Fast PACES Academy Station 5
Fast PACES Academy Station 5
Fast PACES Academy Station 5
Station 5
Topic Page
1 Introduction in Station 5 03
2 Scheme for Station 5 04
3 Side Effects of Medicines Frequently Asked in Station 2 & 5 05
4 Leg Ulcer 06
5 Psoriasis 16
6 Other Possible skin cases in PACES 19
7 Musculoskeletal Cases and Connective Tissue Disorders 20
8 Seronegative spondyloarthropathies 22
9 Ankylosing Spondylitis 23
10 Reactive Arthritis 27
11 Psoriatic arthritis 29
12 IBD 31
13 Rheumatoid Arthritis 35
14 Gout 40
15 Polymyositis and Dermatomyositis 44
16 Systemic Sclerosis 49
17 Anti-Phospholipid Syndrome 54
18 Polymyalgia Rheumatica 55
19 Giant Cell Arteritis (GCA) 56
20 Granulomatosis with Polyangitis 57
21 Swelling in Neck 59
22 Thyrotoxicosis 61
23 Grave’s disease 64
24 Hashitoxicosis or Silent thyroiditis 67
25 Post Viral or sub-acute (de Quervain) thyroiditis: 67
26 Postpartum Thyroiditis 68
27 Toxic Multinodular Goiter 69
28 Toxic adenoma (Plummer disease) 69
29 Medication induced Hyperthyroidism 70
30 Hypothyroidism during pregnancy 71
31 Hypothyroidism 73
32 Thyroid Eye Disease 77
33 Acromegaly 79
34 Cushing Syndrome 83
35 Addisons’s Disease 88
36 Hypopituiarism 92
37 Diabetes Mellitus And Charcot Joint 94
38 Diabetes and Foot Care 96
39 Diabetes and Foot Ulcer 97
40 Problem of Eyes encountered in PACES 99
41 Retinitis Pigmentosa 100
42 Optic Atrophy 103
43 Visual Blurriness 106
44 Double Vision 108
45 Transient Visual Loss 110
46 Cataracts 112
47 Diabetic Retinopathy 114
48 Central Retinal Artery occlusion 116
49 Other Possible cases 118
50 Anemia 119
51 Iron Deficiency Anemia 120
52 Other GI Cases 127
53 Epistaxis Because of Elevated INR (Warfarin) 135
54 Syncope 136
55 Collapse 139
56 Seizure(Fit) 140
57 Chest Pain (Angina) 145
58 Palpitations (AF) 147
59 Other Respiratory cases 149
60 Pulmonary Embolism 150
61 Headache 154
62 Left Sided Weakness in a Young Woman 156
63 Parkinson’s Disease 158
64 6th Nerve Palsy 160
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65 Blackout 161
66 Tremors 164
67 Carpal Tunnel Syndrome 166
68 Peripheral Neuropathy 168
69 UTI / Male Sexual History 170
70 Swollen Calf Causes 171
71 De-Ranged RFTs 172
72 Fever /PUO 173
73 HHT (Osler Weber Rendu Syndrome) 174
74 Other important cases 176
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1.Introduction in Station 5
Well!
Is that fine?
Right!
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Presenting Complaint
Localization
Differentials (1 or 2)
Medical conditions
Medicine
Family Hx
Examination
Targeted
Idea
Concern
Explain
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Tetracycline Photosensitivity
Tamoxifen Cardiomyopathy
Dauxorubicin Cardiomyopathy
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4.Leg Ulcer
Where exactly the ulcer is?
Is it getting worse?
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4.Pyoderma gangrenosum:
Ulcerative cutaneous condition that may start initially as small,red papule or pustule
Pain is the predominant feature
Pathergy may be present
May be associated with underlying systemic condition in 50% of cases like
Hematological malignancy,Liver disease,Rheumatological problems,IBD etc
Legs are more commonly involved but can develop anywhere on the body
Classical form is deep ulceration with a violaceous border and overhanging edge
Questions:
Where exactly the ulcer is?
Do you have Ulcer anywhere else?
Any problem with it like: Pain, Bleeding, Discharge or Itching?
Others
Medical Problem
Medicine
Family Hx
Social History
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Examination
Ulcer
Inspection
Pulses
Sensory
GPE
Concern
Explain
Investigations:
PG is a diagnosis of exclusion
General:
Colonoscopy
Treatment:
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General:
Patient’s education
MDT care package
Avoiding trauma
Topical therapy like wound care,dressings,topical corticosteroids etc
Antibiotics
Specific:
Control of underlying condition with specific therapy like IBD,RA,SLE etc
Specific treatment usually involves
Systemic steroids
Immunosuppressive like Cyclosporine,Azathioprine,Cyclophosphamide etc
Biological agents like Infliximab,Adalimumab,Etanercept etc
Surgery:
Debridement and grafting should be avoided if possible because of Pathergy
DD:
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5.Neuropathic Ulcer:
Questions:
Medicine
Family Hx
Social History
Examination
Inspection
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Idea
Concern
Explain
Investigations:
Usually a clinical diagnosis but investigations may be focused upon underlying cause
General:
CBC,ESR,CRP etc
Others:
Treatment:
General:
Patient’s education
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Specific:
Treatment of underlying condition like DM
Surgical:
Debridement or amputation if required
PEG insertion if sever gastroparesis
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6.Arterial Ulcer:
Questions:
Family Hx
Social History
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Examination
Inspection….may have pale limb and deep ulcer with well defined ulcer edge and
surrounding cyanosis and loss of hair
Sensory
GPE
Finish With
Fundoscopy
BP
Urine for proteinuria
Concern
Explain
Treatment:
General:
Patient education
MDT care package
Diet and exercise
Smoking cessation
Avoiding trauma
Antibiotics for infection
Specific:
Treatment of underlying condition like DM,HTN,Dyslipidemia etc
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7.Venous Ulcers:
Management:
Foot elevation
Compression bandaging
Emoliants for dryness
Antibiotics
Skin grafting if large ulcers
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5.Psoriasis
There are several variants, most common being Chronic Plaque Psoriasis
More than 40 years old should also be evaluated for Metabolic Syndrome
Triggers include:
Lithium etc
Alcohol
Obesity
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Questions: Notes
Where exactly the Rash is?
Do you have rash anywhere else?
Any other problem with your rash like:Pain, bleeding, discharge
or itching in it?
Medical Problem
Medicine
NSAIDS e.g Brufen
ACE inhibitors, B -Blockers
Steroids
Anti-Malarial
Statins
Family Hx
Social History
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Examination
Inspection
Hands
Nails…pitting,ridging.onycholysis,hyperkeratosis,oil
droplet sign,subungual hyperkeratosis
Fingers…dactylitis
Joints…deformities
Hair Line
Behind Ears
Front Of Chest
Finish by:
Looking at External Genitalia
Idea
Concern
Explain
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D/D of Plaque:
D/D
Onychomycosis
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Lichen Planus
Eczema
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Sero-negative spondylo-arthropathies
RA
Gout
Scleroderma
Antiphospholipid Syndrome
Polymyalgia Rheumatica
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8.Seronegative spondyloarthropathies
1. Ankylosing Spondylitis
2. Reactive Arthritis
3. Psoritatic Arthritis
4. Enteropathic Arthropathy
5. Undifferentiated Spondyloarthropathy
Male predominance
Uveitis
HLA-B27 in 50% especially those with IBD and Psoriasis having Sacroilitis
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9.Ankylosing Spondylitis
Young male usually less than 30 years old are more commonly affected
Aneterior Uveitis
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Questions: Notes
Backache? LOQIRAA
Where exactly?
For how long?
Sudden or gradual…(if sudden) what were you doing
at that time?
What type of pain it is?
How intense it is on a scale of 1 to 10?
Does it move anywhere else?
What makes it better?
What make it worse?
Extra-articualr:
Problem with eyes? Like redness or grittiness?
Any pain and stiffness in neck?
Dry Cough? Any difficulty in breathing?
Any racing of heart?
Any pain in ankle?
Any heel pain?
DD of backache:
Any injury or weight lifting before this?
Any problem with legs like weakness or numbness?
Medical Problem
Medicine
Family Hx:
Social History
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Examination
Inspection—Standing
1. Gait and examination of spine especially lower one
2. Neck Movement
3. Lumbar Movement
(Flexion,extension,abduction and lateral rotation)
4. Wall—Occiput Distance
5. Eyes
6. Examination of Chest
7. Examination of heart
8. Heel and foot
9. Finish by doing modified Schober’s test
Idea
Concern
Explain
D/D:
Other Spondylo-arthropathies especially IBD (Bilateral)
CBC, ESR
Specific:
HLA-B27
AR factor and Anti CCP Antibodies to rule out others
Imaging:
X-RAY
MRI
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Treatment:
1.General Measures:
Patient’s education
Physiotherapy
Exercise
Occupational health physician role
2. Medical treatment:
a.NSAIDs
Infliximab
Adalimumab
Etanercept
Golimumab
3.Treatment of complications:
Uveitis
Aortic Regurgitation etc
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10.Reactive Arthritis
Usually follows Dysentery or a sexually transmitted infection (Chlaymydia)
Features include:
Conjuctivitis
Uveitis
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2.Psoriatic arthritis
3.Enteropathic arthropathy
4.Others
RA
CBC,ESR,CRP
Rheumatoid factors
Treatment Physiotherapy
Antibiotics if active infection
NSAIDs
Sulfasalazine
Methotrexate
Biological agents e.g Infliximab
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11.Psoriatic arthritis
Psoriasis Precedes in 80%
Occasionally just a Single Patch of Psoriasis may be present in hidden parts like
umbilicus, Scalp or gluteal cleft
Sometimes the psoriasis lesion may have cleared before the arthritis develops
D/D:
Redness of eyes
SOB (Apical Pulmonary fibrosis)
Rash
Joint pains
Backache etc
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Investigations:
Imaging:
Treatment:
General measures:
Patient’s education
MDT package like ………
Medical treatment:
NSAIDs
Glucocorticoids
Methotrexate
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12.IBD
colitis.
Genetic factors, immune dysregulation and microbial gut flora all influence the
susceptibility
Radiological features
Multiple conditions can mimic IBD but main Differential is Infectious conditions
disease
Fecal Cal-protectin and Stool for Lacto-ferrin can help distinguish IBD from IBS
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Questions: Notes
Medical Problem
Medicine
Family Hx…Infective and autoimmune clues
Social History… Travel history
Other complications:
Malabsorption syndrome
(Vitamin ADEK,Anemia,Hypalbumenimia)
Jaundice and itching (PSC or Cholangiocarcinoma)
Abdominal pain (IBD,Strictures,CA colon)
Renal colic (Renal calculi)
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Examination
GPE
Abdomen
Idea
Concern
Explain
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DD Depends on the underlying features with which patient has
presented e.g
Loose motions
Abdominal pain
Bloody diarrhea
Red Eyes
Oral ulcers
Backache
Arthritis
Rash etc
Investigations General:
CBC,ESR,CRP
LFTs
S/E
RFTs
Specific:
Stool studies especially screening for infections
including C.Difficile
Stool for Calprotectin and Lactoferrin
Endoscopic:
Colonoscopy and biopsy
Enteroscopy
Imaging:
CT enterography
MR enterography etc
b.Specific mesures:
Medical:
5-ASA like pentasa , asacol,rovasa,lialda
Steroids
Immunosupprssives AZA or 6-MP etc
Biological agents like Infliximab and adalimumab
Antibiotics
Treatment of complications
c.Surgical measures
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13.Rheumatoid Arthritis
multiple joints
Symmetric Polyarthritis with predilection for small joints of hands and feet
General
Anemia
Eyes
Lungs
Heart
Kidneys
Splenomegaly
Sensorimotor neuropathy
Subcutaneous nodules
Vasculitis
Can only involve the neck but spares the rest of spine and do not cause sacroilitis
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In which joints you have pain?Problem with any other joints? Notes
Is it getting worse?
Extra-articular Questions:
Medical Problem
Medicine: NSAIDs, Steroids, Others
Family Hx
Social History 36
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Examination (Pillow)
Inspection
Swelling
Wasting
Deformities
Carpal tunnel release Scars
Make a fist
Palpation
Warmth
Tenderness
Grip
Power
Sensations (Median and Ulnar)
Functional capacity
Button / unbutton
Pick up the Coin
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D/D
2.SLE
arthritis
8.Polymyalgia Age >50 years, proximal muscle pain and stiffness,RA factor
Rheumatica negative
aspirin
General
Labs 38
CBC, ESR,CRP
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LFTs
RFTs
Specific
RA factor
Anti-CCP-antibodies
Arthrocentesis
Imaging
X-Rays
Treatment General measures:
Patient’s education
MDT care package
Physiotherapy and rehabilitation
Nutrition
Vaccinations
Specific Measures
Medical:
Corticosteroids
Golimumab
Treatment of Complications
Surgical
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14.Gout
Gout is a metabolic disease and often familial
In chronic cases ,urate deposits in subcutaneous tissue, bones, cartilage, joints and
other tissues
Uric acid kidney stones are present in 5-10 % of patients with gouty arthritis
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In which joint the pain is? Problem with any other joints? Notes
Is it getting worse?
Heart Complications
Difficulty in breathing
Kidneys
Family Hx
Social History
Alcohol
Diet (Meat in excess)
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Examination
Inspection
Arms,ears and feet for tophi
Palpation
Functional Capacity
GPE
Pallor,jaundice,L.N
Abdomen (Hepatosplenomeglay)
Idea
Concern
Explain
Differential Diagnosis:
Investigations:
Specific:
Serum Uric Acid (Not useful in acute attack)
Joint fluid or tophus aspirate for Urate crystals and
others like Cell count,Gram staining and C/S and for
polarized light microscopy to see negatively birefrigent
crystals
Blood cultures to rule out septic arthritis
Imaging:
X Rays
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Treatment:
1.Asymptomatic:
2.Acute attack:
NSAIDs
Colchicine
Steroids
3.Between attacks:
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Can affect any age group but usually in the 5th or 6th decade
They can also be associated with other connective tissue disorders like
Scleroderma, MCD or Sjogren Syndrome etc
Sometimes patients may have just skin disease without overt muscle weakness
No facial or ocular muscle weakness develop but neck muscles can involve in
Polymyositis
Rashes include:
Heliotrope rash
Shawl sign
Periungual Erythema
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Where exactly the rash is? Do you have rash anywhere else? Notes
For how long you have this? Where did it start first?
Is it getting worse? what makes it worse?what makes it better?
fingers?
General
(Fever,fatigue,appetite,weight changes,lumps or bumps)
Chest (Lungs)
Breast (Women)
GIT
Prostate (Men)
Medical Problems
Medicine
Family Hx
Social History
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Examination
Inspection
Cushingoid appearance
Rash
Back of hands….Gottrons Papules
Around eyes…….Heliotrope Rash
Chest
Front……………...V Sign
Back……………….Shawl sign
GPE
Relevant System
Chest
Breast
Abdomen
Prostate
Idea
Concern
Explain
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SLE
Scleroderma
3.Hypothyroidsim
4.Polymyalgia Rheumatica
features
6.Vasculitides like:
PAN
asymmetric
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Investigations:
Specific:
CK, Aldolase
ANA and other specific Antibodies
Skin and Muscle biopsy
EMG
Imaging:
HRCT
CT Chest,Abdomen and Pelvis
Mammography
MRI
Treatment:
General:
Patient education
MDT care package
Limit the sun exposure
Bed rest for severe inflammation
Specific:
Hydroxychloroquine if skin involvement
Corticosteroids like Prednisolone 40-60 mg/day initially
Immunosuppressive therapy like Methotrexate and
Azathioprine
Others like Mycophenolate Mofetil and Rituximab
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16.Systemic Sclerosis
Systemic sclerosis is a chronic disorder characterized by diffuse fibrosis of the skin
the face, neck and distal extremities, have better out come because ILD or
Kidney disease rarely develops but Pulmonary HTN can develop and digital
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Toes?
mouth?
MCD
Other Complications:
Medical Problem
Medicine
Family Hx
Social History
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Examination
Inspection
Hands
Nails…infarcts
Fingers…Ulcer,telangicetasias,color
changes,sclerodactyli
Joints
Palpation—Back of hands
Pulses
Shoulder weakness
Mouth
Opening
Telangiectsias
Heart (P2)
Pedal Edema
Finish with
Fundoscopy
BP
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Investigations:
General:
CBC,ESR
RFTs
Urine dip stick
Urinary protein-creatinine ratio
Immunology:
Anti-centromere antibodies
Anti-Scl 70 antibodies
Anti-RNP polymerse I,II and III antibodies
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Raynaud’s phenomenon
Smoking cessation
Hand warmers
Calcium channel blockers
Prostacycline analogues like Iloprost
ACE-inhibitors
Alfa blockers
Pentoxyphylline
Renal disease:
ACE-inhibiors
Pulmonary fibrosis
Prednisolone
Immunosuppressive like cyclophosphamide
Pulmonary HTN
Bosentan
GERD:
Prokinetics and PPI
Skin sclerosis:
D-Penicillamine
Methotrexate
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17.Anti-Phospholipid Syndrome
Hypercoagulability with recurrent Venous or Arterial thrombosis
Can have different presentations like BCS, Stroke, MI, DVT, Livedo Reticularis,
Thrombocytopenia is common
that include:
Treatment include:
If catastrophic APS
Plasmapheresis
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18.Polymyalgia Rheumatica
Usually a clinical diagnosis based on pain and stiffness of the shoulder and pelvic
Few patients have joint swelling particularly of the knees and wrists
Differentials:
RA
Multiple Myeloma
Malignancy
Positive Lab findings may include Anemia and Markedly elevated ESR
Prednisone 10-20 mg/day, slow tapering after 2-4 weeks, mostly for 1year minimum
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It may present with PUO in 15% of cases above the age 65, which may be high grade
with normal TLC if steroids not given already
It may be considered in Older patients with high grade fever, Normal TLC and
markedly elevated ESR
Finally, thoracic aortic aneurysms can develop that can lead to Aortic
regurgitation, Dissection and Rupture
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glomerulonephritis
Suspected if mild Upper respiratory tract symptoms like nasal congestion, sinusitis
D/D depends on the underlying features whether URT, LRT, Joint Involvement,
Glomerulonephritis or else
Labs may include CBC,ERS, CRP, Urine analysis for Proteinurea, RBCs and Red
remission
plus corticosteroids
Rituximab
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Endocrinology
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Where exactly the swelling is? Do you have swelling anywhere else? Notes
Causes:
Medical Problem
Medicine: Goitrogens, Amiodarone etc
Family Hx
Social History: Iodine Deficient Diet
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Examination
Inspection
Palpation including LN
Percussion
Auscultation (If Hyperthyroid)
Hands
Clubbing (Thyroid acropachy)
Pin Pricks marks (Type 1 DM)
Tremors,warmth,sweating
Pulse
Proximal muscle weakness
Eyes examination
Heart
Legs (Pretibial edema)
Idea
Concern
Explain
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22.Thyrotoxicosis
1. Grave’s disease
2. Hashi-toxicosis
3. Post Viral
4. Post-Partum
6. Toxic adenoma
8. Cancer
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Presenting Complaints:
Notes
Weight Loss
Diarrhea
Palpitations etc
ODPARA
Screening questions
Any problem adjusting to temperatures?
Any changes in weight?
Hands
Shaking of hands
Sweating
Racing of heart
Arms
Any weakness in shoulders
Any weakness while standing from sitting?
CNS
Any changes in Mood, Sleep?
Eyes
Any problem with eyes?
Watering, Dryness?
Pain, Redness?
Decreased vision
Double vision
Color vision
Causes e.g
Autoimmune
Viral
Pregnancy
Malignancy etc
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Medical Problem
Medicine: Amiodarone, Thyroxine in excess etc
Family Hx
Social Hx
Examination
Inspection
General
Thyroid
Tongue Protrusion (Thyroglossal Cyst)
Swallowing
Take a sip of water
Hold it into your mouth
Now plz swallow
Palpation
Swallow
Texture
Extent
Tenderness
Lymph Nodes
Percussion
Auscultation
Hands
Tremors
Sweating
Acropachy
Pulse
Proximal Muscle weakness
Eyes
Vision
Movements
Fundoscopy (Tell)
Heart
Legs (Rash)
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Grave’s disease
There may be increased risk of other Autoimmune disorders like Celiac disease,
Addison’s disease, Pernicious anemia, vitiligo, type1 DM, MG etc
Grave’s Eye manifestations include Lid Lag, Lid retraction and a staring Look
which can also occur with any other cause of Hyperthyroidism
Eye related symptoms may include diplopia, corneal dryness, decreased visual
acuity and color vision( optic nerve compression) and may be asymmetrical
Ocular MG may also sometimes be associated with Grave’s disease with diplopia
Labs include:
a. Thyroid profile
b. TSI or TSHr Abs
c. RAI scan is not required with typical features but helpful if need to rule out
concomitant Strumma ovarii (rare)
d. MRI and CT scanning of the orbits are the methods of choice to visualize
Grave’s Ophthalmopathy and is required in severe or unilateral cases or in
Euthyroid exophthalmos to distinguish it from other lesions
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Treatment:
Propranolol
Thiourea drugs: e.g Propylthiouracil or Methimazole
Iodinated contrast agents: e.g
Radioactive Iodine (131I,RAI)
Thyroid surgery
Details of treatment:
a.Propranolol:
Which are especially useful in mild hyperthyroidism and small goiters. These
are also useful for preparing hyperthyroid patients before surgery and
elderly for RAI treatment .These drug do not permanently damage the
thyroid gland. It may be continued long term if patient is tolerating it well.
Caution about unusual bleeding or onset of any infection (Like sore throat)
is required.
Surveillance with WBCs may be required periodically.changing status is best
monitored clinically and with FT4 as the patient may become hypothyroid 2
weeks or more before the TSH level rise.
Methimazole:
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Propylthiouracil:
e.Thyroid surgery:
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Can follow a flue like viral illness (URTI) and can develop extremely painful
thyroid that can be tender and typically enlarged 3-4 times its normal size
There may be dysphagia and pain can radiate to jaw or ear
Can cause hyperthyroidism for 3-6 weeks followed by hypothyroidism and
10% remain hypothyroid 1 year after
WBC, ESR and CRP are helpful and it should be differentiated from
suppurative thyroiditis as well
RAI uptake is low
Thiourea drugs are ineffective Treatment is just like Hashitoxicosis but for
pain NSAIDs, Corticosteroids or Opiates may be required
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Postpartum Thyroiditis
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Type II is caused by thyroiditis with passive release of stored hormone and thyroid
color flow Doppler shows a normal sized gland without increased vascularity and
IL-6 levels are usually quite elevated
Treatment:
Propranolol ER
Methimazole 30 mg/day as its difficult to categorize thy types
After 2 doses of methimazole, iopanoic acid or sodium ipodate 500mg orally
twice daily for 3 days, then 500mg/day until the thyrotoxicosis is resolved
If above is not available then potassium perchlorate
Other options include Prednisone and Subtotal Thyroidectomy
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In Breast feeding low doses are recommended and are taken just after feeding the
baby
Treatment of complications
1.Cardiac complications
a.Sinus Tachycardia
b.Atrial Fibrillation
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Sub-clinical Hyperthyroidism
Asymptomatic individuals with low serum TSH but normal serum levels
of FT4 and T3
Progression to symptomatic thyrotoxicosis can occur
Scans
High RAI uptake is seen in conditions with increased synthesis of the hormone like
Grave’s disease, Toxic nodular goiter, Type I amiodarone induced thyrotoxicosis
Low RAI uptake is seen in conditions like subacute Thyroiditis, Iodine induced
thyrotoxicosis and Type II amiodarone induced hyperthyroidism
b.Thyroid USG
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23.Hypothyroidism
Weight gain
Fatigue
ODPARA
Any fatigue?
D/D Or Causes:
Any problem with eyes (Grave’s)
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Medicine: like
Amiodarone
Lithium
Radioiodine therapy
Operation on neck
Social History:
Examination
Inspection
General
Thyroid
Swallowing
Palpation
Percussion
Hands
Skin
Temperature
Carpal Tunnel
Pin prick marks
Thyroid acropachy
Pulse
Eyes
Rash on legs
Ankle reflex
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Investigations:
Treatment:
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1. Poor compliance
2. Under replacement
3. Malabsorption due to concurrent drugs, taking with food, GI disorders like
celiac disease etc
4. TSH can be raised by antipsychotic medications
1. For most patients TSH is kept in the lower normal range but for patients
with AF or angina it is kept slightly above normal
2. Some patients with normal TSH continue to have Hypothyroid like
symptoms like Fatigue, lethargy, weight changes, depression etc, such
patients need to be assessed for other concurrent conditions like adverse
reaction of medicines, hypogonadism, depression, anemia, OSA ,Celiac
disease, Addison’s disease etc
1. If serum TSH level is less than the reference range, it is considered low
(0.04-0.4 milli-units/L)
2. If serum TSH level is less than 0.03 milli-units/L , it is considered suppressed
3. If with suppressed level,patient has features of Hyperthyroidism,t he dose of
levothyroxine should be reduced
4. If with Low serum TSH, patient don’t have such hyperthyroid symptoms, it is
important to determine whether Hypopituarism or severe non-thyroidal
illness is present
5. Certain medications can also reduce TSH like: NSAIDs, Steroids, Opioids,
Nifedipine etc and if such causes are absent and patient is euthyroid
clinically, then the lower dose can be used
6. With primary hypothyroidism, there are chances of AF and osteoporosis if
the TSH is suppressed, so lower dose may be used
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Medical Problem
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Examination
Inspection
General
Thyroid
May be scar
Eyes
Hands
Pulse
Pretibial Myxedema
(=Legs)
Treatment of complications
1.Grave’s Orbitopathy
Pioglitazone
Mild symptoms can be treated with Selenium 100 mcg orally twice daily
preferred as 500 mg weekly for 6 weeks , and then 250 mg weekly for 6 weeks
surgery
2.Grave’s Dermopathy:
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25.Acromegaly
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Medical problem:
Medicine:
Family Hx:
Social Hx:
Other associations:
Diplopia
Ptosis
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Examination
Hands
Large broad palms and broad fingers
Sweating
Carpal tunnel release scars? Carpal tunnel syndrome
Thickness of skin
Pin prick marks
Numbness /Tingling
Arms
Proximal Muscle weakness
Under arms (Skin tags, Acanthosis Nigricans)
Face
Prominent Supra-orbital Ridges
Nose,Ears, Tongue and lips
Increased interdental space
Side of face
Proganthism
Finish by:
Fundoscopy
BP
Dip the urine for Glycosuria
Idea
Concern
Explain
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Investigations:
1. Screening is done with random IGF-I, which if normal rules out acromegaly
2. Fasting IGF-I (significant if more than 5 times normal)
3. Then Glucose syrup (100 g) is administered orally, and serum GH is
measured after 60 minutes if which is less than 1ng/ml rules out acromegaly
4. Other tests done in fasting include
Prolactin (secreted by many GH-Secreting Tumors)
Serum calcium (to exclude Hyperparathyroidism)
Serum FT4 and TSH (to exclude secondary hypothyroidism)
Glucose (DM is common)
LFTs and RFTs (as these can misleadingly elevate GH)
Imaging
MRI Brain
X-Ray lateral foot to see the increased thickness of the Heel pad
Treatment
SERM (Tamoxifen)
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26.Cushing Syndrome
Presenting complaint like: NOTES
Weight gain etc.
ODPARA
Medicine:
4) Steroids
Family Hx:
Social History:
Body building
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Examination
Inspection
Cushingoid appearance
Centripetal obesity
Hands and Arms
Clubbing
Pin Prick marks
Numbness or tingling
Bruising
Striae
Proximal
Muscle weakness
Face and Neck
Inter-scapular and Supra-clavicular fat pads
Acne
Excessive hair growth
Eyes
Tongue
Candidiasis
Lymph Nodes
Chest
Abdomen
Scar at the back
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1.Screening:
2.Confirmatory tests:
3.Etiology:
Serum or plasma ACTH level…..not raised but serum cortisol is high then
CT of the adrenals
Screening:
24-Hour urinary free Cortisol and Creatinine is the usual confirmatory test
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Confirmatory tests:
Etiology:
Malignant)
draining the pituitary is performed. If the ACTH level is greater than twice
disease
4. If Inferior petrosal sinus ACTH concentrations are not above the requisite
level, a search for ectopic source of ACTH is made that includes CT scanning
of the chest and abdomen with special attention to the lung, thyums,
5. In about 40%, CT scanning fails to detect the ectopic source than OCT-
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Iatrogenic:
Other causes:
Medicines:
Surgery:
radiotherapy
radiotherapy
DM
HTN
Ostroprosis etc
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27.Addisons’s Disease
Dizziness on standing?
Nausea / vomiting?
Abdominal pain?
DD (Causes)
General
Secondary cause)
Family Hx:
Social Hx:
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Examination
General physical
Pigmentation
Hands
Body
Mouth
Pressure areas
Adrenalectomy scars
Postural BP
Type 1:
Autosomal recessive
Mucocutaneous candidiasis and Hypoparathyroidism in childhood
Adrenal insufficiency and primary hypogonadism in adulthood
Type 2:
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Investigations:
5. Autoantibodies
6. .Plasma cortisol (less than 83 nmol/L) and plasma ACTH (more than 200
Imaging:
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Treatment
Hydrocortisone 15-30mg/day orally, with two third dose in the morning and
one third in the late afternoon or in the early evening, other options
include prednisone and methylprednisolone
Glucocorticoid dose can be increased during stress and also in the third
trimester, the dose can be increased to 50% the usual dose and the dose is
reduced back to normal once the stress is over
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28.Hypopituiarism
Features:
Pale,dry,wrinkled skin
Postural hypotension
ODPARA
Liver (Hemochromatosis)
Medical problem:
Malignancy
Pituitary surgery or radiotherapy
Medicine:
Family Hx:
Social Hx:
Examination:
Idea
Concern
Explain
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Note:
Acute disease can present with sudden loss of ACTH and hypotension e.g Pituitary
apoplexy and infarction
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Medical problem:
I understand that you have diabetes? Please tell me for how
long?
What was last Hb A1c?
Which medicine you are taking?
Any complications?
Do you get regular check ups for your eyes, kidneys
and feet?
Medical problems:
Family Hx:
Social History:
Smoking
Alcohol
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Examination:
General
Inspection
Passive movement
Palpation
Temperature
Dorsalis Pedis
GPE
Complete by
Fundoscopy
Blood pressure
Dip the Urine for glycosuria and proteinuria
Idea
Concern
Explain
Foot Care
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2. Daily wash your feet and dry them gently but not to rub.
3. Do not walk bare foot and wear comfortable shows and socks?
Referrals depend on the underlying problems in Diabetes Mellitus and include the
followings:
General Physician
Diabetes specialist
Diabetes Foot clinic
Clinical nurse specialist
Foot Surgeon
Dietion
Physical trainer
Physiotherapist
Blood channels surgeon
Eye specialist
Kidney specialist
Occupational health physician
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Ischemic (Arterial)
(Neuropathy)
Social history:
Smoking, Alcohol
How you are affected?
Examination
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Inspection
Pin prick
Sensory level
Balance
Walk ± Power
Dorsalis Pedis
Idea
Concern
Explain
Foot Care
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1.Sudden
a.Sudden Permanent
b.Sudden Transient
Amaurosis Fugax
Migraine
2.Gradual
DM
HTN
RP
Others
3.Partial (Quadrants)
Bitemporal Hemianopia
Homonymous Hemianopia
Quadrantanopia
Nasal Fields loss (Tumor)
Double Vision:
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33.Retinitis Pigmentosa
Young with Tunnel vision
Night-time vision problem
Positive Family History
decreased?
ODPARA
Medicine:
Family Hx:
Social Hx:
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Examination
Inspection
General
Lawrence-moon Six fingers or Amputated fingers
Hearing device
Visual Acuity
Finger counting
Hand movement
Throw light
Fundoscopy
Idea
Concern
Explain Driving
DD:
LASER scars
Retinal trauma
Investigations:
Tests for underlying cause
Electro-retinogram
Genetic testing
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Treatment:
No cure,just supportive treatment
General:
Patient and family education
MDT care if required like psychological support and
eye specialist involvement
Visual impairment support like: Walking aids,Guide
dog
Liason with DVLA
Support groups
Medical:
Vitamin E
New therapies underway:
Retinal implants
Transplants
Stem cell therapy
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34.Optic Atrophy
Is it getting worse?
CNS
Family Hx:
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Social History
Smoking
Methyl alcohol
Ethyl Alcohol
Other toxins
Examination
Inspection
General
Eyes
Visual Acuity
Color vision
Field of vision
Central Scotoma on affected side and MS is most likely
Light reflex
RAPD (Early)
Consenual reflex only (Advanced)
Fundoscopy
Pale Disc with normal margins
Idea
Concern
Explain Driving
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1. Compression
2. Demyelination
4. Infections
5. Vasculitis
6. Inflammation
7. BIH
8. Trauma
11. Medicines
12. Radiation
13. Drugs
15. RP
17. Dietary
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35.Visual Blurriness
(Recurrent TIAs)
(Cataract)
Medical problem: DM
Control
Medicines
Complications
Check ups
Medicine:
Family Hx:
Social History: Smoking, Alcohol
Driving
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Examination
Inspection
General
Eyes
Visual acuity
Field of vision
Fundoscopy
Relevant Examination Like:
Power
Reflexes
Idea
Concern
Explain like Mini-stroke etc
Investigation:
Hb A1c
CT Brain
MRI Brain
Treatment:
days
if stenosis is > 70 %
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36.Double Vision
Presenting Complaints:
What exactly the problem is?
In which direction you get double vision?
Looking straight (3rd Nerve)
Right or Left (6th Nerve)
Looking down (4th Nerve)
In which eye?
Any other problem with eyes like pain, redness, watering or
discharge?
Any decreased in vision, blurriness or problem with color vision?
Did you take any cane food before you have this? (Botulism)
Medical:
Family Hx:
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Examination
Inspection
General
Eyes
Visual acuity
Eye Movements
Fundoscopy
Concern
Explain
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In which eye?
Any headache?
Medicine:
Famliy Hx:
Cocaine
Driving
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Examination
General
Specific according to cause
Idea
Concern
Explain
CAUSES:
Amaurosis Fugax (TIA)
Migraine
GCA
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38.Cataracts
Presenting complaint: Notes
What else?
Medical problem
Medicine
Family Hx:
Social History
Examination:
General
Opacity
Visual acuity
Fundoscopy
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Causes:
Senile
DM
Cushing syndrome
Myotonia Dystrophica
Hypo-parathyroidism
Turner syndrome
Down syndrome
Drugs like steroids.amiodarone and tamoxifen
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39.Diabetic Retinopathy
Middle or Old aged patient with vision problem most likely decreased vision
Medical problems especially other Risk factors like HTN,Fat levels etc
Medicines
Family Hx:
Examination
Visual acuity
Field of vision
Fundoscopy
Microaneurysms
Dot and blot hemorrhages
Flame shaped hemorrhages
Hard exudates
Cotton wool spots
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Idea
Concern
Explain:
Stop driving
DD:
Hypertensive Retinopathy
BRVO
CRVO
LASER Therapy
Future treatments:
Bevacizumab
Triamcinolone (Intravitreous Corticosteroids)
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DD:
GCA
Heart problem like AF etc
Medicine
Family Hx:
Social history
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Examination:
General
Eyes
Visual acuity
Color vision
Field of vision
Light reflex
Other
Pulse
Carotid
Heart
Idea
Concern
Explain
Treatment:
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1. Retinal vein occlusion may have variable vision problem like gradual or
2. Hypertensive Retinopathy
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42.Anemia
Anemias
a. Pallor
b. Glossitis
c. Hepatosplenomegaly
d. Lymphadenopathy and
e. Bone tenderness are important Signs to Look for
Riticulocyte count and MCV are important factors in the evaluation of anemias of
all types
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2. Bleeding is the most common cause of iron loss from the body
exertion)
webs)
d. Pica eating
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GIT
Yellowness of eyes?
Nausea, vomiting?
Difficulty in swallowing?
Tummy pain?
General:
Blood Loss:
Bleeding from any site
Recent blood donations
Any recent Injury or operation
Any blood transfusion
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Examination
General Inspection
Hands
Koilonychia
Clubbing
Pallor
Eyes
Lymph Nodes
1.Dietary
Decreased intake of Meat
Zinc Deficiency
3.Malabsorption
Celiac Disease
IBD etc
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HHT
Esophagitis
APD (NSAIDs, other causes etc)
CLD
Malignancy
Inflammatory conditions (IBD etc)
Other causes including causes of occult bleeding
4.Worm Infestation
1.Increased Requirements
Pregnancy
Lactation
3.Hemoglobinurea
5.Herediatary Iron-refractory
6.Idiopathic
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Labs
non specific)
TIBC is Increased
deficits
2.Thalassemia
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Treatment:
Iron therapy is continued for 3-6 months after normal Hematological values
1. Poor compliance
use or above (In such case concomitant Ascorbic Acid may help)
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Indications include:
Example: If
Woman has Hb = 9 gm/dl (Normal for women is 12 gm/dl, which means 25%
less in this case)
Weight = 50 kg
Iron Deficit in this case is: 0.25 27 ml/kg 50 kg = 337.5 mL of Red blood
cells
Which means 337.5 mg of Iron
The parenteral dose is Iron deficit plus 1gram extra to replenish the stores
so in the above case it will be 1.4 gram
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44.Other GI Cases
Hematemesis (Young Patient) Notes
Did you get blood with vomiting i.e mixed with food or with cough
containing Phlegm?
Family hx:
Examination:
GPE
Abdomen (Offer DRE)
Observation charts
Idea
Concern
Explain
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Causes or Differentials:
1. Esophagitis
2. Mallory Weiss tear
3. Acid peptic disease
4. CLD
5. Malignacny
6. Others
Old Patient
Malignancy
CLD
Gastritis
Other causes e.g APD, HHT, Drugs (NSAIDs)
Camera test (Endoscopy)
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NAFLD
Presentation may be with deranged ALT, AST with risk factors like:
Obesity, DM etc
Metabolic causes?
Family Hx:
Examination:
Idea
Concern
Explain (Depending the cause like NAFLD risk factors management etc)
D/D
1. Alcohol
5. Drugs
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Symptoms Assessment
Piercing
Tattooing
Blood transfusions
Medical or Surgical procedures
Sexual History
I/V Drugs
Job risk
Crohn’s Disease
Medical problem:
Medicine:
Family Hx:
Social History:
Examination:
General physical and Abdomen
Idea
Concern
Explain: Camera Test (Colonoscopy)
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Weight loss See History Notes for weight Loss with Good appetite and
with bad appetite
Or
Weight Loss with GI causes and Non-GI causes
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b. TTP, HUS
a. Other features Like Fever, CNS and Kidney involvement
along with Thrombocytopenia and Micro-angiopathic
anemia
c. DIC
d. Hyper-Splenism
e. Heparin Induced Thrombo-cytopenia
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Uremia
2.Non-Thrombotic Disorders
Henosch-Schonlein Purpura
HHT
Scury (Vitamin C deficiency)
Senial Purpura
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DD
Any Flue like illness before this? (ITP)
CNS (TTP)
Liver (CLD)
Kidney (HUS)
Joints (SLE,RA)
R.O.S
Past Hx
Allergy
Ob/Gynae:
Recurrent abortions, Periods
Pregnancy induced Thrombocytopenia
Pre-eclampsia
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I understand that your blood thinning test called INR is on higher side.
Why you are taking this? If not told in the notes (Prosthetic valves, AF, PE or DVT)
Do you have record on Yellow book? Can you please show it to me?
Triggers
Medical Problem:
Medicine:
Family Hx:
Social History:
Examination: Cardiology
Idea,Concern,Explain
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46.Syncope
May be preceded by Pre-syncope i.e Light-headedness or black out or closing in of
visula fields
Gets up quickly
Syncoope is of 3 types
Vasovagal
Situationl
2.Postural
3.Caridac
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Blurriness
Nausea
Sweating
Frightening seen
Fear
Excitement
Exercise stress
others include
Laughing
Sneezing
Coughing
Straining
during
Hanging of clothes
Shaving
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chest pain
IHD
Arrythmias
Aortic Stenosis
HOCM
syncope
Burns
Vasodilators
DM (AutonomicNeuropathy)
Addison’s Disease
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47.Collapse
Falls Syncope Collapse
Dermatomyositis Subarachnoid
Collapse and Syncope Hemorrhage
Parkinson’s disease are interchangeable
terms depending upon Maningtits/
Old Stroke the situation Encephalitis
Drugs etc
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There could be
Altered breathing
Cyanosis
Tonic-clonic seizures
Urinary incontinence
Tongue biting
Drowsiness
Amnesia
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1.Presyncope events:
following)
Hypersensitivity)
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2.During Synope:
3.After Syncope:
blockers
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Pulse
Carotids
Heart
Neurological Examination
Serial Tracings of Heart, 24-hour or 7-days tracing of heart, Scan of Heart and
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Treatment of syncope
Vasodepressor causes:
Avoid triggers
Adequate hydration
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DD:
Chest
GERD
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Medical problem:
Medicine:
Family Hx:
Examination:
General-----Tenderness
Heart
Idea/Concern / Explain
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50.Palpitations (AF)
For how long you have this problem? Notes
Can you please tap for me that how does it feel like and
Associated
Heart
Chest
GERD
Thyroroxicosis
Family Hx:
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Examination
General
Heart
Chest
Thyroid etc
Idea
Concern
Explain
Investigations:
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COPD
Pleural Effusion
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52.Pulmonary Embolism
ODPARA or LOQIRA
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Examination
General
Leg
Chest
Heart
Idea
Concern
Explain
PE likely > 4
PE unlikely < 4
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Treatment:
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Haemoptysis
PCP pneumonia
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53.Headache
Main cases in station 5: Notes
1. Acromegaly
GCA Questions
2. Migraine
Fever, fatigue,
3. Subarachnoid hemorrhage
changes in
4. Exercise induced headache
appetite & weight?
5. GCA
Problem with
6. Analgesic induced headache
memory or
7. SOL Brain
depression?
Vision problem?
Where exactly the pain is?
Jaw pain?
Was it sudden or gradual?
Stiffness in
How does it feel like?
How intense it is on a scale of 1 ot 10? shoulders or hips
Medical problem:
Family Hx:
Social history
Examination:
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General inspection
GPE
Idea
Concern
Explain
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Ever had clot in the blood channels of your legs or lungs? (ASD)
Medical problem:
Medicine:
Family Hx:
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Examination
General
Specific
Idea
Concern
Explain
Causes:
Other causes:
Todd’s Paresis
Migraine (Complex)
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55.Parkinson’s Disease
Falls
Tremors
Medical problem:
Family Hx:
Social history
Smoking
Alcohol
Cocaine
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Examination:
General
Specific according to causee e.g Parkinson’s disease
Idea
Concern
Explain
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Causes:
CNS
Thyroid
Chest
Joints
Medical:
Medicine:
Social History:
Driving
Examination:
Concern
Explain
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Vascular events
Infections
Trauma
Autoimmune
Metabolic
Idiopathic
Neurological malignancy
Psychiatric
Did any one tell you about the color changes of your skin? Or
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When you woke up, were you completely back to normal or any
Medical Problem:
Medicine:
Family Hx:
Social History:
Alcohol
Driving:
Examination
Idea/Concern/Explain
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58.Tremors
Causes:
Resting
Postural- Begin essential, Anxiety Induced
Intentional – Cerebellar
Metabolic Present all the time e.g hyperthyroid
For how long you have this problem? When you get this problem like at rest or
going to hold something like glass of water etc?
CNS
Any problem with Bowel works? (Malabsorption e.g Fat soluble vitamins deficiency
including vit. E and vit. B 12)
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Family Hx:
Examination:
Idea
Concern
Explain
Investigation:
Treatment:
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Medicine CLD
Family Hx:
Kidneys
Social History like Job e.g Farmer and Tractor driving CRF
Nephrotic
Examination syndrome
Dialysis
Idea
Concern Hands
Explain Injury
RA
DD: Occupational
4. Mononeuritis Multiplex
Others
Amyloidosis
Pregnancy
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Investigations:
Treatment:
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60.Peripheral Neuropathy
Which foot? On or both? Exactly upto which level you have this
problem? ? Any other part affected like hands?
Motor
-ve Weakness
+ve Cramps
DD:
Thyroid
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M: e.g DM
Hugs
F HSMN
Sx HIV
Investigations:
Treatment:
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Permission:
Let me assure you whatever you will tell me will be kept confidential
When did you have last intercourse with your casual partner? (Within 3 months)
Is she with you today?Have you both ever visited sexual health clinic?
Did you both have tests for sexually transmitted infections in the past?
170
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1. DVT
2. Dependent edema
4. Cellulitis
5. Sprained muscle
6. Muscle Hematoma
7. Insect bite
8. Injury (Trauma)
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63.De-Ranged RFTs
Causes
Pre Renal
Renal
Post renal
Complications
Encephalopathy
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173
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2.Mostly Telangiectasisas are found on Lips, Oral mucosa and finger Tips
5.It can be life threatening because of embolic strokes and brain abscesses
10.Systems to be asked
a. Bleeding
b. Anemia
c. CNS Sroke
d. Chest AV-Malformations
e. GIT CLD, PHTN
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Treatment of HHT
2.Prevention of Re-bleeding
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Marfan syndrome
SLE
Erythema Nodosum
Hypertensive retinopathy
Small stature
Tall stature
Red rashes
Multiple Sclerosis
Tuberous Sclerosis
176