SURGERY History and Counselling Notes

 

 

SURGERY HISTORY AND COUNSELLING STATIONS

PAGE 1 UPPER ABDOMINAL PAIN (RUQ/LUQ)  2 LOWER ABDOMINAL PAIN (RIF/LIF)  3 HAEMATEMESIS  4  ANAEMIA (FIND THE CAUSE)  5 CHOLECYSTECT CHOLECYSTECTOMY OMY CANCELLED 6 DYSPHAGIA  7 PERRECTAL BLEED  8 MELAENA  9 HAEMATURIA  10 TESTICULAR PAIN  11 BACK PAIN 12 KNEE PAIN 13 HAEMOPTYSIS 

 

UPPER QUADRANT QUADRANT ABDOMINAL PAIN PAIN  STEP 1: P1

What brought you to the hospital today? S

Site of pain: point out with finger

O Onset: Since when, How did it start (sudden or gradual), Is it the first time? C

Character: dull, sharp, colicky

R

Radiation: does it go anywhere –  anywhere –  e.g.  e.g. shoulder, back

A

Associated symptoms –  symptoms –  ask  ask all the cardinal symptoms of GI system

T

Timing: All the time? Comes and goes? Related Relat ed to time of the day?

E

Exacerbating & relieving factors: food, breathing, position

S

Severity: Grade on a scale of 1 to 10, with 10 being the worst

STEP 2: Rule out any remaining D/Ds

Differential Diagnosis of R/L Upper Quadrant & Epigastric Pain

Imagine moving from base of lung l ung downward. Differentials Lungs 

Right basal Pneumonia Hepatitis Hepatitis A Hepatitis B/C

Liver 

Alcoholic hepatitis Autoimmune hepatitis

Relevant Questions

Cough/sputum/fever Cough/sputum/fever General - yellow discoloration of skin & eye Diarrhoea/Vomiting Diarrhoea/Vom iting + travel history Blood transfusion abroad/tattoo/drug abroad/tattoo/drug abuse/sexual Hx Hx of Alcohol

 

Acute cholecystitis

Biliary Tree 

Stomach & duodenum  Pancreas

Fever. fatty food worsens the pain. Radiation to shoulder tip Dark urine & pale stool

Biliary obstruction [gallstones/stricture/Ca head of pancreas] Pain comes and goes, radiates to back Biliary colic Charcot’s triad: fever, jaundice, rigors  rigors   Cholangitis Ulcer/APD

Food worse (gastric) or ease (duodenal) /melaena/vomit blood/NSAIDS or Aspirin or steroid use

Pancreatitis

Radiate to back/ease by leaning forward

Calculi

Hx of passing stones / poor stream /  pinkish colour / burning / Pain while  passing urine / colicky pain Pain of calculi: Renal –  Renal  –  flank  flank Bladder suprapubic Urinary –  Urinary  –  1/3  1/3 upper: loin to groin 1/3 middle: appendicitis R mimics

Kidney and rest of urinary system 

Pyelonephritis

L mimics diverticulitis 1/3 lower: male –  male –  tip  tip of  penis female –  female  –  labia  labia majora All above + fever / recurrent UTI / smelly urine

  STEP 3: Complete P 2, 3-7 MAFTOSA

Task : A 25 year old lady presents with RUQ pain. Talk to the patient. Discuss D/Ds with examiner. Patient History

1.  RUD pain radiating from loin to groin 2.  +/- poor stream 3.  +/- h/o passing stone 4.  +/- pinkish urine 5.   No fever 6.   No discharge 7.   No sexual history

 

8.   No history of excessive alcohol 9.  Lying on the couch in hospital gown Diagnosis:

Ureteric Calculi Task : A 40 year old female/male presents with abdominal pain. Talk to the patient. Discuss D/Ds with the examiner. Patient History

1.  2.  3.  4. 

RUQ pain Flu like symptoms (= fever in GMC) Smelly urine H/o passing stone 5 years ago

Diagnosis:

Pyelonephritis

LOWER QUADRANT ABDOMINAL PAIN   STEP 1: P 1

What brought you to the hospital? S

Site of pain: point out with finger

O Onset: Since when, How did it start (sudden or gradual), Is it the first time? C

Character: dull, sharp, colicky

R

Radiation: does it go anywhere –  anywhere –  e.g.  e.g. shoulder, back

A

Associated symptoms –  symptoms –  ask  ask all the cardinal symptoms of GI system

T

Timing: all the time? Comes and goes? Related to time of the day?

E

Exacerbating & relieving factors: food, breathing, position

 

S

Severity: Grade on a scale of 1 to 10 with, 10 being the worst

STEP 2: Rule out any remaining D/Ds Differential Diagnosis of R/L Lower Quadrant Pain C-AUDIOS-TEMP-F

Differentials Differentia ls C  Cancer bowel Appendicitis

Relevant Questions Lump, nine questions of Ca bowel*

 A   A 

Pain migrates from umbilicus umbilicu s to RLQ,, fever+/-vomiting, fever+/-vomi ting, constipation, diarrhoea

U  UTI

Burning, pain pinkish while passing fever, smelly, urine urine, increased frequency,

Diverticulitis

LIF pain relieved by defecation, PR bleed, signs of infection

IBD (UC/CD) Gastroenteritis / Colitis

Diarrhoea, PR Bleed, skin, joint problem and eye problem Other members of the family also affected

D 

I 

Obstructio n O  Obstruction Calculi

Constipation, Constipati on, not passed wind, vomiting, distension Hx of passing stones / poor stream / pinkish colour /  burning / Pain while while passing urine / colicky pain Pain of calculi: Renal –  flank Renal –   flank Bladder suprapubic Urinary –  Urinary  –  1/3  1/3 upper: loin to groin 1/3 middle: R mimics appendicitis L mimics diverticulitis 1/3 lower: male –  male –  tip  tip of  penis female –  female  –  labia  labia majora

S 

Hernia

Swelling that used to go in. Now tender and doesn t go in. ’

 

T

E

Testicular torsion Torsion of ovary/ovarian cyst

Sudden onset. Increased by lifting testes Previously had U/S which showed fluid filled sac. Fullness in tummy

Epididymorchitis Ectopic

Gradual onset, fever, decreased by lifting testes LMP => 4 wks, +ve sexual hx, pregnancy test, +/- IUCD use

M Miscarriage P

LMP => 4 wks, +ve sexual hx, PV bleed

PID

Fever, back pain, discharge, dyspareunia, IUCD, sexual hx

Fibroid

Dull dragging sensation in abdomen, menorrhagia, anxious to become pregnant.

F

* Ten Questions for bowel cancer written under Station 3 below

STEP 3: Complete P (2,3,4,5,6,7) MAFTOSA

STEP 4: Other D/Ds if you have time

Abdominal aortic aneurysm- pain radiating towards the back. Task : A 25 year old female presents with RIF pain. Talk to the patient and discuss D/Ds with the examiner. Patient History

1.  RIF pain 2.  LMP 5 weeks ago 3.  +/- Using IUCD 4.   No vomiting, fever or discharge 5.  Patient lying on couch in hospital gown Diagnosis:

 

Task : A 20 year old female presents with pain in the lower tummy. Talk to the patient and discuss management with the patient. Patient History

1.  Lower tummy pain since 2 days 2.  Same episode 2 weeks ago

 

3. micturition 4.  Burning Pinkish urine 5.  Flu like symptoms 6.  LMP 2-3 weeks ago 7.   No discharge, h/o passing stone or radiation radiation of pain (Diagnosis = UTI) Management with the patient: (Note: Mx in GMC = Dx, Ix, Rx)

After speaking with you, I think you have got something called urinary tract infection. This means that some bugs/germs are growing in your bladder and related structures/organs. struct ures/organs. But we need to confirm this by doing some tests. We need to take a urine sample from you (mid stream urine for C/S, dip stick for nitrates, protein and leukocytes). We may also consider U/S. (note: U/S must in all paeds + adult male. U/S in adult female only if = > 2 episodes in the last 3 months) Once confirmed, we’ll give you some medications called antibiotics, which will kill those  bugs/germs. By any chance are you allergic to antibiotics? Please drink enough water. We may also give you pain killers if needed.

Task : A 70 year old female presents with LIF pain. Talk to the patient. Discuss D/Ds with the examiner. Patient History

1.  2.  3.  4. 

LLQ pain Altered bowel habit Weight loss (~3kg in last 2 months) Family h/o bowel cancer

Diagnosis: Ten questions of bowel cancer:

i.  ii.  iii. 

Weight loss (late sign of cancer so may not always be there) Loss of appetite general questions for any cancer   Anaemia questions (tiredness/fatigue, heart racing, SOB, light headache)

 

iv.  v.  vi.  vii.  viii.  ix.  x. 

Alternating bowel habit Change in bowel habit Blood in stool Tenesmus Family h/o cancer Abdominal pain Abdominal lump

HAEMATEMESIS  STEP 1: P1

What brought you to the hospital today?

O  Could you you tell me anything more about it? Are you sure it is not from your lungs or mouth? What colour? Bright/dark? Anything else with the blood? Is it mixed with food? Or pure S  blood? O  How did it start? D  Since when? I 

How much blood? Half a cup? How often?

P  Is it getting worse?  A   A  Anything makes it worse? Like food

 

Anything makes it better?

R 

 A   A  Any other symptoms? F  Is it the first time you got this problem? Ask all the cardinal symptoms of GI system Ask questions for Anaemia. C  (tiredness/fatigue, light headedness, SOB, heart racing) (any station with bleeding MUST R/O anaemia)  anaemia) 

STEP 2: Rule out any remaining D/Ds

Differential Diagnosis of Haematemesis I-COUMB

Differentials Differentia ls Infection I  Oesophagitis Cancer C  [oesophageal/stomach] Oesophageal Varices

Relevant Questions Fever? Dysphagia? Or pain on swallowing? Heart burn while lying down Dysphagia? Pain on swallowing? Lump? Weight loss? Loss of appetite? Anaemia questions. Family History? Smoking history. Also fullness (stomach Ca)

O 

Chronic alcohol history? Signs of portal hypertension Or Chronic alcohol signs of liver disease

Ulcer[barret/gastric/duodenal] ric/duodenal] U Ulcer[barret/gast

Pain related to meal, heart burn. Irregular meal. PH

Malorry-weiss Malorry-we iss tear M

B

Four D/Ds of any bleeding Blood thinner

Alcohol binge binge drinking?  drinking? Were you vomiting repeatedly before the blood come? Are you taking any blood thinner medications? Warfarin? Aspirin? NSAIDS or ibuprofen?

 

Bleeding disorder

Did you have bleeding from any part of your body? Or have you or your family member been diagnosed with any bleeding disorder?

Instrumentation Instrumentatio n

By any chance have you gone through any procedure or instrumentation of your gut recently?

Trauma

By chance did you get hurt on your gut? Swallowed anyany object [bone]?

STEP 3: Complete P (2,3,4,5,6,7) MAFTOSA Diagnosis:

Mostly Oesophageal Cancer

ANAEMIA: FIND THE CAUSE   Task : A 45 year old man was planned for herniorrhaphy. herniorrhaphy. Lab report shows his Hb = 8. Talk to the patient and address his concerns. (Note: This station starts with counselling and then goes on to Hx.) Talk to the patient:

I’m here to speak to you about the blood test we did for you. I have the result with me now and it shows that you have anaemia. Do you know anything about it? It means that your blood is weak. In this condition there’s not enough of haemoglobin in the  blood. Haemoglobin has has the important function of carrying O2 to the b body. ody. Because of anaemia, unfortunately we have to postpone your surgery.

P ati ent nt:: why? ((a angr ngry) y)   Doing surgery while you are anaemic can be dangerous. When we put you to sleep,



your body may not get enough O2 from your blood because of lack of haemoglobin.

 

  Also, after the surgery you may face other problems like infection or delay in wound



healing.  Patient: Why didn’t didn’t you tell me before? before? 

Apologize and tell the patient that we did some tests tes ts to check whether you are fit for the t he surgery or not, and that is when we found out.

P ati ati ent: one of my fr frii ends had the same same pr prob oblem lem and dur durii ng sur surgg er y he rre ecei cei ve ved db bloo lood d transfusion. Why can’t I have the same?  The thing is that blood transfusion has its own complications. And it is given only if it is an emergency surgery. But your procedure is not an emergency.

P atient tient:: whe hen n ca can n I hav have e the surg sur g er y? It may take few months but as soon as your haemoglobin level returns to normal, we can have the surgery. (It takes 1 month to increase Hb by 1 unit. Surgery is done at Hb minimum 11) Finding the cause of anaemia:

Explain to the patient that anaemia could be due to many reasons among which are, not eating enough iron, or losing blood from somewhere. Then take history to find out the cause.

STEP : Rule out the D/Ds Differential Diagnosis of Anaemia M5 RBC

Differentials

Relevant Questions

M  Malignancy

Weight loss? Bumps or lumps? FH? Dark stool? Altered bowel habit? Change in bowel habit?

M  Malabsorbtion Malabsorbtio n

Diarrhoea? Steatorrhoea / Hard to flush? Bloating? Discomfort? Past hx

M  Malnutrition Malnutriti on M  Malaria

Diet? How often? Diarrhoea? Food intolerance? Dark urine? Fever? Travel history to tropical country? Cabamazepine? Colchicines? Clozapine? Chemotherapy? Also NSAIDs and other medicine which causes gastric erosion.

M  Medication Rheumatoid R  Arthritis

Small joint pain?

 

B  Bleeding 4 D/Ds

C 

Chronic renal failure

Blood thinners, Bleeding disorder, instrumentation, trauma Bladder habit? Past Hx of kidney problem?

Complete P7 MAFTOSA

1 2 3 4

Questions of symptoms of anaemia Do you feel tired all the time? Do you feel any racing of the heart? Do you feel light headache? Do you feel shortness of breath?

(*note: this station starts with counselling and then goes to history)

years Patient History  : Patient on aspirin since 10 years Management : (Dx, Ix, Rx)

Diagnosis: Aspirin happens to be one of the medications which can cause bleeding inside the t he gut/tummy/stomach. Since you are taking aspirin since a long time, it may be the cause of your anaemia due to bleeding inside. So please stop taking Aspirin. Don’t worry we will give you some alternative which will not cause the bleeding. Investigations: We need to confirm this by doing some tests. test s. We’ll do something called called endoscopy in which a flexible tube with a camera attached is used to see iinside nside your gut. It is inserted through the mouth. We may also take a tissue sample. Also, we may do some other tests (blood for IDA, scans) Treatment: 1.  Stop aspirin. We’ll We’ll give give you some alternative which will not cause the bleeding 2.  Iron tablets

 

3.  Vitamin C and give advice about orange juice. We may refer to dietician.

DYSPHAGIA  Task : A 65 year old man/lady presents with dysphagia. Patient is on H2 blocker cimetidine, some PPI and antacid due to reflux disease since last 5 years. Talk to the patient and discuss investigations in vestigations with the examiner examiner.. STEP 1: P1

What brought you to the hospital today?

O  Could you tell me something more about it? S  Please point out with finger where exactly you feel difficulty? What sort of difficulty occurs? Difficulty in initiating swallowing? Any discomfort? Pain? Regurgitation? Vomiting? Coughing and choking? O  D  I  P   A   A  R   A   A  F  C 

How did is it start? start? Gradual? Sudden? Started with solids or liquids? liquids? Since when? How often? All the time when you eat? Swallowing liquid? liquid? Saliva? Is it getting worse? Anything makes it worse? Particular food? Solid? Cold or hot food? Anything makes it better? Liquid? Small pieces of food? Any other problem? Is this the first time? Stridor? Dysphonia /hoarseness? Pain? Dysphasia? Sore throat?

STEP 2: Rule out any remaining D/Ds

Differential Diagnosis of Dysphagia PEGG COMPASS

Differentials Differentia ls Palsy[Stroke/spine P  injury/botulism/MS/PSP/ALS/Parkinson] Bulbar palsy E 

Endoscopy/instrumentation

Relevant Questions Difficulty in talking? Making sound? Other weakness? Difficulty initiating swallowing swallowing Did you have any procedure done recently?

 

G  GORD

Belching? Heartburn, worse on lying?

G  Globus hystericus

Do you have a sensation of lump in your throat?

C 

Cancer Oesophagus

Starts first with solids Weight loss? Weakness? Smoking? FH? worsening? Steady, gradual

O 

Oesophagitis or Infection of tonsil, larynx or epiglottis

Fever, pain (odynophagia)

M  Myasthenia

Worse in the evening? Feel weakness in evening or after exertion?

P  Pharyngeal pouch

Bad breath? Food on pillow in morning? Old food regurgitated?

 A   A  Achalasia

Starts with liquids

S 

Stricture

Long time heart burn? Or past corrosive ingestion? Any procedures/instrumentations done?

S 

Spasm (diffuse esophageal spasm DES)

Intermittent? Cold or hot food Intermittent? makes it worse?

STEP 3: Complete P (2,3,4,5,6,7) MAFTOSA

Patient History : must ask about smoking

1.  Difficulty started with solids 2.  2 kg weight loss in 2 months 3.  Loss of appetite Investigations Investigatio ns with the examiner:

1.  Ba swallow 2.  Endoscopy

 

3.  CT CT –   –  scan  scan If task says management with the patient:

After speaking with you I’m suspecting there may be an abnormal an  abnormal growth in your food pipe / gullet. But we need to confirm that with some investigations. 1.  We’ll do a special X-ray X-ray in which you will be asked to swallow a dye. d ye. 2.  We’ll also put a put a flexible tube with a camera attached to it, inside the food pipe. We may take some sample. 3.  And we will also do a CT scan If we confirm our diagnosis, the treatment will be surgery.

PER RECTAL BLEED  Task : A 70 year old female presents with bleeding PR. Lab report shows Hb = 6.7, MCV = 65. Talk to the patient and discuss D/Ds with the examiner.

STEP 1: P1

What brought you to the hospital today?

O  S  O  D  I  P   A   A  R   A   A  F  C 

Could you tell me something more about it? What colour? Mucous? Coated on stool? Splashing? On tissue? How often? How did it start? When did you notice it first? How much? Is it getting worse? Anything makes it worse? Food type? Anything makes it better? Any other problem? Is it the first time? Ask all the cardinal symptoms of GI system. Tenesmus? Lump?

STEP 2: Rule out any remaining D/Ds

 

Differential Diagnosis of Per Rectal Bleed BHF CUPPID

Differentials B 

Relevant Questions

H  F  C  U 

Haemorrhoids Haemorrhoids Fissure Cancer colon

Are you taking any blood thinners? Do you have any bleeding problem? Did you have any procedure done recently via your back passage? By any chance got hurt? Splashing blood on pan? Any painless mass coming out? Painful defecation? defecation? Blood on tissue? Visible fissure on opening? Weight loss? Altered bowel habit? Change in bowel habit? FH? Lump?

IBD

Diarrhea, tummy pain? Fever? Past history? Skin lesion?

P  P  I  D 

Polyp Prolapse Gastroenteritiss Gastroenteriti Diverticulitis Diverticul itis

Family history or past history of polyp Mass popping out from back passage? Fever? Diarrhoea? Pain? Other members of the family LIF pain relieved on defecation? Fever? Old age?

Bleeding D/Ds

STEP 3: Complete P (2,3,4,5,6,7) MAFTOSA Patient History

1.  Fresh bleeding 2.  2 kg weight loss in last 1-2 months. 3.  SOB even while talking to you 4.  Tiredness on simple activity 5.  Constipation during last two months 6.  Taking aspirin since 10 years after MI 7.   No family h/o bowel cancer 8.   No tenesmus 9.   No fever 10.  No  No tummy pain Diagnosis:

MALAENA  Task : A 60 year old male/female presents with complain of dark stools. Talk to the patient and give 2 D/Ds to the examiner. STEP 1: P1

What brought you to the hospital today?

 

(Same as PR bleed)

O  S  O  D  I  P   A   A  R   A   A  F  C 

Could you tell me something more about it? What colour? Mucous? Coated on stool? Splashing? On tissue? How often? How did it start? When did you notice it first? How much? Is it getting worse? Anything makes it worse? Food type? Anything makes it better? Any other problem? Is it the first time? Ask all the cardinal symptoms of GI system. Tenesmus? Lump? Ask questions for Anaemia. (tiredness/fatigue, light headedness, SOB, heart racing) (any station with bleeding MUST R/O anaemia)  anaemia) 

STEP 2: Rule out any remaining D/Ds Differential Diagnosis Melaena

Differentials

Relevant Questions

Mallory-Weiss

Alcohol binge binge drinking?  drinking? Were you vomiting repeatedly before the blood come? 

Oesophageal varices

Chronic alcohol history? Signs of portal Chronic alcohol hypertension hyperte nsion Or signs of liver disease 

Gastric cancer

Weight loss, loss of appetite, tiredness, family history

APD (+/- NSAID induced)

Heart burn, pain related to meals, past history, medications

Four D/Ds of any Bleeding

Bleeding disorders, blood thinner medications, instrumentation, trauma

STEP 3: Complete P (2,3,4,5,6,7) MAFTOSA Patient History

1.  On diclofenac since 9 months for osteoarthritis 2.  Feels tired with light headedness 3.  +/- no weight loss 4.   No family h/o bowel cancer 5.   No change in bowel habit habit

 

2 D/Ds:

1.  Diclofenac induced APD 2.  Gastric cancer

HAEMATURIA  Task : A 65 year old man presents with haematuria. Take history and discuss investigations with the patient. STEP 1: P1

What brought you to the hospital today?

O  Could you tell me something more about it? Colour of urine? Do you also get pure blood? Is it at the start of urine or at the S  end or throughout? Is that every time when you pass urine? O  D  I  P   A   A  R   A   A  F 

How did it start? Since when? How much blood? How bad? How pinkish? Is it getting worse? Anything makes makes it worse? Type of food? Sex? Anything makes it better? Any other problem? Is it the first time?

Ask all cardinal symptoms of Genito-urinary system and sexual function C  Ask signs of anaemia (tiredness/fatigue, (tiredness/fatigue, heart racing, SOB, light headache)

STEP 2: Rule out any remaining D/Ds

Differential Diagnosis of Haematuria S-CUBBICS

Differentials S  Substances (false)

Relevant Questions Any change in diet? Does that happen only when you eat particular food?

 

Weight loss? Smoking? Exposure to aniline dye? Cancer[renal/bladder/prost  C  Note: painless haematuria = bladder cancer until R/O ate] otherwise U  UTI

Fever? Pain on passing urine? Change in colour and smell of urine? Are you taking any blood thinners? Do you have any

B  Bleeding 4 D/Ds

bleeding problem? Did u get hurt by any chance? Any procedure done down below?

B BPH

Dribbling, poor stream, waking up at night to go to loo

I 

Infection[pyelonephritis, prostatitis,, urethritis, STI] prostatitis

Fever? pain? Sexual Hx? Discharge? Recurrent UTI

C  Calculi

History of passing stone? Dehydration? Pain while passing urine, colicky pain, poor poo r stream

S  Schistosomiasis

Swimming lake? Travel to tropical countries? Past infection?

STEP 3: Complete P (2,3,4,5,6,7) (2,3,4,5, 6,7) MAFTOSA Patient History

1.  Haematuria since 2-3 weeks 2.   No pain 3.  2 kg weight loss 4.  +/- loss of appetite 5.  Smoking since 25 years of age 6.  +/- frequency, urgency & dribbling 7.   No fever 8.   No h/o passing stone

Diagnosis:

TESTICULAR PAIN  Task : A 30 year old man presents with pain in the private parts. Talk to the patient. Discuss 2 D/Ds and management management options with the patient. STEP 1: P1

 

What brought you to the hospital today?

S

Site of pain: Which side, or both? Where exactly? In a localized area? Or generalized pain?

O Onset: Since when, How did it start (sudden or gradual), Is it the first time? C

Character: dull, sharp

R

Radiation: does it go anywhere

A

Associated symptoms –  symptoms –  ask  ask all the signs of GU system, infertility. Take sexual Hx

T

Timing: all the time? Comes and goes?

E

Exacerbating & relieving factors: position, lifting the testes

S

Severity –  Severity  –  grade  grade on a scale of 1 to 10 with 10 being the worst

STEP 2: Rule out any remaining D/Ds Differential Diagnosis of Testicular Pain M-TESTIS

Differentials

Relevant Questions

M  Mumps

Recent (4-6 wks ago) cheek swelling, pain & flu like symptoms

T  Testicular torsion

Sudden onset severe pain? After brisk activity? Short duration. Upon lifting testes pain gets even worse.

E  Epididymo-orchitis

Gradual? Fever? Quite long duration. +ve sexual history. Upon lifting testes pain gets better.

S Stones[referred pain] T Trauma - haematoma I

Infection [UTI, prostatitis, orchitis, skin lesion]

Hx of passing stones, poor stream, pinkish colour, burning, pain while passing urine, colicky pain

Got hurt by any chance? Fever? Discharge? Sexual Hx? Urinary symptoms

 

S

Swellings [hydrocoele, varicocoele, spermatocoele, ingiunal hernia, tumour]

Significant swelling

STEP 3: Complete P (2,3) MAFTOSA

Patient History: ( 3 possibilities, one is given below)

1.  Pain started two days ago, at which time the score was 4/10 2.  Patient woke up this morning due to severe pain, now the score is 7/10 3.  Pain in both testes 4.  2-3 days ago patient had flu like symptoms 5.   No discharge, no redness, no hotness hotness 6.  Sexual hx: Patient hx: Patient says I says I can’t remember the last time I had sex or I’m not sexually active or the last time I had sex was 6 months ago. 7.  Any increase or decrease in pain upon lifting the testes?  Patient says why should I lift  / I didn’t think about it .

Talk to the patient about 2 D/Ds and management (Dx + Ix+ Rx):

After speaking with you, you, I’m suspecting two conditions.  conditions.  Dx 1: The first is epididymo-orchitis. This means that there is inflammation of the testes and surrounding structures due to some germs / bugs growing there. Ix: But we need to confirm this by doing some tests. We need to take a urine sample from you (dip stick + 1st catch urine culture) We’ll also take a swab  swab  Rx: Once we confirm the diagnosis we’ll give you medications called antibiotics that kill the germs / bugs. By any chance are you allergic to antibiotics? an tibiotics? (< 35 years (STI) (STI) –   –  doxycycline  doxycycline 100 mg BD x 10 days. > 35 years (UTI) –  (UTI) –  ceftriaxone  ceftriaxone 300 mg BD x 10 days) Dx 2: The second is testicular torsion. This means there is twisting of testes inside the sac (scrotum). Rx: This is an emergency and needs surgery right away. awa y. In the surgery we move the testes  back in the normal position and then fix fix both the testes so anything like this doesn’t happen again. Since it happened more than 6 hours ago, there may be significant damage to the twisted testes. In that case, if there is significant damage, we may have to remove the affected testes. (B/L orchidopexy +/- orchidectomy)

 

BACK PAIN  Task : A 55 year old male presents with back pain. Take history and discuss investigations with the patient. Discuss D/Ds with the examiner. STEP 1: P1

What brought you to the hospital today? S

Site of pain: upper or lower back

O Onset: Since when, How did it start (sudden or gradual), Is it the first time? C

Character: dull, sharp

R

Radiation: does it go anywhere –  anywhere –  to  to the arms / legs?

A

Associated symptoms –  symptoms –  tingling  tingling and numbness of limbs

T

Timing: all the time? Comes and goes? Early morning?

E

Exacerbating & relieving factors: rest, exercise

S

Severity –  Severity  –  grade  grade on a scale of 1 to 10 with 10 being the worst

STEP 2: Rule out any remaining D/Ds Differential Diagnosis of Back Pain

Differentials

Relevant Questions

Secondary metastasis Weight loss, loss of appetite, tiredness, SOB Lung

Chest pain, cough, haemoptysis

Breast

Pain / lump in breast

Prostate

Dribbling, poor stream,

Multiple myeloma

Bleeding, infections, anaemia

Osteoporosis of vertebrae

Loss of height over time, hx of fractures

Osteoarthritis

Morning stiffness

 

Trauma

Did you get hurt by any chance?

Prolapse

Did you do any heavy lifting?

Infection (TB/Pott’s) (TB/Pott’s)  

Fever, night sweats, anorexia, weight loss Have you had any red eye? Has anyone in in

Ankylosing spondylitis

your family been diagnosed with ankylosing spondylitis?

STEP 3: Complete P (2,3,4,5,6,7,) MAFTOSA

Patient History

1.  Low back pain becoming worse in the last two months 2.  Wakes up every night to go to loo since last month 3.  One stone weight loss in 2 months 4.  Morning stiffness 5.   No haematuria 6.   No heavy lifting Diagnosis

Secondary metastasis from prostate cancer Investigations Investigatio ns with the patient:

After speaking with you, I’m suspecting some problem with your prostate prostate (abnormal growth), which is also leading to the back pain. But first I need to confirm the diagnosis by doing some investigations. We need to do a blood test (PSA). We will also do an U/S and take a sample (TRUS +  biopsy). And we may also do an X-ray (for bony metastasis) as well as a CT and MRI scan (other organ metastasis)

KNEE PAIN  Task : A 28 year old male presents with complain of knee pain. Take history and discuss D/Ds with the examiner.

 

STEP 1: P1

What brought you to the hospital today? S

Site of pain: Which side, or both? Where exactly? In a localized area? Or generalized pain?

O Onset: Since when, How did it start (sudden or gradual), Is it the first time? C

Character: dull, sharp

R

Radiation: does it go anywhere

A

Associated symptoms –  symptoms –  redness,  redness, hotness, swelling

T

Timing: all the time? Comes and goes?

E

Exacerbating & relieving factors

S

Severity –  Severity  –  grade  grade on a scale of 1 to 10 with 10 being the worst

STEP 2: Rule out any remaining D/Ds Differential Diagnosis of Knee Pain GHRRROSS Differentials

Relevant Questions

G

Gout

Did you have any pain in your big tow before? Thiazide diuretics

H

Haemarthrosis

Bleeding, redness of joint

R

Reiter’s   Reiter’s

Can’t see, can’t pee, can’t climb a tree  tree 

R R

Reactive arthritis Rheumatoid Arthritis

Past infection

O

Osteoarthritis

Small joint pain

S

Septic arthritis

fever

S

Sport injury

Did you get hurt by any chance? Do you play a lot of sports?

STEP 3: Complete P (2,3.4,5,6,7) MAFTOSA Patient History

1.  Knee and ankle pain since last week 2.   No pain in small joints

 

3.  +/- morning stiffness 4.  +/- calf pain 5.  +/- watery eye 6.  Travel history to France 2 weeks ago 7.  Diarrhoea in France ruined holidays 8.   No fever, or burning 9.  Safe sex

Diagnosis:

HAEMOPTYSIS  Task A 65 year old female/male presents with haemoptysis. haemoptysis. Talk to the patient. Discuss D/Ds with the examiner. STEP 1: P1

What brought you to the hospital today?

O  Could you tell me something more about it? Are you sure it is not from your gut or mouth? What is the colour of blood? Is there S  anything with the blood? O  How did it start? D  Since when? I  How often? How much? Half a cup? On tissue? tissue ? F  Is it the first time? P  Is it getting worse?  A   A  Anything makes it worse? Like cough? Smoke? R  Anything makes it better? Rest /sleep  A   A  Any other problem? Ask cardinal symptoms of respiratory system C  Ask signs of anaemia (tiredness/fatigue, heart racing, SOB, light headache)

STEP 2: Rule out any remaining D/Ds Differential Diagnosis of Haemoptysis PEP-C-BATCH

 

 

Differentials

Relevant Questions

P 

Pneumonia

Cough, chest pain, fever. Anyone else in your close contacts has similar symptoms?

E 

Endometriosis Endometriosis

P 

Pulmonary Embolism

Do you get this during your period? Calf pain? Recent surgery? Travel history. Clotting problem?

C 

Cancer[Bronchogenic carcinoma/Kaposi sarcoma/carcinoid tumor/metastatic tumor] Bleeding 4 D/Ds: Bleeding disorder

Weight loss? Family history? Smoking? [In the past / how long? How many in a day]

Bleeding from any other part of body? Any FH?

Blood thinners B (2)

Are you taking any blood thinners? Did you have any procedure or

Instrumentation

instrumentation recently? Trauma/foreign Trauma/f oreign body

By any chance did you hurt yourself or had choking?

Bronchiectasis Bronchiecta sis

Recurrent chest infections. A lot of sputum per day

Abscess

Do you have fever? Yellow smelly sputum?

 A   A 

T 

TB

C 

COPD/Bronchiectasis COPD/Bronchiectasis

Night sweats? Fever? Recent travel abroad? Any contact with TB patient? [or any other people have same symptoms where you live or that you meet often?)

H 

STEP 3: Complete P (2,3,4,5,6,7) (2,3,4,5, 6,7) MAFTOSA

Patient History

1.  Blood in sputum (1/2 cup) in 8 weeks OR;

Smoking? Chronic cough? SOB

 

2.  Had previous episode of haemoptysis within a month ago. Had seen GP who gave antibiotics. Haemoptysis went away but had another episode again now, since last las t few days. 3.  Last time sputum was more yellow with specks of blood. This time it is clearer with specks of blood. 4.  Smoking history since 30 years, 20 cig per day, No history of long travel 5.   No history of long travel 6.   No weight loss 7.   No close contact with TB patient 8.   No family history of cancer Diagnosis: