F&C OSCE

HISTORIES
OBSTETRICS &
GYNAECOLOGY
 GENERAL OBS&GYNAE HISTORY
1. HISTORY OF PC: 5. SEXUAL HISTORY:
 TIME-FRAMES: onset, duration, progression, similar episodes  Regular partner: M/F, how long, how many partners in last 3/6/12 months
*ICE + LIFE EFFECT*  Intercourse: type, pain/discomfort
 Infertility
2. SYSTEMS REVIEW:
 GENERAL 5. CERVICAL SMEAR & CONTRACEPTION HISTORY:
 GYNAECOLOGICAL: PV bleeding (heavy, inter-menstrual, post-coital, post-menopausal),  Smear: date of last smear, results
PV discharge, Pain (pelvic, during periods, during sex), Pregnancy (chance could be  Contraception
pregnant)
 GASTRO: IBS, appendicitis, diverticulitis
6. REST OF HISTORY:
 UROLOGICAL: UTI, incontience
 PMH
 DH: including HRT, allergies
3. MENSTRUAL HISTORY:
 1st day of LMP  FH: history of Ca breast/bowel/ovary

 Cycle: regular/irregular, length, duration, heaviness, pain  SH

 Menarche, Menopause

4. OBSTETRIC HISTORY:
FOR EVERY PREGNANT LADY ASK
 CHILDREN: number, ages, birth weights, delivery, abnormalities of pregnancy
- REDUCED FOETAL MOVEMENTS
 MISCARRIAGES: stage, complications, treatment
- PAIN
 TERMINATIONS: stage, method, problems after
- BLEEDING
 WORK OUT G+P - GUSHING FEELING OF WATER
KEY QUESTIONS
OBSTETRICS GYNAECOLOGY
• PREVIOUS PREGNANCIES (G&P) • PAIN (during sex / pelvic pain / during periods)
• HOW ARE BABYS MOVEMENTS? • PV BLEEDING (IMB, bleeding after sex, PMB)
• BLEEDING? • PREGNANCY (chance?)
• PAIN? • PV DISCHARGE
• GUSHING FEELING OF WATER?
• UP TO DATE SCANS/APPOINTMENTS • CHANGES TO BOWEL AND WATER WORKS?
• SYSTEMIC REVIEW  headaches / changes to • SMEARS!!
vision / swelling / RUQ pain / vomiting / • PREVIOUS GYNAE SURGERY
seizures / tired
• RISK FACTORS  twins / obesity / diabetes / pre-
eclampsia
 RED FLAGS:
- SEVERE PAIN
- BLOOD LOSS FOR MORE THAN 7

MENORRHAGIA DAYS

1. OPENING CONSULTATION: 4. PATIENT PERSEPCTIVE:

 PC – Can you tell me more about this bleeding?
 FEELINGS & EFFECT ON LIFE // IDEAS // CONCERNS // EXPECTATION
 Timeline – When did you first notice this? How did it start? How has it progressed since
then?
5. PMH/FM:
2. SYMPTOM ANALYSIS:  Any previous illnesses?
 ONSET – when did you first notice it?  Any history of previous cancer (breast, ovarian, endometrial, cervical)?
 CHARACTER – how much have you noticed? Cups? Have you passed any clots?  Previous STIs?
 RADIATION – Have you been using towels/tampons and how many do you go through?  Bleeding disorders?
Anytime you’ve noticed it to flood the bedsheets/clothes?
 PREVIOUS SMEAR
 ASSOCIATED SYMPTOMS: pain? (fibroids/endometriosis or ovarian tumors) and
tiredness/SOB? (anemia)
 TIMING – when do you notice the bleeding? Is it there all the time? How often have you 6. DH:
noticed it? Does it occur mid-cycle? Does it come on after sex?  Has he/she been given any medications?
 Does he/she have any allergies?
3. SYSTEMS REVIEW:
 MENSTRUAL HISTORY 7. SH:
 PAIN  Are you working? Occupation?
 SEXUAL HISTORY  Smoking? Alcohol? How much?
 VAGINAL DISCHARGE  Can you tell me about home situation (occupants and difficulties)
 OBSTETRIC HISTORY  Has your problem affected your job or home life in any way?
 CONSTITUTIONAL – have you felt feverish / weight loss / appetite / tired / breathless
 BOWEL AND URINARY SYMPTOMS?
MENORRHAGIA Dx/INVEST.
DIFFERENTIALS FEATURES 1. INVESTIGATIONS:
Abdo and pelvic examination
HYPOTHYROIDISM - Weight gain BLOODS: TFTs / FBC/ clotting/ haematinics / FSH+LH
- Lethargy
- Dry skin PELVIC US
- Brittle hair COLPOSCOPY AND BIOPSY if older than 45
- Cold intolerance CERVICAL SMEAR
PCOS
2. MANAGEMENT:
COAGULATION - Any other bleeding or bruising MEDICAL
DISORDER  Mirena Coil
 Tranexamic acid and mefanamic acid
FIBROIDS - Urinary symptoms  COCP
 Oral progesterone
ENDOMETRIOSIS - Abdo pain and dyspareunia  GnRH analogues to stop production of estrogen and
progesterone
POLYPS - Post coital bleeding and intermenstrual bleeding SURGICAL:
 Endometrial resection of polyps
PID - Pelvic pain, urinary symptoms, discharge and  Myomectomy
systemic symptoms  Hysterectomy
 RED FLAGS:
- SEVERE PAIN
- 5-12 WEEKS SINCE LMP
- WEIGHT LOSS
- POSTMENOPAUSAL BLEEDING

BLEEDING (PCB/IMB/PMB)
- INTERMENSTRUAL BLEEDING
- POSTCOITAL BLEEDING
- MISSED CERVICAL SMEARS

1. OPENING CONSULTATION: 4. PATIENT PERSEPCTIVE:

 PC – Can you tell me more about this bleeding?
 FEELINGS & EFFECT ON LIFE // IDEAS // CONCERNS // EXPECTATION
 Timeline – When did you first notice this? How did it start? How has it progressed since
then?
5. PMH/FM:
2. SYMPTOM ANALYSIS:  Any previous illnesses?
 SITE – when and where exactly did you notice this bleeding? Is it definitely coming from the  Any history of previous cancer (breast, ovarian, endometrial, cervical)?
vagina?
 Previous STIs?
 ONSET – when did you first notice it?
 Bleeding disorders?
 CHARACTER – how much have you noticed? Have you passed any clots? What colour is it?
 PREVIOUS SMEAR
 RADIATION – do you use tampons or passing? Does it soak them?
 ASSOCIATED SYMPTOMS
6. DH:
 TIMING – when do you notice the bleeding? Is it there all the time? How often have you  Has he/she been given any medications?
noticed it? Could it be your period? Does it occur mid-cycle? Does it come on after sex?
 Does he/she have any allergies?

3. SYSTEMS REVIEW:
 MENSTRUAL HISTORY 7. SH:
 Are you working? Occupation?
 PAIN
 Smoking? Alcohol? How much?
 SEXUAL HISTORY
 Can you tell me about home situation (occupants and difficulties)
 VAGINAL DISCHARGE
 Has your problem affected your job or home life in any way?
 OBSTETRIC HISTORY
 CONSTITUTIONAL – have you felt feverish / weight loss / appetite / tired / breathless
 BOWEL AND URINARY SYMPTOMS?
 BLEEDING (PCB/IMB/PMB)
POST-COITAL FEATURES POSTMENOPAUSAL FEATURES INTERMENSTRUAL FEATURES
DIFFERENTIALS DIFFERENTIALS DIFFERENTIALS

ENDOMETRIAL - Risk factors: unopposed oestrogen ECTOPIC PREGNANCY - Sever, sharp, colicky abdominal
CERVICAL - Infection with HPV 16 and 18 CARCINOMA *UNTILL exposure, obesity, old age, pain in a sexually active woman
CARCINOMA - History of multiple partners, STIs, PROVEN OTHERWISE* nulliparity, late menopause and - Diarrhoea and vomiting may also
smoking, missed smears, weight loss polycystic ovarian syndrome be present
and loss of appetite - Requires urgent investigation - Rupture leads to severe pain,
- Can also present as intermenstrual peritonism and shock
bleeding - Occurs in 5-12 weeks of last period
ATROPHIC VAGINITIS - Dry, itchy vagina with subsequent
dyspareunia
- Urinary incontinence and
recurrent UTIs MISCARRIAGE - Loss of pregnancy at any stage up
CERVICAL - Squamocolumnar junction extends to the 24th week
ECTROPION under hormonal influence - Lower abdominal cramps, passing
- Red ring around cervical os on blood clots with tissue
examination ENDOMETRIAL - Exposure to high levels of
HYPERPLASIA oestrogen with insufficient levels
of progesterone
- Diagnosed on endometrial biopsy STI - Sexually active woman with
CERVICAL POLYP - May bleed on contact or curettage discharge that may be smelly
- Can also present as intermenstrual
- Significant risk factor for
development of endometrial - Risk factors  young/adolescent,
bleeding multiple partners/new partner,
carcinoma
unprotected sex

1. INVESTIGATIONS: STI screen 2. MANAGEMENT: STI Ectopic pregnancy  surgical

Abdo and pelvic examination Urgent referral for PMB or IMB/PCB is intervention
Cervical smear
PV exam Polyps  Remove and send for
BLOODS – FBC and clotting Colposcopy after abnormal smear suspicion arises from PV exam
Transvaginal USS Atrophic vaginitis  topical histology
Urine beta-hCG (pregnancy)
STI  appropriate antibiotic
Urgent USS is ectopic lubricant/cream or HRT
treatment
 RED FLAGS:
- PRIMARY AMENORRHOEA
- MENOPAUSAL SYMPTOMS <40
- NEUROLOGICAL SYMPTOMS
- GALACTORRHOEA

AMENORRHOEA/OLIGOMEN.
1. OPENING CONSULTATION: 4. PATIENT PERSEPCTIVE:
 PC – Can you tell me more about the problem
 FEELINGS & EFFECT ON LIFE // IDEAS // CONCERNS // EXPECTATION
 LMP – When did you have your last period?
 CYCLE – what were your periods like before? Were they regular? How often did they come?
How long did they last for? 5. PMH/FM:
 MENARCHE – what age were you when you had your first period?  Any previous illnesses?
 History of thyroid disease, polycystic ovarian syndrome and eating disorders
3. SYSTEMS REVIEW:  Do you know what age your mum reached her menopause?
 HYPOGONADORTOPIC HYPOGONADISM: how often do you exercise? Have you been feeling
low in mood / anxious recently? 6. DH:
 PERI-MENOPAUSE/MENOPAUSE: Have you been suffering from problems with sweating or  Has he/she been given any medications?
hot flushes recently? Has anyone commented on you being more tired or irritable recently?
Can I ask how your libido has been? Have you found sex painful?  Does he/she have any allergies?
 PCOS: Are you affected by acne? Do you find you have hair growing in unusual places? How
has your weight been? 7. SH:
 THRYOID: what has your appetite been like? Any tremor? How have your bowels been? Do  Are you working? Occupation?
you struggle with hot/cold temperatures?  Smoking? Alcohol? How much?
 HYPERPROLACTINAEMIA: have you noticed any discharge from your nipples? Have you had  Can you tell me about home situation (occupants and difficulties)
any problems with your vision?
 Has your problem affected your job or home life in any way?
 PREGNANCY: is there any chance you could be pregnant?
 CONTRACEPTION: do you use contraception? Which one? How long have you been taking
it? What were your periods like before you started taking it?
 OBSTETRIC: Do you have any children? Have you previously had any problems trying to
conceive? If so, do you know why that is?
 AMENORRHOEA/OLIGOMEN.
DDx/INV.
DIFFERENTIAL FEATURES HYPOGONADOTROPIC - low FSH and LH levels
DIAGNOSIS HYPOGONADISM - Most common cause  starvation, excessive exercise, anorexia
nervosa, depression, stress, chronic illness and marijuana use
PRIMARY AMENORRHOEA - Not reached menarche by age 16
- Most commonly constitutional delay, less commonly Turners,
testicular feminisation or PCOS MENOPAUSE - Hot flushes, irregular periods, profuse sweating, irritability, loss of
- In constitutional delay, patients mothers and sisters may also have libido, vaginal atrophy
been late in starting - Menopause occurs when periods have been absent for at least 12
months
- Premature menopause if onset before 40 years
PREGNANCY - Always ask if there is any chance they could be pregnant
- Morning sickness, abdo distension, weight gain HYPERPROLACTINAEMIA - Galactorrhoea, amenorrhoea and subfertility
- Macroprolactinomas may compress optic nerve leading to bitemporal
hemianopia
- Other causes: pregnancy, breastfeeding, stress, drugs
DRUG INDUCED - Progesterone-only contraception in particular can cause periods to
stop
- Reverses within a year upon stopping medication
1. INVESTIGATIONS: 2. MANAGEMENT:
Abdo and pelvic examination PCOS  weight loss and healthy diet, COCP,
POLYCYSTIC OVARIAN - Symptoms due to excessive amounts of andogenic hormones PV exam
SYNDROME - Hirsutism, acne, weight gain, subfertility, polycystic ovaries seen on
Pregnancy test metformin
USS
oligomenorrhoea more common BLOODS – FSH, LH, estrogen, TFTs, Hyperthyroidism  propanolol and
- Insulin resistance and therefore obesity and diabetes associated with
this prolactin carbimazole, radioiodine or surgery when
Pelvic USS medical treatment fails
MRI of head to assess for pit and Hypothyroidism  thyroxine
HYPERTHYROIDISM - Intolerance to heat, tremor, weight loss despite increased appetite, hypothalamic causes
frequent bowel movements, protruding eyes, goitre Hypogonadotropic hypogonadism  lifestyle
advice and CBT
HYPOTHYROIDISM - Intolerance to cold, dry skin, weight gain, constipation, hair thinning, Menopause  topical lubricant or HRT
feeling slowed down and menstrual irregularities
Hyperprolactinaemia  bromocriptine and
surgery
 RED FLAGS:
- DYSPAREUNIA (PAIN DURING
SEX)
- IRREGULAR VAGINAL BLEEDING

DISCHARGE - PYREXIA
- ABDOMINAL PAIN

1. OPENING CONSULTATION: 5. PMH/FM:

 PC – Can you tell me more about this discharge?  Any previous illnesses?
 Timeline – When did you first notice this? How did it start? How has it progressed since  Any history of previous cancer (breast, ovarian, endometrial, cervical)?
then?
 Previous STIs?
 Bleeding disorders?
2. SYMPTOM ANALYSIS:
 COLOUR – What color is it? Is there any blood?  PREVIOUS SMEAR
 ODOUR – does it have a particularly bad or distinctive smell?
 AMOUNT – how much discharge have you noticed?
6. DH:
 Has he/she been given any medications?
 ASSOCIATED SYMPTOMS – high temperature / sweating / headaches / pain anywhere / pain
after or during sex / itchy / rash / weight loss / appetite / tried / breathlessness  Does he/she have any allergies?
 BOWEL AND URINARY SYMPTOMS?
7. SH:
 Are you working? Occupation?
3. SYSTEMS REVIEW:
 MENSTRUAL HISTORY  Smoking? Alcohol? How much?
 PAIN  Can you tell me about home situation (occupants and difficulties)
 SEXUAL HISTORY  Has your problem affected your job or home life in any way?

4. PATIENT PERSEPCTIVE:
 FEELINGS & EFFECT ON LIFE // IDEAS // CONCERNS // EXPECTATION
 RED FLAGS:
- DYSPAREUNIA (PAIN DURING
SEX)
- IRREGULAR VAGINAL BLEEDING

DISCHARGE - PYREXIA
- ABDOMINAL PAIN

DIFFERENTIALS FEATURES
1. INVESTIGATIONS:
PHYSIOLOGICAL DISCHARGE • Clear/creamy, thin, stingy discharge
Abdominal and pelvic examination
• Amount varies but typically increases with pregnancy, COCP, around High vaginal swab for bacterial vaginosis / candida / trichomonas and
ovulation and during sexual arousal
gonorrhea
SEXUALLY TRANSMITTED INFECTION • Chlamydia – although asymptomatic, can cause purulent discharge and Endocervical swabs for gonorrhea and chlamydia
dysuria
• Trichomonas vaginalis – copious amounts of green/yellow discharge that Cervical smear test if not already performed
may smell fishy
• Neisseria gonorrhoea – often asymptomatic in women but can cause Same day referral to GUM for suspected PID or admit if systemically
purulent discharge
• HIV, syphilis, genital herpes and genital warts are not associated with vaginal unwell
discharge Urgent referral for suspected malignancy

NON-SEXUALLY TRANSMITTED • Vulvovaginal candidiasis (thrush) – thick, white discharge with an itchy, red, 2. MANAGEMENT:
INFECTION tender vagina. Associated with pregnancy / COCP / antibiotics and  Removal of foreign bodies to prevent TSS
immunodeficiency
• Bacterial vaginosis – grey/white fishy discharge predisposed to by increasing  All patients with confirmed STIs should to referred to GUM for
vaginal pH levels (sperm, menstruation, using soaps) which kills protective
lactobacilli treatment
 Trichomonas and bacterial vaginosis 0 Metronidazole 7 days
PELVIC INFLAMMATORY DISEASE • Abdominal/pelvic pain, dyspareunia, abnormal vaginal bleeding  Vulvovaginal candidiasis – Clotrimazole pessary or oral fluconazole
• May be asymptomatic, presenting later as subfertility or menstrual disorder
• History of previously known STI  Chlamydia – azihromycin stat dose or 7 day course of doxycycline
 Gonorrhoea – oral cefixime or IM ceftriaxone
FOREIGN BODY • Most common forgetting to remove tampon after menstruation  PID – 14day course of metronidazole and ofloxacin
• Foul smelling
• Can result in toxic shock syndrome  Abstinence from sex until treatment completed for patient and
partners
GENITAL TRACT MALIGNANCY • Red/brown discharge (blood) likely to be smelly
 RED FLAGS:
- SEVERE PAIN
- LARGE VOLUME OF BLOOD
- MULTIPLE PREGNANCIES
- PREVIOUS C-SECTIONS

ANTENATAL HAEMORRHAGE
- ADVANCED MATERNAL AGE
- PREVIOUS PPH

1. OPENING CONSULTATION: 4. PATIENT PERSEPCTIVE:

 PC – Can you tell me more about the bleeding?
 FEELINGS & EFFECT ON LIFE // IDEAS // CONCERNS // EXPECTATION
 TIMELINE – How did it start? How has it progressed since then?

2. SYMPTOM ANALYSIS: 5. PMH/FM:

 SITE – when and where exactly did you notice the bleeding? Is it definitely coming from the  Any previous illnesses?
vagina?  Ask about bleeding disorders, lupus, hypertension, diabetes
 ONSET – when did you first notice the bleeding?  Anyone in your family had any problems during their pregnancy?
 CHARACTER – how much have you noticed? What colour is it? Have you passed clots or
anything odd? 6. DH:
 RADIATION – have you had to use padding? Does it soak them?  Has he/she been given any medications?
 ASSOCIATED SYMPTOMS: pain  Does he/she have any allergies?
 TIMING: is the bleeding there all the time? How often have you noticed it?
7. SH:
3. CURRENT PREGNANCY:  Are you working? Occupation?
 FOETAL WELL BEING – have you felt the baby moving recently? Have you had any pain down  Smoking? Alcohol? How much?
below?
 Can you tell me about home situation (occupants and difficulties)
 LMP: when was the first day of your LMP?
 Has your problem affected your job or home life in any way?
 PROGRESS – how has the pregnancy gone previously to this? Have you been suffering from
high blood pressure, water infections or anything else?
 TESTS – what tests have been performed so far?
ANTENATAL HAEMORRHAGE
DDx/INV.
PPH DIFFERENTIALS – PREGNANCY FEATURES
RELATED 1. INVESTIGATIONS:
• ABCDE approach
PLACENTAL ABRUPTION (MOST SERIOUS) -
-
Placenta either partially or completely detaches from uterus
Painful bleeding with foetal disease
• BLOODS – FBC, cross-match and clotting
- Bleeding may be concealed and therefore not appear as • Must not perform PV examination if PA as hemorrhage can be
severe provoked, do USS to confirm
- Risk factors: smoking, trauma, previous abruption
• Pelvic USS
PLACENTA PRAEVIA - Placenta lying in the lower uterine segment • CTG: evidence of fetal distress?
- Intermittent painless bleeding of increasing intensity
- Foteal distress is not common but can occur with 2. MANAGEMENT:
complications
- Risk factors: smoking, increasing age, obst. complications • Resuscitation if required (100% oxygen, large bore cannula and
fluids)
• Analegsia?
PPH DIFFERENTIALS – NON- FEATURES • Prophylactic anti-D immunoglobulin for RH-NEG
PREGNANCY RELATED • Admission until delivery by c-section at 39weeks
• Urgent c-section is fetal distress of severe bleeding
CERVICAL ECTROPION - Common in pregnancy
- Red ring around cervical os on examination

CERVICAL POLYP - Bleeding may occur postcoitally or anytime

CERVICAL CANCER - Bleeding may occur postcoitally

- History of multiple partners, STIs, smoking, missed smears,
weight loss, loss of appetite
 RED FLAGS:
- SEVERE PAIN
- 5-12 WEEKS SINCE LMP
- WEIGHT LOSS
- POSTMENOPAUSAL BLEEDING

POST-MENOPAUSAL BLEED
- INTERMENSTRUAL BLEEDING
- POSTCOITAL BLEEDING
- MISSED CERVICAL SMEARS

1. OPENING CONSULTATION: 4. PATIENT PERSEPCTIVE:

 PC – Can you tell me more about this bleeding?
 FEELINGS & EFFECT ON LIFE // IDEAS // CONCERNS // EXPECTATION
 Timeline – When did you first notice this? How did it start? How has it progressed since
then?
5. PMH/FM:
2. SYMPTOM ANALYSIS:  Any previous illnesses?
 SITE – when and where exactly did you notice this bleeding? Is it definitely coming from the  Any history of previous cancer (breast, ovarian, endometrial, cervical)?
vagina?
 Previous STIs?
 ONSET – when did you first notice it?
 Bleeding disorders?
 CHARACTER – how much have you noticed? Have you passed any clots? What colour is it?
 RADIATION – do you use tampons or passing? Does it soak them?
6. DH:
 ASSOCIATED SYMPTOMS  Has he/she been given any medications?
 TIMING – when do you notice the bleeding? Is it there all the time? How often have you  Does he/she have any allergies?
noticed it? Could it be your period? Does it occur mid-cycle? Does it come on after sex?

7. SH:
3. SYSTEMS REVIEW:  Are you working? Occupation?
 MENSTRUAL HISTORY
 Smoking? Alcohol? How much?
 PAIN
 Can you tell me about home situation (occupants and difficulties)
 SEXUAL HISTORY
 Has your problem affected your job or home life in any way?
 VAGINAL DISCHARGE
 OBSTETRIC HISTORY
 CONSTITUTIONAL – have you felt feverish / weight loss / appetite / tired / breathless
POST-MENOPAUSAL BLEED
DDx/INVES.
POSTMENOPAUSAL FEATURES 1. INVESTIGATIONS:
DIFFERENTIALS
Abdominal and pelvic examination – feel for any masses
ENDOMETRIAL CARCINOMA - Risk factors: unopposed oestrogen PV examination – confirm PV bleed, look for patholgogy
*UNTILL PROVEN OTHERWISE* exposure, obesity, old age, nulliparity, late
menopause and polycystic ovarian Bloods – FBC and clotting
syndrome Colposcopy if abnormal smear
- Requires urgent investigation
Transvaginal USS
ATROPHIC VAGINITIS - Dry, itchy vagina with subsequent
dyspareunia
- Urinary incontinence and recurrent UTIs 2. MANAGEMENT:
• Urgent referral if suspicion arises frm PV exam
ENDOMETRIAL HYPERPLASIA - Exposure to high levels of oestrogen with • ATROPHIC VAGINITIS – topical lubricant/cream or HRT (topical
insufficient levels of progesterone or systemic)
- Diagnosed on endometrial biopsy or
curettage
- Significant risk factor for development of
endometrial carcinoma
 RED FLAGS:
- SEVERE PAIN
- 5-12 WEEKS SINCE LMP
- WEIGHT LOSS
- POSTMENOPAUSAL BLEEDING

ACUTE ABDO/BLEED - ECTOPIC

- INTERMENSTRUAL BLEEDING
- POSTCOITAL BLEEDING
- MISSED CERVICAL SMEARS

1. OPENING CONSULTATION: WIPE 5. PMH/FM:

Concerns – about pregnancy so far? // how far along are they?  Any previous illnesses?
 Any history of previous cancer (breast, ovarian, endometrial, cervical)?
2. SYMPTOM ANALYSIS:
 Previous STIs?
 PAIN SOCRATES (1st trimester = ectopic/miscarriage), 27-40w = labor/false
labor/preterm labor. Less than 37 weeks = uterine rupture / placental  Bleeding disorders?
abruption. Others = appendicitis / cholecystitis / GORD / UTI /  Any twins?
gastroenteritis
 BLEEDING ONSET / FREQUENCY / VOLUME / PAIN  less than 24 weeks = 6. DH:
miscarriage, ectopic. More than 24w = antepartum hemorrhage / placental  Has he/she been given any medications? Any folic acid??
abruption / PP / uterine rupture
 Does he/she have any allergies?
 ASSOCIATED SYMPTOMS  SOB/ANAEMIA / MORNING SICKNESS /
INDIGESTION / URINARY FREQUENCY / INFECTIONS / BREAST TENDERNESS /
BP / SUGAR LEVELS 7. SH:
 Are you working? Occupation?
3. PMH:  Smoking? Alcohol? How much?
 SCANS IN PREGNANCY – NORMAL?  Can you tell me about home situation (occupants and difficulties)
 OBSTETRIC HISTORY – ANY PREVIOUS PREGNANCIES / TERMINATIONS /  Has your problem affected your job or home life in any way?
MISCARRIAGES / STILL BIRTHS / GESTATION AND MODE OF DELIVERY /
COMPLICATIONS? C-SECTIONS? BIRTH WEIGHTS? RHESUS STATUS?
 GYNAE HX – SMEAR
 PMH: THALASSAEMIA / SICKLE CELLS
ACUTE ABDO/BLEED – ECTOPIC
INV.
INTERMENSTRUA FEATURES 1. INVESTIGATIONS:
L DIFFERENTIALS HISTORY – pain, shoulder tip pain, vaginal bleeding, dizziniess / history of gynae surgeries/ dmage
to fallopian tubes / previous ectopic / endometriosis / progesterone only pill / IUCD / IVF
ECTOPIC PREGNANCY - Sever, sharp, colicky abdominal Observations – may show signs of hypovolemic shock
pain in a sexually active woman Examination – tender abdomen
- Diarrhoea and vomiting may also PV exam – cervical excitation, adnexal tenderness
be present USS
- Rupture leads to severe pain,
peritonism and shock Bloods: serum HCG levels
- Occurs in 5-12 weeks of last
period 2. MANAGEMENT: for ectopic
Conservative management
• Those who have a PUL with minimal or no symptoms and are clinically stable
MISCARRIAGE Medical management – hCG < 1500, no heart beat, enruptured, no significant pain
• The patient should have no significant pain, an unruptured ectopic pregnancy with adnexal mass
PID smaller than 35mm with no visible heartbeat
• Serum hCG level must be less than 1500 IU/L
PLACENTA PRAEVIA - Low lying placenta. More • Methotrexate (folate antagonist)
common in multiparous, • Requires follow up as there is a small risk of rupture
increased age. Can present with • Conservative management  only is asymptomatic / failing HCG
PV bleeding. Surgical management – hCG > 5000, significant pain, large adnexal mass, fetal heartbeat visible
• Anti-rhesus D prophylaxis
PLACENTAL - Placenta seperates from uterine • Serum HCG of 5000 IU/L or more
ABRUPTION wall. Dark, painful antepartum • Laparoscopic salpingectomy
haemorrhage. Can be concealed • Laparoscopic salpingotomy
(cant see blood) Uterus will be
tender and contracted • Laparotomy
INFERTILITY
1. OPENING CONSULTATION: • DH: contraception? Smear result?
• Check patient details, check partner details • PFMH: anyone in family struggle to convince?
• Explain that you will take a history from both of them and then decide on management plan • SH: what do you work as, do you need to travel away? // smoking?
and next steps in investigations
• Systemic review – noticed change in weight? Hair in unusual places? Bowels and water
• OPEN QUESTION – can you tell me more about the problem?
works? Appetite? Exercise?

2. PATIENT PERSEPCTIVE: 5. HISTORY FROM MALE:

 FEELINGS & EFFECT ON LIFE // IDEAS // CONCERNS // EXPECTATION
◦ Occupation
◦ Previous STIS
3. SEX LIFE HISTORY:
◦ Previous MUMPs infection
• I have to ask a few personal questions, but just to reassure you, they will remain strictly
confidential. Is this okay? ◦ Any other children from other pregnancies?
• How long have you been trying for a baby? ◦ PMH: testicular torsion, vasectomy, trauma, mumps, STIs
• Are you married? Do you live together? How long for? ◦ PFMH: anyone in family struggle to conceive?
• Do you have regular sex? How often/week? ◦ SH: smoking or alcohol?
• TYPE: Can I check that you mean penetrative vaginal sexual intercourse? ◦ Any other children with other people?
• PROBLEMS: Do either of you have any problems during sex? Any pain? Any bleeding after
sex? Are there any anxieties around sex *one to one question if possible* 6. SH:
 Can you tell me about home situation (occupants and difficulties)
4. HISTORY FROM FEMALE:  Has your problem affected your job or home life in any way?
• MENSTRUAL HISTORY: LMP, menopause age, menarche. Cycle
length/regular/pain/heaviness
• OBSTETRIC HISTORY: children, miscarriages, pregnancy complications, birth complications,
type of delivery
• PMH: PCOS / MISCARRAIGES / STIS / GYNAE SURGERIES / PREVIOUS CANCER
 INFERTILITY DDx/INV.
DIFFERENTIAL DIAGNOSIS FEATURES
1. INVESTIGATIONS:
Abdominal and bimanual examinatoin
GENERAL CAUSES - Not having regular satisfactory and penetrative sex Testicular examination for varicocoeles
- Dyspareunia Serum progesterone levels on day 21 of menstrual cycle to assess
- Psychosexual issues
- Partner away for large periods of time ovulation
- Premature ejaculation before penetration achieved TFT, prolactin
- Recreational drugs, alcohol, smoking
Semen analysis may reveal low sperm count or poor motility
Pelvic USS
FEMALES CAUSES - Age  female fertility tends to decrease after mid-30s Hysterosalpinogram
- Being overweight
- Systemic conditions such as SLE
- Pelvic surgery 2. MANAGEMENT:
- Ovulatory disorders  PCOS // hyperprolactinaemia // thyroid disorders // • Support and reassureance and advice on the need for regular
premature menopause // hypogonadotrophic hypogonadism
- Tubal pathology  pelvic inflammatory disease // endometriosis sexual intercourse
- Uterine pathology  fibroids // uterine abnormalities • Manage problems with weight, smoking, alcohol and drugs
• Consider psychotherapy for those with psychosexual issues
MALE CAUSES - Testicular trauma • Clomiphene to stimulate ovulation
- Testicular torsion
- Bilateral undescended testicles • IVF
- Systemic conditions • Adoption
- Chemotherapy
- Mumps and orchitis
- Gonorrhoea and chlamydia
- Retrograde ejaculation
UROGYNAE - STRESS
INCONTINENCE
1. OPENING CONSULTATION:  GUT (men) – prolonged dribbling? Feel like there is still some left?
 PC – Can you tell me more about this problem?  OBSTETRIC (women) – how many children / pregnancies / complications
 Timeline – When did you first notice this? How did it start? How has it progressed since  PROLAPSE (women) – do you have a heavy dragging sensation? Have you noticed anything
then? protruding from there when you cough?

2. SYMPTOM ANALYSIS: 4. PATIENT PERSEPCTIVE:

 ONSET – how long has it been going on for?  FEELINGS & EFFECT ON LIFE // IDEAS // CONCERNS // EXPECTATION
 FREQUENCY – How often do you pass water in a day? More than 6 times?
 NOCTURIA – how many times do you go at night? More than twice? 5. PMH/FM:
 AMOUNT – how much water do you pass each time? Small or large amounts?  Any previous illnesses?
 URGE – do you ever get a strong urge to go all of a sudden? Have there been times where  Any history of previous cancer (breast, ovarian, endometrial, cervical)?
you feel like you wouldn’t be able to make it?  Previous STIs?
 STRESS – have you noticed any leaks when straining, coughing or walking?  Bleeding disorders?
 PADS – do you use pads to help keep yourself dry? How many do you use in a day? What
type of pad? 6. DH:
 ACCESS – do you have access to a toilet all the time Do you always make sure you know  Has he/she been given any medications? Any water tablets?
where the toilets are when you are going out?  Does he/she have any allergies?

3. SYSTEMS REVIEW: 7. SH:

 HAEMATURIA  Are you working? Occupation?
 PAIN – any pain when passing water, any pain in abdomen, any new back pain?  Drinking coffee / tea/ fizzy drinks?
 CONSTIPATION  Drink anything before going to bed?
 NS: any muscle weakness  Smoking? Alcohol? How much?
 CONSTITUATIONAL: do you feel ill or feverish? Any weight loss? Do you have pains in your  Can you tell me about home situation (occupants and difficulties)
bones?  Has your problem affected your job or home life in any way?
 UROGYNAE - STRESS
INCONTINENCE
DIFFERENTIAL DIAGNOSIS FEATURES
1. INVESTIGATIONS:
STRESS INCONTINENCE - Weak/damaged pelvic floor or anal sphincter WOMEN:
- Risk factors – multiparty, complications of vaginal delivery, - Abdo exam
surgery, perineal tear, epistotomy - PV exam
- Urine dipstick and MSU
- Urodynamic studies
- Urgent referral if hematuria
MEN:
- Abdo exam
URGE INCONTINENCE - BPH or prostatic carcinoma  common in elderly males, urinary - DRE
symptoms of hesitancy, intermittency, weak stream, terminal - Bloods: FBC, LFT, U&, bone profile
dribbling, feeling of incomplete bladder emptying. Bone pain, - PSA
weight loss, jaundice - Urodynamic study
- Autonomic neuropathy  diabetes
- Urgent USS
- Infection  local irritation leads to urinary symptoms.
- Stool impactation - MRI

2. MANAGEMENT:
• Conservative – lifestyle advice (cut down caffeine, no fluids
before bed, smoking cessation, pelvic floor exercises (3x a day, 3
months, can get physio involved)
• Medication – duloxetine
• Surgery – retropubic mid-urtheral tape, colposuspension
PAEDIATRICS
GENERAL PAEDS HISTORY ASK FOR RED BOOK!
Headaches/ Irritable /
1. TRAFFIC LIGHT SYSTEM: Fever / More tired 3. FEEDING HISTORY (INFANTS & TODDLERS):
 Colour  ‘Does he/she look more Changes in vision  BOTTLE/BREAST  ‘At what age did you start bottle/breast feeding? Details of feed’
pale than usual?’  WEANING  ‘At what age were solids introduced? Was there any difficulty weaning?
Pulling at ear
 Activity  ‘Are they playing and  FEEDING PATTERN  ‘what does he/she eat? Any trouble with certain foods?’
interacting as normal?/more tired Cough / sputum /
than normal?’ vomiting (colour,
projectile)
 Resp  ‘Have you noticed any 4. DEVELOPMENT HISTORY:
difficulty with your child's SOB / wheeze  CONCERNS  ‘Any concerns with how your child is developing?’
breathing?’  MILESTONES ‘Has he/she met all her developmental milestones so far?’ Take full developmental
 Hydration/circulation  ‘how are history if appropriate, otherwise just check a few eg-
they feeding? Are they drinking as Pain / diarrhoea  GROSS MOTOR: when did he/she start walking?
much as usual? Are they having as
 SPEECH & LANGUAGE: when did he/she say their first word?
many wet nappies as normal?
 Other  ‘Have they felt hot? Have Increased/reduced
they had any recorded urine / blood in
5. IMMUNISATION HISTORY:
temperature? Any rashes?’ Rash / pale stools / pain  ‘Has he/she had all their immunisations so far?’
 ‘When was their last one? What was it for?
2. PREGNANCY AND BIRTH HISTORY: ASK ABOUT RECENT TRAVEL
 PRENATAL  ‘Any maternal illnesses during pregnancy (diabetes/pre-
eclampsia/infections?’ Have you (mother) ever smoked, taken drugs or
alcohol during pregnancy? Any complications during pregnancy or
• Make sure to establish who you’re speaking to (mum/dad/aunt)
labor? • Make sure you know the age of child
 NATAL  ‘Was it a normal delivery, assisted or c section? Did the • Adapt history for child’s age and situation
pregnancy reach term? What was his/her birth weight?’ • In FH, look for pattern of inheritance and consider drawing family tree
 POSTNATAL ’Was the child well? Did he/she require admission?’ • Consider whether there is any consanguinity
 WHEN DID THEY PASS MECONIUM? *failure to do so = cystic fibrosis • Take a detailed social history  home, school & social environment
and Hirshsprung disease*
 RED FLAGS:

BREATHLESS BABY
1. OPENING CONSULTATION: 5. PMH/FM:
 Establish child name and age. Who is with them
 TRAFFIC LIGHT SYSTEM: colour / activity / resp / hydration / other (rashes)
 PC – Can you tell me more about his/her breathlessness? What exactly do you mean by
breathlessness?  FEEDING HISTORY

 Timeline – When did you first notice this? How long has it been going on for? How has it  PREGNANCY & BIRTH HISTORY
progressed (better/worse/stayed the same?)  DEVELOPMENTAL HISTORY
 Any previous illnesses?
2. SYMPTOM ANALYSIS:
 Cerebral palsy, tuberous sclerosis, previous meningitis run in the family?
 SEVERITY– Is it there all the time or does it come and go?
 RELEVING FACTORS– does anything make it better? Sitting up?
6. DH:
 EXACERBATING FACTORS – Have you noticed anything making it worse? Cold air/pets  Has he/she been given any medications?
 ORTHOPNOEA/PND– Has it been effecting their sleep? More/less than usual?  Does he/she have any allergies?
 Any COUGH / PHLEGM / RUNNY NOSE / WHEEZE / CHEST / CRYING / TEMPERATURE / MORE  IMMUNISATIONS
TIRED / FLOPPY

7. SH:
3. SYSTEMS REVIEW:  Who is at home? Are you still with his/her mother/father?
 GIT: What are his/her stools like? Does he/she complain of any tummy ache?
 Does he/she have any siblings?
 URINE: Have they wet/soiled nappies as normal?
 Does anyone smoke at home?
 SCALES: Is he/she growing normally? Has he/she been gaining weight?
 How are things at home?

4. PATIENT PERSEPCTIVE:  Is the child at nursery/school/playgroup? How are things there?

 FEELINGS & EFFECT ON LIFE // IDEAS // CONCERNS // EXPECTATION  Has anyone at school or home had similar symptoms?
 BREATHLESS BABY Dx/INVEST.
DIFFERENTIAL DIAGNOSIS FEATURES
1. INVESTIGATIONS:
BRONCHIOLITIS - Coryzal symptoms (sore throat/runny nose/cough) Basic observations / A-E approach
- Wheeze Urine dipstick, BM
- Nasal flaring Chest, abdo and neuro exam
- Chest in drawing
- Poor feeding ABG – check lactate level and acidosis
CONGENITAL HEART DISEASE - Breathless on feeding FBC: anaemia, infection, U&Es (dehydration), LFTs (metabolic
- Sleepy disorders), CRP
- Poor feeding Ammonia (inborn error of metabolism)
- Blue in colour
- Floppy LP (under 3 and not very well)
- Poor growth X-ray if resp sx / suspected CHD
- hepatomegaly
ECH if tachy
DKA - Rapid breathing ECHO is suspected CHD
- Hx increased wet nappies & thirst
- Drowsy 2. MANAGEMENT:
INBORN ERRORS OF METABOLISM - Jaundice
- Poor feeding
- Consanguineous parents (related)
- History of babies ill in early life

SEPSIS/ OTHER INFECTION - UTI

ASTHMA
PNEUMONIA
BREATHLESS HISTORY
Look out for:
• Fever
• Cough
• Breathlessness
• Signs of infection – colored phlegm
INVESTIGATIONS
 CXR
 FBC, CRP
 Blood culture and nasopharyngeal aspirate (NPA) for viral isolation and PCR
MANAGEMENT:
• Penicillin first line in most children
• Cefurozime and flucloxacillin in severe illness
 RED FLAGS:
-

COUGH
1. OPENING CONSULTATION: 5. PMH/FM:
 Establish child name and age. Who is with them
 TRAFFIC LIGHT SYSTEM: colour / activity / resp / hydration / other (rashes)
 PC – Can you tell me more about his/her cough?
 FEEDING HISTORY
 Timeline – When did you first notice this? How long has it been going on for? How has it
progressed (better/worse/stayed the same?) Can you describe the cough for me? (barking =  PREGNANCY & BIRTH HISTORY
croup)  DEVELOPMENTAL HISTORY
 Any previous illnesses?
2. SYMPTOM ANALYSIS:
 Previous chest infections?
 SEVERITY– Is it there all the time or does it come and go? Does it vary on time of day?
 History of asthma, eczema or hay fever?
 RELEVING FACTORS– does anything make it better?
 EXACERBATING FACTORS – Have you noticed anything making it worse? Fur/cold air
6. DH:
 ORTHOPNOEA/PND– Has it been effecting their sleep? More/less than usual?  Has he/she been given any medications?
 Any NOISY BREATHING / SOB / PHLEGM / RUNNY NOSE / CHANGE IN VOICE / ARE THEY  Does he/she have any allergies?
ABLE TO SWALLOW / DROOLING / TEMPERATURE / MORE SLEEPY
 Immunisations

3. SYSTEMS REVIEW:
 GIT: What are his/her stools like? Does he/she complain of any tummy ache?
7. SH:
 Who is at home? Are you still with his/her mother/father?
 URINE: Have they wet/soiled nappies as normal?
 Does he/she have any siblings?
 SCALES: Is he/she growing normally? Has he/she been gaining weight?
 Does anyone smoke at home?

4. PATIENT PERSEPCTIVE:  How are things at home?

 FEELINGS & EFFECT ON LIFE // IDEAS // CONCERNS // EXPECTATION  Is the child at nursery/school/playgroup? How are things there?
 Has anyone at school or home had similar symptoms?
 COUGH Dx/INVEST.
DIFFERENTIAL DIAGNOSIS FEATURES
1. INVESTIGATIONS:
BRONCHIOLITIS - Coryzal symptoms (sore throat/runny nose/cough) Basic observations / A-E approach
- Wheeze Chest exam – check for chest in drawing, sternal recession, nasal
- Nasal flaring flaring
- Chest in drawing
- Poor feeding AVOID SPATULA EXAM OF THROAT INCREASE OF EPIGLOTTITIS
EPIGLOTTITIS - Sudden onset difficulty breathing CXR is pneumonia suspected
- Drooling a lot Sputum culture if phlegm present
- High fever Spirometry, FeNO study and PEFR diary if suspected asthma
CROUP - Hoarseness
- Barking cough 2. MANAGEMENT:
- Harsh stridor
- Difficulty breathing 6 months – 3 years  Bronchiolitis – conservative management
ASTHMA - Wheeze
- Phlegm  Epiglottitis – no action should be taken that could stimulate a child
- SOB
- Hx of atopy in family/child with suspected epiglottitis. Do not lay flat. O2 mask + intubation. IV
- Diurnal/day-to-day variability ceftriaxone and dexamethasone. Prophylactic rifampicin to close
household contacts
PNEUMONIA - Sputum
- SOB
- Tummy pain  Croup – 1 dose dexamethasone, conservative management
- Fever
PERTISSOS (WHOOPING COUGH) - Cough with inspiration  Asthma – salbutamol inhaler plus very low dose ICS (initial
- Whooping sound treatment)
 Pneumonia – antibiotics
 Group B strep (b for baby)
 Treatment: amoxicillin + 4/6 weeks CXR follow up
ASTHMA MANAGEMENT
ASTHMA MANAGEMENT - ACUTE
 RED FLAGS:
- NECK STIFFNESS
- PHOTOPHOBIA
- NON-BLANCHING RASH
- FOREIGN TRAVEL

FEVER - DRENCHING NIGHT SWEATS

- BLEEDING/BRUISING TENDENCY

1. OPENING CONSULTATION: 5. PMH/FM:

 Establish child name and age. Who is with them
 TRAFFIC LIGHT SYSTEM: color / activity / resp / hydration / other (rashes)
 PC – Can you tell me more about his/her fever? What do you mean exactly when you save
fever? How high exactly was the fever?  FEEDING HISTORY

 Timeline – When did he/she first become unwell? What did you notice at the time? How  PREGNANCY & BIRTH HISTORY
have things progressed since then?  DEVELOPMENTAL HISTORY
 OTHER SYMPTOMS – how is your child feeling generally? Pain? Any night sweats? Are they  Any previous illnesses?
behaving differently?
 Ask about previous infections

3. SYSTEMS REVIEW:
 HAEMATOLOGICAL: Have you noticed any bruising or bleeding? If he/she getting recurrent
6. DH:
infections? Has he/she been more tired than normal?  Has he/she been given any medications?
 CV/RS: Has he/she had a cough? Can you describe it? Have you noticed any wheeze or other  Does he/she have any allergies?
strange sounds with his/her breathing? Any sputum? Any chest pain?
 GIT: What does his/her stools look like? Any vomiting or diarrhea? 7. SH:
 GUT: Has he/she been complaining of any burning pains when passing urine?  Who is at home? Are you still with his/her mother/father?
 NS: Does he/she have a headache? Any neck stiffness? A rash?  Does he/she have any siblings?
 CONSTITUTIONAL: Has he/she been abroad recently? Any insect bites? Is he/she growing  Does anyone smoke at home?
well? Lost any weight?  How are things at home?
 Is the child at nursery/school/playgroup? How are things there?
4. PATIENT PERSEPCTIVE:
 Has anyone at school or home had similar symptoms?
 FEELINGS & EFFECT ON LIFE // IDEAS // CONCERNS // EXPECTATION
 FEVER Dx/INVEST.
DIFFERENTIAL DIAGNOSIS FEATURES
1. INVESTIGATIONS:
UPPER RESPIRATORY TRACT INFECTION - General coryzal symptoms (dry cough, headache, sore throat) Physical examination (ENT, CVS, RS, abdo, neuro)
- May develop earache and otitis media secondary to this (esp if under 6years) Re-measure temperature
No investigations usually necessary to diagnose bronchiolitis or
MENINGITIS - Unwell, irritable, drowsy, headache, photophobia, weak/high pitched cry croup
- Non-blanching rash and seizures
- Can present differently Chest x-ray if pneumonia is likely and unwell
Urine microscopy and MSU if no obvious score found / UTI
UTI - Abdominal pain
suspected
- May have dysuria and strong-smelling urine CT head and lumbar puncture if meningitis suspected
- Irritability and poor feeding
2. MANAGEMENT:
BRONCHIOLITIS - Common viral illness seen in the first year of life
- Raspy cough, wheeze, coryzal symptoms and fever
- Less wet nappies, poor feeding and grunting sounds indicate severe infection  URTIs  self limiting so give parental advise like monitor
temperature. Give paracetamol and fluids
CROUP - Viral illness causing a barking cough with stridor and coryzal symptoms
- Commonest in first few years of life and usually self-limiting, worse at night  Suspected Meningitis  Urgent admission for IV cephalosporins
- Can cause airway obstruction
 Bronchiliotis  may require admission for supportive management
KAWASAKI’S DISEASE - Fever longer than 5 days
- Injected pharynx/cracked lips/strawberry tongue , conjuctival injection, change in extremities,  Croup  single dose dexamethasone, admit if resp distress
polymorphous rash, cervical lymphadenopathy
OTHERS - Tonsillitis  sore throat and fever  UTI and pneumonia  antibiotics
- Otitis media  otalgia (or infant pulling at ear), decreased hearing
- Pneumonia  productive cough, fever, unwell with grunting sounds  Otitis media and tonsillitis  self-limiting but antibiotics are
- Epiglottitis  drooling, unwell, soft stridor, severe sore throat , not had Hib vaccination required in some circumstances
- Septic arthritis/osteomyelitis  limb/joint swelling, not using extremities/weight bearing
 Epiglottitis and septic arthritis require urgent admission for IV
antibiotics
 RED FLAGS:
• CHRONIC DIARRHOEA
• DEVELOPMENTAL DELAY

FAILURE TO THRIVE
• REGRESSION (WEIGHT LOSS)

1. OPENING CONSULTATION: 5. PMH/FM:

 Establish child name and age. Who is with them  TRAFFIC LIGHT SYSTEM: colour / activity / resp / hydration / other (rashes)
 FEEDING HISTORY
2. SEQUENCE OF EVENTS AND SYMPTOM ANALYSIS :  PREGNANCY & BIRTH HISTORY
 OPEN QUESTION – Can you tell me more about what's been going on?
 DEVELOPMENTAL HISTORY
 CLARIFY – are you concerned about their height, weight or both?
 Any previous illnesses?
 TIMELINE – when did you first notice this? How has it progressed since then? Has he/she
 How has he/she been before this episode?
always been a small child? What was his/her birth weight? How has his/her growth been
since birth? Has he/she been putting on any weight/height? Has he/she lost any weight?  Coeliac disease, cystic fibrosis and diabetes run in the family?

3. SYSTEMS REVIEW: 6. DH:

 Has he/she been given any medications?
 GIT: What are his/her stools like? Does he/she complain of any tummy ache? Any diarrhea?
Any vomiting?  Does he/she have any allergies?
 RS: Has he/she had a cough? If so, how long? Does he/she bring anything up?  IMMUNISATIONS
 INFECTION: Has he/she had any recurrent infections?
7. SH:
4. PATIENT PERSEPCTIVE:  Who is at home? Are you still with his/her mother/father?
 FEELINGS & EFFECT ON LIFE: What effect has his had on their school and home life?  Does he/she have any siblings?
 IDEAS: Do you have any ideas yourself about what may be causing the vomiting?  How are things at home?
 CONCERNS: Is there anything you are particularly concerned about?  Is the child at nursery/school/playgroup? How are things there?
 EXPECTATIONS: Was there anything in particular you were hoping for when you made the  Has anyone at school or home had similar symptoms?
appointment for today?
 FAILURE TO THRIVE DX/INVEST.
DIFFERENTIAL DIAGNOSIS FEATURES 1. INVESTIGATIONS:
 Physical examination including cardiac murmurs, resp (wheeze/creps), abdo
(masses), neuro (CN and limbs)
PRENATAL - Prematurity, maternal malnutrition, congenital infections, intrauterine growth
restrictions and toxin exposure in-utero (alcohol, smoking, drugs)  Plot measurements on growth and weight centile charts
 Observe child feeding
INTAKE ISSUES - Inability to suck or swallow in neuromuscular disorders (cerebral palsy)
- Cleft palate, long-standing GORD or vomiting after feeds  Bloods: FBC, U&Es, TFTs, LFTs, glucose
 Urinalysis and urine culture
MALABSORPTION - Diarrhoea will be a prominent feature – note when it occurs  Stool culture for ova/parasites/cysts and fecal fat for malabsorption
- Cystic fibrosis – cough with sputum, URTI
- Coeliac disease (when solids introduced), IBD, cow’s milk intolerance and  Anti-gliadin and anti-endomysial autoantibodies for coeliac disease
unspecified chronic diarrhoea can also cause malabsorption
 Sweat test for CF
METABOLIC DISORDERS - Poor metabolism in hypothyroidism and diabetes
- Increased metabolic demand in hyperthyroidism, heart failure and renal failure 2. MANAGEMENT:
CONSTITUTIONAL DELAY - Genetic predisposition (short parent, short child)  General  provide suitable feeding environment, parent education on
- No other issues in history feeding requirements
INADEQUATE FEEDS - Not being fed enough or often enough  Multidisciplinary approach may be required
- Distractions at meal time
- Poor breastfeeding technique
- Bottle feeds not made up correctly
- Could be due to lack of knowledge/supervision or child neglect
- Contributing factors include lack of support and problems in home
environment
 RED FLAGS:
• PROJECTILE VOMITING
• BLOOD IN VOMIT
• BILE IN VOMIT (GREEN)

VOMITING
1. OPENING CONSULTATION: 5. PMH:
 Establish child name and age. Who is with them  How has he/she been before this episode?
 PC – Can you tell me more about his/her vomiting?  TRAFFIC LIGHT SYSTEM: colour / activity / resp / hydration / other (rashes)
 Timeline – When did he/she start vomiting? How has it progressed since then?  FEEDING HISTORY
 PREGNANCY & BIRTH HISTORY
2. SYMPTOM ANALYSIS:  DEVELOPMENTAL HISTORY
 APPEARANCE – What colour is the vomit? (blood/bile/milky)
 Any previous illnesses?
 PROJECTION – Does it hit the wall? (projectile/regurgitation/posseting)
 TIMEING – Is there any particular time when the vomiting starts? Any relation to feeding? 6. DH:
How does he/she feel afterwards? Is he/she hungry for more food?  Has he/she been given any medications?
 EXACERBATING FACTORS – Does anything bring the vomiting on? Is it worse when the child
 Does he/she have any allergies?
is lying down or sitting up? Does anything help?
 IMMUNISATIONS
3. SYSTEMS REVIEW:
 GIT: What are his/her stools like? Does he/she complain of any tummy ache? 7. SH:
 URINE: Have you noticed any strange/offensive smell in his/her urine? Has he/she  Who is at home? Are you still with his/her mother/father?
complained of any pain?  Does he/she have any siblings?
 SCALES: Is he/she growing normally? Has he/she been gaining weight?  How are things at home?
 Is the child at nursery/school/playgroup? How are things there?
4. PATIENT PERSEPCTIVE:  Has anyone at school or home had similar symptoms?
 FEELINGS & EFFECT ON LIFE: What effect has his had on their school and home life?
 IDEAS: Do you have any ideas yourself about what may be causing the vomiting?
 CONCERNS: Is there anything you are particularly concerned about?
 EXPECTATIONS: Was there anything in particular you were hoping for when you made the
appointment for today?
 VOMITING DX/INVEST.
DIFFERENTIAL DIAGNOSIS FEATURES 1. INVESTIGATIONS:
 Physical examination (if GORD / gastroenteritis no further inv. needed)
REFLUX - Very common in first year of life due to functional immaturity of lower
oesophageal sphincter  U&Es (look for signs of dehydration)
- Recurrent regurgitation and vomiting related to feeds, relieved by sitting up  Pyloric stenosis - test feed, feeling for olive-shaped mass in epigastrium
- Child can be distressed after feeding and looking for visible peristalsis, USS to confirm
- Other risk factors: premature delivery and cerebral palsy
 Intussusception – USS abdomen and barium enema
PYLORIC STENOSIS - Peak age 2-7 weeks  Coeliac disease – tissue transglutaminase autoantibodies, duodenal biopsy
- Projectile vomiting straight after feed to confirm
- Child remains hungry after vomiting  Meningitis – neuro exam and look for rash, lumbar puncture (CT head
- Complications: dehydration, constipation, failure to thrive
first), blood cultures and blood glucose
INTUSSUSCEPTION - Peak age 5-10 months
- Colicky abdominal pain around every 10-20 mins, indicated by child drawing 2. MANAGEMENT:
knees into chest and inconsolable crying
- Early  vomiting which rapidly becomes bile stained  Rehydration  with oral intake if mild-moderate, IV fluids if severe (usually
- Later  mucus and blood per rectum (redcurrant jelly stools) all that is required for GORD and gastroenteritis)
COELIAC DISEASE - Peak age 9months – 3 years (after weaning)
- Vomiting, pallor, steatorrhea, abdominal distension and failure to thrive  Pyloric stenosis  pyloromyotomy

MENINGITIS - Vomiting – will not take feeds  Intussusception  air enema/barium enema if diagnosed early, otherwise
- Fever, irritable or lethargic surgery
- Non-blanching purpuric rash
- Cold extremities
- Signs of increased intracranial pressure (bulging frontanelle)  Coeliac disease  lifelong gluten-free diet

GASTROENTERITIS - Diarrhoea and vomiting  Meningitis  antibiotics (benzylpenicillin IM initially and cefotaxime IV) in
- Fever, irritable and unwell bacterial meningitis, antipyretics and analgesia in viral meningitis
- History of recent travel
- There may be someone in family with similar symptoms

IBD (crohns in younger children, ulcerative colitis in

9y+)
PYLORIC STENOSIS (vomiting)
VOMITING HISTORY
Look out for:
 Projectile vomiting straight after feed
 Child remaining hungry after vomiting
 Signs of dehydration, constipation and failure to thrive

INVESTIGATIONS
 Palpation of hypertophied pylorus during feeding test – peristaltic waves might be
visible
 Ultrasound of abdomen to confirm
MANAGEMENT:
• Medical  correction of fluid and electrolyte abnormalities *vital before surgery*
• Surgical pyloromyotomy
 RED FLAGS:
• AGE <5
• WEIGHT LOSS/DYSPHAGIA/VOMITING
• NOCTURNAL SYMPTOMS

ABDO PAIN • RIF PAIN

• BLOOD IN STOOLS

1. OPENING CONSULTATION: 5. PMH:

 Establish child name and age. Who is with them  How has he/she been before this episode?
 PC – Can you tell me more about this tummy pain?  TRAFFIC LIGHT SYSTEM: color / activity / resp / hydration / other (rashes)
 Timeline – When did you first notice that they had tummy pain?  FEEDING HISTORY
 PREGNANCY & BIRTH HISTORY
2. SYMPTOM ANALYSIS:
 DEVELOPMENTAL HISTORY
 SOCRATES
 Any previous illnesses?
 Does the pain wake him/her up at night?
 Vomiting? Color (green/red – Mallory-weiss tear). Diarrhea (colitis). Mucus (IBD)
6. DH:
 Water works: in control? (UTI)  Has he/she been given any medications?
 Eating and drinking okay?  Does he/she have any allergies?
 Infective symptoms: fever, food poisoning, travel, pets, anyone with similar symptoms?  IMMUNISATIONS

3. SYSTEMS REVIEW:
7. SH:
 GIT: What are his/her stools like? Does he/she complain of any tummy ache?
 Who is at home? Are you still with his/her mother/father?
 URINE: Have you noticed any strange/offensive smell in his/her urine? Has he/she complained
of any pain?  Does he/she have any siblings?
 SCALES: Is he/she growing normally? Has he/she been gaining weight?  How are things at home?
 Is the child at nursery/school/playgroup? How are things there?
4. PATIENT PERSEPCTIVE:  Has anyone at school or home had similar symptoms?
 FEELINGS & EFFECT ON LIFE: What effect has his had on their school and home life?
 IDEAS: Do you have any ideas yourself about what may be causing the vomiting?
 CONCERNS: Is there anything you are particularly concerned about?
 EXPECTATIONS: Was there anything in particular you were hoping for when you made the
appointment for today?
 ABDO PAIN DDx/INVEST.
DIFFERENTIAL DIAGNOSIS FEATURES
ACUTE ABDO PAIN DIFFERENTIALS:
Constipation - Abdominal distension /tenderness 1. SURGICAL
• APPENDICITIS
Acute appendicitis - Sharp, stabbing pain
- Migrates to RLQ • INTESTINAL OBSTRUCTION (INTUSSUSCEPTION)
- Fever INGUINAL HERNIA
- Vomiting •
- Diarrhoea • PANCREATITIS
Gastroenteritis - Abdominal pain with nausea and vomiting
- Blood in stools = bacterial infection. Fever = viral infection 2. MEDICAL
• CONSTIPATION
Cows milk Intolerance • GASTROENTERITIS
IBD - Crohns presents at any age. Abdo pain with constipation and diarhorra. Usually • DKA (all children with abdo pain should have BM)
no blood • UTI
- UC usually presents from age 9+. Loose stools, getting worse with bleeding
• PYELONEPHRITIS
Intussecption - Red currant jelly stools
- Acute presentation / severely unwell child • HSP
- Usually under 1 year • SICKLE CELL ANAEMIA?
Meckles Diverticulum
3. OTHERS
• PNEUMONIA
• TORSION OF TESTES
• HIP AND SPINE PROBLEMS
 IBD
FAILURE TO THRIVE / CHANGED BOWELS HISTORY
Look out for:
CROHNS ULCERATIVE COLITIS
 Cramping lower abdominal pain
• Transmural and focal • Chronic, inflammatory  Bloody diarrhea
inflammatory disease condition affecting bowel  Weight loss/faltering growth
that affects mouth to and anus  Perianal disease (abscess or fistula)
anus • MANAGEMENT 
• MANAGEMENT  aminosalicylates with
elemental diet with steroids
steroids for active
replace
• Immunosuppresion
agents: azathiprine and
anti-TNF antibodies
(infliximab)
DIARRHOEA
FAILURE TO THRIVE / CHANGED BOWELS HISTORY DIFFERENTIALS:

Look out for: 1. Infection – blood in stools = bacterial, fever = viral

 Blood in stools 2. Malabsorption - ulcerative colitis
 How often they’re going/ how it’s changed /when it’s
3. Hyperthyroidism
changed
 Change in diet
 Recent travel

INVESTIGATIONS
• Stool sample: suspected infection
• U&Es: assess hydration status

MANAGEMENT:
• Rehydration
CONSTIPATION
FAILURE TO THRIVE / CHANGED BOWELS HISTORY DIFFERENTIALS:

Very common in children. Majority is idiopathic 1. Idiopathic

Look out for: 2. Diet-related (not enough fiber / not enough liquids)
 Starts in first few weeks of life
3. Malabsorption  coeliac / crohns / cystic fibrosis
 Meconium passed >24 hours
 Faltering growth 4. Hypothyroidism
 Delayed walking / lower limb neurology 5. Hirschsprungs disease (rare)
 Abdominal distension or vomiting
 Child protection concerns

MANAGEMENT:
• Laxatives and re-establishing a regular bowel habit
Treatment
Ask• about diet: is prolonged and often requires psychological support

- How many portions of fruit and veg

- How much water are they drinking

 RED FLAGS:

UTI
1. OPENING CONSULTATION: 5. PMH:
 Establish child name and age. Who is with them  How has he/she been before this episode?
 PC – Can you tell me more about this?
 TRAFFIC LIGHT SYSTEM: color / activity / resp / hydration / other (rashes)
 Timeline – When did you first notice that this?
 FEEDING HISTORY
2. SYMPTOM ANALYSIS:  PREGNANCY & BIRTH HISTORY
 Frequency – how often are they having to go?
 DEVELOPMENTAL HISTORY
 Any pain when passing urine?

 Any previous illnesses?
Chang to voiding/incontinence?
 Any tummy pain?
 Any blood present in urine? 6. DH:
 Any smell/colour/cloudiness?  Has he/she been given any medications?
 Happening at night? Waking up from sleep? Bed wetting?  Does he/she have any allergies?
 DIRUAL  day and night wetting, older than 5 years, atleast 2x week  IMMUNISATIONS
 PRIMARY  never been dry, delayed maturation (UTI / STRESS / DIABETES / RENAL)
 SECONDARY  previously dry (psychological stress / UTI / DM / threadworms) 7. SH:
 Infective symptoms: fever / lethargy / constipation?  Who is at home? Are you still with his/her mother/father?
 Does he/she have any siblings?
3. SYSTEMS REVIEW:
 GIT: What are his/her stools like? Does he/she complain of any tummy ache?  How are things at home?
 SCALES: Is he/she growing normally? Has he/she been gaining weight?  Is the child at nursery/school/playgroup? How are things there?
 Has anyone at school or home had similar symptoms?
4. PATIENT PERSEPCTIVE:
 FEELINGS & EFFECT ON LIFE: What effect has his had on their school and home life?
 IDEAS: Do you have any ideas yourself about what may be causing the vomiting?
 CONCERNS: Is there anything you are particularly concerned about?
 EXPECTATIONS: Was there anything in particular you were hoping for when you made the appointment for today?
UTI DDx /
INVESTIGATIONS:
1. INVESTIGATIONS:
DIFFERENTIAL DIAGNOSIS FEATURES  Full history and examination
 Urine dipstick plus urine MSU+culture
BED WRTTING  Bloods: FBC / U&Es / CRP

TYPE 1 DIABETES

2. MANAGEMENT:
 Antibiotics –

 Renal USS within 6 weeks of discharge

 Recurrent UTIS (younger than 6 months): mictuaring cystogram

KIDNEY CONDITIONS
SUMMARY
OTHERS:

• HORSE-SHOE KIDNEY; both kidneys fused

together, may be asymptomatic / nausea /
NEPHROTIC : PROTEINS NEPHRITIC: BLOOD abdo pain / kidney stones / UTI. Diagnosed on
DMA scan. No treatment
Damage to glomeruli = leaky proteins filter into Glomeruli becomes inflamed = blood in urine • WILM’S/NEPHROBLASTOMA; most common
urine • Haematuria, hypertension and proteinuria renal malignancy. Present with unilateral
• Proteinuria, hypoalbuminaemia and oedema • Caused by post-strep GN infection and IgA flank mass, haematruia with no pain =
• Increased lipids nephropathy URGENT REFERAL +
• Hypercoagulable state due to loss of • IgA (Bergers disease) develops after UTRI FBC/U&E/URINALYSIS/USS/CT/MRI.
antithrobmin III • IgA antibodies deposited in glomerulus
• Increased risk of infections
• TREATMENT  steroids and fluid restriction
 INVESTIGATIONS:

KIDNEY CONDITIONS
1. URINALYSIS
2. FBC / BONE PROFILE /
BICARBONATE

SUMMARY
3. USS RENAL TRACT
4. FLUIDS
5. EXTRAS

URINALYSIS BLOODS USS FLUIDS EXTRAS

PRERENAL:
• Should be • Abnormalities • Look for renal • Results in • Treat underlying
• Intravascular fluid depletion / poor renal normal due to cause of vein thrombosis Increase in cause, ensure
perfusion • Osmolarity hypoperfusion urine output fluid status
• normal (WCC = sepsis) • Reduction in maintained
Acute fluid loss/poor intake/poor outflow uea/creatinine • Strict
• Sepsis input/output,
• Weak pulses, Increase HR, signs of daily weights
dehydration
• Blood and • Evidence of • Increase in size • No effect on • Discuss with
RENAL: protein in urine haemolysis / and urine OP or nephrology
• Acute tubular necrosis • Osmolarity low low platelets echogenicity creatinine • Same as above
• Acute glomerulonephritis • Urinary sodium common • Cosnider
high • In acute on diuetic/addition
• HX: oedema, poor urine output, chronic = may al treatment
headache, SOB be
small/shrunken/
• O/E: oedema, increased BP, HF signs cystic
• S&S: rash cause, joint symptoms cause

OBSTRUCTIVE: • Haematuria • WCC may be • diagnostic: • CONTRAINDICA • Discuss with

common high if infection TED nephrology
• Poor outflow/stream/pain • Indications of present • Same as above
• Enlarged bladder, indwelling catheter UTI
(nitrates/leukoc
ytes/blood)
 RED FLAGS:
• LOSS OF SKILL AT ANY AGE
• NOT FIXING OR FOLLOWING OBJECTS
• CAN’T SIT UNSUPPORTED BY 12M
• NO SPEECH BY 18M

DELAYED WALKING/SITTING
• NOT STANDING BY 18M
• PERSISTENT TOE WALKING
• LOSS OF HEARING

1. OPENING CONSULTATION:
Establish child name and age. Who is with them

2. SEQUENCE OF EVENTS AND SYMPTOM ANALYSIS :

OPEN QUESTION – Can you tell me more about what's been going on?
TIMELINE – can you talk me through how he/she has developed since birth and when he/she reached any milestones you
noticed? How old is your child now? (consider now whether the child is truly late meeting the milestone
3. SYMPTOM ANALYSIS:
DEVELOPMENT – how has your child been developing otherwise? Tell me about him/her. What can she/he manage to do now?
Do you have his/her red book with you?
CONCERNS – are you concerned about his/her development in any other areas?
FAMILY PATTERN – do you know what age his/her parents first started walking? Siblings?
I would now like to ask some quick questions to check your child’s development, is that OK?

4. GROSS MOTOR:
Have you got any concerns about their physical development?
HAND DOMINANCE – do they favor either hand? How long has he/she been like that for?
EARLY MOTOR – what age did your child first hold their head up? Sit up? Crawl? How does he/she crawl? On both knees? With
one leg trailing behind? Bottom shuffling?
WALK – When did he/she start walking unsupported ? Are they a bottom shuffler? (they walk later)

5. VISION AND FINE MOTOR:

Have you got any concerns with his/her eyesight or development of finer skills?
FIX & FOLLOW – when did you notice he/she first started following things with his/her eyes?
OBJECTS – when did he/she start reaching out for things? Transferring things from one hand to other? Make a pincer grip?
DRAWINGS – What does he/she draw when you give pencil and paper? Is she able to scribble circle or cross? Would she be able
to copy if you drew it?
STACKING TOYS – can they build towers with blocks? How many levels can they build?
 RED FLAGS:
• LOSS OF SKILL AT ANY AGE
• NOT FIXING OR FOLLOWING OBJECTS
• NO SMILE @ 8WEEKS
• CAN’T SIT UNSUPPORTED BY 12M

DELAYED WALKING/SITTING
• NO SPEECH BY 18M
• NOT STANDING BY 18M
• PERSISTENT TOE WALKING
• LOSS OF HEARING
6. HEARING, SPEECH AND LANGUAGE:
HEARING - Have you got any concerns about their hearing? Does he/she react to sounds out of sight? Does he/she
respond when you call him/her?
SPEECH – what can he/she say now? What age did he/she first babble? When did he/she say his/her first words?

7. SOCIAL, EMOTIONAL & BEHAVIOURAL:

Have you got any concerns with his/her social interactions with others?
ACTIONS – What age did you first see him/her smile? Wave bye bye?
PLAY – does he/she pretend to play with teddy? Does he/she play and share with others?

8. OTHERS: ASK ABOUT HEARING AND VISION!

9. SYSTEMS REVIEW:
TRAFFIC LIGHT SYSTEM

10. PATIENT PERSEPECTIVE:

FEELINGS // IDEAS // CONCERNS // EXPECTATIONS

11. BACKGROUND HISTORY:

PMH + PREGNANCY AND BIRTH HISTORY +FEEDING HISTORY (infants and toddlers)
DH+ ALLERGIES + IMMUNISATION HISTORY
FH – ask about Duchenne's muscular atrophy, when did mum and dad start walking?
SH
DELAYED WALKING + SPEECH DIFF.
DIAG:
DIFFERENTIAL FEATURES DIFFERENTIAL FEATURES
DIAGNOSIS – DIAGNOSIS –
DELAYED DELAYED
WALKING/SITTING SPEECH/LANGUAGE

NORMAL VARIATION - Often a family history of delayed development of motor skills NORMAL VARIATION - Often a family history of delayed speech development
- Normal in all other aspects but slow in developing motor - Otherwise normal developing child
- When motor skills are achieved, they are of a normal standard
- Children who are bottom-shufflers or commando-crawlers are more HEARING DIFFICULTIES - Otitis media with effusion is common in childhood and can cause
likely to develop motor skills later in life delayed speech and language development

AUTISTIC SPECTRUM - Impaired reciprocal social interaction and communication and

CEREBRAL PALSY - Disorder of motor function caused by non-progressive pathology DISORDER repetitive stereotyped behaviours
- Abnormal tone and posture and delayed achievement of motor - Delayed or complete lack of speech development with no other forms
milestones of communication
- Often widespread dysfunction – learning difficulties - Abnormal social, emotional and behavioural development
- 3 types  spastic / ataxic hypotonic and dyskinetic
- Causes  antenatal: vascular occlusion, congenital infection. Perinatal
OTHER - Cleft palate
 prolonged hypoxia in birth. Postnatal  head trauma, - Learning difficulties
meningoencephalitis - Environmental deprivation and neglect
- Premature babies higher risk

DUCHENNE MUSCULAR - X-linked recessive condition

DYSTROPHY - Delayed achievement of motor milestones, waddling gait and possible
global delay 1. INVESTIGATIONS:
- Gower’s sign: child uses hands to climb up legs in order to stand up
Observation of child at play
OTHER - HIP DISPLACEMENT Neurological examination
- Causes of global development delay (Downs) Ear examination and hearing assessment for speech and
- Metabolic disorder – rickets, hypoglycaemia language delay
- Environmental – child who is always kept in cot or bedbound through
illness Creatinine phosphokinase levels (Duchenne muscular dystrophy)
Chromosomal karyotyping
DEVELOPMENT MILESTONES
SUMMARY
6 weeks 6 months 12 months

• GROSS MOTOR: • GROSS MOTOR: • GROSS MOTOR:

o Raises head when on tummy o Head control o Walking *longer than 18m = worry*
o Head lag, chin lifting o Rolls on tummy or back • FINE MOTOR:
• FINE MOTOR: o Can sit without support o Pincer grip
o N/A • FINE MOTOR: o Can build 2 bricks
• VISUAL: o Palmar grasp • VISUAL:
o Follows movements with eyes o Transfers hand to hand o Follows movements with eyes
• SPEECH & LANGUAGE: • VISUAL: • SPEECH & LANGUAGE:
o Startles at loud noise/turns to sound o Follows movements with eyes o Understands ‘ where’s mummy’
• SOCIAL: • SPEECH & LANGUAGE: o 3 words
o Social smile o Babbles / understands ‘bye bye’ o Points to body parts
• SOCIAL: • SOCIAL:
o Puts object to mouth / shakes rattle o Waves ‘bye’ / clapping / drinks from beaker
DEVELOPMENT MILESTONES
SUMMARY
18 months 2 years 3 years

• GROSS MOTOR: • GROSS MOTOR: • GROSS MOTOR:

o Runs (16m) o Runs on tiptoes o Hops on 1 foot
o Jumps (18m) o Up and down stairs – 2 feet per stair o Walks upstairs and downstairs – 1 foot per
• FINE MOTOR: • FINE MOTOR: stair
o Can build 4 bricks o Can draw vertical line • FINE MOTOR:
• VISUAL: • VISUAL: o Turns 1 page of book at time
o Follows movements with eyes o Follows movements with eyes • VISUAL:
• SPEECH & LANGUAGE: • SPEECH & LANGUAGE: o Follows movements with eyes
o Shows understanding of nouns – ‘show me o Shows understanding of verbs – ‘what do • SPEECH & LANGUAGE:
xxx’ you draw with/eat with’ o Understands negatives – ‘which of these is
o 1 to 6 different words in sentence • SOCIAL: NOT an animal?’
• SOCIAL: o Eats skilfully with spoon • SOCIAL:
o Initiates everyday activities o Shares toys with friends / bowel control
 RED FLAGS:
• NECK STIFFNESS
• PHOTOPHOBIA
• NON-BLANCHING RASH

PYREXIA • NIGHT SWEATS

• BLEEDING/BRUISING

1. OPENING CONSULTATION: 4. PMH:

 Establish child name and age. Who is with them  How has he/she been before this episode?
 CLARIFY – what do you mean exactly when you say ‘fever’?  FEEDING HISTORY
 PC – When did you first notice them getting unwell? What did you notice at the  PREGNANCY & BIRTH HISTORY
time? How have things progressed since then?  DEVELOPMENTAL HISTORY
 OTHER SYMPTOMS – how is your child feeling generally? Any vomiting? Pain? Any
 Any previous illnesses?
night sweats? *clarify dates*

2. SYMPTOM ANALYSIS: 5. DH:

 Has he/she been given any medications?
 Headaches? Neck stiffness? Rash? More tired than usual?
 Does he/she have any allergies?
 Running nose? Sore throat? Ear ache? Any discharge from ears? Any change in
their hearing?  IMMUNISATIONS
 Loss of appetite? What are they eating at the moment/breast feeding
 Cough? SOB? Any chest pain? 6. SH:
 Any tummy pain? How are there water works and bowels?  Who is at home? Are you still with his/her mother/father?

 Any bruising or bleeding? Have they been getting recurrent infections?  Does he/she have any siblings?

 Is he/she growing well? Any weight loss? Night sweats? How are they sleeping?  How are things at home?

 Have they been abroad recently? Any insect bites?  Is it a smoke free house?
 Any pets?
 Is the child at nursery/school/playgroup? How are things there?
3. PATIENT PERSEPCTIVE:  Has anyone at school or home had similar symptoms?
 FEELINGS & EFFECT ON LIFE // IDEAS // CONCERNS // EXPECTATIONS
 RED FLAGS:
• NECK STIFFNESS
• PHOTOPHOBIA
• NON-BLANCHING RASH

PYREXIA DIFFERENTIALS • NIGHT SWEATS

• BLEEDING/BRUISING

CONDITION FEATURES 1. INVESTIGATIONS:

URTI • General coyzal symptoms: runny nose, dry cough, headache, sore throat  Physical examination (ENT/CVS/RS/ABDO/NEURO)
• May develop ear ache and otitis media secondary to this *esp if under 6*  No investigations to diagnose bronchiolitis or croup
 Chest x-ray if pneumonia
MENINGITIS • Unwell child, irritable, drowsy, headache, photophobia, weak/high pitch cry  Urine microscopy or MSU for UTI
• non-blanching rash and seizures
• Abdo pain  CT head or lumbar puncture if meningitis

UTI • Abdominal pain 2. MANAGEMENT:

• Dysuria and strong-smelling urine
• Irritability and poor feeding
 URTIs: self-limiting, monitor their temperature
BRONCHIOLITIS • Common viral illness seen in first year of life
• Raspy cough, wheeze, coryzal symptoms and fever  Urgent admission for IV cephalosporins for suspected meningitis
• Less wet nappies, poor feeding and grunting sounds indicate severe infection
 Bronchiolitis – may require admission or supportive management
CROUP • Viral illness causing barking cough with stridor and coryzal symptoms
• Common in first few years of life, usually self-limiting  Croup – single dose dexamethasone, admit if in resp distress
• Worse at night
• Can cause airway obstruction  Antibiotics for UTI and pneumonia

KAWASAKI’S • Fever more than 5 days and 4/5 of:  Otitis media and tonsillitis – usually self limiting, but antibiotics required in
DISEASE • Injected phaynx/cracked lips/strawberry tongue/conjunctical injection/ change in some circumstances
extremities / polymorphous rash / cervical lymphadenopathy
 Epiglottitis and septic arthritis – urgent admission for IV antibiotics
OTHERS • Tonsilitis – sore throat and fvere
• Otitis media – otalgia, decreased hearing
• Pneumonia – productive cough, fever, unwell with grunting sounds
• Epiglotitis – drooling, unwell, stridor, severe sore throat
• Septic osteomyelitis – limb/joint swelling
 RED FLAGS:

BEHAVIOUR
1. OPENING CONSULTATION: 4. ATTENTION DEFICIT HYPERACTIVITY DISORDER FEATURES:
 Establish child name and age. Who is with them  Hyperactivity  would you say he/she is hyperactive? Is he/she restless, fidgety and
 CLARIFY – what do you mean exactly when you say ‘change in behavior’ constantly talking? Is she/he ‘constantly bouncing off the walls?’
 When was this first noticed? By whom? Where? Looking back, has he/she always  Impulsiveness  does he/she take turns or constantly interrupt conversations?
been this way? How have things changed over time?  Inattention  how are his/her concentration levels? Is he/she easily distracted?
 Can you think of anything that may have triggered this behavior? 5. AUSTIC FEATURES:
 Communication – does he/she have any difficulties with communication?
2. ENVIRONMENTS:
 Social impairment – does he/she have friends? Is he/she able to play with other
 Is he/she the same way at school and home? children? Does he/she enjoy imaginary play?
 Home: how is she/he at home? Who else is at home? What are his/her  Repetitive behaviors – Does he/she like to follow a strict routine? If so, what would
relationships like with them? happen if this was changed?
 School: how is he/she at school? Is it a mainstream school? What do the teachers 6. SYSTEMS REVIEW:
say about him/her? How is she/he doing academically?
 DEVELOPMENTAL – in detail
 Social: How is she/he elsewhere? Can you take him/her out to public places like
restaurants?  PREGNANCY AND BIRTH HISTORY

3. CONDUCT:  IMMUNISATIONS
 Does he/she get in trouble often? If so, in what ways exactly?  FEEDING HISTORY (infants and toddlers)
 If conduct is an issue, explore  does he/she respect any rules? Has she/he ever 7. OTHERS:
missed school? Does he/she get involved in bullying? Can he/she be violent or  ICE
cruel to either humans or animals? Has he/she ever been in trouble with the law?
Has he/she ever drunk alcohol, smoked or used illicit drugs?  PMH
 DH
 FH
 SH
 RED FLAGS:

BEHAVIOUR
CONDITION FEATURES 1. INVESTIGATIONS:
 Physical examination to rule out medical causes
ATTENTION • Usually affects children between 3 and 7  Hearing assessment including audiometry
DEFICIT • Inattention – short attention span with difficulty concentrating in class
HYPERACTIVITY Hyperactivity – unable to sit still for long periods and constantly fidgeting  Speech and language assessment if developmentally delayed
•
DISORDER • Impulsiveness – unable to wait in turn and little sense of danger  MDT
• Symptoms must be present for more than 6 months across 2 different
environments
2. MANAGEMENT:
 MDT
CONDUCT • Usually affects children and adolescents above the age of 7
DISORDER • Violence, bullying, theft, vandalism and cruelty to animals
• Problems at school, including truancy and often expulsion  AUTISM – behavioral modification, speech and language assessment,
• Disobedience and lack of respect for authority occupational therapy
• Can be precipitated by situation at home, including being bullied or abused,
parental drug or alcohol addiction  ADHD – behavioral modification, parent education, family therapy

 CONDUCT DISORDER – behavioral modification and family therapy

AUTISTIC SD • Social impairment – lack of interest in playing with others
• Communication impairment – delayed language development, few social gestures
• Repetitive behaviours – deviating from set routines causes great difficulty to them,
stereotypy is another feature
• Risk factors: gestational age <35 weeks, family history, chromosomal disorders,
cerebral palsy

OTHERS • Oppositional defiant disorder

• Hearing or visual impairment
• Learning difficulties
• TIC disorder
 RED FLAGS:
• SEIZURE LASTHING MORE THAN 15MINS
• FOCAL SEIZURE
• RECURRENT WITHIN SAME ILLNESS

CONVULSIONS • OTORRHOEA
• SUSPECTED MENINGITIS

1. OPENING CONSULTATION: 3. SYSTEMS REVIEW:

 Establish child name and age. Who is with them  TRAFFIC LIGHT SYSTEM: colour / activity / resp / hydration / other (rashes)
 Can you tell me more about this episode?
4. PATIENT PERSEPCTIVE:
 TIMELINE – when did it first happen? Has he/she had any further episodes?
 FEELINGS & EFFECT ON LIFE // IDEAS // CONCERNS // EXPECTATION

2. SYMPTOM ANALYSIS :
 BEFORE 5. PMH/FM:
 TRAFFIC LIGHT SYSTEM: colour / activity / resp / hydration / other (rashes)
- WITNESS: did you witness this episode? Can you talk me through what happened?
 FEEDING HISTORY
- PRECEP. FACTORS: What was he/she doing before it happened? Was he/she scared or
crying? Had he/she fallen or hit their head before the episode? Had he/she been unwell?  PREGNANCY & BIRTH HISTORY
-  DEVELOPMENTAL HISTORY
AURA: Did he/she describe any funny feelings or sensations before the episode?
 Any previous illnesses?
 DURING
 Cerebral palsy, tuberous sclerosis, previous meningitis run in the family?
- DURATION: how long did the episode last?
- LOC: Did he/she lose consciousness? Did he/she fall to the floor? (did they hit head) 6. DH:
- SEIZURES: Was he/she shaking? Can you describe? Did their whole body jerk or part only?  Has he/she been given any medications?
- TONGUE BITING: Did he/she bite tongue? Front or side?  Does he/she have any allergies?
- INCONTINENCE: Did he/she soil or water themselves?  IMMUNISATIONS
- PALLOR/CYANOSIS: Did he/she appear pale or blue during the episode?
7. SH:
 AFTER  Who is at home? Are you still with his/her mother/father?
- POSTICTAL STATE: how did they feel immediately after the episode? Do they remember the  Does he/she have any siblings?
event?
 How are things at home?
- PREVIOUS EPISODES: Has this ever happened before?
 Is the child at nursery/school/playgroup? How are things there?
- GENERAL HEALTH: how are they doing generally? Are they growing and gaining weight  Has anyone at school or home had similar symptoms?
normally? Are they sleeping okay?
 CONVULSIONS DX/INVEST.
DIFFERENTIAL DIAGNOSIS FEATURES
1. INVESTIGATIONS:
FEBRILE CONVULSIONS - Affects children between 6months – 5 years  Neurological examination  Kernigs sign, Brudzinksi sign (meningitis) and
- High temperature at time of seizure, due to viral infection
- Tonic and/or colonic, symmetrical, generalised seizure usually lasting <5mins
look for bulging frontelle, inspection of rashes)
 If normal, typical history of FC then no further Inv. Needed
REFLEX ANOXIC SEZIURE - Brief and spontaneous, paroxysmal episodes triggered by fear, anxiety or pain
- Episodes lasting less than 1min  Lumbar puncture and blood cultures (meningitis)
- Child becomes pale and limp, losing consciousness briefly  FBC, U&Es, LFTs, glucose
- Then followed by involuntary colonic movements of limbs
- Urinary incontinence may be evident and child may feel groggy afterward  ECG to rule out underlying arrhythmias
- Tongue biting IS NOT a feature
 EEG: during seizure
BREATH HOLDING ATTACK - Often precipitated by emotions such as anger or frustration or trauma
- Crying episode often ensues, breath is withheld and pallor or cyanosis develops 2. MANAGEMENT:
- LOC may occur, recovery is quick
 Hospital admission and pediatric assessment if this is the first convulsion
EPILEPSY - Risk factors: birth asphyxia, cerebral palsy, trauma
- Watching TV and lack of sleep  Parent education
- Partial seizures cause symptoms depending on part of brain (simple – no LOC,
complex – impaired level of consciousness)
- Generalised seizures: absence (frequent episodes, remains still and stares 2-  Put child in recovery position
3seconds. Tonic-colonic: classic episodes of stiffening of body lasting 10-20
seconds followed by violent shaking of limbs, tongue biting, incontinence  Keep temperature down when pyrexia and give plenty fluids and
paracetamol
MENINGITIS - Unwell, drowsy, convulsions with pyrexia
- Non-blanching rash  Epilepsy: specialist pediatric or neurological referral (sodium valporate for
partial seizures and carbamazepine for generalized seizures)
OTHERS - Tuberous sclerosis  non cancerous tumours develop around body including brain
- Vasovagal syncope
- Benign paroxysmal vertigo
- Hypoglycaemic attack
CONDUCT DISORDER
• Conduct disorder is a serious behavioral and emotional disorder that can occur in children and teens. A
child with this disorder may display a pattern of disruptive and violent behavior and have problems
following rules.
• It is not uncommon for children and teens to have behavior-related problems at some time during their
development. However, the behavior is considered to be a conduct disorder when it is long-lasting and
when it violates the rights of others, goes against accepted norms of behavior and disrupts the child's or
family's everyday life.
 RED FLAGS:
• NON-BLANCHING RASH
• HEADACHE
• NECK STIFFNESS

RASH • PHOTOPHOBIA
• GENERALLY UNWELL

1. OPENING CONSULTATION: 5. PMH:

 Establish child name and age. Who is with them  How has he/she been before this episode?
 PC – Can you tell me more about this rash?  TRAFFIC LIGHT SYSTEM: color / activity / resp / hydration / other (rashes)
 Timeline – When did you first notice the rash? How did it start? How has it progressed since then?  FEEDING HISTORY

2. SYMPTOM ANALYSIS:  PREGNANCY & BIRTH HISTORY

 S- where exactly is it?  DEVELOPMENTAL HISTORY
 O- when did it start?  Any previous illnesses?
 C- what does it look like?
 R – does it spread anywhere else or is it just in one area? Bilateral vs unilateral 6. DH:
 A- itchy? Sore/painful? Discharge? Burning or numbness? Does it disappear or go white if you press it?  Has he/she been given any medications?
 T – is it always there? Has it changed? Have you had a similar rash before?  Does he/she have any allergies?
 E – can you think of anything that triggers it? Does anything make it better or worse? Are you using any  IMMUNISATIONS
new hand creams? Perfumes? Washing powders or other substances? Is it worse in the sun?

3. SYSTEMS REVIEW: 7. SH:

 Headaches / neck stiffness / vomiting?  Who is at home? Are you still with his/her mother/father?
 GIT: What are his/her stools like? Does he/she complain of any tummy ache?  Does he/she have any siblings?
 URINE: Have you noticed any strange/offensive smell in his/her urine? Has he/she complained of any  How are things at home?
pain?
 Is the child at nursery/school/playgroup? How are things there?
 SCALES: Is he/she growing normally? Has he/she been gaining weight?
 Has anyone at school or home had similar symptoms?
4. PATIENT PERSEPCTIVE:
 FEELINGS & EFFECT ON LIFE: What effect has his had on their school and home life?
 IDEAS: Do you have any ideas yourself about what may have caused it?
 CONCERNS: Is there anything you are particularly concerned about?
 EXPECTATIONS: Was there anything in particular you were hoping for when you made the appointment
for today?
 RED FLAGS:
• NON-BLANCHING RASH
• HEADACHE
• NECK STIFFNESS

RASH DIFFERENTIALS • PHOTOPHOBIA

• GENERALLY UNWELL

DIFFERENTIAL DIAGNOSIS FEATURES

1. INVESTIGATIONS:
ATOPIC ECZEMA - Red exudative or scaly lesion, vesicles  Full derm examination
- On flexor surfaces, face and neck
- Itchy  Dermoscopy for detailed examination of lesion
- FH
 Diascopy to reveal non-blanching rashes
PURPURIC RASH - Small purple raised spots on skin which do not blanch  Biopsy o confirm diagnosis
- Wide range of causes: meningococcal septicaemia  Skin scrapings for fungal infections
- Henoch-Schonlein purpura affects lower extremities and buttocks
 Swabs
PSORIASIS - Typically, well-demarcated red scaly plaques  FBC and clotting is purpuric
- Usually found on extensor surfaces
- FH present
- Itchy, may be associated with arthropathy and nail changes 2. MANAGEMENT:
CONTACT DERMATITIS - Similar in presentation to eczema but with irritant or allergy  Herpes zoster – oral aiclovir within 72 hours of rash onset
- Commonly found on hands
 Purpuric rash – IV antibiotics
CHICKENPOX/VARICELLA ZOSTER - Diffuse, itchy and painful vesicular and pustular lesions at different stages of
development
- Shingles presents in immunocompromised adults
- Herpes zoster ophthalmicus may occur in trigeminal nerve involvement

URTICARIA - White, itchy papule surrounded erythema – multiple, localised or diffuse

- They occur very acutely, usually a reaction to topical allergen
- Can progress to anaphylaxis = angioedema
 RED FLAGS:
• FEVER
• MENINGITIC FEATURES
• RECCURENT INFECTIONS
• RECENT ANAEMIA

CHILD WITH BRUISING

• WEIGHT LOSS
• INCONSISTENT HISTORY
• BRUISES IN NON-BONY AREAS

1. OPENING CONSULTATION: 5. PMH:

 Establish child name and age. Who is with them  How has he/she been before this episode?
 PC – Can you tell me more about what's been going on? Start from the beginning  TRAFFIC LIGHT SYSTEM: color / activity / resp / hydration / other (rashes)
 Timeline – When did you first notice the bruising?  FEEDING HISTORY
 PREGNANCY & BIRTH HISTORY
2. SYMPTOM ANALYSIS:
 DEVELOPMENTAL HISTORY
 S- where exactly is it? How many are there?

 Any previous illnesses?
O- when did you first notice them? How has it progressed?
 C- Can you describe the bruises? Are they large or like pin pricks?
6. FH:
 R – Do they have any bruises anywhere else?
 Any bleeding conditions that run in the family?
 A- systems review
 Any other conditions?
 T – have they previously had bruising?
 E – Any recent bumps or injuries? 7. DH:
 Has he/she been given any medications?
3. SYSTEMS REVIEW:
 Does he/she have any allergies?
 Headaches / neck stiffness / photophobia/ vomiting?
 IMMUNISATIONS
 Recent chest infections?
 Any vomiting? Loss of appetite? Changes in vision?
8. SH:
 Tummy pain? Changes in bowel and water works?  Who is at home? Are you still with his/her mother/father?
 Pain anywhere else? Bleed for long periods of time?  Does he/she have any siblings?
 Fever / weight loss / night sweats / more tired  How are things at home?
 Is the child at nursery/school/playgroup? How are things there?
4. PATIENT PERSEPCTIVE:
 ICE  Has anyone at school or home had similar symptoms?
 RED FLAGS:
• FEVER
• MENINGITIC FEATURES
• RECCURENT INFECTIONS
• RECENT ANAEMIA

CHILD WITH BRUISING DIFF.

• WEIGHT LOSS
• INCONSISTENT HISTORY
• BRUISES IN NON-BONY AREAS

DIFFERENTIAL DIAGNOSIS FEATURES 1. INVESTIGATIONS:

 FBC, LFTS, clotting and blood smear
NON-ACCIDENTAL INJURY - History incompatible with child’s development – old bruises / limp /
scald/burn  Bleeding time
- Must involve consultant and social services  Mixing studies and factor
 Platelet antibody assay
SIMPLE UNCOMPLICATED TRAUMA - Bruise preceded by an obvious trauma  Bone marrow biopsy
- Common locations include anterior lower legs and forearms  Urine analysis
- Less likely if bruise is on back / buttocks / upper arm or abdomen //
child under 9
2. MANAGEMENT:
HENOCH-SCHONLEIN PURPURA - Younger children with preceding URTI
- Rash looks similar to bruises and starts on back of legs and buttocks  Hematological – urgent referral
- May be associated with abdo pain / bloody diarrhoea / joint pain
 NAI – involvement of seniors and social services
ALL (and other leukaemia's) - PALE
- Acutely unwell  HSP – supportive treatment
- Recurrent infections
 ITP – according to symptoms. Monitor platelet levels. Oral
MONGOLIAN BLUE SPOT - Birthmark frequently misdiagnosed as possible NAI prednisolone/immunoglobulins

VITAMIN K DEFICIENCY - New born child, not given Vit K after birth  Haemophilia A and B – recombinant factors VIII and IX

THROMBOCYTOPENIA - Bone marrow failure, hypersplenism, haematological malignancy,  Vitamin K deficiency – IM vitamin K injections
uraemia, autoimmune disorders
- Poor platelet function often results in petechiae and mucosal bleeding
- Lymphadenopathy and recurrent infections may suggest leukaemia

HAEMOPHILIA A AND B - Defects of factors VIII and IX

- Hallmark symptoms of haemarthoses

VON WILLEBRANDS DISEASE - Most common inheritable bleeding tendency

- Mucosal bleeding
 RED FLAGS:

EARLY/PRECOCIOUS PUBERTY
1. INVESTIGATIONS:
DIFFERENTIAL DIAGNOSIS FEATURES 

FAMILIAL/IDIOPATHIC 2. MANAGEMENT:
CNS ABNORMALITIES - History of hydrocephalus
- Hypoxic brain injury

INTRACRANIAL TUMOUR - Neurological symptoms

ADRENAL TUMOUR HYPERPLASIA - Excessive pubic hair

- Penis/clitoris enlargement
- Weight gain

OVARIAN/TESTICULAR TUMOUR - Ovarian: bloating / pelvic pain / menorrhagia

- Testicular: painless lump
PREMATURE THELARCHE - Breast development only

PREMATURE PUBARCHE - Pubic hair growth only

EXTERNAL SEX HORMONE USE

 RED FLAGS:

DELAYED PUBERTY
1. INVESTIGATIONS:
DIFFERENTIAL DIAGNOSIS FEATURES 

CONSTITUTIONAL - 8 and 13 in girls

- 9 and 14 in boys 2. MANAGEMENT:
SYSTEMIC DISEASE - IBD / CF/ ANOREXIA

HYPOTHYROIDISM - Delayed growth

- Fatigue
- Cold intolerance
- Dry skin
- Coarse hair
KLINEFELTERS - Small testes
- Gynaecomastia
- Tall and thin

TURNERS - Short stature

- Amenorrhoea
PCOS - Oligo-amenorrhoea
- Hirsutism
- acne
BREAST
ONCOLOGY
 RED FLAGS:

BREAST LUMP
1. OPENING CONSULTATION: 6. PFMH:
 Patient name and DOB  Any breast cancers in the family?
 PC – Can you tell me more about this lump?  Surgical history
 Timeline – When did you first notice it? How did it start? How has it progressed since then?
6. DH:
2. SYMPTOM ANALYSIS:  Any regular medications?
 S- where exactly is it? How has it changed (over what duration)
 Allergies?
 O- when did it start? Gradual? Sudden?
 HRT?
 A- itchy? Sore/painful? Discharge? Burning or numbness? Nipple changes? Skin changes?
 Oral contraceptive?
 Pain related to menstrual cycle?
 Systemic: weight loss / fever / lethargy / pain elsewhere? / gland swelling?
7. SH:
 Who is at home?
3. PATIENT PERSEPCTIVE:

 How are things at home?
FEELINGS & EFFECT ON LIFE: What effect has his had on their life?
  Smoking /alcohol / drugs
IDEAS: Do you have any ideas yourself about what may have caused it?
 CONCERNS: Is there anything you are particularly concerned about?  Occupation – worse at work?
 EXPECTATIONS: Was there anything in particular you were hoping for when you made the
appointment for today?  SYSTEMIC REVIEW IF YOU HAVE TIME

5. PMH:
 Any previous illnesses? Any cancers?
 Age of menarche / menopause
 Pregnancy? Breast feeding?
 Breast trauma?
BREAST LUMP DIFFERENTIALS
DIFFERENTIAL DIAGNOSIS FEATURES 1. INVESTIGATIONS:

TRAUMATIC - Fat necrosis (hard, irregular bump with trauma history)
- Can present like carcinoma due to tethering and nipple inversion
2. MANAGEMENT:
INFECTIVE - Pyogenic abscess (tender, hot with pus caused by bacterial infection)
- Staph aureus, localised oedema and erythema

PHYSIOLOGICAL - Fibroadenosis > 35 years

- Usually UOQ and cyclical
- Greatest premesnstrually

NEOPLASTIC: FIBROADENOMA - 25 to 35 years old

- Benign
- 1-3cm
- Highly mobile
- Smooth
- Well-circumscribed and rubbery hard
- Can be bilateral and multifocal
NEOPLASTIC: CARCINOMA - Malignant if firm
- Irregular mass that are rarely painful
- Tethered or fixed to skin
NEOPLASTIC: PHYLLOIDS TUMOUR - 30-50years. Rare fibroepithelial tumour
- Painless, large, bulky, fast growing masses that are firm, smooth and
mobile

NEOPLASTIC: DUCT PAPILLOMA - Benign changes in epithelium in major ducts associated with pain and
bloody discharge in single nipple and swelling lateral to areola
 RED FLAGS:

BREAST PAIN
1. OPENING CONSULTATION: 6. PFMH:
 Patient name and DOB  Any breast cancers in the family?
 PC – Can you tell me more about this pain?  Surgical history

2. SYMPTOM ANALYSIS:
 S- where exactly is it? How has it changed (over what duration)
6. DH:

 Any regular medications?
O- when did it start? Gradual? Sudden? Cyclical? Worse at luteal phase?
 C- what does it feel like?  Allergies?
 R- Does the pain move anywhere else?  HRT?
 A- itchy? Sore/painful? Discharge? Burning or numbness? Nipple changes? Skin changes?  Oral contraceptive?
 T- how long for?
 E- anything make it better or worse? 7. SH:
 S- rate to 10  Who is at home?
 Systemic: weight loss / fever / lethargy / pain elsewhere? / gland swelling?  How are things at home?
 Smoking /alcohol / drugs
3. PATIENT PERSEPCTIVE:
 FEELINGS & EFFECT ON LIFE: What effect has his had on their life?  Occupation – worse at work?
 IDEAS: Do you have any ideas yourself about what may have caused it?
 CONCERNS: Is there anything you are particularly concerned about?  SYSTEMIC REVIEW IF YOU HAVE TIME
 EXPECTATIONS: Was there anything in particular you were hoping for when you made the appointment for
today?

5. PMH:
 Any previous illnesses? Any cancers?
 Age of menarche / menopause
 Pregnancy? Breast feeding?
 Breast trauma?
 Menstrual history + smear
BREAST PAIN DIFFERNTIALS
DIFFERENTIAL DIAGNOSIS FEATURES 1. INVESTIGATIONS:
 Score on pain chart and keep diary
CYCLICAL BREAST PAIN - Affects women before menopause and period  Ibuprofen
- 2/3 women experience at some point in their life 
- Heaviness, a week or so before period Reduce caffeine and alcohol
- Goes after period/menopause  Exercise and healthy diet
- Radiates to axilla and arm  Supportive bra
- 20-30% settle
 Relaxation therapies
 Changing pill or non hormonal contraception
NON CYCLICAL BREAST PAIN - Benign condition
- Surgery and injury
- Stress and anxiety 2. MANAGEMENT:
- Chest wall pain = costrochondritis
 Mastitis  non lactating: co-amoxiclav for 14days. Lactating: continue
breast feeding, flucloxacillin . Should settle within 48 hours.
MASTITIS - Need to rule out inflammatory breast Ca using USS
- More common if  breast feeding, restricted bra’s, trauma,
nipple piercing, previous mastitis, immunosupressed,
nullparity
- Staph aureus, coag neg staph
- Strep viridans
ONCOLOGY
MSCC
INFECTIOUS
DISEASE
 SYMPTOMS TO ASK FOR:
• DISCHARGE / PAIN / BLEEDING
• ITCHING
• GENITALSKIN CHANGES

SEXUAL HISTORY
• SWELLING / LUMPS / BUMPS
• ABDO PAIN

1. OPENING CONSULTATION: 5. PMH:

 Patient name and DOB  Previous STIs and tests
 In order to get a better picture of why you’ve come into today, I may have to ask some  Smears
questions about your sexual health and relationships. I understand this can be very
 Have you ever had a blood test for HIV or hepatitis?
sensitive and personal, however I just wanted to reassure you that everything we discuss
today will be kept confidential. Any questions before we start?  Vaccinations

2. HISTORY OF PRESENTING COMPLAINT 6. PFMH:

• EXPLORE SYMPTOM: timeframes / symptom specific questions  Any breast cancers in the family?
• SEXUAL HEALTH REVIEW: discharge / dysuria / swellings/ lumps and bumps / pain (pelvic,  Surgical history
sex) / PV bleeding and menstrual history
6. DH:
3. PATIENT PERSEPCTIVE:  Any regular medications?
 ICE
 Allergies
4. THE 4 PS: PARTNERS/PRACTISES/PROTECTION/PREGNANCY:  Contraception
 PARTNERS: Sexual orientation and where they are from
 PRACTISES: type of sex (vaginal / anal / oral) 7. SH:
 Who is at home?
 PROTECTION: condoms? Contraception? Previous contraception?
 How are things at home?
 Sexual contacts in last 3 months (dates / gender / country born / condom / type of sex)
 Smoking /alcohol / drugs
 High risk encounters for HIV – sex with men / sex with partners born abroad / paying or
being paid for sex / needle sharing / tattoos, piercings )
 PREGNANCY: is there any chance you could be pregnant?
 SYSTEMIC REVIEW IF YOU HAVE TIME
SEXUAL HISTORY
DIFFERENTIALS
 RED FLAGS (FOR TB):
• COUGHING MORE THAN 3 WEEKS
• HAEMATESIS
• CHEST PAIN

INFECTION/TRAVEL HISTORY • FEVER / FATIGUE / NIGHT SWEATS

• LOSS OF APPETITE

1. OPENING CONSULTATION: 5. PMH

 Patient name and DOB • Previous infections?
 PC: explore (timeframe, SOCRATES)
6. PFMH:
2. HISTORY OF PRESENTING COMPLAINT  Any TB in the family?
• SPECIFIC SYMTPOMS: rash / breathing difficulty / bruising / jaundice? / night sweats /
weight loss / loss of appetite / fever / bowel and water works 6. DH:
 Any regular medications? Abx?
3. PATIENT PERSEPCTIVE:  Allergies
 ICE
 Vaccinations

4. TRAVEL HISTORY:  Any prophylaxis treatment? Compliance?

 DESTINATION: specific areas / nature (mountains, beach) / duration of each visit / hostel or  Insect repellent use?
hotel?
 PURPOSE: farmer (fish), health worker, cave explorer 7. SH:
 ACTIVITIES: swimming in open water? DIET WHILST THERE?  Any similar symptoms at home or with anyone who travelled with you?

 CONTACT WITH POPULTION: any unprotected intercourse? Anyone have any similar  Smoking /alcohol / drugs
symptoms? Any known disease contacts?  Long haul travel ?
 INSECT/ANIMAL BITES, SCRATCHES OR LICKS
 ANY INJURGIES? – how were they treated / injections given / blood taken? / surgery / any
venipuncture or tattoos?
 SYSTEMIC REVIEW IF YOU HAVE TIME
• PLACE
• PURPOSE
• PEOPLE
• SWIM/FOOD/ANIMALS
• TATTOOS/SEXUAL INTERCOURSE
• DISEASE OUTBREAK / TREATMENT
TRAVEL HISTORY
SYSTEMIC SYMPTOMS: RISK FACTORS: PREVENTION:
• RESP  SOB / COUGH / CHEST PAIN
• SEXUAL • VACCINATIONS
/ HAEMOPTYSIS
• ABDO  D&V / ABDO PAIN • PROCEDURES • PROPHYLAXIS (AND
• GU  DYSURIA / FREQ / • ANIMALS COMPLIANCE)
HAEMATURIA
• CONTACTS
• NEURO  NECK STIFFNESS /
HEADACHE / SEIZURE • EATING AND DRINKING
• SKIN  RASH / SWELLING /
ERYTHEMA
• SWIMMING
• RED FLAGS  WEIGHT LOSS /
NIGHT SWEATS / BLEEDING
DERMATOLOGY
 RED FLAGS:
• NON-BLANCHING RASH
• HEADACHE
• NECK STIFFNESS

RASH • PHOTOPHOBIA
• GENERALLY UNWELL

1. OPENING CONSULTATION: 5. PMH:

 Establish child name and age. Who is with them  Any previous illnesses? Skin cancer?
 PC – Can you tell me more about this rash?  Eczema / asthma / hay fever?
 Timeline – When did you first notice the rash? How did it start? How has it progressed since then?
6. DH:
2. SYMPTOM ANALYSIS:
 Any regular medications?
 S- where exactly is it?
 Allergies?
 O- when did it start? Gradual? Sudden?
 C- what does it look like? (size / colour / shape)
 Antibiotics?
 R – does it spread anywhere else or is it just in one area? Bilateral vs unilateral  New perfumes? Skin products?
 A- itchy? Sore/painful? Discharge? Burning or numbness? Does it disappear or go white if you press it?
 T – is it always there? Has it changed? Have you had a similar rash before? 7. SH:
 E – can you think of anything that triggers it? Does anything make it better or worse? Are you using any
 Who is at home?
new hand creams? Perfumes? Washing powders or other substances? Is it worse in the sun?  How are things at home?
 Smoking /alcohol / drugs
3. SYSTEMS REVIEW:
 Headaches / neck stiffness / vomiting?  Occupation – worse at work?
 Bowel and water works okay?  TRAVEL – recent travel?
 Any abdominal pain?
 Any joint pain?  SYSTEMIC REVIEW IF YOU HAVE TIME
 Fever / weight loss / tiredness

4. PATIENT PERSEPCTIVE:
 FEELINGS & EFFECT ON LIFE: What effect has his had on their life?
 IDEAS: Do you have any ideas yourself about what may have caused it?
 CONCERNS: Is there anything you are particularly concerned about?
 EXPECTATIONS: Was there anything in particular you were hoping for when you made the appointment
for today?
DESCRIBING A RASH/SKIN
CHANGES
LESS THAN 0.5CM MORE THAN 0.5CM PSORASIS:
• Multiple well-demarcated, raised erythematous
plaques over the extensor surfaces
• These range in size from 1-6cm
MACULE PATCH • There is a scaling across the surface, no other
secondary features
• These lesions are consistent with chronic plaque
type psoriasis

SMALL PLAQUE LARGE PLAQUE

ECZEMA:
• Multiple papules and vesicles on an erythematous
base, over the flexor surfaces
• Range in size from 1-6mm
• Some evidence of lichenification and scaling, no
PAPULE NODULE evidence of secondary infection
• Lesions are consistent with atopic eczema

FLUID FLUID
SEBORRHOEIC KERATOSIS/WART:
VESICLE BULLA • Multiple well-demarcated dark brown papules on
the upper part of patients back
• 4mm in diameter, regular border and stuck on
PUS PUS appearance
ABSCESS • Lesion is raised, with a rough surface, no
PUSTULE
secondary features
• Lesion is consistent with seborrheic keratosis
ALLERGIC REACTION
GP
BACK PAIN
TWO WEEK REFERAL