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Histories Flashcards

1
Q

Chest pain

A

SOB (orthopnoea, PND, excercise tolerance)
Nausea, vomiting, sweating
Palpitations (regular, irregular)
Syncope (LOC, dizziness, light headed)
Ankle swelling (unilateral/bilateral)
Calf swelling (pain, redness)
Haemoptysis (PE, pneumonia, mitral stenosis, lung cancer, TB)

Modifiable risk factors: smoking, alcohol, hypercholesterolemia, obesity (central), hypertension, diabetes mellitus, sedentary lifestyle, poor compliance with medication, stress.

Non-modifiable risk factors: age, male, family history, previous CVD.

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2
Q

Productive cough

A

Chest pain (unilateral, worse on deep inspiration)
SOB (acute/intermediate/chronic onset)
Previous breathing problems
PND/orthopnoea
Stridor (inspiratory, upper airway obstruction by foreign body or tumour)
Wheeze (expiratory, obstruction of small airways, cardiac wheeze in pulmonary oedema, ?when: night, cold, exercise, monophonic/polyphonic)
Cough
Sputum
Haemoptysis

Ask about previous respiratory investigations (lung function test, CT scan, allergen testing)

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3
Q

Abdominal pain

A

SOCRATES
Nausea, vomiting (haematemisis, relationship with food)
Abdominal distension (bowel obstruction, ascites)
Anorexia, weight loss
Dysphagia (solids or liquids?)
Dyspepsia (OTC antacids?)
Diarrhoea (increased frequency? loose consistency?)
Constipation (last bowel movement, flatus)
Blood or mucus PR (mixed with stool, coating stool, on toilet paper, fresh blood, melena)

Urological: frequency, dysuria, haematuria, hesitency, terminal dribbling

Gynaecological: discharge, bleeding, dyspareunia, LMP

Smoking (GI malignancy, Crohn’s, protective in UC), alcohol (pancreatitis), recent travel (enterotoxogenic E.coli)

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4
Q

DDx for umbilical pain

A 
Early appendicitis
Intestinal obstruction
Acute gastritis
Peptic ulcer disease
Acute pancreatitis
Ruptured abdominal aortic anneurysm
Gastroenteritis
IBS
IBD
Constipation
Perforated viscus
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5
Q

DDx for RIF pain

A

GI: appendicitis, diverticulitis, IBD, intestinal obstruction, Meckel’s diverticulitis, perforated viscera, obstructed/incarcerated inguinal or femoral hernia.

Gynaecological: ruptured ovarian cyst, torsion of ovarian cyst, PID, ectopic pregnancy

Urinary: UTI, renal calculi

Other: testicular torsion, musculoskeletal

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6
Q

Diarrhoea

A

Stool description (volume, consistency, colour, blood, mucus, tarry, floating)
Timing (frequency, nocturnal, duration)
Previous bowel habit
Tenasmus

Medications: ABX (C. difficile), laxatives, cytotoxics, PPIs, NSAIDs
Recent travel: food, activities, vaccinations
Contact: animals, individuals suffering with diarrhoea
Diet: meat, eggs, seafood, dairy, wheat, unusual
PMH: diabetes, IBD, abdo surgery, HIV, organ transplant, malignancy, chemo, radiotherapy, constipation
Occupation: vetinary surgeon, NHS staff symptom-free for 48h before return to work
Family Hx: IBD, coeliac’s disease

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7
Q

Causes of diarrhoea without blood

A

Enterotoxigenic E.coli (traveller’s diarrhoea)
Malaria (P. falciparium)
Giardiasis
Enterotoxin producing strains of Staph aureus
Cholera

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8
Q

Causes of diarrhoea with blood

A

Enterohaemorrhagic E.coli
Shingella, salmonella, campylobacter
Clostridium difficile
Schistosomiasis

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9
Q

Extra intestinal manifestations of IBD

A

Eye: uveitis, iritis, episcleritis

Musculoskeletal: seronegative arthritis*, osteoporosis

Dermatological: erethema nodosum, pyoderma gangrenosum. aphthous mouth ulcers

Other: AI haemolytic anaemia, finger clubbing, growth failure, primary sclerosing cholangitis~, interstitial lung disease (rare)

*More common with Crohn’s
~More common with UC

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10
Q

Headache

A
  1. New acute onset? Headache part of chronic/recurrent headache history?
  2. Exclusion of intracranial haemorrhage (SAH), intracranial infection (meningitis, encephalitis)

SOCRATES
Neurological (LOC, motor/sensory deficit, gait, disturbances in vision, speech, hearing, incontinence)
Meningism (neck stiffness, photophobia, headache)
Infection: Fever, diarrhoea, malaise
Rashes
Scalp tenderness when brushing hair/pain on chewing gum (temporal arteritis)
Nausea and vomiting
Visual disturbance/ aura
Watering of eyes/nasal congestion (cluster headaches)
Wears glasses?

PMH: kidney disease (damage kidney->hypertension->PKD->berry anneurysm-> SAH), TIA/stroke, migrain/tension headache

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11
Q

Subdural haemorrhage features

A

Recent head injury
Gradual onset headache, constant/fluctuating
Fluctuating levels of conciousness: loss at time of injury, lucid interval, deterioration as haematoma forms

More common in ELDERLY and ALCOHOLICS

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12
Q

Extradural haemorrhage features

A

Recent head injury
Gradual onset headache, constant/fluctuating
Fluctuating levels of conciousness: loss at time of injury, lucid interval, deterioration as haematoma forms

More common in YOUNG (dura mater less fixed to skull) and ALCOHOLICS

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13
Q

Intracranial haemorrhage features

A 
Sudden onset, severe headache
Symptoms of raised ICP (waking up with headache, vomiting without nausea)
Focal neurology (corresponds to area of brain damaged)
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14
Q

Subarachnoid haemorrhage features

A

Sudden onset, severe headache
Meningism (neck stiffness, photophobia, headache)
Drowsiness/ LOC
Focal neurology

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15
Q

Meningitis/encephalitis features

A

Fever
Rash (non-blanching, meningococcal septicaemia)
Meningism (neck stiffness, photophobia, headache)
Infective symptoms: flu-like, sweating, malaise, joint pain, diarrhoea
Nausea and vomiting
Drowsiness/ LOC

NOTIFY PUBLIC HEALTH AUTHORITIES OF MENINGOCOCCAL INFECTION (immunisation and prophylaxis for contacts, rifampicin for ‘kissing’ contacts)

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16
Q

Space occupying lesion features

A

Absence of other clear diagnosis for headache
Old age at onset
Focal neurological symptoms and signs
Headache on walking (more commonly caused by migraine)
Vomiting without nausea

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17
Q

Temporal arteritis features

A 
Usually in patients >60years
Frontal or occipital
Jaw pain (whilst eating or talking)
Scalp tenderness
Visual disturbances
Malaise and proximal muscle weakness
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18
Q

Cluster headache features

A

Localised around one eye, associated with anatomical features such as lacrimation and nasal congestion
Occurs for 15 mins- 2 hours for 6-8 weeks, then subsiding for months

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19
Q

Cervical spondylosis features

A

Headache associated with neck pain

Worsens with neck movements

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20
Q

Migraine features

A

Chronic or recurrent headache
May have a prodrome or aura (only ~10% of those with migraines will have neurological aura)
Non- specific triggers (cheese, chocolate, stress)
Related to OCP
Photophobia or other visual disturbances such as zigzag lines
Nausea and vomiting
Family Hx

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21
Q

Tension headache features

A

Band-like dull ache, sometimes with sharp exacerbations
In scalp rather than cranium
Can last throughout the day, worsening in evening
May get tired or dizzy

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22
Q

Intermittent claudication

A

SOCRATES
Sudden pain: embolic>thrombotic
Radiation: dermal distribution consider nerve compression
Worse when bending/twisting: musculoskeletal pain/ spinal stenosis
Worse at night: in PVD patients hang leg off side of bed to reduce pain, improves circulation with assistance from gravity
Foot ulcers
Feet feel numb or cold? (warm if collateral vessels have developed)
Impotence (phrase sensitively)
Muscle weakness
Angina
Palpitations in context of AF
Malignancy (increased risk of thrombotic disease)
CVS risk factors

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23
Q

Buttock/thigh pain indicates?

A

Arterio-iliac disease

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24
Q

Calf pain indicates?

A

Femero-popliteal disease

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25
Acute embolism symptoms
Sudden onset AF/mural thrombus/post MI No other symptoms of intermittent claudication Cold leg (no time for collateral supply formation) Normal vasc exam in other leg
26
Ix for intermittent claudication
``` Doppler, MRA, CTA Urinalysis, BP, ECG Bloods : FBC, U&E, lipid profile, fasting glucose Exercise testing Electrocardiography ```
27
Management for intermittent claudication
Risk factor management (stop smoking, weight loss, diet changes) Exercise (develop collateral circulation) Careful not to injure leg Aspirin, statins, ACEi Treat risk factors: hypertension, diabetes
28
Breast history
Breast lump: - Site, size, consistency, painful - Onset - Preceding trauma - Breast/nipple changes - Nipple discharge (bloody?) - Changes throughout menstrual cycle - Similar lump in past? - Parity, LMP - Breastfeeding (protective)? Duration? - SOB - Skin changes elsewhere - Weight loss - Swelling (especially arm on affected side) - Malaise - Backache Ask about OCP, HRT Risk factors: previous breast cancer, smoking, early menarche, late menopause, nulliparity, family Hx of breast or ovarian cancer (age, 1st degree)
29
Breast cancer management
Medical: - CMF chemo (cyclophosphamide, methotrexate, 5-flurouracil) - Hereceptin - Tamoxifen - Aromatase inhibitor (letrozole, anastrozole, exemestane) Surgical: - Wide local excision of lump (sentinel lymph node biopsy) - Simple mastectomy Axilliary node clearance additionally done: - USS/FNAC/core needle biopsy positive for metastasis - Sentinel node biopsy positive for mets (morbodities: lymphoedema, bruising, shoulder stiffness, reduced movement) Cosmetic: nipple tattoo, abdominal sheath flap, latissimus dorsi flap.
30
DDx for breast lump
``` Fibroadenoma (20-35 yrs) Fibrocystic change (20-40 yrs) Abscess (20-30 yrs, child bearing age) Cyst (40-50 yrs, perimenopausal) Malignancy (40-70) ```
31
Back pain
``` SOCRATES Bone pain? Constant or progressive? Nocturnal pain? Does pain radiate to foot? (Sciatic pain) Problems walking? Cancer Hx (ask about type and Tx) Incontinence (fecal/urinary) Difficulty passing urine Bowel/bladder symptoms Numbness, tingling, leg weakness (peri-anal numbness =saddle anaesthesia Fever, unexplained weight loss, night sweats Morning stiffness Leg claudication ```
32
Back pain causes in 15-30 years
Trauma, fracture, prolapsed disc, ankylosing spondylitis
33
Back pain causes in 30-50 years
Degenerative disease, prolapse disc, malignancy (mets e.g. breast, lung, prostate, kidney, thyroid cancer)
34
Back pain causes in 50 years+
Degenerative disease, osteoporosis (wedge fracture), malignancy, myeloma
35
Mechanical back pain: 1. Low back pain arising from an anatomical structure e.g. muscle, ligament or intervertebral disc due to trauma, deformity, degenerative change 2. Osteoporotic fracture
``` Clinical presentation: Sudden onset Eased by rest Unilateral Increased by coughing/sneezing Heavy lifting... ``` Muscular pain, not central (paraspinal muscles)
36
Inflammatory back pain: 1. Inflammatory spondylitis 2. Epidural abscess 3. Malignancy 4. Paget's disease
Clinical presentation: Predominant stiffness (>30mins in the morning) Gradual onset and progressive Increased pain with rest Disturbs sleep Stiff/rigid spine on examination, symmetrical restriction +/- joint tenderness
37
Cauda equina syndrome Compression of the cauda equina e.g. posterior disc herniation, metastatic deposits
``` Urinary and fecal incontinence Urinary retention Persistant, progressive Bilateral leg pain Normal leg pulses Pain eased by leaning forward Stiff spine on examination Bladder/bowel disfunction ``` URGENT ASSESSMENT AND MANAGEMENT: MRI and consideration for surgery, radiotherapy
38
Sciatica Compression of a lumbosacral nerve root by a protruding disc
Pain radiates from buttock down back of leg and into foot often accompanied by paraesthesia with same distribution Conservative management (analgaesia + physio). ?Surgery
39
Discitis
Fever, systemic upset | Risk factors: injecting drug user
40
Joint pain/stiffness/swelling
``` SOCRATES Morning stiffness (30mins=inflammation, 5 mins=OA) Better or worse after exercise? Sleep disturbance Loss of function ```
41
Rheumatoid arthritis
``` Slowly progressive Symmetrical polyarthritis Small joints (commonly hand) Deforming Early morning stiffness ```
42
Gout
First MTP joint most commonly affected Isolated swollen, hot painful joint Hyperuricaemia risk factors e.g. diuretics, excess alcohol (esp. beer), renal disease
43
Psoriatic arthritis
Associated skin plaques, nail changes Early morning stiffness Many patterns of joint involvement
44
SLE
Systemic illness, intermittent fevers Photosensitive rash Generalised myalgia and arthralgia Other systemic (psychological disturbance, pleuricy, ulcers)
45
Enteropathic arthritis
Symmetrical arthritis of lower limb joints and sacroiliac joints Early morning stiffness Symptoms/diagnosis of Crohn's or UC
46
Osteoarthritis
Elderly | Worse on movement (rest helps) and at end of day
47
Septic arthritis
Isolated, hot, red swollen joint Agonisingly painful Systemically unwell with fever
48
Drug Hx
Current and recently prescribed drugs (GP, specialists, privately) - Ask specifically about: contraceptives, ear/eye drops, inhalers, creams/ointments, injections, patches, vitamins, food, dietary supplements. - Smoking and alcohol - Ask about name, strength, formulation, frequency, dose, duration - Indications (incl. patient's perception) Current and recent non-prescribed drugs (OTCs, complementary and herbal/homeopathic remedies, borderline substances, recreational drugs incl. illicit substances) Any drug related problems (ADRs) Allergies (non drug=eggs, nuts, drug allergies) and hypersensitivities (signs, symptoms, severity and duration) Response to treatment Treatment failure Adherence to treatment regimens.
49
Alcohol Hx
CAGE questionnaire (>2, alcohol abuse/dependence) ``` How much in a week? How often? Binge or steady? What time? What makes you start drinking? (e.g. stress, alcohol availability) Where? (alone, with company) What do you drink (beer, wine, spirits) How much on a typical day? ``` Past alcohol Hx: When did you start? Longest period without drinking? Family Hx of alcoholism? Health problems associated with alcohol? Anaemia Cirrhosis, pancreatitis GORD, peptic ulcer disease Epilepsy, ataxia, peripheral neuropathy, amnesia Depression (assess mood), hallucinations, Wernicke's encephalopathy, Korsakoffe's syndrome (assess cognition) IHD, cardiomyopathy, hypertension Screen for alcohol dependence syndrome Social complications: Absenteeism, loss of job, divorce, driving convictions, decreased job productivity, relationships trouble, police encounter Prev. Tx: Detox programmes, AA Maintaining factors: Access to alcohol? Social isolation? Avoidance of withdrawal symptoms Assess motivation to change...
50
Alcohol dependence syndrome features
ICD-10, 3 of 6 criteria below (over 12 months): -Strong desire, sense of compulsion to take substance - Difficulties controlling intake of the substance (either its onset, termination or levels of use) - Physiological withdrawal state or use of the same/similar substance to prevent such a withdrawal state- What happens when you stop drinking? - Tolerance- Are you finding yourself drinking more to get drunk? - Lack of other activities and interests - Ongoing substance misuse despite clear evidence of harmful consequences.
51
Urological Hx
``` Dysuria Polyuria (fluid intake) Frequency, volume Urgency Nocturia Haematuria (how much? tiredness, breathlessness on exertion) Hesitency/terminal dribbling Poor urinary stream Urinary incontinence Fevers, rigors Nausea, vomiting ?Catheter ```
52
Cystitis
Dysuria, burning pain on urination | Frequency and urgency
53
Urethritis
Dysuria | Purulent urethral discharge
54
Pyelonephritis
Dysuria Loin pain Fever/chills/rigors Vomiting
55
Benign prostatic hyperplasia
Poor flow, terminal dribbling Hesitancy Overflow incontinence Elderly male
56
Bladder transitional cell carcinoma
Painless haematuria | History of aromatic amine exposure e.g. dye washers, painters, decorators
57
Urethral trauma (e.g. catheter)
History of catheter use or trauma
58
UTI
Frequency/urgency/dysuria
59
Calculi
Loin to groin pain
60
Diabetes mellitus
``` Polydipsia/thirst Polyuria Weight loss Tiredness Visual disturbance ```
61
Diabetes insipidus
Polydipsia/thirst | Polyuria
62
Chronic kidney disease
Non-specific symptoms e.g. fatigue, weakness, puritis, dyspnoea
63
Stress incontinence (incompetent sphincter)
Small losses with effort e.g. coughing, bending, exertion Risk factors: multiple pregnancies, post-menopause
64
Urge incontinence (Detrusor instability in idiopathic cystitis or stone. Hhyperreflexia such as in MS, CVA, spinal cord injury)
Urge to pass urine followed by uncontrollable bladder emptying
65
Overflow incontinence (prostatic hypertrophy, stricture or stone)
Dribbling and poor stream Hesitency Elderly male or history of obstruction
66
Fistula between bladder and vagina or urethra
Continuous urine leak
67
Urethral stricture
Retention | History of trauma or recurrent catheter use
68
Bladder neck obstruction (e.g. tumour, calculus)
Retention | Haematuria

OSCE (6 decks)

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