The Final Examination of the
Saudi Board for Family Medicine
A. Assaggaf
The final examination of the Saudi Board for Family Medicine consists of two parts: I. The Written examination
II. The Clinical and Oral Examination
I. The Written examination, consists of the following three components: 1. Multiple Choice Questions.
2. Modified Essay Questions. 3. Critical Reading Questions.
II. The Clinical and Oral Examination, which also consist of three components: 1. Simulated Clinics.
2. Data and slides Interpretation. 3. Oral Examination.
I. The Written Examination
1. Multiple Choice Questions Paper Time allowed is three hours
This paper consists of around 100 questions in the best answer format, 75 questions are in the form of patient management questions (PMQ) and 25 questions are traditional factual knowledge questions.
The distribution of the question will be as the following: Areas Number of Question Pediatrics Therapeutics Psychiatry Internal Medicine Obstetrics/Gynecology Surgery/Orthopedic Dermatology Accident and Emergency Community Medicine ENT Ophthalmology 19 8 12 13 11 9 7 8 5 4 4
2. Modified Essay Questions (MEQ) Usually three MEQs will appear in the exam Time allowed: 11/2 hours
3. Critical Reading Questions (CRQ) Time allowed: 2 hours
The guidelines for appraisal of scientific papers recommended by the Evidence-Based Medicine working group published in JAMA are adopted
Time allowed: 11/2 hours
Marking of the written part.
1. MCQ…………..40 marks
2. MEQ………… 35 marks
3. CRQ…………...25 marks
II. Clinical And Oral Examination
Only those who pass the written examination will be allowed to set for the clinical examination.
1. Simulated Clinics:
The main objective is assessment of adequate consultation skills, which include the following:
History-taking skills. Communication skills
Health education and health promotion Patient management skills
Prescribing.
Effective use of resources: the primary health care team, referral system and use of investigations
Evidence of being a competent and safe doctor. Categories of Cases:
The cases or the their themes may include all or many of the following: Acute cases.
Chronic disease management. Difficult patient
Difficult situation, e.g.: breaking bad news or patient with multiple problem Clinical examination.
Telephone consultation / Referral. Patient education.
2. Data and Slides Interpretation Format of date interpretation exam:
A group of candidates may sit in a hall or a big room and would be given a booklet containing the data and shown slides using slide projector and are supposed to write their
Urine/Stool Hormonal assay Growth Chart
Pulmonary function test
Audiogram
X-ray
ECG
Etc.
B) The slides may cover some or all of the following board areas: General Medicine
Dermatology
Ophthalmology
Other relevant topics
3. The Oral Examination:
Each candidate will be examined by two panels, spending around 25-30 minute at each one
Each panel consist of two examiners
One of the panels will have a specialist in community medicine as examiner. The areas covered in one panel will not be repeated in the other one.
Marking of the Clinical and Oral Examinations:
The marking of the clinical and oral examinations is distributed as the following: The mark distributed as follows:
1. Simulated clinic 40% 2. Data and slide interpretation 30% 3. Oral examination 30%
According to the Saudi Council for Health Specialties Examination Regulation, the grading of the candidates at the clinical and oral examination will be in the following categories:
1. Clear pass
2. Pass
3. Borderline Pass
4. Fail
(For more details see General Examination Rules and Regulations Revised, November 1999; Page 9-11 Saudi Council for Health Specialties)
(For more details about the contents, format and instructions see “The Final Examination of the Saudi Board for Family Medicine / Contents and Instruction For Candidate” September 2000, by Dr. Eiad Al Faris and Dr. Hamza Abdul Ghani)
Arab Board Final Examination
A. Assaggaf
Arab Board Final Written ExaminationThe final written examination consist of a total 210 MCQs Divided to two parts:
Part I:
Content: 150 Traditional MCQ (Factual Knowledge questions) Time Allowed: 3 hours.
Part II:
Content: 60 Question in the form of patient management Question (P.M.Q) Time allowed: 2 hours.
Passing Score & marks distribution:
Each one of the 210 multiple choice questions (Part I + Part II) is given an equal score & the exam mark will be out of 210 which then will be transferred into percentage (%). To pass the written examination, it is essential to score 60% as a minimum.
Only those who pass the written examination will be allowed to set for the Clinical examination.
Arab Board Final Clinical Examination (OSCE)
The final clinical examination consist of two parts: I. Objective Structured Clinical Examination (OSCE) II. Oral Exam
I. Objective Structured Clinical Examination (OSCE) What is OSCE?
The objective structured clinical examination (OSCE) is an approach to the assessment of clinical competence in which the components of competence are assessed in a planned or structured way with attention being paid to the objectivity of the examination.
The student is assessed at a series of stations with one or two aspects of competence being tested at each station. The examination can be described as a ‘focused’ examination with each station focusing on one or two aspects of competence. In a typical examination there
One circuit of 20 stations will allow 20 students to be examined simultaneously. If the number of students is greater than 20, this can be accommodated by running parallel circuits of stations or by repeating the single circuit with another group of students.
Although the concept of an examination with stations round which students rotate represents an important aspect of the OSCE, the examination is more than just a ‘multi-station’ examination.
OSCE
O “Objective” Subjective bias is removed as possible
S “Structured” The content of the examination are planned carefully in advance
C “Clinical” It is a performance assessment, It is concerned with what candidate can do rather with what they know
E “Examination”
Objective:
Traditional clinical examinations have been criticized on the grounds that they lack objectivity. In the OSCE, subjective bias is removed as far as possible.
In any clinical examination there are three variables. The patient, the examiners and the candidate. In the OSCE attempts are made to minimize any examiner subjective bias and to minimize any bias and to minimize any bias introduced by candidates seeing different patients. The following contribute to the objectivity of the examination.
Candidates see a number of examiners in the course of the examination, usually eight or more.
What is to be assessed at each station is agreed in advance and a marking schedule is produced which lists what is expected of the candidate at each station.
Examiners use a checklist, which reflects what is to be tasted at the station. The examiners agree this in advance.
The aim in the examination is to produce a profile for each candidate rather than a single composite mark. A candidate, for example, may be competent in physical examination techniques, but have an unsatisfactory attitude and may be taking in interpersonal skills.
The standard on criteria for pass, distinction (if appropriate), fail, and dangerous fail can be agreed.
Examiners can be trained for the task expected of them and their performance can be assessed in advance on practice videotapes.
The examination tests a wide range of skills thus greatly reducing the sampling error. This very significantly improves the reliability of the examination.
Students all face the same tasks.
Simulated patients help to ensure that all students are presented with a similar challenge.
Structured
The examination is structured in such a way that the content of the examination and the competences to be tested are planned carefully in advance. Thus the examination can sample different subject areas, e.g. cardiovascular system, dermatology, accident and
emergency medicine, geriatrics, etc. and different skills, e.g. history-taking, physical examination, problem-solving, patient education including attitudes.
In this way the examination is designed to reflect adequately the objectives of the course and to make the maximum use of the time available for the exam. It is structured so that competencies in history-taking, physical examination, patient education, problem-solving, etc. are tested in a range of areas and not in one or two areas of medicine, e.g. a patient with a myocardial infarction or a patient with chronic bronchitis
Clinical
The OSCE is a clinical or practical examination. It is a performance assessment and is concerned with what students can do rather than with what they know. Here are some examples of competencies assessed at stations in an OSCE.
History taking from a patient who presents with a problem, e.g. abdominal pain. History taking to elucidate a diagnosis, e.g. hypothyroidism.
Educating a patient about management, e.g. use of inhaler for asthma.
General advice to a patient, e.g. on discharge from hospital with a myocardial infarction.
Explanation to patient about tests and procedures, e.g. endoscopies.
Communication with other members of health care teams, e.g. brief to nurse with regard to a terminally ill patient.
Communication with relatives, e.g. informing a wife that her husband has bronchial carcinomas.
Physical examination of system or part of body, e.g. examination of hands. Physical examination to follow up a problem, e.g. CCF.
Physical examination to help confirm or refute a diagnosis, e.g. thyrotoxicosis. A diagnostic procedure, e.g. ophthalmoscopy.
Written communication, e.g. writing referral letter or discharge letter.
Interpretation of findings, e.g. charts, laboratory reports or findings documented in patient’s records.
Management, e.g. writing a prescription.
Critical appraisal, e.g. review of published article or pharmaceutical advertisement.
Problem solving, e.g. approach adopted in a case where a patient complains that her weight as recorded in out-patients was not her correct weight.
In the examination it is what the examinee does, when confronted with a patient or a situation, that is assessed not what he knows and the answers he writes to a theoretical question on the subject. A range of techniques can be employed in the OSCE to emphasize the practical nature of the examination. These include simulated patients, videotape and simulators: of these, simulated patients have the greatest to contribute to the OSCE. In traditional clinical examinations all too often history-taking ability is assessed by the examiner scoring the candidate’s written or verbal report of the history and no attempt is made to watch the candidate taking the history. In the OSCE the process as well as the product, is measured in the examination. The technique he uses taking the history and the questions he asks are assessed as well as his findings and his conclusions based on the
What About Arab Board OSCE Exam:
You will rotate round 17 stations (Number 1-17) spending 7 minutes at
Each station. A bell will ring at the beginning of the examination and at the end of each 7-minute period.
1) At each station you will be asked to perform certain tasks e.g. a) Take history
b) Examine a patient
c) Interpret x-rays or other clinical materials d) Describe management …………etc.
2) Two (2) of the 17 stations are rest station where you will do no task.
3) All stations have an equal value from the total mark allocated for the OSCE. II The Oral Examination:
a) Two panels will examine each candidate, spending around 25-30 minutes at each one.
b) Each panel consists of two examiners. Marking of the Clinical Examination:
The marks of clinical examination are distributed as the following: 1) OSCE 60%
2) Oral Exam. 40%
To pass the Clinical examination, it is essential to score a minimum of 60% of the total mark for the clinical examination. (By adding the marks obtained in the OSCE & the Oral).
1.
Approach to Common Chronic Problems in PHC
Approach to Patient With Asthma
F. Rayes, M. Alatta & A. Al Harthy
The following items may need to be considered in each follow up visit: Doctor-patient relationship
Encouragement of patient contribution Patient’s cues
Well-being and psychosocial context of the problem Physical complaints:
E.g. Any recent exacerbations Current level of treatment Problems with medication Smoking habits
Restrictions on lifestyle:
o E.g. Exercise tolerance o Time off work
Examination:
Chest examination Current peak flow (PF):
The percentage of best and predicted PF Before and after bronchodilators Consider spirometry
Inhaler technique
Review of home recordings of PF Management:
Discuss any concerns
Provide printed information if required Consider others tests, e.g. allergy Agree management program:
Self-management protocol Action in emergency Arrange for follow-up
The frequency of follow-up depends on the severity of the asthma, medication use, number of exacerbations, etc. Well-stabilized patients with asthma probably do not need review more than yearly.
Common problems in follow up of asthmatic patients: o Denial and refusing to accept the diagnosis
Asthma General Advice: Establish rapport
Encourage patient’s contribution:
Active listening and use of open-ended questions
Explore the social & psychological context of the problem (Is he a student? Is he a smoker? Any association with sport?) Exploration of patient’s Ideas, Concerns & Expectations Examples (Afraid to be addicted to the inhalers
Afraid from corticosteroids Frequent absence from collage
Drop out from sport team Expect to change to tablets) Health education:
o Explanation of asthma
o Explanation of asthma drugs: bronchodilator , anti-inflammatory o Stress on the importance of correct technique
o Discuss The possible triggering factors & how to avoid them:
E.g. house dust mites, animal dander and house pets, cockroaches, respiratory infections, environmental irretant, tobacco smoke, cold air, exercise, air pollution, chemical gases or fumes
Drugs (aspirin, NSAID, beta-blockers, food preservative (sulfates) o Action plan: recognize deterioration, what action to take, o Importance of PEFR
Respond to patient cues (his understanding ability, his anxiety…) Provide patient with health education material
Arrange for follow up
Inhalation Technique Instructions:
If the patient is using dilator or anti-inflammatory Explain why it is used and what is there effect Explain about machine and its parts
o Remove cap (hold in correct position not upside down) and shake. o Breath out gently through your mouth.
o Put the mouthpiece into your mouth (or 4 cm) always and in front of your mouth. o Start to breathe in slowly, then in the middle of the breath press the canister down
go on breathing (head up right and back) and keep pressing.
o When you can not breath in any more take the inhaler out and hold breath 5-1 0 seconds.
o In case of more than one puff repeat steps 4-8 after one min. o Wipe mouthpiece of inhaler and cover it.
o Check the expiratory date of the medicine Wash it twice a week.
Demonstrate to patient
Let him do it and observe him, in order to correct him. Tell him about spacer and its benefits.
If patient using 2 types. Use dilator first. If using steroids wash mouth after.
Take feedback and encourage patient to ask questions Arrange for follow up
How to Use the Peak Flow Meter?
As a doctor you should have your peak flow meter at your clinic to measure your patient peak flow rate.
The educated patient should have at home to check his own peak flow rate specially if sign is worsening to start the action plan (see later).
This is a checklist of proper use of peak flow meter: o Explain the machine and why to use it?
o Put mark to zero o Stand up
o Finger away of horizontal not too tight o Breath in as much as you can
o Lip sealing tongue should not be inside o Breath out as hard and as fast as you can
o Write down the level (aside) put marker back to zero o Repeat three times and record the maximum on chart o Demonstrate (change mouth pieces)
o Let him do it and observe to correct o Monitor bid daily, it is not a flat line
o Any drop below the zone step up medications PEFR & Severity of Acute Attack:
80-100% of the patient best = Mild attack 50-80% of the patient best = Moderate attack ≤ 50% of the patient best = Sever attack
< 33% of the patient best = Life threatening attack
Patient Education: What is asthma?
Asthma is a chronic breathing problem, it’s symptoms varies from cough, (which usually more at night and increase after exercise) shortness of breath, wheezing.
These symptoms are caused by decrease air entry to the lung due to inflammation ( narrowing) of the air way.
If the patient take care of the disease and follow proper medical advice he can have normal activity, but asthma can be a life threatening if the case neglected & did not receive the proper management.
The illness may start in childhood which may improve when child is getting older or may continue to adulthood. Also it can start at adulthood in previously healthy child. What is an asthma attack?
Asthma frequently present in attacks which mean the person can have no symptoms, then when he is exposed to a precipitating factor. The attack start (and this cause many doctors miss the diagnosis if they see the patient in between attacks).
What is the precipitating factors of asthma attack?
Avoidance of Irritant & Allergens:
Smoking: Both active and passive smoking must be avoided if family member smoke and not ready yet to quit he should not smoke at home, in the car or other closed places where patient may stay in.
Wood smoke, household sprays, bakhoor, cooking oil, detergent, some strong small should be avoided.
House dust mite: Which is increase in humid areas. These measure lower it amount:
o Washing all the bedding sheets, blankets and covers in hot water.
o Vacuum the carpet regularly while the patient not in the room (if you can takeout the carpeting out).
o Avoid having animals in the house (cats or birds).
o Frequent cleaning and apply insecticide when asthmatic not present. o If the patient has occupational exposure to allergies should be referred to specialist.
Action Plan: (as mentioned in the National Protocol)
The action plan can be symptom based and/or peak flow based to suit the person’s understanding of his/her problem. All people with asthma need to:
o Be able to recognize deterioration o Know what action to take
o Have their action plan reviewed and, if necessary, modified o Following an acute attack
o All people with asthma should know how to obtain prompt medical assistance: o Provide patients and families with a written ACTION PLAN –CARD
The Traffic Light Zone System:
The following zone system that puts the control asthma into one of 3 different zones each with specific instructions. Traffic light colors indicating the various zones have been chosen since most patients are familiar with them.
Green zone: Indicates all is clear, PEF is at 80-100% with less then 15%
variability. There are minimal symptoms (ideally none) related to asthma. The patient is to continue maintenance therapy as previously instructed by the physician. Inhaled 2
agonists may be used if needed prior to exercise or for occasional mild symptoms.
Yellow zone: Indicates caution, PEF is 60-80% predicted with 15-25% variability. Asthma symptoms such as nocturnal cough, shortness of breath or wheezing may occur. This would indicate:
Either an acute exacerbation in which case guidelines in following section should be followed,
Or a gradual deterioration in the severity of asthma where intensification or stepping up of maintenance therapy is required, this should be done in consultation with the physician. A doctor ought to be consulted within 48 hours.
Red zone: This signals a medical alert. PEF is less than 60% and asthma symptoms are present at rest and interfere with activity. Inhaled 2 agonist should be taken immediately, if PEF remains below 60% immediate medical attention at an acute care facility is recommended, if PEF improves to above 60% instructions for the yellow zone should be followed. Physician has to be consulted within 4 hours or less.
These are broad guidelines. Instructions given to each patient should be individualized taking into account factors such as reliability, level of understanding, availability of medical care and the doctor patient relationship. In some patients instructions on when to
Approach to Patient With Diabetes Mallets
M. Alatta & F. Rayes
The following items may need to be considered in each visit: Doctor-patient relationship
Encouragement of patient contribution Patient’s cues
Well-being and psychosocial component of patient problem Physical complaints
Dietary problems Medication problems Examination & investigation: Fasting, blood glucose Urinary protein and glucose Body mass index
Blood pressure Visual acuity
Management & education:
Discussion of immediate concerns Discussion of current management Follow-up arrangement made
The following items may need to be considered in annual visit: Smoking habit
Pruritus
Pain and/or paraesthesia in legs Sexual problems Visual problems Angina Claudication Examination: Fundoscopy Inspection of feet: o Circulation o Reflexes Blood creatinine Blood cholesterol Education:
o Check self-care & lifestyle o Self-monitoring
o Foot and eye care
o Smoking habit o Diet
o Exercise Smoking habit
Common problems in follow up of diabetic patients: o Uncontrolled or poor control of DM
Counseling Newly Diagnosed Diabetic Patient: Doctor-patient relationship
Encouragement of patient contribution Patient’s cues
Exploration of patient ideas, worries and concerns
(What do you know about diabetes?)
Explanation about diabetes:
It is a common, chronic illness, characterized by primary hyperglycemia. It is two types:
o The first type: Represent 10% of diabetic patients, they are called IDDM (they always take insulin).
o The second type: Consisted 90% of cases and they are called NIDDM their body secretes either too little insulin which is not enough or large amount but not effective.
When the body secretes no insulin sugar level will increase. So diet and exercise are important to control diabetes.
By some modification in patient’s life style he can live a normal life. Diet:
o Eat three meals a day at regular times.
o Eat nothing between meals except a snack (specify hours). o Eat no sweet for now (sugar, dates, honey)
Exercise:
Start by increasing your daily physical activity, like walking. Other exercises may by added when you are feeling better. Glucose Monitoring
o This will help you feel that you have more control over your health. o Specify time: e.g. before breakfast & supper.
Blood Glucose Level:
o Home blood glucose measurement technique if the patient has glucometer o It is the best way of monitoring
o Show the patient how to use this monitoring device. Urine Glucose Level:
o Explain to patient how to use the dipstick. o It is less effective way of monitoring. Medication:
Insulin:
o There is no insulin in tablets form.
o They must be taken as subcutaneous injections.
o They are usually taken twice per day: 30 min. before breakfast & 30 min. before supper.
o Schedule may be changed till we find the best for you.
o The nurse will show you the technique for injecting your self & how to store and take care of your insulin.
Tablets:
o They are not insulin
o Given to patient whose bodies make insulin. o They help your insulin to work better. Low Blood Sugar:
o Your medication may cause sometimes your blood sugar to drop too low. o When this happen you may feel the following:
What to do if you develop symptoms of hypoglycemia: o Quickly eat or drink something sweet.
o (Sugar in water, Orange juice, honey) o Call your doctor right away.
Medic alert card:
You can buy it from drug stores. Wear it all time. Care of your feet:
o It is very important for you to always keep your feet dry and clean. o Wear socks and good shoes.
o Health educator will give you a pamphlet about foot care. Driving:
It is advisable to stop driving until your sugar is well controlled if you are taking medication, because risk or low sugar.
Traveling:
Talk with your doctor before you travel to help you to fit your diet and medication into your travel schedule.
Give patient printed educational material (Leaflets or booklets).
Arrange appointment with dietitian within two weeks. Follow up in 4-8 weeks
You can ask the patient to come with care taker e.g. his wife, his mother. Take continues feedback and answer any questions.
Approach to Patient With Hypertension
H. Al Hajjar & F. Rayes
The following items may need to be considered in history taking in the first visit: Doctor-patient relationship
Encouragement of patient contribution Patient’s cues
Well-being and psychosocial component of patient problem Date of onset of hypertension, duration
Levels at time of onset
Specific question to rule-out secondary hypertension: o Hairsutism
o Easy bruising
o Palpitation, sweating o Muscle cramps o Leg claudication
Symptoms suggestive end organ damage: o Chest pain
o Breathlessness o Orthopnia o claudication
o Transient visual loss Past medical history :
o Renal disease
o Obstetric history (pre eclampsia) Cardiovascular risk factors:
o Smoking o Obesity
o Hyperlipidemia o Diabetes mellitus
Family history (Assessment of degree of risk) : o Hypertension
o Ischemic heart disease o Stroke
o Hyperlipidemia
o Premature cardiovascular death
o Renal disease as autosomal dominant polycystic kidney Drug history :
o For hypertension : efficacy and side effects
o Other drugs : OCP, Steroids, Thyroid hormone, NSAID o Over the counter medications
o Alternative medicine products o Substance abuse
Social history : o Smoking and alcohol o Diet : salt, fat, weight gain o Caffeine
o Leisure activity & exercise o Work environment and stresses o Family and home situation o Education level
The following items may need to be considered in examination of patient with hypertension the first visit:
Blood pressure measurement: o Tow or more
o Sitting or supine (after 2 min) plus o Standing (after 2 min)
o Both arms (take the higher reading) General examination:
o Height and weight (BMI), waist circumference o Skin for signs of : mainly secondary causes o Chronic renal failure
o Xanthelasmata
o Stigmata of cushing, Neurofibromatosis o Yellowish finger staining
o Fundoscopy : for hypertensive retinopathy Neck examination :
o thyroid enlargement o distended vessels o carotid bruits
Lungs :
o signs of heart failure (basal crepitations) o sings of bronchospasm (to avoid b-blockers)
Heart :
o left ventricular lift, S3,S4 ( heart failure – end organ damage)
o loud AS2, loud systolic murmur in chest and back , delayed femoral pulses (coarctation of aorta)
o high pitched end diastolic murmur (aortic regurgitation – apparent isolated systolic hypertension)
Abdomen:
o masses or enlarged kidneys o signs of chronic liver disease
o bruits lateral to midline (renal artery stenosis) o aortic pulsation
Extremities :
o pulses for radiofemoral delay, diminished or absent o edema, bruits and neurological assessment
CNS :
o focal deficit (old stroke)
o For elderly patients: nuro-psychiatric assessment ( multi infarct dementia )
Guidelines for blood pressure measurements o Patient relaxed in a quiet room
o Use od accurate cuff dimensions
o Ensure forearm is supported and at heart level o Inflate cuff to 30 mmHg above pulse occlusion o Observe at ‘eye level’ with mercury column
White Coat Hypertension :
o Incidence is 10-20% of hypertensive patients.
o Diagnosis by home monitoring or ambulatory monitoring. o No drug treatment unless there is end organ damage. o Follow-up annually using home or ambulatory monitoring
When do you suspect secondary hypertension? o Renal cause: if the patient has end organ damage. o Onset of hypertension at very young or elderly (> 55 y). o Aldosteronism: if blood k+ < 3.5 mEq /L.
o Pheochromocytoma:in labile hypertension with severe headache. o Coarctation: if the patient is young with systolic hypertension.
The following items may need to be considered in every visit and annually:
Well-being
Physical complaints Any side-effects Examination in every visit: Blood pressure
Weight and body mass index Chest examination
Examination and investigation annually: o Fundoscopy o Urinary protein o Blood creatinine o Blood cholesterol Also consider: o Chest X-ray o ECG
o Ambulatory blood pressure Education:
Complications of BP.
Importance of non pharmacological treatment However medications is also sometime needed Relative safety of anti-hypertension medications
The effect of medications to decrease morbidity & mortality Need for good compliance with medication & advice
Need for follow-up Management:
Shared understanding of problems Appropriate prescribing
Advise about possible side effects Follow-up arrangement
Stressing on non-pharmacological treatment Discussion management or change management Follow-up arrangements made
Poor Compliance
Poor compliance is a common problem inpatient with a symptomatic chronic disease, e.g. patient may not respond to doctor’s advices and he may not take his medication.
The following approach may need to be considered in dealing with poor compliant patient:
Establishing and maintain effective doctor-patient relationship: o Great the patient, empathetic approach,
o Respond to verbal & non verbal cues o Use open ended questions
o Respect patient autonomy o Encourage patient’s contribution
o Active listening
Exploration of patient’s health beliefs: o What the patient knows about hypertension? o What the patient knows about medications? o What dose he beliefs about himself?
o What does he expect from the doctor?
Explore the social & psychological context of the problem: e.g. possible life stresses
Assessment of degree of risk (if it is not clearly documented in the patient’s file) and use the information to improve patient’s compliance
o Family history of BP., IHD.CVA. o Complication of BP / DM.
o Or other significant systemic disease Education and reassurance:
o Shared understanding of problems
o Discuss possible complications of hypertension.
o Stress the importance of non pharmacological treatment o However medications is also sometime needed
o Relative safety of anti-hypertension medications o Insurance of accessibility
o The effect of medications to decrease morbidity &mortality
o Emphasize the need for good compliance with medication & advice o Emphasize the need for follow-up
Approach to Patient With Arthritis
F. Rayes
The following items may need to be considered in history taking in the first visit: Doctor-patient relationship
Encouragement of patient contribution Patient’s cues
Explore patient believes, ideas, concerns and expectations about his complain Details of the complain:
o Pain: Onset, duration, severity, distribution, aggravating factors and relieving factors
o Stiffness: Onset, severity, duration o Weakness: Degree?
o Swelling
o Deformity: Malalignment, subluxation or dislocation Occupational history:
o Repetitive overuse o Biomechanical o Positioning
Family history: Osteoarthritis (OA), ruematoid arthritis (RA) or gout Systemic illness: Systemic upset in RA, gout, sepsis
Sleep disturbance or depressed mood Specific extra-articular feature:
o Alopecia: SLE
o Rash: SLE or Reiter’s syndrome o Ocular symptom: Reiter’s syndrome o Oral symptom: SLE, Reiter’s
o Paraesthesias
o GIT or urinary symptom: May indicate inflammatory bowel disease, drug, or fibromyalgia.
Effect on daily functioning
Shared understanding of the problem with the patient. Exploration of any relevant continuous problem if any
The following items may need to be considered in examination of patient with joint pain in the first visit:
Inspection:
Attitude: Relax, normal, restricted movement abnormal posture Skin Changes:
o Scars of skin disease
o Erythema: periarticular inflammation o Red joint or bursa: sepsis or crystals Swelling: fluid, soft tissue or bone
Deformity:
o Correctable: soft tissue abnormalities
o Non-correctable: capsular restriction or joint damage o Muscle wasting
Inspection during active movement Palpation:
Warmth, swelling and tenderness Palpation during movement:
o Passive movement: crepitus
o Active movement: muscle power, instability, swelling General examination:
Nodules: back of the hands, elbow, posterior heel, sacrum Palmer erythema: RA
Nail changes:
o Clubbing (arthritis with COAD) o Pitting (psoriasis, Reiter’s syndrome) o Splinter: Vasculitis
Mucous membrane lesion: Reiter syndrome / Lupus Vasculitis
Eye changes:
o Episcleritis (RA)
o Iritis: Ankylosing spondylitis chronic Reiter’s disease o Iridocyclitis: juvenile chronic arthritis
o Conjunctivitis: Acute Reiter’s disease
Assimilation of findings:
Number of joints involved Distribution
Degree of inflammatory component Extra-articular features
Differential Diagnosis of Joint Pain
Ostioartheitis Arthritis Reuhmatoide Arthritis Fibromyalgia Common in elderly patients
More in female - Duration months to
several years Clinical features: - Hand stiffness
bilaterally, lasting for less than 30 minutes - Morning worse
- Bony swelling, DIP joints (Heberden shoder)
- Bony swelling, DIP joints (Bouchord’s nodes)
Common in middle age More in female
- Duration months to several years Clinical features:
- Morning stiffness both hands, lasting for more then 30 min
- pain both wrists.
- Fatigues, malais, wt loss parasthesias & vague pain both wrists. - Swelling, redness &
tenderness PIP & metacarpo-phalangeal joints
- Nondules over elbow extenso
- Swelling in the metacarpophalangeal joints.
Common in middle age More in female - Chronic aching Clinical features: - Pain : cervical, shoulders, pectoral lumbosacral areas. - Headache sleep
disturbance & fatigue - Swelling numbness &
morning stiffness
- No evidence of joint swelling
- Multiple tender areas
Differential Diagnosis of Joint Pain (Continue)
Gout
Gonococcal Septic Arthritis Nongonococcal Septic Arthritis- More in males - Monoarticular, first metatarsophalagel 90% - Very painful. - Signs of intense inflammation. - Definitive diagnosis : urate crystals in synovial fluid. Management: - Colchicine dramatic improvement NSAID (indomethacin). - Female 2/3 of patient. - One or two joints, wrist,
finger, knee & ankles. - Migratory arthritis - Synovitis
- Conococcemia : fever, polyarthralgias & skin eruption prior to arthitis compare to other septic arthritis. Management: - Hospitalization Ceftriaxime 1 g IV TDS. - Both genders
- Swelling, pain, warmth With severe constitutional symptoms
- Monoarticular synovitis particularly knee rarely small joints.
- 75% gram positive stapheloccocal aureas. Management:
- Hospitalization - Drainage & rest - Antibiotic guided by
Preliminary Investigations:
o Erythrocyte Sedimentation Rate (ESR) o Complete Blood Count (CBC)
o Rheumatoid Factor (RA) o X-Ray of the affected joint
Laboratory Findings in rheumatoid arthritis: o High ESR
o Normocytic normochomic anemia
o Rheumatoid Factor in 80% of the patient is positive o Antinuclear antibody in 20-60% of the patient is positive o Anti DNA is usually negative
Facts about Rheumatoid Factor (RA factor): o It does not confirm the diagnosis of RA
o It can be of prognostic significance, as patient with high titers tend to have severe progressive RA.
o All patient with extra-articular manifestation of RA have positive Rh factor.
Other Conditions with Positive RA factor: o 5% of healthy persons
o 10-20% individual over 65 years old o SLE
o Sjogren’s syndrome o Chronic liver disease o Sarcoidosis
o Interstitial pulmonary fibrosis o Hepatitis B
o TB o Leprosy
o Sub-acute bacterial endocarditis o Syphilis
o Malaria
o Visceral leishmania o Bilharziasis
Approach to Patient With Backache
F. Rayes & H. Al Hajjar
The following items may need to be considered in history taking from patient with backache
Doctor-patient relationship
Encouragement of patient contribution Patient’s cues
Duration of pain, onset, quality, characteristic, location, radiation, concurrent infection.
Risk Assessment:
Symptoms potentially indicative of serious underlying pathology;” e.g. fever, progressive severe neurologic deficits bilateral deficits, bladder dysfunction saddle anesthesia” Aggravating activities & alleviating factors
“Morning stiffness relieved by activity suggests ankylosing spondylitis or other inflammatory conditions. Worsening by standing or walking spinal sclerosis and relief by bending Check for depression and somatization”.
Work situation and situation at home Consequences in term of daily functioning Past history of pain
The following items may need to be considered in examination of patient with backache
Patient Standing: Inspection:
o Gait (patient without shoes)
o Back for scoliosis, lordosis, swelling, masses, color, & scars. Palpation:
o Spine land marks: C7, T3 (scapular spine), T7 (inferior angle of scapula) & L4 (iliac bone).
o Skin for hotness, tenderness (infection, fracture, ) & masses. o Muscle spasm.
o Sacroiliac joints.
Percussion: for deep tenderness. Movement:
o Toe-walk S1 o Heal - walk L5 o Squat & rise L4
o Movement: flexion, extenuation, lateral flexion. Patient Sitting:
Inspection: scoliosis, muscle wasting. Movement:
o Rotation
o Extend knees role out disc prolapse. o Knee reflex.
Patient Supine: Examine free side first. Movement:
o Straight leg raising test (S L R) Active, passive & crossed SLR o Bragard test.
o Lasegue test.
o Figure of four (sacro-iliac joint) Power:
o Hip flexion. L1 - L2 o Knee flexion; L5 – S1 o Knee extension: L3 – L4 o Foot planter flexion. S1 o Foot dorsi flexion. L4 – L5 o Big toe dorsi flexion o Foot inversion: L4 – L5 o Foot eversion: L5 – S1 Reflexes:
o knee reflex: L3 – L4 (if not done while patient is sitting) o Ankle reflex: S1
Sensation.
o Medial side of foot. L4 o Dorsum of foot. L5 o Lateral side of foot: S1 Patient Prone:
o Femoral nerve stretch. L4 o Compress midline as in CPR Examination of the abdomen
Differential Etiological Factors in Backache: Mechanical disturbance
Poor muscle tone / Poor posture / Unstable vertebrae / Severe Scoliosis
Extrinsic disease such as aortic aneurysm, uterine fibroids, prostate disease, hip disease
Degenerative disc or facet disease
Psychological, this includes hysteria, malingering, and acute remunerative spinal pain (Green-Poulitice disease).
Inflammatory arthritis - rheumatoid and Marie-Strumpell's disease Infections, acute and chronic
Trauma: Acute sprain or strain / Chronic sprain or strain / Fractures / Subluxated facet (facet syndrome) / Spondyfolisthesis with strain.
Toxicities from heavy metals
Counseling Patient with chronic backache:
Explore patient’s Ideas about backache, concerns & expectations. Educate patient about backache.
o Multiple etiology &- mechanics. o Nature.
o Prognosis.
o Why acute pain became chronic? (Social, psychological, stress) What to do in acute attack?
(Bed rest, heat / cold, posture, analgesia)
Disc herniation may need up to 3 weeks bed rest
However there is little evidence to support prolonged bed rest (EBM) Prevention:
o Lifting technique o Standing
o Posture o Seating
o Demonstrate to the patient o Bed
o Work: chairs + desks o Exercise
o Wt. Reduction
o Smoking, personal habits Other treatment modalities:
o Massage o Traction o Manipulation: osteopathy o Chiropractic o Acupuncture Leaflets, booklets Follow up
Preliminary Investigations:
Erythrocyte Sedimentation Rate (ESR) X-ray of lumbar spine and pelvis
The routine ordering of plan lumbosaeral spine feature is neither cost- effective nor useful for decision making. Finding normal disc spaces does not rule out disc herniation.
Specific investigation for abdominal or pelvic causes: e.g. urine examination, renal or pelvic ultrasound
Indications For X-ray:
Suspect malignancy (over 50 years, persistent bone pain)
Compression fracture (prolonged use of corticosteroids severe trauma, focal tenderness)
Ankylosing spondylitis (young male, limited spinal motion, sacroiliac pain) Chronic osteomyelitis (low grade fever, ESR)
Major trauma
Major neurological deficit Indications For Referral:
Rapidly progressive neurologic deficits
Symptoms suggestive of cunda equina syndrome or cord compression Suspicion of osteomyelitis or epidural abscess
Persistent pain after 4-6 weeks of conservative management For reassurance if patient insist
2.
History Taking
N. Dashash, A. Assaggaf, A. Al Harthy & H. Al Hajjar
In history taking stations some time patient presents with typical story, the candidate may reach the final diagnosis from the first impression and ignore to ask relevant and specific questions to prove it objectively. Candidates are advised to think loudly to give the examiner the chance to understand how he think, in order to give him the desirable evaluation mark
(For more advices see simulated clinic exam)
(1) History Taking from Patient Complaining of Palpitation
A. Al Harthy The following items may need to be considered:
Introduce yourself and establish doctor-patient relationship Encourage patient contribution
Respond to patient’s cues
Clarification of the symptom (what the patient means by palpitation). Exploration of the details of the main complaint:
Onset, course, frequency, duration, rate, rhythm, pattern (how it end abrupt or gradual), precipitating factors and relieving factors.
Associated symptoms: e.g. chest pain, shortness of breath, fainting, sweating, tremor, feeling of tension (fear), any symptoms of thyrotoxcosis.
Presence of mood changes, concentration or memory problems any phobias (e.g. social phobia).
Past history of cardiac disease.
Drug history or stimulant use: e.g. tea, coffee (it’s amount). Social history & any history of stressful life events.
Exploration of patient s ideas, concerns and expectations and the effect of the problem in patient’s life.
Family history of.
Exploration of any continuous problems or at risk factors: DM, hypertension, asthma or smoking (the amount of smoking).
A good history is often diagnostic, particularly with respect to precipitating factors. Differential Hypotheses
o Anxiety
o Cardiac causes: e.g. sinus ventricular tachycardia, ventricular ectopics, atrial fibrillation or flatter or sinus tachycardia
o Drug induced arrhythmias o Thyrotoxicosis or anemia Management:
o In case of infrequent palpitation or missed beats with no associated symptoms: reassurance and advice patient to avoid the precipitating factors
o In case of frequent palpitation associated with chest pain or breathlessness: - Urea and electrolyte
- TFTs and treat if abnormal
(2) History Taking from Patient Complaining of Tremor
N. Dashash The following items may need to be considered:
Introduce yourself and establish doctor-patient relationship Encourage patient contribution
Respond to patient’s cues
Exploration of patient Ideas, Concerns, Expectations and feeling. Problem identification:
o What is meant by tremor?
o Is it visible or only a sensation of tremor? o Duration of the problem?
o Onset gradual or sudden?
o Part of the body involved? (Head, voice, trunk... o Type of movement and its spread.
o Is it a resting tremor or a movement tremor? o Aggravating and relieving factors.
Other associated symptoms of: o Cerebellar disease
o Hyperthyroidism o Anxiety
o Parkinson’s
The effect of the problem on the patient's life (e.g. work, marital life). History of drugs: e.g.
o Lithium
o Tricyclic antidepressants.
History of alcohol drinking and smoking Past medical history:
o Brain disorder or head trauma o Multiple sclerosis
o Other diseases, e.g. DM or hypertension. Family History of similar problems.
Differential Hypotheses: o Alcohol o Medications o Cerebellar disease o Hyperthyroidism o Anxiety o Parkinson’s
(3) History Taking from Patient Complaining of Pruritis
N. Dashash & F. Rayes The following items may need to be considered:
Introduce yourself and establish doctor-patient relationship Encourage patient contribution
Respond to patient’s cues Identification of the problem:
o What is meant by pruritis?
o Which part of the body is involved? o Onset, duration, clinical course. o Precipitating factors.
o Severity of pruritis (interfering with sleep and daily activity) o Any associated skin rash or any skin changes (describe it). Associated symptoms of:
o Hyperthyroidism. o Renal failure o Drug reaction,
o Iron deficiency anemia o Malignancy
o Liver failure o Pregnancy.
Sensitivity to food, soap, perfumes... Any thing new in the patient's life. Past medical history
Drug history: opiates, amphetamine, quanidine, aspirin, and vitamin B. Occupational history.
Family history of similar problem. Psychological stress.
Exploration of patient ideas, concerns, expectations and feeling.
Exploration of the effect of the problem on the patient's life (work, marital life. Systemic Causes of Pruritus
Cholestasis:
o Primarily biliary cirrhosis, pregnancy
o Extrahepatic obstruction, drugs e.g. Contraception
Endocrine:
o Thyrotoxiosis, myxoedema o Hyperparathyroidism, DM
Haematological / myeloproliferative: o Iron deficiency, polycythemia o Hodgkin’s disease, multiple
myeloma
Chronic Renal Failure
Malignency
o Miscellaneous e.g. gout, psychological, old age. Investigation of Pruritus:
With no overt skin disease
o Urine: Glucose, protein, and urine microscopy
o Stool: Occult blood & parasites
o CBC, differential white blood count & blood film
o ESR, U & E, serum iron and uric acid o TFT & LFT
o Chest-X Ray
Management of Pruritus
o Elimenation of underlying cause o Emollients as dry skin the most
common cause of itching. o Calamine lotion
o Crotamiton (Eurax) cream 0.5% o Systemic antihistamines e.g. Benadry
QID, Atrax, Hisenanal.
o Topical corticosteroid ointment o Unidazole combination.
(4) History Taking from patient Complaining of Anxiety
N. Dashash
The majority of patients may present with somatic complaint, e.g. palpitation or dyspnoea or chest tightness. Candidate needs to suspect the diagnosis from the patient’s verbal and nonverbal cues, e.g. excessive hand movement…
The following items may need to be considered:
Introduce yourself and establish doctor-patient relationship Encourage patient contribution
Respond to patient’s cues Identify the problem:
o Duration of symptoms, onset: sudden or gradual
o Course: continuous or episodic (to rule out panic attacks and phobia) o Change in severity
o Precipitating factors e.g. problem at work or home, death of relative Exploration of patient ideas, concerns, expectations and feelings
Effect of the problem in patient life (physical, social and psychological) Etiology: It is necessarily to exclude the following diseases:
o CVS diseases: ask about palpitation, chest pain, paroxysmal nocturnal dyspnea, relation of symptoms to exercise and irregular beats.
o Depression: ask about loss of interest, low mood, change in wt ... etc. o Hyperthyroid: ask about heat intolerance, excessive sweating...etc. Symptoms of anxiety disorder (diagnostic criteria):
o Psychological: excessive worrying, nervous mood, apprehension, irritability, disturbed sleep, and difficulty in concentration. Psychotic features (e.g. hallucinations).
o Neurological: dizziness, headache, twitching, paraesthesia, blurring of vision o CVS: palpitation, chest discomfort, flushing
o Respiratory: hyperventilation, difficult breathing, and chest tightness.
o GIT: dry mouth, nausea, difficult swallowing, choking, frequent loose motions, abdominal discomfort, wt. Loss, and nausea/vomiting
o Urinary: frequency and/or urgency. o Menstrual disturbances and reduce libido. o Others: muscle aches and tension, tiredness
Drugs History: e.g. Alcohol, drugs, benzodiazepene withdrawal, caffeine (amount) and smoking history.
Past History:
o Similar problems, or any psychiatric problem
o Medical or surgical problem (hypertension, DM, hyperthyrodism or asthma.) Family history of similar problem or any psychiatric problems
(5) History Taking from Patient Complaining of Depression
A. Assaggaf
The majority of the depressed patients may present to their family doctor complaining of fatigue or somatic symptoms. Candidate needs to suspect the diagnosis from the patient verbal and nonverbal cues, e.g. lack of eye contact, self-neglect, or multiple somatic complains does not fit to any diagnosis…
The following items may need to be considered:
Introduce yourself and establish doctor-patient relationship Encourage patient contribution
Respond to patient’s cues Clarification of the symptom History of the problem:
o Duration o Mood
o Loss of interest in his usual activities o Activity level:
Decrease, retarded, slow, loss of energy or increase, restless or agitated. o Diurnal variation
o Sleep disturbance: (increase or decrease) o Change in appetite and weight
o Loss of libido
o Decrease ability to concentrate o Guilt feelings
o Suicidal thoughts and/or attempts
Patient's ideas, concerns, expectations and effects of the problem Etiology of the problem
Psychosocial history: o Home environment, o Emotional problems o Financial problems
o Loss of job or loss of relative. Drug History
o Substance abuse
o Antihypertensives or steroids.
Presence of somatic complaint e.g. headache, back pain, shortness of breath, ---etc. General medical illness
Past history of similar condition (or other psychiatric illnesses) Family history of similar condition (or other psychiatric illnesses)
Prescribing of Antidepressants
Fayza Rayes
Associated problems
Suggested
Treatment
CommentsDepression 1) SSRIs
2)Tricyclic antidepressants
Consider the cost Depression with Psychosocial stress 1) SSRIs 2)Tricyclic antidepressants Social support Psychotherapy Depression with Anxiety symptoms 1) Imipramine (Tofranil) 2) SSRIs (Prozac) 3) (Tofranil) + Alprazolam Benzodiazepin (Xanax) (75-150 mg) (20-60 mg) (250-500 microgram) TDS for 6Ws then tapered slowly over 4 Ws Depression with insomnia Amitryptylin (Tryptezol) Dothiapin (Prothadin) Maprotiline (Ludiomil) Trazodone(Trazolan)
(25-300mg)Strong sedative, dizziness anticholinirgiceffects:wt.gain,constipa tion hypotension, cardiotoxic,
tachycardia
(25 250 mg)Less cardiotoxic, less wt gain, not in pregnancy
(75 150 mg) not in eplipsy (150-400mg in deveded dose) hypotension
Depression with DM SSRIs No Wt. gain
Depression with CHF or IHD
SSRIs Less cardiotoxic
Depression with Arrhythmia SSRIs Trazodon (Trazolan) Less cardiotoxic (see insomnia) Depression with Hypertension SSRIs
Trazodon (Trazolan) (see insomnia) Depression with Hypotension Nortriptylin (Nortrilen) SSRIs (10-150mg in devided dose) no hypotension, no sedation, less anticholinigic, safe in elderly Depression with Urologic disease Trazodon (Trazolan) SSRIs (see insomnia) Depression with Parkinson 's Disease Nortriptylin (Nortrilen) Trazodon (Trazolan) (see Hypotension) (see insomnia) Depression with Stroke SSRIs
Nortriptylin (Nortrilen) (see Hypotension) Depression with Migraine headache Amitryptylin (Tryptezol) Imipramin (Tofranil) Nortriptylin (Nortrilen) (see Insomnia)
(25-300 mg in devided dose) not sedative constipation, nausea, headache, sexual disfunction (see Hypotension) Depression with Chronic urticarea , Amitryptylin (Tryptezol) Imipramine (Tofranil) (see Insomnia) (see Migraine)
Choices of Antidepressants
Fayza Rayes
Drug & Dose Significant Side effect Indication Amitriptylin
(Tryptyzol) 25-300 mg in devided dose
Histaminic blockade / Sedative Anticholinergic effect
Alpha 2 adrenoreceptor blokade Hypotension/sexual dysfunction
Depression with insomnia Migraine
Not for hypotensive patient
Imepramine
(Tofranil) 25-300 mg in devided dose
Seratonin uptake blokcade / Constipation, dizziness Not sedative Depression GAD Panic attacks Clomipramine (Anafranil) 10-250 mg
Seratonin uptake blokcade / Constipation, dizziness Not sedative
OCD (Drug of first choice) Phopias
Panic attacks (Drug of first choice)
Nortriptylin (Nortrialen) 10-200 mg / day
No hypotension, no sedation Less Anticholinergic effect
Elderly
Maprotiline (Loduomil) 25- 150 mg
Not in epelipsy or risk of convulsion
Depression with insomnia
Trazodone (Trazodam) 150- 400 mg / day Minimum effects Hypotenssion Priapism (1/6000 cases)
Depression with insomnia Strong sedatve / Insomnia (half tablet for 3 days)
Sertralin
(Zoloft)or (Lustral) 25-100 mg
Seratonin uptake blokcade : GIT / anxiety / tremor / insomnia / palpitation /drowsiness / agitation / hypomania / hypotenssion / convulsion / movement disorders & dyskinezia / neuroleptic malignant
syndrome / violent behavior / hematological complications Cautions: cardiac diseases Mania / epelipsy / concurrent ECT / hepatic or renal
impairement / pregnansy / breast feeding / interactions
Depression 50-200 mg Maintenance 50 mg Fluoxetine (Prozac) 10- 80 mg / day Depression 20 mg Bulimia 60 mg OCD 20- 60 mg GAD & Panic attacks Citalopram
(Cipram) 20-60mg
Depression 20-60 mg
Panic disorder 10mg increase evrey week by 10mg / mux 60 mg Fluvoxamine (Faverin) 100-300 mg in devided doses Depression 100-300 mg OCD (the drug of first choice) Insomnia
Parooxetine (Seroxat) 20-60 mg
Depression 20mg increse by 10 mg every week / mux 50 mg OCD / start by 10 mg / mux 60 mg
(6) History Taking from Patient Complaining of Dizziness/ Vertigo
H. Al Hajjar & M. Alatta Doctor-patient relationship
Encouragement of patient contribution Respond to patient’s cues
Clarify what patient means exactly by dizziness
(Is it true vertigo or light headedness or disequillibrium) Severity of symptom: e.g. associated nausea and/or vomiting.
Effect of problem on patient's life, his ideas, worries & expectations. Course: constant or attacks (duration & frequency)
Onset and timing. Precipitating factors:
o Change in head position o Standing o Auricle manipulation, o Fatigue o Valsalva maneuver o Viral infection o Hyperventilation o Explosion History of pervious attacks.
Ear disease:
o Hearing loss / tinnitus. o Fullness or stuffiness o Otalgia / discharge. o Pervious ear surgery.
Rule out associated brain stem symptoms: o Double vision.
o Numbness and/or weakness in arm face and leg. o Difficulty in speech.
o Confusion or loss of consciousness. o Swallowing problems.
Associated symptoms: o Valvular disease. o Palpitation.
o Syncope on exertion. o Prolonged bed ridden. o Head & neck trauma o Seizure
o Symptoms of DM, hypertension, anxiety, depression or panic attacks. Drugs history
Differential Diagnosis of Vertigo: Benign paroxysmal vertigo
o Sudden vertigo positional changes (e.g. head turning) o Recurrent lasting minutes to hours.
Menieres disease.
o Sudden onset. Common in adults
o Recurrent similer attack with Adults long free intervals. o Lasting hours to days
o Associated with tinnituss, hearing loss, ear fullness and
naauseaa+vomiting.nystagmuss presented by menstruation, emotional stress
Vestibular Neuritis or Labyrithitis.
o Sudden onset after U.R.T.I lasting days to weeks o Nausea & vomiting
o Tinnitus hearing loss Acoustic Neuroma
o Gradual onset. Onset in adult o Persistent
o Progressive. Unilateral hearing deficit. Tinnitus. o Facial numbers, weakness
o Diplopia, dysarthria, dysphagia, Dysporiea o Uncordination, Paraesthsias
Vertebro Basillar insufficient. o Acute onset. Onset in elderly o Recurrent
o Brainstem Symptoms. No Nausea OR vomiting o Nystagmus.
Multiple Sclerosis
o Sudden or transient, persistent as or Recurrent o Lasting day’s pr wks.
o Other discrete CNS symptoms. Acoustic Neuroma.
Gradual/ onset in adult: o Persistent
o Progressive, unibateral hearing deficit, tinnitus.
o Numbness, weakness, diplopia, dysanthria, dysphagia, dysphonia o Uncordination and paraesthsias.
Acute/ onset in elderly: o Recurrent
o Brain Stem Symptoms: No Nausea OR vomiting o Vertebro Basillar insufficiency: Nystagmus Drugs: o Antibiotics o amino glycosides o Quinines o Anticonvulsants, Hypnotics
Disappear when Drug Discontinued
.
o Antidepressent
o Diuretics & antihypertensive o Hydrocarbons exposure o Organic -Carbon Monoxide.
(7) History Taking from Male Complaining of Impotence
H. Al Hajjar
The majority of impotent patients do not complain directly from impotence. Candidate needs to suspect the hidden agenda from the patient’s verbal and nonverbal cues, e.g. patient may ask for vitamins or any other tonics, or he may complain of backache or psychological symptoms…
The following items may need to be considered:
Introduce yourself and establish doctor-patient relationship Encourage patient contribution
Respond to patient’s cues
Details of the complain: onset & course of the impotence Degree of dysfunction: chronic, occasional or situational. Early morning and nocturnal erection.
Is there other wife? Is the problem the same with her? Precipitating factors:
o Is the marriage stable & Happy?
o Does the wife contribute to the problem?
o History of: pelvic trauma, pelvic surgery, and spinal cord surgery. o History of: diabetes, renal failure, hepatic cirrhosis,
o Medications: Diuretics, antihypertensives, H2 blockers Antidepressant or alcohol.
o Any new stressful event Associated symptoms:
o Loss of libido, Gynecomastia.
o Presence of visual or neurological symptoms. o Psychosocial history: depressive symptoms
Exploration of patient's ideas, concerns & expectations. Effect on patient life & relation to wife and family. Previous treatment modalities
(8) History Taking from Female Complaining of Infertility
A. Assaggaf The following items may need to be considered:
Introduce yourself and establish doctor-patient relationship Encourage patient contribution
Respond to patient’s cues Detail of the complain:
o Nature of the problem. Is it infertility? o Duration
o Type of infertility: primary or secondary?
Patient’s ideas, concerns, expectations & Effect of the problem.
Etiology
Menstrual History o Age of the patient o Age at menarche o Duration of periods o Menstrual irregularities o History of amenorrhea Obstetric History: o Previous pregnancies o Abortion o Ectopic pregnancy o Complicated deliveries. Gynecological History o History of PID o Fibroids
Marked weight loss Excess exercise
Symptoms of general diseases e.g. DM., hypothyroidism or hyperprolactinemia. Marital relationship
o Duration of marriage
o Sexual activity: (technique and frequency). Information about the husband:
o Age, occupation (exposure to toxin or radiation)
o History of previous marriage, children & age of youngest child. o Past medical history
o History of mumps, undescended tests, varicocele.
(9) History Taking from Patient Complaining of
Vaginal Discharge
A. Assaggaf, M. Alatta & F. Rayes The following items may need to be considered:
Introduce yourself and establish doctor-patient relationship Encourage patient contribution
Respond to patient’s cues Identify the problem:
o What does the patient mean by vaginal discharge o Onset
o Duration of symptoms
Description of the discharge in relation to: o Amount,
o Color & appearance o Odor
o Consistency
o Any associated blood with the discharge. Associated symptoms:
o Dysurea o Pruritus o Pelvic pain o Dyspareunia o Fever or skin rash.
Menstrual history and LMP. Relation to menstrual cycle Relation to intercourse Symptoms in the partner Previous history of discharge Possible etiological factors: e.g.
o DM
o Concurrent use of medications (steroids or antibiotics), o Use of tampons, pessaries & antiseptics,
o Possible exposure to STD
o Use of contraception (Pills, IUD).
Exploration of patient’s ideas, concerns and expectations.
Exploration of patient’s fear or anxieties related to the discharge. Exploration of the effect of the problem in patient’s life
(Physical, social and psychological)
Differential diagnoses for causes of vaginal discharge Symptom Alternative Diagnosis o Dysuria Urinary tract infection
Differential diagnoses for causes of vaginal discharge (continue) Candida:
o Most common
o Itchy, white, thick, lumpy discharge Bacterial vaginitis:
o Copious greyish & fishy smelling, burning or itching Trichomonas vaginalis:
o Offensive, greenish yellow, thin, bubbly discharge, with pruritis valvae. Chlamydia:
o 8% of VD in UK, and only 0.5% of VD in KSA Gonorrhoea:
o Very uncommon cause purulent vaginal discharge.
Microbiological investigations for vaginal discharge. Investigations Infection
o High vaginal swab Candidiasis, bacterial vaginosis, Trichomonas vaginalis
o Cervical swab Gonorrhea
o Endocervical swab (culture, direct Chlamydia trachomatis fluorescent antibody or enzyme
Immunoassay)
Investigations for no infective causes of vaginal discharge
Investigation Cause
o Urinalysis/blood glucose Diabetes
o Midstream urine Urine infection
o Serum follicle-stimulating Oestrogen deficiency Hormone and oestradiol -perimenoausal
-Inadequate hormone replacement Treatment
Treatment of vaginal discharge:
Condition Drug Treatment
Bacterial vaginosis
Trichomoniasis Candidiasis
Metronidazole (Flagyl) 400 mg BD X 5 ds Or Nimorazole (Naxogin 500) 2 g single dose.
Metronidazole 400 mg BD X 5 days or 2 g single dose. Clotrimazole (Canesten) single 500 mg pessary
