OSCE Internal Medicine Focused

GUIDE History

INDEX :

Symptom Page

Chest pain………………………………………………..…. 2

SOB………………………………………………………..……. 4

Cough…………………………………………………..……… 7

Limb swelling…………………………………………….…..9

Hemoptysis…………………………………………………..10

Palpitations…………………………………………....…….11

Epigastric Pain…………………………………………….…12

Upper GI bleeding…………………………………………14

Jaundice ……………………………………………………….16

Diarrhea…………………………………………….………….18

Abdominal Distension…………………………………..20

Neck Mass…………………………………………..………..22

Red Dark Urine………………………………………….…..24

Joint pain………………………………………………..……..26

Weight loss…………………………………………………....29

Back pain …………………………………………………..…..30

Follow Up DM ………………………………………………..32

1
 Chest pain
Pts profile: Age, Gender, and Chief Complaint

1. Duration
2. SOCRATES
o Site ? (Retrosternal , lateral )
o Onset ( when & how ) , sudden or gradual
o Character ( heaviness , stabbing , dull … )
o Radiation ( to left shoulder , neck , teeth ?? or maybe not )
o Timing ( night , day , with exertion , at rest ) & time of each episode ( 5, 10 ,30 min ) ??
o Associated symptoms
o Exacerbating and reliving factors ( increased by exertion , relieved by NTG or rest,
related to position, or respiration ( pleuritic chest pain )
o Severity ( out of 10 )
- If there is any associated symptom analyze it ..
o SOB
o orthopnea , Palpitations , ankle swelling
o nausea , Sweating, VOMITING
o Hemoptysis
o Cough, sputum
o Fever, rigors & chills
o Arthritis, Skin rash ( don’t forget)

- Ask about the Risk Factors for the most likely diagnosis :
If MI : age , HTN , DM , Hyperlipidemia , premature death in the family , Smoking
Family hx of IHD,HTN,DM

If PE : ask about recent travel and how long , bed rest , hypercoagulabe state
Ask about Trauma, Skin rash ( don’t forget )

- a quick systemic review for the other DDx ( don’t repeat) : wt. loss , loss of appetite, general
fatigue

Past hx :

- Ask about previous attacks ( very important ) ,

- previous Caths or Stents m or MI
- Previous DVT ( if PE suspected )
- previous hospital admissions , previous surgeries
- trauma

Drug Hx :

HTN , DM drugs and if controlled

Oral contraceptives ( If PE )
Aspirin , anticoagulants , B- blockers
Allergy to drugs

2
Social hx :
Smoking , Alcohol

DDX :

MI  if it was sudden retrosternal chest pain for 1-4 hrs heavy in nature , at rest , not relieved by
rest or NTG , and usually associated with sweating and vomiting ( don’t forget to ask about them
)

Unstable angina  sudden retrosternal chest pain for usually 30 min heavy in nature , at rest ,
not or slightly relieved by NTG or rest and usually there’s not sweating and vomiting

Stable angina  gradual retrosternal pain or chronic (intermittent heavy in nature) , comes only
with exertion and relieved by rest or NTG

PE  sudden lateral or central pleurtic chest pain with SOB and sometimes with frank blood
hemoptysis and cyanosis and don’t forget to ask about DVT …

Pneumonia  gradual pleuritic chest pain ( with respiration) , with cough , sputum , Fever &
chills

Pericarditis  precordial stabbing pleuritic pain , increased with cough, relieved on leaning
forward

Herpes Zooster -- > if there is skin rash on the chest

Trauma

Investigations :

For MI , or Angina  ECG , Cardiac enzymes

PE  D-dimer , CT angio
Pneumonia  Chest X-ray

3
 SOB
Pts profile: Age, Gender, and Chief Complaint

- Duration
- Sudden or gradual
- Progression
- Timing
- Severity
- Exacerbating and relieving factors? comes with exertion ( exertional dypsnea ) or at rest
- Associated symptoms : ( analyze the positive symptom)

it depends according to the DDx … read the DDx below

- COMPLETE the cardinal symptoms of the system and quick systemic review ( don’t repeat) :

General fatigue , weight loss , loss of appetite , fever , arthritis , low back pain , hematuria or
frothy urine , ……

Past hx :

- previous attack
- chronic respiratory disease ( Fibrosis , Brochiectasis , Asthma , COPD ..) or heart diseases ( HF , MI
…)
- DM, HTN , Hyperlipidemia , chronic renal disease , any chronic disease
- Previous surgeries

Drug Hx :

- B blockers, Calcium channel blocker , Ask about allergy for any thing

Family Hx: respiratory , cardiac , DM,HTN….

Social : SMOKING ( its better to ask it in history of present illness ) , Alcohol , occupation

DDX :

Sometimes the question is SOB with ejection fraction < 30%  HF , so this is cardiac
Sometimes dizziness/SOB/fatigue with low Hb  anemia
Sometimes only SOB and in the history there is cough, sputum and fever  pneumonia or
something respiratory

SO MAKE SURE YOU KNOW WHERE YOU ARE GOIN … SO YOU SHOULD modify your history

HOW ??!!

4
- IF there is cough , sputum , fever & chills , concentrate on the respiratory system because
most likely its chest infection .

- If the SOB comes at night with dry cough and wheezes so this is most likely asthma … or if its
associated with small amount of sputum and a long history of smocking so most likely its
COPD.

- If its sudden shortness of breath with hemoptysis and pleuritic chest pain so you should think
of PE … so :

- ask about previous DVT ,

- risk factors for atherosclerosis,
- Ask about recent long travels ,
- Ask specifically for oral contraceptives ,
- bed rest or immobility ,
- pregnancy ,
- hereditary causes of hypercagulable states

- If there is a large amount of sputum with chronic cough and SOB and sometimes hemoptysis so
most likely its Bronchiectasis so you should ask about :

-
- Ask him if he is aknown case of bronchiectasis and if he knows the
cause , maybe cystic fibrosis so you can ask about it clearly.
- If he has recurrent infections and recurrent admissions
- Blood streaked sputum
- ask if it’s hard to extract the sputum
- ask about if he has children If he’s married because Cystic fibrosis and
primary ciliary diskinesia pt’s are infertile
- smoking

- it could be Restrictive lung disease ( Lung fibrosis or Sarcoidosis ) SOB with dry cough and
intolerance to exercise and sometimes Hypoxia, so ask about lymphadenopathy, skin rash,
arthralgia, exposure to asbestos or dust , occupation is important.

- if there is ejection fraction of less than 30 % for example so this is HF … CONCENTRATE on the
cardiac symptoms ,, you can ask about:
- Orthopnea ( the most important )
- angina chest pain ,
- leg swelling , ascites , cyanosis , palpitations , previous MI , HTN , DM ,
Smoking .

- if there is low Hemoglobin( HB) you should modify your history so ask anything that causes
anemia :

5
 For the most important you should ask about bleeding from any site
- and the most important the GIT … SO ask about ,,, Melena , bloody
diarrhea or rectal bleeding , epigastric pain ( PU) and ask about Aspirin
Specifically , hematemisis, coffee ground blood with vomitus

- Hemoptysis of large amounts , hematuria , menstrual loss….. any

bleeding

- ask specifically for hemolytic anemias if there’s jaundice or hematuria if

he has sickle cell , thalassemia , G6PD ( ‫ )تفول‬or if there’s family history of
splenectomy , bleeding disorders .

- Ask about anemia of chronic diseases (renal failure , liver failure , RA ,

SLE )

- Ask about nutrition ( meat for B12 OR iron ) , weight loss, or

malabsorbtion syndrome , inflammatory bowel disease

- Ask about general symptoms like general fatigue , fever ,

lymphadenopathy , bleeding under the skin , infections  lymphoma,
leukemia, collagen vascular diseses or infection

- Cold intolerance for hypothyroidism

Investigations:

- Chest X ray if you suspected infection or pulmonary edema or even asthma and COPD or lung
fibrosis …
- Spirometry : for asthma COPD or fibrosis
- D-dimer and CT angio for PE
- CBC for anemia but if the hemoglobin is known you can ask for specific investigations … for GI
Bleed you ask for upper and lower endoscopy … for hypothyroidisim you ask for TSH ,T3,T4 …..

6
 COUGH
Pts profile: Age, Gender, and Chief Complaint

- Onset
- Progression
- Sudden or gradual ??
- Dry or productive ?
- Time ( at night , early morning , daytime ,
- Character ( dry , wheezing , harsh)
- Severity ( weak , so severe that causes syncope , wakens you up )
- Any relieving of aggravating factors?
- Associated symptoms :
- SOB
- Sputum : amount , color , smell
- Fever & chills
- Wheeze , stridor
- Orthopnea , PND
- Hemoptysis : frank blood , blood stained or streaked
- Night sweats and weight loss
- Chest pain ( angina or pleuritic )
- Heart burn , regurgitation
- Skin rash , neck mass , arthralgia  sarcoidosis
- Nasal discharge
- Complete the cardinal symptoms of the systems suspected RS , CVS , GI …

PAST HX :

Previous attacks , previous respiratory ( asthma , COPD , lung fibrosis… ) , cardiac ( HF ) , GI ( GERD ) ,
allergic ( rhinitis , Eczema )

HTN , DM , IHD . Any chronic illness , history of surgeries

Family hx :

Respiratory or cardiac disease , DM, HTN ….

Drugs :

ACE inhibitors or B blockers ..

Allergy from dust , olives , animal contact … allergic to drugs

Social & occupational :

SMOKING , alcohol , certain occupations , house ventilation , nearby factory .

7
DDx:

- If SOB , wheeze , dry cough , sometimes with clear sputum , increased at night asthma

- Small amount of clear sputum especially at morning , hx of smoking, wheeze  COPD

Note if the sputum in asthma or COPD is yellow or green then this is infection or if there is increased
sputum or SOB or cough this is called exacerbation of Asthma or COPD .

- If fever, green or yellow sputum , with cough  infection

- If the cough is weak and chronic (months) with sometimes with hemoptysis , weight loss , fatigue
 Cancer

- If there is night sweats, fever , weight loss and hemoptysis with chronic cough  TB ….. In
TB you should ask about risk factors like contact to someone has TB , OR tattoos and sexual
practices ( HIV is a risk factor ) … or if he has TB before ( recurrent TB )

- If sudden with SOB, hemoptysis  PE

- If recurrent dry cough with SOB and intolerance to exercise  lung fibrosis

- If there is orthopnea, PND HF

- If the cough is dry and mostly at night with heartburn and regurgitation  GERD

- Nasal discharge and dry or clear sputum only with no other symptoms  Atopy

Investigations :

Chest X ray

Spirometry

And specific investigations if you suspect TB , PE ….

8
 LIMB SWELLING
Pts profile: Age, Gender, and Chief Complaint

- Duration ( over how much time )

- Extent of swelling
- Redness, pain , hotness
- Unilateral or bilateral??

If unilateral : If bilateral :
- Redness , pain , hotness, pitting - Other sites of swelling: abdominal
edema  DVT distention, around the eyes
- Chest pain , SOB , Hemoptysis  - Cough and orthopnea and PND 
PE pulmonary edema as a cause of
- Fever& chills , brown areas , rapid HF
progression , ulcers  cellulitis - Bleeding tendency, spider nevi,
- Morning stiffness , arthritis  RA abdominal distention, Hx of Hep
- Trauma B  liver Cirrhosis
- Nocturia , frothy urine, freaueny ,
amount of urine  renal failure
- Nutrition, malabsorbtion 
hypoprotenemia
- Wt gain , cold intolerance ,
lethargy , fatigue 
hypothyroidism

- A quick systemic review with the cardinal symptoms of the system involved

Past hx :
Ask about previous DVT ,varicose veins, long travel , bed rest , heart diseases , renal
failure , liver cirrhosis or history of hepatitis , DM ( cause albuminurea ) , HTN …
chronic inflammation , history of surgeries , Family hx of DM ,HTN , IHD , Renal
disease, DVT …

Drugs :
Diuretics , B-blockers , OCP
Allery

Investigations :
D-Dimer and Doppler Ultrasound  DVT
LFT, KFT, CBC , TSH T3 T4

9
 HEMOPTYSIS
Pts profile: Age, Gender, and Chief Complaint

- Duration ( how long )

- How often do you cough blood ?
- Amount? And is it painful ?
- Is it Fresh Blood, or is it streaked , stained with sputum ??
- Is there bleeding from other sites ?? ( rectal , hematuria , hematemesis.. )
- Ask about Smoking ??
- Is there any leg swelling?? ( DVT OR as a cause of HF)
- Associated symptoms? ( analyze the positive symptom)
- Sputum ( amount , color , smell) , recent change in amount
- Fever & chills and night sweats
- Chest pain ( angina or pleuritc)
- SOB
- Weight loss , fatigue
- Quick review of the related systems :
Cough , wheeze , palpitations , orthopnea, PND , Abdominal distention , leg swelling ,
Skin rash , loss of appetite , arthritis

Past hx :

history of TB , Bronchectasis , respiratory diseases ... history of IHD , HF , DVT bleeding disorders
, history of surgeries , family history of IHD, bleeding disorders , Cancer

Drugs :

Warfarin , heparin , anticoagulants , NSAIDS.

Social and occupational:

Smoking, alcohol , exposure to factories smoke and pollution, travel Hx, previous DVT

DDx :

- If the pt is male with age > 50-60 with chronic cough and hemoptysis , weight loss , loss
of appetite and fever , with hx of smoking  LUNG CA
- If there is fever , night sweats and chronic cough , hemoptysis  TB
- if there is hx of recurrent infections and large amount of sputum  Bronchectasis
- sudden with SOB , Hx of DVT  PE ….
- Acute bronchitis , warfarin overdose , AVM ,COPD

Investigations :

Bronchoscopy for lung CA , Acid fast stain for TB .

10
 PALPITATIONS
Pts profile: Age, Gender, and Chief Complaint

- Onset (duration)
- Continuous or intermittent??
- If intermittent frequency and duration of the attack ??
- At what time do you feel it the most ? ( at night or day ?)
- The rhythm ( ask the pt to tab it)
- What factors make it appear or make you feel it .. ( exercise , large meal, stress, anxiety,
alcohol, coffee drinking, smoking )
- Relieving factors ( rest ? )
- Associated symptoms :
- Chest pain
- Syncope
- Dizziness
- SOB , limb swelling , Pale , fatigue  anemia
- Polyurea
- Joint pain
- Heart intolerance, wt loss , irritability  thyrotoxicosis
- Fever, Cough, night sweats , hemoptysis  TB or Cancer

Past hx :

- Similar attacks
- Any chronic diseases ( HF , IHD ,HTN,DM , Hyperthyroidism)
- Previous surgeries
- Family hx of IHD, HTN DM . …

Drug hx :

- Digoxin, salbutamol, alphazosin

Social:

Smocking & alcohol, coffee drinking

DDx :

If its intermittent and sometimes with chest pain and SOB  Arrhythmia ( SVT , Tachycardia, AF
..) which is caused IHD, HF , Valvular heart disease most of the time

If its continuous with wt loss and heat intolerance , sweating and increased appetite 
Hyperthyroidism

ANEMIA , Menopause , anxiety , pheochromocytoma are in the differential diagnosis also.

11
 EPIGASTRIC PAIN
Pts profile: Age, Gender, and Chief Complaint

SOCRATES

- Duration ( acute or chronic )

- Sudden or gradual over time ?
- Continuous or intermittent (remitting- relapsing) ?
- If intermittent.. Time and frequency??
- SITE?
- Radiation
- Character
- Aggravating factors ( food , position , movement )
- Relieving factors ( food , position , drugs )
- Severity
- Associated symptoms :
- Dyspepsia ( feeling tired after the meal )
- Vomiting blood (fresh blood, coffee ground, clotted?)
- Amount, color, smell , and content of the bloody vomitus
- Melena , Hematechezia
- Regurgitation ,water brush, heartburn, cough , hoarseness of voice
- Nausea , Vomiting , diarrhea
- Constipation
- Dysphagia, odynophagia
- Fever and chills
- Jaundice , color of urine and stool , itching hepatitis or cholestasis
- Chest pain , SOB , sweating  MI
- Orthopnea , PND
- Arthritis & skin rash
- Complete with a quick systemic review : early satiety, wt loss , loss of appetite , cough,
sputum …..

Past hx :

- History of peptic ulcer , GERD , IHD , HTN , DM , Hyperlipidemia

- History of hepatitis B, C .. or BLOOD TRANSFUSION , sexual contact
- Hemorrhoids or bleeding from any other site
- Family history of PUD , IHD , HTN, DM

Drug Hx :

Ask about Aspirin or NSAIDS specifically .

12
Social Hx :

Smoking, Alcohol, contact to anyone has Hepatitis

DDx :

Localized remitting relapsing Epigastric pain which is aggravated by food associated sometimes
with bloody vomitus (coffee ground ) and melena if there was any bleeding and usually there is
Hx of NSAIDs use for arthritis or any chronic pain  Gastric ulcer BUT If it’s relieved by food and
usually comes at night and wakens the pt up  Deudonal Ulcer

If there is heartburn, water brush regurgitation cough and hoarseness of voice it could be GERD

Note that it could be an Inferior wall MI , or MI in DM pts could come with epigastric pain so
ASK about cardiac symptoms …

Ask about jaundice, change in urine or stool color because it could be Hepatitis or something in
the liver so ASK also about Alcohol , blood transfusion , DM

If the pain is radiated to the right hypochonrium and between the scapulea and the pain is
related to fatty food then it could be acute or chronic cholecystitis

If the pain is relieved by bending forward it could be Pancreatitis but not necessarily.

It could be gastritis. (acute viral , or uremic …… )

Investigations:

For peptic ulcer  Upper Endoscopy

13
 UPPER GI BLEEDING
Pts profile: Age, Gender, and Chief Complaint

- Duration
- Amount , color , smell , content of the bloody vomitus
- Frequency
- Fresh blood, clotted or coffee ground ?
- Is it increased or decreased over time?
- Was there severe recurrent vomiting before the bleeding ?
- Alcohol abuse?
- Jaundice , change in urine , stool color ??
- Melena ?
- Bleeding from other sites?
- Associated symptoms :
- Abdominal pain ( Analysis)
- Dysphagia , Odynophagia
- Naseua , vomiting , diarrhea
- Retching , regurgitation , waterbrush , cough, hoarseness of voice
- heartburn
- Hemorrhoids
- SOB , Dizziness, fainting , palpitation, sweating
- Fever, rigors & chills
- Wt loss , early satiety and loss of appetite

Past Hx :

- Previous similar attacks

- PUD , Hepatitis , Cirrhosis
- Family hx of gastric CA , PUD
- History of blood transfusions or previous surgeries or admissions
- Hx of trauma

Drug Hx :

- Aspirin , NSAIDS , PPI , Antacids

Social Hx :

Smoking , Alcohol Abuse , sexual contact

14
DDx :

Mallory weiss tears as a complication of recurrent vomiting usually in binge alcohol drinkers

Esophageal Varices if there is large fresh bloody vomitus and usually comes with liver cirrhosis

As a complication of PUD if there is epigastric pain and a good history suggesting it .

Gastric CA , eosophageal CA

Investigations :

Upper endoscopy

15
 Jaundice
Pts profile: Age, Gender, and Chief Complaint

- Duration?
- Is the discoloration of your Eyes only or the Skin also?
- Is there any abdominal pain? Is it colic or constant dull pain? (Pain Analysis)
- Change in urine color? Tea color? Red in color?
- Change in stool color? Lighter in color??
- Itching??
- Alcohol?
- Blood transfusion?
- Is there anyone in the family had these symptoms?
- Was there any contact to anyone had the symptoms?
- Fatigue, shortness of breath, dizziness, headache, coldness in your hands and feet,
pale skin, and chest pain anemia
- Ascitis , limb swelling, bleeding tendancy  liver cirrhosis
- Quick systemic review : fever, wt loss, fatigue, loss of appetite, bleeding tendency,
vomiting , diarrhea, constipation, abdominal distention ……

Past Hx :

Any hx of hepatitis, liver cirrhosis, gallstones , cholecystitis or any liver diseases .

DM, HTN, Hyperlipidemia,

Don’t forget blood transfusions

Family Hx of hepatitis, liver of GI cancer or the pt himself if he is treated for any cancer.

Drug Hx:

INH, Rifampin  anti TB drugs ,

methotrexate for RA or any cytotoxic chemotherapeutic drug

OCP , Ketokonazole , Amphotericin B , Paracetamol ..

Social Hx :

Smoking , ALCOHOL , sexual contact , sharing needles, travel to endemic areas of malaria or hx
snake bites.

16
DDx :

Prehepatic: hemolysis, malaria, sickle cell, thalassemia, G6PD,

Hepatocellular: acute or chronic hepatitis, Cirrhosis, drug induced hepatitis, primary biliary
cirrhosis, ……

Post-hepatic (obstructive jaundice) : gall stones, masses, biliary atresia, cholangiocarcinoma,

But the most common causes are :

Acute Hepatitis  usually acute comes with RUQ abdominal pain and discoloration of the eye
and skin with hx of contact to Hepatitis A , or Hx of blood transfusion for Hepatitis B,C , if its
chronic usually jaundice is a late symptom .

Hemolytic anemias  thalassemia, hemolytic crisis of sickle cell anemia , G6PD, hereditary
spherocytosis

obstructive jaundice is caused by a stone, tumor or a mass occluding the bile duct could be
hepatocelluar Carcinoma or cholangiocarcinoma , or pancreatic CA sometimes … maybe a
stricture or stones in the bile duct so think gallbladder stones or primary biliary cirrhosis …. If its
neoplastic usually it causes painless jaundice unlike gall stones which is painful .

We think of obstructive jaundice when we have dark urine ,light stool, or itching … these
symptoms are specific for OJ and we should do ultra sound for biliary system.

Liver Cirrhosis  ascitis, limb swelling , bleeding tendancy, bruising , hematemesis.

Sometimes the cause is congenital …..

Investigations :

Serum bilirubin , direct and indirect

ALT, AST  Acute hepatitis

ALP,GGT  biliary disease

PT, Albumin  chronic liver disease or cirrhosis

CBC, RETICS  Hemolytic anemia

Ultra sound , CT, ERCP, for biliary system  masses, strictures or Stones

17
 Diarrhea
Pts profile: Age, Gender, and Chief Complaint

- Duration ( for how long )

- Frequency? (how many times per day? )
- Consistency (is it watery, loose, normal? )
- What’s the nature of the stool ? ( fatty , pale , foul smell )
- Is it large or small in volume??
- Is there any blood or mucus ?
- If there is blood is it fresh blood , clots , Black tarry stool ??
- Is it associated with pain and straining? ( tenesmus)
- Is it related to food or even at fasting? ( after meals you go to the bathroom ?)
- is there any abodominal pain? Is it relieved with NSAIDs ?
- Does defecation relieves you?
- Have you eaten or drunk anything you suspect is spoiled in the last 24 hrs like
chicken, mayo , Salad, Eggs …. ??
- Has any other family member has the same symptoms after eating the food ?
- Have you traveled recently ?
- Associated symptoms ?
- Fever , Chills & Rigor
- Sweating
- Nausea , Vomiting
- Abdominal pain ( Analysis )
- Hematemesis or coffee ground vomitus
- Constipation alternating with diarrhea
- Abdominal distention
- Skin rash or ulcer , Mouth Ulcer , Eye manifestation , Arthritis , Back pain
- Neurological symptoms  BOTOLINUM toxin
- Increased or Loss of appetite , wt. loss , early satiety
- SOB, Dizziness, fatigue, sweating, angina  hypovolemia
- Complete with a quick review of the GI, urinary , and other systems .

Past Hx :

- Similar attack
- Chronic GI diseases ( Inflammatory bowel disease, Irritable bowel syndrome, peptic
ulcer, GERD, lactose intolerance, malabsorption syn. …. )
- Family Hx of IBD, IBS , Malabsorption syn. COLON CA.
- Any travel Hx , areas that you can get parasitic infestations?
- Any chronic disease

18
Drug hx:

- Antibiotics ( it may cause the diarrhea ) , NSAIDs , laxatives, colichicine

Social hx :

Smoking , alcohol , ask about low fiber diet if you suspected Colon Ca .

DDx :

If it is acute think of infectious causes … diarrhea with vomiting ,fever & chills gastroeneritis

passing large volumes of loose stool with blood or mucus and there is a hx of eating spoiled food
or water  bacillary dysentery or Ameba

If it’s chronic passing small but frequent loose bloody stool usually nocturnal and/or postprandial
tenesmus occasionally with skin ulcers and arthritis  Ulcerative colitis , if it was not frequent
bloody diarrhea and there’s RLQ abdominal pain with wt. loss and extraintestinal manifestations
like arthritis , conjunctivitis , skin ulcers  Crohn’s Disease

Wt loss fatigue with abd pain and diarrhea you should put Colon CA in you DDx especially if
there is family Hx ..

If there was black tarry stool with hx of peptic ulcer and hematemesis  PUD

If the diarrhea was chronic and its is only diarrhea with no other symptoms other than bloating
and tenesmus relieved after defecation and mostly the early morning and sometimes
alternating with constipation  irritable bowel syndrome ( but it is a disease by exclusion all
other causes )

Investigations:

For infectios colitis  stool cultures

For inflammatory bowel disease and colon CA  lower endoscopy and Upper endoscopy if there
is upper GI involvement especially in CD.

19
 Abdominal distension
Pts profile: Age, Gender, and Chief Complaint

- Duration?
- Was it progressive over time?
- Is it painful? ( pain analysis )
- Is there any breathing difficulty, SOB ?
- Is there any swelling in the legs or other sites?
- Orthopnea, PND, fatigue, loss of appetite??
- Edema around the eyes , oliguria , anuria , frothy urine , polyurea, frequency of
urine output, hesitancy , straining , hematuria ??
- Upper GI bleeding , Hemorrhoids , Hx of alcohol , Liver Cirrhosis ?
- Nausea , vomiting , fever & chills ?
- Diarrhea?? Bloody stool ??
- Is there any bloating (gases), constipation, and change in bowel habit?
- Is there any history of chronic constipation, Irritable bowel syndrome ?
- pregnancy?? ( if female )
- Associated symptoms :
- Wt loss , fatigue , loss of appetite ,early satiety , heart burn , water ,
vomiting blood …..

Past Hx :

- History of similar attacks ?

- Hx of HF? IHD, HTN , DM , MI, Family Hx
- Hx of RF , nephrotic or nephritic syndromes ?
- Hx of inflammatory bowel disease, Irritable bowel syndrome, protein losing
enteropathy ?
- Malnutrition ?
- Hx of abdominal surgery ? blood transfusions ? contact to anyone has hepatitis ?
- Family Hx of hepatitis , IBS ….

Drug Hx :

Corticosteroids , IV FLUID may cause fluid overload …

Antidiarrheal drugs may cause constipation

Drugs for HTN,DM,IHD,IBS,….

20
Social Hx :

Smoking , ALCOHOL , recent travel

DDx : 5F’s : Fat , Fetus , Flatus , Feces , , Functional (Fluid or a mass)

Fluid over load  Heart failure , Renal failure , Liver cirrhosis , protein losing enteropathy ,
malnutrition , over hydration

Flatus (gases), Feces  constipation , obstruction, pseudo-obstruction , aerophagia

Fetus  pregnancy …. Fat  Obesity :P

a mass  ovarian CA…..

investigations:

Abdominal X-ray or CT …

21
 NECK MASS
Pts profile: Age, Gender, and Chief Complaint

- Duration (how long do you have this mass?)

- Site? (central around the trachea or lateral)
- Size? (How big is it?)
- Consistency? ( hard, firm or soft )
- Is it tender?
- Is it mobile or fixed to the underlying tissue?
- Is there any other masses in the neck , Axilla or inguinal region ?
- Does it move with swallowing?
- Trauma?
- Exposure to irradiation?
- Associated symptoms :
- If the hx suggested lymphadonopathy ?
- Fever, Chills & rigors
- Sore Throat
- Cough , hemoptysis
- Nasal discharge ( acute or chronic)
- Night sweats , wt loss TB
- SOB, Fatigue, Bleeding tendency, infections, Bone pain  leukemia,
lymphoma
- Skin lesions , arthritis, uvietis  sarcoidosis
-
- If the hx suggested thyroid mass :
- Breathing Difficulty, dysphagia , Hoarseness of voice, chronic sore throat
- Heat intolerance, tremor, restlessness, increase appetite, wt loss, diarrhea,
headache, palpitations, sweating, muscle weakness, fatigue,
oligomenorrhea  thyrotoxicosis
- Cold intolerance, slow speech, dry skin, jauindice, pallor, brittle hair,
hoarsness of voice, hypothermia, limb swelling  hypothyroidism
- Loss of appetite , early satiety , abdominal pain

Past Hx:

- Similar previous attack, Hx of TB , recurrent sinusitis, chronic sore throat,

Sarcoidosis.
- Hx of cancer, Hx of salivary glands inflammation or infection, dental hygiene ,
thyroid cancer.
- Hx of surgery

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Drug Hx :

- Irradiation, Chemotherapy ….

Social Hx :

- Smoking , alcohol, animal contact, recent travel , diet ( eating cabbage)

DDx:

This history is about neck mass in general. A neck mass has a long list of DDx but for the internal
OSCE exam I think it will be more obvious like giving another symptom with the neck mass like
fever , heat intolerance or whatever but most likely it will be Cervical lymphadenopathy or
Thyroid enlargement … so you should modify your hx if you knew which system is involved .

Acute symptoms, such as fever, sore throat, and cough  adenopathy resulting from viral or
bacterial upper respiratory tract infection. Or TB .

Chronic symptoms of sore throat, dysphagia, change in voice quality, or hoarseness are often
associated with anatomic or functional alterations in the pharynx or larynx and the most
common cause is  thyroid enlargement

A history of smoking, heavy alcohol use, or previous radiation treatment increases the likelihood
of  malignancy (primary - lymphoma or metastasis – lung or gastric CA)

It could be a lymph node involvement in Sarcoidosis with symptoms of SOB and hypoxia
because the restrictive lung disease or skin or eye involvement.

Although congenital anomalies are not common in males but there are many congenital
anomalies can cause a neck mass in general ..

Central : thyroglossal duct cyst (most common), thymic rests and dermoids.

Lateral : Branchial cysts, sinuses, and fistulae (most common ), cystic hygromas
(lymphangiomas) and dermoids.

Investigations :

The gold standard is Biopsy … but you can do CBC, CXR, Any specific investigation …

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 Red Dark Urine
Pts profile: Age, Gender, and Chief Complaint

- Duration ( onset)
- Frequency (every time or just once?)
- Color? ( Red, Dark or Dark-Brown)
- Which part of the stream? (all, early, late?)
- Progression? (Sudden or gradual?)
- Odor or Clots?
- The amount of urine?
- Associated symptoms :
- Upper abdominal pain, jaundice, light stool color (pain analysis) biliary
obstruction
- Flank pain (pain analysis), cloudy dark urine  renal stones
- Fever, Chills, Naseua, Vomiting, Palpitations, SOB pyelonephritis
- Muscle pain or major trauma  rhabdomyolysis
- epistaxis, hemoptysis, bloody stool Bleeding diathesis
- Burning micturation, urgency, polyurea  Urethritis
- Skin rash, malar rash, arthritis, Rrenayd’s, chest pain  SLE
- Poor stream, dribbling , straining prostate enlargement

Past Hx:

- Hx of same problem
- DM,SLE,Hemolytic anemias
- Hx of surgeries
- Trauma ( Foley Catheter)
- Blood transfusions
- Family Hx of Hemolytic anemia, Chronic diseases

Drug Hx :

- Heparin, Warfarin, Rifampin, Cytotoxic Drugs, NSAIDs, Gentamycin

Social Hx:

- Smoking , Alcohol, Travel Hx, Diet ( may eat something stains)

DDx:

Dark urine means: 1- blood,

2- hemoglobin or its products urobillonigen, billirubin

3- or myoglobin

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 - UTI, Bladder and Renal stones, nephritic syndrome , , Pyelonephritis, Renal Ca,
polycystic Kidney, prostate enlargement, , trauma all cause hematuria .

- Obstructive jaundice due to Gall stones or hepatocellular carcinoma,

colangiocarcinoma, pancreatic head CA, Pancreatitis hemolytic anemias (
G6PD,PNH,Sickle cell..) cause Dark brown urine due to increased serum bilirubin .

- Rhabdomyolysis which is skeletal muscle damage due to injury like crush or trauma
or due to drugs, Infections, and infarctions cause Dark Urine due to myoglubinurea.

Investigations :

- CBC with Riticks count to see if there is hemolytic anemias

- Ultrasound and X-ray for Stones sometimes CT
- In older patients, Cystoscope and Biopsy to exclude malignancy.

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 Joint pain
Pts profile: Age, Gender, and Chief Complaint

- How many & what joint(s) are involved? Small or large joints? (Ex: shoulders, knees,
MCP, PIP, DIP …??
- Is it symmetrical on both sides? Left and right hands or feet?
- Duration? The first attack?
- Sudden or gradual?
- Continuous or intermittent?
- What time does it get worse? At night? Or morning
- Morning stiffness? Wake up like (‫ )مخشب‬then improvers after an hour?
- Aggregated by movement or cold weather?
- Relieved by rest or movement or any drugs?
- How severe is it? Does it affect the movement?
- Redness? Swelling? Deformities?
- Is it migratory? The pain moves from one joint to another?  Rheumatic fever
- Associated symptoms :
- Fatigue, anorexia, wt loss ,Fever, nausea, vomiting
- Skin rash, butterfly rash, photosensitivity
- Cough, chest or abdominal pain , SOB , Hemoptysis
- Oral or genital ulcers
- Anurea, oligourea , hematuria
- Headache, convulsions
- Eye problems, redness, itching
- Pallor, cyanosis and redness of the hands ( Raynauds Phenomena)
- Dysphagia, odynophagia.
- Back or Neck pain, tingling or numbness of the feet
- Bloody diarrhea , RLQ pain
- Urethral Discharge gonnorheal infection
- A quick Systemic review : cough, hemoptysis,

Past Hx:

- Previous attack
- Hx of RA, SLE, Gout or any chronic disease
- Family Hx of RA,SLE, Previous surgeries

Drug Hx:

- NSAIDS, Hydralazine, procainamide, INH, duirits

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Social Hx :

- Smoking, Alcohol, sexual conact

DDx :

Rheumatoid Arthritis (RA) usually a female over 40 yrs, small hands and feet joints pain and
swelling with symmetrical involvement, usually the DIP and lower joints are spared, BUT the
arthritis is usually destructive so there is some deformities of the hands like ulnar deviation or
swan neck . There may be some extra articular manifestations like rheumatoid nodules .

- Investigations : Rheumatoid factor (RF), anti CCP, CBC , ESR, Xray

SLE  non destructive arthritis, malar rash, photosensitivity , discoid rash, serositis
(inflammation of the pleura or peritoneum) , renal involvement, oral ulcers, neurologic (
sezures, psychosis), hematologic ( hemolytic anemia , leucopenia, thrompocytopenia).

- Investigations : ANA, anti-smith Ab , Anti-ds DNA ab

Scleroderma  thickening of the skin , raynauds phenomena, eosophageal dysmotilities,

pulmonary fibrosis, acute renal failure , CREST syndrome (Calsinosis , Raynauds, Esophageal
Dysmotilities, Sclerodactyly, Telangiectasis) .

- Investigations: ANA (+) , Anticentromere Ab

Inflammatory myopathies  polymyositis : proximal muscle weakness without pain, difficulty

swallowing, Arthralgia, Myalgia, if ther is Skin rash its called dermatomyositis.

- Lab Investigations : elevated Creatine phosphokinase, aldolase

Sponyloarthropathies:

- Ankylosing Sponylitis : affects usually the lower back joints, the pt usually complains
of lower back pain that improves after movement ( morning stiffness), also there is
peripheral joint involvement but is asymmetrical unlike RA ans SLE , extraarticular
manifestations usually include anterior uvietis, aortitis, aortic regurg, pulmonary
fibrosis
- Reactive arthritis : complication of an infection
- Psoriatic arthritis : commonly involves the DIP, cause sausage shaped digit
- Enteropathic : comes with Ulcerative colitis and Crohn’s Disease.

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Gout : usually Monoarthritis, affects the 1st MTP joint (podegra), but can affect other joints, pain
comes at night with warmth swelling and redness, the pain goes away spontaneously after 3-4
weeks.

- Investigation : analysis of the synovial fluid, (Urate crystals)

Pseudogout

Septic Arthritis : after a gonnorheal infection or staph in elderly.

FMF (Familial Mediterranean Fever) : fever, Abdominal pain, Mono arthritis, Chest pain,
pericarditis.

Behcet’s Disease: recurrent oral ulcers, genital ulcer, Erythema nodsum, anterior/posterior
Uvietis.

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 Weight loss
Pts profile: Age, Gender, and Chief Complaint

Analysis:

- How many kg are lost?

- The duration of the wt loss?
- When did you last weigh yourself? And how much was that?
- What is your current wt?
- Are you on diet + are you taking medications to lose wt (is the wt loss intentional)?
- How is your appetite? ( decreased appetite with no other underlying disease may suggest
anorexia nervosa )
- Any lifestyle/ exercise or occupational changes recently?

- Is there any problem that prevents eating (teeth / odentophagia ) ?

- Diarrhea (analyze it ) + abd. Pain/bloating + signs of anemia ( easy fatigability /pallor + SOB ) +
skin dryness  Malabsorption syndrome that could be due to many diseases as CD / UC /Celiac
disease etc …

- Tremor + heat intolerance + palpitation + sweating + diarrhea  hyperthyroidism

- Ployurea( nocturnal ) + polydipsia +polyphagia  DM
- Night sweats + fever  malignancy
- Hyperpigmintation + postural hypotension + changes in distribution of body hair + fatigue 
Addison disease
- Heartburn + waterbarsh + epigastric pain related to food+abd. Bloating /fullness + melena +
hematemesis  peptic ulcer disease / GERD

Past hx :

- Chronic illnesses ( DM / HIV / GERD / PUD / IHD )

- Family history of CA + DM + malabsorption syndromes + anemia + Parkinson disease +
Alzheimer+ PUD

Drug Hx : what drugs does the patient take ( ask abt aspirin and other NSAIDs + amphetamine + diet pills )

Social Hx : smoking + alcohol + stress and anxiety + depression + occupation

Investigations:

- If suspect any malabsorption syndrome  lower GI endoscopy ( may require a biopsy )

- Hyperthyroidism  thyroid function test
- DM  Fasting plasma glucose level / oral glucose tolerance test
- Addison disease  ACTH stimulation test
- Peptic ulcer disease / GERD  upper endoscopy

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 Back pain
Pts profile: Age, Gender, and Chief Complaint

- When did the pain start?

- Where is the back pain exactly (central /peripheral or thoracic / lumber)?
- Nature of pain?
- Did the back pain start after an injury or lifting sth ?
- Radiation of pain to any other site ?
- Aggravating and relieving factors ? ( rest / activity /standing /walking /sitting / menstruation )
- Previous attacks?
- Is your back pain worse when you wake up in the morning or later in the day?
- Is it continuous or intermittent ?
- Severity?
- Associated symptoms:
- pain / stiffness / swelling in any other joint
- back stiffness
- leg pain and parasthesia
- Bladder symptoms
- recent gastroenteritis
- diarrhea / abd. Pain / bloody stool ( symptoms of UC and Crhon)
- Fever
- skin rash
- Eye problems ( conjunctivitis ..) + urthritis ( painful urination penile discharge or vaginal
discharge )
- Burning micturation ( UTI symptoms )
- Depression

Past history :

- Medical  osteoarthritis / ankylosing spondylitis / IBD /HTN /DM/Psoriasis / SLE

/Cushing/hyperthyroidism / CA ( breast / lung / prostate / thyroid )

- if female ask about early menopause +

- Blood transfusion / allergies / surgeries
- social : smoking /alcohol / occupation / high caffeine intake /physical activity / calcium and vit D intake (
ask about nutrition )

Drug Hx : ask specifically about warfarin + steroids

Diff. Dx :
- Trauma or injury

- Ankylosing Spondylitis
- RA
- Painful menstruation

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- Bone tumor
- Muscular strain
- Osteoarthritis
-Reactive arthritis
-Psoriatc arthropathy
-Compression of spinal cord or nerve roots from a disc prolapsed
-Reiter syndrome
-Osteoporosis
-Acute vertebral osteomyelitis

Investigations:
- X-ray

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 Follow Up DM
Pts profile: Age, Gender, and Chief Complaint

- For how long you have the DM?

- Is your blood sugar controlled?
- Do you measure your blood sugar routinely? How much was it the last time?
- Are you on oral hypoglycemic drugs or insulin or both?
- What drugs do you have? Dose? If insulin ask how many units per day?
- Do you take your drugs as the doctor told you at the time?
- Life style, exercise, eating habits?
- Obesity? BMI ?
- Diet? Polyphagia, polydepsia
- Ask about complications of DM :
- Loss or decreased vision  Retinopathy
- Polyurea, anurea, frothy urine, or symptoms of uremia : nausea, vomiting,
abdominal pain, chest pain  Nephropathy
- Parasthesia of the limbs, urinary incontinence Neuropathy
- Symptoms of hypoglycemia: hunger, tremor, palpitation, anxiety, pallor,
sweating, impaired thinking, irritability, convulsion, hypotonia  Hypoglycemia
- Chest pain, SOB , headache, paralysis, nausea, Foot ulcers, redness, swelling 
Atherosclerosis (previous MI, CVA)
- Nausea, vomiting, polyurea, polydipsia, anorexia, rapid and deep breathing,
tachycardia, dehydration  DKA ( if type1 DM)
- Hair loss, easy bruising, Delayed wound healing sexual dysfunction,
gastroparesis.
- Ask About last lab results if the pt is educated :
- Las HBA1c reading )‫(التراكمي‬
- Last urine analysis report
- Blood tests or other tests

Past Hx :

- Other chronic illnesses ( HTN, IHDs,hyperlipidemia, renal failure ….), Hx of other

endocrine diseases
- Any previous MI, stents or Caths
- Previous admissions, surgeries
- Family Hx for DM, HTN, IHDs …..

Drug Hx :

- Drugs for DM IN DETAILS

- Other drugs
- Allergy to drugs

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Social Hx :

- Smoking, Alcohol

Done By:
Ziedan saleh

Hope 2010
B1

Thanks for rinad al-ali,

saja smadi for the help.

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