UCL MBBS (Subject) / Core presentations (Lesson)

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• Abdominal pain History: SOCRATES Screening (for other common symptoms - GI Hx): Nausea & vomiting - Timing? Relation to meals? Amount? Content? Frequency? Haematemesis - Fresh/dark? NSAIDs/warfarin? Surgery? Smoking? Dysphagia - Level? Onset? Solid/fluids? Pain? Difficulty swallong? Intermittent? Indigestion/heartburn/reflux/dyspepsia - Timing? relation to meals Change in bowel habit Diarrhoea / constipation - Quantify. Mucus? bloody? Melaena - Pain? Mucus? fresh/dark/black? On paper/in the pan? Appetite / weight change - intentional? quantify. reason? (dysphagia, pain) Jaundice - pruritus? pale stools? dark urine? S/R: urinary, bowel, systemic, eye, joints, neurological PMH: peptic ulcer, cancer, jaundice, hepatitis, blood transfusion, tatoos, previous operations, LMP, dietary change DH: Steroids, the Pill, NSAIDs, ABx; allergies FH: IBS, IBD, peptic ulcer disesae, polyps, cancer, jaundice SH: Smoking, alcohol, rec drugs, travelling, tropical illnesses, exposures (jaundiced people, occupational), sexual history Systems Review:
• Acute confusion and coma Definition & GCS Causes for DELIRIUM
• Blackouts / Loss of consciousness Before / during / after - use collateral Explore epilepsy: tonic-clonic, incontinence, post-ictal phase Cardiac, vasovagal, neurogenic, situational syncope Mechanical fall - accidental vs incidental Battery of investigations 2ary complications: rhabdo, CKD, fractures, bleeds → Falls, dizziness, vertigo
• Bloating Distension Ascites: Liver, cardiac, renal failure; peritonitis; nephrotic syndrome Faeces / Flatus: last B/O, nausea / vomiting, previous surgery Biliary colic? Full GI Hx, explode symptoms as appropriate
• Change in bowel habit DDx: IBS / IBD, malignancy, infection (diverticular disease, GE, ...) Hx Quantify diarrhoea, constipation; blood and/or mucus? Abdominal Hx, incl B symptoms S/R, PMH, PSH, DH & allergies F/H Ix based on findings, e.g. bloods, endoscopy, stool cultures
• Chest pain DDx: ACS, PE, aortic dissection, myocarditis; MSK, pneumonia, pericarditis, reflux ...Hx: Good SOCRATES Chest symptoms: palpitations, SoB, cough, fever Risk factors: CV (angina, previous MI, smoking, cholesterol, BP, diabetes, family Hx); Lung: Immobility, cancer, OCP, Hx of VTE; Gastro: previous reflux, medications (NSAIDs) Investigations: O2, bloods, ECG, ABG, CXRManagement: DR ABCDE → according to diagnosis
• Cough DDx: Pneumonia (→CURB-65), viral/reactive (→reassure), asthma (→assess), heart failure Analysis of PC: Timing: Onset, duration, time of day Sputum: Purulent, white, dry; volume Haemoptysis Related symptoms: Full respiratory Hx, incl systemic, B systemic (fever, weight loss, niht sweats) Full S/R PMH/PSH: DH: Treat: ABx SE: ACE-I FH: Travel, TB riskICE
• Dizziness Clarify: vertigo vs imbalance vs blackout Good Hx of PC: situational?, provoked by standing etc? dehydration? Relevant systems Cardiovascular: arrythmias, valve defects, hypotension Ear / balance, incl hearing, pain, discharge vasovagal / neurogenic syncope Neurological, e.g. Parkinson's disease; headache, weakness, vision Epilepsy? Infection - UTI, bowel Any falls? → fractures, rhabdo, LOC? Metabolic conditions? Diabetes? Exam: Epstein manoeuvre, CVS, RS, neurological, abdominal DH: Medication review, allergies, any changes Investigations: L/S BP, ECG, urine dipstick, FBC , U&E, glucose, CXR, EEG, CT/MRI head DDx: Drop attacks, factitious, hypoglycaemia; BPV, merniere's acoustic neuroma → Falls, blackout
• Falls Causes Cardiac (arrhythmia), mechanical, vasovagal, infection Epilepsy? LOC? Consequences Fractures, rhabdo, kidney, head, bleeding Investigations: ECG, LS/BP, CXR, urine dipstick, FBC, U&E, LFT, clotting, CXR, ± head imaging → dizziness, vertigo, blackout
• Fever ---
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• Headache Migraine Meningitis SAH - thunderclap, vomiting, neck stiffness Tension - by exlcusion Cluster - parasympathetic, eyes, nose Glaucoma Medication overuse Venous sinus trombosis Inracranial pressure: Benign or due to SOL
• Itching / Pruritus Skin vs liver - localized vs generalizedGood APCScreen for Skin: dry / flaky skin, nodules, plaques; asthma / hayfever / allergies, also FHx Liver disease: Obstruction (pale stools, dark urine), confusion, pain Causes: Alcohol, any liver diagnosis,e.g. PBC? bowel symptoms; renal failure; lymphoma; thyroid Polycythaemia ⇒ clotting, worse after bath Drugs? e.g. morphine Complete Hx, Ix as neededExam: Check for local causes, incl scabies Systemic: hepato/splenomegaly, jaundice, lymphnodes, flushed face & thyroid signs Treatment: Emollients, antihistamines (chlorphenamine 4mg PO), ursodeoxycholic acid in pregnancy / colestyramine
• Low back pain DDx: MSK, disc prolapse, malignancy (mets, myelomo), degenerative; pancreas, kidney, leaking triple AHx: SOCRATES Red flags: <20y/o, >50y/o, acute onset in elderly, constant/progressive, nocturnal, fever, night sweats, weight; malignancy, abdo mass, throacic, morning stiffness, bilateral leg pain, sciatica, sphincter disturbance, infection, immunesuppression, leg claudication Exam: GALS, neurologial exam of spine & legs, PR (sensation, tone, prostate)Investigations: MRIManagements: Analgesia; PT; MRT, Ca2+, CT CAP, PSA
• Nausea & vomiting Analysis of PC: Relation to meals Timing: Frequency, onset, duration Content - liquid/solid; blood? bile? Colour Related symptoms: GI Hx Full Systems Review, incl chest pain (?MI), SoB (?aspiration), urinary (?dehydration) PMHDH To treat: Ondansetron, cyclizine, metoclopramide/domperidone, scopolamine SE: almost all, incl. colchicine, Misoprostol, erythromycin, metformin Allergies? FHSH: Travel, unusual food, sick contacts Causes: GI: Gastritis/-enteritis, pancreatitis Medical: AKI/ddison's, Brain, Cardiac, DKA, Ears, Foreign bodies, Gravida, Hypercalcaemia, Infection → abdominal pain
• Obesity Hx: Comorbidities: cardiovascular (BP, angina), metabolic (diabetic, cholesterol), hypoventilation Impact on life Management: Conservative, medical, surgical
• Palpitations DDx: Arrythmias, e.g. AF, SVT; anxietyHx: APC, incl tapping it out Chest symptoms Risk factors for arrythmias: thyrotoxicosis, medications, known heart problems Management: DR ABCDE → Bloods, ECG, +/- ABG, CXR
• Polysymptomatic Hx: Be guided by the patient Exam: Perfusion, temperature, pulse, icterus, pallor, cyanosis, lymphadenopathy, peripheral oedema
• GI bleeding Upper (haematemesis & melaena) vs lower (fresh & occult blood in stool)DDx: Upper: gastric / duodenal ulcer, oesophageal varices; haemoptysis Lower: Malignancy, piles, polyps; IBD Hx: Abdominal Hx, incl anaemia and ALARM signsManagement: DR ABCDE, upper/lower GI endoscopy
• Shortness of breath APC Timing, onset, duration Exertional or at rest Gotten worse Other symptoms:  cough, fever, sputum, oedema, wheeze Bleeding → anaemia PMH/FSH Rest
• Sleep problems DDx: organic vs psychiatric Hx quantify and elaborate: falling / staying asleep, aking early; sleep/-iness during the day Sleep hygiene? Screen time, beverages, caffeine, alcohol Pain? Urinary frequency? Thoughts / worries? Any endocrine causes / diagnosis? PMH: Hypertension? Depression? Ix: sleep study
• Swollen legs Local vs systemic DDx Renal / liver / cardiac failure; nephrotic syndrome; Venous insufficiency, DVT, cellulitis Trauma, Charcot-joint (painless), effusion, arthritis Drugs, e.g. amlodipine Pregnancy Non-pitting: lymphatic obstruction (1ary vs 2dary) Compartment syndrome! Pain with passive stretch APC ⇒ explode symptoms & narrow down DDx
• Tired all the time Timeline Sleep Anaemia Hypothyroid Cancer Depression Drugs
• Genitourinary Hx Screening questions: Pain: dysuria; loin, scrotal, abdominal Control: frequency / nocturia, urgency; Incontinence - stress, urge Contents: Cloudy / offensive urine, haematuria Prostatism: poor initiation & stream, terminal dribbling, retention Associated features Fever / rigors Discharge, previous STIs Malignancy - weight loss, anorexia, night sweats, malaise Uraemia - confusion, pruritis, asterixis Peripheral oedema Hypertension - headache, visual disturbance GynHx (bleeding, ObHx, symptoms, Sex/fertility, previous Tx, cervical smear)PMH, S/R, DH, FH, SH
• Weight loss DDx: Malignancy, endocrine (hyperthyroid, diabetes), psychiatric, malabsorption / -nourishment Analysis of PC: How much? over what time? Previous episodes? Planned, unplanned? Body self-image Eating habits? Exercise? Idea about causes? Any other symptoms Related symptoms: Constitutional: Anorexia, nights sweats, lethargy, fever Hyperthyroid: Agitation, sweating, tremor; possible AI Hx Relevant GI Hx, esp bowel habit, malaena / rectal bleeding, anaemia Relevant Resp Hx: Smoking, cough, haemoptysis, SoB Relevant Psych Hx: Organic, Psychological, Behavioural signs of anorexia Be guided by the patient; Ix based on findings to narrow down DDx
• Wheeze → asthma, COPD, cardiac failure; foreign body Hx as appropriate APC + cardiovascular / resp + S/R
• Abdominal Hx APCScreening (for other common symptoms): Pain - SOCRATES Dysphagia - Level? Onset? Solid/fluids? Pain? Difficulty swallong? Intermittent? Indigestion/heartburn/reflux/dyspepsia - Timing? relation to meals Nausea & vomiting - Timing? Relation to meals? Amount? Content? Frequency? Haematemesis - Fresh/dark? NSAIDs/warfarin? Surgery? Smoking? Change in bowel habit Diarrhoea / constipation - Quantify. Mucus? bloody? Melaena - Pain? Mucus? fresh/dark/black? On paper/in the pan? Appetite / weight change - intentional? quantify. reason? (dysphagia, pain) Jaundice - pruritus? pale stools? dark urine? PMH / PSH; PUD, carcinoma, jaundice, hepatitis, transfusions, tattoos, any OPs, LMP, dietary changesDH: Steroids, NSAIDs, antibiotics, OCP; allergiesFH: IBS, IBD, PUD, polyps, cancer, jaundiceSH: Smoking, alcohol, drugs, travel, tropical illness, ill contactsICE
• Cardiovascular Hx Screening Questions: Chest pain - SOCRATES Palpitations Dyspnoea / SoB Dizziness / blackouts Claudication PMH: Angina, previous MI or stroke, rheumatic fever; diabetes, hypertension, high cholesterol; previous precedures (ECG, angiograms/-plasty, echo, scintigraphy, CABG)DH: Aspirin, GTN spray, β-blocker, diuretics, ACE-I, digoxin, statinFH: CV events in 1st degree relatives < 60yrsSH: Smoking, alcohol, impact on daily life
• Respiratory Hx Screening questions: Dyspnoea Cough Haemoptysis Hoarseness, wheeze, stridor Fever / night sweats / weight loss (→malignancy) Chest pain → SOCRATES PMH: Pneumonia/bronchitis, TB; atopy, previous CXR abnormalities; lung surgery; myopathy; neurological disorderDH: Resp. drugs (Steroids, bronchodilators); Others: ACE-I, cytotoxics, β-blockers, amiodarone, lithiumFH: Atopy, emphysema, TBSH: Smoking (pack·year), occupational exposure (asbestos), pets, travel
• Neurological Hx Screening Questions: Headache Fits/faints/funny turns/involuntary movements ------ Visual disturbance Special senses Speech disturbance Dysphagia ------- Weakness Skin sensation disturbance Tremor (Cognitive state) PMH: meningitis/encephalitis, head/spine trauma, seizures, previous oeprations, diabetes-hypertension-smoking-cholesterol; travel; pregnancyDH: anti-convulsant/-psychotic/-depressants? psychotropics. SE - isoniazid etc.FH: any neurological or psychiatric diseaseSH: Functional (ADLs), Barthel index score, consanguinity
• Psychiatric Hx PC: ListenHPC: Details (current state and onset), precipitating factors, effects on life Screening questions: Depression Anxiety and Avoidance behaviour Obsessions (thoughts) and compulsions (behaviours) Hallucinations Delusions Suicidal thoughts or plans Alcohol and other drugs Present circumstances: Housing, finance,work, marriage, friendsFH: Health, personality, occupation of parents and siblingsBackground Hx: Biography (family, friends, school, work, sexual relationships)PMH: including psychiatric and medical Mental state exam:
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• Orthopaedic trauma Hx Mechanism of injury Normal level of function Suitability for anaesthesia Healing: smoking, diabetes, PVD Full medical Hx
• Obstetric Hx Not tested in finals Talk about complications before / during / after previous pregnancies, incl Number of pregnancies, ToP, miscarriages, vaginal deliveries / CSs Hypertension, diabetes, pre-ecclampsia Placenta praevia, abruption, APH, PPH Infections, results of previous screens for HIV, syph, Hep B and gonorrhoea General Hx, incl Cardiovascular, respiratory, gynacological, Hb-opathy Good family hx, consanguinity
• Sexual Hx APCScreening for symptoms Discharge - urethral, vaginal, anal; colour, odour, consistency Pain - genitals, pelvis, abdomen; dyspareunia Skin changes - lumps, bumps, rashes, ulcer Systemic - fever, rigors, urinary, jaundice, joint / eye problems Partner any symptoms? Previous STIs? Sexual relations Last sexual contact Male/female? ⇒ Had sex with them before? ⇒ regular partner? Mode of intercourse? Condom? Contraception? Partner demographic? - HIV, IVDU, subSaharan Africa, MSM Anyone else in the last three monhs At least two, same questions Risk factors Travel abroad Paid or been paid for sex MSM, or high-risk partner IVDU, blood transfusion abroad PMH Previous tests? ⇒ results Vaccinations? ⇒ HepB GynObHx DH: ABx in last month, allergiesS/R, FH, SH, ICE
• Breast lump HIstory:  HPC: How / when noticed Any changes; with menses? Symptoms: pain, discharge (blood, pus, milk); skin changes? Other / previous lumps What do think it is? PMH Risk factors Family history (1st degree relatives, young, men) Oestrogen exposure:  OCP, HRT; early menarche; nulliparity; not breastfeeding Smoking DH, NKDA, systems review, SH Red flags: Bloody discharge, skin changes, hard / painless Key points: Always refer for triple assessment and MDT
• Urinary symptoms Classify as Pain Control Contents Prostatism or LUTs vs storage symptoms Do GU ± Gyn Hx Red flags: Back pain, MS, drugs, prostata, unexplained haematuria
• Limb ischaemia Symptom - 6 P's Motor: Paralysis Neuro: Paraesthesis, Pain Vascular: Pallor, Pulselessness, Perishingly cold Causes: PVD (diabetes, smoking cholesterol, BP)Investigations Check for ulcers, risk factors Do ABPI (critical < 0.5) ± angiography
• Ascites Chronic: Liver cirrhosis CCF Hypoalbuminaemia Acute on chronic: HCC Drugs SBP / infection / sepsis Management: Ascitic tap Spironolactone Diuresis, when Na+ and K+ normalized
• Hepatomegaly DDX Cirrhosis: PBC, alholic liver disease Malignancy: HCC, mets (caggy) Congestion: CCF, hepatic vein thrombosis (Budd-Chiari) Haematological: lympho-/myeloproliferative disorders, sickle cell, heamolytic anaemia Infectious: EBV, malaria, viral hepatitis, schistosomiasis Anatomical: Riedel's lobe Others: Amyloid, Gaucher's, porphyria, fatty liver
• Splenomegaly DDx Massive: myelofibrosis, chronic myeloid leukaemia, malaria (clinically: crosses midline; gold standard: weight; caudal-cranial extension) Moderate: Portal hypertension, liver failure, AIHA Mild: Examination Percussion
• Clubbing Cardiac Infective endocarditis Cyanotic congenital heart disease Atrial myxoma Infected  grafts, aneurysms Respiratory Chronic suppurative: bronchiectasis, empyema, CF bronchial CA Mesothelioma TB GI Inflammatory bowel disease Chronic liver disease, cirrhosis GI lymphoma Malabsorption, e.g. coeliac Rare: Thyroid acropachy, familialUnilateral: Hemiplegia, vascular lesions
• ENT Hx APCScreening for cardinal symptoms Ear: Hearing loss, discharge, pain, tinnitus, vertigo Nose: epistaxis, congestion Throat: stridor, hoarseness, dysphagia, neck lumps PMH/PSH, DH incl allergies, FH, S/R, SH, ICE
• Eye Hx APCScreening Vision loss / disturbance, floaters / flashes (photopsia → retinal detachment) Pain, itchiness, redness Discharge Systemic: Nausea, headache, arthritis, fever PMH/PSH, DH, S/R, FH, SH, ICE
• Paeds Hx Not tested in finals, unless GP case! Birth history Immunisations Feeding, elimination (wet nappies, stools) Always do and record temperature, HR, RR Emergencies: Stridor (→epiglottitis), intussusception, acute asthma, FTT, etc
• Gynaecology Hx APCScreening questions Bleeding Hx: Menses: LMP, length, regularity; Heavy? (clots, floods, pads); painful? Intermenstrual, post-coital, post-menopausal bleeding? Age at menarche / menopause? From other sites Obstetric Hx:  Children - how many, when born? Antenatal problems, gestation, delivery, outcome (incl weights); miscarriages / abortions Symptoms: Pain (dyspareunia, pelvic, abdominal → SOCRATES), discharge (amount, colour, smell, itch); prolapse; urinary & bowel incontinence; anaemia; constitutional Sex & contraception: Active? (→partners, STIs) Any emotional / physical problems? Contraception (compliance, barrier)? Fertility? STIs? Other: Previous gynae treatment; Last smear incl result; HRT PGHx smear: date and result polyps, prolapse, fibroids surgery PObHx parity and gravidity modes of delivery and complications terminations and miscarriages Subfertiity PMH / PSHDH, incl allergiesSHICE
• Illegal drug Hx APC What drugs? How much? For how long? Where / when / how / why taken? How did it start? Financing? Criminal activity? Dependence syndrome? - compulsion, lack of control, tolerance, withdrawal, social neglect, continue despite harm Screening Effects on health: Infections, STIs, liver, mental health Effects on social life: job, family, education Risk: Any OD / hospital admissions? Suicide if appropriate PMH/PSH, DH incl allergies, FH, S/R, ICEManagement: Treat medical problem; motivational interview, refer to drug counseling services if appropriate
• Anaemia Definition: Low HbCauses Deficiencies Iron deficiency anaemia: intake, malabsorption, blood loss (menses, occult colonic, hook worms) → microcytic, hypochromic Vit 12 / Folate: PA, vegan diet, short-bowel syndrome → macrocytic megaloblastic EPO: Chronic kidney disease Hamolysis AIHA: warm (IgG, DAT; SLE, CLL; extravascular in the spleen); cold (IgM, CAS; Mycoplasma infection) MAHA: HUS, TTP (pentad of symptoms), ITP, DIC; mechanical heart valves Hypersplenism Infections Paroxysmal nocturnal haemoglobinuria (PNH) Micro vs macrocytic Micro: IDA, thalassaemia, chronic disease, sideroblastic anaemia (heavy metal poisoning) Macrocytic: Vit 12 / folate; haemolysis; alcoholc Normocytic: SCA, CKD, chronic disease
• Erythema nodosum ---
• Gaits Parkinson: festinent, shuffling Myopathic: sunken Footdrop: high knees Sensory loss: stamping Ataxic: drunkard, broad-based
• Dyskinesia Tremor ir-/regular rhythmic, frequency? resting postural intention Wilson's Dystonia primary/secondary: age of onset, associated features, leg vs craniocervical treatment: anticholergics, bolulinum toxin, DBS normal cognition Chorea symptoms casuses: 1ary (Huntington's, BHC) vs 2ary treatment Tics simple/complex, motor/speaking Tourette's Myoclonus positive / negative multiple causes treatment: benzos, e.g. clonazepam Durg-induced: Tardive, acute, akathisia
• Weakness Pyramidal → UMN lesion, e.g. stroke Proximal → myopathies, e.g. steroid-induced in MG Distal → length-dependent polyneuropathy, e.g. CIPD Isolated, e.g. carpal tunnel (median nerve)

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