Approach to Consultations

Question 1

Developing differential diagnoses from stem
1. VITAMIN ABCDEK
2. Then by systems

Answer 1

Vitamin ABCDEK
Vascular
Infections
Trauma
Autoimmune
Metabolic
Iatrogenic or idiopathic
Neoplastic
Social - can omit, won’t come out in exam

Alcohol
Behavioural/psychiatry
Congenital
Drugs and toxins, degenerative
Endocrine
Karyotype

Systems
Neurology
Thyroid
ENT
Respiratory
Cardiovascular
Hepatology
Renal
Gastroenterology
Endocrine
Reproductive
Skin
Joints and rheumatology

Question 2

Prep time for consultation station

Answer 2

Pre time: 5 minutes
Recommended allocation: 7/5/3 minutes (or 8/4/3 if there is significant history)

Divide paper into 4 quadrants:

Symptom1 symptom2 symptom3 Examination
- differentials - additional differentials Wishlist
———————————————————————
ICE Mx

Investigations

Question 3

History taking in consultation station

Answer 3

Introduction
- Good morning, I am Dr ___. How may I address you?

HOPC
1. I understand that you have (symptom). Could you describe it further for me?
- Patient is informed to start with open ended questions and vomit out a long history
2. SOCRATES on chief complaint (symptom)

Ruling out differentials
1. Rapid fire screening questions on key features of differentials

Zooming onto possible differentials
1. Specific and detailed questions on possible differentials
- Gather and expand on history, collecting evidence

Medication List
1. Chronic medications
2. Traditional medications
3. Over the counter medications

Family and social history
1. Family history
2. Recent travel history
3. Pets at home
4. Have you ever smoked?
5. Have you ever drank alcohol?
6. I would like to ask you personal questions, are you sexually active?
6A. Who is your sexual partner?
7. Menstrual history in women important

ADL and QOL
1. What do you work as?
2. How is this condition affecting your job and life?

Question 4

Physical examination in consultation station

Answer 4

1. Start from peripheral
2. Focus on system pertinent to each and every symptoms
   - Chest pain, SOB - examine chest and respiratory first
   - GI symptoms - examine abdomen first
   - Back pain - examine back first
   - Skin lesion - examine the skin first
3. Then only go for other systems to examine for complications

Offer wishlist
1. Fundoscopy
2. Digital rectal examination
3. Spirometry ?

Question 5

Addressing patient’s concerns in consultation station
- ICE
- Explanation on diagnosis and management plan

Answer 5

ICE
- Ideas: what do you think about your condition?
- Concerns: what are your main concerns?
- Expectations: how can we help you?

Informing diagnosis and management plan
I think that you have a condition called (disease)
- Elaborate definition in Layman’s term
- Complications that patient might be having now
- I understand this may sound worrying to you. We can (Admit or outpatient)
- We will offer (investigations)
- Once proven, we will suggest to start on (treatment)

Explore further on patient’s additional concerns
Patient will often react to the information provided
To provide assurance

Question 6

Investigations and Management in consultation station

Answer 6

Investigations
1. Go straight for definitive investigations
- Endoscopy for visualisation, biopsy and culture
- Comuted tomography to look for malignancy, etc
- Stool calprotectin for IBD
- Magnetic resonance imaging for (disease)

2. Blood tests as secondary - FBC, RP, etc

Management
1. Multidisciplinary team
- Medical specialties - medical, surgical, etc
- Allied health: PT, OT, dietitian, ST, Podiatry
2. Definitive treatment
3. Supportive treatment as secondary
4. Monitoring of response