Communica tion Skills Introductio n

Communication Skills = Sharing information

With whom you share information? 1- Patient/ Relative 2- Medical Colleagues

Giving Vs Getting (Gathering) ( introduce & greeting Open Interview Close)

- Both = INFORMATION GIVING 1. Give & take information but - Giving > Gathering 2. Should give information in simple language no medical terms 3. A fetal mistake = To give wrong medical information 4. Should Cover The following 3 items: . Medical .Social .Psychological 1. Waiting area ( 5min),To read scenario 2. Actor Interview ( 10 min) The examiners will not talk to or discuss you only they will assess your communication skills that should cover critical items within the interview, & how you Begin & end the interview 2 examiners assess you 4 4 INFORMATION GATHERING - Gathering > Giving

Event description

- Marks

1. Waiting area ( 5min),To read the scenario 2. Actor Interview ( 10 min)= 1st bay The examiners will not talk to or discuss you only they will assess your communication skills - you are allowed to write notes regarding H/o of the condition as you will present Later after taking The patient (= Actor) 3. 2nd bay ( 10 min) = Present the case for the Examiners & They will discuss you about the future plan for the case 1st bay the 2 examiners assess you 4 4 2nd bay the 2 examiners assess you 4 4

Introduction

Objectives

General skills

- Same important as clinical examination - Tested between actor playing (patient / relative) & you - Based on ( Information giving & Information gathering followed by presentation to a consultant) - Should give accurate clinical information + good communication skills - Assessment of communication skills - Competent performance within time given - Skills to recognize situations (or knowledge) outside personal experience but ability to act appropriately Ask consultant to provide further details Assistance from other members of the team - Introduction (Name - Explain role - Checks patients name - Appropriate greetings - Non-verbal behaviour appropriate to culture - Establishes purpose of interview ( Clarify why interview is taking place (patient perspective, own perspective - Check patient happy to proceed - Establish outcome of interview - Establish baseline knowledge / understanding ( Open questions Listens - Confirms what learned -Signals to move to information giving at the end 1. Picks up& responds to the patient concerns, anxieties and doubts 2. Listens actively 3. empathy 4. Offers support 5. Presents information non-judgmentally 6. Uses language patient understands 7. Uses appropriate body language - Open/closed questions used appropriately - Allows control of interview to: - alternate between doctor and patient - Signposts change of direction - Give the information & ensure that pt understanding - Summaries / next steps

General Manner

Questioning style Control of interview Information giving Summarizing

The rules of preferred body language: 1. Sitting while speaking, + open posture + eye contact apply 2. Privacy may be less than optimal, in a busy clinic. Every attempt should be made to provide a separate, quiet space. Asking the patient to quiet their personal communication technology prior to the conversation can also minimize distraction. 3. Reducing or eliminating body signals that illustrate nervousness is very important in establishing rapport with the patient. Simply placing your feet flat on the floor with your ankles

together and putting your hands, palms downward, on your lap is a successful neutral position. Maintaining eye contact with your patient will help ensure your attentiveness.
1- Sensitivity to needs to patient / relative 2- Professional Dealing With Assessment of candidates: - Great & respect the patient , smile , be gentle & be polite - Empathize & sympathize but be clear, honest & Professional - Taking into account ethnicity, cultural, age & disability factors - Responding appropriately to verbal and non-verbal ( body) language - Listen to patients account Emotion/ social element - Variable emotional responses by the patient / relatives - Variable cultural / religious backgrounds and ethnic backgrounds Medical element - Complaints appropriately - Variable questions& situations that are beyond level of competence of candiciate Time element - Time constraints accurate information in an appropriate manner Informatio - To the patient / relatives n Giving 1. Obtaining informed consent 2. Breaking bad news 3. Explain risk/benefits& possible impact of investigations in clinical situation 4. Explaining diagnosis or differential diagnosis 5. Explain options available and option not to treat 6. Explain uncertain diagnosis, outcome or prognosis Ability to use background information to formulate an appropriate response - Checking for understanding and summarizing at appropriate intervals - Involving the patient in decision making to the level that they wish - Offer opportunities available for further information e.g. 2nd opinion - Using feedback to regulate pace and content of consultation - To colleagues/ other Healthcare professionals 1. Verbal communications 2. Written communications - Clinical letters to medical colleagues - Investigation request forms 3. Telephone communication Informatio - To the patient / relatives n - Brief H/O from patient in OPD / ward Gathering - Consultation with relative of patient Ability to use background information& that gathered to formulate an appropriate response Discussion of management plan Ability to summarize information appropriately

3- communication Ability

 ) ( ) ( Information Giving Information Gathering ( .1 = Breaking bad news - Brief H/O from patient in Dealing with .2 = Angery patient or relative OPD / ward - Consultation with relative of .3 Explaining diagnosis or differential diagnosis patient Explain risk/benefits& possible impact of investigations .4 Explain options available of treatment Explain outcome or prognosis .5 + Obtaining informed consent .6 + Organ transplant consent ( - = Verbal communications -2 = Written communications Clinical letters to medical colleagues - Investigation request forms -2 Telephone communication ) ( ( ( -1 = + -2 3 -: + + )= ( -3 = - -

) = ( ) = ( ) ( ) ( .... ) ( ....... ........ ..... /)........ = ( ) ( / ......... ) ( - ) + (

 ) - ( ) ) ( ) ( ) ( ) = ( + ) = offer contact e.g social worker specialized care (nurse(cancer, stoma amputation offer contact (bleep, office or telephone) + (OPD appointment =Verbal communications Presentation of H/o taking

-1 -2 -3 -4 ) ( = ) + ( + ) ( -5 + ) ( = ) + ( + ) ( ) ( + ) ( -6 Verbal communications

I- In The waiting area (5 min) ( Read, Record data & Mapping) INFORMATION GIVING INFORMATION GATHERING I- Read the scenario > time II- Record Data important Items You Name if given , & Job position (CT , SHO, Registrar). Patient Name , Age , Venue ( hospital/ department, ER, OPD, Ward ) Consultant name if given/ specialty Find & Record Medical problem, Social points to be covered, Psychological element the 3 Items II- Mapping Medical prepare yourself about points to be covered prepare A diagram about the medical problem .Social .Psychological prepare yourself about The Social point/s you should offer help for it offer this in a question Ex:prepare yourself about the Psychological points you should offer help for it offer this in a question Ex:-

II- In Actor Area (10 min)= Actor Interview ( introduce & greeting Open Interview - Close) INFORMATION GIVING INFORMATION GATHERING INTERODUCE 1. Greeting the patient, smile, check hands 2. Introduce yourself - Same 3. Check patient identity Is it Mr. / Mrs..? OPEN INTERVIEW OPEN Differ according each situation QUESTION THE INTERVIEW Actor Interview ( 10 min), 1. Actor Interview ( 10 min)= 1st bay - Task - Take H/O & Systemic review is focused on - Scenario may go beyond - you are not allowed to write notes important points scope of junior doctor, you The examiners will not talk to or discuss you - you are allowed to write notes regarding H/o must recognize & should only they will assess your communication skills of the condition as you will present Later after refer matter upwards; that should cover critical items within the taking The patient (= Actor) but take . Ask consultant to provide interview, & how you Begin & end the interview permission. further details The examiners will not talk to or discuss you . Assistance from other only they will assess your communication skills members of the team Rules :- You Should Cover The following items: Rules :- - Same - Should deal with aspects 1. Medical - You should say that you will now speak to of situation of patients 2. Social your consultant condition as they emerge in 3. Psychological conversation 3. Present the case ( 5 min) = 2nd bay 1. Medical Should be logical, structured,& in clinical - Simple language (no medical terms, language & no abbreviations) Presentation Skills - Simple sentence & in a small chunk. - Simple language - A fetal mistake = To give wrong medical - Methodical approach information - Comprehensive + Ensure that the patient under standing you. - Succinct (keep to 5 minute limit) Do you have any questions? - Emphasis and significance - keep appropriate - Medical plan. to surgical context 2. Social:- offer help for it - Interpretation of ideas and concerns 3. Psychological:The examiners will discuss you about - empathize & sympathy but be 1. What DD would you suggest at this stage honest & tell the truth .e.g. cancer based on the history? - Listen to his concern & dont interrupt 2. What signs would you look for specifically in offer help for it the examination - Smile & use body language( nodding the 3. What investigations would you request for head), this patient? END INTERVIEW= - Close appropriately (check if has no further - Same questions, and knows what will happen next) - Summary all these in simple sentences - End Question Do you have any questions? Before we end - Thanks & smile

Medical Terms & ABBREVIATIONS VS Simple Language

Medical Terms & Abbreviations C/O Investigations Body regions/Organs Thorax Abdomen Gluteal region/ buttock Anus Testis Scrotum Vessels/ Nerves/ LNs Axillary a Axillary Optic N Occulomotor N Coronary a Pathology Congenital Atherosclerosis Ischaemic Heart disease (IHD) never said that Angina Myocardial Infarction Diabetes mellitus HTN Shock Mass Malignant tumour Biopsy Recurrence ulcer Operative surgery Incision Scalpel Excision = .ectomy Drain Ryle/ NGT Urinary catheter Clostoma/ stoma Haemorrhage Haematoma Haematemsis Melena Endoscope Simple Language Concern/ problem Some tests to do Chest Tummy/ belly bottom Your back passage Your balls Skin contains your balls Artery in your armpit Glands in your armpit The nerve of vision A nerve that control the muscles move you eye Artery that supply/ feed your heart Disease born with it Narrowing or occlusion to artery that supply.. Narrowing or occlusion to artery that supply / feed your heart Pain in your chest as a result of Narrowing or occlusion to artery that supply / feed your heart Pain in your chest and part of your heart muscle dead as a result occlusion to artery that supply / feed your heart High blood sugar High blood pressure Low blood pressure Lump cancer Cells we take out Come back ulcer Cut Knife Remove or take (The Lump or your organ) out Tube take fluid out Tube take fluid & content of your stomach out Tube take Urine out A bag take content of your bowel out Bleeding Bruises Blood come back from your stomach Dark blood from your back passage A special tube with a camera connected to a special monitor We enter it through your .. ..So we can see the problem Inside/ take some cells/ or others for diagnose & we can do some surgery through - A special tube with a camera connected to a special monitor - We enter it in your tummy through a small 1cm cut So we can see the problem Inside/ take some cells/ or others for diagnose - We can also do surgery through another small cuts with entering special tubes for knife/ scissors & so on

Laparoscope

Difficult situations VS Solutions Difficult situations Solutions If patient( actor) plays as he is In pain - Ok I will give you a pain killer play as you call a sister to give him it Dyspneic Ok I will give you oxygen play as you call a sister for help , sister we need oxygen & mask here hurry please Depressed - Speak about the future plan Anxious - Be calm & explain Talkative - Summarize what they told you & give him the information Uncooperative - Use closed questions Angry - I am sorry, I understand why you are angry, I have to tell you ..e.g. your Operation/ tests have been postponed and give the cause for postpone. Aggressive If stand stand ( Be at same level of his eye) If shout Be firm , polite , raise your voice but not shout Last solution leave the room & call the security Saying "I will kill my self if Offer postpone test is positive" Offer to call one of his close relatives Suicide Trial As Above + offer contact to psychiatrist after bad news dont discharge Patient questions Cancer biopsy test:- I am afraid to tell you, that the cells taken from you are positive for cancer. Is it cancer? It will kill me? - Still early to decide before we do some tests to role out spreading of the cancer cells in other body system It kill my mother, it may kill I am afraid to tell you, yes me? How long I will life? Dont tell, why all asking this Q ? Relatives - Ask about the relative degree? What is your relative degree? - Did Mr. / Mrs. Know that you are here today? Is it Mr. / Mrs. Know what we are going to talk about today? If No dont give any information Consent Deal with consent for surgery & organ transplants Angry relative deal with him as angry pt. ,offer to speak in office not the patient area Social help offer Psychological offers

Information Giving

Explaining diagnosis or DD

Explaining Treatment options

Introduce Raise your voice to make all listen Be self confident Be warm/&sympathy

1. Introduce yourself Hello, I am . Name if given , & Job position (CT , SHO, Registrar) Check hand & Smile, eye contact Is it Mr. / Mrs..( Family name of the patient)?

2. Check patient identity - Offer a chair...Do you have a chair Mr./ ? If he has a chair Ask him to sit. .. Sit down please? If no offer a chair - Sit infront look at his face (don't give him your side), But dont give your back to the examiners. stay calm relaxed

Explain why interview I am asked by Dr/.( or team) to come to talk to you about you concern Open questions 1- Would you like someone to be with us in this consultation? 2- I would like to ask you, what do you know about the problem?

Explain why interview I am asked by Dr/.( or team) to come to talk to you about you concern and the treatment options Open questions 1- Would you like someone to be with us in this consultation? 2- I would like to ask you, what do you know about the problem?

Medical: = Inform the patient directly ( be clear & honest) - Do you know Why this Diagnosis? - Ok I will start to explain & if anything isnt clear or if you have any Question please stop me to re-explain clearly& answer your questions. Social /psychological =Sympathy:- Medical: = Explain in brief(No much technical information) What is this diagnosis mean what are possible other diagnosis what is the next plan in management = test or therapy During the discussion Frequently establish That the pt understands. Is it ok? Do you have any question? Social/psychological =Sympathy:- Listen to concern, idea& fear + offer (Answer, sympathize & offer solving for any social Q).

. Medical: = Inform the patient directly ( be clear & honest) - Do you know what the treatment options for your concern mean? - Ok I will start to explain & if anything isnt clear or if you have any Question please stop me to reexplain clearly& answer your questions. Social /psychological =Sympathy:- Medical: = Explain in brief(No much technical information) what is the diagnosis mean What are the treatment options mean? What are the available a treatment options? And indication for each What are the risks without treatment = complications of the disease What are the risks/ benefits with each treatment option what is the outcome = prognosis During the discussion Frequently establish That the pt understands. Is it ok? Do you have any question? Social/psychological =Sympathy:- Listen to concern, idea& fear + offer (Answer, sympathize & offer solving for any social Q). - Summary all these in simple sentences.. - End Question. Do you have any question, Before we end? - Offer contact? - Thanks the patient ..Thank you Mr. / Mrs..? & smile/ greeting/ check hand

- Scenario may go beyond scope of junior doctor, you must recognize & should refer matter upwards; . Ask consultant to provide further details . Assistance from other members of the team - Should deal with aspects of situation of patients condition as they emerge in conversatio n

Same

Angry patient Ex: postponed surgery bec busy OR

Breaking bad news ex FNAC is positive

due to RTA
Same with all Explain why interview I am asked by Dr/ .( or team) to come to talk to you about you concern Open questions Social /psychological I am Sorry I understand why you are angry, (but dont blame others or yourself or talk instead of others; take a neutral position; I am Sorry I am afraid I am not allowed to talk about that). Explain why interview I am asked by Dr/.( or team) to come to talk to you about you concern Open questions 1- Would you like someone to be with us in this consultation? 2- I would like to ask you, what do you know about the problem? Or I would like to ask you, if you expect the result?

Social =Sympathy:If pt said that:- " I dont want to know the result of test offer postpone. I "ll kill myself if the test is +ve offer postpone + offer a Relative call Try to suicide offer postpone + offer a Relative call+ offer psychiatrist contact + dont discharge

-:Medical Inform the patient directly ( be clear & honest)

I am Sorry I am afraid that I have to tell you your OR is postponed/ cancelled

Social/psychological =Sympathy:= Warn"Fire a Warning Shot" =incoming news is not good. "Unfortunately I have some bad news to tell you," or "I am sorry to tell you," Medical: = Shot I am afraid that , the result of test is positive for cancer Inform the patient directly ( be clear & honest) = no false hope Social /psychological =Sympathy:=
Wait & check for the patient response+ react with him/ her emotion ( use both verbal& body language + always your eyes contact with pt's eyes) Range of normal reaction is wide 1. If the patient keep silent you should be silent for a moment, dont interrupt & give a chance to take the shock of this bad news. 2. If cry offer tissue Social =Sympathy:-Break this silence, I am sorry Mr. / Mrs. I understand it is difficult to you. Would you like to call someone to be with us? Are you ok? if Ok, go on to the Next step. Move to Medical plan:-= future plan for treatment Before discussing a treatment plan, it is important to ask your patients if they are ready for such a discussion. - I would like to Ask you, do you want to tell you more about your concern? - Would you like to start from the result of the test? - Ok I will start to explain & if anything isnt clear or if you have any Question please stop me to re-explain clearly&

- Scenario may go beyond scope of junior doctor, you must recognize & should refer matter upwards; . Ask consultant to provide further details . Assistance from other members of the team - Should deal with aspects of situation of patients condition as they emerge in conversation

Diffuse the situation = offer a solution Defusing negative circumstances & allowing everybody to focus instead on good medicine. (A) Social/ emotion reaction= sympathize:be gentle, polite, but firmly & Apologize Listen = the main bulk to solve the problem Listen to concern, idea& fear + offer

(Answer, sympathize & offer solving for any social Q). Listen to concerns &
Understand: - Empathize: - Ex; "I understand," "I can see why you're concerned," or "I can see why you feel that way", - Body language; According to Mehrabian, communication consists of: - 55% body language, 38% tone of voice, & 7%talk. So, mirror the angry patient's, body language& tone of voice. So, move closer to them, tilt your head forward, and speak in similar volume. - Agree: "The problem is with the , right? Is that correct?" yes I agree you - Problem Do I understand correctly? Is this the problem?" it involves the patient in problem-solving. - Address a problem & not include him in the process ("Please tell me one more about your concern.") - Provide confirmation repeat what he said ("Just to be sure I understand correctly..."). - Summarize c/o = concerns:- Release fear, tell him Ex: your concern is important to our team & you still have the priority (B) Medical:. Last is to move the patient/ relative to future plans with hopefulness

answer your questions. Start discussion:- (No much technical information) Share information with the patient & involve him/ her in the plan and prepare a patient for participation in treatment decisions + respect the level of information desired. Start by aligning with what patient knows 1- The result of test is positive 2. Diagnosis, are some tests still to do? Explain 3. Treatment options, Surgery/Radiotherapy /

chemotherapy or palliative 4. Prognosis, 3. If the patient said that is the cancer will kill me? I am afraid to tell you; yes 4 .If the patient how long I live dont tell , still early to tell you we have some tests to do & this including analysis of the tissue/ & or glands we will remove. 5.support Including :- cancer care Nurse During the discussion of the treatment plan Frequently establish That the pt understands. Is it ok? Do you have any question? Listen to concern, idea& fear + offer (Answer, sympathize & offer solving for any social Q)
Same Summary all these in simple sentences .. - End Question. Do you have any thing to tell it to me or any question, Before we end? - Offer contact? To you / team/ consultant Thanks the patient ..Thank you Mr. / Mrs..? & smile/ greeting/ check hand

Summarize Any Q Offer contact Thanks

Informed Medical Consent

.Know the medical facts and their implication before initiating the conversation :Stick to basic rules of interview: question-listen-hear-respond Informed consent= -Sufficient information giving to a patient (patient's right), by either the physician or their

(patient's right)

Who give Consent Who Obtain Consent Validity time If consent is not obtained Type Consent?

What is Sufficient information to be giving

representative, to allow the patient to make an informed decision regarding whether or not to consent to a treatment or procedure. -Sufficient information giving to allow the patient to make an informed decision - To refuse medical care for any reason e.g. religious grounds any other personal, even if you as physician consider their grounds to be in poor judgment. - Adult> 16y ( organ donation >18y) Responsible with complete mental capacity - If children or not fill that ( parent or legally responsible relative or persons) A health care provider who is reasonably involved with the patient's care. 30 days. In cases where planned treatments in advance .e.g. chemotherapy 6 mo The patient has the right to sue for medical malpractice. Informed consent is necessary any time the physician is going to either touch the patient or perform an invasive procedure Written consent All cases performed in OR / invasive procedures/ Contrast Rad. Oral consent Clinical exam/ simple treatment requirements e.g. canula/ Injections/ NGT No Consent Only in life saving + pt unable to give (whatever the cause) or refuse. 1. Diagnosis 2. Treatment / procedure 3. Risks &benefits of treatment/ procedure. 4. Alternatives to treatment / procedure 5. Risks of not receiving treatment / procedure

Informed Medical Consent

Establish What The patient Know

Discussion all ( in brief) 1. Diagnosis = why 2.Treatment/ = procedure 3.Risks &benefits of treatment/ procedure. 4. Alternatives to treatment / procedure 5.Risks of not receiving treatment / procedure

Sympathize - Ensure patient Understand - Listen to concerns/ Answer Q - Offer contact:Breast Care Nurse Prosthetics Nurse End - Summarize - Ensure patient Understand -Offer contact

 + Obtaining Informed Medical Consent

Same with all Explain why interview I am asked by Dr/..( or team) To come & talk to you about your operation that is planned tomorrow / next week ? Open questions 1st establish what he Know - Do you know Why this operation/ surgery are planned for you? -Ok I will start to explain some of the aims, benefits, risks and alternatives to this procedure (operation/treatment). We want you to be informed about your choices to help you to be fully involved in making any decisions and at the end if you are satisfied you will sign an informed consent for the surgery. - Please ask about anything you do not fully understand or wish to have explained in more detail Remember, you can change your mind about having the procedure at any time Medical: = Inform the patient directly ( be clear & honest) - Do you know Why this Operation? (= bec the Diagnosis) - Ok I will start to explain & if anything isnt clear or if you have any Question please stop me to reexplain clearly& answer your questions. Social/psychological =Sympathy:- Medical: = Explain in brief(No much technical information) Discussion all ( in brief) During the discussion Frequently establish That the pt understands. Is it ok? Do you have any question? Social/psychological =Sympathy:- Listen to concern, idea& fear + offer (Answer, sympathize & offer solving for any social Q). Social =Sympathy:5.support Including :- cancer care Nurse - Summary all these in simple sentences.. - End Question. Do you have any question, Before we end? - Offer contact? - Thanks the patient ..Thank you Mr. / Mrs..? & smile/ greeting/ check hand

:Discussion EX: a mastectomy & Axillary Clearance

Name of & Why this Operation benefits of procedure Who perform Hospital stay & OP Time Anaesthesia During the procedure Ok, You have been recommended to have a mastectomy and removal of lymph glands in the armpit (axilla) as the surgical treatment for your breast cancer. Aim of Cure It will be performed by a breast surgeon who is a member of the Breast Team. Normally; - You will be admitted to hospital on the day of surgery. - OP Time generally lasts 1- 2 hrs. - You will a stay in hospital of up to 5 days. It will be performed GA (which means you will not be conscious during the surgery). The anaesthetist will see you before the procedure to assess your state of health& discuss the details with you. Anaesthetic and/or sedation will be given to you Mastectomy: This involves making incisions (cuts) around the breast, removing most of breast tissue, including nipple & areola (dark skin around the nipple), + some of breast skin, which leaves a scar that is flat against the chest wall. Axillary Clearance: Lymph glands under the arm (armpit) drain lymphatic fluid from breast & arm. Sometimes the cancer spread to these glands. The procedure = removal of these glands (if present) as far as surgically possible). This wills possibility of a recurrence of the cancer under the arm, + informing us whether the glands are involved by the cancer, which helps us plan the next treatment. Recovery: - After your operation You will wake up in the recovery room You may feeling sleepy. You may have an oxygen mask on your face to help you breathe. - You will have an intravenous line (called a drip) in your arm. This may be attached to a bag of fluid (called a drip), which provides fluid until you are well enough to eat and drink by yourself. - A nurse will check your pulse & blood pressure regularly. - When you are well enough to be moved, you will be taken to the ward. Drain - You may have a plastic tube coming from your wound collects tissue fluid in a small collecting chamber, which is measured daily. When there is fluid collected < 50ml/d the tube will be removed, which is a simple procedure. It will be possible for you to go home with the drain in place. Eating and drinking: you will be able to drink & eat (usually 2-4 hrs. Mobilization: You will be encouraged to get out of bed as soon as possible and move around, this is to help prevent blood clots forming in your legs. We will arrange for a physiotherapist visit you on the ward to give advice exercises. Before you leave the ward, you will be given two temporary prostheses comfies. Fitting the

After the procedure

Post surgical treatment

Alternative procedures that are available

Complications/ risks Very common = 10 % common= 1% Uncommon (1 /1000 ) Rare= (1/ 10,000) very rare= (1/100,000)

permanent one will be about six to eight weeks after your operation and the service is provided free of charge. Leave hospital: if you are well enough. you may go home the day of or day after your surgery Begin gentle work within 1- 2w, but a little longer( 6w) for more vigorous activity. Special measures to take after procedure: You will be given more detailed information about any special measures & about things to watch out for that might be early signs of problems (e.g., infection). The skin stitches are dissolvable and will not need to be removed. You will have a light dressing covering your wound to keep it clean, and this will usually be in place for the first day or so. These will gradually come off in the bath or the shower. Check-ups and results: You will be given a date to return to clinic for the results of your surgery. By then the tissue removed at the operation will have examined and your results discussed by the Breast Care Team. Any further treatment, if recommended, will be discussed with you then. Plan the next stage of treatment (adjuvant therapy) to help prevent recurrence of cancer &improve your outcome. When deciding if you need post-surgical treatment (called adjuvant therapy), your team will assess several factors, including: the risk of cancer recurring, characteristics of the cancer,& how much the treatment will benefit you. This will be discussed with you by a member of the Breast Team. Information and support. Additional information will be given to you in the form of a Patient Information Breast Care Pack. Social/psychological =Sympathy:- Do feel free to speak to a member of staff if you have any questions or anxieties. Breast Care Nurses Prosthetics Nurse Mastectomy In some cases it is possible to treat cancer by removing part of the breast only. When surgery is inappropriate, the cancer can be treated by radiotherapy or medication alone. Axillary clearance Radiotherapy to the axilla. However, the present recommendation by the Breast Team is that in your case, mastectomy and axillary clearance is the best form of treatment at this stage. Other forms of treatment may be utilized in the treatment of cancer such as radiation therapy (using high-dose x-rays to kill cancer cells), chemotherapy (drugs kill cancer cells), and hormone therapy (hormones to stop the cells from growing)..These will be discussed with you if and when appropriate. Surgery: All operations have a small risk of side effects, such as pain, bleeding and infection. The risks associated with general anaesthesia include potential breathing and heart problems, as well as possible reactions to medications will be discussed by The anaesthetist . Serious or frequently occurring risks Mastectomy: Altered sensation: You might have tingly feelings or shooting pain where the breast was removed, this can last for six months or longer. Additionally, some women notice a change in their balance due to the loss of the breast weight. Wearing a prosthesis helps with this problem. Seroma; is a collection of fluid under your chest scar after surgery. It is relatively common, but is easily treated by simple procedure = drainage through a small needle.. Axillary clearance: Numbness: You may experience numbness and discomfort in the armpit and upper arm. The numbness usually lessens slowly, after treatment, but might not resolve completely Shoulder stiffness: The shoulder may become stiff and painful after your operation. Performing shoulder exercises (taught to you after the operation) improves mobility. Lymphoedema is a swelling in the tissue below the skin caused by lymph fluid which cannot drain away. This can occur when the lymph glands are removed (by surgery) or blocked (by radiotherapy) secondary to scar tissue formation. The hand and or arm may swell at any time after the surgery. It can affect about 15 to 20% of women but only around 5% to a significant degree. There are certain precautions you need to take to prevent lymphoedema, these will be discussed with you by the Breast Care Nurse.

( 5 ) ) = ( + = ) - I )+ ( ( = -1 = -2 -3 ......... ..... ........ = -4 ( ) -5 + - = -6 ) = ( =

 II =) = ( ) . = ( ) = ( -: -1 -2 ... -3 ..... -4 .... = + ) 10 ( -: .... -: ) ( ....... ........ ..... -: /)........ = ( ) ( : / ......... -: ) ( - I = ) ( ) + = = = ........ .............. ) ( = - + ) = ( + = II =) = ( ) . = ( ) = ( ) = ( -: -1 -2 ... -3 ..... -4 .... ........... +
Thyroidectomy

= + ) 10 ( -: .... -: ) ( ....... ........ ..... -: /)........ = ( ) ( : / ......... -: ) (

Explain why interview I am asked by Dr/..( or team) To come & talk to you about your ? operation that is planned tomorrow / next week Open questions 1st establish what he Know ?- Do you know Why this operation/ surgery are planned for you -Ok I will start to explain some of the aims, benefits, risks and alternatives to this procedure (operation/treatment). We want you to be informed about your choices to help you to be fully involved in making any decisions and at the end if you are satisfied you will sign an informed consent for the surgery.

- Please ask about anything you do not fully understand or wish to have explained in more detail Remember, you can change your mind about having the procedure at any time

Preoperative Before Surgery Explain; Simply

What is a thyroidectomy? A thyroidectomy is the removal of all (total) or part (partial) of the thyroid gland. Why is a thyroidectomy? You may need to have this operation because you have a swelling which could be cancerous or because your gland is overactive. If you do not understand any of the information please ask, since it is important that you make the right decision. When will the operation be done? Time in Preoperative= OPD Admission/ Fitness Assessments:- Attend OPD before surgery( 1- 2w before surgery = assess fitness for sugery &1day for Admission) 1day before You will be admitted through the outpatient clinic your operation one or two You will be invited to attend a pre-admission assessment clinic to assess your health weeks before needs and carry out routine tests which may be required prior to surgery such as your operation blood tests, a heart tracing also known as electrocardiogram (ECG), or a chest X-ray. + Ear/ose/ larynx physician will assess the normal function of the nerve that controls your voice-box OR Time 1-2 hours. Consultant/or Team( name if given in scenario) GA/ -position Supine with head lower 20o & sandbags between shoulder/ skin prepared +draped Through an 8 cm transverse skin cut in lower neck then layers opened in .. .. . The surgeon will either remove one half of the thyroid (called a thyroid lobectomy) or remove the whole thyroid (called a total thyroidectomy), depending on the abnormality of the thyroid gland. ( ectomy =excision =Removal of the organ out = + after control of blood supply + ensuring stop bleeding) Time in Post operative + Treatment General Any operation can have potential risks ( bleeding, infections( chest, UTI , wound), Clots in leg veins lung vessels ( & special precaution will be taken according to patient risks), other cosmetic of scar problem( hypertophic / Keloid)

Operative Surgery Name of Surgeon Anaesthesia Steps (simple)

Post operative After surgery

Specific few Day risks of Surgery

- Damage to the nerve that controls your voice-box (0.5 -1% chance), this can leave you hoarse. Most patients are a little husky after the operation, this Recovery .. Following the operation you are kept in the theatre recoverybut area for is aroundby 3-4 hours and then returned to theneck ward.and having a tube placed down your caused having an operation on your Drip for When you wake up,usually there will be a drip in a your arm Through which fluids+ Antibiotics throat breathing and settles after few weeks. +pain killer you. - Damage togiven your to parathyroid glands (5% chance). These are four little glands Drain: Also, a little drain( tube to a small bag to remove next to your thyroid, whichplastic control theconnected blood calcium. Weplastic will perform routineany blood remaining blood out) in your neck with a dressing around it. tests after your operation to make sure that the blood calcium level is normal. If the Drink You will be allowed to drink the same night + Walk You are encouraged to be as blood calcium level is low, then we will start you on calcium tablets. The chance of active as possible. needing calcium tablets at one year after the operation is aboutgland 1%. called Daily calcium test in blood to check Hypofunction of other nearby - Significant bruising (3% chance) that blood)that need return tobe operation room again to parathyroid wound gland ( control calcium () in your my damaged or removed
evacuate clot +control bleeding Day next drip and the drain(1- 2d or output < 100cc for 2 d) will be removed. Depending on the type of operation that was done on your thyroid, you may be started on thyroxine therapy this is a natural hormone that replaces the job of the thyroid gland. And If your gland has been over-active, then the anti-thyroid medication is stopped. Discharge Usually on the 2nd day after you surgery you will allowed to go home There will be one stitch under the skin, which will be removed by your GPs nurse, five days after the operation. You can return to work You will attend OPD to assess thyroid function by doing hormone tests (TFTs)

1st Day after Surgery 2nd Day after Surgery 5th Day after Surgery 1- 2w after Surgery 6-8w after Surgery

Complications Very common = 10 % common= 1% Uncommon (1 /1000 ) Rare= (1/ 10,000) very rare= (1/100,000)

Complications In OR Post operative Immediate ( 1st day )

General - Death/ bleeding - Pain - Bleeding / haematoma - Those of Anaesthesia lung collapse due air passage block Bleeding , bruises, infections( wound, UTI Respiratory) wound open DVT/ PE ( clots in leg/ lung vs)

Specific - injury of the nearby structures - Effects of the nearby structures injury) - wound blood clot may need push to operation room again to evacuate clot +control bleeding - Wound Abscess) wound open effects of the nearby structures injury) - Effects of the nearby structures injury)

Early ( 2nd d 1 2 w)
st

Late (after 2 w) Delayed ( after 2 mo), Scar ( Keloid/Hypertrophic)

- Effects of the nearby structures injury) - Effects of the nearby structures injury) Effects of organ removal ( hypofunction - Recurrence

 II =) = ( ) . = ( ) = ( ) = ( -: -1 -2 ... -3 ..... -4 .... ........... +

Common surgery consent

= + ) 10 (
Same in all OR Consent

Preoperative Before Surgery Explain; Simply Operative Surgery Name of Surgeon Anaesthesia Steps (simple)

What is? Surgery definition Why is.? = treatment option Diagnosis If you do not understand any of the information please ask, since it is important that you make the right decision. When will the operation be done? Day case or otherwise same in all elective OR Time .hours. Consultant/or Team( name if given in scenario) GA/ -position skin prepared +draped Through Acm skin cut in then other layers opened in .. .. . The surgeon will remove. . ( ectomy =excision =Removal of the organ out = + after control of blood supply + ensuring stop bleeding) to be sent for analysis Time in Post operative + Treatment Same as before Unless A day case surgery (discharge in same day) and some few specific Postoperative follow up (Drain removal stitch removal General Specific Any operation can have potential risks ( bleeding, infections( chest, UTI , wound), Clots in leg veins lung vessels ( & special precaution will be taken according to patient risks), other cosmetic of scar problem( hypertophic / Keloid)

Post operative After surgery Complications Very common = 10 % common= 1% Uncommon (1 /1000 ) Rare= (1/ 10,000) very rare= (1/100,000)

few risks

Complications In OR Post operative Immediate ( 1st day ) Early ( 2nd d 1 2 w)

st

General - Death/ bleeding - Pain - Bleeding / haematoma - Those of Anaesthesia lung collapse due air passage block Bleeding , bruises, infections( wound, UTI Respiratory) wound open DVT/ PE ( clots in leg/ lung vs) Scar ( Keloid/Hypertrophic)

Specific - injury of the nearby structures - Effects of the nearby structures injury) - wound blood clot may need push to operation room again to evacuate clot +control bleeding - Wound Abscess) wound open effects of the nearby structures injury) - Effects of the nearby structures injury) - Effects of the nearby structures injury)

Late (after 2 w)

Problem =

- Effects of the nearby structures injury) Delayed ( after Effects of organ removal ( hypofunction 2 mo), - Recurrence Refusing surgery = Complication of the disease + inform him that you have all rights to refuse surgery And a 2nd surgical opinion is available for but should know what the benefit of surgery ( cure) and what is the risks of refusing surgery= Progression +Complications of the disease Other Treatment options if pt Afraid of Complications give him what other option if available for his case = indications+ benefit &risks for each e.g. medical /radiotherapy radioactive iodine,/ radiation/ chemotherapy As

( =) = II ) = ( ) = ( ) . = ( -1 -: -3 ..... -2 ... -4 .... ........... +

Obtaining Organ transplant consent Obtaining Organ transplant consent +

I- Breaking bad news II- Informed Organ transplant Consent Same as with all I- Breaking bad news Explain why interview I am asked by Dr/.( or team) to come to talk to you about you concern Open questions 1- I would like to ask you, what is your relation to the patient ? 2- Would you like someone to be with us in this consultation? 3- I would like to ask you, what do you know about the problem? Social/psychological =Sympathy:If pt said that:- " I dont want to know offer postpone. I- Breaking bad news Inform death ( warn / Shot ) (wait & Listen react) Then cut the silence Explain ( Brain death) Social/psychological =Sympathy:= Warn"Fire a Warning Shot" =incoming news is not good. "Unfortunately I have some bad news to tell you," or "I am sorry to tell you," Medical:, Shot I am afraid to tell you = Inform the relative t directly ( be clear & honest) = no false hope Social /psychological =Sympathy:= Wait & check for the patient response+ react with him/ her emotion ( use both verbal& body language + always your eyes contact with pt's eyes) Range of normal reaction is wide 1. If the patient keep silent you should be silent for a moment, dont interrupt & give a chance to take the shock of this bad news. 2. If cry offer tissue Social =Sympathy:-Break this silence, I am sorry Mr. / Mrs. I understand it is difficult to you. Would you like to call someone to be with us? Are you ok? if Ok, go on to the Next step. Move to Medical plan:-= Explain brain death + Possibility to Disconect breating machine Before discussing , it is important to ask the relative if they are ready for such discussion. - I would like to Ask you, do you want to tell you more about this? - Ok I will start to explain what does the brain death mean? & if anything isnt clear or if you have any Question please stop me to re-explain clearly& answer your questions. (Start discussion: Explain ( Brain death discussPossibility to Disconect breathing machine it is the breathing machine that make him lives and without it he cannot take his breath During the discussion Frequently establish That the pt understands. Is it ok? Do you have any question? Social /psychological =Sympathy:- Listen to concern, idea& fear + offer (Answer, sympathize & offer solving for social Q). II- Informed Organ transplant Consent Medical: = Explain Organ transplants - Explain in brief(No much technical information) - Do you know What this mean? - Ok I will start to explain & if anything isnt clear or if you have any Question please stop me to reexplain clearly& answer your questions. Social/psychological =Sympathy:- Medical: = During the discussion establish That pt understands. Is it ok? Do you have any question? Social /psychological =Sympathy:- Listen to concern, idea& fear + offer (Answer, sympathize & offer solving for social Q). - Summary all these in simple sentences.. - End Question. Do you have any question, Before we end? - Offer contact? Thanks the patient ..Thank you Mr. / Mrs..? & smile/ greeting/ check hand -

Information Gathering

Information gathering History (H/O) Taking

The history of the present illness (HPI) includes all of the patient's history, both recent and remote, that is pertinent to understanding the current illness Complete present history (= you will have collected a great deal of data) the remaining medical history = past medical history+ family history+ social history/patient profile ( sympathy ), and + review of systems. Of course, new information may appear at any time. During the remainder of the interview, the physician directs the patient to fill in the blanks, completing the rest of the history. Each new piece of information is assessed for reliability, completeness, and relevance to the patient's problem. The physician should repeatedly scan the information already gathered looking for symptom complexes or diagnostic patterns. For example, the physician interviewing a 30-year-old woman with fever, back pain, and urinary frequency would immediately consider the possibility of a urinary tract infection. With increasing knowledge of clinical syndromes, the clinician's ability to form more complex diagnostic hypotheses improves. Each hypothesis is tested for validity with further specific questions such as, "Have you ever had a bladder or kidney infection? Any kidney stones? Are you sexually active?" Through this process, speculations are tested against objective reality and accurate hypotheses are generated.

Social /psychological =Sympathy:-= Frequently, problems in the interview. Patients often

have specific, perhaps unrealistic, fantasies about what the physician will or can do. The interviewer should try to identify these. The patient's explanatory model of illness, differing with each patient and with each cultural group, may significantly determine an individual's behavior during an illness and affect compliance with medical therapy. Negotiation may bring doctor and patient closer together 1- Patient's emotional reactions = (anxiety, fear anger or helplessness) Pick up during the interview Listening=physician's interest and concern + encourages the patient to go on talking. React = Responses vary with the severity of illness, past experiences, personality, current stresses and supports. Reassurance may be provided an attempt to reduce the patient's anxiety but avoid false reassurance the unrealistic promise of a happy outcome. Statements such as "Anyone would be upset if they didn't know what caused their pain" or "Waiting for biopsy results is pretty tough for most patients" may increase the patient's self esteem and let him or her know that it is all right to share experiences with the physician . 2- + Social history. Sex During the sexual history, patient's often respond more candidly to the statement "Some patients with heart problems find that they have difficulties with sexual function . Has this been a problem for you?" rather than "How is your sex life?" Social history Patients often respond defensively to questions such as "How much do you drink?" minimizing the quantity to please the interviewer. Smoking, Alcohol, Living (who is living with youcare you at home is it away from hospital is there telephone

3- Empathy is closely related to reassurance . Empathic statements communicate the

physician's recognition of the patient's feelings and provide feedback that the interviewer understands . Empathy begins with the interviewer identifying the patient's emotional state . The following statement communicates the physician's recognition and acceptance of the patient's feelings and encourages further exploration of what is going on : "You look sad when you talk about your son Can you tell me more about him?" Pointing out the patient's emotion is a form of gentle confrontation . It focuses attention on an aspect of the patient's feelings that has been communicated through statements or behaviors . Communication problems Example; Patients cry peace= best to let the storm pass. Then gently resume "You seem angry about that . Can you tell me more about what has been going on?"

patient does not want to talk about issues that seem important. "You seem reluctant to talk with me about your problems. I wonder if you may be uncertain about whether or not you can trust me . .. For me to be able to help you I need to know as much as possible about your problems . . . . How do you think we should proceed?" These statements identify the problem with a confrontation, suggest a possible cause for the problem (distrust), establish the physician's need to know more, and invite patient participation in deciding what course the interview will take . Type of Questions Begin each line of inquiry with an open-ended question and proceed to more specific questions to fill in the gaps. Effective questions are usually simple. Avoid double-barreled questions, such as "Are you having any stomach pains or bladder problems?" To do a complete ROS, however, would take forever. Look in any good history and physical examination book and see the list that they dedicate to ROS. Impossible. LIST of RoS questions from the Schwarz physical exam book onto a cheat sheet. who on earth asks about exposure to diethylstilbestrol?! I don't ask about this on all of my patients especially if I think I know what is going on or the patient has a specific organ system complaint. I also occasionally ask more if I have no idea what is going on. What the other poster said about a focused ROS is acutally called associated symptoms which should be part of your HPI. Usually when I see a patient I will tailor my ROS to areas that are appropriate to the pts age. I usually always ask about the lungs, heart and abdomen. You'd be surprised how much of this is positive. Most of it is just passing annoyances, but you never want to miss a red flag or a collection of positives that may indicate an underlying syndrome (such as cold intolerance, recent weight gain, and thinning hair possibly indicating a thyroid abnormality). A Review of Common Problems 1 . Confusing the traditional, rigid order of the written medical history with the actual process by which information emerges during the medical interview. 2. Relying too heavily on directed, closed questions . This style discourages the patient's associations and spontaneous report of symptoms . 3. Ignoring the patient's emotional responses and concerns during the interview process . 4. Narrowing the scope of inquiry too early in the interview. 5 . Failure to clarify the seven dimensions of a symptom in the patient's own words . 6 . Insisting that the interview must be accomplished in one session . (Experienced clinicians return to the patient again and again to clarify the history .) 7 . Limiting the list of diagnostic hypotheses before adequate data has been collected . 8. Using questions that are leading, too complex, double barreled, or unclear . 9. Failure to follow basic courtesies in the interview : lack of clear introductions, ignoring the patient's comfort, and failure to establish an atmosphere of trust and confidentiality . 10. Failure to elicit the patient's own ideas about the cause of the problem and the patient's fantasies about what the doctor will do .11 . Note taking that interrupts the flow of the interview . REVIEW OF SYSTEMS (ROS):- If positive analysis as usual ( OCD + what you think it cause this Site Quantity/ Quality what & what.

History (H/O) Taking Never to use medical term use simple language if you cannot know just simplify the term by defining it. as we call it.OR Ask patient to describe what he feels. How you feel during he pass urine Is there any trouble ?

History (H/O) Taking

Same as with all

Explain why interview:- I am asked by Dr/.( or team) to come to talk to you about you concern Social /psychological =Sympathy:- I will ask you some questions about your concern that are very important in assessment of your diseases and so its management Take a permission to write these notes: 1st please I would like to ask you a permission to write these notes bec I will present these information to my consultants at the end of the interview Is it ok? I am going to star now is it ok?

Medical:- = Social /psychological = Social /psychological =Sympathy:- = Listen to concern, idea& fear + offer (Answer, sympathize & offer solving for any social Q). SOCIAL POINTS, Offer help in a question PSYCHOLOGICAL POINTS, Offer help this in a question Medical:PERSONAL H/O: Your name is Mr. / Mrs.,(Family Name) ., Age.y, work as . So I am right? Are you having kids? if yes how many.. + Social H/O :- (Sexual H/O :- HIV risk, married/kids/) & , special habits Are you Smoking? if yes how much /day? For how long? Are you alcohol? if yes how much What is the problem What is you concern? . Pain Swelling Dysfunction Others ( in patient wards) Analysis the main symptom s - ex ( pain..) Should mention (OCD) onset, course and duration. What & What . You Should Ask Aboutas follow.. - Duration:- when The condition start what happen 1st (H/O of main symptoms) is it sudden/ acute/ insidious(Onset ) What do you think it cause this? ( cause/ ppt factors) (Following H/O of cause) - With........................................... ex ( pain) how is pain severity/ 10( is it slight moderate or sharp and severe ....is it constant or coming and going...character ((what does it feel like? is it / burn/ can you describe it .where is it ?.. referred to ( is it go to another site? .. What ..& What .. - Course :- ( progressive/ regressive/ stationary) ASSOCIATED SYMPTOMS (Other related) symptoms Same disease & organ ( system ) You Should Ask Aboutas follow.. Do you have any .. ............................................ ............................................ - Start with related system then nearby then away - Aiming to elicit what can cause this problem Effects and complications of the disease & to differentiate other diseases that may be similar & mistaken for your disease - This to make sure we do not mess anything that may be important. - If positive analysis as usual ( OCD + what you think it cause this Site Quantity/ Quality what & what). -You Should Ask About as follow.. Do you have any.. 1. Cause and risk factors............................................ 2. Complications symptoms = Effects of the disease

C/O= concern / problem PRESENT H/O:-

A REVIEW OF SYSTEMS (ROS):-

Local = Regional = LNs= other swellings/ or their effects e.g. pressure symptoms General e.g. Constituational .. Systemic effects .. 3. DD symptoms Systems You Should Ask Aboutas follow.. Do you have any trouble with. Systematic direct questions -I'm now going to ask you a series of questions about common medical problems. This to make sure we do not mess anything that may be important. System review CVS Do you have any trouble with your heart, chest pain or palpitation? Respiratory Do you have any trouble with your lungs, shortness of breath, coughing or sputum? GIT Do you have problem in digestion, lose weight, difficulty in swallowing, heart burn, nausea/vomiting, abdominal pain, swelling, change of bowel habits, rectal bleeding? Genitourinary Do you have any problems passing urine, change of color, pain, smell? Female Do you have problems in menstruation? Do you have children? How many? How old is the youngest? (Female) You Should Ask Aboutas follow.. Do you receive or treatment or Do any test for this proble

H/o of present invest/ ttt PAST H/O

Transitional statements prepare the patient for what is coming next Now I would like to ask you some questions about your past health.".
(SURGICAL):- Do you have any 1- Surgery Past history Did you have any operation before? Have you been admitted to any hospital before? 2 - Previous evaluation of or (treatment for) a disease (e.g., medications, injections, surgery, compression). Did you have any 3 - Other diseases:- Did you have any Related disease/ Associated. (MEDICAL) 1- Medical Systemic disease (affect outcome) (e.g. DM, HTN, CHD, CVA) 2- Medications Do you take any medication or contraceptive pills (Female)? 4- Allergy ( food, Drugs) Do you have any allergy? = (Genetic) H/O of disease ( 1st relatives).

FAMILY H/O

Transitional statements prepare the patient for what is coming next Now I would like to ask you some questions about
Do you have any similar problem in your family (children, parents, brothers, sisters)? Does anyone of your family have a heart disease, DM, blood pressure, tumor or any chronic disease? Social /psychological =Sympathy:Patient concern "Before we go on, let's see if I understand your history. I am going to summarize what you told me to be sure that I am not missimg any thing important Ok. Summary all these in simple sentences (+ve. findings) Last March you first noticed .." This summary gives the patient a chance to

check the accuracy of the history and gives the physician a chance to review the history for gaps or lack of clarity ..
Social /psychological =Sympathy:Patient concern ?Is It ok? Is this all things? Are you concerned about anything else Do you have any question,? Offer opportunities available for further information Offer contact? . So I am going to present these information to my consultants is it - Thank you Mr. / Mrs..? & smile/ greeting/ check hand

Again General sheet (H/O Taking)

Hello I am (position) Is it Mr. . Sit down please. (Smile with eyes contact)
Explain why interview:- I am asked by Dr/.( or team) to come to talk to you about you concern Social /psychological =Sympathy:- I will ask you some questions about your concern that are very important in assessment of your diseases and so its management Take a permission to write these notes: 1st please I would like to ask you a permission to write these notes bec I will present these information to my consultants at the end of the interview Is it ok? I am going to star now is it ok?

Medical:- = Social /psychological = The main task Medical:Personal history Name - Age Occupation (Already known from scenario) Social history Sex ( active or not / married or not ) have kids or not Smoking (how much / d X how long) Alcoholic ( How much / w X how long) Complaint Pain Swelling Dysfunction Others ( in patient wards) Present History IPresent History Analysis IIA Review of Systems ( mainly that related to disease) Aiming to elicit ( Causes & Risk factors / complications /D.D/ fitness for surgery) IIIH/ O of Present Investigation & treatment Past History Surgery (any surgery if yes( what when & complications including anaesthesia) Medical (diseases/ drugs/ allergy last meal in emergency surgery) Family History Social /psychological =Sympathy:- = Listen to concern, idea& fear + offer (Answer, sympathize & offer solving for any social Q). SOCIAL POINTS, Offer help in a question PSYCHOLOGICAL POINTS, Offer help this in a question During H/ O Taking frequently establish that the pt any question. Do you have any question? Is it ok? Or something to added or explain Anything else or any thing to explain Social /psychological =Sympathy:- Listen to concern, idea& fear + offer (Answer, sympathize & offer solving for any social Q).
Social /psychological =Sympathy:Patient concern

"Before we go on, let's see if I understand your history. I am going to summarize what you told me
to be sure that I am not missimg any thing important Ok. Summary all these in simple sentences (+ve. findings) Last March you first noticed .." This summary gives the patient a chance to

check the accuracy of the history and gives the physician a chance to review the history for gaps or lack of clarity ..
Social /psychological =Sympathy:Patient concern ?Is It ok? Is this all things? Are you concerned about anything else Do you have any question,? Offer opportunities available for further information Offer contact? . So I am going to present these information to my consultants is it - Thank you Mr. / Mrs..? & smile/ greeting/ check hand

(Verbal)

PRESENTATION of History (H/O) Taking ( 5min)

(+ve. findings)

- Simple language - Methodical approach - Comprehensive - Succinct (keep to 5 minute limit) - Emphasis and significance - keep appropriate to surgical context - Interpretation of ideas and concerns PERSONAL H/O: -Mr. / Mrs.,(Family Name) ., Age.y, work as Social H/O :- (Sexual H/O) :- ..married/ kids/) .Smoking / day.. alcohol /w C/O= concern / problem PRESENT H/O:- = Main Bulk I- Analysis the main symptoms:- The condition start since with. of sudden/ acute/ gradual( onset).. of ..= main symptoms) (Following H/O of cause) - The .= main symptoms).......................................... ex ( pain) how is pain severity/ 10( is it slight moderate or sharp and severe ....is it constant or coming and going. ..character ((what does it feel like? is it / burn/ can you describe it .where is it ? .. referred to ( is it go to another site? .. What ..& What .. - Course :- ( progressive/ regressive/ stationary) ............................................ ASSOCIATED SYMPTOMS (Other related) symptoms Same disease & organ ( system ) ............................................ ............................................ II- A REVIEW OF SYSTEMS (ROS):- If positive analysis as usual ( OCD + what you think it cause this Site Quantity/ Quality what & what. 1. Cause and risk factors............................................ 2. Complications symptoms = Effects of the disease Local = Regional = LNs= other swellings/ or their effects e.g. pressure symptoms General e.g. Constituational .. Systemic effects .. 3. DD symptoms Systems CVS Respiratory GIT Genitourinary Female III- H/o of present invest/ ttt PAST H/O (SURGICAL):1- Surgery Past history admitted to any hospital at / / 2 - Previous evaluation of or (treatment for) a disease (e.g., medications , surgery, compression). 3 - Other diseases:Related disease. Associated. (MEDICAL) 1- Medical Systemic disease (affect outcome) (e.g. DM, HTN, CHD, CVA) 2- Medications Do you take any medication or contraceptive pills (Female)? 4- Allergy ( food, Drugs) Do you have any allergy? FAMILY H/O The examiners will discuss you about ( 5 min) 1. What DD would you suggest at this stage based on the history? 2. What signs would you look for specifically in the examination 3. What investigations would you request for this patient? - Thanks all examiners

Main sympto ms Pain

Present History Analysis You should know what you Ask about Analysis of The Main Symptoms
Site & referral OCD Onset Course by time Is it or no change constant? Duration Severity Character (Burning, throbbing, stabbing, constricting, tightness, colicky or just a pain) Relation to act (= meal / effort (walking exercise elevation Relation to rest ( rest/ sleep) & position stand/ lying flat ) Exacerbating factors Relieving factors

Questions

Where is it? Where it goes? Is it sudden or gradual? How often does it happen? When did it start? How bad is it? 1/10 What does it feel like?

What brings it? Or What eases it? Or

A Review of Systems ( mainly that related to

disease)

Aiming to elicit ( Causes & Risk factors / complications /D.D/ fitness for surgery)
ROS = Other associated /Symptoms or H/O of the 1- Cause like trauma,infection, inflammation, PVD, Venous, Neuropathy, cancer 2- Complications Local ( same organ/ system of the main complain + nearby) (swelling/ disturbed function) Regional LNs Ask about Swellings ( Associated/ complication local or regional e.g. LNs) or DD General Constitutional symptoms Systemic symptoms (cause/ complication/ DD/ surgery fitness ( Heart, breathing, Neurology, GIT, GUT, PVD, Ortho) ) other body system quick direct Questions & if any +ve analysis 3- DD ( could be local causes/ referred/ same system or other system) Why do you think you've got it? Do you have trouble with .. Do you have any lumps? Did you become feverish? Do you have trouble with ..

Do you receive any recent treat or have any test for your problem

H/ O of Present Investigation & treatment

Swellings Lumps

Analysis of The Main Symptoms

Site OCD Onset Course Duration Ass symptoms ( Painful/ painless) ( cause / complication/ DD)

Where is it? Is it sudden or gradual? By time Is it or no change constant? When did it start? Is it painful?

A Review of Systems ( mainly that related to

disease) ROS = Other associated /Symptoms or H/O of the. 1- Cause congenital (dating since birth or shortly) trauma, infection, inflammation, PVD, Venous, Neuropathy, cancer 2- Complications Local ( same organ/ system of the main complain + nearby) (swelling/ disturbed function) = pressure or difficulty in (function) Regional LNs Ask about other Swellings ( Associated/ complication local or regional e.g. LNs) or DD General Constitutional symptoms Why do you think you've got it? Do you have. Do you have any other lumps? Did you become feverish?

Systemic symptoms (cause/ complication/ DD/ surgery fitness ( Heart, breathing, Neurology, GIT, GUT, PVD, Ortho) ) other body system quick direct Questions & if any +ve analysis 3- DD ( could be local causes/ referred/ same system or other system)

Do you have trouble with ..

H/ O of Present Investigation & treatment

Ulcer

Do you receive any recent treat or have any test for your problem

Analysis of The Main Symptoms

Site OCD Onset Course Duration Ass symptoms ( Painful/ painless) ( cause/ complication/ DD)

Where did it start? Is it sudden or gradual? By time Is it or no change constant? When did it start? Is it painful?

A Review of Systems ( mainly that related to

disease)

Aiming to elicit ( Causes & Risk factors / complications /D.D/ fitness for surgery)
ROS = Other associated /Symptoms or H/O of the. 1- Cause congenital (dating since birth or shortly) trauma, infection, inflammation, PVD, Venous, Neuropathy, TB, malignancy, SCC, BCC/ Marjolin) 2- Complications Local ( same organ/ system of the main complain + nearby) (damage & spread /swelling/ disturbed function) = other ulcer/ swelling/ or difficulty in (function) + Ask about other ulcer Regional LNs Ask about other Swellings ( Associated/ complication local or regional e.g. LNs) or DD General Constitutional symptoms Systemic symptoms( cause/ complication/ DD/ surgery fitness ( Heart, breathing, Neurology, GIT, GUT, PVD, Ortho) ) other body system quick direct Questions & if any +ve analysis 3- DD ( could be local causes/ referred) Do you have trouble with .. Why do you think you've got it? Do you have. Do you have other ulcers? Do you have any lump? Did you become feverish?)

H/ O of Present Investigation & treatment

Do you receive any recent treat or have any test for your problem

SYSTEMS Do you have any trouble with. General/Constitutional

Ask about Do you have? Do you feel..?

o Fevers? o Chills? o Sweats? o Weight changes? o Weakness? o Fatigue? o Heat/cold intolerance? ..Do you prefer cold/ hot weather o Bleeding? o Blood transfusions/possible reactions? o Rashes? o Itching? o Easy bruising? o Dryness? o Changes in skin/hair/nails? o Headaches o dizziness o Fainting? o H/o of head injury? o Use of glasses/contacts o Change in vision? o Double vision? o Pain when looking at light? o Pain? o Redness? o Discharge? o Infections? o Excessive tearing? o Recent eye exams? o H/o of eye Injuries? o Hearing difficulty ? o Use of hearing aid? o Discharge? o Pain? o Ringing in ears? o Infections? o Nosebleeds? o Infections? o Discharge? o change in smell o Frequency of colds? o Nasal obstruction? o History of injury? Mouth o Pain o Discharge o Lump o change in Taste o Condition of teeth o Condition of gums o Bleeding gums Throat o Frequent sore throats o Hoarseness o Voice changes o Past nasal discharge o Pain o Pain on mvmt o Discharge o Lump/ Lumps o Goiter o Lumps o Discharge o Pain swollen glands in armpit o

Skin

Head

Eyes

Ears

Nose

Mouth/Throat

Neck Breasts Chest Respiratory

o Pain o Shortness of breath o Cough o Sputum (quantity, appearance) o Coughing up blood Wheezing o Last x-ray o Chest pain o High blood pressure o Palpitations o Shortness of breath with exertion/ when lying flat/ or Sudden While sleeping? attack

Heart

o History of heart

Vascular

o Pain in hips, legs, calves, thigh while walking o Coolness of extremity o Loss of hair on legs o Discoloration of extremity o Swelling of legs o Varicose veins o Ulcers o Appetite (is the desire to eat or is to cause discomfort ) o Excessive hunger o Excessive thirst o Nausea o Vomiting ( OCD amount color relation to meal + what & what. + pain/associated Symptoms) o Vomiting blood Oesophagus o Difficulty in Swallowing( OCD site, relation to meal fluid vs. solid what & what. + pain/associated Symptoms) o Heartburn o Excessive belching Abdominal pain ( OCD site, radiation severity 1/10, type can you describe how you feel it , relation to meal + what & what. + Ass symptoms) Colorectal & anal Change in bowel movements o Laxative or antacid use o Constipation o Diarrhea( OCD amount consistency, color odor, mucus blood what & what. + pain/ass symptom) o Hemorrhoids o Rectal pain o Rectal bleeding o Black, tarry stools Liver disease o Ascites (do you have any Change in abdominal size + wt gain o Jaundice (do you have any yellow change in your eye colour) abd pain/ fever/ chills o Hepatitis o Gallbladder disease( OCD site, radiation severity 1/10, type can you describe how you feel it , relation to meal + what & what. + associated Symptoms Jaundice / fever ) You going to the bathroom okay? Anything hurting you?

GIT

Frequent Urgent do you pass too much o Awakening at night to urinate o H/O of retention o Incontinence o Bed-wetting o Urine color o Urine odor o Infections o Stones o Flank pain Male genitalia Female genitalia o Pain o Discharge o Lump o Sexual Activities o Frequency of intercourse o Infections o Fertility

A cerebrovascular accident (CVA) or stroke is a sudden onset of irreversible neurological deficit. A transient ischaemic attack (TIA) is a sudden onset of neurological deficit that resolves within 24h musculoskeletal o weakness o paralysis o muscle stiffness o limitation of movement o joint pain o joint stiffness o INCEDENCE:CVA is the 3 rd most common cause of death in the UK after coronary heart disease and cancer. arthritis CVA has an incidence of 2 /1000. 15% of these are due to atherosclerotic disease of the carotid arteries. o gout o back problems o muscle cramps o deformities -:Risk factors Same as Atherosclerosis -:Causes neurologic o fainting o dizziness o blackouts o paralysis o strokes Complications (cerebral-ocular (stroke , TIA, amaurosis fugax o numbness o tingling o burning o tremors o unsteadiness of gait o loss of memory o loss PATHOPHYSIOLOGY of consciousness o psychiatric disorders o Mechanisms:- Atherosclerosis and thrombosis. Thromboemboli. Fibromuscular dysplasia. general behavioral change o mood changes o nervousness o depression o speech disorders o Atheromatous plaques form at the bifurcationoof the common carotid artery and progress into the external and internal carotid hallucinations disorientation vessels. CVA or TIA arise from disease and may be due to: Pathophysiology Ocular or cerebral symptoms: an atherosclerotic plaque (commonest extracranial lesion) at the carotid bifurcation (origin of the internal carotid artery). Platelet aggregation from the surface of the plaque (usually after an acute rupture or opening of the plaque surface); embolization of atheromatous material from the plaque& platelet embolization. CVA or TIA or Ocular symptoms. Symptoms due to flow reduction are rare in the carotid territory, but vertebrobasilar symptoms are usually flow related. Reversed flow in the vertebral artery in the presence of ipsilateral subclavian occlusion leads to cerebral symptoms as the arm steals blood from the cerebellum subclavian steal syndrome. H/O Ask Usually male >65y smoking , HTN, DM, with other risk factors of atherosclerosis & associated atherosclerosis diseases IHD, AAA, PVD (( should ask about) Symptoms ( should ask about & analysis onset/ duration) Several clinical variants of a classic CVA are recognized. Stroke in evolution. Progressive neurological deficit occurring over hours/days Completed stroke. The stable end result of an acute stroke lasting over 24h. Crescendo TIAs. Rapidly recurring TIAs with increasing frequency, suggesting an unstable plaque with ongoing platelet aggregation and small emboli. Neurological features:- These depend on:- the territory supplied by the vessel affected by the embolism. the degree of collateral circulation to that territory. - and the size/resolution of the embolism. Cerebral (or ocular) Transient or permanent Cerebral symptoms motor (weakness, clumsiness or paralysis of a limb); (contralateral) sensory (numbness, paraesthesia); speech related (receptive or expressive dysphasia). Ocular symptoms (ipsilateral): amaurosis fugax (transient loss of vision described as a veil coming down over the visual field).

o Pain o itching o Discharge o Lump o lump/ passing gush of small amount of urine (on straining) o Sexual Activities oCarotid Frequency of intercourse o Fertility Artery disease o pain on intercourse o Infections problems Contraception H/o o birth control methods o OCP exposure H/o age at menarche( period) + ( interval between periods o carotid duration o amount o date of Extracranial arterial periods disease is aocommon disorder 1st characterized by atherosclerosis of the or period o bleeding between periods o menstrual pain vertebral arteries last cerebral-ocular (stroke, TIA, amaurosis fugax) or Obstetric H/o o number of pregnancies o abortions Vertebrobasilar symptoms: Cerebellar (vertigo, dizziness, bilateral paraesthesia, visual o term deliveries o number ofataxia, living children osyncope, complications of pregnancies o description of labor hallucinations). o age at menopause o menopausal symptoms o post menopausal bleeding

Amaurosis fugax. Transient monocular visual loss (described as a curtain coming down across the eye) lasting for a few seconds or minutes central retinal artery. Hemianopia. loss of vision in one half of the visual field. Internal capsular stroke. Dense hemiplegia usually including the face striate branches of the middle cerebral artery. Mapping 1- Pathology = Carotid Atherosclerosis 2- Complication = Cerebral-ocular (stroke, TIA, amaurosis fugax) 3- Causes/ Risk factors( DM, HTN, OBESITY, smoking) 4- Associated other arterial atherosclerosis( CHD, AAA, PVD) - Introduce - Expose neck Proceed as for neck examination. - Wash your hand

Environment

Inspect Look Palpate

Look for Pulsatile swelling noted in line of carotid artery at base of neck or scar. Look for neurological associations For Artery itself may be firm due to calcified plaque - Expansile Mass

Feel Auscultation Both side

Completing

pulse ( one by one from behind) - Bruit over carotid arteries, best heard over course of common carotid artery (anterior triangle) & in expiration. Tell the examiner you will hear /Listen over praecordium to ensure not transmitted aortic stenosis( ejection systolic murmur at Right 2nd intercostal space, parasternal) - Carotid bruits are detectable in over 10% of patients > 60 years of age and do not correlate well with the degree of stenosis or risk of CVA. So it is an unreliable indicator of pathology. Patients with a significant stenosis may have no audible bruit. Neurological Examination ; Previous CVA ; focal neurological signs, ipsilateral Horner's syn.,) Examine for cardiovascular associations (BP, peripheral pulses, heart) Check for signs of atherosclerosis elsewhere

Investigations All patients with transient neurological symptoms should undergo screening for carotid disease clinical examination is not accurate. In addition to those in general with atheroscelrosis; CBC, FBS, Urine, RFTs. Carotid colour duplex scan: B-mode scan and Doppler ultrasonic velocitometry: method of choice for assessing degree of carotid stenosis. all patients who have had a TIA or stroke within the last 6 months. 95% accuracy for assessment of degree of stenosis. CT or MRI brain scan: demonstrate the presence of a cerebral infarct. Carotid angiography: no longer essential prior to surgery( itself risk of stroke = 2%). MRA is reserved for those patients in whom duplex are inconclusive or difficult due to calcified vessels. Treatment:Conservative Medical management; Same as Atherosclerosis Best medical therapy is an antiplatelet agent (e.g. aspirin, dipyridamole), smoking cessation, optimization of BP and diabetes control, and a statin for cholesterol lowering. Anticoagulation is indicated in patients with cardiac embolic disease. Surgery Carotid endarterectomy (CEA):- Targeted carotid endarterectomy offers optimal risk benefit in stroke prevention. 6-fold reduction in stroke / 3 years Offered to patients with symptomatic > 70% stenosis of the internal carotid artery. ECST (Europe) and NASCET (North America) have both demonstrated a reduction in stroke in the first year following CEA, from 18% with best medical treatment to 3-5% with surgery and best medical therapy. There is no significant benefit to symptomatic patients with < 70% stenoses. ACST (UK) and ACAS (North American) trials have shown some benefit of CEA to asymptomatic patients with > 70% stenosis but the number needed to prevent one stroke is 22 patients treated. Indication Carotid distribution TIA or stroke with good recovery after 1-month delay: 70% ipsilateral stenosis; 50% ipsilateral stenosis with ulceration. Asymptomatic carotid stenosis >80% (controversial). Carotid endarterectomy has about 5% morbidity and mortality. stenting Carotid angioplasty - controversial Technical Increasingly undertaken under regional (LA) block. details Oblique incision anterior to sternomastoid. Carotid vessels controlled after dissection. IV heparin prior to trial clamp (if patient awake). Cerebral circulation protected in 10% of awake patients without an intact circle of Willis with a shunt (Pruitt/Javed). Shunt in GA patients depending on surgeon preference and cerebral monitoring (stump pressure of 50mmHg or transcranial Doppler monitoring of middle cerebral artery blood flow). Patch closure with Dacron if small vessel. Close monitoring of BP and neurological state. Death or major disabling stroke, 1-2%. Minor stroke with recovery, 3-6%. Myocardial infarction. Wound haematoma. Damage to hypoglossal nerve, ansa cervicalis, vagus. Prognosis of patients with TIAs 80% of TIA's are in the carotid territory and the risk of stroke following a TIA is around 18% in the first year, 20% of which may occur in the first month of the TIA. The overall risk is 7x the risk of stroke for an agematched population. Carotid artery aneurysm Normally unilateral Causes/ & risk = Symptoms of Atherosclerosis associations (HTN, IHD, CVA, PVD, AAA,& Aortic Dissection) H/o of (Trauma &Previous carotid surgery) Complications neurological (ipsilateral horner's syndrome; focal neurological signs) Previous carotid - Investigations ( Duplex scan / Digital subtraction angiography) - Surgery Postoperative Complications

Prognosis

Peripheral Vascular system history Vital points:- Name/ Age/ Occupation C/O ( in pt wards) -Present H/O:- + analysis OCD of the C/O& risk factors Vascular symptoms Risk factors Fitness for surgery Smoking Diabetes Previous medical history Intermittent claudication Hypertension Anaesthetic history Rest pain Cholesterol Drug history and allergies Critical ischaemia Previous history Social history (related to post-operative rehabilitation) Family history IHD, CVA What you should Ask About:- .. + Analysis of each OCD 1. Symptoms Pain of intermittent claudication Site Stenosis of lower aorta & common iliac arteries: buttock claudication + impotence External iliac artery: thigh claudication Superficial femoral artery: calf claudication Intensity Felt in muscles due to increased oxygen demand Lactic acidosis occurs when insufficient oxygen demands are met Pain due to anoxia, acidosis and build-up of metabolites Precipitating and relieving factors Exercise after a fixed distance Comes on more rapidly walking uphill Relieved by a few minutes of resting Rest Pain Site : Occurs in the least perfused area of the leg (toes and forefoot) Intensity :- Severe, Wakes patient up from sleeping Precipitating and relieving factors Comes on at night (lying flat in bed loss of gravity, reduced cardiac output at rest, relative dilation of skin vessels due to warmth of bedclothes) Relieved by getting up and walking on a cold floor Pain relieved by hanging leg off bed Critical Ischaemia Ulcers or gangrene Rest pain for >2w weeks ABPI <50mmHg 2. Systems Risk factors:- Smoking, DM, HTN, Cholesterol, Previous history, Family history Review Complications - Risk factors Functional impact; Life, work, sleep - Going to shops - Walking aids Limp - Associated diseases Complications - Associated 3. Differential Calf pain due to diagnosis Musculoskeletal: knee, ankle, hip pathology Neurological: spinal stenosis Vascular: intermittent claudication, deep vein thrombosis 4.Fitness for Previous medical history surgery Anaesthetic history Drug history and allergies Social history (related to post-operative rehabilitation

Dysphagia

INCEDENCE:Within the lumen - FB - Oesophageal web (scleroderma) - Plummer-Vinson syndrome In the wall Congenital:- web, OA &TOF, Dysphagia Lusoria Traumatic ( FB, Corrosive, Iatrogenic instrumentation, Violent vomiting,/ rupture) Oesophagitis (Candida, corrosive, or chronic reflux) Strictures:- Benign (Post-radiation/ corrosive /or chronic reflux) - Malignant Cancer Tumours benign malignant Outside the wall = compression:- Neck ( Goitre/ Pharyngeal pouch) in chest (mediastinal syndrome, Retrosternal goitre, LN, Lung carcinoma) Co-ordination Motility disorders :- Oesophageal spasm - Achalasia abnormalities Neurological disease :- Myasthenia gravis, Bulbar palsy (including MND), CVA Complications Weight loss & Cachexia ( Cancer) Regurgitation & Aspiration pneumonia Stasis infection ulceration, He Metastasis ( cancer) PATHOPHYSIOLOGY Risk factors:Causes:Mechanical Obstruction

Mapping

Pathology= Difficulty swallowing . Causes/ ppt/ risk factors Complications

Be conscious of the possible serious pathologies

H/O Ask

Vital = The main task + Risk ( Age/ smoking, family + precancerous diseases) Medical:PERSONAL H/O: C/O= concern / problem PRESENT H/O:/ patient or Mr. / Mrs.,(Family Name) ., Age.y, work as . + Social h/o married/kids/ special habits Dysphagia = difficulty in swallowing

Present History Analysis

- Should mention onset, course and duration. What & What . You Should Ask About.. 1 - Duration& Onset:- The condition start since of sudden/ acute/ insidious( onset) 2 - Following H/O of (cause):- "At what level does the food appear to stick?" "What is causing difficulty: solids, liquids, or both?" solids often first in strictures whereas liquids first in neurological 3- With (H/O of symptoms) ........................................... What ..& What .. 4 - Course :- ( progressive/ regressive/ intermittent/ stationary)

A Review of Systems ( mainly that related to disease) Aiming to elicit ( Causes & Risk factors / complications /D.D/ fitness for surgery)
H/O of Causes/ Risk factors / DD H/O of Complications Weight loss? Can you eat a full meal? Regurgitation:- "Does the food come back up or eventually goes down?" - System review Systemic symptoms:- weight gain or loss, altered appetite, fever Respiratory symptoms:- shortness of breath, stridor, cough Gastrointestinal symptoms Neurological Associated: Lump in throat (globus), neck bulge (pouch), pain on swallowing (odynophagia), heartburn( reflux) PAST H/O (MEDICAL &SURGICAL):-

H/ O of Present Investigation & treatment Past History ( fitness & risks) Surgery (any surgery if yes( what when & complications including anaesthesia)

- Past evaluation of or (treatment for) a disease (e.g., medications, injections, surgery, compression). diseases

Medical (diseases/ drugs/ allergy last meal in emergency surgery) Other diseases:- Related disease/ Associated Previous dysphagia, reflux, or known ulcer disease Stroke, neurological disorders (bulbar palsy, myasthenia)
Systemic disease (affect outcome) (e.g. DM, HTN, coronary artery disease, CVA) 3- Medications:-NSAIDs, steroid inhalers 4- Allergy ( food, Drugs) = (Genetic) H/O of disease ( 1st relatives). Cancers

FAMILY H/O

DD= causes
Investigations Barium swallow / Endoscopy (+ biopsies) / 24 hrs PH monitoring (for reflux), Oesph. Manometry (Motility disorders). Staging cancer:- CT chest/ Endoscopic US/ Abd US& LFTs

Treatment:- Conservative Surgery Prognosis Lumps & ulcers history

Listen carefully to the instructions Establish the patient's details - name, age, occupation Introduce yourself Question:- Straight questions about the Lump / ulcer Onset What made you notice the lump? When did you notice it? Were there any predisposing events? Symptoms How does it bother you? Has it changed? Are there any other lumps? Has it ever healed? Relevant surgical questions - fitness for anaesthesia What treatments have you had in the past for this lump? What do you think is the cause of the lump?

Orthopaedic history taking Key elements in H/O:- Deformity/ Swelling + Pain/ Loss of function/ Stiffness/ (OCD)+ Associated

Thyroid History Approach I- Analysis of Main Symptoms Neck Lump Site OCD Onset Course; change in size - suddenly increased (haemorrhage into necrotic nodule, subacute thyroiditis, rapidly growing carcinoma) Duration Cosmetic symptoms Ass symptoms ( Painful/ painless) ( cause / complication/ DD) pain other associated ( Causes/ complications Symptoms from the swelling) II- A Review of Systems (ROS) ( mainly that related to disease) mainly to elicit Causes/ DD/ complications Ask for A Review of Systems ROS = other associated /Symptoms or H/O of the. 1- Cause congenital (dating since birth or shortly) trauma, infection, inflammation, PVD, Venous, Neuropathy, Tumour (compress or / infiltrate nearby structures/ LNS, Distant metastasis) 2- Complications Symptoms= effect of disease (local regional & general constuitional fever anorexia wt loss) + systemic metastasis Benign Goitre (Cosmetic/ compress nearby structures) Malignant r Goitre (infiltrate nearby structures/ LNS, Distant metastasis) Discomfort during Goitrogenic Goitre (Cosmetic/ compress nearby structures + Hypo Thyroid hormones Function) Toxic Goitre (Cosmetic/ compress nearby structures + Exaggerated Thyroid hormones Function)

Thyroid status Hyperthyroidism General Increased appetite, loss of weight Hypothyroidism Decreased appetite, weight gain, lethargy Preference for hot weather Dry skin, "peaches and cream" complexion, Muscle fatigue Constipation

Thermogregulatory Preference for cold weather Dermatological Musculoskeletal Gastrointestinal Cardiovascular Gynaecological Increased sweating Proximal myopathy (autoimmune) with wasting and weakness Change in bowel habit - diarrhoea, frequent defecation Tachycardia, atrial fibrillation Oligomenorrhoea, amenorrhoea Nervousness, easy irritability, emotional lability, insomnia, psychosis

Bradycardia Menorrhagia Slow thought, speech, action, Psychiatric depression, dementia Symptoms of carpal tunnel Neurological Fine tremor syndrome Other associated symptoms Eye symptoms - protruding / staring eyes, difficulty closing eyelids, double vision (secondary to ophthalmoplegia) and pain in eye (secondary to corneal ulceration) Local swallowing/dysphagia - oesophageal compression Dyspnoea (tracheal compression) Hoarseness - recurrent laryngeal nerve paralysis secondary to malignant infiltration Pain Regional LNs Ask about other Swellings ( Associated/ complication local or regional e.g. LNs) or DD General Constitutional symptoms ( fever wt loss) + General weakness any yellowish colour change of eye+ preference to hot cold & dry or sweaty skin Systemic symptoms (cause/ complication/ DD/ surgery fitness ( Heart, breathing, Neurology, GIT, GUT, PVD, Ortho) ) other body system quick direct Questions & if any +ve analysis 3- DD ( could be local causes/ referred/ same system or other system) H/ O of Present Investigation & treatment Past H/O Surgical; Previous operations on thyroid gland Medical history Medications - antithyroid drugs, thyroxine, iodine-containing medications Radioiodine therapy for previous Grave's disease Fitness for surgery ( DM, HTN IHD, CRF, CVAetc) , allergies & other drugs Family H/O of similar thyroid diseases Trauma history Vital points = AMPLE (Allergies; Medications; Past illness ( quick Not detailed); Last Meal; Events or Environment related to injury= History of mechanism of trauma + Symptoms of trauma;) Tumour / cancer history = Main Bulk I- Analysis of Main Symptoms pain/ Lump/ Ulcer + associated II- A Review of Systems (ROS) Ask for Causes Risk factors DD Complications ( local regional & general constuitional fever anorexia wt loss) + systemic metastasis III- H/ O of Present Investigation & treatment Type Calcium oxalate Prevalen ce 75% Urinary tract calculi Composition Spiky / mulberry shaped Caused by hypercalciuria (moans, stones, psychic groans) Rare enzyme deficiency Increased oxalate absorption: coeliac, diverticulae of bowel, chronic pancreatitis Associated with proteus infection "Staghorn calculi" (from urease) Primary gout: HGPRT deficiency (Leesh-Nyhan) Secondary gout: increased purine breakdown - tumours, RT, chemo, psoriasis... Results from primary cysteinuria, inborn error of metabolism

Ammonium phosphate Urate

15% 5%

Cysteine

3%

Management 1. 2. 3. History: precipitants, family history, personal history Examination Investigations o Urine dipstick - blood, nitrates (UTI cause) o U/Es, serum electrolytes, WCC, CRP o KUB - 90% renal tract stones are radio-opaque (calcium, ammonium , cysteine) urate/xanthine stones radiolucent o IVU: determines degree / level of obstruction (hydronephrosis) - sites for blockage: (1) renal pelvis (2) pelvic brim (3) insertion into bladder - contrast contraindicated in pregnancy, allergy, anaphylaxis, raised serum creatinine o USS: - no contrast, detects stones >5mm, determines hydronephrosis and obstruction o CT Abdo: identifies radio-opaque and lucent stones, secondary signs of obstruction Analgesia - morphine, pethidine, NSAIDs Hydration

4. 5.

Definitive treatment <4mm Watch and wait 90% pass spontaneously 4-6mm 60% pass spontaneousl y 6mm - 2cm 1- Upper or lower 1/3 (middle difficult to visualise apparently) Extra-corporeal shockwave lithotripsy (ESWL): contraindicated in pregnancy, aneurysms, pacemakers 2- lower 1/3 Ureteroscopy +lithotripsy: stones in lower 1/3 collected using stone basket or fragmented and pieces collected > 2cm 1-in renal pelvis - Percutaneous nephrolithotomy tract made percutaneously into renal collecting system and stone extracted (large stones can be broken up first). 2-obstructed - percutaneous decompression + JJ stenting 3- Open surgery (less than 1% patients) - for stones that just are bad to the bone

UTI :- Organisms:- Enterococci: E.coli, proteus, pseudomonas, klebsiella, staph aureus Infection of bladder, ureter, kidney (via renal pelvis) NB. Urethral infection is considered a STD Predisposition :Anatomy : Female anatomy: proximity of urethra to anus Congenital abnormalities affecting flow: ectopic vesicae, ureteric duplication, urethral valves, congenital stricture, VUJ reflux Urine stasis Mechanical obstruction: hydronephrosis, stricture, stone, neurogenic bladder, prostatic hypertrophy Prostatic enlargement Instrumentation Indwelling catheters Systemic disease Diabetes Immune deficiencies Diagnosis:- Urine dipstick: RBCS, WCC, nitrates/ Microscopy/ Culture