:
 Patient job? How much his symptoms affect his job and usual daily activity? Refer the patient to an
occupational health care worker if his work is affected and to a social worker if his social life is affected.
 With whom the patient is living? Who is supporting him at home?
120
Summary:
I'm going to summarize the positive data of our discussion today:
 You have been complaining of both Lower limbs weakness since today morning suddenly after waking up
from sleeping , which is stationary with difficulty of walking, you played football match and eat high rich
carbohydrate diet last night.
 You had history of similar problem 3 months ago which continued for 2 days and gradually resolved without
seeking medical care.
 Do you want to add anything else?
What could be the cause of my both legs weakness doctor?
 I appreciate your concern, we have to do full examination and investigations first to confirm our diagnosis
 Your symptoms may be related to some sort of electrolyte disturbance (low potassium level) causing your
muscle weakness, Can be percolated by heavy exercise and rich carbohydrate diet.
 So what we are going to do is to admit you right now, do further blood test and may be tracing for your
muscles to confirm our diagnosis, then we will refer you to a MDT to give you the plan of management.. Is
it alright with you? - Any other concern?
What: is your Diagnosis and DD?
My Diagnosis is periodic paralysis for differential diagnosis:
 First DD is Hypokalemic periodic paralysis precipitated by rich carbohydrate diet, heavy exercise.
 Hyperkalemic, normokalemic periodic paralysis has to be considered but less likely.
 Thyrotoxic periodic paralysis is other DD, but against that there are no hyperthyroid symptoms.
121
 Apart from basic investigations: CBC, Electrolytes, RFT, LFT, Inflammatory markers.
 Specific investigations: Serum K, TFT, EMG, Muscle biopsy.
What is the treatment pian?
-Non pharmacotogicat treatment:
 Patient education and counseling.
 Psychosocial support.
 Occupational support.
 Physiotherapy.
 Avoidance of precipitants.
- Pharmacotogicat treatment:
 MDT approach - Potassium replacement - High potassium diet
122
Abnormal sensation in both Lower limbs
Scenarios: Mr. Salem is 55 years old is complaining of abnormal sensation in both Lower limbs for the last 2 months,
He is known case of DM, HNT, ESRD on dialysis for 2 years for your kind care.
Make your DD list in your paper before going inside:

 Restless led syndrome.
 Akathisia.'
 Neuropathy.
 Radiculopathy.
 Nocturnal leg cramps.
 Peripheral Vascular disease.
Introduction:
 Shake hands.
 Confirm agenda of meeting (I have a letter from your GP informing me that you are complaining of abnormal
sensation in both legs for the last 2 months)
 I'm going to write some notes, be sure it will be confidential and my full attention will be with you.
 Onset, course, duration, progression, worsening factors, improving factors, associated symptoms:
 When your symptoms started exactly? Suddenly or gradually? Coming on and off or all the time? Is it
 Any diumal variation, more at night, midday or morning?
 Worsening factors: Did you notice anything worsen your condition like rest or movement?
 Improving factors: Do you notice anything improve your condition like movement or rest or friction?
 Did you notice any urge to move your legs, especially at rest?
123
Restless Leg syndrome:
 An urge to move the legs that is usually accompanied by or occurs in response to uncomfortable and
unpleasant sensations in the legs, characterized by all of the following:
 The urge to move the legs begins or worsens during periods of rest or inactivity.
 The urge is partially or totally relieved by movement.
 The urge to move legs is worse in the evening or at night than during the day or occurs only in the evening
or at night.
 Symptoms occur at least 3 times per week and have persisted for at least 3 months.
 Symptoms cause significant distress or impairment in social, occupational, educational, academic,
behavioral or other areas of functioning
 The symptoms cannot be attributed to another mental disorder or medical condition (e.g., leg edema, arthritis,
leg cramps) or behavioral condition (e.g. positional discomfort, habitual foot tapping).
 The disturbance cannot be explained by the effects of a drug of abuse or medication.
Peripheral Neuropathy:
Can have symptoms similar to those of RLS. Typical sensory complaints include numbness, tingling, and pain.
However, neuropathic symptoms also differ from RLS symptoms in that they usually are not associated with motor
restlessness or helped by movement, nor do they worsen in the evening or at night. Neuropathy and RLS may coexist.
RLS occurs more frequently in patients with hereditary neuropathies but not in patients with acquired neuropathies,
such as diabetic neuropathy
How to ask about PN: Any pins or needles in feet or hands? , do you feel you are walking in a piece of cotton? Do
you fall down when you close your eyes?
Akathisia:
Is characterized by an inner urge to move all or part of the body, without a focal sensory complaint in the limbs.
Often, it does not correlate with rest or show circadian variation, and it usually results from medications such as
selective serotonin reuptake inhibitors (SSRIs), neuroleptics, or other dopamine-blocking agents.
124
Nocturnal leg cramps:
Are typically unilateral, painful, palpable, involuntary muscle contractions that are often local with a sudden onset?
Like RLS, they may have a circadian pattern and often occur at rest. However, nocturnal leg cramps are associated
with physical changes, including a muscle hardening not seen in RLS.
Peripheral Vascular disease (Including deep vein thrombosis and claudicating):

Must be considered. Patients with RLS have intact peripheral pulses and typically do not have edema or cool
extremities. Also, vascular disease does not exhibit a circadian pattern and usually worsens with activity, not with
rest.
Risk factors for RLS:

 Familial: Any family history of similar condition?
 Renal faiture: Any kidney problem, any change in water work amount, color or frequency? - If the patient
on dialysis? For how long? How many sessions per week?
 Iron deficiency anemia, Fotate and Vit B12 deficiency: Being pallor than before, SOB, dizziness, fatigue?
What about your diet, is it balanced diet? Is it reach in red meat, liver? Any hx of bleeding from anybody
orifice, if female: What about your periods? Regular or not, how much blood coming out, how many tampons
are you using per day?
 Diabetes: For how long he has DM, What medications the patient on for DM, Is he compliant on his
medications or not, what about the last HBA1C?
 Hypothyroidism: Any history of weight gain, cold intolerance, fatigue, constipation, low mood?
 Drug History: Any regular drugs like antidepressant, cold or anti allergic medications?
 Pregnancy: If female patient, when was the period cycle.
 Sleep deprivation: Do you have any sleep disturbance?
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General symptoms: Any fever, fatigue, loss of weight, lumps or bumps?
GIT symptoms: Mouth sores, difficulty of swallowing, getting or feeling sick, yellow discoloration of the eye balls,
altered bowel motions, vomiting up blood, blood in stool?
CNS symptoms: Headache, LOC, visual disturbance, altered speech, weakness, altered sensation, abnormal gait,
shaking of the body, uncontrolled water work or bowl motions?
CVS symptoms: Chest pain, racing of heart rates, SOB, leg swelling?
Pulmonary symptoms: Any cough, coughing up blood, Noisy chest, runny nose, bleeding from the nose?
Genitourinary: You asked about all.
Musculoskeietai: Any muscle pain, joint pain, skin rash?
Sexual history: May I ask some personal questions please? Are you sexually active? How many partners do you have?
patient is using.
Hematology symptoms: you asked about Hx of bleeding per any orifice before.
Travelling history: if there, take detailed travelling history.
Medical history: Of any medical history of long standing disease like DM, HNT, heart disease.
Surgical history: Any history of surgical operation, blood transfusion, dental procedures, tattooing, piercing, needle
sharing?
Family history: Of similar condition or long standing disease?
126
Social history:
occupational health care worker if his work is affected, and to social worker if his social life is affected.
 With whom the patient is living? Who is supporting him at home?
Summary:
Now Pm going to summarize the positive data in our discussion today.
You have been complaining of abnormal sensation in both legs for the last 2 months, more at rest and night, improved
by movement of both legs with urge to move your legs.
You have been complaining of kidney failure for 2 years for which you are on dialysis, you have history of DM
which seems to be controlled on insulin, Anything more you want to add?
Concerns: May i ask what is your concern?
What could be the cause of abnormal sensation of both my legs?
 Most probably you have a condition called (Restless leg syndrome), caused by a lot of factors you have like
kidney failure, anemia, and impairment of peripheral nerve cables conduction.
 So what we are going to do, is to do further blood test, and what is called nerve conduction study to confirm
our diagnosis, then we will refer you to MDT to correct your anemia and give you some medications to
improve your symptoms.
Discussion with the Examiner
 My First DD is Restless leg syndrome supported by criteria of abnormal unpleasant sensation which urge
the patient to move his legs, worsened by rest and improved by movement.
127
 Second DD is Peripheral sensory neuropathy, but against that, it doesn't urge to move the legs, and not related
to rest or movement, and doesn't show circadian variation.
What investigations you are going to do for the patient:
 Apart from basic investigations: CBC, RFT, LFT Efectroiytes specially (Mg).
 Specific investigations: Iron profile, Nerve conduction study, sleep study.
What is the treatment for RLS?
-Non pharmacological treatment:
 Psychosocial support Occupational support
- Pharmacological treatment:
 Iron supplementation: transfusion or infusion or oral according to HB level.
 Dopamine agonist.
 Benzodiazepens.
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Ataxia
Scenario: Mr. Hamed is 65 years otd, complaining of abnormal gait and recurrent falls for the last 6 weeks, he is
known case of HNT on Amlor 10 mg. For your kind car.
You are SHO of neurology clinic, you asked to discuss this issue with Mr Ahmed his son.
 CNS causes:
 Cerebellar Ataxia (Space occupying lesion, demyelination, vascular, drugs, alcohol)
 Akinetic rigid disease (Parkinson and Parkinson plus).
 Frontal lobe lesion (Dementia, Normal pressure hydrocephalus NPH)
 Lower limb weakness (UMNL, LMNL)
 Peripheral Sensory ataxia.
 Peripheral Motor ataxia.
 Musculoskeletal: Myositis, Arthritis.
Introduction:
 Shake hands.
 Confirm the son identity.
 Confirm he is next of kin of the patient.
 Confirm agenda of meeting (I have a letter from your GP informing me that your father has been complaining
of abnormal gait and difficulty of walking and recurrent falls for 6 weeks)
 Can you tell more about the complaint of your father please?
129
 Onset, course, duration, progression:

 When the abnormai gait started exactly? Suddenly or gradually?
 Coming on and off or all the time? Is it increasing, decreasing or the same?
 Can you prescribe the gait of your father?
1. Does he shuffle his feet along the ground, is his step is narrow or wid (Parkinsonian gait)
2. Does he drag one foot at one side? (Hemiplegic gait).
3. Does he drag both feed at the side? (Spastic gait).
4. Does he lift his feet high off the ground? (High steppage gait).
5. does his gait looks like waddling from side to side? (Waddling gait).
6. Does your father loss his balance when he walking? (Ataxic gait).
Cerebellar ataxia:
a) Any visual disturbance, altered speech, shaking of the hands.
b) Other CNS symptoms: Weakness. Altered sensation, headache, seizures.
c) Any History of stroke or ministroke? (Risk factor for cerebellar infarction).
d) Do your father drink alcohol? How many unites per week? For how long?
e) What drugs he is on? (Antipsychotic, Antidepressant, Benzodiazepines).
Akinetic rigid disease (Parkinson and Parkinson pius):

Difficulty of initiating movements, rigidity, loss of arm swing during walking, shaking of one hand or both hands,
change in hand writing.
Frontai lobe lesion:

Any altered mental power, forgetfulness, loss of concentration, abnormal behavior, loss of control of water work or
bowel habits? Any visual or auditory hallucination?
Peripheral sensory neuropathy:

Any pins or needles in the feet or hands, any falling down when he closes his eyes, does he feel that he is walking,
on a piece of cotton 2 any ear pain?
Peripheral motor neuropathy: Any limb weakness or heaviness?
Musculoskeletal: Any joint pain, muscle pain?
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Systemic review: Don't ask about symptoms you asked about before?
General symptoms: Fatigue, Fever, loss of weight, lumps or bombs?
GIT symptoms: Any acid brush, heart bum, difficulty of swallowing, getting sick or feeling sick, yellow
discoloration of the eye ball, tummy pain, altered bowel motions?
CVS symptoms: Any chest pain, racing of heart beats, SOB, leg swelling?
Pulmonary symptoms: Any cough, phlegm, coughing up blood, noisy chest, runny nose, bleeding from the nose?
Genitourinary: Any change in water work? Amount, color, frequency, frothy urine?
Musculoskeletal: You asked before
Sexual history: May i ask some personal questions.. Is he sexually active? How many partners he has?
patient is using?
Hematology symptoms: Any bleeding from anybody orifice, bleeding under the skin?
Medical history: Of any medical history of long standing disease like DM, HNT, heart disease?
sharing?
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Drug list? What is his drug list piease? Any over the counter medication? Any recreational drugs?
Social history:
 Patient job? How much his symptoms affect his job and usual daiiy activity? Refer the patient to an
occupational health care worker if his work is affected, and to a social worker if social life is affected.
Summary:
Now I'm going to summarize the positive data in our discussion today.
Your father have been complaining of abnormal gait and recurrent falls for the last 6 weeks, He has been complaining
of some cognitive impairment and forgetfulness, loss of concentration and uncontrolled water work.
He is known to has hypertension for which he is receiving Amor 10 mg for 5 years, do you want to add anything
else?
What could be the cause of my father's abnormal gait Dr?
 I appreciate your concern, we have to do full examination and investigations first to confirm your father's
diagnosis.
 Most probably your father has a Condition called Normal pressure hydrocephalus due to increased secretion
or decreased absorption of the fluid inside his brain cavities causing a triad of deteriorated of mental power,
uncontrolled water work and loss of normal reflexes leading to recurrent falls.
 So what we are going to do is to do further blood test and imaging to and may be a special procedure by a
needle to be inserted into your father s back under aseptic condition, local anesthesia, image guided to
confirm our diagnosis (This procedure will be discussed in details later on).
 If our diagnosis is confirmed, we will refer your father to a MDT from a brain doctor, psychotherapist, social
worker to give your father the proper care and plan of management.. Any other concern?
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 My first DD is Normal pressure Hydrocephalus as the patient has triad of (Dementia, Areflexia, urine
incontinence)
 Second DD could be other types of Dementia like Alzheimer disease, but against that urine incontinences at
the late stages of Alzheimer and it is not associated with areflexia.
 Lewy body-dementia, but against that there is no visual or auditory hallucination
 Apart from basic investigations: CBC, LFT, KFT, Electrolytes.

 CT, MRI brain for dilated ventricles.
 Lumber puncture for normal pressure.
What is the treatment for NPH?

 Non pharmacological treatment:
 Patient education and counseling.
 Psychosocial support.
 Occupational support.
 Pharmacological treatment:
 Levodopa challenge may be helpful to rule out idiopathic Parkinson disease. Patients with normal
pressure hydrocephalus (NPH) have no significant response to levodopa or dopamine agonists.
 Surgical treatment
 CSF shunt (Ventricloperitoneal, Ventricolopleural, Ventricoloatrial).
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Tremors
Scenario: (GB tetter) Mr.Osama is 29 years old has been complaining of tremors for the last lweek for your kind care.
He is known case of HNT for which he is receiving Ramipril and Hydrochlorothiazide.
You are SHO in the medical outpatient clinic, you are asked to discuss this issue with him.
Make your differential diagnosis list in your white paper:
 Physiological causes: Anxiety, coffee, cold, fear.
 Hereditary causes: Wilson disease, Primary essential tremors.
 CNS causes:
 Akinetic rigid disease (Parkinson and Parkinson plus).

 Cerebellar syndrome (demylenating, vascular, drugs, alcohol. space occupying lesion)
 Endocrinal causes (Pheachromcytoma, Hyperthyroidism)
 Drug induced (Salbutamol, Antipsychotic, Antiepileptic, Cocaine, Amphetamines)
 CLD, CKD, COPD (Flapping tremors)
Introduction
 Shake hands.
shaking of both hands for one week).
 I’m going to write some notes, be sure they will be confidential and my full attention will be with you.
134
Analysis of the complain:
 Onset, course, duration, progression, worsening and improving factors.
 When this shaking started exactly? Suddenly or graduaiiy? Coming on and off or alt the time? Is it increasing,
decreasing or the same? For how long it continue?
 Worsening factors: Do you notice anything worsen your condition, fike cold fear, anxiety, rest, movement,
catching things?
 Improving factors: Do you notice anything improve your condition like rest or movement, catching things,
alcohol?
 Site: is it in one hand or both hands, any shaking in your trunk, on your head in your jaw?
 Character: Is it fine shaking like that... Or coarse shaking like that?

Physiological
 Any Anxiety or mood disturbance recently, Cold, excessive coffee?
CNS causes:
 Akinetic rigid syndrome (Parkinson, Parkinson plus): Any rigidity, difficulty of initiating movements, loss
of arm swing during walking, abnormal gait, altered speech?
 Cerebellar syndrome: Any altered speech, abnormal gait, visual disturbance, Other CNS symptoms
(weakness, altered sensation, headache, loss of consciousness, uncontrolled water work or bowel motions)?
Hereditary causes
 Primary essential tremors: Any family history of similar condition, Increased with alcohol, any change in
your hand writing, became smaller or more large?
 Wilson disease: Any history of tummy pain, yellow discoloration of the eye balls, abnormal behavior, mood
disturbance?
Enduerinai causes:
 Pheochromocytoma: Any loss of weight (How many Kg, for how long, intended or not, what about your
appetite), racing of heart beats, anxiety, headache, recurrent sweating, high BP (controlled or not)?
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 Hyperthyroidism: Any hot intolerance, loose motions (other symptoms are asked in pheochromocytoma).
Drug induced:
 Any inhalers (Salbutamol), drugs for mood disturbance, recreational drugs like Amphetamines and Cocaine?
 Risk factors of lithium toxicity (Loose motions, recurrent vomiting, Drugs (diuretics, ACE inhibitor,
NSAIDS)?
General symptoms: Any fever, fatigue, lumps or bumps?
CVS symptoms: Any chest pain, SOB, leg swelling?
Pulmonary symptoms: Any cough, coughing up blood, bleeding per nose, noisy chest?
GIT symptoms: Any mouth sores, acid brush, difficulty of swallowing, tummy pain, altered bowel motions, blood
in the stool?
Musculoskeletal: Any joint pain, muscle pain, skin rash?
Sexual history: May i ask private question please? Are you sexually active, How many partners do you have?
Medical history: Of any long standing disease like DM, HNT, heart disease, any history of admission before?
136
sharing.
Family history: you asked before.
Social history:
 Patient job? How much his symptoms affect your job and usual daily activity? Refer the patient to an
occupational health care worker if his work is affected, and to a social worker if his social life is affected
 With whom the patient is living? Who supporting him or her at home?
Summary:
I'm going to summarize the positive data we discussed today, you have been complaining of shaking in both hands
for 1 week with fine movements, increased by movement, most of the time with you, no shaking of any other body
parts.
You don't have mood changes recently, you are receiving treatment for mood disturbance called Lithium for the last
1 year, you have been complaining of loose motions for 2 weeks which started to resolve recently, you have high
blood pressure for which you are receiving treatment called
Hydrochlorothiazide, Ramipril..
Concerns: Do you want to add anything more? Do you have any concerns?
What could be the cause of shaking of my hands Dr?
 I appreciate your concern, we have to do full examination and investigations first to reach a diagnosis.
 Most probably shaking of your hands is due to increase level of lithium you are receiving for you mood
disturbance, secondary to recent diarrhea you had causing dehydration and lithium toxicity, your blood
pressure medications may also have a rule.
137
 So what we are going to do, is to admit you and do some biood tests and check for lithium ievei to confirm
our diagnosis.
 If confirmed you wili stop lithium and we will do urgent consultation to a psychiatrist to reevaluate this
medication.
 Regarding your biood pressure medications they may increase iithium ievei, so that we are going to exchange
them with other medications safe in your condition.. Any other concern?
Discussmm with the examiner:
 My diagnosis is Lithium toxicity secondary to dehydration due to diarrhea, ACE inhibitor and
hydrochiorothiazide also can induce lithium toxicity.
 Second DD is anxiety flaring up of his mood disturbance, but against that no history of mood changed
recently.
 Third DD is Wilson disease specially with history of mood disturbance and tremors, but against that no
family history.
What you are going to do for the patient?
Investigations:
 Apart from basic investigations: CBC, Electrolytes, RFT, LFT.

 Specific investigations: Lithium level, ECG.
Treatment:
- Non pharmacotogicak
- Pharmacotogicak
 Stopping lithium and urgent psychiatrist consultation,

 Good hydration, and correction of electrolyte disturbance,
 Exchanging the offending drugs.
 Haemodiaylisis: If lithium > 6mEq/L with sever neurological symptoms (Confusion, seizures)
138
Scenario: Mr. Omar is 50 years old has been complaining of Back pain for the last 6 weeks, not relieved by pain
killers, for your kind care.
Make your differential diagnosis list:
 Back trauma.
 Disc prolapse, Cord stenosis, Cord compression.
 Osteoporosis, Osteomalacia.
 Hyperparathyroidism.
 Seronegative arthritis.
a. Ankylosing Spondylitis.
b. Psoriatic arthropathy.
c. Enteropathic Arthritis
d. Reactive arthritis.
 Infection: Viral, Bacterial, TB.
 Malignancy: Primary, secondary, Multiple myeloma.
Introduction:
 Shake hands.
 Confirm agenda of meeting (I have a letter from your GP informing me that you are complaining of Back
pain for the last 6 weeks)
 Onset, course, duration, progression, improving and worsening factors, associated symptoms:
 When this back pain started exactly? Suddenly or gradually? Is it increasing, decreasing or the same? Coming
on and off or all the time?
139
 Did you notice anything increase this pain like rest, movement, coughing, sneezing, straining (cord prolapse
and compression), (Seronegative arthritis increases by rest)
 Did you notice anything relieve this pain like rest, movement, bending forward (spinal stenosis), any pain
killers Seronegative arthritis relieved by movement
 Site: Where is the pain exactly, in lower, middle or upper back, any other joint pain?
 Grade: How much grade of the pain (0 is the minimum- 10 is the maximum)
 Time: Is it more at the morning or at the end of the day, any morning stiffness, does it relieve by movement
(Seronegative arthritis)?
 Radiation: does this pain radiates to anywhere else?
 Associated symptoms: Lower limb weakness, altered sensation, abnormal gait, uncontrolled water work or
bowel habits? (Red flag symptoms require urgent MRI and referral to a Neurosurgeon)
Trauma: Any history of back trauma?
Disk prolapse, Cord stenosis, Cord compression:

Explored in your analysis of the complaint (Increases by movement, sneezing, coughing, straining).
Osteomalacia:
What about your diet, is it balanced diet, does it contain milk products, eggs?
- What about exposure to sun?
Osteoporosis:
If female patient - What about your periods, when was the last period? Any weight gain, flushing, low mood
(postmenopausal symptoms).
Seronegative arthritis:
Any history of skin rash, loose motions, burning water work, morning stiffness (if there analysis of the stiffness:
comer stone of diagnosis of Ankylosing spondylitis, more at early morning, improving with movement and exercise),
limitation of spine movement, eye pain or redness.
140
Malignancy:
 Fever, fatigue, ioss of weigh, dizziness, being pailor than before, lumps and bumps?
 Hypercaicemic symptoms (Soiid cancers, Muitipie Myeioma, Hyperparathyroidism): Increased thirsty,
water work frequency, constipation, low mood?
Infection: Fever, contact with TB patient?
General symptoms: were asked before
GIT symptoms: Mouth sores, difficulty of swallowing, getting or feeling sick, Tummy pain, yellow discoloration
of the eye balls, altered bowel habits, vomiting up blood, blood in stool?
CNS symptoms: Any headache, LOC, visual disturbance, altered speech weakness, altered sensation, abnormal gait,
CVS symptoms: chest pain, racing of heart rates, SOB, leg swelling?
Pulmonary symptoms: Any runny nose, bleeding per nose, Cough, coughing up blood, noisy chest?
Genitourinary: Any change in water work color, amount, frequency, frothy urine?
Musculoskeletal: Any muscle pain, skin rash.
Sexual history may i ask some personal questions please, are you sexually active, how many partners you have?
patient is using.
Hematology symptoms: Any history of bleeding per any orifice, bleeding under the skin?
141
Travelling history: If there when and where, for how long, where the patient stayed? In Urban or rural area?, Any
insect bite there? Any swimming in local pools there? Any endemic disease there? Any relation with local girls
there?
Medical history: Of any medical history of long standing disease like DM, HNT, heart disease.
sharing?
Social history:
Summary:
 Now Fm going to summarize the positive data in our discussion today.
 You have been complaining of low back pain for the last 6 weeks, not related to rest or movement.
 You lost about 10 kg in the last 2 months, not intended, with decreased appetite.
 You have been complaining of increased thirsty, water work frequency, constipation, bad mood for the last
4 weeks.. Anything else you want to add?

Is It cancer doctor?
142
 I'm sorry to tell you that cancer is a possibility in your condition, may be some type of cancer in blood called
Multiple myeloma or other types of cancer invading your spine.
 So we have to admit you now and to do further blood tests and imaging to confirm our diagnosis, then if
diagnosis is confirmed we will refer you to a MDT from Blood physician, kidney doctor, and social work,
MacMillan nurse to give you the proper care and management.
Discussion with the Examiner
 My First DD is Multiple myeloma
 Second DD is primary cancer or secondary
What investigations you are going to do for the patient:
 Apart from basic investigations: CBC, RFT, LFT, Electrolytes, Inflammatory markers.
 Specific investigations: X ray spine, S. calcium, Plasma electrophoresis, urinary Bence jons protein, blood
smear, DEXA scan, Tumors markers.
What is the treatment forWSitipie myeloma?

 MDT Approach.
 Treatment of hypocalcaemia: good hydration, Bisphisphonate, diuretics, steroids
 Chemotherapy - Bone marrow transplantation (Plan of management to be decided by Hematologist)
143
Monoarthritis
Scenario: Mr. is 45 years old compiaining of right knee joint pain for two weeks, He is known case of DM on
metformin, HNT on hydrochlorothiazide, ramipril for your kind care.
 Trauma.
 Septic Arthritis.
 Gout, Pseudo Gout.
 Osteoarthritis, RT.
 Seronegative Arthritis.
 Enteropathic.
 Psoriatic arthropathy.
 Reactive Arthritis (Reiter's).
 Haemarthrosis i.e. Hemophilia.
 Lyme disease.
Introduction:
 Shake hands.
right knee joint pain for the last 2 weeks).
 Fm going to write some notes, be sure they will be confidential and my full attention will be with you.
 Onset, Course, Duration, Progression, Worsening factors, improving factors
 When this joint pain started exactly, suddenly or gradually, decreasing, increasing or the same
 Did you notice anything worsen this pain like movement or rest?
144
 Did you notice anything improving this pain, iike movement or rest or any pain killers?
 Recurrence: Any Hx of similar problem in the past?
 Site: Any other joint pain or back pain
 Grade of pain: If the pain is from 0-10 - how much do you give this pain?
 Radiation: Does it radiate to anywhere else?
 Associated symptoms: Any associated skin redness, joint hotness Morning stiffness (For how long? >lh in
RA and <1 h in Osteoarthritis, SLE and psoriatic arthropathy.
Ask about your differential diagnosis list:
Traumatic: Any history of trauma?
Septic arthritis: Any high temperature, shivering, sweating?
Seronegative arthritis:
1. Enteropathic arthritisis: Any tummy pain, loose motions?

2. Reactive arthritis: Any burning water work, eye pain or redness?
3. Psoriatic arthropathy: Any skin rash, nail changes?
Gout: What about your diet, is it rich in protein, any kidney problem, any gravels in urine?
Pseudo gout: Any tummy pain, yellowish eye balls, SOB, DM, tanning of the skin, loss of sexual desire (Pseudo
gout in hemochromatosis)
Any weight gain, cold intolerance, fatigue, constipation (Peudogout in Hypothyroidism).
Haemoarthrosis: Any history of blood disease, and history of bleeding per anybody orifice, any F.H of similar
condition, or blood disease, any drug thinner like Aspirin, warfarin?
General symptoms: Any fatigue, loss of weight or Wight gain, lumps or bumps?
GIT symptoms: Acid brush, heart bum, mouth sores, difficulty of swallowing, yellow discoloration of the eye ball,
feeling or getting sick, altered
145
Loose motions?
CVS symptoms: Any chest pain, racing of heart beats, SOB, leg swelling?
Chest symptoms: Cough, phlegm, coughing up blood, noisy chest, runny nose, bleeding from the nose?
Genitourinary: Any change in your water work? Amount, color, frequancy frothy urine, burning water work?
Musculoskeletal: Any other joint pain, muscle pain skin rash?
Sexual history: May I ask some personal questions please? Are you sexually active, how many partners you have?
(Gonorrhea induced reactive arthritis)
patient per day?
Hematology symptoms: You asked before
Travelling history: If there take detailed travelling history (For Lyme disease).
Surgical history: Any history of surgical operation, blood transfusion, needle sharing, tattooing, piercing?
146
Social history:
 Patient job? How much his symptoms affect his job and usuai daily activity? Refer the patient to an
occupationai heaith care worker if his work is affected and to a social worker if his sociai iife is affected.
Summary:
 Now I'm going to summarize the positive data in our discussion today.
 You have been complaining of right knee joint pain for the last 2 weeks, which is mildly swollen, painful
with pain increased by movement with a grade from 4-5, no fever, you have history of left foot pain 2 months
ago in the base of your big toe which subsided after some pain killers.
 You have hypertension for which you are receiving ramipril and hydrochlorothiazide for 1 year and DM for
which you are receiving Glucophage and is controlled, do you want to add anything else?
What could be the cause of my knee joint pain Dr?

 Most probably gouty arthritis is the underlying cause secondary to deposition of uric acid crystals in your
joint, precipitated by hydrochlorothiazide you are receiving for your blood pressure.
 What we are going to do is to do further blood tests and imaging and may be to have a snip of the fluid inside
your knee for analysis by a needle under aseptic condition after your consent.
 If our diagnosis is confirmed we have to exchange hydrochlorothiazide to another safe treatment.
 We will refer you to MDT from joint physician, physiotherapist social worker, occupational health care
worker for further investigations and management plan.
147
 My first DD is Gouty arthritis, precipitated by hydrochlorothiazide, supported by history of right big toe
base arthritis which is common in gouty arthritis.
 Peudogout couid be the second DD.
 Septic arthritis can be considered, but against that no history of fever.
What investigations you are you going to do?
 Apart from basic investigations: CBC, LFT, RFT, Electrolytes, inflammatory markers.
 Serum uric acid (can be normal in the acute attack).

 Synovial fluids aspiration and analysis under immunofluorescence negatively birefringent urate crystals
in gout.
What is the treatment for Gout?

 Patient education and counseling.
 Psychosocial support.
 Occupational support.
 Avoidance of high protein diet.
 Avoidance of triggering drugs.
 NSA1DS.
 Colchicine (if patient not tolerant to NSAIDS.
 High dose Aspirin.
 Oral and Local injection of steroids.
148
Osteoporosis
Scenario: Mrs Mona is 47 years old, she had history of recurrent fractures in the last 3 months, DEXA scan done
for her revealing that she has osteoporosis, for your kind care.
- Life styie risk factors:

 Low calcium diet.
 Low body index.
 Low exercise practice.
 Low chance of sun exposure.
 Heavy smoking and alcohol intake.
 Family History.
- Systemic diseases:
 Endocrinal causes: Hyperparathyroidism, Hyperthyroidism, Postmenopausal, Cushing, Acromegaly,
Adrenal insufficiency.
 GIT causes: Malabsortion, IBD.
 Systemic diseases: Chronic liver disease, Chronic kidney disease, Rheumatoid Arthritis, SLE, Connective
tissue disease, Malignancy,
 Drug induced: Steroids, Anti epileptics, Antipsychotics, Heparin.
Introduction
 Shake hands.
recurrent fractures for the last 3 months, is it right?).
 Em going to write some notes, be sure it will be confidential and my full attention will be with you.
149
 Onset, course, duration, progression: Any history of similar fractures in the past? Any history of trauma?
Life styie factors:

1. What about your diet, is it balanced diet, is it rich with milk, eggs, animal products?
2. What about exposure to sun?
3. Do you practice any exercise?
4. What about your weight?
5. Do you smoke at all? How many cigarette per day? For how long? Do you drink alcohol? How many unites
per week?
Postmenopausal: Last period, flushing, mood variation, painful breasts (Postmenopausal symptoms)
Hyperparathyroidism: Increased thirsty, increased water work frequency, constipation (symptoms of

hypercalcemia).
Hyperthyroidism: Loss of weight, hot intolerance, racing of heart rate, shaking of the hands, sweating, anxiety.
Cushing syndrome: Weight gain, abnormal hair growth, skin eruption, back pain, history of DM or High BP.
Acromegaiy: Change in your facial features, change in ring or shoes size.
Malabsorbtion, IBD: Tummy pain, loose motions, mouth sores.
Systemic disease: Any long standing disease?

1. R.A, SLE, Ankylosing: Joint pain, back pain or stiffness, falling of hair, skin rash, mouth sores.
2. CLD: Tummy swelling, yellow discoloration of eye balls.
3. Malignancy: Loss of weight, fever, lumps or bombs, fatigue?
150
Drug induced: Are you receiving any regular medications like steroids, anti-psychotics, antiepiieptic medication?
Totai hysterectomy: Any surgical operations in the past?
Systemis review: Don't ask about symptoms you asked before?
General symptoms: Were asked before
GIT symptoms: Acid brush, heart bum, difficulty of swallowing, feeling or getting sick, vomiting up blood, blood
in stool, yellow discoloration of the eye balls?
CVS symptoms: Chest pain, SOB, leg swelling?
Pulmonary symptoms: Cough, phlegm, coughing up blood, noisy chest, runny nose, bleeding per nose?
Genitourinary: Any change in your water work? Amount, color,
Frequency,
Frothy urine?
Musculoskeletal: Any joint pain, skin rash?
Sexual history: May I ask personal question please? Are you sexually active, How many partners do you have?
Menstrual history: Asked before
Medical history: Of any long standing disease like DM, HNT, heart disease.
151
Surgical history: Any history of surgical operation (Oophorectomy or hysterectomy as risk factbrs), any history of
tattooing, piercing, needle sharing?
Drug list: What is your drug list please? Any over the counter medications? Any recreational medications?
Social history:
Summary:
Now I'm going to summarize the positive data in our discussion today.
You have been complaining of recurrent fractures in the last 2 months, youf last period was at the age of 44, you are
heavy smoker and drinking alcohol moderately, your are working as swimming trainer, and regular on exercise.
Do you want to add anything else?
What could be the cause of my Fragile bone Dr?

 I appreciate your concern, most probably your fragile bone is due to hormopal disturbance secondary to early
menopause, Risk factors like smoking and alcohol may worsen your condition.
 So what we are going to do is to do further blood test, hormonal assay to confirm our diagnosis, then we will
refer you to a MDT to give you the proper management plan.
 Smoking may worsen your condition, so we can refer you smoking cessation clinic to help you give up
smoking if you don't mind.
 Alcohol also may worsen your condition, so you are advised to stop alcohol intake.
152
I'm working as swimming trainer. Do I have to stop my work?
 Actually swimming is good for your condition, and even you can get benefit from some weight bearing
exercise as it increases the bone density and muscle bulk, but you have to avoid vigorous exercise and sports
like rugby and football as it may expose you to recurrent bone fracture.
What is your diagnosis?

Postmenopausal osteoporosis due to early menopause, with risk factors of excessive smoking and alcohol intake.

 Apart from basic investigations: CBC, LFT, RFT, Electrolytes
 Specific investigations: Serum Vitamin D, Calcium, Hormonal assay: (FSH, LH, Estrogen)
What is the treatment of osteoporosis?

- Non pharmacological:
 Occupational 1 support
- Modification of life style:
 Wight bearing exercise
 Avoidance of vigorous exercise
 Calcium rich diet
 Encourage Sun exposure
 Vit D, Calcium supplementation.
 Bisphosphonate: Alendronate, Risedronate.
 Raloxifene: Selective estrogen receptor modulator (if patient not tolerant to bisphsphonate.
 Parathyroid hormone derivative.
153
Hematurea in young Female
Scenario: Mrs. Soha is 27 years old is complaining of Hematurea for the last 4 weeks or your kind care.
 Renal stones.
 Infection (cystitis, pyelonephritis, Bilharesiasis)
 Pulmonary renal syndrome (wegner granulmatosis, microscopic polyangitis, Goodpature syndrome, SLE)
 Glomerulonephritis (IgA nephropathy, post streptococcal glomerulonephritis)
 Polycystic kidney disease.
 Bleeding tendency (HHT, blood disease, drug induced)
 Rabdomylosis (Myoglobinurea).
 Vasculitis (churg strauss).
 Malignancy.
Introduction:
 Shake hands.
 Introduce your self.
 Confirm agenda of meeting (I have a letter from GB informing me that you are complaining of blood in urine
for the last 4 weeks).
 Fm going to write some notes, be sure it will be confidential and full attention will be with you.

 Onset, course, duration, progression, associated symptoms:
 When this bloody urine started exactly? Suddenly or gradually? Coming on and off or all the time? Is it
 Is it dark reddish or bright reddish, dark red or coffee colored?
 Is it in the beginning or the end or all over the stream?
154
 Worsening factors: Did you notice anything precipitate your condition iike special type of food or (jrugs or
heavy exercise?
 Improving factors: Do you notice anything improve you condition?
 Frequency: Any change in the odor, amount or frequency?
 Consistency: Does it contain any graveis or clots?
 Volume: What about the amount, is it large, moderate, or little amount?
 Timing: Any diumal variation, more at morning, mid day or night?
 Associated symptoms: Is it associated with burning pain or pain in your tummy?
Renal Stone: Any history of kidney stones, pain in the sides of your flank?
Infection (cystitis, pyelonephritis, Biiharesiasis):

Any history of burning water work, fever, history of swimming in jungle pools?
Pulmonary renal syndrome (Wegener’s granulomatosis, microscopic poiyangitis, Goodpature syndrome, SLE):
Any associated flue like symptoms, runny nose, bleeding per nose, cough, coughing up blood, noisy chest, SOB?
Giomeruionephritis (igA nephropathy, post streptococcai glomeruionephritis):

Any recent chest infection in the last few days or 2 weeks.
Any falling of hair, skin rash, mouth sores, joint pain, frothy urine? (SLE)
Poiycystic kidney disease:

Any history of flanks fullness or pain, family history of kidney disease or similar condition?
Vasculitis:
Any tummy pain, pins and needles, skin rash, weakness?
Bieeding tendency:
Any history of similar attack or bleeding from anybody orifice, history of blood disease or family history of blood
disease, Any drug thinner like warfarin?
155
Malignancy: Loss of weigh, fatigue, lumps and bumps?
Systemic review: Don't ask about symptoms you asked about before?
General symptoms: were asked before
GIT symptoms: Mouth sores, difficulty of swallowing, getting or feeling sick, yellow discoloration of the eye balls,
altered bowel habits, vomiting up blood, blood in stool?
CVS symptoms: Chest pain, racing of heart rates, SOB, leg swelling?
Pulmonary symptoms: You asked about all before.
Genitourinary: You asked about all.
Musculoskeietai: You asked before
Sexual history: May i ask some personal questions please, are you sexually active, how many partners do you have
?
patient is using per day?
Hematology symptoms: You asked before
Travelling history: If there when and where? For how long? Where the patient stayed? In urban or rural area? Any
insect bite there? Any swimming in local pools there? Any endemic disease there? any relation with local girls there?
Surgical history: Any history of surgical operation, blood transfusion dental procedures, tattooing, piercing, needle
sharing?
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Social history:
Summery:
Now Fm going to summarize the positive data in our discussion today, you have been complaining of bloody urine
for 2 weeks. Also you have flue like symptoms, dry cough, recurrent nasal bleeding, joint pain, loss of weight not
intended with no change in appetite.
Do you want to add anything more?
 Cancer is unlikely in your condition, but we have to exclude as well .Most probably you have a condition
called Pulmonary renal syndrome, mostly a disease called Wagner granulomatosis which is a multisystem
disease affecting kidneys, lungs, and may be other body systems due to disturbance of the defensive system.
 So we are going to do further blood test and may by nasal snip to confirm our diagnosis, then if diagnosis is
confirmed we will refer you to MDT from kidney doctor, lung doctor, and joint doctor to give you the proper
care and management.
Is it curable doctor?
Fm sorry to tell you it is not curable, but can be controlled on medications.
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Discussion with the Exammimer:
 My First DD is pulmonary renal syndrome, Wegener's granulomatosis is the most probable one, second may
by Microscopic polyangitis.
 Other DD could be IgA Nephropathy (the most common cause of glomerulonephritis all over the world), but
against that the pulmonary symptoms came after urinary and were sustained.
What investingations you are going to do for the patient:
 Apart from basic investigations: CBC, RFT, LFT, Inflammatory markers.
 Specific investigations: C- ANCA, P-ANCA, ANA, Urine analysis, Nasal biopsy, Chest x Ray, Abdominal
US.
-Pharmacological treatment:
 Cyclophosphamise: Oral cyclophosphamide in combination with high dose glucocorticoids (ie, prednisone
lmg/kg/day) has been the criterion standard for induction of remission
 Steroids: In combination with Cyclophosphamise or Methotrexate.
 Methotrexate: A combination of methotrexate (oral or subcutaneous) and glucocorticoids can be considered
as a less-toxic alternative to cyclophosphamide for the induction of remission of non-organ-threatening or

non-life-threatening
 Plasma exchange: May be considered in patients with rapidly progressive renal disease (serum creatinine
level >5.65mg/dL) in order to preserve renal function.
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Scenario: Mr. Kamal is 29 years old has been complaining of recurrent chest pain for the last 4 weeks, his BP:
142/90 for your kind care.
Make your DD list in your white paper:
 Cardiac causes (IHD, pericarditis, myocarditis, endocarditis, aortic dissection, pulmonary edema).
 Pulmonary causes (P.E, pleuritis, pneumonia, bronchitis, bronchiactasis)
 GIT causes (Peptic ulcer, GERD).
 Endocrinal causes (Pheachromcytoma, Hyperthyroidism both are highly associated with recurrent chest pain
and high BP)
 Musculoskeletal (myositis, chondritis)
 Drug induced (Amphetamines, Cocaine)
 Herpes zoster (far differential as long hx of chest pain)
Introduction:
 Shake hands.
chest pain for the last 4 weeks and high BP).
 Em going to write some notes, be sure they will be confidential my full attention will be with you.

 Onset, course, duration, progression, worsening and improving factors.
 When this chest pain started exactly? Suddenly or gradually? Coming on and off or all the time? Is it
increasing, decreasing or the same? For how long it continue?
 Worsening factors: Do you notice anything worsen your condition, like after feeding, exertion, movement,
breathing, pressure on site of pain?
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 Improving factors: Do you notice anything improve your chest pain iike rest, laying dowii or leaning
forward?
 Site: where is the pain in your chest exactly?
 Radiation: is it radiating to any elsewhere?
 Character: May you prescribe for me what is the character of this pain, is it burning, stabbing, compressing,
dull aching, or sharp pain?
 Intensity: How much grade of this pain 0 is the minimum, 10 is the maximum?
Cardiac
Ischemic heart disease:

Any history of high lipid profile? Any family history of ischemic heart disease? History of smoking,
How many cigarette per day? For how long?
Any shortness of breath, racing of heart beats, leg swelling?
Pulmonary
Pulmonary embolism
(Symptoms): Any history of cough, phlegm, coughing up blood?
SOB, racing of heart rate?
(Risk factors):
Any history leg swelling? (DVT).
Any history of long journey recently?
Any history of immobility for long time recently?
Any history of Cancer?
Any history of blood clot, or family history of blood clot?
Pneumonia, bronchiactasis: Fever, noisy chest?
GET:
(GERD, P.U): Heart bum, acid brush sensation, increased after food?
Muscuioskeietal: Pain increased with movement.
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Endocrinal causes:
Pheochromocytoma:
Any loss of weight (How many Kg, for how long, intended or not, what about your apetite), racing of heart beats,
anxiety, headache, sweating, shaking of the hands, flushing?
 MEN2a (Modularly cell carcinoma, Hyperparathyroidism, marfenoid features): neck lump, hypercalcemic
symptoms: increased thirsty, increased water work frequency, constipation, low mood?
 Von hippel lindu: Visual disturbance, abnormal gait, altered speech, change in water work color, amount,
frothy urine?
 Neurofibromatosis: Skin rash, diminution of hearing, mouth deviation, dripping of saliva, altered facial
sensation?
Hyperthyroidism: Hot intolerance, increased appetite, loose motions (other symptoms are asked in
pheochromocytoma).
What about your BP? For how long you have this high BP? Any medication you receive for this BP? Is it controlled
or not?
General symptoms: Fever, fatigue, lumps or bumps?
CVS symptoms: (You asked about all before).
Pulmonary symptoms: (you asked about all of them before).
GIT symptoms: Mouth sores, difficulty of swallowing, tummy pain, yellow discoloration of the eye ball, altered
bowel motions, blood in the stool?
Muscuioskeietai: Any joint pain, skin rash?
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Sexual history: (I would like to ask personal question if you don't mind - Are you sexually active? How many
partners do you have?
sharing?
Drug list: Are you regular on any medications? Any over counter medications? Any recreational drugs?
Social history:
 Patient job? And how much his or her symptoms affect your job and usual daily activity? Refer the patient
to occupational health care worker if work is affected, and to social worker if social life is affected.
Summary-
 I'm going to summarize the positive data in our discussion today.
 You have been complaining of chest pain, recurrent, all over your chest, may come even at rest, compressing
in nature, 6-7 in intensity.
 You have been complaining of loss of weight about 6 kg in the last 8 weeks, not intended with good appetite,
recurrent sweating, shaking of the hands, and anxiety.
 You have high BP for the last 4 weeks measured by your GB, who prescribed for you medication called
Ramipril with sustained high BP.
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 You have family history of ischemic heart disease, as you father had history of long standing ischemic heart
disease- Do you want to add anything more?
Concerns:
What could be the cause of my chest pain Dr, is it heart attack like my father?
 I appreciate your concern, we have to do full examination and some blood test and heart tracing first to
confirm our diagnosis.
 Heart attack is unlikely in your condition, but we have to exclude as well.
 Most probably you have a condition called pheochromocytoma. It is due to overgrowth of the glands located
above your kidneys secreting excess hormones called adrenaline and noradrenlaine, which is responsible for
all your symptoms of recurrent chest pain, racing of heart beats, recurrent sweating, shaking of the hands,
loss of weight and High BP.
 So what we are going to do is to admit you, do further blood tests, cardiac enzymes, heart tracing to confirm
our diagnosis.
 If pheochromocytoma is confirmed, we will refer you to a gland doctor to give you the proper care and
management plan.
What is your diagnosis and DD diagnosis Dr?

 My first diagnosis is isolated pheochromocytoma.
 Second DD could be Hyperthyroidism, but against that no polyphagia or hot intolerance.

 Apart from basic investigations.
 ECG, Cardiac enzymes. Echocardiography.
 24 H Urinary Catecholamine, plasma metanephrines.
 CT or MRI (more accurate) abdomen and brain, Scintigraphy (Reserved for biochemically confirmed
cases in which CT scanning or MRI does not show a tumor)
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-Non pharmacological:
 Patient education and counseling.
 Psychosocial support.
 Occupational support.
-Specific treatment:
 Surgical resection is the treatment of choice, has to be preceded by alpha blocker 10-14 days with
phenoxybenzamine 10-14 days preoperatively to allow for expansion of blood volume. Initiate a beta
blocker only after adequate alpha blockade (usually, 2 days).
If beta blockade is started prematurely, unopposed alpha stimulation could precipitate a hypertensive
crisis.
Case Discussion:
 Pheachromocytoma is a common case in the exam.
 In pheachromocytoma you will find positive data in the form of Loss of weight, racing of heart beats,
recurrent headache, recurrent chest pain, recurrent sweating, shaking of the hands, High BP.
 It may be isolated or involved within other syndrome like (MEN 2, Vbn hippel lindu, Neurofibromatosis)
that you have to ask about.
 Family Hx here is very important - Isolated pheochromocytoma may be familial in 10 % of cases - or

Autosomal dominant if involved within other syndromes - for example you may find Family Hx of father
died because of cancer kidney, this will guide you to the possibility of Inherited Von hippel lindu (Exam
case)
 Pheochromocytoma may come in different scenarios like: Recurrent chest pain and high Bp in young patient,
palpitation and like our case, recurrent sweating and glycosurea.
164
Recurrent Sweating and Glycosurea
Scenario? Mr. Osama is 30 years old has been complaining of recurrent hand sweating for the last 4 weeks, urine
dipstick revealed glycosurea for your kind care.
Make your differential diagnosis list in your white paper:
 Anxiety and mood disturbance.
 Pheocromocytoma (Isolated, MEN 2, Von hippel Undo, Neurofibromatosis).
 Hyperthyroidism.
 Acromegaly.
 Hypoglycemic attacks (Insulinoma, Drug induced)
Introductions
 Shake hands.
 Introduce your self.
 Confirm agenda of meeting (I have a letter fromoyur GP informing me that you have been complaining of
recurrent sweating for 4 weeks and glucose in urine).
 Can you tell me more about your complaint please?
Analysis off tlhe complaint?
 When this sweating started exactly? Suddenly or gradually? Coming on and off or all the time? Is it
increasing, decreasing or the same? For how long it continue?
 Worsening factors: do you notice anything worsen your condition, like exertion, anxiety?
 Improving factors: Do you notice anything improve your sweating like rest or, good mood?
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Anxiety: Any mood changes recently, being anxious than before?
Acromegaly: Any shange of your facial features, any change in youe ring or shoes size?
Pheochromocytoma: Any loss of weight (how many K.g, for how long, intended or not, what about your appetite),
racing of heart beats, headache (simple analysis of the headache), shaking of the hands, flushing, did you check your
BP before, if high what medications you on, is it controlled or not? - did you check your glucose level before?
 MEN2 A (Modularly cell carcinoma, Hyperparathyroidism, marfenoid features): Any neck lump,
hypercalcemic symptoms: Increased thirsty, water work frequency, constipation, low mood)
 Von hippel lindu: Visual disturbance, abnormal gait, altered speech, Change in water work color, amount,
frothy urine.
 Neurofibromatosis: Any skin rash, diminution of hearing, mouth deviation, dripping of saliva, altered facial
sensation.
 Family history of similar condition or long standing disease (for familiar isolated pheachromocytoma or
other syndromes)
Hyperthyroidism: Any hot intolerance, loose motions, increased appetite (other symptoms were asked in
pheochromocytoma)
What about your BP? Did you check your BP before? For how long you have this high BP? Any medication you
receive for this BP? Is it controlled or not?
Systemic review: Don’t ask about symptoms you asked before?
General symptoms: fever, fatigue, lumps or bumps, (you asked about weight loss before)
shaking of the body, Uncontrolled water work or bowl habits?
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CVS symptoms: Any chest pain, SOB, leg swelling, (you asked about racing of heart beats before)
Pulmonary symptoms: Any cough, phlegm, coughing up blood, noisy chest, runny nose.
GIT symptoms: Any mouth sores, acid brush, heart bum, difficulty of swallowing, tummy pain, yellow
discoloration of the eye ball, altered bowel motions, blood in the stool?
Musculoskeletal: Any joint pain, skin rash.
Sexual history: (I would like to ask personal questions if you don’t mind - Are you sexually active, how many
partners do u have?
patient per day?
Travelling history: Any history of traveling abroad?
Medical history: Of long standing disease like DM, HNT, heart disease?
sharing.
Drug list?
Social history:
 With whom the patient is living? Who is supporting hiip or her at home?
167
Summary:
 I’m going to summarize for you the positive data we discussed today.
 You have been complaining of recurrent sweating of both hands for the last 4 weeks, associated with loss of
weight about 5 KG, which is not intended, recurrent racing of heart beats and headache, anxiety and flushing
 You have been complaining of High BP for which you are receiving captopril, which seems to be difficult
to be controlled.
 Your father died because of cancer kidneys at the age of 50 and had history of high BP- Do you want to add
anything more?
 I appreciate your concern, we have to do full examination and some blood test and heart tracing first to
confirm our diagnosis..
 Most probably you have a condition called pheochromocytoma. It is due to overgrowth of the glands located
above your kidneys secreting excess hormones called adrenaline and noradrenlaine, which is responsible for
all your symptoms of recurrent racing of heart beats, recurrent sweating, shaking of the hands, loss of weight
and High BP.
 It may be related to your father condition, a familial condition called Von hippel Lindu syndrome, a
syndrome of multisystem disease.
 So what we are going to do is to admit you, do further blood tests and imaging to confirm our diagnosis.
 If pheochromocytoma is confirmed, we will refer you to a gland doctor to give you the proper care and
management plan.
Discussion with the examiners

 My 1st diagnosis is Pheochromocytoma - may be a part of Von hippel lindu as his father died because of
Renal cell carcinoma- VHI syndrome (retinal angiomas, CNS hemangioblastomas, renal cell carcinomas and
pheochromocytomas)
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 2nd DD is Hyperthyroidism, against that there is no other hyperthyroid symptoms like hot intolerance,
increased appetite.

 Apart from Basic Investigations: CBC, RFT, LFT, Electrolytes.
 24 H Urinary Catecholamine, plasma metanephrines.
 CT or MRI (more accurate) abdomen and brain, Scintigraphy (Reserved for biochemically confirmed
cases in which CT scanning or MRI does not show a tumor)
 Genetic testing.
-Non pharmacological:
- Specific treatment: MDT approach if von hippel lindu or Isolated Pheochromocytoma is confirmed
 Surgical resection is the treatment of choice, has to be preceded with B blocker, alpha blocker 10-14 days
before surgery to avoid hypertensive crisis during the operation.
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Skin rash and SOB
Scenario; Mrs.Heba is 28 years old, has been complaining of skin rash and shortness of breath for the last 8 weeks,
for your kind care.
 Sarcoidosis.
 Pulmonary Renal Syndrome.

 Wegner granulomtosis.
 Microscopic polyangitis.
 Good pasture syndrome.
 SLE.
 Vasculitis (Churg Strauss)
 Infection (Streptococcal - TB - HIV)
 Rheumatological (Systemic sclerosis-Psoraitic Arthropathy- Dermatomyositis)
Introduction:
 Shake hands.
 Confirm agenda of meeting (1 have a letter from your Gp informing me that you have been complaining of
skin rash and SOB for the last 2 month, is that right?
 Onset, course, duration, progression, precipitating factors, relieving factors:
Skin rash:
 When this skin rash started exactly? Suddenly or gradually? Coming on
 And off or all the time? Is it increasing, decreasing or the same?
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 Site, distribution: where is the rash in your body exactly?
 Color: what is the color of the rash?
 Recurrence: is it the first time to have this rash or recurrent?
 Worsening factors: do you notice anything worsen this skin rash like
 Trauma, stress, exposure to sun, smoking, alcohol, any drugs?
 Improving factors: Do you notice anything improve this skin rash?
 Is it painful at all?
 Is it blenchable?
 Any discharge coming out?
Cough:
 When this cough started exactly? Suddenly or gradually? Is it increasing, decreasing or the same? Coming
on and off or all the time?
 Worsening factors: Do you notice anything worsen this cough like exertion, pollens, dust, pets, cold,
perfumes?
 Improving factors: Do you notice anything improve this cough like avoidance of all triggers factors I
mentioned to you?
 Associated symptoms: any associated Shortness of breath, phlegm, coughing up blood, nasal discharge or
blockage, bleeding per nose?
Sarcoidosis:
 Any history of joint pain (if there take brief analysis).
 Any eye pain or redness or visual disturbance?
 Increased thirsty, water work frequency, constipation, low mood? (Hypercalcemic symptoms)
 Any chest pain, racing of heart beats, leg swelling? (Cardiac symptoms).
 Any change of your water work amount, color, frequency, frothy urine? (Renal symptoms)
Pulmonary renal syndrome:

 Wegner granulomtosis, Microscopic polyangitis, Good pasture: Any Runny nose, bleeding per nose,
cough, coughing up blood (Were asked in analysis of the complain) - Genitourinary symptoms (Asked in
Sarcoidosis)
 SLE: Any falling of hair, facial rash, mouth sores, fatigue,

(Musculoskeletal, Genitourinary were asked before in-Sarcoidosis)
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Vasculitis (Churg Strauss):
Fatigue, loss of weight, (other symptoms of skin rash, musculoskeletal, Genitourinary were asked before)
Infection (Streptococcal -TB-HIV)
 Any history of high temperature, loss of weight, contact with TB patient?

 (Risk of HIV): Surgical operation, dental procedure, blood transfusion, tattooing, piercing, needle sharing,
May i ask private question, Are you sexually active, how many partners do you have?
Rheumatologic (Systemic sclerosis-Psoraitic Arthropathy)

 Any history of tight shiny skin, finger color changes when exposed to cold weather, nail changes, difficulty
of swallowing, (urinary and cardiac symptoms were mentioned before)
Systemic review. Don’t ask about symptoms you asked before?
General symptoms: Were asked before.
GIT symptoms: Acid brush, heart bum, feeling sick or through up, difficulty of swallowing (was asked before),
yellow discoloration of the eye ball, loose or less motions?
CNS symptoms: Headache, LOC, visual disturbance, altered speech, weakness, altered sensation, abnormal gait,
CVS symptoms: Asked before.
Pulmonary symptoms: Asked before.
Genitourinary: Asked before.
Musculoskeletal: Asked before.
Sexual history: Asked before (Risk of HIV).
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Travelling history: If there is when and where, for how long, where the patient stayed? In urban or rural area, Any
insect bite there? Any swimming in local pools there? Any endemic disease there? any relation with local girls there?
Medical history: Of any long standing disease like DM, HNT, heart disease.
sharing (were Asked before).
Family history: Of similar condition, or long standing disease.
Social history:
 With whom the patient is living? Who supporting him at home?
Summery:
 I’m going to summarize the positive data in our discussion today.
 You have been complaining of skin rash for 2 month in front of your legs, which is increasing, reddish in
color, painful, not itchy associated with dry cough which is progressive can be on exertion or rest associated
with shortness of breath.
 You have been complaining of pain in your small joints of both hands on and off, which is mild pain with
no stiffness or finger color changes or nail changes.
 You have been complaining of increased thirsty and water work frequency, fatigue and constipation for 2
months as well (hypercalcemic symptoms).
 Do you want to add anything more?
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Is it cancer Dr?
 I appreciate your concern, we have to do full examination and investigations

 First to confirm our diagnosis.
 Cancer is unlikely in your condition, but we have to exclude as well.
 Most probably you have a condition called Sarcoidosis, It is a multisystem disease involving the lungs
causing cough and shortness of breath, joints* skin and may be also the heart and kidneys.. Aslo may cause
high calcium level in the blood causing symptoms of thirsty, increased water work frequency and
constipation.
 So what we are going to do is to do some blood test and imaging to cOnfirjti our diagnosis and if confirmed
we will refer you to MDT from joint doctor, lung doctor, social worker, occupational health care specialist
to give you the proper care and management plan.
 Any other concern?
 My first DD is Sarcoidosis supported by presence of erythema nodosum, arthritis, hypercalcemic symptoms.

 Second DD could be Vasculitis, but against that the skin rash doesn’t look like vasculitic rash.
 Apart from basic investigations: CBC, Electrolytes, LFT, RFT, CRP, ESR
 Serum markers: Serum CA, ACE, Serum amyloid A (SAA), soluble interleukin-2 receptor
 Imaging: Chest X ray, High resolution CT scan, Bronchoscope, ECG, Echocardiography.
 Pulmonary Function Test, A carbon monoxide diffusion capacity test of the lungs for carbon monoxide
(DLCO)
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What is the treatment for sarcoidosis?
-Non pharmacologic
-Pharmacological treatment:
 Most patients (>75%) require only symptomatic therapy with NSAIDs. Approximately 10% of patients need
treatment for extrapulmonary disease, while 15% of patients require treatment for persistent pulmonary
disease
-Steroid treatment:
 Corticosteroids are the mainstay of therapy.
 Generally, prednisone given daily and then tapered over a 6-month course is adequate for pulmonary disease.
Earlier recommendations suggested an initial dose of 1 mg/kg/d of prednisone
 High-dose inhaled corticosteroids may be an option can be used in patients with endobronchial disease.
-Nonsterold treatment
Noncorticosteroid agents are being increasingly tried. Common indications for the initiation of such agents include
steroid-resistant disease, intolerable adverse effects, or patient desire not to take corticosteroids.
 Methotrexate (MTX) has been a successful alternative to prednisone and is a steroid-sparing agent.
 Chloroquine and hydroxychloroquine are antimalarial drugs with immunomodulating properties, which have
been used for cutaneous lesions, hypercalcemia, neurological sarcoidosis, and bone lesions. Chloroquine has
also been shown to be efficacious for the treatment and maintenance of chronic pulmonary sarcoidosis.
 Cyclophosphamide has been rarely used with modest success as a steroid-sparing treatment in patients with
refractory sarcoidosis.
 Azathioprine is another second-line therapy, which is best used as a steroid-sparing agent rather than as a
single-drug treatment for sarcoidosis.
175
 CMorambudl is an alkylating agent that may be beneficial in patients with progressive disease unresponsive to
corticosteroids.
 Cydosporiee is a fungal cyclic polypeptide with lymphocyte

Suppressive properties and may be of limited benefit in skin sarcoidosis or in progressive sarcoidosis resistant to
conventional therapy.
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Syncope
Scenario: Mrs. Jack is 45 years old had syncopal attack today morning when he was running in the track, He is
known case of diabetes mellitus and hypertension for your kind care.
Make your Differential diagnosis:
Neurocardiogenic syncope (Vasovagal):
Reflex (Emotional):
 Unpleasant or shocking sight, horrible/frightening experience.
 Suddenly emotionally upset like death of on relative.
 Standing still for long periods, hot weather.
Situational syncope (Physical): This is also a type of neurocardiogenic syncope:
 Coughing.
 Defecating.
 Lifting a heavy weight, and some other demanding physical activities
 Sneezing.
 Urinating.
Orthostatic syncope:
 Severe dehydration.
 Cardiac syncope (Arrhythmia, Valvular defects, Hereditary like HOC, Burgada, long QT interval).
 Carotid sinus syndrome: wears a tight collar or tie or shaving.
 Autonomic dysfunction (Uncontrolled diabetes).
 Alcohol.
 Dmg induced.
 Some neurological conditions - such as Parkinson's disease.
Neurological cause: Epilepsy, Space occupying lesion, TIA
What happened during the attack?

 Did you lose your conscious completely, or just rotation of the surroundings?
 For how long you stayed unconscious?
177
 Any shaking of the body during the attack?, Any tongue biting, uncontrolled water work , injury to anybody part?
(Epilpsy).
 Any change in your color during the attack like being bluish or pallor?
What happened after the attack?
 Did you resumed your conscious rapidly or stayed confused for some time? (Post ictal confusion)?
 Any headache or limb weakness after the attack? (Post ictal paresis).
What happened before syncope?

 Any history of similar condition in the past?
 Any abnormal sensation or strange voices or hallucinations before the attack? (Aura of epilepsy)
Ask about differential diagnosis list:
Neurocardiogenic syncope (Vasovagal):
Reflex syncope: Any history of unpleasant or shocking sight, horrible/frightening experience, Sudden emotional
upset like death of one relative? Standing still for long periods, existence in hot weather?
Situational syncope: Any history of coughing, straining, sneezing, urinating, defecating, lifting heavy object before
the syncopal attack?
Orthostatic Syncope:
 Severe dehydration: Any history of loose motions, feeling sick, vomiting, diminished oral intake recently,
bleeding from anybody orifice?
 Cardiac syncope: Any history of chest pain, racing of heart beats, shortness of breath, Family history of similar
condition, heart problem or sudden death?
 Carotid sinus syndrome: Wearing tight collar or tie or shaving?

 Autonomic dysfunction (Uncontrolled diabetes):
 Any history of DM? For how long? What medication you are on? Are you compliant on your medications?
What about your last HB A1C? Any hypos before?
 Symptoms of uncontrolled DM: Any pins and needles in the feet or hands. Any visual disturbance, any chest
pain or heart attacks, any diminished water work or frothy water work?
 Alcohol: Do you drink alcohol, how much amount per day?
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 Drug induced: Are you regular on any medications? What medications? Any new medication added recently?
Any change in the dose recently? Any over the counter medications? Any recreational drugs?
Neurological cause: Any history of visual disturbance, altered speech, limb weakness, abnormal gait?
Systemic review: Don’t ask about symptoms you asked before?
General symptoms: Any history of high temperature, loss of weight, lumps or bumps?
GIT symptoms: Any acid brush, heart bum, tummy pain, loose motions or less motions, vomiting up blood or blood
in stool, yellow discoloration of the eye balls?
CNS symptoms: Altered speech, visual disturbance, muscle weakness, abnormal gait?
CVS symptoms: You asked about all before.
Musculoskeletal: Any skin rash, muscle pain, joint pain?
Sexual history: May i ask some personal questions... Are you sexually active? How many partners do you have?
Menstrual history: (If female patient) When was your last period , regular or irregular, amount of blood , how many
tampons the patient is using per day?
Hematology symptoms: You asked before.
Medical history: Of any medical history of long standing disease like DM, HTN, heart disease.
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Surgical history: Any history of surgical operation, dental procedure, needle sharing, tattooing, piercing,
recreational drug?
Family history: Of similar condition, long standing disease, heart disease or sudden death?
Drug list: You asked before.
Social history:
occupational health care worker if his work could be affected, and to a social worker if his social life could
affected.
Summary:
 Now I'm going to summarize the positive data in our discussion today:
 You had one attack of syncope today morning while running in the track, with complete loss of consciousness
for 4 to 5 minutes with no shaking or tongue biting of water work incontinence.
 You didn’t feel any abnormal sensation before the attack.
 You resumed your conscious completely after the attack without confusion ar headache or weakness.
 You have DM for 15 years for which you are receiving insulin and it seems that it is not controlled with your
last HBA1C is 10.5.
 You have hypertension for which you are receiving labetolol and Amlodipine which has been added recently.
 Do you want to add anything more?
 I appreciate your concern, we have to do full examination and investigations first to confirm our diagnosis
 Most probably your syncope is related to transient decreased of blood pressure because of:
 Antihypertensive medications you are receiving specially the newly added amlodipine recently.
 Or maybe as a result of long standing uncontrolled diabetes causing transient hypotension.
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 So what we are going to do is do some blood tests and heart tracing and imaging to your heart to rule out
other causes and what is called table tilt test to confirm our, diagnosis.
 We have to review you antihypertensive medications and exchange them with another safe medications, And
also to review your diabetic medications to strictly control your medications.
 Furthermore we are going to refer you to a MDT from internist, diabetic nurse, social worker to give you the
proper care and management plan.
 My diagnosis is orthostatic hypotension, Could be:
 Drug induced as side effect of Antihypertensive medications.
 Autonomic neuropathy of long standing uncontrolled DM.
 Cardiogenic syncope.
 Apart from basic investigations: CBC, RFT, LFT, Electrolytes.
 Specific investigations: ECG, Echocardiography, carotid Doppler ultrasound, 24H Fiolter, FIBA1C, Tilt
table test.
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Cases
Station 5
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About station 5 (Brief consultation)
 Station 5 includes 2 cases, every case is 10 minutes, 8 minutes with the patient and 2 minutes discussion
with the examiner.
 You are given 5 minutes before going inside to read and prepare both scenarios carefully.
 Structure of Station 5 is only Focused history, Focused Examination and replying the patient concerns.
Golden points in station 5
In these 5 minutes read and focus on the patient name, the surrogate name and your position in the hospital (For
identity).
Focus on every information given to you in the scenario: The main complain, medications of the patient, blood tests
and images results to narrow the differential diagnosis list.
Your focused history should be targeted for analysis of the main complain and for your differential diagnosis list or
systemic review related to the case and social history.
Don’t ask unnecessary questions not related to the diagnosis or differential diagnosis list, not to waste time.
Your examination should be targeted and related to your diagnosis or differential diagnosis list only, not to waste
time.
Don’t do unnecessary examination not related to the your diagnosis or the differential diagnosis list, not to waste
time.
Be dynamic, targeted, acting like a repot, to finish your case in a proper time.
Present your physical signs to the examiner in an organized and arranged pattern and don’t miss any positive finding.
Practice is the comer stone to pass paces. (Practice a lot on patients and with your colleagues even alone).
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Structure of Brief consultation (Station 5)
INTRODUCTION
 Shake hands.
 Confirm Agenda of meeting and take permission to start discussion.
 Ask open question can you tell me more about your condition please.
FOCUSED HISTORY
Analysis of the complaint avoiding jargons:
 Onset.
 Course.
 Duration.
 Progression.
 Improving factors.
 Worsening factors.
 Associated symptoms.
Ask about symptoms of your differential diagnosis list:

If you have 7 or 8 differential diagnosis, then you have to ask about symptoms of every differential diagnosis.
Or systemic review related to the case:

If the condition is clear in front of you by inspection, so just take history of the symptoms related to the case (No
need for differential diagnosis list hereji.e. (Acromegaly, Ankylosing spondilitis, Rheumatoid arthritis, Systemic
sclerosis, Vitiligo).
Social history:
 Patient job? How much his or her symptoms affect her or his job and usual daily activity? Refer the patient
to a social worker or occupational health care worker.
 Financial support.
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 Smoking and alcohol history.
Medical history: Of long standing disease like DM, HTN, heart disease, surgical operations?
N.B - Please don’t ask questions not needed in the case and not related to your differential diagnosis or not related
to the systemic review of the case, not to waste time.
FOCUSED EXAMINATION
 Examination should be focused, targeted and related only to your differential diagnosis or systemic review
related to the case.
CONCERNS
 Explain simply the diagnosis of the patient without jargons.
 Explain what you are going to do for the patient:
 Further blood tests and imaging for example without details and without mentioning the name of the
tests or imaging.
 Referral to a Multidisciplinary team from specialized doctors to give the proper care and management plan.
N.B: If you are not sure about your diagnosis , Talk in general (Your condition has differential diagnosis , so we
have to do for you some blood tests and imaging to conform our diagnosis then we will refer you to A
Multidisciplinary team to give you the proper care and management plan) - This is not to lose your concern.
- During the reply of your concern, be comprehensive; organized and informative, don’t give wrong or doubtful
information.
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Vitiligo
Scenarios
 Skin rash and fatigue.
 Skin rash and dizzy spells.
FOCUSED HISTORY
Analysis of the complaint (Skin rash):
 Onset: When this skin rash started exactly?
 Course: Suddenly or gradually?
 Duration: coming on and off or all the time with you?
 Progression: Is it increasing, decreasing or the same?
 May I have a look please: try to expose the patient and inspect the skin rash?
 Worsening factors - Ask it by name like trauma, stress, exposure to sun, smoking, alcohol, drugs?
 Improving factors-anything improve your condition like avoidance of what I mentioned or any drugs?
 Painful?
 Oozing?
 Blanchable?
 Itchy?
Associated Symptoms (other auto immune disease):
-Autoimmune emdocrinaS diseases:

 Hyperthyroid: Hot intolerance, anxiety, sweating, shaking of hands, racing of heart beats, loss of weight,
loose motions, increased appetite, what about your period, last period, regular or irregular, how much the
amount of blood coming out, how many tampons are you using per day?
 Hypothyroidism: Weight gain, cold intolerance, fatigue, constipation, low mood?
 Diabetes meilitus: History of DM, increased thirsty, increased appetite, increased water work frequency?
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 Addison: Loss of weight, tanned skin, tummy pain, feeling sick or getting sick, dizzy spells specially with
changing your position?
-Rtieumatologic autoimmune diseases;

 SLE: Butterfly rash on the face, hair falling, mouth sores, frothy urine, joint pain in the hands or other site?
 RA: Joint pain, cough, shortness of breath, fingers color changes in cold weather?
 Systemic sclerosis: Tight skin, difficulty of swallowing, fingers color changes in cold weather?
 Sjogren: Dry mouth, gritty sensation of the eyes?
Gastrointestinal autoimmune diseases;

 (PSC, PBS, autoimmune hepatitis, celiac): Tummy pain, yellowish discoloration of the eye balls, loose
motions.
 Pernicious anemia: Dizziness, fatigue, headache, burning sensation of hands?
 Alopecia areata: Falling of hair?
Social history:
 What are you doing for living? - How much the symptoms impact his job & usual daily activity? I am sorry
I will refer you to a social worker and to unoccupational health care worker to manage any social or job
troubles you have.
 With whom Patient is living? Who is supporting the patient at home?
 Smoking & alcohol history?
Medical history: Any history of long standing disease like DM, HTN, Cardiac problem, surgical operations?
Family history: Any family history of similar condition or long standing disease?
Drug history: What is your drug list please? Any over the counter medications? Any recreational drugs?
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FOCUSED EXAMINATION
Skin rash: Inspect the rash and its distribution.

Hands: Examine the hands for:
 Finger prick marks (DM).
 Polyarthropathy (RA, SLE).
 Pulse rate (Bradycardia in hypothyroidism, Tachycardia in Hyperthyroidism and Addison).
 Palmer creases for hyperpigmentation (Addison).
Month: Examine the oral mucosa for hyperpigmentation (Addison).
Eyes: Examine the conjunctiva for pallor (pernicious anemia) and sclera for jaundice (Autoimmune hepatitis, PSC,
PBS).
Abdomen: Examine for CLD signs, organomegaly (Auto immune hepatitis, PSC) (Ask the examiner).
Blood pressure: Ask the examiner (I would like to examine BP in supine and erect position) (Addison).
CONCERNS
What this skin rash could be doctor?
 This is what we call (vitiligo) .It is due to disturbance in your defensive system which supposed to attack
bugs and protect the body, in your condition the defensive system attacks the pigment layer in your skin
resulting in the milky whitish discoloration of your skin.
 What we are going to do further blood test to exclude other associated diseases and is to refer you to MDT
including skin physician, gland doctor (if associated Addison or Hypothyroidism) and psychiatrist to give
you the proper plan of treatment.
Regarding dizziness doctor, what it could be (if Addison)?
 Most probably you have disturbance in your defensive system which attacking many systems in your body
like the skin and one of the glands located above your kidneys leading to deficiency in one of the most
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Important hormone in the body called (cortisone) which lead to your symptoms of hypotension and dizzy spells, loss
of weight, tanned skin, getting sick and some electrolyte disturbance.
 So what we are going to do is to do some blood tests and if confirmed will refer you to a MDT including
skin physician, gland doctor and psychiatrist to give you the proper plan of treatment, which mainly will be
in the form of replacement therapy of cortisone.
 If our diagnosis is confirmed, you have to wear medic alert bracelet to make the others to know about your
condition at any emergency situation.
 Also you will have to carry one ampoule of cortisone to be given in emergency if neede.
Is it serious condition doctor (Addison)?

 I’m sorry it is serious if untreated, but it can be controlled if you will be completely compliant on your
medications and regular follow up.
What about complications of long term steroids Doctor (If Addison)?

 You are going to receive steroids as replacement therapy to normalize serum cortisone in your body, so that
you are not going to suffer from any side effects at all, may be some stomach soreness which can be managed
by simple oral medication.
Regarding dizziness doctor, anemia)?

 Most probably you have disturbance in your defensive system which is attacking many systems in your body
like the skin and lining of your stomach leading to destruction of the lining and malabsorbtion of the nutrients
like iron, vitamin B12, folic acid leading to anemia and dizziness.
What about exposure to sun doctor?

 Exposure to sun worsen your condition as this will darken the around healthy skin, so avoidance of sun
exposure and applying sun screen is advised.
My children could have the disease doctor?

 Although there is no fixed mode of inheritance for this disease, but the chance of your children to have the
disease is more than the others.
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Psoraisis
Scenario:
 Skin rash, known hypertensive on captopril and labetolol.
 Skin rash with recent diagnosis of HCV for Interferon alpha.
FOCUSED HISTORY

 Duration: Coming on and off or all the time with you?
 Worsening factors - Ask them by name like trauma, stress, exposure to sun, smoking, alcohol, drugs?
 Improving factors - anything improve your condition like avoidance of what all I mentioned or any drugs?
 Painful?
 Oozing?
 Blanchable?
 Itchy?
Systemic symptoms related to the case:

 Joints (Arthropathy): Any joint pain, back pain, nail changes?
 Eyes (Anterior uveitis): Any eye pain, eye redness, visual disturbance?
 Apical lung fibrosis: Any Cough, shortness of breath?
 Hyperurecemia: Any flank pain or water work gravels?
Social history:
 What are you doing for living? - How much your symptoms impact your job & usual daily activity? I am
really sorry, I will refer you to a social
191
Worker and to an occupational health care worker to manage any social or job troubles you have.
 Smoking & alcohol history (Smoking is triggering factor).
Medical history: Of long standing disease like DM, HTN, Cardiac problem or surgical operations?
Drug history: What is your drug list? (Very important for drug triggering Psoraisis)-(ACE Inhibitors, Beta
blockers, Interferon alpha, NSAIDS, Anti malarial, Lithium)
FOCUSED EXAMINATION
Skin rash: Inspect the rash and its distribution.
Hair line: For scalp Psoraisis.
Hands: Examine the hands for:

 Arthropathy
 Nail changes: nail pitting, transverse ridges, oncholysis, subangul hyperkeratosis.
Eyes: For redness of anterior uveitis.
Respiratory: Ausultate for apical fibrosis.
CVS: Auscultate for Aortic regurge, aortitis.
Different Types of psoriasis

 Plaque Psoriasis
 Guttate Psoriasis
 Inverse Psoriasis
 Pustular Psoriasis
 Erythrodermic Psoriasis
 Nail Psoriasis
 Psoriatic Arthritis
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CONCERNS
What it could be doctor?
 Most probably you have a condition called psoriasis. It’s due to disturbance in your defensive system which
normally supposed to defend the body against bugs, in your condition your defensive system is attacking
your skin causing such this skin eruption.
 What we are going to do is to do basic blood test and to take snip for the eruption to confirm our diagnosis,
then we will refer you to a skin doctor in outpatient clinic to give you the proper plan of treatment.
 Precipitating factors (very important to mention in the concern):
 At the time being you have to stop smoking as it is one of the triggering factors for your skin eruption,
we can help you in this issue by referring you to a smoking cessation clinic if you don’t mind, (if smoker)
 You have to stop drinking alcohol as it is one of the triggering factors as well, (if drinking alcohol)
 We have to exchange for you drugs (i.e. Beta blocker, ACE inhibitor, lithium, Antimalarials, NSAIDS,
Tetracycline) with another safe drugs as such drugs may trigger your skin eruption.
My bowel doctor prescribed to me a drug named interferon alpha for my hepatitis c. Is it ok Dr?
 Interferon alpha is one of the triggering drugs for psoriasis, in the same time it is very important treatment
for hepatitis c.
 So we will make multidisciplinary team from a gut doctor and a skin doctor to out weight the risk versus the
benefits of interferon alpha in your condition, and according to that the decision will be taken in the best
interest of your condition.
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Hereditary Hemorrhagic Telangectesia (HHT)
Scenario:
 Skin rash with fatigue or shortness of breath.
 Skin rash with low Hemoglobin.
 Recurrent epistaxis.
FOCUSED HISTORY

 Worsening factors - ask it by name like trauma, stress, exposure to sun, smoking, alcohol, drugs?
 Improving factors - anything improve your condition like avoidance of all I mentioned or any drugs?
 Painful?
 Oozing?
 Blanchable?
 Itchy?
Systemic symptoms related to the case
 NOSE (Recurrent epistaxis): Any history of nasal bleeding or bleeding from any other body orifices?
(Amount - color - how frequent).
 Pulmonary (AV Malformation): Any cough, coughing up blood, shortness of breath, noisy chest?
 CVS (anemic heart failure): Any SOB, chest pain, racing of heart beats, leg swelling?
 GIT (Telangectasia, AV Malformation, portal hypertension, hepatomegaly): Any history of tummy

pain, tummy swelling, feeling or
194
Gening sick, vomiting up blood, blood in the stool, yellow discoloration of eye balls?
 CNS (AV Malformation, Aneurism, paradoxical embolism). Any headache, LOC, seizures, weakness,
altered sensation, unsteady gait, uncontrolled water work and bowel habits?
 Inheritance: Any family history of similar condition, or recurrent nasal bleeding, or sudden death?
Social history:
 What are you doing for living? - How much the symptoms impact your job i usual daily activity? I am sorry
I will refer you to a social worker and to an occupan: ral health care worker to manage any social or job
troubles you have.
Medical history: .Any history of DM. HTN, Cardiac problem, surgical operations?
Family history: Was asked before.
Drug history: What is your drug list please?
EXAMINATION
 Skin rash: Inspect the rash and its distribution (telangectasia).

 Hands: For clubbing, Koilonechias.
 Eyes: For conjunctival pallor, Sclera for jaundice.
 Pulmonary: Auscultate for bruit (AV malformation)
 CVS: (Signs of heart failure):
 Pulse: reactive tachycardia.
 JVP.
 Bibasal lung fields auscultation for rales.
 LL for pitting oedema.
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 ABDOMEN:
 Signs of portal hypertension.
 Palpate for hepatomegaly.
 Auscultate for bruit of AV malformation.
 CNS: Ask the examiner (I would like to do full neurological examination] for the patient)- Mostly will not
allow you.
TABLE 1. Diagnostic Criteria for Hereditary Hemorrhagic Telangiectasia (HHT)
Criteria Definition
Epistaxis Spontaneous, recurrent nosebleeds
Telangiectasias Multiple at characteristic sites (lips, oral cavity, fingers, nose)
Visceral involvement Pulmonary, liver, cerebral, spinal or ga strain testi na I vascular
mal formations
Family history A first-degree relative with definite HHT
Diagnostic Criteria
Definite HHT Three or four criteria are present
Probable HHT Two criteria are present
HHT unlikely Only one criterion is present
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CONCERNS
What could be the cause of my fatigue doctor?
 Most probably you have fatigue due to sever anemia because of continuous blood loss.
 Most probably you have a condition called HHT it is a multisystem disease affecting the skin causing
dilatation of the superficial small blood conduit and skin rash, easy bleeding per nose, it may involve your
lungs, your gut, liver, your brain, it is a familial condition, it means that it runs in families.
 What we are going to do is to do blood tests, including CBC to know how much your anemia is, and some
imaging to check for any other systemic involvement.
 Then we will refer you to a multidisciplinary team including genetic doctor, internist, Lung physician, gut
physician and may be brain doctor to give you the proper plan of management.
What will be the treatment doctor?
 May be blood transfusion, or iron injection through a needle according to your HB level, then you can
continue on oral tablets of iron, with regular fellow up with the multidisciplinary team.
Would my children have the same disease doctor?
 Unfortunately the chance of your son to have the disease is 50% for each we can refer you all to genetic
counseling team for screening for the disease to start early treatment and fellow up.
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Pemphigus
Scenario:
 Skin rash and fatigue.
 Skin rash and double vision.
 Chronic mouth ulcer.
FOCUED HISTORY
 May I have a look please: Try to expose the patient and explore the skin rash?
 Worsening factors - ask it by name like trauma, stress, exposure to suit, smoking, alcohol, drugs?
 Improving factors - anything improve your condition like avoidance of what I mentioned or any drugs?
 How was this skin rash when started? Was it like sacs filled with fluid? W. it easy to rupture or difficult to
rupture?
 Painful?
 Oozing?
 Blanchable?
 Itchy?
Associated Symptoms (other auto immune disease):
- Autoimmune endocrinal diseases
 Myasthenia gravis: Any fatigue at the end of the day, double vision, dropping of the eye lid, muscle weakness
(difficulty of combing your hair or raising up from a chair)?
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 Hyperthyroid: Hot intolerance, anxiety, sweating, shaking of hands, increased appetite racing of heart beats,
loss of weight, loose motions, increased appetite, what about your period, last period, regular or irregular,
how much the amount of blood coming out, how many tampons are you using per day?
 Hypothyroadism: Weight gain, cold intolerance, fatigue, constipation?

 Diabetes mellitus: Hx of DM, increased thirsty, increased appetite, increased urine frequency?
 Addison: loss of weight, tanned skin, tummy pain, feeling sick or vomiting, dizzy spells specially with
changing your position?
-Rheumatologic autoimmune diseases
 SLE: Butterfly rash on the face, hair falling, mouth sores, frothy urine, joint pian in the hands or other site?
 RA: Joint pain cough, shortness of breath, fingers color changes in cold
 Systemic sclerosis SS: Tight skin, difficulty of swallowing, fingers color changes in cold weather?
 Sjogren: Dry mouth, gritty sensation of the eyes?
-Gastrointestinal autoimmune diseases
 (PSC, PiSb, autoimmune hepatitis, celiac): Any tummy pain, yellowish discoloration of the eye ball, loose
motions?
 Pernicious anemia: Any dizziness, fatigue, headache, burning sensation of hands?
 Alopecia areata: Any falling of hair?
Social history:
 What are you doing for living? - How much the symptoms impact his job & usual daily activity? I am I will
refer you to a social worker and occupational health care worker to manage any social or job troubles
 You have.
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(Very important for drug precipitating pemphigus.ie. Penicillamine, penicilla cephalosporins, ACE inhibitors,
NSAIDS, Aspirin, nifidipine, phenobarbitone)
FOCUSED EXAMINATION
 Skin rash: Inspect the skin rash and its distribution.
 Mouth: Examine the oral mucosa for ulcers.
 Associated autoimmune diseases:
 Hands: Examine the hands for:
 Finger prick marks (DM).

 Polyarthropathy (RA, SLE).
 Pulse rate (bradycardia in hypothyroidism, tachycardia in Hyperthyroidism and Addison).
 Palmer creases for hyperpigmentation (Addison).
 Eyes:
 Examine the conjunctiva for pallor (pernicious anemia) and sclerJ for jaundice (Autoimmune hepatitis, PSC,
PBS)
 For eye drop.
 Eye movement: by your index finger H shaped movement.for double vision.
 Abdomen: Examine for CLD signs, organomegaly (Auto immune hepatitis, PSC) - (Ask the examiner)
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Pemphigus
Bullous Pemphigoid Pemphigus Vulgaris
tends to affect elderly Tends to affect those older than 50
antibodies against hemidesmonal proteins antibodies against desmoglein
tense, sub-epidermal blisters flaccid blisters
mouth usually sparred mouth involved in 50-70%
IgG and C3 at dermoepidermal junction IgG throughout epidermis
Treatment: oral corticosteroids Treatment: oral steroids, immunosupression
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CONCERNS
What this skin rash could be doctor?
 Most probably you have a condition called (Pemphigus). It is due to disturbance in your defensive system
which supposed to attack the bugs an protect the body, in your condition the defensive system attacks your
skin resulting in such skin rash.
 What we are going to is to do further blood tests and may be to take a skin snip to confirm our diagnosis.
 Then we will refer you to a MDT including skin physician, social worker, occupational health care worker,
and psychotherapist to give you the prop;- plan of management.
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Neurofibromatosis
Scenarios:
 Skin rash and diminution of hearing.
FOCUSED HISTORY
 Onset: when this skin rash started exactly?

 May I have a look please: Try to expose the patient and inspect the skin?
Rash? Any rash in your arm pits or groin (axillary and inguinal freckling)
 Worsening factors - Ask them by name like trauma, stress, exposure to
Sun, smoking, alcohol, drugs?
 Improving factors - Anything improve your condition like avoidance of
What all i mentioned or any drugs?
 Painful? Oozing?
 Blanchable?
 Itchy?
- Ocular symptoms (optic glioma, retinal hamartoma, lich nodules):

Any eye pain or redness, diminution of vision, double vision, painful eye movement?
- Neurological syiraptopras (acoustic neuroma, brain aneurism, spinal cord AVmalformation):

Any diminution of hearing, mouth angle deviation, dripping of saliva, impaired facial sensation any headache, LOC,
seizures (jerky movements), weakness, altered sensation, unsteady gait, uncontrolled water work or bowel habits,
educational difficulties, behavioral changes.
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- Pulmonary symptoms: (lung fibrosis, pneumothorax): Any chest pai cough, phlegm, SOB?
- Cardiovascular symptoms:
(Restrictive cardiomyopathy, PA stenosis): Any chest pain, racing of heart beats, SOB, leg swelling
(Phaeochromcytoma, Renal artery stenosis): Any high blood pressure, is controlled or not?
- Gastrointestinal symptoms: (Carcinoid tumors): Any tummy pain or bloating, feeling sick or getting sick,
altered motions, flushing?
- Musculoskeletal symptoms: (kyphoscoliosis, sphenoid dysplasia, bowing of long bones, scoliosis): Any
joint pain, back pain, bone deformity:
- Family history: Of similar problem or medical disease (Autosomal dominance).
Social history:
 What are you doing for living? - How much the symptoms impact your j and usual daily activity? I am sorry
I will refer you to a social worker anc occupational health worker to solve any social or job troubles you
haye.
 With whom Patient is living? Who is supporting the patient at home?'
FOCUSED EXAMINATION
Skin rash: Explore the skin rash all over the body, axillary and inguinal freckling.
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CNS Examination: Check for nerve palsies related to acoustic neuroma:
 Hearing aid, Weber and rinne test (CN8).

 Facial sensation in temporal, maxillary, mandibular area (CN5).
 Smiling for mouth angle deviation, closing the eyes against resistance (CN7).
Chest Examination: (Pneumothorax): Auscultation of bilateral mid clavicular line for lung fibrosis.
CVS Examination (Cardiac rabdomyloma):
 For raised JVP.

 Auscultation for any murmurs.
 LL for edema.
 BP for high blood pressure (Ask the examiner)
CONCERNS
What doctor could be the cause of my skin rash and diminution of hearing?
 Most probably you have a condition called Neurofibromatosis, which is a familial condition which runs in
families. It is a multisystem disease involving your skin, your brain, your lungs, your heart, your kidneys
and may be your bones.
 We are going to do for you further blood tests, imaging to check for any systemic involvement.
 Then we will refer you to a MDT including skin physician, brain doctor, genetic doctor, psychiatrist, social
worker, to give you the proper care and mamgemtYA p\m.
This skin eruption is embarrassing me a lot doctor, do you have any solution for it?
 We will refer you to a MDT from skin physician and plastic surgeon for cosmetic management of your skin
eruption.
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Table 1. Diagnostic Criteria for Neurofibromatosis Type 1 Per National Institutes of Health*
Two of the following conditions must be met:
1. Six or more cafe-au-lait macules >5 mm in diameter in pre-pubertal individuals and > 15 mm in diameter in
post-pubertal individuals; on each lesion, the longest diameter is measured.
2. Two or more neurofibromas of any type or one plexifomi neurofibroma.
3. Freckling in the axillary or inguinal regions.
4. Optic glioma.
5. Two or more Lisch nodules (iris hamartoma).
6. A distinctive bony lesion such as sphenoid dysplasia or thinning of the long bone cortex writh or without
pseudoarthrosis.
7. A first-degree relative (parent, sibling, or offspring) with neurofibromatosis tyrpe 1 based on the above criteria.
* National Institutes of Health, 1988; Femer etal. 2007; Jett and Friedman, 2010.
Table 1
Diagnostic Criteria of Neurofibromatosis Type 2
 Bilateral vestibular schwannomas (VS) OR family history of NF-2 1 unilateral VS
OR
 Any 2: meningioma, glioma, neurofibroma, schwannoma, or posterior subcapsular lenticular opacities
Additional criteria
 Unilateral VS 1 any 2: meningioma, glioma, neurofibroma, schwannoma, or posterior subcapsular opacities
OR
 Multiple meningioma (>2) 1 unilateral VS OR any 2: glioma, neurofibroma, schwannoma, or cataract
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Chronic Mouth Ulcer
Differential Diagnosis:
 Traumatic.
 Infection: herpes simplex, candidiasis, syphilis, HIV.
 Malignancy.
 Pemphigus.
 Behcet disease.
 GIT disease: IBD - celiac.
 SLE, Seronegative arthritis
 Immunodeficiency: hereditary, acquired (fungal infection).
 Drug induced i.e. Alendronate, NSAIDS, Propylthiouracil, methotrexate, Chemptherapy.
FOCUSED HISTORY
 Onset: when this mouth sores started exactly?

 Progression: is it increasing, decreasing or the same?
 Painful or painless, any painful swallowing?
 Worsening factors - ask it by name like trauma, any drugs, smoking? Improving factors - anything improve
your condition like any dmgs?
Symptoms of Differential diagnosis list:
Trauma: Any biting of your cheek, lip or tongue, Sharp or broken tooth?
Malignancy: Any loss of weight, high temperature', sweating, lumps or bombs?
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Behcet disease: Any sores down below, eye pain or redness, skin rash, joint pain, chest pain, blood clot?
Pemphigus symptoms: any historyof skin eruption, if there do analysis and detailed history of the eruption?
GET causes (Celiac, IBD): Any tummy pain, loose motions after specific type of food containing gluten, feeling
or getting sick, sores in private areas down below?
SLE: any small joint pain in both hands, butterfly rash, hair falling, frothy urine?
Seronegative arthritis: any eye pain or redness (conjunctivitis), burning water work (urethritis), joint pain, back
pain (arthritis)?
HIV risk factors: Hx of surgical operation, blood transfusion, dental procedure, tattooing, piercing, sharing needles,
travelling abroad, are you sexually active, how many partners do you have?
Drug list: what is your drug list, for any drug induced mouth ulcers i.e.' steroid therapy, Alendronate, NSAIDS,
Propylthiouracil, methotrexate, chemptherapy.
Social history:
 What are you doing for living? - How much the symptoms impact your job & usual daily activity? I am sorry
I will refer you to a social worker to soh: any social or work troubles?
Medical history: Of long standing disease like DM, HTN, Cardiac disease, surgical operations?
Family history: Of Similar condition or long standing disease?
Drug history: Mostly you will find the patient on steroids for long time (Fo- pemphigus)
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FOCUSED EXAMINATION
I would like to see the observation chart for vital signs.
Body examination:
 For any skin rash.

 Trunacal obesity, stria Alba and rubra (complication of steroids).
 Thin skin and bruises (complication of steroids).
Head examination:
 Examine the oral cavity and pharynx by torch for ulcers.

 Examine the face for butterfly rash of SLE
 Examine the eyes for anterior uveitis, ulcers, bullae.
 Abnormal hair growth, Acne valgaris (complication of steroids)
Hand examination:
 For polyarthropathy (associated SLE, RA).

 Thin skin and bruises (complication of steroids).
Ask the examiner to examine the genitalia for ulcers (Behcet).
Ask the examiner for abdominal examination for IBD, CELIAC.
CONCERNS
What could be the cause of my mouth sores doctors?

 I appreciate your concern, most probably these mouth sores is related to a condition called Pemphigus
valguris.
 A condition due to disturbance of your defensive system which supposed to attack the bugs and viruses, in
your condition it attacks your skin and the lining of your oral cavity causing such soreness.
 So what we are going to do is to do further blood tests and may be a snip from the lesion to be examined
under microscope to reach a definitive diagnosis.
 If confirmed we are going to refer you to a MDT including skin doctor, social worker, occupational health
worker, psychotherapist to give you the proper care and management plan.
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Tuberous Sclerosis
Scenario: Skin rash and Seizures
FOCUSED HISTORY

 Onset: when this skin rash started exactly?
 Worsening factors - Ask them by name like trauma, stress, exposure to sun, smoking, alcohol, drugs?
 Improving factors - Anything improve your condition like avoidance of what all i mentioned or any drugs?
 Painful?
 Oozing?
 Blanchable?
 Itchy?
-CNS symptoms (Tubers in the brain - Obstructive hydrocephalus, mental retardation in 50%, seizures in 75%):
Any history of headache, Loss of consciousness, shaking of the body, educational troubles, visual disturbance,
altered speech weakness, altered sensation , unsteady gait uncontrolled water work or bowel motions?
– Ocular symptoms (Retinal hamartoma, Phacomata, angoifibromata of the eyelids):

Any eye pain, visual disturbance?
- Oral symptoms (Gingival hamartoma, high arched paiate, bifid uvula):

Any teeth or mouth cavity abnormality?
- Pulmonary symptoms (Lung cysts, lymphangioleomyomatosis):

Any chest pain, cough, phlegm, shortness of breath?
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– CardiovascmSar symptoms (Restrictive cardiac rhabdomyoma):
Any chest pain, racing of heart beats, SOB, leg swelling?
– Gastrointestinal symptoms (Hamartoma, polyposis):

Any tummy, feeling sick or getting sick, altered bowel motions, bloody stool, yellow discoloration of eye
balls?
– Renal symptoms (Renal hamartomas, angiomyolipomas, cysts):

Any change in water work amount, color, frequency, frothy urine?
– Musculoskeletal symptoms (Bone cysts, sclerotic lesions):

Any history of bone pain or fractures?
– Family history: Of similar problem or medical disease (Autosomal dominance).
– Driving: Do you drive? You have to inform DVLA about your condition to assess your condition, as driving
may be risky for you and for the others.
Social history:
 What are you doing for living? - How much your symptoms impact your job & usual daily activity? I am
sorry I will refer you to a social worker and an occupational health care worker to solve any social or work
troubles you have.
 Do you have sisters and brothers? Do have children? Are they doing well? We can offer your family members
to be referred to the genetic counseling team for screening for early proper management.
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FOCUSED EXAMINATION
Skin rash: Explore the skin rash all over the body
 Adenoma sebaceum in the face (salamon colred papules and nodules in butterfly distribution involving
nasolabial fold).
 Shagreen patches (irregular shaped green-brown thickened plaques the lumbosacral region).
 Ash leaf macules (hypopigmented macules over the trunk and buttocks).
 Cafe-au-laite spots: multibe irregular pigmented macules).
 Periungual fibroma: Smooth form nodular lesions adjacent to the nails).
Eye Examination: Ask the examiner for fundus examination.
CNS Examination: Ask the examiner
 Tone, power, reflex, coordination, sensation

 Cranial nerve examination
 IQ assessment.
Chest Examination (Pneumothorax): Auscultation of bilateral mid clavicular line.
CVS Examination (Cardiac rabdomyloma):

 For raised JVP.
 Auscultation for any murmurs.
 LL for edema.
CONCERNS
What could be the cause of my skin eruption and seizures doctor?
 Most probably you have a disease called Tuberous sclerosis.

 It is a familiar condition with nms in families due to some gene abnormality, involving many systems in
your body like the skin. The brain, the heart, the lungs and may be the kidneys.
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 So what we are going to do is to do genetic test and other blood tests and imaging to confirm our diagnosis
and complications of the disease.
 Then if conformed we will refer you to a MDT from a skin physician , nerve doctor, psychiatrist, social
worker, occupational health care doctor to give you the proper care and management plan.
System Findings
Neurologic (50%)  Cortical tubers

 Subependymal giant cell astrocytomas
 Seizures and mental retardation
Dermatological (70%)  Angiofibromas in a malar distribution on the face
 Hypomelanotic macules
 Non-traumatic unguai/periungual fibromas
 Shagreen patches and cafd-au-lait macules
Cardiac (30%)  Intramural rhabdomyomas
Renal  Angiomyolipomas
 Polycystic kidneys
 Renal cell carcinoma
Oral  Fibrous plaques on the anterior gingiva
manifestations  Enamel hypoplasia
 Cystic hyperostosis
 Palatal anomalies
 Bifid uvula, cleft lip and palate
 Hemangioma, macrogiossia
 Delayed eruption
 Diastema between the maxillary canine and lateral incisor
 Multiple osteomas
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Acromegaly
Scenario:
 Headache and visual disturbance.
 Pain in both hands (Carpal tunnel).
 Fatigue and Headache (OSA).
FOCUSED HISTORY
Analysis of the complaint (Headache and visual disturbance):

 Onset: When this headache started exactly?
 Site, character, radiation, timing, grade (0-10).
 Worsening factors - like stress, coughing, sneezing, straining.
 Improving factors - Like rest or any pain killers.
 What about your visual disturbance (Onset, course, progression)
 Do you see the wall of the room or the sides of the road when looking straight forward (For bitemporal
hemianopia?)
Systemic symptoms related to the Acromegaly:
Hamids:
 Any pain in your hands (Carpal tunnel) -If there is do analysis of the pain (Site, character, grade, radiation,
timing, improving and relieving factors)
 Any change in your ring size or shoes size?
Arms: Any difficulty of combing your hair or raising up from a chair (Proximal myopathy).
Head: Anyone noticed change in your facial ieatures, do you have UN old photo of you? - Any problem in the
private relationship (Impotence, loss of lipido).
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Neck:
 Any skin abnormality, tanned skin, neck lump in your neck (skin tags, Acanthosis nigricans, thyroid
swelling)?
 Any snoring during sleeping or day time sleepiness and headache (OSA)?
CVS: Any chest pain, racing of heart beats, shortness of breath, leg swelling (Cardiomyopathy).
GIT: Any tummy pain or loose motions, blood in the stool (Colorectal cancer)?
Musculoskeletal: Any joint pain (Pseudo gout, osteoarthritis)?
DM, HTN: Any history of diabetes, high glucose level, increased thirsty or water work frequency? Any history of
hypertension, did you check your blood pressure before?
MEN1;
 Any heart bum or acid bmsh (Gastrinoma)?
 Any dizzy spells, sweating, LOC (Insulinoma)?
 Any constipation, increased thirsty, water work frequency, low mood (Hypercalcemia of
hyperparathyroidism)?
Driving: Do you drive? You have to inform DVLA about your condition as driving my endanger your life and lives
of the others.
Social history:
I will refer you to a social worker and to an occupational health care worker to solve any social or work
troubles you have.
Medical history: Of long standing disease like DM, HNT, heart problems.
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FOCUSED EXAMINATION
 Start to examine the main complaint first:

 If visual  Start with eye examination.
 If hand pain Start with hand for carpal tunnel.
- Visual examination:
 Visual acuity by counting fingers.
 Eye movement for double vision.
 Visual field for bitemporal hemianopia.
 Fundoscopy for optic atrophy (Ask the examiner)
-Hands examination:
 Inspection: Spade like- sweating - pulse rate.
 For carpal tunnel (if there is positive history of pain in the hands):
 Inspection for wasting of the thenar eminence.
 Motor power for muscles innervated by median (LOAF muscles)
 Nerve.
 Sensation of distribution of median nerve
 Phalen’s test: Reversed prayer sign for 10 seconds induce electric like sensation in median nerve
distribution (take permission from the examiner).
 Tinel test: Palpation on the volar aspect of the hands induce electric like sensation (Take permission from
the examiner).
– Upper limbs: Arms against resistance (Proximal myopathy).
– Head:
 Prominent supraorbital ridges - enlarged nose, lips, tongue and ears prognansithm - interdental separation.
 Neck: inspect for skin tags or thyroid swelling.
– Cardiovascular: signs of heart failure (Cardiomyopathy):
 Raised JVP.
 Auscultate bases of lung fields for crepitations.
 Examine LL for pitting edema.
 Blood pressure (ask the examiner).
- Abdominal examination: Ask the examiner (For colorectal cancer).
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CONCERNS
What may be the cause for my visual disturbance doctor?

 Most probably you have a condition called Acromegaly in which there is enlargement of the maestro gland
in your head, secreting excessive protein called growth hormone causing your coarse fissures, visual
disturbance, compression on the nerve cable of the back of your eyes causing this visual disturbance.
 What we are going to do is to do further blood tests and imaging of your brain to confirm our diagnosis.
 lf the diagnosis is confirmed, we will refer you to a MDT from a gland doctor, brain surgeon, social worker
to give you the proper plan of management.
What may be the cause for my hands pain doctor?
 Most probably you have a condition called Acromegaly in which there is enlargement of the maestro gland
in your head, secreting excessive protein called growth hormone causing your coarse fissures, visual
disturbance, compression on special nerve cable in your arms causing such pain in your hands.
 What we are going to do is to do further blood tests and imaging of your brain to confirm our diagnosis and
a special test called (Nerve conduction study) to check the nerve work in your upper limbs.
 If the diagnosis is confirmed, we will refer you to a MDT from a gland doctor and nerve doctor to give you
the proper plan of management.
The LOAF muscles (an acronym for the following)

 Lateral 2 lumbncal
 Opponens Pollids
 Abductor PolIcis Brevis
 Flexor Pollcis Brevis
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Addison Disease (Hyperpigmentation)
Scenario:
 Loss of weight.
 Dizzy spells with electrolyte disturbance.
 Hyperpigmentation.
Differential diagnosis (Hyperpigmentation):
 Racial - Familial.
 Addison.
 Nilson's syndrome.
 ACTH secreting Cushing disease.
 Heamochromatosis (primary, secondary).
 Thalasemia (Repeated blood transfusion).
 Porphyria catunia tarda.
 CLD - CKD.
 Drug induced i.e Amiodarone.
FOCUSED HISTORY
Analysis of the complaint (Hyperpigmentation)
 Onset: When this tanned skin started exactly?
 Worsening factors - like exposure to sun?
 Improving factors.
Ask about Differential diagnosis:
- CLD: Any live disease, history of tummy pain, tummy swelling, yellowish discoloration of the eye balls?
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- CKD: Any history of kidney problem, change in water work amount, color, frequency.
- Haemochrmniatosls: Any history of DM, SOB, leg swelling, joint pain, blood transfusion, loss of sexual
desire?
- ACTH secreting Cushing: Any history of weight gain, stretch marks, abnormal hair growth, difficulty
combing your hair or getting up from a chair (proximal myopathy), back pain (osteopenia), disturbed periods?
- Porphyria cmfteamea tarda: Any history of skin rash, itching?
Nilson: Any history of surgical operations or gland removal?
Addison:
 Any history of loss of weight - how much kg - for how long - intended or Not - what about appetite?
 Any history of dizzy spells when getting up from supine or setting position (Postural hypotension)
 Tummy pain, feeling sick or getting sick?
 Tanning of the lining of oral cavity, tanning of scars.
 History of TB, or contact with TB patient.
 SOB, cough, coughing up blood (TB lung)
 Associated autoimmune disease: DM, celiac disease (tummy pain, loose motions), areas of hair lost
(Alopecia) joint pain of the hands (RA), Falling of hair, mouth sores, frothy urine (SLE)
Social history:
I will refer you to a social worker and occupational health care worker to manage any social or job troubles
you have.
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Family history: Of Similar condition or long standing disease?
Drug history: What is your drug list? Any heart medication to control your heart rate (Amiodaron)
FOCUSED EXAMINATION
Vital signs: I would like to see the observation chart of the patient for Vital signs.
 Hyper pigmented creases and scars

 Pulse rate for reactive tachycardia.
Oral cavity: By torch for hyperpigmentaion.
Adremlectainniy scars: Look to the back for any scars indicating adrenelectomy (Nilson).
Postural hypotension: Ask the examiner i would like to check the patient BP in supine and erect position.
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CONCERNS
What could be the cause doctor (otherwise weigh loss, hyperpigmentation, dizzy spell?
 Most probably you have a condition called Addison disease, problem in the glands located above your kidney
not secreting a special protein called cortisone in a proper amount, which may cause your tanned skin like
your condition, dizzy spells due droop of the blood pressure, loss of weight, feeling sick or getting sick.
 What we are going to do is to admit you, do further blood tests to check your cortisone level and do one test
called Synactin test to confirm our diagnosis and
 If confirmed we will refer you to a gland doctor to give you the proper plan of treatment in the form of
replacement therapy of cortisone.
 I’m sorry it is serious if untreated. But it can be controlled if you received the proper treatment, you have to
put Medic alert bracelet and to keep cortisone ampoule with you to receive it in emergency situation.
WTiat about complications of steroids doctor?
 You are going to receive steroids as a replacement therapy to normalize steroid level in your blood, so that
you are not going to suffer from such complications, may be some stomach soreness which can be managed
by simple medications.
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Cushing Syndrome (Weight gain)
Scenario:
 Weight gain.
 Ecchymosis.
 Young patient with high BP.
 Fatigue, headache, daytime somnolence (OSA).
Differential diagnosis (Weight gain):
Endocrinal causes:
 Hypothyroidism.
 Cushing syndrome.
 DM.
 Insulinoma.
 Polycystic ovary syndrome.
 Hypothalamic insufficiency.
Causes due to salt and water retention

 CLD.
 CKD.
 Nephrotic syndrome.
 Congestive heart failure.
 Hypoalbuminaemia (Nutritional and malabsorbtion, Nephrotic).
 Drug induced: Steroids, NSAIDS, Anti epileptics, Anti Psychotics.
FOCUSED HISTORY
Analysis of the complain (Weight gain):
 Onset: when this weight gain started exactly?

 Is intended or not, what about your appetite?
 Where do you put weight exactly, all over the body or on certain parts like trunk and neck?
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Symptoms of Differential diagnosis list of weight gain:
- Hypothyroidism: Cold intolerance, fatigue, constipation, low mood, irregular period, excessive blood in periods,
how many tampons is using per day?
- DM: History of high glucose level, increased appetite, increased thirsty and water work frequency?
- Insulinoma: Fainting attacks, sweating, low glucose level measured before?
- Cushing disease:
 The last period, period irregularity, how much blood coming out?
 Any thin skin, stretch marks, acne, hair growth in abnormal sites, tanned skin, mouth sores?
 Any bad mood?
 Any back pain or joint pain (Ostopenia)?
 Difficulty of combing hair or raising up from a chair? (P roximal myopathy).
 Any headache, snoring during sleeping, disturbed sleep, day time somnolence and fatigue (Obstructive sleep
apnea)?
 Any history of DM, HPN - Did you check your glucose level or BP before controlled or not?
 Any drug intake like steroids? (Factitious Cushing).
- Congestive heart failure: Any chest pain, SOB, difficulty of breathing with exertion or laying down, awaken you
from sleeping searching for air, leg swelling.
- CLD: Tummy pain, tummy swelling, yellow discoloration of eye balls? -Nephrotic syndrome: Change in water
work amount, color, frothy urine, morning puffy eye lids?
Social history:
for that, I will refer you to a social worker and occupational health care worker to manage any social or work
troubles you have.
Medical history: Any long standing disease like DM, HTN, Cardiac problem, surgical operations?
Drug history: What is your drug list?
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FOCUSED EXAMINATION
- General examination:
 Truncal obesity.
 Supra clavicular and intrascapular fat deposition.
 Stria Alba and rubra, steroid purpra due to easy bruising.
- Upper limbs:
 Hands: For thin skin, bruises, pin prick marks for DM.
 Arms against resistance: for proximal myopathy.
-Face:
 Round and plethoric face, acne, hirsutism.
 Buccal mucosa for fungal infection.
- Back palpation: Palpate the back for tenderness (osteopenia).

- Blood pressure: Ask the examiner i would like to measure BP and urine dipstick for glycosurea.
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CONCERNS
What could be the cause of my weight gain doctor?
 Most probably you have a condition called Cushing syndrome. A condition due to excessive secretion of a
specific protein called steroid secreted from the gland located above your kidneys.
 Excessive secretion of this hormone leads to complications to many systems in your body like weight gain,
abnormal hair growth, thin skin and eruption, high blood pressure, high glucose level, muscle weakness,
fragile bones and low mood and irregular periods.
 So we are going to do some blood tests and imaging to confirm our diagnosis.
 If confirmed we will refer you to a gland doctor to give you the proper plan of management.
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Neek lump (Graves’ disease)
Scenario:
 Neck lump.
 Neck lump and shortness of breath (Thyrotoxic cardiomypathy).
 Neck lump and visual disturbance.
Differential diagnosis
 Lymphadenopathy.
 Graves.
 Solitary nodule.
 Multinodular goiter.
 Thyroid cancer.
FOCUSED HISTORY
 Onset: When this lump started exactly?
 Is it painful at all?
 Any associated lumps or bumps in the body, in arm pits or groin? (Lymphoma)
 Any associated high temperature, fatigue, itching, loss of weight (How much, for how long, intended or not,
what about appetite) (For lymphoma)
Systemic review related to the case (Graves' disease):
Since you confinned it is a case of Graves' disease not lymphoma by the patie general look and history start your
systemic review of Graves':
- Compressiom symptoms:
 SOB, difficulty of breathing (Could be due to thyrotoxic cardiomypathy)
 Change in voice character
 Difficulty of swallowing.
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Hyperthyroid symptoms:
 Hot intolerance.
 Loss of weight.
 Increased appetite.
 Racing of heart beats.
 Shaking of the hands.
 Recurrent sweating.
 Loose motions.
 Period abnormalities (last period, regularity, amount of blood, how many tampons per day)
- Hypothyroid symptoms: (Post radiation) - If no hyperthyroid symptoms:

 Weight gain Cold intolerance.
 Constipation.
 Low mood.
 Period abnormalities (Asked before).
 N.B: Graves' disease can by Euthyroid if under treatment.
- Visual disturbance: Any eye pain, redness, double vision painful eye movement? (Grave’s ophthalmopathy).
- CVS: (For thtrotoxic cardiomypathy): Any chest pain, cough, SOB, leg swelling
Social history:
you have.
Medical history: Of long standing disease like DM, HTN, Cardiac problem, surgical operations?
Family history: Similar condition or long standing disease?
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FOCUSED EXAMINATION
Neck:
 Inspection for neck lump, neck scar.
 Inspection for Movement of the lump with swallowing a sip of water.
Eye:
 Inspection of the eye: For exophthalmus (rim of sclera above the Lowe eye lid) - Lid retraction (rim of sclera
below the upper eye lid).
 Eye movement:
 By Cross + finger movement and ask the patient when you see double vision just tell me (diplopia of
vision)
 By Crescent backward ©finger movement for lid lag (a rim o: sclera seen below the upper eye lid with
the eye ball moving downwards (Lid lag)
 Fundoscopy: Ask the examiner (For optic nerve atrophy due to compression).
Hand examination:
 For sweating.
 Palmer erythema.
 Tremors.
 Clubbing (thyroid acropachy).
 Pulse rate and rythm.
Arms: Power against resistance for proximal myopathy.
Inspect laterally: For eye protrusion.
From behind:
 Palpate the lump-Then palpate with swallowing (for movement with swallowing).
 Palpate for lymph nodes (anterior auricular, posterior auricular, submandibular, supraclavicular, cervical,
occipital.
Percussion: Of upper sternum for retrosternal extention.
Auscultation:
 Of the mass for bruit.
 Lung fields for crackles (Cardiomypathy).
LL examination: For pretibial myxoedema - Pitting edema.
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CONCERNS
What could this lump be doctor?

 If hyperthyroid...Most probably you have enlarged hyperactive gland called thyroid gland which located in
front of your neck... This gland is responsible for the activity of all body systems.
 What we are going to do is to do blood tests including thyroid function test and imaging of the gland to
confirm our diagnosis and we will arrange another appointment to discuss the results.
231
 Then will refer you to a gland doctor to decide for you the proper plan of treatment.
 If hypothyroid... Most probably you have enlarged hypoactive gland called thyroid gland which located in
front of your neck... This gland is responsil for the activity of all body systems.
 What we going to do is to do blood tests including thyroid function test an imaging of the gland to confirm
our diagnosis and we will arrange another appointment to discuss the results and we will refer you to a gland
doctor l decide for you the proper plan of treatment.
Is it serious condition doctor (hypo or hyperthyroid)?
 I’m sorry it is serious if not treated, but it can be controlled if you receive the proper treatment and regular
fellow up.
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Obstructive sleep Apnea (Hypothyroidism)
Scenario: Mrs. Mai is 35 years old has been complaining of fatigue, morning headache and day time somnolence for
the last 2 months for your kind care.
Catases:
 Simple obesity.
 Acromegaly.
 Hypothyroidism.
 Cushing syndrome.
 Alcohol and Smoking.
 Aggravating drugs (sedative, narcotics).
 Family history.
FOCUSED HISTORY

Onset, course, duration, progression, worsening and improving factors:
 When this fatigue and headache started exactly?
 Suddenly or gradually? Is it increasing, decreasing or the same? Coming on and off or all the time?
 Site: Where is the headache exactly, in one side or all over the head?
 Time: Is it more at morning, midday or night?
 Intensity: What is the grade of your headache from 0 to 10?
 Character: Is it dull aching, throbbing, pulsating or sharp headache?
 Radiation: Does it radiates to anywhere else?
 Did you notice anything increase this headache like leaning forward, sneezing, coughing, straining, strong
flashes or voices?
 Did you notice anything improve this headache like any pain killers?
 Any history of sleep disturbance, snoring during sleeping, day time sleepiness?
Analysis of symptoms of underlying causes:
Simple obesity: Any history of weight gain, how much KG, for how long? Intended or not, what about appetite where
did you put weight, all over the body or certain area like your trunk and neck?
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Hypothyroidism : Any history of cold intolerance, dry skin, constipation, low mood, muscle weakness , difficulty of
combing your hair or getting up from a chair, period disturbance, when was the last period, how much the amount of
blood, how many tampons are you using per day?
Acromegaly: Any change of your facial features, change in your ring size or shoes size?
Cushing: Any stretch marks, thin skin (Linea alba and rubra), bleeding under skin (Echemosis), abnormal hair growth
(Acne valguris), mouth sores Joint pain or back pain (Osteopenia), high blood pressure, high glucose level, increase thirsty
or water work frequency?
Alcohol and smoking: Do you drink alcohol (How many unites per day or week and for how long), Do you smoke
(How many cigarette per day and for how long)?
Aggravating drugs: Are you receiving any sleep pills, pain killer medications, cortisone, medications to alleviate your
mood?
Social history:
 What are you doing for living? How much the symptoms impact your job & usual daily activity? I am sorry for
that I will refer you to a social worker and occupational health care worker to manage any social or job troubles
you have.
 Smoking & alcohol history (Were asked before)
Medical history: Of long standing disease, DM, HNT, or Cardiac disease?
Family history: Was asked before.
Drug history: What is your drag list please? Any over the counter medications? Any recreational drugs?
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FOCUSED EXAMINATION
General look:
 For weight gain, distribution of weight gain (Truncal and supra scapular, intraclavcular fat deposition in
Cushing - Generalized obesity in hypothyroidism and simple obesity).
 Expose the abdomen: For truncal obesity, Linea Alba and rubra in the abdomen - echemosis.
Hand examination:
 For thin skin, echemosis (Cushing).
 Dry skin (Flypothyroidism).
 Pulse rate: For bradycardia in hypothyroidism.
Arms Examination: Arms against resistance for proximal myopathy.
Head examination:
 For Acne valgaris, abnormal hair growth, plethoric face, mouth sores (Cushing)
 Eye brow hair loss (Flypothroidism).
Slow releasing reflex: Knee tendon jerk for slow releasing reflex (FIypothroidism)
CONCERNS
What could be the cause of my fatigue and Headache doctor?

 Most probably your fatigue and headache is related to a condition called obstructive sleep apnea due to sleep
disturbance.
 This is as a result of deficiency of specific protein called thyroxin secreted from a gland in front of your neck
causing weight gain and therefore sleep disturbance.
 So we are going to do further blood tests and thyroid function test and imaging to the gland in front of your
neck and sleep, study to confirm our diagnosis.
 If our diagnosis is confirmed then we will refer you to a MDT from a gland doctor, sleep doctor, social
worker, occupational health worker (o give you the proper care and management plan.
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Ankylosing Spondilitis
Scenario:
 Low Back pain, Neck pain.
 Shortness of breath.
 Back pain and visual disturbance.
 Back pain and shortness of breath.
FOCUSED HISTORY
Analysis of the complaint (Back pain):

 Onset: when this back pain started exactly?
 Site: Is it in lower back, middle back or upper back? Any other joint pain?
 Nature of the pain (Is it dull aching, stabbing, burning, electric like?
 Grade of the pain: How much intensity do you give this pain from 0 to 10?
 Timing of the pain: Is it more at morning or at night?
 Radiation of the pain: Does it radiates to anywhere else?
 Morning stiffness: Is there any morning stiffness, for how long? (Usually ankylosing is associated with
morning stiffness which is improved with exertion)
 Worsening factors: Did you notice anything worsen your joint pain like movement, rest?
 Improving factors: Did you notice anything improve your joint pain like rest, movement, any pain killers?
Systemic symptoms of Differential Diagnosis (Seronegative arthritis):
 Enteropathic arthritis: Any mouth sores, tummy pain, loose motions?

 Reactive arthritis: Any burning water work, eye pain or redness?
 Psoriatic Arthropathy: Any skin rash, nails changes?
Systemic symptoms related to Ankylosing spondilitis:

1. Any eye redness: eye pain or visual disturbance?
236
2. Atlanto axial sublaxation: Any neck pai, limited neck movement?
3. Apical lumg fibrosis: Any cough, coughing up blood, phlegm, noisy chest, shortness of breath?
4. Aortic reguirg, Mitral reguirg, AY comduictloE defect, 2nd pul monary hypertension: Any chest pain,
awareness of heart beats, shortness of breath, on rest or exertion, awaken him from sleeping searching for
air, leg swelling?
5. Amyloidosis: any change of water work amount, frequency, color, frothy urine?
6. ArnHe tendonitis: any pain in the back of your feet?
7. Driving: Do you drive? You have to inform DVLA about your condition to be assessed by their team before
driving. Driving may be risky on yourself and for the public because of limitation of your neck movement.
Social history:
 What are you doing for living? How much your symptoms impact your job & usual daily activity? I am sorry
for that I will refer you to a social worker and occupational health care worker to manage any social or job
troubles you have.
Medical history: Any history of long standing disease like DM, HTN, Cardiac problem, surgical operations,?
237
FOCUSED EXAMINATION
Spine movement Examination:

 Order the patient to stand up  Question mark position (kyphoscoliosis, loss of lumbar lordosis).
 Ask the patient to look to the right, left, flexion, extension to the head  limited.
 Ask the patient to lean forward, move his spine on both sides  limited
 Occiput wall test  Make the back of the patient to touch the wall and order him to touch the wall by his
occiput: limited
 Ask the examiner: I would like to measure the chest circumference in inspiration and expiration.
 I want to do modified schober test, (mostly will not allow you)
 Lower back palpation: For tenderness
EYES: For redness (Anterior uveitis).
Pwilmoraary Examination: Auscultate the apex of the lungs (for apical lung fibrosis).
CVS:
 Pulse for bradycardia (A-V conduction defect).
 Auscultate the heart for AR, MR.
 Auscultate pulmonary area: For load pulmonary component of the 2nd heart sound (Pulmonary hypertension).
Occiput to wall distance
 Patient stands, with heels and buttocks against the

wall; the head is placed back as far as possible, keeping
the chin horizontal
 Patient extends his neck maximally in an attemptto

touch the wall with the occiput.
 Normally = 0.
238
Modified Schober test
 In this test marks are made 5 cm below and 10 cm
above the sacral dimples.
 The distance between these marks should increase

from 15 cm to at least 20 cm with lumbar flexion.
 The distance less than 5 cm is abnormal.
CONCERNS
What it could be the cause of my back pain doctor?
 Most probably you have a condition called Ankylosing spondylitis in which there is multisystem
involvement: stiffness and rigidity of the spine causing limited spine movement, your lungs may be involved
also in the form of scarring of the lung apex, your heart can be involved as well in the form of some electricity
disturbance and valvular dysfunction.
 So what we are going to do is to do for you further blood tests and imaging for your spine, lungs, heart to
confirm our diagnosis, then we will refer you to a multidisciplinary team from a joint doctor, physiotherapist,
lung and heart doctor if needed, social worker, occupational health worker to give you the proper plan of
management.
 Regarding driving you have to inform DVLA about your condition, because driving may endanger your life
and the public.
What about exercise doctor, does it worsen my condition?
 No, exercise is the corner stone of treatment in your condition.
239
May my children have the disease doctor?
 Although it doesn’t have a specific mode of inheritance, but unfortunately the chance of your children to
have the disease is more than the others.
 We will refer you to a genetic counseling team to discuss this issue in details
Is it curable condition doctor?
 I’m sorry it’s not curable, but it can be controlled on medication and regular follow up.
240
Psoraitic Arthropathy
Scenarios:
 Small joints pain in both hands.

 Low back pain (Sacroileitis).
FOCUSED HISTORY
Analysis of the complain (Small joints pain in both hands):
 Onset: When this joints pain started exactly?

 Nature of the pain (Is it burning, dull aching, electric like, pins and needles) to differentiate between
polyarthritis, Raynaud’s and carpal tunnel
 Site of pain: One hand or both hands, which joints are involved (knuckles near joints or far joints), any other
joints are involved, any back pain?
 Timing of the pain: Is it more at morning or at night (carpal tunnel more at sleep time).
 Morning stiffness: Is there any morning stiffness, for how long (usually more 1 h in RA and less than 1 h in
SLE and psoriatic arthropathy)
 Worsening factors: Did you notice anything worsen your joint pain like movement, rest, cold weather,
shaking of the hands?
Systemic symptoms of DD (seronegatine arthritis):
 Psoriatic arthropathy: Any skin rash, if there is analysis of the rash.

 Enteropathic arthritis: Any tummy pain, loose motions?
 Reactive arthritis: Any burning water work, eye pain or redness?

 Skim rash: Analysis of the rash (Onset, course, duration, progression, site, worsening factors, improving
factors)
241
 Eyes (Conjunctivitis in 20%, Anterio uveitis in 7%): Any eye pain, eye redness, visual disturbance.
 Apical lung fibrosis; Cough, shortness of breath.
 CVS (Aortitis, aortic insufficiency): Chest pain, racing of heart beats, SOB leg swelling.
 Hyperarecemias any gravels in urine.
Social history:
 What are you doing for living? How much the symptoms impact your job & usual daily activity? I am really
sorry I will refer you to a social worker and occupational health care worker to manage any social or job
 Troubles you have.
Medical history: D.M, HTN, Cardiac problem, surgical operations?
Drug history: What is your drug list? (Very important for drug triggering Psoraisis) - (ACE Inhibitors, Beta
blockers, Interferon alpha, NSAIDS, Anti malarial, Lithium)
- FOCUSED EXAMINATION
 Skin rash: Inspect the rash and its distribution.
 Hand examination:
 LOOK: For joint swelling, deformity, scars, muscle wasting.

 FEEL:
 For warmness by comparing by between hand joints and forearms of the patient by the dorsum of your
hand,
 For soreness by delicate compression of the joints between your fingers (take permission from the
patient).
 MOVE (Functional status): prayer sign - reversed prayer sign - fest compression - picking up coins -
buttoning and unbuttoning (2 actions are enough).
 Hair line: For scalp Psoraisis.
 Eyes: For redness of conjunctivitis and anterior uveitis.
 Respiratory: Ausultate the lung apex for apical lung fibrosis.
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 CVS:
 Auscultate for Aortic regurge, aortitis.
 Signs of secondary pulmonary hypertension (Put the stethoscope in the pulmonary area: Load pulmonary
component of the 2nd heart sound)
CONCERNS
 Most probably you have a disease called psoriatic arthropathy. A disease due to disturbance of your defensive
system.' It is a multisystem disease involving your skin, joints, and in some cases the valves of the heart and
may be scaring of your lungs.
 What we are going to do is to do further blood tests and imaging to your joints, heart, lungs and may be a
snip from your skin to confirm our diagnosis, and will arrange another appointment to discuss the results.
 If confirmed, we will refer you to a multidisciplinary team from a joint doctor, skin doctor, physiotherapist,
social worker to give you the proper plan of management.
 Precipitating factors (very important to mention in the concern):
 At the time being you have to stop smoking as it is one of the triggering factors for your skin eruption,
we can help you in this issue by referring you to a smoking cessation clinic if you don’t mind, (if smoker)
 You have to stop drinking alcohol as it is one of the triggering factors too. (if drinking alcohol)
 We have to exchange for you the drugs you are receiving (i.e. Beta blocker, ACE inhibitor, lithium,
Antimalarials, NSAIDS, Tetracycline) with another safe drugs because such drugs may precipitate your
skin eruption.
My bowel doctor my prescribed to me a drug named interferon alpha for my hepatitis c Is it ok Dr?
 Interferon alpha is one of the triggering drugs for psoriasis... In the same time it is very important treatment
for hepatitis C.
 We will make multidisciplinary team from gut doctor and skin doctor to outweigh benefits versus risk of
interferon alpha in your condition, and according to that the decision will be taken.
243
Rheumtoid Arthritis
Scenario:
 Small joint pain of both hands (Deforming polyarthropathy).
 Pain in the hands (Reynaud’s, Carpal tunnel, Polyarthropathy)
 Small joint pain of both hands and SOB (Rheumatiod lung, complication of methotrexate)
FOCUSED HISTORY
Analysis of the complain (Small joint pain of both hands)
 Onset: When this joint pain started exactly?

 Nature of the pain (Is it burning, dull aching, electric like, pins and needles) to differentiate between
polyarthritis, Raynaud’s and carpal tunnel
 Site of pain: one hand or both hands, which joints are involved (knuckles near joints or far joints), any other
joints are involved, any neck or back pain?
 Grade of the pain: How much intensity do you give this pain from 0 to 10? Timing of the pain: Ii it more at
morning or at night (carpal tunnel more at sleep time).
 Momipg stiffness: Is there any morning stiffness, for how long (usually more 1 h in RA and less than 1 h in
Systemic symptoms of Differential diagnosis list (seronegatine arthritis):
 Enteropathic arthritis: Any mouth sores, tummy pain, loose motions?

 Reactive arthritis: Any burning water work, eye pain or redness?
 Psoriatic arthropathy: Any skin rash?
244
Systemic symptoms related to RA:
- Carpal tunnel syndrome:
Any pins and needles, burning sensation, electric like sensation in the fingers of the hands, specially these 3 fingers,
does it increase at bed time or by shaking of the hands?
- Eye symptoms:
(Scleritis, Episcleritis, keratoconjuctivits sicca, Scleromalacia perforans, Sjogren syndrome): Any eye pain, eye
redness, dry eyes, gritty eye sensation?
- Respiratory symptoms:
 (Rheumatoid lung, complication of methotrexate): Any cough, phlegm, noisy chest, SOB?
- CVS symptoms:
 (Accelerated IHD, 2nd pulmonary hypertension): Any chest pain, racing of heart rate, SOB on exertion, on
rest, SOB awaken him from sleeping searching for air, leg swelling
 (Reynaud’s phenomenon): Any finger color changes when exposed to cold weather?
- Renal symptoms:
 (Amyloidosis- Glomerulonephritis): Any change in your water work amount, color, frequency, frothy
urine?
Ask for Mixed connective tissue disease symptoms:

 SEE: Any Falling of hair, mouth sores, facial skin rash?
 Systemic sclerosis: Any tight shiny skin, difficulty of swallowing, any
 Finger color changes in cold weather (Reynaud’s)?
 Polymyositis: Any muscle pain or weakness, difficulty of combing your hair or getting up from a chair?
(Proximal myopathy)
Social history:
 What are you doing for living? — How much the symptoms impact your job & usual daily activity? I am
sorry I will refer you to a social worker and an occupational health care worker to manage any social or job
troubles you have.
245
Medical history: Of long standing disease like DM, HTN, Cardiac problem, surgical operations?
FOCUSED EXAMINATION
- Hand examination:
 LOOK: For joint swelling, deformity, scars, muscle wasting.
 FEEL:
 For warmness by comparing by between hand joints and forearms of the patient by the dorsum of your hand,
 For soreness by delicate compression of the joints between your fingers (take permission from the patient)
buttoning and unbuttoning (2 actions are enough)
 Examine the extensor aspect of the forearms: palpate with your dorslim aspect of hands for any nodules or
olecranon bursa.
- Carpal tunnel syndrome examination (If there is symptoms of carpal tunnel):

 Inspection for wasting of the thenar eminence.
 Motor power for muscles innervated by median nerve (Loaf muscles)
 Sensation of distribution of median nerve
 Phalen’s test: Reversed prayer sign for 10 seconds induce electric like sensation in median nerve distribution
(take permission from the examiner).
 Tinel test: palpation on the volar aspect of the the hands induce electric like sensation (take permission for
the examiner).
- Arms: Power against resistance for proximal myopathy (Overlapping polymyositis, steroid therapy)
- Head:
 Eyes: For redness (Scleritis, Episcleritis, keratoconjuctivits sicca,
Scleromalacia perforans, Sjogren syndrome).
246
 Cushingoid features: butterfly rash, plethoric, round face (Steroid therapy complication)
 The oral cavity for any mouth sores (Overlapping SLE).
 Examine the SCALP: for hair falling or scarring (overlapping SLE).
- Respiratory: Auscultate for basal lung fibrosis.
- CVS:
 For JVP- Any Murmurs
 Auscultate pulmonary area for load pulmonary component of the 2nd heart sound (2nd pulmonary
hypertension)
- Lower Limbs: For edema (As a complication of cardiac or renal involvement).
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CONCERNS
What could be the cause of my hands joint pain doctor?
 Most properly you have a disease called Rheumatoid arthritis, due to disturbance in your defensive system,
attacking many systems in your body involving your joints, may be your lungs, heart and may be your
kidneys.
 We are going to do for you further blood tests and imaging to confirm our diagnosis, we will arrange another
appointment to inform you the results
 If confirmed then we will refer you to a multidisciplinary team involving joint doctor, lung doctor, social
worker, physiotherapist, to give you proper plan of management and outpatient fellow up.
What could be the cause of the in my hands doctor (If Carpal tunnel syndrome)?
 Most properly you have a condition called (Carpal tunnel syndrome) due to compression on one nerve cable
present in your forearms called median nerve.
 Most probably it is one of the complication of a disease called Rheumatoid arthritis disturbance which is a
multisystem disease involving many systems in your body like joints, lungs, heart and kidneys,
 So what we are going to do is do for you further blood tests, tracing for your nerve cable and imaging to
confirm our diagnosis, we will arrange another appointment to inform you the results.
 If confirmed then we will refer you to a multidisciplinary team involving joint doctor, nerve doctor, lung
doctor, social worker, physiotherapist, to give you proper plan of care and management.
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Systemic Lupus Erythematosus
Sceraario;
 Small joint pain in both hands.
 Skin rash.
FOCUSED HISTORY
Analysis of the complain (Polyarthropathy):

 Onset: When this joints pain started exactly?
 Nature of the pain (Is it burning, dull aching, electric like, pins and needles (To differentiate between
polyarthritis, Raynaud’s and carpal Tunnel).
 Site of pain: One hand or both hands, which joints are involved (knuckles near joints or far joints), any other
joints are involved, any back pain?
 Timing of the pain: Is it more at morning or at night (carpal tunnel more at sleep time).
 Morning stiffness: Is there any morning stiffness, for how long (usually > 1 hour in RA and < 1 hour in SLE,
osteoarthritis, psoriatic arthropathy)
Systemic symptoms of differential diagnosis (seronegatine arthritis):
 Psoriatic arthropathy: Any skin rash, if there is analysis of the rash (malar rash of SLE, Psoriasis)?
 Enteropathic arthritis: Any tummy pain, loose motions?
 Reactive arthritis: Any burning water work, discharge from down below, eye pain or redness?
249
Ask about other criteria of SLE:
 Any mouth sores?
 Falling of hair? (Discoid lupus)
 Joint pain? (Arthritis)
 Chest pain, racing of heart beats, SOB on rest, on exertion, on lying down, awaken you from sleeping, leg
swelling? (Pleuritis, pericarditis, myocarditis, libman-sacs endocarditis)
 Any lumps or bumps? (Lymphadenopathy)
 Any pallor or fatigue? (Anemia)
 Any change in urine amount, color, frequency, frothy urine, eye puffiness? (Lupus nephritis)
 Any headache, seizures, weakness, altered sensation? (Lupus cerebritis)
Ask for Anti phospholipid syndrome symptoms:

Any history of abortion - blood clot - family history of blood clot?
 Rheumatoid arthritis: Any hand deformity (other symptoms were asked before).
 Systemic sclerosis: Any tight shiny skin, difficulty of swallowing, any finger color changes in cold weather
(Raynaud’s)?
 Polymyositis: Any muscle pain, difficulty of combing your hair or getting up from a chair (proximal
myopathy)?
Social history:
 What are you doing for living? How much the symptoms impact your job & usual daily activity? I am sorry,
you have.
Medical history: DM, HTN, Cardiac problem, surgical operations?
250
FOCUSED EXAMINATION
Hand examination:
 LOOK: For joint swelling, deformity, scars, rash, muscle wasting.
 FEEL:
 For warmness by comparing between hand joints and forearms of the patient by the dorsum of your hand,
 For soreness by delicate compression of the joints between your fingers (Ask the patient if you felt any
pain please tell me)
Arms: Power against resistance for proximal myopathy (Overlapping polymyositis, steroid therapy).
 Butterfly rash.
 Cushingoid features: plethoric, round face (steroid therapy complication)
 The oral cavity for any mouth sores.
 Examine the scalp: for hair falling or scarring.
Trunk: For truncal obesity, intrascapular, supra clavicular fat deposition, stria Alba and rubra (complications of
steroids).
CVS: JVP- murmurs for libman-sacs endocarditis.
Pulmonary: Bilateral midclavicular line lung auscultation for pleuritic rub and basal crepitation.
Lower Limbs: (as a complication of cardiac or renal involvement).
N.B: Don’t forget in Jaccod arthropathy in SLE there is hand deformity looks like RA,
- In Jaccod arthropathy the deformity can be corrected by prayer or reversed prayer sign, and no X ray changes like
in RA.
251
What could be the cause of difficulty of swallowing doctor?
 Most probably you have a disease called Systemic sclerosis, which is a multisystem disease involving your
food pipes causing dysmotility and difficulty of swallowing, your small blood conduits of your fingers cau
narrowing, coldness and color changes of your finger when exposed to weather, your lungs causing scarring
and SOB, and may be your kidney; 1 causing high BP which can be seriously high.
 We have to do further blood tests and imaging to confirm our diagnosis, n confirmed we will refer you to a
multidisciplinary team involving joint doctor, lung doctor, physiotherapist, psychotherapist, social worker
and : give you the proper plan of management.
 I’m sorry it’s not curable, but it can be controlled by restrict compliance on your medications and regular
fellow up.
252
Systemic sclerosis
Scenario:
 Diffficulty of swallowing (Esophageal dysmotility).
 Cough – SOB (Due to GERD, Restrictive cadiomopathy, lung fibrosis, pulmonary hypertension).
 Pain in both hands (Reynaud’s)
 Skin rash (Telangiectasia)
FOCUSED HISTORY
Analysis of the complian (Difficulty of swallowing):
 Onset: When this difficulty of swallowing started exactly?
 Progression: It it increasing, decreasing or the same?
 It it on starting of swallowing or after food pass to your food pipe (to differentiate between oropharengeal
and esophageal dysphagia)
 Is it more to solids or fluids or both?
 Do you feel the food particles stuck to your food pipe? At which site?
 Any feeling sick or through up?
 Any associated loss of weight? How much KG? For how long? What about your appetite?
Systemic symptoms related to Systemic sclerosis:
- Skin and Musculoskeletal symptoms:

 Any skin changes like being more tight, shiny, smooth than before?
 Any skin rash (Telangiectasia, Purpura, Morphea)?
 Any joint pain? Any muscle pain?
- Respirator symptioms: Any cough, SOB? (Lung fibroisi)

- CVS Symptoms:
 Any chest pain, racing of heart beats, leg swelling, difficulty of breathing with rest, with exertion, awaken
you from sleeping searching for air? (Myocardial fibrosis, pericarditis, 2ndary pulmonary hypertension)
253
 Any fingers color changes when exposed to cold weather? (Reynaud’s phenomenon).
- GIT symptoms:
 Any heart bum, acid brush, tummy pain, tummy distension, loose motions or less motions? (GERD,
Esophageal dysmotility, bacterial overgrowth).
 Any change in your water work amount, frequency, color, frothy urine? (Glomerulonephritis).
 Any history of high blood pressure, did you check your BP before, is it controlled or not? (Renal crisis).
 SLE: Any Falling of hair, mouth sores, facial skin rash?
 RA: Any hand deformity? (Others are asked in SS symptoms)
 Polymyositis: Any muscle pain, difficulty of combing your hair or getting up from a chair (proximal
myopathy)?
Social history:
 What are you doing for living? How much the symptoms impact your job & usual daily activity? I am really
sorry I will refer you to a social worker and occupational health care worker to manage any social or job
troubles you have.
Medical history: DM, HTN, Cardiac problem, surgical operations?
254
FOCUSED EXAMINATION
- Skin sign: Telangectasia, Morphea, Tight shiny smooth skin.
- Hand examination (For arthropthy):
 LOOK:
 For finger tip ulcers, atrophies, color changes (Reynaud’s phenomenon.
 For joint swelling, deformity, scars, muscle wasting.
 FEEL:
 For warmness by comparing between hand joints and forearms of the patient by the dorsum of your hand,
 For soreness by delicate compression of the joints between your fingers (take permission from the
patient)
 MOVE: (Functional status): Prayer sign - reversed prayer sign - fest compression - picking up coins -
 Pinch: The skin of the forearms and arms by your fingers for comparison (Limited or diffuse SS).
- Arms: Power against resistance for proximal myopathy (Overlapping polymyositis, steroid therapy).
- Head:
 Pinched nose, peri oral freckling, Facial telangectasia.
 Tongue protrusion: Microglossia.
 The oral cavity for any mouth sores (overlapping SLE)
 Examine the scalp: For hair falling or scarring (overlapping SLE)
- Respiratory: Auscultate for Bibasal lung fibrosis.
- CVS:
 For JVP.
 Auscultate: For any Murmurs, pulmonary area for load pulmonary component of the 2nd heart sound
(Secondery pulmonary hypertension)
 I would like to examine this patient BP (For renal crisis) and to see the observation chart for vital signs.
255
Table 1 - Classification of systemic sclerosis
Type Description
Skin thickening present in the trunk in addition to face
Diffuse scleroderma
and extremities
Skin thickening limited to sites distal to elbows and
Limited scleroderma
knees, face and neck also involved
No skin changes but characteristic internal organ
Sine scleroderma
involvement
Presence of systemic sclerosis with features of other
connective-tissue diseases (systemic lupus
Overlap syndrome
erythematosus, rheumatoid arthritis, inflammatory
myositis)
The limited symptoms of scleroderma are referred to as CREST
256
Table 2 - Systemic involvement in systemic sclerosis
System Manifestation Approximate frequency,
when known
Cardiovascular Raynaud phenomenon >95%
Cardiac conduction abnormality 30% - 40%
Pericardial effusion <5%
Congestive heart failure3 —
Diastolic dysfunction —
Erectile dysfunction/impotence —
Digital ischemic changes: digital >90%
p'rtting/ulcer, abnormal nail fold
capillaries, acro-osteolysis
Skin Hyperpigmentation/depigmentation, —
calcinosis, thickened/hidebound skin
Gl GERD, Barrett esophagus, Intestinal 80%
malabsorption, GAVE
syndromeAvatermelon
cfcrsmark neat frlA-nhctn irtinn
pneumatosis cystoides intestinalis
Pulmonary Pulmonary arterial hypertension, interstitial 25%
lung disease, pleurisy, cancer
Renal Renal crisis 10%-15%
Musculoskeletal Puffy hands, flexion contractures, tendon

—
friction rubs, muscle atrophyb
GERD, gastroesophageal refliet disease; GAVE, gastric antral vascular ectasia.
a Secondary to left ventricular fibrosis.

b
Secondary to myositis (overlap syndrome), deconditioning.
257
CONCERNS
 Most probably you have a disease called Systemic sclerosis, which is a multisystem disease
involving your food pipes causing dysmotility and difficulty of swallowing, your small blood
conduits of your fingers causing narrowing, colness and color changes of your finger when exposed
to cold weather, your lungs causing scarring and SOB, and may be your kidneys causing high BP
which can be seriously high.
 We have to do further blood tests and imaging to confirm our diagnosis, if confirmed we will refer
you to a multidisciplinary team involving joint doctor, lung doctor, physiotherapist,
psychotherapist, social worker and to give you the proper plan of management.
I’m sorry it’s not curable, but it can be controlled.
258
Monoarthritis
Differential diagnosis (The common causes):

 Traumatic.
 Septic arthritis.
 Osteoarthritis.
 Crystal arthropathy (Gout, Pseudo Gout).
 Seronegative arthritis:
 Enteropathic arthritis.
 Reactive arthritis.
 Psoriatic arthropathy.
 Haemarthrosis - Hemophilia.
FOCUSED HISTORY

 Onset: When this joint pain started exactly?
 Recurrence: Any other joint pain, any previous similar history of joint pain?
 Nature of the pain: Is it dull aching, sharp, burning, electric like?
 Timing of the pain: Is it more at morning or at night?
 Morning stiffness: Is there any morning stiffness, for how long (usually more 1 h in RA and less than 1 h in
 Worsening factors: Did you notice anything worsen your joint pain like movement, rest?
Systemic symptoms of Differential diagnosis list:
- Traumatic: Any history of trauma?
- Septic arthritis: Any high temperature, shivering?
259
- Seronegative arttirntis:
 Enteropathic arthritis: Any mouth sores, tummy pain, loose motion?

 Reactive arthritis: Any burning water work, eye pain or redness?
 Psoriatic arthropathy: Any skin rash, nail changes?
- Crystal arthropathy:
 Gouty arthritis: What about diet, is it rich in protein, any kidney disease, any gravels in urine?
 Peudogout:
 Any tummy pain, yellowish eye balls, SOB, DM, tanning of the si (pseudogout 2ndery to
hemochromatosis)
 Any weight gain, cold intolerance, fatigue, constipation (peudogout 2ndery to hypothyoidism).
- Hemophilia, Haemoarthrosis: Any history of blood disease, any history of bleeding from anybody orifice, any
family history of blood disease, any erf thinning your blood like Asprin, Warfarin?
Social history:
 What are you doing for living? How much the symptoms impact yourjo: J usual daily activity? I am sorry
trouble,' you have.
Medical history: Any history of long standing disease like DM, HTN, Cardiac problem, surgical operations,?
FOCUSED EXAMINATION
1. Look:
 Skin: Scars, previous operations or trauma, redness, braising, rash.
 Shape: any deformity, Swelling.
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 Muscle wasting.
 Position: flexed, extended, everted, inverted.
2. Feel:
 Ask the patient if he felt pain anytime please tell me before you start to feel (very important)
 Temperature: compare with opposite joint using the back of your hand.
 Define swelling: by milking test i.e. effusion, bony hard.
 Tenderness: important to look at the patient at this point as not to miss painful expression, tenderness.
3. Move
 Active: This must be assessed before passive movement to allow observation of any limitation due to pain
and not to over step this mark on passive examination, for all joints remember planes of movement: extension
and flexion, adduction and abduction, external and internal rotation.
 Passive: After active movement, appraisal of what causes the patient pain if possible and avoid if possible
during passive movement, put your hand on the joint for crepitus.
CONCERNS
What could be the cause of my joint pain doctor if (osteoarthritis)?
 Most probably you have a degenerative disorder called osteoarthritis affecting your joint.
 What we are going to do is to do further blood test, imaging for your joint to confirm our diagnosis, and we
will arrange another appointment to inform you the results, in the time being we will give you a good pain
killer to relieve your pain.
 We will refer you to MDT from joint doctor, physiotherapist, social worker, occupational health care worker
to give you the proper plan of management
 If there is effusion: Tell the patient that you are going to have a sample from the fluids inside your joint by
a needle under aseptic condition, image guided and local anesthesia after his consent to make analysis of the
fluid to confirm our diagnosis and exclude others.
 I’m sorry it is not curable but in can be controlled by good follow up, good treatment compliance, weight
loss and good physiotherapy.
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Retinitis Pigmentosa
Scenario: Visual disturbance.
FOCUSED HISTORY
 What do mean by visual disturbance? Is it just blurring of vision? Or loss part of vision?
 Onset: When this visual disturbance started exactly?
 Course: Suddenly of gradually?
 Duration: Is it coming on and off or all the time with you?
 One eye or both eyes?
 Any painful eye movement, eye redness, gritty eye sensation (RA), eye lie drop?
 Night vision: Any change of night vision?
 Tunnel vision: Do you see the walls of the rooms or the sides of the road when look straight forward?
 Color vision: Any change of the color vision? Can you distinguish betw the traffic lights colors?
 Double vision: Do you see the things double?
 Associated symptoms like headache, analysis of the headache (Acromega: BIH).
 Associated long standing disease: Like DM, hypertension? (Diabetic and hypertensive retinopathy)
 May I examine you please: Do fundoscopy to confirm your diagnosis ear! (Hyperpigmented bone spicule
configuration in the peripheral field of the retina)
Systemic symptoms of the underlying Differential diagnosis list
Usher disease: Any history of deafness or diminution of hearing, family history of deafness?
Refsum disease:
Any pins and needles in the feet or hands (Peripheral neuropathy) –
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Any Skin changes or rash (Ichthyosis) -
Any chest pain, racing of heart beats, SOB on rest, on exertion, awaken him from sleeping searching for fresh air,
leg swelling (Cardiomyopathy) - Any unsteady gait (ataxia).
Abetalipoproteimensia: Any Tummy pain, loose motions (steatorrhea), unsteady gait (spinocerebellar and dorsal
columns tracts due to vitamin E deficiency).
Kearms—Sayre syndrome: Any awareness of your heart beats, slow heart beats
(AV conduction block), unsteady gait (cerebellar Ataxia).
Bardlet Biedl syndrome: any fingers deformity (polydactly), any Kidney problem: Any change of your water work
amount, color, frothy urine?
Alport syndrome: Deafness, kidney problem?
Driving: May I ask if you drive.

You have to inform DVLA about your condition, and I’m going to write in my notes that I advised you to inform
DVLA.
Driving may carry a risk on your life and for the others as well.
Social history:
 What are you doing for living? How much the symptoms impact your job & usual daily activity? I am sorry
for that I will refer you to a social worker and occupational health care worker to manage any social or
 Work troubles you have.
Medical history: Any history of DM, HTN, Cardiac problem, surgical operations, long standing disease?
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FOCUSED EXAMINATION
Eye Examination:
 Visual acuity: By counting fingers (Each eye separately)
 Eye movement: H chapped pattern by your index for double (Tell the patient if you see double please tell
me).
 Visual field: by your index and middle finger movement in all direction while the patient is looking
straightforward into your e > (Each eye separately).
 Fundoscopy: For hyperpigmented bone spicule configuration - the peripheral field of the retina.
Ear examination:
 For hearing aid.
 Weber and Rinne test (Ask the examiner)
Skin exammattnoini:
 For Ichthyosis.
CVS:
 Ask the examiner: For JVP, Bilateral lung fields (For Cardiomyo: al
CNS:
 Ask the examiner: For ataxia.
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CONCERNS
What could be the cause of visual disturbance doctor?
 Most probably you have a condition called Retinitis Pigmentosa due to deposition of pigmentation in the
back of your eyes.
 Mostly it is due to a condition called Usher disease affecting both your ear cables and the back of your eye.
It is a familial condition which mn in families.
 What we are going to do is to refer you to MDT from brain physician, eye physician, ear physician,
psychotherapist, social worker to give you the proper care and management plan.
I'm going to be blind doctor?
 I’m sorry it is a progressive condition, but we are going to do our best to give you the full social, occupational
and psychological support.
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Papilloedema
Scemarso: Visual disturbance and headache.
FOCUSED HISTORY
Visual disturbance:
 What do mean by visual disturbance? Is it just blurring of vision? Or part of vision?
 Is it in one eye or both eyes?
 Any painful eye movement, eye redness, gritty eye sensation (RA), e y drop?
 Tunnel vision: Do you see the walls of the rooms or the sides of the roa when look straight forward?
 Color vision: Any change of the color vision? Can you Distinguish be: the traffic lights colors?
 Associated symptoms like headache, analysis of the headache (Acrorr. BIH).
 Associated long standing disease: Like DM, hypertension? (Diabetic hypertensive retinopathy).
 May I examine you please: Do fundoscopy to confirm your diagnosis early? (Hyperemic ill defined optic
disc with dilated vessels)
Headache:
 Onset: When this headache started exactly?
 Site, character, radiation, timing, grade (0-10).
 Worsening factors - like stress, coughing, sneezing, straining.
 Improving factors - Like rest or any pain killers.
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Systemic symptoms of the underlying Differential diagnosis list
Space occupying lesion: Any history of headache - analysis of the headache: Onset, course, duration, progression,
character, site, time, grade, worsening factors like coughing, sneezing, staining, improving factors - Any history of
LOC, seizures, pins and needles, unsteady gait, feeling sick, vomiting, uncontrolled water-work or bowel habits?
Optic neuritis (M.S): Any history of similar attack in the past, (CNS systems are asked before)
Malignant hypertension: Any history of high blood pressure, did you check your blood pressure before?
Venoms sinus thrombosis, central retinal vein thrombosis: Any history of blood disease or blood clot?
Risk factors for Idiopathic intracranial hypertension:

 Drag induced: Any history of intake of Oral contraceptive pills, other drugs precipitating BIH i.e.
Doxycycline, Tetracycline, Steroids, isotretinoin (drug induced BIH).
 Weight: Any weight gain recently? How much KG? For how long? What about your appetite?
 Pregnancy: When was the last period? May I ask if your periods are regular? Any change in the amount of
blood?

 You have to inform DVLA about your condition, and I’m going to write in my notes that I advised you to
inform DVLA.
 Driving may carry a risk on your life and for the others.
Social history:
troubles you have.
 With whom you arc living? Who is supporting you at home?
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Medical history: Any history of DM, HTN, Cardiac problem, surgicai operations, long standing disease?
FOCUSED EXAMINATION
Eye Examifliniatioira:
 Visual acuity: By counting fingers (Each eye separately).
 Eye movement: H chapped pattern by your index for double visi (Ask the patient if you see double vision
tell me).
straightforward into your eyes (Each eye separately).
 Fundoscopy: For Hyperemic ill defined optic disc with dilated vessels.
CNS: (Ask the examiner: I would like to examine this patient neurologically)
 Tone, power, reflexes, coordination, sensation.
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CONCERNS
 Most probably you have a condition due to increased pressure in the back of your eyes secondary to a disease caHed
idiopathic intracraniai hypertension, a condition due to increased secretion of the fluids inside your brain cavities , May
be triggered by the oraf contraceptive pills you are receiving.
 So what we are going to do it to do urgent imaging to your brain and checking the pressure inside your spinal canal by
inserting a needle into your back under aseptic condition, image guided and local anesthesia after you consent.
 If our diagnosis is confirmed we will refer you to MDT from a brain physician, eye physician, social worker to give
you the proper care and management plan.
 Your oral contraceptive pills may precipitate this condition, so you have to stop this medication and we will refer you
to obstetrician to give you another alternative safe drug for contraception.
I'm going to he blind doctor?
 I'm sorry it is a progressive condition if untreated, but we are going to do our best to stop the progression of the disease
by relieving the pressure in the back of your eyes, hoping that will improve you visual disturbance and save your vision.
269
Optic Atrophy
Causes of Optic Atrophy:

 Hereditary (Friedreich ataxia, iebers hereditary optic neuropathy, DIDMOAD syndrome).
 Post MS-optic neuritis.
 Tumor compressing optic nerve.
 Ischaemic (Temporal artertitis, Central retinal artery or vein occlusion).
 Drug induced (isoniazid, ethambutol, chloamphenicol, quinine).
 Metabolic (Vitamin b 1,2,3,6,12 deficiency, DM).
 Tobacco retinopathy, Alcohol/nutritional retinopathy.
FOCUSED HISTORY

 What do mean by visual disturbance? Is it just blurring of vision? Or lQss of part of vision or loss of color vision?
 Any painful eye movement, eye redness, gritty eye sensation (RA), eye lid drop?
 Tunnel vision: Do you see the walls of the rooms or the sides of the road when look straight forward?
 Color vision: Any change of the color vision? Can you distinguish between the traffic lights colors?
 Associated symptoms like headache, analysis of the headache (Acromegaly, BIH).
 Associated long standing disease: Like DM, hypertension? (Diabetic and hypertensive retinopathy).
 May I examine you please: Do fundoscopy to confirm your diagnosis early? (For pale well defined optic disc).
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Systemic symptoms of the underiying causes:
Hereditary (Friedreich ataxia, iebers hereditary optic neuropathy, DiDMOAD syndrome): Any family history of
similar condition?
Post MS-optic neuritis: Any history of simitar problem in the past, altered speech, altered sensation, weakness,
unsteadiness, shaking of the hands?
Tumor compressing optic nerve: Any history of headache, feehng sick or vomiting, seizures attacks,
weakness, abnormal gait?
Ischaemic (Temporai arteritis, Centrai retina) artery or vein occiusion):

 Any history of headache, temporal pain, pain during chewing, cord like protrusion in the side of the head?
 Any fever, loss of weight, joint pain (Polymylagia reumatica which is highly associated with temporal
arteritis)?
 Any history of blood clots before or family history of blood clot?
Drug induced isoniazid, ethambutol, chloamphenico), quinine).

Are you regular on any medications?
Metabolic (Vitamin b 1,2,3,6,12 , DM):

What about your diet, is it balanced, rich in vegetables and red meat?
Tobacco retinopathy, Alcohol/nutritional retinopathy:

 Do you smoke at all? How many cigarettes per day? For how long?
 Do you drink alcohol?

 You have to inform DVLA about your condition, and Fm going to write in my notes that I informed you to
inform DVLA.
Social history:
 What are you doing for living? How much the symptoms impact your job & usual daily activity? 1 am sorry
for that 1 will refer you to a social worker and occupational health care worker to manage any social or job
trouates you have.
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 Smoking & alcohol history? (Asked before).
Medical history: Any history of long standing disease Hke DM, HTN, Cardiac problem, surgical operations, TB?
FOCUSEiD EXAMINATION
- Eye Exsimmatnom:
 Visual acuity: By counting fingers (Each eye separately).

 Eye movement: H chapped pattern by your index for double vision (Inform the patient if you see my finger
double or any pain please tell me).
 Fundoscopy: For pale well defined optic disc.
CNS: (Ask the examiner: 1 would like to examine this patient neurologically).
 Tone, power, reflexes, coordination, sensation.

 Chest examination: If suspected TB Lung (Drug induced optic atrophy)
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CONCERNS
 Most probably you have a condition called Optic atrophy due to degeneration of the nerve cable in the back
of your eyes, this is secondary to the previous history of multiple sclerosis which affected your brain, main
nerve cable of the body and nerve cable of the back of the eyes.
 What we are going to do is to refer you to brain physician, eye physician physiotherapist, psychotherapist,
social worker to give you the proper care and management plan.
 I'm sorry to tell you it is a progressive condition, but we are going to do our best to give you the full social,
occupational and psychological support.
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Diabetic & hypertensive Retinopathy
FOCUSED HISTORY
Analysis of the compiaint:
 What do mean by visual disturbance? Is it just blurring of vision? Or loss of

 Part of vision?
 Any painful eye movement, eye redness, gritty eye sensation (RA),
 Eye lid drop?
 Color vision: Any change of the color vision? Can you distinguish between?
 The traffic lights colors?
 Associated symptoms like headache, analysis of the headache (Acromegaly, BIH).
 Associated long standing disease: Like DM, hypertension? (Diabetic and hypertensive retinopathy).
 May I examine you please: Do fundoscopy to confirm your diagnosis early.(Search for:
(Mircoaneurisms- dot and blot hemorrhage - hard exudates - soft exudates - new vascularization - faime shapped
hemorrhage - thickening of arterioles - AV nipping - papiitoedema - maculopathy)
Analysis of Diabetes:
 For how long you have DM?
 What medications you take lor DM?
 Are you compliant on these medications or not?
 Dow much the reading of the last HBAlc?
274
Systemic symptoms of uncontroiied DM:
 Peripheral neuropathy: Any pins and needies or burning sensation in the hands or the feet?
 Diabetic nephropathy: Any change in your water work amount, frequency, coior, frothy urine? Any facial or eyes eye
puffiness specially at morning?
 Cardiac complications: Any chest pain, racing of heart beats, shortness of breath, leg swelling?
 Any history of loss of consciousness due to high glucose level or low glucose level?
Hypertensive analysis:
 For how long you have high BP?
 What medications you take for hypertension?
 Are you compliant on your medications?
 What are the readings your BP?
 You have to inform DVLA about your condition, and I'm going to write in my notes that I advised you to inform DVLA.
Social history:
 What are you doing for living? How much the symptoms impact your job & usual daily activity? I am sorry for that I
will refer you to a social worker and occupational health care worker to manage any social or job troubles you have.
Medical history: Any history of long standing disease?
Drug iist: What is your drug list please?
275
FOCUSED EXAMINATION
Eye Examination:
 Visuai acuity: By counting fingers (Each eye separately)

 Eye movement: H chapped pattern by your index for doubie vision (Ask the patient if you feel pain
or see doubie, please tell me).
 Visual fieid: by your index and middle finger movement in all direction while the patient is looking
 Fundoscopy:
 For Back ground, preproliferative, proliferative changes.
 Hypertensive changes.
 Macula for maculopathy (by ordering the patient to look straight forward to the light.
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277
CONCERNS
What could be the cause of visual disturbance doctor (If Proliferative diabetic
retinopathy with maculapthy?
 Most probably your visual disturbance is due to long standing uncontrolled DM causing some changes in
the blood vessels and back of your eyes.
 So what we are going to do it refer you urgently to an eye doctor as the back of your eyes has some changes
need urgent referral and management by laser ablation to save your vision.
 Later on we will refer you a to MDT from gland doctor, diabetic nurse, dietician, exercise training program
to give you the proper plan of management to strictly control your DM.
 If your DM is strictly controlled so that we can control your condition and save your vision.
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Limb weakness in young female
Scemanto:
 Mrs. Noha is 27 years oid had been comptaming of right sided weakness today morning white watching TV,
which continued for hatf an hour and then comptetety resoived (Mostty surrogate).
Differenacial diagnosis list:
 Functional
 Migraines hemiparesis
 Post ictat paresis
 TIA:
 Cardiac emboti (Arrhythmia, Vatvutartesion).
 Vacuities (Antiphosphohpid syndrome, Behcet syndrome).
 Hereditary thrombophiha (Protein C, S, Factor 5 Leiden, Anti thrombin til deficiency).
 Hypercoagutabte state (Pregnancy, Essential thrombocytosis).
 Sickle cett anemia.
FOCUSED HTSTORY

 Onset: When this weakness started exactty?
 Course: Suddenty or graduatty?
 Progression: Was it increasing, decreasing or the same? , do you stiH feet any weakness? Did it resotve
comptetety?
 Duration: For how tong did it sustain?
 Site: Where did you feet the weakness exactty?
 Recurrence: Any history of simitar symptoms in the past?
 Associated symptoms (Other CNS symptoms): Any history of toss of consciousness, dizziness, visuat
disturbance, attered speech, attered sensation, unsteady gait, shaking of the body, uncontroHed water work or
bowet work?
279
Systemic symptoms of Differential Diagnosis:
- Fumctitmai: Any history of bad mood or stress recently?
- Migraines hemiparesis:
 Any history of headache (If there anatysis of the headache): Onset, course, duration, progression, triggering
factors, worsening factors, associated symptoms)?
 Migraine is more in females , can be unilateral or bilateral, worsened by strong voices and flashes , stress ,
preceded by Aura, continue for 4-72 H, Recurrent 1-10 times per month, associated more with blurring of
vision , nausea and vomiting , strong family history.
- Postictal: Shaking of the body with loss of consciousness, tongue pitting, dropping of saliva, uncontrolled water
work?
- TIA secondary to:
 Cardiac emboli: Any history of chest pain, racing of heart beats, shortness of breath, leg swelling?
 Vacuities:
 Anti Phosphotipid Syndrome: Any history of miscarriage before, history of blood clot before?
 Secondary APS (SLE symptoms): Any history of joint pain, fading of hair, facial rash, mouth sores, frothy
urine?
 Behcet syndrome: Any history of skin rash, mouth sores, down below sores, joint pain?
 Hereditary thrombophilia: Any family history of blood disease, family history of blood clot?
 Hypercoagulable state: When was your last period? Regular or irregular, how much the amount of blood
coming with every period?
 Sickle cell anemia: Any history of blood disease or family history of blood disease?
- Driving: Do you drive? You have to inform DVLA about your condition to be assessed by their team before
driving. Driving may be risky on yourself and for the otners.
280
Sociai history:
 What are you doing for iiving? How much your symptoms may affect your job & usuat daiiy activity? 1 am sorry for
that I will refer you to a sociai worker and an occupational heaith care worker to manage any sociai or job troubles you
may have.
 Financiai support?
 Smoking & aicohoi history?
Medicai history: Any history of iong standing disease tie DM, HTN, Cardiac probiem, surgicai operations?
Family history: Of Simitar condition or iong standing disease?
Drug history: Are you reguiar on any medications iike orai contraceptive bids? (Precipitating factor in APS and migraine).
FOCUSED EXAMHMATEOM
- CVS:
 Puise rate and rhythm: For any Atriai fibriiiation, SVT.
 Auscultation: for murmurs, carotid bruit.
-CNS:
 For tone, power, reflexes .coordination, sensation. (Ask the examiner)
- Face: For hair falling, butterfly rash, mouth sores. (SLE)
Hands: For arthropathy signs.
CONCERNS
What couid be the cause of my iimh weakness doctor?

 I appreciate your concern, most probably you have migraine, and this weakness is one of the complications of migraine.
 So what we are going to do is to refer you to a MDT from a nerve doctor, social worker to give you the proper care and
plan of management.
 Oral Contraceptive Pills may trigger your migraine so we are going to stop it and to refer you to an obstetrician to give
you another safe contraceptive method.
281
Discussion with the examimer:
What is your ciinicai finding here?
 Cardiovascular including pulse and ausculatation are normal
 Full neurological examination including tone, power, reflexes, coordination, sensation, cranial nerves are
normal.
(Mostly surrogate)
What is your diagnosis? (If Migrainous hemeparesis)
Migranous hemiparesis is my first diagnosis in this case as the patient headache fills most of the criteria of migraine.
 Migraine is diagnosed clinically
 I can do basic investigations like CBC, RFT, Electrolytes.
 CT brain if TIA is suspected to rule out central cause.
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Differential diagnosis:
 TIA.
 Diabetic maculopathy.
 Retinal or vitreous haemorrhage.
 Temporal arteritis.
 Central retinal vein or branch thrombosis
FOCUSED HISTORY
 Onset: When this loss of vision started exactly?
 Site: On one eye or both eyes? Partial or complete?
 Recurrence: Any history of similar symptoms before?
- TIA:
 CNS symptoms: Any LOC, seizures, weakness, altered sensation, altered speech, double vision, difficulty
of swallowing, uncontrolled water work or bowel habits, unsteady gait?
 CVS symptoms: Any chest pain, racing of heart beats, SOB, leg swelling?
- Diabetic maculopathy: Any history of diabetes, for how long, what medications you are on for DM, controlled or
not, what about last HBAlc, (hypoglycemic symptoms) any hx of flushing, sweating, dizzy spells, measuring of low
glucose in blood?
Temporal arteritis: Any headache, painful chewing, temporal pain, cord like protrusion in your temple, pain during
combing your hair?
Polymylagia Rheumatica symptoms: Any joint pain, fatigue, loss of weight, fever?
- Retinal vein or branch thrombosis: Any History of blood clot, family hx of blood clot?
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- Retinal or vitreous hemorrhage: Any history of biood disease, any drug thinning blood like warfarin or aspirin?
- Driving: Do you drive? I'm sorry to tell you have to inform DVLA about your condition to be assessed by their team before
driving. Driving may be risky on yourself and for the public because of possibility of recurrence of loss of vision during driving.
Is it ok with you?
Social history:
 What are you doing for living? How much the symptoms impact your job & usual daily activity? I am sorry for that I
will refer you to a social worker and occupational health care worker to manage any social or job troubles you have.
Medical history: Surgical operations, long standing disease like DM, HTN, Heart problem?
FOCUSED EXAMNATION
Eye examination:
 Visual, acuity (By counting fingers).
 Eye movement (By H shaped imdex finger moveme)
 Visual field (In all directions. Each eye separate)
 Fundocopy: (Ask the examiner) if suspecting dj retinal vein thrombosis.
CVS:
 Pulse rate and rhythm: For any Atrial fibrillation
 Auscultation: for murmurs, carotja bruit
CNS: (Ask the examiner) if suspected TIA, for tone, power, reflexes, coordination, sensation.
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CONCERNS
What could be the cause of loss of vision?
 Most probably you had ministroke caused occlusion of one of the your brain blood conduits.
 So we are going to admit you now (if ABCD2 score = or > 4) and to do urgent imaging to your brain and to
do tracing and imaging to your heart to know the underlying cause.
 We will refer you to a brain physician to give you the proper care and management plan.
 Regarding driving you have to inform DVLA about your condition, because driving may carry risk on
yourself and on the others because of the risk of recurrence of loss of vision.
The ABCD2 Rule
Risk Factor Points
Age >60 years 1
Initial BP > l40/90 1
Unilateral Weakness 2
Speech Impairmentwithout Weakness 1
Symptom Duration 10-59 minutes 1
Symptom Duration > 60 minutes 2
History of diabetes 1
Low risk = 0-3  Moderate risk = 4-5  High risk > 6
 Score > or = 4: The patient needs admission and urgent CT scan.
 Score < 4: Patient can be managed as outpatient and CT can be done within one week.
 Crescendo T1A (2 or more attacks of TIA within 24 hours): Needs admission and urgent CT brain.
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Both lower limb swelling
DafferemtmS diagnoses:
 Congestive heart faiture.
 Chronic iiver disease.
 Chronic kidney disease.
 Nephrotic syndrome.
 Hypoaibuminaemia (nutritional, maiabsorbtion)
FOCUSED) HISTORY

 Onset: When this both ieg sweiiing started exactly?
 Site: What is the level of the swelling? Below or above the knee?
 Prescription of swelling: Any redness, hotness, or pain?
 Pitting: When you make pressure with your finger, does it leave a-mark?
 Worsening factors: Did you notice anything worsen this swelling like sitting, movement, rest?
 Improving factors: Did you notice anything improve swelling like elevation of your legs, water tablets?
 Associated symptoms: Any associated tummy swelling, swelling down below in the private areas, Cough or
shortness of breath. (Symptoms of volume overload)
Systemic symptoms of Differential diagnosis:
- CVS symptoms: Any chest pain, racing of heart beats, difficulty of breathing on rest, on exertion, on lying down,
awaken you from sleeping?
- CRT symptoms: Any tummy pain, tummy swelling, yellow discoloration of the eye balls, Any history of vomiting
up blood, blood in the stool (risk factors of CLD) i.e. blood transfusion, sharing needles, surgical operation?
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- CKD: Any change in your water work amount, color, frequency?
 Any Facil puffiness specially at morning, frothy water work?

 Facial skin rash, falling of hair, mouth sore, joint pain? (SLE symptoms).
 What about your diet is it balanced? (MuMtiomai).
 Any tummy pain, any loose motions? (Matabsorbtion syndrome).
Social history:
 What are you doing for living? How much your symptoms impact your job & usual daily activity? I am sorry
for that, I will refer you to a social worker and to an occupational health care worker to manage any social
or work troubles you have.
Medicai history: Any history of long standing disease like DM, HTN, Cardiac problem, surgical operations,?
Drug history: What is your drug list please? Any over the counter medications? Pain killer? (For any drugs causing
ATN, TIN)?
FOCUSED EXAMINATION
Lower limbs:
 Expose and inspect: For redness, rash, level of swelling, nail atrophies.
 Palpate:
 For pitting edema.
 Pulsation of dorsalis pedis artey.
 Hotness of both legs by the dorsum of your hand.
Upper limbs:
 For arthropathy (SLE).
 For clubbing, Duputren contracture (CLD).
 Flapping tremors (CLD).
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Head:
 Eyes: Conjunctiva for pailor and sclera for jaundice.
 Hair: For falling of hair (SLE).
 Facial rash: For malar rash (SLE).
 Mouth: For mouth sores (SLE).
Abdomen:
 Inspection: for CLD signs (Temporalis wasting, abdominal swelling, spider naevi, gynecomastia, dilated
veins, caput medusa, everted umbilicus).
 Palpation: for organomegaly.
 Percussion: For dullness and shifting dullness (Ascites
CVS:
 JVP: For raised JVP.
 Auscultate: For bilateral lung Felds for crackles (Pulmonary congestion)
CONCERNS
What it could be the cause of both legs swelling doctor?
 Most probably you have a condition Nephrotic syndrome which is a condition in your kidneys causing loss
of protein in urine resulting in such this legs swelling, and may also cause tummy swelling and shortness of
breath.
 So what we are going to do is to do for you further blood test and 24 hProtein in urine to confirm our
diagnosis.
 If our diagnosis is confirmed we will refer you to a kidney doctor for further investigation for the cause and
What could be the cause doctor?
 Could be secondary to other diseases, some drugs, or related to some types of infection or may be idiopathic
means unknown cause. Until now there no obvious cause so that you may need further investigations to
know the underlying cause.
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Chest pain (Pulmonary embolism)
Differential Diagnosis (Common causes):
 Cardiac: ACS, Pericarditis, Myocarditis, aortic dissection.

 Pulmonary: Pleurisy, Chest infection, Pneumothorax.
 Pulmonary Embolism.
 Pulmonary edema.
 GERD.
 Musculoskeletal.
 Herpes Zoster.
FOCUSED HISTORY
 Onset: When this chest pain started exactly?

 Duration: For how long this pain continue?
 Recurrence: How frequent is the pain per day?
 Site: Where is the pain exactly in your chest?
 Nature of the pain (Is it dull aching, sharp, burning, stapping, compressing
 Radiation of the pain: Does it radiates to anywhere else, Radiating to the back?
 Worsening factors: Did you notice anything worsen this pain like movement, rest, exertion, pressure on the
site of pain?
 Improving factors: Did you notice anything improve your pain like rest, movement, any pain killers?
 Associated symptoms: Any associated shortness of breath, racing of heart beats?
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Systemic symptoms of Differential diagnosis:
Cardiac symptom (ACS, Pericarditis, Myocarditis):
 Any history of racing of heart beats, do you feel it rapid or slow, regular or irregular, any SOB on lying
down, on rest, with exertion, awaken you from sleeping searching for air, leg swelling?
 Any history of high lipid profile? Any family history of cardiac disease or heart attacks?
Padmomatry symptoms (Pieurisy, Chest infection, Puimonary edema, Pneumothorax): Any history of fever,
cough, coughing up blood, phlegm, noisy chest?
Pulmonary embolism (Risk factors of PE):

 Any history of leg pain or swelling, any history of long journey recently, history of immobility for long time
recently, any history of surgical operation recently, history of cancer, any history of blood clot before?
 Anti phosphoiipid syndrome: What about your periods, when was the last period (pregnancy), any history
of abortions before? Do you receiveoral contraceptive pills?
 Hereditary thrombophiiia: Any family history of blood disease, or blood clot?
 SLE symptoms (Secondary APS): Any joint pain, falling of hair, mouth sores, frothy urine?
GERD: Any acid brush, heart bum, feeling sick or getting sick, increased pain after food intake?
Musculoskeletal: Increasing with movement, increasing with pressure at the site of pain.
Herpes Zoster: Any skin rash on the chest?
Social history:
troubles you have.
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Famiiy history: Similar condition or long standing disease?
FOCUSED EXAMENATTON
ABCD Protocol: As in any emergency case (Tell the examiners):

 I would like to see the observation chart for the patient for vital signs.
 1 would like to follow ABCD protocol for the patient.
 I would like to put the patient under close observations of vital signs.
Upper limb: Pulse rate and rhythm (Tachycardia in PE).
Head: For falling of hair - Malar rash - Mouth ulcers (SLE as a cause of secondary APS)
CVS Examination:
 For raised JVP.

 For signs of 2ndary pulmonary HNT Auscultate the pulmonary area for loud pulmonary component of 2nd
heart sound, parasternal heave.
 I would like to check this patient BP.
Chest Examination: Auscultate the midclavicular line bilaterally for any crackles or wheezes.
Lower limbs:
 For pitting edema.
 For swelling and tenderness (DVT) - Ask the examiner I would like to measure both mid legs circumference
- Pitting edema.
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CONCERNS
Do I have heart attack doctor (If the case is PE)?
 Heart attacks is uniikeiy in your condition, but we have to ruie out.
 Most probabiy you have a blood ciot in your blood channels which supply your lungs.
 What we are going to do is to do further blood test, urgent imaging to your lungs with a special dye which
need written consent to confirm our diagnosis.
 If diagnosis is confirmed we will admit you and refer you to a MDT from blood physician and lung physician
 Unfortunately it's serious and life threatening condition if untreated, But we are going to refer you to a blood
physician and lung physician to give you the appropriate treatment in the form of drugs to thin your blood,'to
prevent further blood clot in the future.
For how long i wiil receive this blood thinner doctor?
 This will be decided by the blood physician himself, may be for few months or long life, this will be decided
according to the underlying cause.
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Hematemsis and Melena
 Peptic and duodenal ulcer (Long standing gastritis, drug induced).
 Portal hypertension (CLD, Bilharesiasis).
 Malignancy (gastric carcinoma, colorectal cancer).
 Mesenteric ischemia (Melena).
 Bleeding tendency (Familial and drug induced).
FOCUSED HTSTORY
Analysis of the compiaint (Meiena):

 Color: What is the color of the stool exactly, is it mixed with blood, fresh reddish, terry ground in
appearance?
 Frequency: How frequent is that black stool?
 Volume: How much the volume? Is it mild, moderate, large volume?
 Recurrence: Any history of similar problem in the past?
 Pain: Any associated pain during your motions (Local cause like anal fissure, hemorrhoids).
 Associated symptoms (Anemic symptoms): Any history of LOC, dizziness, pallor, fatigue, racing of heart
beats.
Peptic ulcer symptoms:

 Any history of upper tummy pain, heart bum, acid brush sensation, vomiting up blood?
 Drug induced P.U: Did you receive any pain killers or Steroids recently, how frequent, for how long, for what?
Portal hypertension (CLD, Bilharesiasis):
 Any history of liver disease, tummy pain, tummy swelling, yellow discoloration of the eye balls.
 (Risk factors of hepatitis) blood transfusion, surgical operations, needle sharing, dental procedures, tattooing
or piecing.
 Any history of travelling abroad, swimming in pools jungles. (Bitharisiasis)
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Malignancy: Any history of loss of weight, high temperature, lumps or bumps?
Mesenteric ischemia: Any history or racing of heart beats or heart beats irregularity?
Bleeding tendency: Any history of blood disease, any bleeding from any other body orifice before, any family
history of blood disease, any blood thinner drugs like Aspirin or Warfarin?
Social history:
 What are you doing for living? How much the symptoms affect your job & usual daily activity? I am sorry
for that I will refer you to a social worker and occupational health care worker to manage any social or
work troubles you have.
FOCUSED EXAMINATION
ADCD Protocol (Like any emergency case - Tell the examiner):

 I would like first to see the observation chart for vital signs.
 I would like to follow ABCD protocol with the patient.
 I would like to put the patient under close observation of vital signs.
@ Then go to the patient:
Harnd exatmimadom:
 For clubbing, palmar erythema, Dupuytren's contracture (CLD signs), e Check Pulse rate.
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Heatd exammstdom:
 For temporal wasting.
 Conjunctiva pallor and sclera for jaundice.
Abdominal exammadom:
 Inspect: For abdominal swelling, Gynecomastia, Spider naevi, Caput medusa, everted umbilicus (CLD signs)
 Palpate: For Organomegaly.
 Percussion: For dullness and shifting dullness (Ascitis).
 Auscultation: For intestinal sounds, Venous hum.
Lower limbs examination: For edema
Examine for lymphademopathy: I would like to examine for Lymphadenopathy (to be done earlier if suspected
malignancy) and rectal examination (to be done earlier in melena with fresh blood to exclude surgical causes.
CONCERNS
Is it cancer doctor? (If due to NSAIDS induced PUD)?
 Cancer is unlikely in your condition, but we have to rule out.
 Mostly probably this is due to bleeding from soreness of your stomach precipitated by receiving large amount
of pain killers for long time.
 So what we are going to do is to admit you now and put you under close monitoring, give you some fluids
and blood transfusion if needed and to do urgent blood tests.
 We will refer you urgently to a bowel physician and prepare for urgent camera test for diagnostic and
therapeutic purposes.
 You have to stop this pain killer and we will provide you with another safe pain killer, and stop smoking (if
smoker) as it increase the risk of stomach sores, we can help you in this issue by referring you to smoking
cessation clinic.
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Treatment for Hematemisis and Melena:
1. First of all to feliow ABCD protocol.
2. Close monitoring of V/S.
3. Insertion of 2 Wide bore cannula.
4. Starting crystalloid infusion.
5. Bolus and maintenance dose of PPI.
6. Blood grouping and Preparation of 4 units of blood for possible blood transfusion.
7. Urgent endoscopy after patient stabilization.
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Scenario:
 Multiple lymph nodes in the body.
 Neck lump.
 Infection: (HIV, TB, EBV, CMV, Typhoid fever, Toxoplasmosis, Brucellosis, Cat scratch disease).
 Neoplastic and proliferative disorder: Acute lymphocytic leukemia. Lymphomas (Hodgkin's, non-Hodgkin).
 Autoimmune disorders and collagen: Juvenile rheumatoid arthritis, Systemic lupus erythematosus.
 Sarcoidosis.
 Drug reactions: Phenytoin, Allopurinol.
 Storage Diseases: Gaucher disease, Niemann-Pick disease.
FOCUSED HISTORY
Anatysis of the complaint:
 Onset, course, duration, progression.
 Site: Any other lumps or bumps in the body like Arm pit or groin, your nape?
 Is it painful? (Painful in infectious causes) - Painless in (Neoplastic and proliferative disorder, Sarcoidosis)
Systemic symptoms of Differential diagnosis Hist:
Infection:
 TB: Any history of contact with TB patient, any hx of cough, coughing up blood, SOB, sweating?
 HIV: Any hx of blood transfusion, surgical operations, dental procedure, needle sharing, tattooing, piercing
- May i ask personal question please, Are you sexually active? How many partners do you have?
 Brucellosis, Cat scratch disease: Any history of contact with animals, or consuming animal products?
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Neoplastic and proliferative disorder (ALL, Lymphoma):
 Constitutional symptoms: Any history of high temperature, sweating, itching?
 Any ioss of weight? How many KG? For how iong? Intended or not? What about your appetite?
Autoimmune disorders amid coMagem (RA, SLE):
 Any joint pain, skin rash on the face, failing of hair, mouth sores, frothy urine?
Sarcoidosis:
 Any cough, shortness of breath?
 Any skin rash on the legs. (Erythema Nodosum)
 Any increased thirsty, water work frequency, constipation, iow mood. (Hyperciacemic symptoms)
Drug reactions (Phenytoin, Allopurinol):

What is your drug iist piease? Any over the counter medications? Any recreational drugs?
Storage Diseases: Any family history of similar condition?
Social history:
troubles you have.
Drug history: You asked before.
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FOCUSED EXAMINATION
Lymph node examination:

 From behind the patient: Anterior auricular, posterior auricular, mental, submandibular, cervical,
supraclavicular, occipital, Axillary. Take permission for inguinal lymph node exam.
Head Examination:
 For hair falling, malar rash, Mouth sores (SLE).
 Conjunctiva for pallor, Sclera for jaundice.
Chest Examination:
 Auscultate the midclavicular area for crepitations (TB, Sarcoidosis).
Abdominal examination:
 Inspection - Palpation for organomegaly - Percussion for ascites.
Lower iimbs examination: For erythema nodosum.
CONCERNS
What couid be the cause of my neck jump doctor?

 I appreciate your concern
 I'm sorry to tell you that Cancer is one of the possibilities, one kind of cancer is one of the lymph glands
causing increased size of the lymph glands.
 So we are going to admit you for further blood tests and imaging and may be take a snip from one of the big
glands under aseptic condition, image guided and local anesthesia after your consent to know the nature of
that growth.
 If confirmed then we will refer you to a MDT from a blood doctor , Macmillan nurse , social worker and
psychiatrist to decide for you the proper plan of care and management plane.
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Tall Stature (Marfan syndrome)
Scenario:
 Tall stature.
 Back pain and visual disturbance,
 Back pain and shortness of breath.
DifferemtM diagnosis:
 Familial (Constitutional).
 Endocrine: pituitary gigantism, precocious puberty, thyrotoxicosis, Acromegaly
 Genetic: Marfan syndrome, MEN2b, Homocystinuria, Klinefelter syndrome, Soto’s syndrome.
FOCUSED HISTORY
Anaiysis of the complaint:
 Onset: When this tall stature started exactly, since childhood or after being adult?
Familial: Any history of similar condition in your family like your parents or any of your family members?
Thyrotoxicosis: Any history of hot intolerance, Loss of weight, increased appetite, racing of heart beats, loose
motions, shaking of hands, Sweating, anxiety?
Acromegaiy: Any change in your facial features, change in ring and shoes size, headache, visual disturbance,
sweating, shortness of breath, joint pain?
Klinefelter: Decreased body hair, married or not, do you have children (infertility)?
Homocystinuria: Any educational troubles, any history of blood clots. Joint pain?
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Marfan syndrome:
 Museuiosketefa) (ductai ectesia, kyphoscoiiosis, pectus excavtum and craniatum, high arched paiate, joint
hypermobiiity):
Any back pain, shortness of breath, joint pain, iax joints?

 Ocuiar (Upward dispiacement of the Senses, retina! detachment, heterochromia of the iris):
Any eye pain, visual disturbance, double vision?
 Cardiac (AR, iViR, Pneumothorax, Aortic aneurism and dissection):

Any chest pain, racing of heart beats, shortness of breath, leg swelling, any family history of sudden death
MEN2b (Marfenoid features): Any neck lump, loss of weight, fever, lumps or bombs (medullary carcinoma), any
buccal, lips or tongue abnormality (mucosal neuroma) any history of high BP (pheochromocytoma).
Sociai history:
for that 1 will refer you to a social worker and occupational health care worker to manage any social or job
troubles you have.
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FOCUSED EXAMENATEON
Musculoskeletal:
 Tall stature the arm span is disproportionately longer in relation to the body length span.
 High arched palate.
 Arachnodactly:
 The thumb (Steinberg) sign is positive when the thumb completely enclosed within the clenched hand,
protrudes beyond the ulnar border.
 The wrist (Walker) sign is positive if the 1st and 5th digits of one hand overlap when wrapped around
the opposite wrist.
 Kyphoscolosis.
 Hyperextensible joints
Chest examination:
 Pectus exacvatum (most common) or craniatum.
 Scars for previous pneumothorax.
CVS:
 Auscultation for AR and MR.
 Signs of 2"d pulmonary hypertension.
 I would like to check BP (Pheochromocytoma in MEN2B)
Eye examination:
 Blue sclera, heterochromia of the irides,
 Tell the examiner I would like to do (fundoscopy) and (slit lamp examination) for this patient (Forupward
lens dislocation, glucoma, retinal detachment).
Examine for MEN2b:

Examine neck for thyroid lump (medullary carcinoma), mucosal neuroma (lips and tongue), 1 would like to check
this patient BP (pheochromocytoma).
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CONCERNS
What could be the cause of my tail stature doctor?
 Most probably you have a condition calied Marfan syndrome due to gene mutation which runs in families,
it's a muitisystem disease which affect your skeleton, valvular fesion of your heart, eye problems
 What we are going to do is to do some blood test, genetic test, and imaging to your spine, heart, and special
eye examination to confirm our diagnosis and to refer you to a MDT from a genetic doctor, heart doctor,
joint doctor, and eye doctor to give you the plan of management.
 If the patient have visual disturbance inform him it's mandatory to inform DVLA to assess his vision for
driving, because driving may carry a risk to your life and to the others.
 At the time being you have to avoid vigorous exercise, as it may carry risk on your life.
Can my children have the disease doctor?
 Unfortunately it's a hereditary disease, it runs in families, the chance of any of your children to have the
disease is 50%
 We will refer you and your children to genetic counseling team for counseling and screening of the disease.
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Pruritus
 Local skin disease: Eczema, Scabies, Viral infections such as chicken pox, Urticaria, Pruritus of old age
and xeroderma.
 Pregnancy and menopause.
 Pruritus reiated to systemic diseases: Liver disease renal disease Malignancy (leukemia, lymphoma),
Anemia due to iron deficiency, Hyper or hypoactive thyroid, Diabetes, HIV, Psychogenic.
 Drug induced: i.e. Morphine, Codeine, Aspirin, NSAID.
FOCUSED HISTORY
Analysis of the complain
 Onset: When this itching started exactly?
 Progression: Increasing, decreasing or the same
 Site: generalized or localized? Any specific site in the body?
 Worsening factors: Did you notice ant thing worsen your itching like any food (eggs, banana, strawberry,
fish), contact with any materials or wearing any specific clothes? (Allergy, Eczema, Urticaria)
 Improving factors: Anything improves your itching like avoidance any type of food or clothes or applying
any creams?
 Recurrence: Any history of similar symptoms in the past?
 Timing: Any diurnal variation?
 Associated Symptoms: Any SOB, noisy chest, dizziness, loss of consciousness (anaphylaxis, urticaria)
- Local causes:
 Any itching after ingestion of specific food, ingestion of drug or contact with specific material or clothes
(Mentioned before)
 Any member of the family has the same problem (Allergy, Scabies).
- Pyegnamcy and memopause:
 Last menstrual cycle, pregnancy if female (pregnancy).
 Hot Flashing, low mode, decreased libido, body pain (postmenopausal)
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- SYSTEMIC CAUSES:
Leukemia, lymploma, Malignency:
History of loss of weight, high temperature, night sweating, lumps or bombs, pallor than before, recurrent infection,
easy bleeding?
CLD: Any history of liver disease, tummy pain, yellow discoloration of the eye ball?, change in urine or stool color?
CKD: Any history of kidney problem, change in urine volume, color, frothy urine, puffins of the eye lids.
Thyroid disease:
 (Hyperthyroid) Any history of loss of weight, racing of heart beats, sweating, shaking hands, anxiety, loose
motions, period abnormality?
 (Hypothyroid) Any history of weight gain, cold intolerance, constipation, dry skin?
DM: Any history of DM, increased glucose level, increased thirsty, water work frequency?
Iron deficiency Anemia: Any history of dizziness, headache, pallor than before, SOB?
HIV: Any history of surgical operations, blood Transfusion, needle sharing, tattooing, piercing, travelling abroad,
may i ask personal question, are you sexually active, how many partners do you have?
- Psychogenic: Any history of low mood or mood disturbance?
- Drug induced: What is your drug list please? Any over the counter medications? Any recreational drugs?
Social history:
 What are you doing for living? How much the symptoms impact your job & usual daily activity? I'm sorry
troubles you have.
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Medicai history: Any history of DM, HTN, Cardiac problem, surgical operations, long standing disease?
Drug history: You asked before.
FOCUSED EXAMHNATMN
Examine the skin: For any skin eruption and scratch marks.
Hands:
 For clubbing, nail koilonychias, dupuytren contracture (CLD signs)
 Palmer erythema, sweating, tremors (Hyperthyroidism).
 Pulse: Tachy or Bradycardia (hyper, hypothyroid).
Eye examination:
Sclera for jaundice, conjunctiva for pallor (CLD, Anemia)
Abdominal examination: Inspection, percussion, palpation for organomegaly (CLD, malignancy).
Lymph node examination: (Take permission) for lymphoprolifrative disorder (Leukemia, lymphoma,
malignancy).
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Miscellaneous Notes
Station 2 and 5
(Acute emergency cases):
(Acute chest pain, Hematemisis and meiena, acute DVT, acute exacerbation of BA or COPD.. etc
-When you are going to do examination for the patient, before touching the patient, you have to teii the examiner:
 I Wouid tike to see the observation chart of the patient BP, PR, RR, Temp, to rute out that the patient in shock,
 I wanttofoiiowABCD protocoi,
 I want to put the patient under ciose monitoring of vital signs.,
-Then start your focused examination.

-This is wit) impress the examiner and wiii consider you a safe doctor.
Station (2 and 5) - How to reply the Concern perfectly?
If the patient asked what Couid i have doctor?
1 - Expiain simpiy what the patient most probabiy has (the most proper diagnosis and avoid jargons (medicat
terms).
2 - Expiain what you are going to do for the patient (btood tests and imaging) (avoid detaiis) to confirm your
diagnosis and to exciude others, if the patient for admission inform him.
3 - Referrai - teii the patient that you wiii give another appointment to discuss the resuits and refer him to a
specialized doctor or to a MDT if the diagnosis is confirmed
Communication (Station 4)
Concern - patient has cancer with metastasis
For how iong Fm going to iive doctor?
- it's not advised to teii a duration .i.e. for weeks or may be for months.. Don't give the examiner chance to catch
you, if you repiied may be for weeks, the examiner comment couid be he is not giving hope for the patient, if
you repiied may be months, the examiner might write he is giving faise hope for the patient.
-So the proper repiy is:
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-It varies from one patient to the other, according to your general Condition. Progression of the cancer and response
for treatment, but we will do our best, going to give him the full sociai, occupationai and financial support and to
keep you pain free att the time.
If the case is very advanced and just for only palliative treatment:
I'm sorry to tell you that his condition is very advanced, and he is not going to live for a long time.. But.. We will do
our best and will give him the full social, psychoiogical, financial support and to keep him pain free all the time.
In a case of advanced cancer with metastasis
The patient concern is: There is no hope doctor?
- Don't repiy yes or no.. As the examiner will catch you in both. If you replied No, the examiner comment will be
that the candidate didn't give hope for the patient..
- If you replied yes, there is hope, The examiner comment will be that the candidate is giving false hope in advanced
cancer.. So you have to be smart and to catch the stick from the middie.
- So the perfect reply would be: Unfortunately your condition seems to be advanced, but we will do our best for you
to help you as much as we can and to give you the full social, occupationai and financiai support and to keep you
pain free aii the time.
Showing empathy and sympathy
In a case of breaking bad news or counseling for chronic illness, don't forget to mention some important empathetic
sentences from time to the other like:
- How do you feel now Mrs., Mr....?

- I'm really sorry for these bad news today.
- I highiy appreciate your feeiing.
- I know how much these new are hard for you.
- Be sure that we are here to heip you as much as we can.
Station 5: Patient with Retinitis pigmentosa
Concern; Am i going to be btind doctor?
I’m sorry to tei! You that your condition is progressive, but we are going to give you the fuii sociai, psychoiogicai
and occupationai support. Studies and researches are going on, and we hope to find something promising in the
future..
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Station 5 – A tricky case
-There is SLE case mimicking all Deformities of RA, caited Jaccoud arthropathy.
-How to differentiate between Arthropathy of RA and Jaccoud arthropathy of SLE?
 Clinically: jaccoud arthropathy deformities can be corrected with movement.
 Radiologically: it is non erosive with no X ray finding.
In Station 2 and 5
If the examiner asked what is the treatment plan for the patient?
It’s very important to mention the non pharmacological treatment to impress the examiners..
You have to mention to the examiner that the treatment plan is:
 Non pharmacoiogicai in the form of
- Patient education and counseling

- Psychosocial support
- Occupational support (these 3 are fixed for all the cases).
- Physiotherapy if needed.
- Avoidance of triggers like any drugs or sun exposure for example,
 Pharmacological treatment according to the case.
Communication (St4)
Young lady with Multiple Sclerosis
Concern, i'm planning for marriage soon doctor, there will be any troubles in my marital life?
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-Congratulations. MS has some impact on usual daily activities and marital life despite that a lot of patients with
MS has successful marital life.
you and your partner are advised to do counseling before marriage, and we can arrange for another meeting for that.
-Regarding pregnancy: If you are planning for pregnancy, you can get pregnant without any complications.
if you are planning for pregnancy you should inform your nerve doctor and Obs doctor to make MDT team give you
the best care during pregnancy .
The Father has cancer.

You are discussing his condition with his son, his son asked you not to inform his father that he has cancer.
-I appreciate your feeling for your father. May 1 know why you don't your father to know?
As your father has the full mental capacity and is competent so that he has the right to know everything about his
condition and to share information and management plan with him (Patient Autonomy) we will provide him
information gradually according to his worries or quires.
-The examiner asked you in the discussion: Are you going to inform the patient even if he didn't ask about his
condition?
Reply: I'm going to provide him information according his quires and worries.
History taking (Station 2)
How to reply a concern in vague case and not clear proper diagnosis?
-Reply in general way, don't tell the patient proper diagnosis if the case has numerous DD with no clear proper
diagnosis, not to lose the concern.
-For example: (After listening to your history, i have to do full examination and investigations for you and admit
you (if indicated).. your symptoms has many underlying causes, we have to do for your further blood tests and
imaging to confirm our diagnosis, then we will arrange another appointment to tell you the results and we will refer
you to a specialized doctor to give you the proper plan of management)
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Communication (Station 4).. Osteoporosis
Concern: Dr I'm working as swimming trainer.. Do i have to stop my work?
-Actually swimming is good for your condition, and even you can get benefit from some weight bearing exercise as
it increase the bone density and muscle bulk, but you have to avoid vigorous exercise and sports as rugby and football
as it may expose you to recurrent bone fracture.
History taking (Station 2)
Pheochromocytoma
-Pheochromocytoma is a common case in Station 2.

May come in different scenarios like: Recurrent chest pain, high BP in young patient, palpitation, recurrent sweating
and glycosurea..
-In pheachromocytoma: you will find positive data in the form of Loss of weight, racing of heart beats .recurrent
headache, Anexiety .recurrent chest pain, recurrent sweating .shaking of the hands, High BP.
-It may be isolated or involved within other syndrome like (MEN 2, Von hippel lindu, Neurofibromatosis)
-Family history here is very important - Isolated pheochromocytoma may be familial in 10 % of cases - or Autosomal
dominant if involved within other syndromes - for example you may find Family history of father died because of
cancer kidney, this will guide you to the possibility of Inherited Von hippel lindu (Exam case)
Station 5
How to present a case of potyarthropathy in Station 5?
Three important things are required during your presentation to prescribe any polyarthropathy:
1 -Symmetrical or asymmetrical, deforming or non deforming polyarthropathy.
2 -Signs of active synovitis in the form of warmness and tenderness or absent active synovitis
3 -Functional status (Mild, moderate, or sever functional impairment)
Plus other signs of other systemic involvement.
For exampte, presentation of imaginary case of R.A:
This lady has symmetrical deforming polyarthropathy.

 Signs of active synovitis in the form of warmness and tenderness.
 Impaired functional status evidenced by difficult buttoning and unbuttoning and picking up coins.
 No evidence of other mixed connective tissue disease.
 The patient has bilaterai fine end inspiratory crackles indicating basal lung fibrosis.
312

Al-Rokh's Pacemaker of Paces

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Al-Rokh's Pacemaker of Paces

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Al-Rokh’s

Communication - History - Brief consultation

By/ Dr. Sadek Al-Rokh

No part of thispublication may be reproduced, printed or

Publisher: Middle East Libraries

And of knowledge, you (mankind) have been given only a little.

And to my wonderful wife for her patience and encouragement.

About Communication (Station 4)…..2

(Medical error) Angry son - Father developed Allergy for codeine…..35

Complication of a procedure Angry son - Father

died after a procedure (PCI) …..38

Counseling for DNR decision…..41

Counseling for Steroid therapy Side effects…..44

Counseling for Warfarin side effects…..47

Counseling for Genetic test…..50

Counseling for a procedure (SLE for Renal biopsy) …..53

Breaking bad news Counseling for hickman line

(Hodgkin Lymphoma for hickman line) …..56

Patient with Suicidal Attempt Asking For Discharge…..62

Somatization Somatoform Disorders…..66

Chronic Cough and Wheezy chest.....94

Chronic cough and hyponatremia.....100

Both Lower limb weakness.....105

Abnormal sensation in both Lower limbs.....115

Low Back pain.....131

Hematurea in young Femate.....146

Recurrent chest pain in young mate.....151

Recurrent Sweating and Gtycosurea.....157

Skin rash and SOB.....162

About station 5 (Brief consuitation)….176

Hereditary Hemorrhagic Telangectesia (HHT) ….186

Chronic Mouth Ulcer….199

Addison Disease (Hyperpigmentation)....212

Cushing Syndrome (Weight gain) ….216

Neck lump (Graves' disease) ….220

Obstructive sleep Apnea (Hypothyroidism) ….225

Systemic scterosis ….245

Diabetic& hypertensive Retinopathy….266

Limb weakness in young femaie….271

Sudden paintess loss of vision….275

Both lower limb swelling….278

Chest pain (Pulmonary embolism) ….281

Hematemsis and Metena….285

Tall Stature (Marfan Syndrome) ….292

Golden points in communication

 Beneficence: to do good for the patient.

 Non malfeasance: not to harm the patient.

Other Ethical issues according to the case:

of HIV and Genetic testing)

 Admission under the mental health act: If the patient has

– Shake hands with the surrogate.

Gradual breaking of the news:

– Start breaking of the news:

Shwoing empathy and sympathy:

Explanation of the disease:

Do you want me to explain to you more about your condition?

 Main points of management without details.

 Smoking and alcohol history?

– Nice to meet you - Shake hands.

Breaking the news gradually:

Explain the disease simply without jargon:

Concerns: Do you have any concern?

- Is it curable condition Dr?