• Consider list of possible differentials 

• Generate list of possible questions you can ask patient to help differentiate between diagnosis

Write key red flags:

• Generate list of questions to exclude any red flags

Write key psychosocial/ICE/impact questions:

• Could any psychosocial factors be contributing to symptoms?

• Could the symptoms be impacting on psychosocial circumstances?

• Does the patient have any thoughts or worries?

Write key differentials for presenting symptoms:

• Consider acute or urgent conditions

• Consider chronic conditions

• Use of a surgical sieve

• Acute or chronic? Duration, frequency, timing

• Intermittent normal/loose stools? Overflow?

• When bowels last opened? Passing flatus?

• Severity (eg. Bristol Stool Chart)

• Associated symptoms (eg. bloating, pain, tenesmus, incontinence, blood)

• Urinary symptoms (eg. urgency, retention, incontinence)

• Gynae symptoms (eg. change in periods, dyspareunia)

• Previous medical history (eg. IBD)

• Drug history (eg. opioids)

• Family history of bowel disease (eg. colorectal ca)

• Tried so far, eg. OTC remedies, self-help measures

Key red flags:

• Acute abdomen, systemically unwell

• Suspected obstruction (eg. vomiting, no flatus)

• 2WW criteria (eg. older adults, change bowel habits)

• Suspected malignancy (eg. weight loss, malaise)

Psychosocial/Impact/ICE:

• What do they mean by contipastion?

• Any associated anxiety, depression, eating disorders?

• Dietary history, fluid intake, toileting habits

• Smoking, alcohol, illicit drugs

• Exercise, ADLs, occupation (eg. do they tend to hold the bowels)

Examination to consider:

• Basic obs, weight

• Abdominal examination (distention, tenderness, masses)

• DRE, pelvic examination

Key differentials:

• Functional constipation, dietary, IBS

• Medication-related

• Bowel disease (eg. diverticular disease, malignancy)

• Pelvic disease (eg. ovarian tumour, endometriosis)

• Anorectal disease (eg. anal fissure)

• Endocrine/metabolic (eg. hypothyroidism)

• Neurological (eg. autonomic neuropathy, multiple sclerosis, PD)

• Acute or chronic? Duration, frequency, timing

• Intermittent normal/loose stools? Overflow?

• When bowels last opened? Passing flatus?

• Severity (eg. Bristol Stool Chart)

• Associated symptoms (eg. bloating, pain, tenesmus, incontinence, blood)

• Urinary symptoms (eg. urgency, retention, incontinence)

• Gynae symptoms (eg. change in periods, dyspareunia)

• Previous medical history (eg. IBD)

• Drug history (eg. opioids)

• Family history of bowel disease (eg. colorectal ca)

• Tried so far, eg. OTC remedies, self-help measures

Key red flags:

• Acute abdomen, systemically unwell

• Suspected obstruction (eg. vomiting, no flatus)

• 2WW criteria (eg. older adults, change bowel habits)

• Suspected malignancy (eg. weight loss, malaise)

Focused History

·       Ear pain - onset, severity, laterality

·       Worse on pulling the ears (Otitis externa)

·       Ear discharge

·       Fever

·       Hearing loss

·       Flu-like - rhinorrhoea, bunged up nose

·       Sore throat

·       History of swimming (otitis externa or swimmers ear)

·       History of recurrent ear infection

·       Making adequate urine or wetting nappies

·       Pregnancy, birth, immunizations etc (if younger than 12)

Key Red Flags

·       Swelling at the back of ears (mastoiditis)

·       Neck stiffness,

·       Lack of balance,

·       Headache

·       Reduced consciousness, very drowsy etc

Psychosocial/Impact/ICE:

·       Caregiver's understanding

·       Impact on home life

·       Impact on school

·       Similar illness in other kids at home (if applicable)

Examination to consider:

·       Basic obs, weight

·       Ear examination

·       Neck examination

·       Throat examination

Key differentials:

·       Otitis externa

·       Cholesteatoma

·       Foreign body

·       Impacted ear wax

·       Referred pain: Pain can originate from the teeth, throat, neck, or sphenoidal sinus.

·       Chronic mucosal otitis media

·       Otitis media with effusion (OME)

Focused History

·       History and number of past miscarriages

·       Gestational age of past miscarriages

·       Triggers or events around past miscarriages (trauma, stress etc)

·       Any pregnancy carried till term

·       Last menstrual period

·       Currently pregnant?

·       Periods - regular, heavy, painful

·       Bleeds between periods

·       Bleed or pain during sex

·       Family history of miscarriages

·       Use of over-the-counter medications

Red Flags

·       Excessive vaginal bleeding

·       Severe abdominal pain

·       Dizziness or light-headed

·       Shoulder tip pain

·       Suicidal ideation

Psychosocial

·       Impact on Daily activity at home

·       Impact on Daily activity at work

·       Alcohol intake - quantity

·       Smoking

·       Illicit drug use

·       Support network

·       Mood issues

·       Impact on mental health, partner or family

Examination to consider:

• BP pulse Heart  weight

·       Abdominal examination

1. Pain; site, onset, duration, character, radiation, aggravating and relieving factors, associated symptoms.

2. unilateral/bilateral

3. Back/buttock/thigh pain

4. Any pain at rest

5. skin change/ulcer/hair loss

6. any chest pain/palpitation

7. erectile dysfunction.

   Red flags:

   1. 5 P: Pallor, paresthesia, paresis, excruciating pain, parishingly cold

   2.swelling/redness

   Psychosocial/impact:

   occupation

   smoking, alcohol, BMI, diet, lifestyle

   Examination:

   Vitals

   BMI

   leg examination

   ABPI

   
   

   Differentials:

   Acute limb ischemia

   DVT

   Cellulitis

   Arthritis

Focused history

• Irregular periods. Duration of symptoms.

• Oligomenorrhoea or amenorrhoea

  
  

• Menstrual hx - menarche, LMP, normal period and cycle duration

• Any hx of menorrhagia, IMB, PCB, dyspareunia, dysmenorrhoea, abdo/pelvic pains, PV itch/rash/discharge

• Smears up to date?

• Contraceptive hx, including possibility of pregnancy

  
  

• Menopausal sx (hot flushes, night sweats, irritability, brain fog, reduced concentration, vaginal dryness)

• PCOS sx (weight gain, acne, hirsutism)

• Prolactinoma sx (galactorrhoea, headache, visual changes)

  
  

• PMHx (endometriosis, fibroids, PCOS)

• PSgHx (any gyne operations)

• FHx (age at menopause, PCOS)

• DHx (antipsychotics, steroids)

• SHx

  ?smoke/alcohol/recreational drugs

  ?excessive exercise

  ?restricted diet

  ?body image issues

  ?eating disorder

  ?stressful life/work

Key Red Flags

• Malignancy (WL, LOA, tiredness)

• Systematically unwell (fever, rigors, drowsiness, reduced oral intake / N+V)

Psychosocial/ICE/impact

• Patient's ICE

• Impact on patient's quality of life and activities of daily living

• Impact on relationship

• Is patient trying to get pregnant?

Key differentials

• Exercise, dietary, lifestyle changes

• Stress/anxiety

• Infective (PID)

• Malignancy (androgenic tumour)

• Endocrine (pregnancy, menopause, PCOS, Cushing's syndrome)

• Congenital (imperforate hymen, gonadal dysgenesis)

Focused history

·       Onset, associated tremors, palpitation etc.

·       Menstrual history: Menarche, duration, interval, pain, volume, pain, LMP

·       Sexual history: Active/not, multiple partners? previous STI

·       Up-to-date with smear

·       Contraception: current or previous use, type and when last used.

·       Other associations: use of anticoagulants, family Hx, OTC meds

·       Pressure symptoms: urgency, frequency, bloating, feeling of fullness

Key red flags

·       Bleeding from other parts of the body

·       Weight loss, night sweats, poor appetite

·       Lethargy, dizziness/drowsiness, SOB, TATT

Psychosocial/ICE/Impact

·       Smoking

·       Relationship, work, sleep, ADLs

·       Mood

Examination to consider

·       Palour, HR, BP, BP

·       Abdominal examination, Bimanual examination

Key differentials

·       Pregnancy (miscarriage/ectopic pregnancy)

·       Uterine fibroid

·       Blood dyscrasias

·       STI

·       Endometriosis

·       Endometrial CA

·       Dysfunctional uterine bleeding

1 Duration of low mood ,frequency of low mood.

2 Ask about frequency of lack on interest in the last one month.

3 Triggers - for example loss of job, stress, finance.

4 Sleep and Appetite

5 Red flags-suicidal thought / self harm and harm to other people.Also check for hallucination.

6 Family History of Depression

Impact and psychosocial

1 Smoking , alcohol and recreational drug use

2 Support at home and protective factors

3 Impact on family / job /daily activities

-          Onset, course, duration

-          What make it worse and what help to ease the pain?

-          Any pain in other joints?

-          Any fever, and how do you feel generally?

-          Is it worse in the morning or after rest? And any morning stiffness?

-          Any history or spinal injections e.g. spinal anaesthesia, lumbar puncture?

-          What pain killers did you try so far and which you found most helpful?

-          Did you receive and physio?

Red flags

-          Any history of trauma?

-          Did you notice any changes in passing urine? Any accidents or you don’t feel that you empty your bladder?

-          Any numbness in your bottom?

-          Any unintentional loss of weight?

-          Any weakness in you legs or change in sensation?

-          Any change of colour of your legs?

Psychosocial/ Impact/ ICE

-          What are you doing for living? Do you thing your job triggered the pain?

-          How is this pain affecting your ability to carry on your daily activities and your job?

-          What was your expectations from today’s consultation e.g. pain management, imaging, sick leave ….?

Key Differential:

-          Ankylosing spondylitis

-          Discitis

-          Multiple myeloma

1. If both hands are affected

2. change in colour , how long it takes to resolve

3. triggers? cold, vibration, emotions

4. abnormal sensations, numbness, tingling, itchiness

5. pain in hands

6. extremities other than digits, ear lobes, nose tip, tongue

7. neck pain

   
   

   Red flags

   1. weakness in hands

   2. ulcers

      
      

   Key differentials:

   Crest syndrome ( dry skin, swallowing difficulty ,rashes, swellings)

   Chillblains (itchiness)

   
   

   PSO/Impact

   Smoking, alcohol, occupation/hobbies

Examination to consider

examine hands for ulcers, pulse, BP

·      Onset and duration

·      Shortness of breath

·      Cough, wheeziness

·      Chest pain – pleuritic?

·      Fever

·      Phlegm - Coloured

·      Aches and pain

·      Asks about treatments already tired

·      Possible triggers

Key Red Flags:

·      Speaking in full sentences

·      Breathing fast

·      Haemoptysis

·      Cyanosis signs - Bluish colour of the lips, tips of fingers

Psychosocial/Impact/ICE:

·      Asks about lifestyle – smoking, exercise, fluids intake

·      Asks about work and impact of illness

Examination to consider:

·      Check temperature

·      Examine chest and throat

·      Check Peak flow (PEFR)

Key Differentials:

·      Non-infective exacerbation of asthma

·      Pneumonia

·      COVID

·      PE

·      ACS

Current daily routines and behaviours observed

Social Interaction

• Avoids eye contact

• Limited interest in peers

• Difficulty understanding social cues

Communication

• Delayed speech or language development

• Echolalia (repeating phrases)

• Difficulty with non-verbal communication (gestures, facial expressions)

Behavioural Patterns

• Repetitive behaviours (hand-flapping, spinning)

• Resistance to changes in routine

• Intense focus on specific objects or topics

Sensory Sensitivities

• Overreaction or underreacting to sensory stimuli (sounds, lights, textures)

• Discomfort with touch

Red Flags for Early Screening

• Lack of response to name by 12 months

• No meaningful gestures (e.g., pointing) by 14 months

• No two-word meaningful phrases by 24 months

Family history of developmental disorders

Child’s developmental milestones

Any regression in skills

ICE/IMPACT/PSYCHOSOCIAL

·       Parent understanding of autism,

·       Explore parents or nursery staff concern.

·       What the parents hopes to achieve from the consultation.

·       Impact  on parents and on child home, nursery, School, work.

·       Home environment and support circle.

Examination:

·       Gestures, Facial Expressions, and Eye Contact.

·       Shared Attention:

·       Assess if the child follows pointing gestures or initiates pointing to share interests with others.

·       Sensory Reactions e.g loud noises or touch.

Key Differential:

·        Language Delay or Disorder.

·        Hearing loss.

·        Intellectual Disability (ID).

·        Attention Deficit Hyperactivity Disorder (ADHD).

·        Anxiety Disorders.

·       Location of pain

·       Progression - worse, better or still the same

·       Joint swelling

·       Presence of redness

·       Presence of fever

·       Reduced joint movement

·       Presence and duration of joint stiffness

·       Night pain and awakenings from sleep.

Key Red Flags

·       Severe joint pain

·       Trauma to the joint

·       Fever

·       Weight loss

Psychosocial/ICE/Impact

·       Impact on home life

·       Impact on occupation

·       Smoking

·       Alcohol intake

·       Weight gain

·       Exercise issues

Examinations to Consider

·       Temperature

·       Pulse

·       Body mass index

·       Joint examination

Key Differentials

·       Septic arthritis

·       Rheumatoid arthritis

·       Gout

·       SLE

when started

sputum

hemoptysis

fever, chest pain,

SOB, wheeze, worse at night

blocked/runny nose, mucus at back of throat

heart burn, sour taste on tongue

smoker/ ex smoker

occupation

Key red flags:

wt loss, night sweats, loss of appetite, fatigue

Key Differentials:

Acute: < 3 wks viral URTI, asthma/copd flare, PE, Pneumothorax

Sub acute: 3-8 wks post infective, whooping cough

Chronic : > 8wks Ca Lung, GORD, PND, asthma, copd, ACE i, smokers cough

·       Reason for the test

·       Any symptoms? Expand on symptoms; onset, progression etc.

·       Other associated symptoms not mentioned eg abdo pain/swelling, itching, early satiety, change in bowel habits.

·       Sexual history: History of multiple sexual partners.

·       Travel history.

·       Meds including OTC

· Family history of any liver problems

Key red flags

·       jaundice, itching, easy bruising or bleeding from any part of the body

·       Weight loss, night sweats, poor appetite

·       Lethargy, dizziness/drowsiness, SOB, TATT

Psychosocial/ICE/Impact

·       Alcohol history: volume, type and frequency. Thoughts of stopping (if drinking), symptoms of dependence.

·       Diet

·       Exercise level

· Knowledge of weight/BMI

· Effects on mood, sleep, work and relationship/family

Examination to consider

·       General examination, OBS

·       Abdominal examination

Key differentials

·       NAFLD

·       Alcoholic liver disease

·       Viral hepatitis/STI

• Unilateral?

• Redness:

  • Pain with eye movement:

    • Keratitis (inflammation of the cornea)

    • Anterior uveitis (pain + pupil involvement + ciliary flush + association with ankylosing spondylitis, HLA B27 positive)

    • Scleritis (pain + headache, e.g., related to rheumatoid arthritis)

  • Painless:

    • Subconjunctival hemorrhage (history of trauma or Valsalva maneuvers)

• Vision Changes:

  • Blurred vision

  • Double vision

  • Tunnel vision

    • Causes: RCGP O (Retinitis pigmentosa, Choroidoretinitis, Glaucoma, Papilloedema, Optic atrophy due to tabes dorsalis)

  • Night blindness

  • Vision loss

  • Painful vision loss:

    • Temporal arteritis (typically seen in those over 65; symptoms include central vision loss, temporal headache, RAPD, raised ESR, swollen optic disc; managed with steroids and biopsy)

    • Optic neuritis (progressive pain with vision loss, worsened by movement, RAPD; associated with multiple sclerosis, diabetes, syphilis; managed with referral, steroids, MRI)

  • Painless vision loss:

    • Causes: 3CAR VPM

    • Amaurosis fugax (brief loss of vision lasting less than 60 minutes, accompanied by neurological symptoms such as slurred speech or hemiparesis)

    • CRAO (central retinal artery occlusion; managed with globe massage, rebreathing into a paper bag, IV acetazolamide)

    • CRVO (central retinal vein occlusion; symptoms include loss of central vision, RAPD, swollen optic disc, "sunset" appearance, often associated with glaucoma, hypertension, diabetes)

    • ARMD (age-related macular degeneration; sudden distortion of straight lines, reduced visual acuity, glare sensitivity, difficulty adapting to dark environments, normal peripheral vision)

    • Vitreous hemorrhage (sudden, painless loss of vision with appearance of floaters, dark swirling clouds)

    • Ocular migraine (occurs in individuals under 40, characterized by unilateral intermittent visual symptoms such as flashes of light, resolving within 30 minutes, without headache; triggers include stress and smoking)

• Flashes/Floaters:

  • Any new onset of flashes or floaters warrants urgent referral to an ophthalmologist within 24 hours.

  • Vitreous detachment (floaters and flashes with normal visual acuity)

  • Retinal detachment (starts in the peripheral visual field, progressing toward the center; visual field defects, RAPD)

• Photophobia

• Swelling and Discharge (Itchy, Burning, Sticky, Watery)

• Deformity (distortion of the eyelid margin, loss of eyelashes, ulceration, bleeding, recurring cysts in the same location)

• Systemic Symptoms (fever, rash, headache, third nerve palsy, drooling from the eye)

• Other Considerations:

  • Papilledema (HIMS: Hydrocephalus, Hypercapnia, Idiopathic Intracranial Hypertension, Malignant hypertension, Space-occupying lesion)

    • Idiopathic intracranial hypertension: typically seen in young women with high BMI, presenting with headaches and visual disturbances.

  • RAPD (Relative Afferent Pupillary Defect):

    • Painful causes: Temporal arteritis, Optic neuritis, Glaucoma

    • Painless causes: CRVO, CRAO, Retinal detachment

  • Dry eyes (often associated with scleroderma; managed with carbomer drops and paraffin-based eye ointments)

    • Dry mouth (associated with Sjögren's syndrome; Schirmer’s test; increased risk of lymphoma)

  • Contact lens use

  • Glasses (for near or farsightedness)

Management:

• General eye care measures:

  • Avoid triggers (e.g., contact lenses, rubbing eyes, sharing items that could transmit infections)

  • Frequent rest periods

  • Maintain eyelid hygiene (cold compresses)

  • Medications: topical antihistamines, ocular diclofenac, artificial tears

• Location: Identify which joint(s) are affected (small/large, proximal/distal, symmetrical).

• Pain Characteristics:

  • Inflammatory Arthritis Pain (e.g., RA): Typically worse after periods of rest, especially in the morning, and often paired with stiffness. This pain often improves with activity and usually affects smaller joints like hands and feet bilaterally.

  • Referred Pain: Pain may be referred from other areas, e.g., cervical spondylosis presenting as shoulder pain.

  • Elderly Considerations: Severe pain in both shoulders or morning stiffness in the pelvic region may indicate polymyalgia rheumatica.

• Swelling: Look for joint swelling.

• Pattern:

  • Morning stiffness: Ask about the duration (inflammatory if >30 minutes).

  • Exercise: Does pain improve with activity (inflammatory) or worsen after activity (osteoarthritis)?

• Mechanical Symptoms:

  • Locking (cartilage involvement) or joint instability/giving way (ligament damage)

  • A popping sensation may indicate an ACL injury.

• Muscle Involvement: Assess for muscle pain or tenderness.

• Neurological Symptoms: Check for changes in sensation and weakness.

• Deformities/Functionality:

  • Note any joint deformities, loss of function, weight-bearing difficulties, mobility issues, or impact on activities of daily living (e.g., cooking, washing, dressing).

Associated Symptoms (AS - 7 Areas)

• Mood/Sleep/Memory: Could indicate systemic conditions like SLE, vasculitis, or antiphospholipid syndrome (APS).

• Fever/Weight Loss/Bony Pain: May suggest malignancy or inflammatory arthritis.

• Skin Changes: Look for redness, warmth, swelling, psoriasis, SLE rash, or nodules (e.g., calcinosis).

• Eye Symptoms: Conjunctivitis, uveitis, or scleritis can be linked to reactive arthritis, spondyloarthropathies, or RA.

• Mouth Symptoms:

  • Dryness (Sjögren’s syndrome).

  • Oral ulcers (Behçet’s disease).

• Chest Symptoms:

  • Pericardial/pleuritic chest pain could suggest connective tissue disease.

  • MSK chest pain may point to spondyloarthropathies.

  • Shortness of breath (SOB).

• Abdominal Symptoms:

  • Pain or diarrhea may indicate reactive arthritis, ulcerative colitis, or Crohn’s disease.

• Urinary Symptoms: Dysuria or hematuria could be seen in reactive arthritis.

History of Preceding Events:

• Preceding Illness:

  • Sore throat (rheumatic fever).

  • Gastrointestinal symptoms (reactive arthritis).

  • Upper respiratory tract infection (transient synovitis).

Pediatric Considerations:

• Referral Indications:

  • Age <3 years.

  • Inability to bear weight.

  • Pain with restricted movement.

  • Red, hot, swollen joints.

  • Signs of maltreatment (social services).

  • Symptoms worsening or not improving within a week.

    
    

• Red Flags:

  • Signs of malignancy, infection, or inflammatory conditions (e.g., systemic symptoms, nighttime pain like osteosarcoma, unexplained bruising or rash, limping, morning stiffness, severe pain following trauma).

    
    

• Transient Synovitis: Often follows a viral illness, with the affected leg held in flexion, abduction, and external rotation.

• Storage (FUND+I---Frequency, nocturia, leak urine, discharge)

• Infection (dysuria, haematuria, odour)

• Prostate/voiding (SHED—change in stream, difficulty starting, incomplete empty, dribbing)

• Haematuria

o Symptoms of UTI (fever, pain (flank pain), prostate symptoms) Relationship to urinary stream (beginning or end of stream)

o Menstruation

o Rashes, arthritis (SLE, HSP)

o Bloody diarrhoea (hemolytic uremic syndrome)

o Hearing/FH (Alport syndrome)

• Systemic

o Fever, rash/itch, weight lost, bony pain

o N/V

o Hearing

o Bloating

o Bowel symptoms

o CES symptoms: numbness around anus region, shooting pain into legs, back pain

o Prolapse symptoms: dragging sensation

• Period + Gynaecology + Sexual hx

• Trigger (infection, stone, malignancy, trauma, medication, food)

o Causes of red urine: phenytoin, ibuprofen, rifampicin, warfarin, aspirin, food colouring, beets

o Infection: Recent sore throat (group A streptococcus), streptococcal skin infection (glomerulonephritis)

o Travel (schistosomiasis)

Key urological symptoms

Symptoms that are typically associated with urological disease include:

·       Urinary frequency: commonly associated with UTIs.

·       Urinary urgency: may be associated with UTIs or detrusor instability.

·       Nocturia: associated with UTIs and prostate enlargement (e.g. benign prostatic hyperplasia).

·       Dysuria: typically associated with urinary tract infection (UTI), including sexually transmitted infections (e.g. chlamydia, gonorrhoea).

·       Haematuria: associated with UTIs, trauma (e.g. catheter insertion) and renal tract cancers (e.g. bladder cancer, renal cancer).

·       Urinary hesitancy, terminal dribbling and poor urinary stream: associated with enlargement of the prostate (e.g. prostate cancer, benign prostatic hyperplasia).

·       Urinary incontinence: associated with a wide range of pathology including UTIs, detrusor instability and spinal cord compression (e.g. cauda equina syndrome).

·       Fevers and rigors: typically associated with pyelonephritis.

·       Nausea and vomiting: typically associated with pyelonephritis.

·       Weight loss: associated with malignancy and uraemia.

·       Uraemic symptoms: nausea, vomiting, fatigue, anorexia, weight loss, muscle cramps, pruritis and confusion.

• Shortness of Breath: Duration, frequency, severity, and specific triggers.

• Symptoms of Infection: Presence of purulent sputum, fever, or any recent infections.

• Systemic Symptoms: Fatigue, anorexia, or unintended weight loss.

• Heart Failure Symptoms: Peripheral oedema, breathlessness on exertion, orthopnoea (difficulty breathing when lying flat).

• Medication and Compliance: Current medications, adherence to prescribed treatments, and any recent changes in medication.

Red Flags:

• Chest Pain: Onset, duration, and characteristics.

• Haemoptysis: Presence and amount of blood in sputum.

• Weight Loss: Unexplained or significant changes in weight.

• Speech Limitations: Difficulty completing a full sentence due to breathlessness.

• Signs of Cyanosis: Blue discoloration of lips or fingertips.

Psychosocial/Impact:

• Smoking History: Type of tobacco, quantity (packs per day), duration (years), and any attempts to quit.

• Alcohol Use: Frequency and quantity.

• Functional Disability: Impact of breathlessness on daily activities and quality of life.

• Home Situation: Support available at home, including family or caregiver assistance.

• Work Situation: Employment status, job-related activities, and any work-related limitations due to respiratory issues.

Examination:

• Vitals: Blood pressure, heart rate, respiratory rate, and temperature.

• Respiratory Examination: Inspection, palpation, percussion, and auscultation of the lungs.

• Cardiovascular Examination: Assessment of heart sounds, jugular venous pressure, and signs of heart failure.

Differentials:

• Chronic Obstructive Pulmonary Disease (COPD)

• Asthma

• Heart Failure

• Pneumonia

• TB

name of the substances

duration of use, frequency in a day

route of use

history of needle sharing

Any physical symptoms

(symptoms of HIV Hepatitis B or C or STIs)

use of other substances: alcohol smoking

what makes you thinking of stopping this now

sexual health history:

number of Partners, stable or unstable, type of sex, use of condoms, any previous history of STI or bloodborne viruses like HIV or hepatitis

Mental Health: anxiety low mood self-harm or harming to others, any suicidal thoughts.

Psychosocial:

living situation

employment

effect on relationship,

safeguarding: related to child care or care to others

financial situation

any support system

Past medical history

any previous hospitalization

Medication history

Family history of substance abuse

Key red flag:

needle sharing.

self harm/suicide

safeguarding issues

Symptoms review: dizziness, shortness of breath, palpitation, feeling tired or fatigue,

unusual bleeding or bruising, abdominal pain

Red flags:

weight loss

loss of appetite

any change of bowel habit

presence of blood in the stool

psychosocial:

Dietary history,

avoidance of any specific food

home situation managing activities of daily living including cooking or eating balanced diet

past medical history

medication history including over the counter medications like ibuprofen

lifestyle factor: smoking alcohol, Recreational drugs

D/D:

Dietary deficiency

malabsorption

blood loss

Effect of medication

Chronic conditions

Cancer

·         Pain (analyse pain as usual, explore pain in specific sites e.g. pelvic, spine, thigh and shin)

·         Headache, change in skull shape

·         Most of the cases asymptomatic

·         Ask about dental problems if considering treatment with bisphosphonates.

Key Red Flags:

·         Sciatica (tingling/electric shock down any leg)

·         Cauda equina (numbness around the ring, urine/stool incontinence ….

·         Hearing loss and tinnitus

·         Ask about falls and possible fractures.

·         Rapid change in pain nature (e.g. new night pain), change of bone shape, or weight loss (suggestive of possible osteosarcoma)

·         Heart failure (rare complication to Paget’s disease)

Psychosocial/ICE/Impact:

·         Pain management

·         Can I still work / exercise?

·         Would it change to cancer in the future? There is a rare and uncommon bone cancer called osteosarcoma that was reported in less than 1:10.000 cases of Paget’s disease.

·         Are my children at risk of having Paget’s disease? Yes, the children of the people who have Paget’s disease are about seven times more likely to develop this disease.

Key differentials

·         Osteoarthritis

·         Liver disease (if presented only with raised ALP)

·         Menopause symptoms

·         Osteoporosis

Ask about back pain

Ask if pain moves anywhere

Ask if pain is getting worse or still same

Ask about if pain wakes patient up at night

Ask about weakness in legs

Ask if patient can control bladder and bowel

Ask about weight loss

Ask about fever and night sweats

Ask about loss of appetite, tiredness etc

Ask about other symptoms of hypercalcaemia (such as abdominal pain, confusion,

muscle weakness, constipation, thirst, and polyuria)

Ask about family history of any condition

Ask about Anaemia red flags (headache, dizziness, palpitations, SOB, chest pain

etc)

Find out how patient is coping at home.

Mohammed Eltahir

Open question, encourage patient to give more information.

Explore ICE. Also explore patients reasoning behind every aspect of ice.

Red flags (ask about weight loss, night sweats, lumps and bumps, rash on body, joint pains)

Impact. Explore home situation and functional status of the patient.

Past history of any fractures , parental fracture (as will potentially start patient of steroids.)

Lifestyle : Smoking, alcohol, caffeine intake, diet, exercise.

Differentials

PMR

RA

Malignancy

Autoimmune condition.

order of investigations -

Eosinophils raised or FENO> 50 - with suggestive history -> diagnose asthma,

if not -> >12% reversible pattern on spirometry + 200ml improved reversible airflow with hx suggestive -> diagnose asthma,

If not -> BDR with peak flow >20%? and hx suggestive -> diagnose asthma,

If not ->bronchial hyperresponsiveness? (with specialist referral) - if yes then asthma diagnosed.

Gout

Key Questions

• Pain: location, severity, onset.

• Swelling, redness, joint movement.

• Other joints affected, Lumps or fever

• Impact on daily life/work Alcohol, smoking, diet

Red Flags

• Severe pain/swelling, fever, inability to move joint.

Examination

• Check for redness, swelling, tenderness, limited movement.

• Look for tophi, signs of infection.

Investigations

• U&Es, uric acid, CRP, ESR. Check urine ACR if CKD.

Differentials

• Gout 

• Septic arthritis 

• Pseudogout 

• RA/OA 

Treatment

• First-line: NSAIDs if no contraindications.

• Colchicine: 500 mcg 2–4x/day (max 6 mg per course, wait 3 days before restarting).

• Alternatives: Prednisolone 30-35 mg for 3-5 days, intra-articular steroids.

• Ice packs, paracetamol for pain relief.

•  urate-lowering therapy (allopurinol/febuxostat).

Referral

• Rheumatology if CKD stage 3b–5.

Lifestyle Advice

• Healthy diet, weight loss, reduce alcohol, hydration.

  Rehab Ali

2.Gather data about the issue+ red flags

3.Address the main issue- eg titrate pain medication, give laxatives

4. Ask about preferred place of care/death

5. Who has got LPA and any advance directives + DNAR in place?

6.Does the patient have capacity? If not, you need to get in touch with 5 above.

7.Are they at the End of Life and so do they need Just in Case meds prescribed?

8. Is the patient depressed? Consider prescribing antidepressants.

9. Deprescribe unnecessary medications or those likely to make things worse

10. Ask if they have assessed documents that facilitate care and benefits eg SR2

11. Check that they have appropriate care/carers and palliative team input.

Inattention: Does the child have any problems with focussing on task?

Hyperactivity: Is he/she always on the go? Difficult to stay seated?

Impulsivity: Do they find it hard to control their anger and emotions?

Family history of ADHD/Autism

Same behaviour in multiple settings: Do they behave the same in school as well as at home?

Differential: Autism: Do they have any specific set of toys that they really like playing with?

Do they follow any strict patterns or routines?

Key Red flags:

Violent behaviour

Suicidal/self harm

Home situation and safeguarding

Recreational drugs, alcohol, smoking

Impact/psychosocial/ ICE

Explore impact on the child for example, performance at school. affect on daily life. impact on mental health and mood.

Explore impact on parents and family for example, how are the parents coping. impact on other siblings.

ask about parents ICE. understanding about ADHD. Worries and hopes.

Frequency - How often do you feel the pain /fatigue

Duration

worsening

triggers /relievers

Widespread Pain-where do you feel the most pain

Associated symptoms - headache , numbness tingling

sleep - do you have trouble sleeping or have early morning waking

Mental Health - ask about mood /anxiety symptoms

PMH

Medication History

Social History : relationship, support, occupation, diet smoking , alcohol.

Impact on Life

ICE

Differentials

Anaemia

Thyroid issues

Diabetes

sleep apnoea

Red Flags

Weight loss

any lumps

loss of appetite

any weakness of muscles

Explanation : Fibromyalgia/ chronic fatigue syndrome is a condition that causes wide spread pain, tiredness and sleep problems .It happens because brain and nerves become extra sensitive making even normal touch and movement painful.

Managing it usually involves gentle exercises , stress reduction ,good sleeping habits and sometimes medications

Safety netting - for red flags

Follow up - 4-6 weeks

• Vasomotor symtoms - hot flushes and night sweats - can be embarrassing

• Cognitive impairment - anxiety/low mood or mood swings/irritability/sleep disturbance/poor concentration and memory/difficulties in multitasking

• Genitourinary symptoms - vulvovaginal irritation, itching,dryness, dyspareunia,reduced libido,dysuria,recurrent UTI

• Others - joint and muscle pains, headache, fatigue

• Periods - frequency, duration, flow

• Post coital bleeding and intermenstrual bleeding

• CV risks - DM/HTN/VTE/Stroke

• Hx of hormone dependent cancers - breast, endometrial, ovarian

• Previous medical(endometriosis, bone health)or surgical treatment - chemotherapy/radiotherapy,hysterectomy and/or bilateral oophorectomy

• Smoking and alcohol status

• Psychosocial impact

  ICE

• What are there thoughts on there symptoms - perimenopause/menopause or something else? Have they researched there symptoms or spoken to friend/colleague/family member?

• What are they most worried about?

• How do they want us to address there condition?

• Examination is not mandatory except concerning pelvic symptoms. Take BP and BMI

  Treatment

• Clarify regarding need for bloods investigations as per NICE/CKS guidance - <40 years YES, > 45 years usually NO without atypical symptoms, 40-45 years - if atypical symptoms/menstrual change/screening for other conditions

• Discuss benefits (control of vasomotor symptoms, bone and muscle strength, improved genitourinary symptoms including libido) and risks (VTE, stroke,breast/endometrial cancer) of HRT

• Provide information leaflets

• Initiate HRT or option to discuss at a later date

Questions about diabetes symptoms-

1. Increased drinking/thirst

2. Urinary frequency (polyuria)

3. Blurry vision

4. Weight loss or weight gain

5. Tingling sensation in legs, wounds or ulcers in foot

   
   

   Red flags -

   Vomiting, abdominal pain, fruity smell in breath

   
   

Questions about medication-

1. Compliance to medications

2. If not compliant, ask why not?

I might give the results at this stage and ask ICE:

• Any thoughts why the blood sugar is high

• Any worries about high blood sugar

• Expectations

Psychosocial / Life style question -

Alcohol

Smoking

Weight

Diet

Exercise

Work

Driving

Diagnosis :

What does the patient understand by diabetes and long term complications