UKMLA OSCE Master Handbook

Focused History · Red Flags · NICE Investigations & Management · Physical Examination · Dundee Guide 2024-25

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Psych · Paeds · O&G · Derm · Ophth — Full Ix & Management (26 topics)
Psychiatry ★ 2025Bipolar disorder + Mental Health Act
Recurrent episodes of mania/hypomania alternating with depression. BPAD I = mania + (usually) depression; BPAD II = hypomania + depression.
❓Key Questions
  • "Have you had thoughts of harming yourself or anyone else?"
  • "In the last week, have you needed less sleep than usual but not felt tired?"
  • "Have you been spending more money than you can afford, or making big decisions you wouldn't normally make?"
  • "Are you hearing or seeing things that other people can't?"
  • "Have you felt that you have special powers, or that people are out to get you?"
  • "Are you using any drugs — cannabis, cocaine, MDMA?"
  • "Do you understand what's happening, and would you accept treatment if offered?" (insight + capacity)
🔍Signs & Symptoms
  • Mania (≥1 wk): elevated/irritable mood · grandiosity · ↓ need for sleep · pressured speech · flight of ideas · distractibility · ↑ goal-directed activity (sex, spending, projects) · psychosis possible
  • Hypomania (≥4 d): same features but milder, no marked impairment, no psychosis
  • Depression: low mood, anhedonia, fatigue, sleep/appetite change, hopelessness, suicidality
  • MSE (ASEPTIC): Appearance · Speech (pressured) · Emotion (elated/irritable) · Perception (hallucinations in mania) · Thought (grandiose, racing, flight of ideas) · Insight (poor in mania) · Cognition
🚨Red Flags
  • Suicidality / suicidal plan — full risk assessment, urgent admission
  • Psychosis with command hallucinations — admit, antipsychotic now
  • Severe self-neglect — not eating/drinking → admit
  • Risk to others — section + police involvement if needed
  • Pregnancy + bipolar — lithium teratogenic; specialist perinatal psych input urgently
🧪Investigations
  • Bedside: obs, urine drug screen (rule out stimulant intox), ECG (baseline before lithium/antipsychotic — QTc)
  • Bloods: FBC, U&E (lithium = renal), TFTs (lithium = thyroid), LFTs, glucose, lipids (antipsychotic metabolic), Ca²⁺, β-hCG (women of reproductive age)
  • Imaging: CT/MRI brain only if first episode + neurological signs / atypical features
  • Why: Exclude organic causes (thyroid, drugs, frontal lobe lesion); baselines before mood stabilisers
💊Management (NICE)
NICE CG185:
  • Acute mania: stop antidepressant. 1st line: antipsychotic — haloperidol, olanzapine, quetiapine, or risperidone. Add benzodiazepine (lorazepam) for agitation.
  • If antipsychotic ineffective → switch antipsychotic; if still no response add lithium (or valproate — never in women of childbearing potential without PPP)
  • Bipolar depression: fluoxetine + olanzapine, or quetiapine alone, or olanzapine alone, or lamotrigine. Avoid antidepressant monotherapy (manic switch).
  • Long-term: Lithium 1st line (target 0.6–0.8 mmol/L, or 0.8–1.0 if poor response). Valproate or olanzapine if lithium not tolerated.
  • Psychological: CBT, family-focused therapy, psychoeducation
  • Lithium monitoring: level 12 h post-dose, weekly until stable then every 3 mo · TFTs + U&E every 6 mo · pregnancy → switch (Ebstein anomaly)
  • Mental Health Act (Scotland 2003):
    • EDC (Emergency Detention Certificate) — 72 hrs · any FY2+ doctor · MHO consent if possible · for assessment when STDC would cause unwanted delay
    • STDC (Short-Term Detention Certificate) — 28 days · requires AMP (Approved Medical Practitioner) + MHO
    • CTO (Compulsory Treatment Order) — 6 months · Tribunal-approved
    • EDC criteria: mental disorder · SIDMA (significantly impaired decision-making ability) · risk to self/others · necessary to detain
PsychiatryDepression + suicide-risk assessment
Persistent low mood, anhedonia and fatigue (≥2 of 3) for ≥2 weeks, with sleep / appetite / concentration / guilt / suicidality.
❓Key Questions
  • Suicide risk — Before/During/After:
  • "Have you had thoughts that life isn't worth living, or thoughts of ending your life?"
  • "Have you made any plans? Have you written a note, given things away, or said goodbye?"
  • "Have you tried before? When? What did you do?"
  • "What has stopped you so far?" (protective factors)
  • "Do you have access to medication / a means of harming yourself?"
  • "What would you do if these thoughts came back tonight?"
🔍Signs & Symptoms
  • Core (ICD-11): low mood, anhedonia, fatigue (≥2/3 ≥2 wk)
  • Other: sleep change, appetite/weight change, ↓ concentration, guilt/worthlessness, psychomotor change, suicidal ideation
  • PHQ-9: 0–4 none · 5–9 mild · 10–14 moderate · 15–19 mod-severe · 20–27 severe
  • MSE: appearance — unkempt, ↓ eye contact; speech — slow, monotone; mood — low, congruent; thought — hopeless, suicidal; insight — preserved (usually)
🚨Red Flags
  • Active suicidal plan + means + intent — A&E / admission
  • Psychotic features — guilt delusions, nihilistic thoughts → specialist
  • Severe self-neglect — not eating, social withdrawal extreme
  • Postnatal depression with thoughts of harm to baby — perinatal team urgently
  • Hopelessness — strongest single predictor of suicide
🧪Investigations
  • Bedside: PHQ-9 score, urine drug screen if suspicion
  • Bloods: FBC, U&E, LFTs, TSH (rule out hypothyroid), Ca²⁺, glucose, B12/folate (mimic depression)
  • Why: identify reversible / contributing organic causes before starting SSRI
💊Management (NICE)
NICE NG222:
  • Mild–moderate (PHQ-9 5–14): active monitoring · guided self-help · group CBT · individual CBT/IPT
  • Moderate–severe (PHQ-9 15+): SSRI sertraline 50 mg OD 1st line + CBT/IPT. Review at 2 weeks (1 week if <25 yr, suicide risk)
  • Continue antidepressant 6 months after remission · 2 years if recurrent
  • Severe / psychotic: refer specialist · may need antipsychotic adjunct · ECT for severe non-responsive / catatonic
  • Discontinuation: taper over 4 weeks (fluoxetine has long half-life, easier to stop)
  • SSRI side effects to warn about: initial anxiety/GI upset (1–2 wks), sexual dysfunction, hyponatraemia (elderly), GI bleed risk (consider PPI if NSAID/anticoag), suicidal ideation in <25 yr (review weekly)
PsychiatryGAD / Anxiety disorders
Excessive worry on most days for >6 months with somatic features. Distinguish from panic disorder (sudden discrete attacks), phobias, OCD.
❓Key Questions
  • "How much of the day do you spend worrying?"
  • "What things do you worry about? Are they realistic?"
  • "Are you avoiding any places / situations because of anxiety?"
  • "Have you had panic attacks — sudden episodes of severe anxiety with physical symptoms?"
  • "Are you using alcohol or any drugs to cope?"
  • "Any thoughts of harming yourself?"
🔍Signs & Symptoms
  • Cognitive: excessive worry, inability to control it, anticipating worst
  • Somatic: restlessness, fatigue, ↓ concentration, irritability, muscle tension, sleep disturbance
  • Panic attack features: palpitations, sweating, trembling, SOB, chest pain, choking, fear of dying / going crazy — peaks in 10 min
  • GAD-7: ≥10 = moderate · ≥15 = severe
🚨Red Flags
  • Suicidal ideation + anxiety = high acuity
  • Severe agoraphobia — housebound, unable to function
  • Substance / alcohol misuse as self-medication
  • OCD with severe rituals — refer specialist
  • Atypical features (sudden severe onset >40 yr) — exclude organic / phaeo / hyperthyroid
🧪Investigations
  • Bedside: GAD-7, ECG (rule out arrhythmia), urine drug screen, caffeine intake
  • Bloods: TFTs (hyperthyroid mimics), FBC, glucose, U&E, calcium
  • Why: exclude organic mimics; never miss thyrotoxicosis or phaeochromocytoma in young patient
💊Management (NICE)
NICE CG113 — stepped care:
  • Step 1: education + active monitoring
  • Step 2: low-intensity psych — CBT self-help, applied relaxation
  • Step 3: CBT + SSRI sertraline 50 mg OD (or escitalopram). Warn re: initial worsening 1–2 wk · review 1 wk if <25 yr, then 2 wks, 4 wks
  • Step 4: specialist input — alternative meds (SNRI venlafaxine; pregabalin; BZD short-term only)
  • Avoid long-term BZD — tolerance, dependence, falls in elderly
  • Lifestyle: ↓ caffeine/alcohol, exercise, sleep hygiene, mindfulness
PsychiatryAlcohol misuse + withdrawal
Harmful drinking (>14 units/wk for women & men UK guidance) → dependence → withdrawal. Withdrawal can cause seizures, delirium tremens, Wernicke's.
❓Key Questions
  • CAGE (≥2 = significant): "Have you ever felt you should Cut down? Annoyed by criticism? Guilty about drinking? Eye-opener — first drink in the morning?"
  • "How many units do you drink in a typical week?"
  • "Have you ever had withdrawal symptoms — tremor, sweating, seizures?"
  • "Have you ever blacked out and not remembered what you did?"
  • "Has drinking affected your work, relationships, finances?"
  • "Are you driving / looking after children when you've been drinking?"
🔍Signs & Symptoms
  • Dependence (ICD-11): ≥3 of: craving, ↓ control, withdrawal, tolerance, neglect, persistence despite harm
  • Withdrawal (6–24 h): tremor, sweating, anxiety, tachycardia, ↑ BP, nausea
  • Withdrawal seizures (24–48 h): grand mal
  • Delirium tremens (48–72 h): confusion, hallucinations (typically visual — Lilliputian), tachycardia, tremor — 10 % mortality
  • Wernicke's triad: confusion, ataxia, ophthalmoplegia (only ~10% have all 3)
🚨Red Flags
  • Withdrawal seizure / DTs — admit, IV diazepam, monitor
  • Wernicke's encephalopathy — IV Pabrinex urgently · untreated → Korsakoff (irreversible)
  • Hepatic decompensation — jaundice, ascites, hepatic flap, encephalopathy
  • Suicidality / self-harm — common comorbidity
  • Driving while intoxicated — DVLA notification
🧪Investigations
  • Bedside: CAGE questionnaire, AUDIT-C / full AUDIT, blood alcohol, urinary drug screen
  • Bloods: FBC (macrocytic anaemia · ↑MCV), U&E, LFTs (AST:ALT >2 → alcoholic), GGT (sensitive marker), clotting (synthetic liver function), glucose, B12/folate, magnesium
  • Imaging: USS liver if cirrhosis suspected
  • Why: assess severity of organ damage; baseline before pharmacological detox
💊Management (NICE)
NICE CG115:
  • Screening + brief intervention (FRAMES): Feedback, Responsibility, Advice, Menu of options, Empathy, Self-efficacy
  • Quantify units: % ABV × volume (mL) ÷ 1000. UK low-risk <14 units/wk over ≥3 days
  • Detox (community / inpatient): chlordiazepoxide reducing regimen 10–40 mg QDS tapering over 5–7 days · monitor with CIWA-Ar score
  • Pabrinex IV 1+2 BD for 3 days for all dependent drinkers (prevent Wernicke's). Continue PO thiamine 100 mg TDS. Don't give glucose first — precipitates encephalopathy in thiamine-deficient.
  • Maintenance pharmacotherapy: acamprosate (anti-craving), naltrexone (anti-craving), disulfiram (aversive — only if motivated)
  • Psychosocial: AA, SMART recovery, key worker, Community Alcohol Team referral
PsychiatryFirst-episode psychosis / schizophrenia
Disturbance of thought, perception and behaviour. Schizophrenia: continuous signs ≥6 mo with ≥1 mo active phase (delusions, hallucinations, disorganised speech).
❓Key Questions
  • "Do you ever hear voices or see things others can't?"
  • "What do the voices say? Do they tell you to do things?"
  • "Do you feel anyone is watching you, following you, or trying to harm you?"
  • "Do you feel your thoughts are being put in or taken out of your mind?"
  • "Are you using cannabis or any other drugs?"
  • "How are you sleeping? How are you managing day to day?"
  • "Any thoughts of harming yourself or others?"
🔍Signs & Symptoms
  • Positive (Schneider's first-rank): auditory hallucinations (3rd-person, running commentary, thought echo) · thought insertion/withdrawal/broadcasting · delusions of control · primary delusions
  • Negative: blunted affect, alogia, avolition, anhedonia, social withdrawal — often more disabling
  • Disorganised: word salad, tangentiality, knight's-move thinking, neologisms
  • Cognitive: attention, working memory, processing speed deficits
  • Prodrome (months–years): social withdrawal, ↓ function, attenuated symptoms — early intervention key
🚨Red Flags
  • Command auditory hallucinations instructing self-harm or harm to others
  • Catatonia — mute, immobile, posturing — needs urgent admission
  • Neuroleptic malignant syndrome — fever, rigidity, autonomic instability, raised CK — STOP antipsychotic, supportive Tx
  • Clozapine + neutropenia — STOP, haematology referral
  • Postpartum psychosis — emergency, perinatal mother & baby unit
🧪Investigations
  • Bedside: urine drug screen (cannabis, amphetamines, cocaine — exclude drug-induced)
  • Bloods: FBC, U&E, LFTs, TFTs, glucose, lipids, prolactin (baseline before antipsychotic), HIV/syphilis, B12/folate, calcium, autoimmune screen
  • Imaging: CT/MRI brain (rule out SOL, especially if focal signs or atypical age)
  • ECG: baseline QTc before antipsychotic
  • Why: exclude organic psychosis (drug-induced, lupus, thyrotoxicosis, brain tumour) before committing to long-term antipsychotic
💊Management (NICE)
NICE CG178:
  • Acute: assess risk · admit if risk to self/others · use MHA if needed · Early Intervention in Psychosis (EIP) referral
  • 1st line antipsychotic — atypical (olanzapine, risperidone, quetiapine, aripiprazole). Start low, titrate. Avoid 2 antipsychotics simultaneously.
  • Monitor: weight, BP, lipids, HbA1c, prolactin, ECG (QTc), EPSEs
  • Treatment-resistant (failed 2 antipsychotics ≥6 wk each) → clozapine with mandatory FBC monitoring (agranulocytosis 1%)
  • Psychological: CBT for psychosis · family intervention · arts therapy
  • Social: housing, benefits, employment support, carer support
  • Physical health: annual review — CV risk doubled vs general pop
Paediatrics ★ 2025Croup (laryngotracheobronchitis)
Parainfluenza virus infection in children 6 mo–6 yr. Causes upper airway inflammation → barking cough, stridor, hoarse voice.
❓Key Questions
  • "When did the cough start? Worse at night?"
  • "Has the breathing become noisy when in?" (stridor)
  • "Is your child drooling? Can they swallow their saliva?" (epiglottitis red flag)
  • "Any fever? How high? How are they when the fever is down?"
  • "Have they been drinking? Wet nappies in last 12 h?"
  • "Any choking episode or could they have inhaled something?"
  • "Are immunisations up to date — including Hib?" (epiglottitis prevention)
  • "Have you noticed blue around the lips, or are they becoming very sleepy?"
🔍Signs & Symptoms
  • Hallmark: seal-like / barking cough · inspiratory stridor · hoarse voice · low-grade fever
  • Coryza prodrome 1–2 days before
  • Worse at night · improves with cool air
  • Westley score: mild <2 · mod 3–7 · severe ≥8 — based on stridor, retractions, air entry, cyanosis, GCS
  • vs Epiglottitis: rapid onset, high fever, drooling, tripod position, NO cough — do NOT examine throat
  • vs Bronchiolitis: <2 yr, expiratory wheeze + fine crackles + feeding difficulty (RSV)
🚨Red Flags
  • Stridor at rest — moderate or severe
  • Drooling, tripod position, no cough — think EPIGLOTTITIS · do NOT examine throat · senior anaesthetics + ENT now
  • Cyanosis, ↓ GCS, exhaustion — pre-arrest, intubate
  • Inhaled foreign body — sudden choking episode + unilateral stridor
  • Bacterial tracheitis — toxic, high fever, copious purulent secretions, doesn't respond to adrenaline
🧪Investigations
  • Mainly clinical Dx
  • Bedside: RR, SpO₂, HR, CRT, hydration, work of breathing
  • Avoid examining throat if epiglottitis cannot be excluded — risk of airway obstruction
  • Imaging: not routinely; lateral neck X-ray would show "steeple sign" (subglottic narrowing) but rarely needed
  • Why: Diagnosis from history + examination; investigations only if atypical, severe, or to exclude differentials
💊Management (NICE)
NICE CKS Croup:
  • Mild (well child, no stridor at rest): single dose oral dexamethasone 0.15 mg/kg · discharge with safety-net
  • Moderate (stridor at rest, no distress): dex 0.15 mg/kg PO · observe 2–4 h · ± nebulised budesonide 2 mg if oral not tolerated
  • Severe (distress, ↓ air entry): nebulised adrenaline 1:1000 5 mL + dex · observe ≥2 h (rebound) · escalate paediatric ICU if no improvement
  • Supportive: sit child up, allow them to find comfortable position, calm parent (don't distress child = ↑ work of breathing), antipyretic for fever (paracetamol 15 mg/kg QDS)
  • Avoid: antibiotics (viral), nebulised adrenaline routinely (only severe), steam (no evidence + scald risk)
  • Safety-net to parent: "Come back / call 999 if breathing very fast, stridor at rest, drooling, blue around lips, very drowsy or floppy"
PaediatricsBronchiolitis (RSV)
Lower respiratory tract infection in infants <2 yr (peak 3–6 mo), usually RSV. Inflammation of bronchioles → wheeze + crackles + feeding difficulty.
❓Key Questions
  • "How old is your baby? Were they born prematurely?"
  • "How many wet nappies in the last 24 h?"
  • "How much milk are they taking compared with normal?"
  • "Any pauses in breathing where they go quiet for a few seconds?" (apnoea)
  • "Are they working hard to breathe — pulling in around the ribs?"
  • "Any fever? How are they between feeds?"
  • "Anyone at home with a cold?"
  • "Any underlying heart or lung condition? Have they had palivizumab?"
🔍Signs & Symptoms
  • Coryza first for 1–3 days, then breathing problems
  • Cough, wheeze, fine crackles bilaterally
  • Feeding difficulty — <50% of normal feeds
  • Apnoeas in young infants — feature of severity
  • Recession — subcostal, intercostal, sternal
  • Peak in winter (Nov–March in UK)
🚨Red Flags
  • Apnoea — admit, monitor, may need CPAP/HFNC
  • SpO₂ <92% on air
  • Severe respiratory distress / exhaustion — pre-arrest, escalate
  • Poor feeding <50% — dehydration risk
  • Age <3 mo — lower threshold to admit
  • Ex-premature, congenital heart disease, immunodeficiency
🧪Investigations
  • Mainly clinical
  • Bedside: RR, SpO₂, HR, hydration, capillary refill, work of breathing
  • NPA (nasopharyngeal aspirate): RSV PCR — confirms but rarely changes management
  • CXR: only if atypical / severe / not improving (hyperinflation, peribronchial cuffing)
  • Bloods: only if dehydrated / sepsis suspected
  • Why: Confirm Dx + cohort isolated + assess severity for admission decision
💊Management (NICE)
NICE NG9:
  • Supportive only — no specific treatment
  • Feeding: small frequent feeds; NG tube if poor intake; IV fluids if dehydrated and unable to tolerate NG
  • Oxygen: if SpO₂ <92% (some centres <90%)
  • Suction: upper airway secretions if blocking feeding
  • NO benefit: salbutamol · ipratropium · antibiotics · steroids · adrenaline · hypertonic saline (current consensus)
  • Admit if: SpO₂ <92%, RR >70, <50% feeds, apnoeas, severe distress, dehydration, age <3 mo, congenital heart/lung disease, ex-prem
  • Palivizumab RSV monoclonal antibody — prophylaxis for high-risk infants (CLD, congenital heart, ex-prem) Oct–March
  • Course: 3–7 days, can cough for 2–3 weeks; safety-net for worsening
PaediatricsFebrile convulsion
Generalised tonic-clonic seizure in a child 6 mo–5 yr with fever, no CNS infection or metabolic cause. Simple <15 min, generalised, single in 24 h. Complex >15 min, focal, or recurrent in 24 h.
❓Key Questions
  • "How long did the seizure last? What did it look like — whole body or just one side?"
  • "Did they bite their tongue? Wet themselves? Lose colour?"
  • "How were they before — fever, off food, runny nose?"
  • "How are they now — fully awake and back to themselves?"
  • "Any rash that doesn't fade with a glass test?" (meningococcal)
  • "Any neck stiffness, light hurting their eyes?"
  • "Any past seizures? Any family history of epilepsy or seizures?"
  • "Are immunisations up to date — including Hib, MenB, MMR?"
🔍Signs & Symptoms
  • Generalised tonic-clonic seizure with high fever
  • Most last <5 min
  • Post-ictal drowsiness 30–60 min
  • Source of fever: usually viral URTI, otitis media, gastroenteritis, UTI
  • Family Hx in 25%
🚨Red Flags
  • <6 months or >5 years — not typical FC, look for cause
  • Complex features — focal, >15 min, recurrent in 24 h
  • Meningism / non-blanching rash / bulging fontanelle — meningococcal / meningitis
  • Persistent ↓ GCS after seizure — encephalitis, ↑ ICP
  • No source of fever found in young child — UTI / occult bacteraemia / sepsis
  • Family Hx of epilepsy + complex FC — higher epilepsy risk
🧪Investigations
  • Look for source of fever: ENT exam, throat swab, urine dip + MSU, FBC + CRP + blood cultures if unwell
  • LP if <12 mo, signs of meningism, prolonged drowsiness, complex features
  • Bloods: FBC, U&E, glucose, calcium (rule out metabolic)
  • EEG: not routinely · only if complex or developmental concern
  • CT/MRI head: only if focal seizure, developmental delay, focal neurology
  • Why: Confirm simple FC vs complex/serious cause (meningitis, encephalitis, metabolic, structural)
💊Management (NICE)
NICE CKS:
  • Acute seizure: ABCDE · recovery position · time the seizure · don't restrain · don't put anything in mouth
  • If >5 min: buccal midazolam 0.5 mg/kg OR rectal diazepam 0.5 mg/kg (parent can give)
  • Treat fever source if identified
  • Antipyretics (paracetamol 15 mg/kg QDS / ibuprofen 10 mg/kg TDS) — for comfort, NOT to prevent recurrence (no evidence)
  • Don't give aspirin (Reye's syndrome)
  • Reassurance to parents: simple FC = good prognosis, doesn't cause epilepsy or brain damage. ⅓ have another. Epilepsy risk: 1% baseline → 2–4% (still low).
  • Safety-net: "Call 999 if seizure >5 min · recurrent · breathing difficulty · doesn't wake afterwards"
  • Discharge from ED if: simple FC + alert + source of fever found + parents reassured + safety-net given
PaediatricsNon-accidental injury (safeguarding)
Suspected child abuse — physical, emotional, sexual, neglect. Concerning if injury inconsistent with history, developmental stage, or pattern.
❓Key Questions
  • "Tell me exactly what happened — when, where, who was there?"
  • "Can you walk me through the moment they got hurt?"
  • "Has anything like this happened before?"
  • "Who else looks after them?"
  • "Is there anyone in the household who would harm them?" (open, non-leading)
  • "How are things at home — any stress, financial worries, mental health, drink, drugs?"
  • "Are immunisations up to date? Have they been to all health-visitor checks?"
  • "Are there any other children at home? How are they?"
  • To child if old enough: "Is there anything you want to tell me about how this happened?"
🔍Signs & Symptoms
  • TEN-4 bruising rule: bruises on Torso · Ears · Neck · age <4 mo OR <4 yr without explanation
  • Patterned bruising: fingertip, slap, ligature, bite mark, cigarette burn
  • Spiral fracture in non-ambulant child · metaphyseal corner fractures · multiple fractures of different ages · rib fractures in infants
  • Retinal haemorrhages — shaken baby syndrome
  • Inconsistent / changing history
  • Delayed presentation
  • Disclosure — child says something happened
  • Concerning behaviour: withdrawn, fearful of carer, sexualised behaviour
🚨Red Flags
  • Spiral fracture in non-ambulant child — almost pathognomonic of NAI
  • Retinal haemorrhages + subdural haematoma + ↓ GCS = shaken baby
  • Multiple fractures of different ages on skeletal survey
  • Burn pattern suggesting forced immersion (glove-and-stocking, sharp demarcation, no splash marks)
  • Disclosure of sexual abuse — specialist FME exam, police, social services
  • Sibling has same/similar injuries
🧪Investigations
  • Bedside: body map (document every mark), photographs, height/weight on growth chart
  • Bloods: FBC, coagulation, vWF, factor VIII/IX (rule out bleeding disorder), bone profile (rule out rickets)
  • Imaging:
    • Skeletal survey — mandatory in suspected NAI <2 yr
    • CT head if neurological signs, age <1 yr, suspected shaking
    • Ophthalmology for retinal haemorrhages
  • Why: Document the injuries, exclude organic mimics (bleeding disorder, rickets, mongolian blue spot), gather evidence for safeguarding
💊Management (NICE)
UK child protection:
  • 1. Safety first — admit child if any concern (don't send home unsafe)
  • 2. Senior paediatrician + named safeguarding lead immediately
  • 3. Refer social services + police · written referral within 24 hrs
  • 4. Document meticulously — body map, verbatim quotes, time/date, professionals involved
  • 5. Consider: Section 47 enquiry, child protection conference, child protection plan
  • 6. Don't tell parents you're making a referral if it would put child at risk — discuss with safeguarding lead first
  • 7. Cannot promise confidentiality to disclosing child — be honest about what you'll do
  • 8. Listen, don't interrogate — open questions only · don't lead
  • 9. Check siblings — they may also be at risk
PaediatricsChildhood asthma + inhaler teach
Chronic inflammatory airway disease with reversible airflow obstruction. Atopic triad: eczema, hayfever, asthma. Diagnosis often clinical <5 yr, spirometry-based ≥5 yr.
❓Key Questions
  • "How often is the cough waking them at night?"
  • "Are they using their reliever inhaler more than 3 times a week?"
  • "Are they missing school because of it?"
  • "What triggers it — running around, cold air, pets, dust?"
  • "Anyone in the family with asthma, eczema or hayfever?"
  • "Have they been admitted to hospital before? Any PICU stays?"
  • "Anyone smoke at home?"
  • "Can you show me how they use their inhaler?" (always teach-back)
🔍Signs & Symptoms
  • Episodic wheeze, cough (often nocturnal), SOB, chest tightness
  • Triggers: URTI, exercise, cold air, allergens, smoke, emotions
  • Atopy: eczema, hayfever, food allergy, family Hx
  • Acute severity (BTS):
    • Moderate: SpO₂ ≥92, PEF 50–75%, can talk in sentences
    • Severe: SpO₂ <92, PEF 33–50%, can't complete sentences, RR >30 (5+ yr) / >40 (1–5 yr), HR >125 / >140
    • Life-threatening: PEF <33%, SpO₂ <92%, silent chest, exhaustion, cyanosis, hypotension, ↓ GCS
🚨Red Flags
  • Silent chest — pre-arrest
  • SpO₂ <92% on air
  • Exhaustion / drowsy / cyanosis
  • PEF <33% predicted
  • Previous PICU admission — high risk recurrence
  • Brittle asthma / poor compliance / ED frequent flyer
  • Missing school routinely — poor control
🧪Investigations
  • Clinical diagnosis <5 yr (no reliable spirometry)
  • Spirometry ≥5 yr: FEV1/FVC <0.7 + ≥12% reversibility post-bronchodilator
  • FeNO: ≥35 ppb supports diagnosis
  • Peak flow: diary 2–4 weeks · variability ≥20%
  • Skin-prick / specific IgE for allergens
  • Acute attack: SpO₂, PEF, ABG if severe
  • Why: Confirm diagnosis (avoid over-diagnosis), identify triggers, monitor control
💊Management (NICE)
BTS/SIGN 2024 + NICE NG244 children 5–16:
  • 1. SABA PRN (salbutamol)
  • 2. Add low-dose ICS (e.g. beclomethasone 100 µg BD)
  • 3. Add LTRA (montelukast) or LABA (formoterol) → ICS-LABA combination
  • 4. Increase ICS to medium dose · refer specialist
  • 5. Consider MART regimen (single ICS-formoterol inhaler)
  • Acute exacerbation:
    • O₂ to target 94–98% (88–92% if Type 2 RF — rare in children)
    • Salbutamol via spacer 10 puffs (or neb 2.5 mg <5 yr / 5 mg ≥5 yr) — back-to-back if severe
    • Ipratropium neb if severe (250 µg <12 yr / 500 µg ≥12 yr)
    • Oral prednisolone 1–2 mg/kg (max 40 mg) for 3 days · IV hydrocortisone if can't tolerate
    • IV magnesium sulphate 40 mg/kg (max 2 g) if life-threatening
    • Escalate to PICU if not improving / silent chest / exhaustion
  • Inhaler teach (MDI): shake → exhale fully → seal lips → slow inhalation + actuate simultaneously → hold breath 10 s → wait 30 s before 2nd puff → rinse mouth (ICS to prevent thrush)
  • Spacer: 5 tidal breaths per puff in young children · clean monthly with detergent · air dry (don't rub — ↑ static)
  • Personal Asthma Action Plan (BTS/SIGN): green = well, yellow = worsening (↑ inhaler, see GP), red = severe (999, 10 puffs salbutamol via spacer)
O&G ★ 2025Pre-eclampsia
New hypertension ≥140/90 after 20 weeks + proteinuria ≥0.3 g/24 h (or PCR ≥30 mg/mmol or ≥1+ on dip) OR end-organ dysfunction.
❓Key Questions
  • "Any headache that won't go with paracetamol?"
  • "Any visual changes — flashing lights, blurred vision?"
  • "Pain just under your ribs, especially on the right?" (HELLP / liver capsule stretch)
  • "Sudden swelling of face or hands?"
  • "Have you noticed your baby moving normally today?"
  • "Any bleeding, fluid loss, or contractions?"
  • "How were your previous pregnancies — any pre-eclampsia, GDM, prematurity?"
  • "Any kidney disease, lupus, diabetes, high BP before pregnancy?"
  • "Are you taking aspirin?" (high-risk prophylaxis)
🔍Signs & Symptoms
  • Symptoms (severe): headache, visual disturbance (flashing lights, blurred), epigastric / RUQ pain, sudden facial/hand swelling, reduced fetal movements
  • Signs: BP ≥140/90 (severe ≥160/110), proteinuria, hyper-reflexia, clonus, oedema
  • HELLP: Haemolysis, Elevated LFTs, Low Platelets <100
  • Severe features: BP ≥160/110, headache, visual sx, RUQ pain, plt <100, ↑ ALT, ↑ Cr, pulmonary oedema, seizures (= eclampsia)
  • Risk factors: nulliparity, age >40, BMI >30, multiple pregnancy, prior PET, FHx, chronic HTN/CKD/DM/SLE/APS
🚨Red Flags
  • BP ≥160/110 — severe pre-eclampsia, IV antihypertensive, MgSO₄
  • Eclamptic seizure — MgSO₄ 4 g IV STAT + 1 g/h, ABCDE, urgent delivery
  • HELLP — admit, deliver, blood products as needed
  • Pulmonary oedema — frusemide, fluid restriction, ITU
  • Reduced fetal movements / abnormal CTG — urgent delivery
  • Persistent severe headache or visual disturbance — imminent eclampsia
  • Placental abruption — sudden abdominal pain + PV bleed + fetal distress
🧪Investigations
  • Bedside: BP both arms · urine dipstick (PCR confirm if ≥1+) · CTG · fetal Doppler
  • Bloods: FBC (low plt = HELLP) · U&E · LFTs (↑ALT) · urate (↑) · coagulation · PlGF (placental growth factor — rule out at 20–34 wk)
  • USS: fetal growth, dopplers (umbilical artery), AFI
  • Why: Confirm diagnosis, assess severity (mild vs severe), assess fetal wellbeing, plan delivery timing
💊Management (NICE)
NICE NG133:
  • Mild–moderate (BP <160/110, no severe features): admit if any concern, oral antihypertensive
  • 1st line antihypertensive: labetalol 200 mg PO TDS (or IV bolus 50 mg slow if severe)
  • 2nd line: nifedipine modified-release 10–20 mg BD
  • 3rd line: methyldopa 250 mg TDS
  • Aim BP <135/85
  • Severe (BP ≥160/110 or severe features):
    • Admit · senior obstetric review · IV access
    • MgSO₄ 4 g IV bolus over 5 min, then 1 g/h infusion (continue 24 h post-delivery) — for severe PET / eclampsia
    • Monitor reflexes, RR, urine output (Mg toxicity)
    • Reverse Mg toxicity: 10 mL 10% calcium gluconate
  • Definitive treatment = delivery — timing balanced against gestation
  • If <34 weeks → corticosteroids (betamethasone 12 mg IM × 2 doses 24 h apart) for fetal lungs
  • Postnatal: monitor BP for 5 days, switch to enalapril (safe in BF), continue antihypertensives until BP normalises
  • Prevention if high risk (prior PET, CKD, autoimmune, DM, chronic HTN): aspirin 75–150 mg OD from 12 weeks
O&G ★ 2025Post-menopausal bleeding / menorrhagia
PMB = vaginal bleeding ≥12 months after LMP — endometrial cancer until proven otherwise. HMB = excessive menstrual blood loss interfering with QOL.
❓Key Questions
  • "When was your last period?" (confirm post-menopausal)
  • "How much blood — light spotting or heavy bleeding?"
  • "Any bleeding after sex, or between periods?"
  • "Any abdominal swelling, bloating, or feeling full quickly?" (ovarian)
  • "Weight loss, night sweats, loss of appetite?"
  • "Are you on HRT? Tamoxifen?"
  • "Any family history of breast, ovarian, bowel or womb cancer?"
  • "When was your last cervical smear? Any abnormal results?"
  • "Any bowel or bladder symptoms — change in habit, blood, urgency?"
🔍Signs & Symptoms
  • PMB: any bleeding after 12 months of amenorrhoea
  • HMB symptoms: flooding, clots, changing pad/tampon <2 hrly, double protection, anaemia symptoms (fatigue, breathlessness, palpitations)
  • Examine: abdo (palpable mass = fibroid?), speculum (cervix — ectropion, polyp, cancer), bimanual (uterine size, mobility, adnexal mass)
  • Causes PMB: atrophic vaginitis (most common), endometrial polyps/hyperplasia, endometrial cancer (10–15%), HRT-related, cervical cancer
  • Causes HMB: dysfunctional (no cause), fibroids, adenomyosis, endometriosis, polyps, IUD, coagulopathy (vWD), hypothyroid
🚨Red Flags
  • PMB — always urgent gynae 2-WW
  • Persistent IMB / PCB + age >40 — endometrial / cervical cancer
  • Pelvic mass + abdominal distension + early satiety / weight loss — ovarian cancer (CA-125 + USS, 2-WW)
  • Severe anaemia Hb <80 — admit for transfusion / IV iron
  • Fibroid degeneration in pregnancy — severe pain, refer urgently
  • Tamoxifen + PMB — high endometrial cancer risk
🧪Investigations
  • PMB pathway (NICE NG12): 2-week wait gynaecology · TVUS endometrial thickness ≥4 mm → hysteroscopy + endometrial biopsy
  • HMB:
    • Bedside: urine pregnancy, BP, abdo + speculum + bimanual
    • Bloods: FBC (anaemia), TFTs (hypothyroid), coagulation (vWD if young + heavy from menarche), ferritin
    • Imaging: TVUS — endometrial thickness, fibroids, polyps, adenomyosis
    • Hysteroscopy + biopsy if abnormal USS or persistent symptoms
  • Why: Confirm/exclude cancer (PMB), exclude organic cause (HMB), assess for anaemia
💊Management (NICE)
NICE NG88 (HMB) + NG12 (cancer):
  • HMB — no structural cause / fibroids <3 cm:
    • 1st line: Mirena IUS (levonorgestrel 52 mg) — ↓ blood loss 70–95%, contraceptive, lasts 5 yrs
    • 2nd line non-hormonal: tranexamic acid 1 g TDS (during period only) ± mefenamic acid 500 mg TDS
    • 2nd line hormonal: COCP, cyclical norethisterone, depot
    • 3rd line: GnRH analogue (short-term, with HRT add-back)
    • Surgical: endometrial ablation, myomectomy (preserve fertility), hysterectomy (definitive)
  • Iron replacement if anaemic — ferrous fumarate 210 mg OD-TDS
  • PMB management — by cause:
    • Atrophic vaginitis: topical oestrogen (estriol cream / pessary)
    • Polyps: hysteroscopic removal
    • Endometrial hyperplasia (no atypia): Mirena 6 mo + repeat biopsy
    • Endometrial hyperplasia + atypia / carcinoma: total hysterectomy + BSO ± lymphadenectomy ± radiotherapy
    • Cervical cancer: stage-dependent (LLETZ → radical hysterectomy → chemoradiotherapy)
  • Cervical screening: if eligible, also offer (England 25–49 q3y, 50–64 q5y; Scotland 25–64 q5y HPV-primary)
O&GMiscarriage / early pregnancy bleeding
Pregnancy loss before 24 weeks. Threatened (closed os, viable), inevitable (open os), incomplete (POC remaining), complete, missed (no FH, asymptomatic).
❓Key Questions
  • "When was your last menstrual period? Have you had a positive pregnancy test?"
  • "How heavy is the bleeding? How many pads in the last hour?"
  • "Any clots or anything passed that looked like tissue?"
  • "Where is the pain? Is it on one side?" (ectopic)
  • "Any shoulder-tip pain?" (diaphragmatic irritation from ectopic blood)
  • "Have you felt dizzy, faint, or had your heart racing?" (shock)
  • "Any past pregnancies — miscarriages, ectopics, terminations?"
  • "Any history of pelvic infection, IUD, tubal surgery, fertility problems?"
  • "What is your blood group?" (anti-D)
  • "Who do you have at home with you for support?"
🔍Signs & Symptoms
  • PV bleeding ± clots ± products of conception passed
  • Cramping abdominal pain
  • Speculum: open vs closed os; products at os
  • Shock features if heavy bleed / ruptured ectopic — pale, tachy, hypotension
  • Always consider ectopic: amenorrhoea + abdo pain + PV bleed + shoulder-tip pain
🚨Red Flags
  • Haemodynamic instability — shock, tachy, ↓BP → resuscitate, theatre, exclude ectopic
  • Suspected ectopic — amenorrhoea + PV bleed + abdo pain ± shoulder-tip pain
  • Sepsis (septic miscarriage) — fever, foul-smelling discharge, tender uterus → IV abx, ERPC
  • Excessive bleeding — >500 mL or sustained, products in cervical os
  • Recurrent miscarriage — full workup
🧪Investigations
  • Bedside: urine β-hCG, obs (shock?), pregnancy test if not already done
  • Bloods: FBC, group + save, serum β-hCG (rising/plateau/falling — >63% rise in 48 h = viable IUP, plateau = ectopic, halving = miscarriage)
  • Imaging: TVUS — fetal pole, CRL, fetal heart, gestational sac. If pregnancy of unknown location (PUL), repeat hCG 48 h
  • Why: Confirm intrauterine pregnancy + viability, exclude ectopic (life-threatening), guide management
💊Management (NICE)
NICE NG126:
  • Threatened: reassure, watch and wait, anti-D if Rh-ve and ≥12 wks, repeat scan if persistent symptoms
  • Missed / incomplete:
    • Expectant — wait 7–14 days, repeat scan
    • Medical — mifepristone 200 mg PO then 24–48 h later misoprostol 800 µg PV/PO
    • Surgical — manual vacuum aspiration (MVA) under LA, or evacuation of retained products of conception (ERPC) under GA
  • Complete miscarriage: reassure, anti-D if appropriate, advise re: emotional support
  • Ectopic:
    • Stable + size <35 mm + no FH + hCG <1500: methotrexate IM 50 mg/m² (single dose, can repeat)
    • Unstable / ruptured / large / FH / hCG >5000: laparoscopic salpingectomy (or salpingotomy if contralateral disease)
  • Anti-D 250 IU IM if Rh-ve and: ≥12 wks gestation OR surgical management OR ectopic
  • Communication: acknowledge loss, sensitive language ("I'm so sorry"), pause, written info, Miscarriage Association / SANDS, advise can try again next cycle, no clear cause usually identified
  • Recurrent miscarriage (≥3 consecutive): refer for antiphospholipid screen, parental karyotype, pelvic USS, thrombophilia screen
O&GEctopic pregnancy
Pregnancy implanted outside the uterine cavity (95% tubal — ampulla most common). 1 in 80 pregnancies. Leading cause of 1st-trimester maternal death.
❓Key Questions
  • "When was your last period? Have you had a positive pregnancy test?"
  • "Where exactly is the pain? Has it moved? On one side?"
  • "Any pain in the tip of your shoulder?" (haemoperitoneum)
  • "How heavy is the bleeding? Is it dark or fresh red?"
  • "Have you fainted, gone dizzy, or felt your heart racing?"
  • "Any previous ectopic, miscarriages, or fertility treatment?"
  • "Any history of PID, chlamydia, tubal surgery?"
  • "Are you using any contraception — coil, sterilisation?"
  • "What is your blood group?" (anti-D)
🔍Signs & Symptoms
  • Classic triad: amenorrhoea (6–8 wk) + unilateral pelvic pain + PV bleed (often dark, scanty)
  • Shoulder-tip pain — diaphragmatic irritation (ruptured = haemoperitoneum)
  • Adnexal tenderness ± mass on bimanual
  • Cervical motion tenderness
  • Shock if ruptured — pale, tachy, hypotensive, peritonism
  • Risk factors: previous ectopic, tubal damage (PID, surgery, endometriosis), IVF, IUD in situ, smoking, age >35
🚨Red Flags
  • Haemodynamic instability — ruptured, theatre now
  • Severe abdominal pain + shoulder tip + collapse — ruptured ectopic
  • Cornual / interstitial ectopic — present later (8–12 wks), catastrophic rupture
  • Heterotopic pregnancy — IUP + ectopic (consider in IVF)
  • Persistent trophoblast post-salpingotomy — monitor hCG
🧪Investigations
  • Bedside: urine β-hCG positive, obs (shock?), urinalysis
  • Bloods: FBC, group + crossmatch, serum β-hCG (single + 48 h trend), U&E, LFTs (baseline before MTX)
  • Imaging: TVUS — empty uterus + adnexal mass + free fluid in Pouch of Douglas. β-hCG >1500 + empty uterus = high suspicion ectopic. Pseudosac in uterus is misleading.
  • Why: Confirm pregnancy, exclude IUP, identify ectopic location, guide treatment (MTX vs surgery)
💊Management (NICE)
NICE NG126:
  • Stable + small (size <35 mm + no fetal heart + hCG <1500 + asymptomatic + reliable for follow-up):
    • Expectant if hCG <1500 + falling, asymptomatic — repeat hCG every 48 h
    • Medical: methotrexate IM 50 mg/m² single dose. Repeat hCG day 4 + 7 — should fall ≥15% between days 4–7. Can repeat MTX.
    • MTX advice: avoid pregnancy for 3 months, no NSAIDs, alcohol, sun, folate
  • Unstable / ruptured / size ≥35 mm / FH / hCG ≥5000 / unable to follow up:
    • Laparoscopic salpingectomy (preferred — lower failure rate)
    • Salpingotomy if contralateral tube diseased / nulliparous and fertility concern (~1 in 5 will need further treatment, ~1 in 10 develops persistent trophoblast)
  • Acute resus if ruptured: ABCDE, 2× large-bore IV, fluids → blood, group + crossmatch 4 units, theatre URGENT
  • Anti-D if Rh-ve and surgical management
  • Comms: acknowledge, written info, EPAU follow-up, fertility counselling (~70% normal fertility after one ectopic)
O&GPostpartum haemorrhage
Primary PPH = blood loss >500 mL after vaginal delivery (or >1 L after C-section), within 24 h. Major if >1 L or signs of shock. Secondary = 24 h–6 weeks postnatal.
❓Key Questions
  • "When did the delivery happen? Was it vaginal or C-section?"
  • "Was there any instrumental delivery, episiotomy, or tear?"
  • "How long was the labour? Was the placenta complete?"
  • "How much blood — is it pooling on the bed, or just trickling?"
  • "Any clots passed?"
  • "How is she feeling — dizzy, faint, breathless?"
  • "Any allergies? Any past PPH?"
  • "What's her blood group? Has she had a Hb taken today?"
  • "Asthma? Hypertension? Pre-eclampsia?"
🔍Signs & Symptoms
  • 4 Ts (causes):
    • Tone (70%) — uterine atony — boggy, soft, non-contracted uterus
    • Trauma — vaginal/perineal/cervical lacerations, uterine rupture
    • Tissue — retained placenta or POC
    • Thrombin — coagulopathy, DIC, anticoagulation
  • Risk factors: prolonged labour, instrumental delivery, multiparity, big baby, GA, retained placenta, prior PPH, anticoagulants, multiple pregnancy, polyhydramnios, fibroids, pre-eclampsia
  • Shock: tachycardia first, then hypotension late (young pregnant women compensate well)
🚨Red Flags
  • Persistent bleeding despite first-line measures — escalate, theatre
  • Signs of shock (HR >110, BP <90, ↓ urine output) — major haemorrhage
  • Coagulopathy / DIC — give FFP, platelets, cryoprecipitate
  • Asthma + carboprost contraindication
  • HTN/PET + ergometrine contraindication
  • Concealed bleed (placental abruption, uterine rupture) — internal blood loss masked
🧪Investigations
  • Bedside: obs continuously, urine output (catheter), ABG (lactate)
  • Bloods: FBC, coagulation, fibrinogen (low = severe), U&E, LFTs, group + crossmatch 4–6 units, activate major haemorrhage protocol
  • Repeat coag every 1 h while bleeding
  • USS if retained products suspected post-bleeding controlled
  • Why: Quantify blood loss + ongoing rate, identify cause, guide blood product replacement
💊Management (NICE)
RCOG Greentop:
  • 1. Call for help — obstetric registrar, anaesthetist, theatre, blood bank, additional midwife
  • 2. ABCDE — 15 L O₂, 2× large-bore IV, head down / legs up
  • 3. Bloods + activate major haemorrhage protocol · 1:1:1 RBC:FFP:platelets, give TXA 1 g IV early
  • 4. Stop bleeding stepwise:
    • Mechanical: rub up uterine fundus · bimanual compression · catheterise (empty bladder)
    • Medical:
      1. Syntocinon 10 IU IM/slow IV + IV infusion 40 IU in 500 mL Hartmann's
      2. Ergometrine 500 µg IM (avoid if HTN / pre-eclampsia)
      3. Carboprost (haemabate) 250 µg IM every 15 min, max 8 doses (avoid asthma)
      4. Misoprostol 800 µg PR
      5. Tranexamic acid 1 g IV over 10 min (within 3 h of bleeding)
    • Surgical: EUA · intrauterine balloon tamponade (Bakri) · B-Lynch suture · uterine artery ligation/embolisation · hysterectomy (last resort)
  • 5. Treat cause: manual removal of retained placenta, repair lacerations
  • 6. Post-event: debrief, document, monitor for AKI/DIC, iron + transfusion if Hb low, thromboprophylaxis once bleeding stopped
DermatologyMelanoma
Malignancy of melanocytes. UK incidence rising. Subtypes: superficial spreading (most common), nodular, lentigo maligna, acral lentiginous.
❓Key Questions
  • "When did you first notice the mole? Has it changed?"
  • "Has it changed in size, shape, or colour?"
  • "Does it itch, bleed, ooze, or crust?"
  • "Have you had blistering sunburn, especially as a child?"
  • "Have you used sunbeds?"
  • "Any family history of skin cancer — melanoma, pancreatic cancer?"
  • "Any other moles you're worried about?"
  • "Any weight loss, night sweats, lumps, headaches, abdominal pain, breathlessness?" (mets screen)
🔍Signs & Symptoms
  • ABCDE of melanoma:
    • Asymmetry
    • Border — irregular, ragged
    • Colour — variation (brown/black/red/white)
    • Diameter — >6 mm
    • Evolution — change over time
  • 7-point Glasgow checklist:
    • Major (2 pts each): change in size · irregular shape · irregular colour
    • Minor (1 pt each): diameter ≥7 mm · inflammation · oozing/crusting · itch
    • ≥3 points → 2-WW referral
  • Risk factors: fair skin, >50 moles, dysplastic naevi, FHx melanoma, sunbed use, UV exposure, immunosuppression
🚨Red Flags
  • Bleeding / ulcerated lesion — high suspicion, urgent excision
  • Subungual lesion (Hutchinson sign) — acral lentiginous melanoma
  • Breslow >4 mm — <50% 5-yr survival
  • Lymph node enlargement, hepatomegaly, neurology — metastatic spread
  • New / changing mole in adult — never reassure without examination
  • Patient under 25 with new pigmented lesion — uncommon, refer
🧪Investigations
  • Bedside: dermoscopy (in primary care if trained), full skin + lymph node exam
  • Excisional biopsy — gold standard. Never shave biopsy a suspected melanoma (underestimates Breslow → wrong management)
  • Sentinel lymph node biopsy if Breslow >1 mm
  • Staging: CT thorax/abdo/pelvis ± brain MRI ± PET-CT for Stage III+
  • Mutation testing: BRAF, NRAS, KIT — guides targeted therapy
  • Why: Histological diagnosis + Breslow thickness (strongest prognostic factor) + staging guides treatment
💊Management (NICE)
NICE NG14:
  • Wide local excision with margins by Breslow:
    • In situ → 5 mm
    • <1 mm → 1 cm margin
    • 1–2 mm → 1–2 cm margin
    • >2 mm → 2 cm margin
  • Sentinel lymph node biopsy if Breslow >1 mm — staging, not therapeutic
  • Adjuvant therapy (high-risk Stage IIB+):
    • Immunotherapy: pembrolizumab, nivolumab (PD-1 inhibitors), ipilimumab (CTLA-4)
    • Targeted: dabrafenib + trametinib (BRAF + MEK) if BRAF V600 mutation
  • Stage IV: immunotherapy + targeted ± radiotherapy for symptomatic mets
  • Follow-up: regular skin checks for 5+ yrs depending on stage; self-examination education
  • Sun safety advice: SPF ≥30 broad-spectrum, reapply 2 h, hat/sunglasses, avoid 11 am – 3 pm, no sunbeds
  • Family screening if ≥3 first-degree relatives or melanoma + pancreatic Ca
DermatologyBCC, SCC + actinic keratosis
Non-melanoma skin cancers. BCC — most common, locally invasive, almost never metastasises. SCC — can metastasise, especially on lip / ear. AK — pre-malignant.
❓Key Questions
  • "How long has this lesion been there? Is it growing?"
  • "Does it bleed, ulcerate, or scab repeatedly?"
  • "Any pain or numbness?" (perineural invasion)
  • "How much sun exposure have you had — outdoor work, sunny holidays, sunburn?"
  • "Sunbeds?"
  • "Any history of immunosuppression — transplant, lymphoma, HIV?"
  • "Any prior skin cancers?"
  • "Family history of skin cancer?"
🔍Signs & Symptoms
  • BCC: pearly rolled edge · telangiectasia · central ulceration · slow-growing · sun-exposed (face, ears, scalp). Subtypes: nodular, superficial, morpheic.
  • SCC: keratotic, scaly, ulcerated, may be tender; sun-exposed; can grow rapidly. Subtypes: well-differentiated, poorly-differentiated, in situ (Bowen's = scaly red plaque).
  • AK: rough, scaly, sandpaper-textured, sun-exposed; pre-malignant (~1% per yr → SCC)
  • Seborrhoeic keratosis (BENIGN): "stuck-on" appearance, well-circumscribed, raised, brown/black, evenly coloured
🚨Red Flags
  • SCC on lip / ear / immunosuppressed patient — higher metastasis risk
  • Rapidly growing keratotic lesion — keratoacanthoma vs SCC
  • BCC with bone / cartilage invasion — extensive surgery / RT
  • SCC with palpable lymphadenopathy — metastatic disease
  • Recurrence post-excision — Mohs / RT
  • Multiple AKs / field change — manage entire field
🧪Investigations
  • Bedside: dermoscopy
  • Punch / excisional biopsy for diagnosis
  • SCC staging: high-risk = lip/ear, immunosuppressed, >2 cm, poorly-differentiated, perineural invasion → consider USS regional nodes / CT staging
  • Why: Histological diagnosis confirms BCC vs SCC vs other; identifies risk factors for metastasis (SCC)
💊Management (NICE)
NICE / British Association of Dermatologists:
  • BCC:
    • Excision with 4 mm margin (1st line)
    • Mohs micrographic surgery for face / recurrent / large / morphoeic — tissue-sparing
    • Curettage + cautery for superficial BCC
    • Topical imiquimod 5% / 5-FU for superficial BCC
    • Photodynamic therapy for superficial
    • Radiotherapy if surgery not appropriate
    • Vismodegib (Hedgehog inhibitor) for advanced / metastatic
  • SCC:
    • Wide local excision with 4–6 mm margin (10 mm if high-risk)
    • Mohs for face / recurrent / large / cosmetically sensitive
    • Sentinel node biopsy if high-risk
    • Adjuvant radiotherapy if perineural invasion / positive margin
    • Cetuximab / immunotherapy for advanced
  • AK: sun protection · cryotherapy (LN₂) · 5-FU cream · imiquimod · diclofenac gel · photodynamic therapy
  • Bowen's: 5-FU / imiquimod / cryo / curettage / excision
  • Sun safety education for all skin Ca patients
DermatologyAtopic eczema (atopic dermatitis)
Chronic, relapsing, itchy inflammatory skin condition. Atopic march: eczema → food allergy → asthma → hayfever. Skin-barrier dysfunction (filaggrin) + immune dysregulation.
❓Key Questions
  • "When did the rash start? Where on the body?"
  • "Is it itchy? Does it disturb sleep?"
  • "What makes it better — bath, cream? Worse — heat, stress, particular soaps?"
  • "Any allergies — food, pollen, animals?"
  • "Any asthma or hayfever?" (atopic triad)
  • "Family history of eczema, asthma, hayfever?"
  • "What treatments have you used? How well do they work?"
  • "Any cold sores or anyone in the family with cold sores recently?" (eczema herpeticum)
  • "Pets at home? House dust mite control?"
🔍Signs & Symptoms
  • Distribution: infants — face, scalp, extensor; older children/adults — flexures (antecubital, popliteal, neck, wrists)
  • Acute: erythematous, weeping, vesicles, intense itch
  • Chronic: lichenification (thickened skin from scratching), excoriations, hyperpigmentation
  • Atopic features: Dennie-Morgan lines (lower eyelid creases), keratosis pilaris, palmar hyperlinearity
  • Triggers: dryness, irritants (soap, wool), allergens (HDM, pets), heat, stress, infections (S. aureus colonisation)
🚨Red Flags
  • Eczema herpeticum — clustered punched-out vesicles, fever, systemically unwell · IV aciclovir, admit, ophthalmology if peri-ocular
  • Bacterial superinfection — yellow crust, weeping, S. aureus → flucloxacillin
  • Erythroderma (>90% body surface) — admit, fluid balance, temperature regulation
  • Steroid abuse / withdrawal — face, ↑ rebound on stopping
  • Failure to thrive in infant — severe eczema can affect growth, feeding
  • Severe pruritus + new symptoms in adult — exclude lymphoma (CTCL)
🧪Investigations
  • Clinical diagnosis — Hanifin–Rajka or UK Working Party criteria
  • Bedside: infection swab if pustular / weeping (S. aureus, eczema herpeticum)
  • Bloods: total IgE, specific IgE / RAST if allergen suspected
  • Patch testing if contact dermatitis suspected (Ni, fragrance, rubber)
  • Why: Confirm Dx, identify triggers, exclude superinfection (eczema herpeticum can be life-threatening)
💊Management (NICE)
NICE CG57 / NG198 (newer):
  • Foundation — emollients and avoidance:
    • Emollients liberally 3–4×/day (250–500 g/wk for adults) — even when clear
    • Soap substitutes (avoid soap, bubble bath) · short lukewarm showers
    • Avoid known triggers · cotton clothing · short nails
  • Stepped topical steroids (intermittent flare control):
    • Mild flare → mild steroid (hydrocortisone 1%)
    • Moderate flare → moderate steroid (clobetasone butyrate 0.05%)
    • Severe flare → potent steroid (mometasone, betamethasone 0.1%)
    • Face / flexures: only mild–moderate, short courses
    • Apply after emollient (wait 15 min)
  • 2nd line topical: tacrolimus / pimecrolimus (calcineurin inhibitors) — face, flexures, steroid-sparing
  • Wet wraps for severe acute flares (under specialist supervision)
  • Phototherapy (NB-UVB) for resistant chronic eczema in adults
  • Systemic (specialist): ciclosporin, methotrexate, azathioprine; biologics — dupilumab (IL-4/13), abrocitinib (JAK)
  • Antibiotics only if infected (flucloxacillin 500 mg QDS for 7 d)
  • Antiviral aciclovir IV for eczema herpeticum (medical emergency)
  • Patient education + Eczema Action Plan
DermatologyPsoriasis
Chronic immune-mediated condition with epidermal hyperproliferation. Plaque psoriasis = 90% of cases. Associated with psoriatic arthritis, depression, metabolic syndrome.
❓Key Questions
  • "When did it start? Where on the body?"
  • "Any joint pain, stiffness, or swelling — particularly in fingers / lower back?" (PsA)
  • "Any nail changes — pitting, separation?"
  • "How is it affecting your daily life — work, relationships, sleep, mood?"
  • "Any recent throat infections?" (guttate trigger)
  • "Family history of psoriasis or psoriatic arthritis?"
  • "Smoking? Alcohol? Stress?"
  • "Any medications — lithium, β-blockers, antimalarials, steroids you've stopped?"
  • "Any history of cancer / TB / hepatitis?" (pre-biologic screening)
🔍Signs & Symptoms
  • Plaque psoriasis: well-demarcated, salmon-pink/erythematous plaques with silver scale, extensor surfaces, scalp, sacrum
  • Auspitz sign: pinpoint bleeding when scale removed
  • Koebner phenomenon: lesions appear at sites of trauma
  • Nail changes: pitting, onycholysis, oil-drop sign, subungual hyperkeratosis (50% have, more if psoriatic arthritis)
  • Subtypes: guttate (small drop-like, often post-strep), pustular (von Zumbusch — emergency), erythrodermic, inverse (flexural), palmoplantar, nail
  • Triggers: strep throat (guttate), stress, alcohol, smoking, drugs (lithium, β-blockers, antimalarials, withdrawal of steroids)
  • Psoriatic arthritis: 5 patterns — distal IPJ, asymmetric oligoarthritis, symmetric polyarthritis, spondylitis, arthritis mutilans
🚨Red Flags
  • Pustular psoriasis (von Zumbusch) — sheets of sterile pustules, fever, hypocalcaemia — admit, supportive, urgent dermatology
  • Erythrodermic psoriasis — >90% body surface, fluid/temperature dysregulation — admit
  • Psoriatic arthritis — early Tx prevents joint damage, refer rheumatology
  • Severe nail involvement — predicts PsA
  • Significant DLQI / depression — escalate, mental health support
  • Withdrawal of oral / potent topical steroid — rebound, avoid systemic steroids in psoriasis
🧪Investigations
  • Clinical diagnosis — appearance + distribution
  • Skin biopsy if uncertain — Munro abscesses, parakeratosis, acanthosis
  • Bloods (severe): FBC, U&E, LFTs (baseline before methotrexate), HIV/Hep B/C (before biologics)
  • QFT / TB workup before biologics
  • PASI score: Psoriasis Area Severity Index — guides systemic therapy decision (≥10 typically)
  • DLQI: Dermatology Life Quality Index — >10 = significant impact on QOL
  • Why: Confirm Dx, assess severity, screen for comorbidities (PsA, metabolic, cardiovascular), pre-treatment workup
💊Management (NICE)
NICE CG153:
  • 1st line — topical (mild-moderate):
    • Emollients
    • Vitamin D analogue + potent steroid (calcipotriol + betamethasone — Dovobet, applied OD-BD up to 4 wks)
    • Coal tar for resistant patches
    • Salicylic acid for thick scale
    • Scalp: medicated shampoo, salicylic + steroid combination
  • 2nd line: phototherapy — narrowband UVB · PUVA (psoralen + UVA) — for resistant disease
  • 3rd line systemic (severe / PASI ≥10 / failed phototherapy):
    • Methotrexate 7.5–25 mg weekly + folic acid 5 mg weekly (different day) — monitor FBC, LFTs, U&E
    • Ciclosporin 2.5–5 mg/kg/day — short-term flares · monitor BP, U&E
    • Acitretin 25–50 mg/day — pustular/erythrodermic · teratogenic for 3 yrs after
    • Apremilast (PDE-4 inhibitor) — oral, fewer monitoring
  • Biologics (for failed / contraindicated systemic):
    • Anti-TNF: adalimumab, etanercept, infliximab
    • IL-12/23: ustekinumab
    • IL-17: secukinumab, ixekizumab
    • IL-23: guselkumab, risankizumab
  • Lifestyle: stop smoking · ↓ alcohol · weight loss · stress management
  • Comorbidities: screen + manage PsA · CV risk · depression · anxiety
DermatologyCellulitis
Acute bacterial infection of dermis + subcutaneous tissue. Most often S. pyogenes or S. aureus. Entry portal: skin break, eczema, fungal infection, ulcer, IV drug use.
❓Key Questions
  • "When did the redness start? Has it spread quickly?"
  • "Any pain — and is it in proportion to how it looks?" (necrotising fasciitis: pain out of proportion)
  • "Any cut, scratch, insect bite, fungal infection, or IV drug use?"
  • "Fever, chills, feeling generally unwell?"
  • "Any past episodes? Any chronic swelling of the leg?"
  • "Any diabetes, peripheral vascular disease, immunosuppression?"
  • "Any allergies — particularly penicillin?"
  • "Tetanus immunisation up to date?"
  • "Any recent travel, animal bites, sea / freshwater exposure?"
🔍Signs & Symptoms
  • Cardinal: erythema · warmth · swelling · tenderness · well-demarcated
  • Lymphangitis (red streaks tracking proximally) · regional lymphadenopathy
  • Systemic: fever, malaise, nausea
  • Erysipelas = upper dermis cellulitis — sharply raised border, bright red, often face (S. pyogenes)
  • Eron classification:
    • Class I: systemically well, no comorbidities → oral abx, GP
    • Class II: systemically well + comorbidity → IV abx, OPAT or admit
    • Class III: systemically unwell → admit, IV abx
    • Class IV: sepsis / necrotising fasciitis → resus, surgical debridement
  • Differentials: DVT, ruptured Baker's cyst, lipodermatosclerosis, contact dermatitis, gout, necrotising fasciitis
🚨Red Flags
  • Necrotising fasciitis red flags: pain out of proportion · crepitus · dusky/black/bullous skin · rapid spread · systemically unwell · LRINEC >6 → URGENT surgical debridement + broad-spectrum abx + ITU
  • Sepsis — Sepsis 6 within 1 h
  • Periorbital / orbital cellulitis — proptosis, ↓ visual acuity, painful eye movements → CT, IV abx, ENT/ophth
  • Dental / facial cellulitis — risk of cavernous sinus thrombosis
  • Recurrence — investigate cause (chronic oedema, tinea, IV drug use)
  • Animal / human bite — co-amoxiclav (Pasteurella, mixed)
🧪Investigations
  • Bedside: obs, mark border with pen, photograph, swab if open wound
  • Bloods: FBC, CRP, U&E, blood cultures (if systemic / IV abx required)
  • Imaging: USS Doppler if DVT cannot be excluded; MRI if necrotising suspected
  • LRINEC score (Lab Risk Indicator for Necrotising Fasciitis): >6 = consider, >8 = highly suspicious
  • Why: Confirm cellulitis vs differentials, assess severity, identify pathogen if severe, exclude necrotising fasciitis
💊Management (NICE)
NICE NG141:
  • Class I (mild, GP): flucloxacillin 500 mg–1 g QDS PO for 5–7 days. Clarithromycin 500 mg BD if penicillin-allergic. Doxycycline if pregnant + pen-allergic.
  • Class II–III (admit): flucloxacillin 1–2 g QDS IV, switch to PO when improving and afebrile 48 h. Co-amoxiclav 1.2 g TDS IV if facial / orbital / oral.
  • MRSA suspected: vancomycin / teicoplanin / linezolid
  • Class IV (necrotising fasciitis): SURGICAL EMERGENCY → fluclox + benzylpenicillin + clindamycin (anti-toxin) + metronidazole + gentamicin · urgent surgical debridement · ITU
  • Adjuncts: elevation, mark border, repeat obs, analgesia (paracetamol + NSAID if no contraindication)
  • Source control: treat tinea pedis (entry portal), treat ulcer, address IV drug use
  • Prevention: maintain skin integrity, treat eczema/tinea, compression for chronic oedema
DermatologyShingles (herpes zoster)
Reactivation of latent varicella-zoster virus in dorsal root ganglion. Unilateral, dermatomal vesicular rash. Risk: ↑ age, immunosuppression.
❓Key Questions
  • "When did the rash start? Was there pain before the rash?"
  • "Where is the rash? Does it stay on one side?"
  • "Have you had chickenpox before?"
  • "Any vesicles near the eye, on the tip of nose, or in the ear?"
  • "Any visual changes, eye pain, light sensitivity?"
  • "Any facial weakness, hearing changes, vertigo?"
  • "Headache, neck stiffness, fever, drowsiness?" (CNS)
  • "Any past zoster? Have you had the shingles vaccine?"
  • "Any immunosuppression — chemo, steroids, transplant, HIV?"
  • "Anyone at home pregnant or with weak immune system?"
🔍Signs & Symptoms
  • Prodrome: burning / tingling pain in dermatome 2–3 days before rash · malaise · fever
  • Rash: erythematous → papular → vesicular → pustular → crusts (over 7–10 days). Strict dermatomal distribution, unilateral, doesn't cross midline
  • Most common: thoracic dermatomes; ophthalmic V1 division; cervical
  • Hutchinson's sign: vesicles on the tip / side of nose → involvement of nasociliary branch of V1 → high risk ophthalmic involvement
  • Ramsay Hunt syndrome: herpes zoster oticus (geniculate ganglion) — ear pain, vesicles in external ear, unilateral facial palsy ± vertigo, hearing loss
🚨Red Flags
  • Hutchinson's sign / V1 distribution — same-day ophthalmology · risk of keratitis, uveitis, retinal necrosis
  • Ramsay Hunt — facial palsy + ear vesicles → aciclovir + steroids · ENT
  • Disseminated zoster (>20 lesions outside primary dermatome) — admit, IV aciclovir, exclude immunosuppression
  • Encephalitis / meningitis — fever, headache, ↓ GCS, focal neurology → IV aciclovir, LP
  • Pregnant + zoster — obstetric review, generally safe (unlike primary VZV in pregnancy)
  • Immunocompromised + zoster — IV aciclovir, monitor for dissemination
🧪Investigations
  • Clinical diagnosis — characteristic dermatomal vesicles
  • Vesicle PCR / direct fluorescent antibody if uncertain
  • HIV test if young + multidermatomal / disseminated
  • Why: Confirm Dx (atypical cases), exclude immunocompromise (esp. young patient with severe / atypical zoster)
💊Management (NICE)
NICE CKS / BNF:
  • Antivirals if started within 72 h of rash onset (or any time if ophthalmic / immunocompromised / new lesions still appearing):
    • Aciclovir 800 mg 5×/day PO for 7 days
    • OR valaciclovir 1 g TDS PO for 7 days (better bioavailability, BD–TDS)
    • OR famciclovir 500 mg TDS PO for 7 days
    • IV aciclovir (10 mg/kg TDS) for ophthalmic, severe, immunocompromised, encephalitis, disseminated
  • Pain management: paracetamol + ibuprofen → codeine → amitriptyline / gabapentin / pregabalin (for postherpetic neuralgia)
  • Topical: calamine for itch · capsaicin / lidocaine patch for PHN
  • Ophthalmic zoster: urgent ophthalmology referral · IV/PO aciclovir · topical lubricants · corticosteroid drops only under specialist
  • Ramsay Hunt: aciclovir + prednisolone 50 mg OD 10 days · ENT referral · eye care · most recover but some residual palsy
  • Postherpetic neuralgia (pain >3 mo): amitriptyline 10 mg ON titrate · or duloxetine 30 mg OD · or gabapentin 300 mg ON · pregabalin · capsaicin / lidocaine patches · TENS
  • Infection control: avoid contact with pregnant women / immunocompromised / non-immune until lesions crusted (chickenpox to non-immune)
  • Vaccination: shingles vaccine (Shingrix) — recombinant zoster vaccine for adults ≥65 yr (UK schedule) and ≥50 yr immunocompromised
OphthalmologyAcute angle-closure glaucoma
Sudden ↑ intraocular pressure due to closure of irido-corneal angle. Sight-threatening emergency. Usually presents in elderly hypermetrope at dusk / pupil dilatation.
❓Key Questions
  • "When did the eye pain / headache start?"
  • "Are you seeing rainbow halos around lights?"
  • "Has your vision become blurred?"
  • "Any nausea or vomiting?"
  • "Were you in a dimly-lit room or did this start when going to bed?"
  • "Are you long-sighted? Do you wear glasses for reading and distance?"
  • "Any family history of glaucoma?"
  • "Any new medications — antihistamines, antidepressants, anticholinergics?"
  • "Any history of eye surgery, uveitis, or trauma?"
🔍Signs & Symptoms
  • Symptoms: severe unilateral eye pain, frontal headache, blurred vision, haloes around lights, nausea/vomiting (often misdiagnosed as migraine or GI)
  • Signs:
    • Red eye, hazy/cloudy cornea (corneal oedema)
    • Fixed mid-dilated pupil (4–6 mm)
    • Hard, tender globe (tonometry: IOP >40 — normal 10–21)
    • Visual acuity reduced
    • Shallow anterior chamber on slit lamp
  • Triggers: dim light (pupil dilatation), anticholinergics, sympathomimetics, prone position
  • Risk factors: hypermetropia, age >50, female, Asian / Inuit, family Hx, shallow anterior chamber
🚨Red Flags
  • Acute visual loss + red eye + hard globe — AACG until proven otherwise
  • IOP >50 — severe, irreversible damage in hours
  • Corneal decompensation — late, poor prognosis
  • Bilateral simultaneous AACG — rare but emergency
  • Atypical presentation in young patient — exclude secondary causes (uveitis, lens subluxation)
🧪Investigations
  • Bedside: visual acuity, IOP (Goldmann tonometry — >30 mmHg diagnostic, often >50), slit lamp (corneal oedema, shallow AC, fixed dilated pupil)
  • Gonioscopy — closed angle (gold standard but not in emergency)
  • Fundoscopy if possible — optic disc cupping
  • Why: Confirm Dx + measure IOP to track response to treatment + plan definitive management
💊Management (NICE)
UK ophthalmology / RCOphth:
  • SAME-DAY OPHTHALMOLOGY REFERRAL — sight-threatening emergency
  • Position: lay patient supine (helps lens fall back, reopens angle)
  • Pharmacological reduction of IOP — combine 3 mechanisms:
    1. ↓ aqueous production:
      • Acetazolamide 500 mg IV (or 250 mg PO if PO tolerated)
      • Topical β-blocker — timolol 0.5% one drop
      • Topical α₂-agonist — apraclonidine / brimonidine
    2. ↑ aqueous outflow / pupil constriction:
      • Topical pilocarpine 2–4% — every 5 min for 30 min then QDS (constricts pupil → opens angle)
    3. Osmotic agent:
      • Mannitol 1–2 g/kg IV if not responding (caution in HF / renal impairment)
  • Analgesia + antiemetic (cyclizine; avoid metoclopramide — dopamine antagonist OK)
  • Definitive treatment: YAG laser peripheral iridotomy (LPI) once IOP controlled — creates hole in iris to bypass blocked angle. Bilateral (other eye prophylactic).
  • Severe / failed laser: surgical iridectomy / trabeculectomy / lens extraction
  • Avoid: mydriatics, anticholinergics, prone position
OphthalmologySudden painless visual loss — CRAO / CRVO / GCA
CRAO — embolus / thrombus blocks central retinal artery. CRVO — thrombosis of central retinal vein. Amaurosis fugax — transient = TIA equivalent.
❓Key Questions
  • "When exactly did your vision change? Was it sudden?"
  • "Was it like a curtain coming down, or did everything go grey?"
  • "Was it painful?" (painless = vascular)
  • "Did vision recover, or has it stayed lost?"
  • "Have you had episodes like this before — even brief ones?"
  • "Any headache, scalp tenderness, jaw pain when chewing?" (GCA)
  • "Aching in shoulders or hips?" (PMR)
  • "Weight loss, fevers, night sweats?"
  • "Any irregular heartbeat, AF, valve disease?"
  • "Diabetes, BP, cholesterol, smoking, family history of stroke?"
🔍Signs & Symptoms
  • CRAO: sudden complete unilateral painless visual loss (count fingers / hand movements / NPL) · RAPD · pale retina · cherry-red spot at macula · attenuated arteries
  • CRVO: sudden unilateral visual loss (variable severity) · "blood and thunder" fundus — flame haemorrhages, dilated tortuous veins, cotton wool spots, disc oedema
  • BRAO / BRVO: visual field defect in distribution of branch
  • GCA: >50 yr, jaw claudication, scalp tenderness, headache, weight loss, polymyalgia rheumatica overlap → amaurosis fugax / sudden permanent loss
  • Amaurosis fugax: transient (minutes) painless loss like a curtain — TIA, refer URGENT
🚨Red Flags
  • Sudden complete painless visual loss — CRAO / GCA · same-day ophthalmology + start treatment
  • Amaurosis fugax — TIA equivalent · stroke risk in next 7 days · TIA clinic <24 h
  • Headache + jaw claudication + scalp tenderness + visual symptom — GCA · prednisolone NOW
  • Bilateral CRVO — hyperviscosity (myeloma, polycythaemia)
  • CRVO with neovascularisation / iris rubeosis — neovascular glaucoma · urgent
  • CRAO + new headache — exclude carotid dissection
🧪Investigations
  • Bedside: visual acuity, RAPD, fundoscopy, BP both arms, ECG (AF)
  • Bloods: FBC, ESR + CRP urgent (GCA), glucose, lipids, U&E, coag, ANA, antiphospholipid (in young patients)
  • Imaging: carotid Doppler · echocardiogram (cardioembolic source) · CT/MRI brain if associated stroke / TIA
  • Temporal artery biopsy within 7 days if GCA suspected (don't delay treatment)
  • OCT retina · fluorescein angiography for confirmation
  • Why: Identify cause (embolic, thrombotic, GCA), prevent contralateral / further events, manage cardiovascular risk
💊Management (NICE)
RCOphth / NICE:
  • CRAO (within 4–6 h of onset — "stroke of the eye"):
    • Ocular massage · pulse globe · or breathe into bag (↑ CO₂)
    • IV acetazolamide / mannitol
    • Anterior chamber paracentesis (specialist) ↓ IOP
    • Refer hyperacute stroke pathway — IV thrombolysis can be considered <4.5 h within stroke service
    • Outcome usually poor — most permanent visual loss
  • CRVO:
    • Refer urgently to ophthalmology
    • Treat macular oedema: intravitreal anti-VEGF (ranibizumab, aflibercept) · or intravitreal steroid (dexamethasone implant, triamcinolone)
    • Pan-retinal photocoagulation if neovascularisation
    • Treat cardiovascular risk factors
  • Amaurosis fugax / GCA / suspected TIA:
    • If GCA suspected: prednisolone 60 mg PO STAT (60 mg + IV methylprednisolone if visual symptoms) · don't wait for biopsy · PPI cover · bone protection
    • Aspirin 300 mg STAT for embolic events · TIA clinic <24 h · carotid endarterectomy if >70% stenosis on symptomatic side
    • Long-term: clopidogrel 75 mg + atorvastatin 80 mg + BP control
  • Secondary prevention CV risk: antiplatelet, statin, BP, glycaemic control, smoking cessation
OphthalmologyDiabetic retinopathy + maculopathy
Microvascular complication of diabetes. Most common cause of blindness in working-age adults UK. Stages: background → pre-proliferative → proliferative · separate maculopathy.
❓Key Questions
  • "When were you diagnosed with diabetes? Type 1 or 2?"
  • "What was your last HbA1c?"
  • "Have you had your annual eye screening?"
  • "Any blurred vision, difficulty reading, missing patches?"
  • "Floaters or flashing lights? Sudden visual loss?"
  • "BP and cholesterol — under control?"
  • "Any kidney disease, neuropathy, foot ulcers?" (other complications)
  • "Smoking?"
  • "Are you driving? Any concerns about your vision while driving?"
  • "Are you pregnant or planning pregnancy?"
🔍Signs & Symptoms
  • Background: microaneurysms (dots), blot haemorrhages, hard exudates (lipid)
  • Pre-proliferative: + cotton-wool spots (ischaemic), venous beading, IRMA (intraretinal microvascular abnormalities)
  • Proliferative: + neovascularisation (NVD/NVE), pre-retinal / vitreous haemorrhage, fibrovascular proliferation, tractional retinal detachment
  • Maculopathy: macular oedema, hard exudates threatening fovea — most common cause of visual loss in T2DM
  • Symptoms: often asymptomatic until advanced · floaters (vit haem), sudden visual loss (vit haem / RD), gradual ↓ vision (maculopathy)
  • Risk factors: duration of diabetes, poor glycaemic control (HbA1c), HTN, hyperlipidaemia, pregnancy, smoking, renal disease
🚨Red Flags
  • Sudden visual loss in diabetic — vitreous haemorrhage / tractional RD · same-day ophthalmology
  • Floaters + flashes — retinal detachment
  • Pre-proliferative or worse — refer ophthalmology, don't just review next year
  • Pregnancy + diabetes — accelerated progression, optimise tightly
  • Rubeosis iridis — neovascularisation of iris → neovascular glaucoma
  • Patient missing screening — flag, re-engage
🧪Investigations
  • Annual digital retinal screening (UK Diabetic Eye Screening Programme) — from age 12, all diabetics
  • Visual acuity
  • Fundoscopy / slit lamp + 78D / 90D lens
  • OCT (optical coherence tomography) — quantify macular oedema
  • Fluorescein angiography — areas of ischaemia, neovascularisation
  • Bloods: HbA1c (target 48 / 53), lipids, U&E, BP
  • Why: Early detection prevents vision loss (treatable in early stages); monitor progression; assess overall metabolic control
💊Management (NICE)
NICE NG17 / NG28 / NG136:
  • Foundation: tight glycaemic control (HbA1c <53), BP <140/90 (<130/80 if albuminuria), statin (atorvastatin 20 mg), smoking cessation
  • Background: annual screening
  • Pre-proliferative: 6-monthly review, optimise control
  • Proliferative: pan-retinal photocoagulation (PRP) — laser to ischaemic peripheral retina · ↓ neovascularisation
  • Maculopathy with macular oedema:
    • Intravitreal anti-VEGF 1st line — ranibizumab, aflibercept (monthly to start)
    • Intravitreal steroid — dexamethasone implant, triamcinolone
    • Focal laser if non-central
  • Vitrectomy: for non-clearing vitreous haemorrhage, tractional retinal detachment, fibrovascular proliferation
  • Pregnancy: retinopathy can rapidly progress · screen pre-pregnancy + each trimester · treat aggressively
  • Driving: DVLA notification if visual standards not met (Snellen 6/12, >120° horizontal field)
OphthalmologyAge-related macular degeneration
Most common cause of irreversible visual loss in over-50s UK. Dry (90%) — drusen, atrophy, gradual. Wet (10%) — choroidal neovascularisation, sudden, treatable with anti-VEGF.
❓Key Questions
  • "When did you first notice the change in your vision?"
  • "Has it been gradual or sudden?"
  • "Are straight lines looking wavy?" (Amsler / wet)
  • "Difficulty recognising faces, reading, watching TV?"
  • "Any patches missing in your central vision?"
  • "Is your peripheral / side vision OK?"
  • "How is the other eye?"
  • "Smoking — current or past?"
  • "Family history of AMD?"
  • "Are you driving? Any falls / accidents?"
  • "Are you managing at home — cooking, shopping?"
🔍Signs & Symptoms
  • Dry AMD: gradual central visual loss, ↓ reading vision, scotoma. Drusen (yellow deposits) at macula on fundoscopy. Geographic atrophy in advanced disease.
  • Wet AMD: sudden / rapid central distortion (metamorphopsia — straight lines look wavy on Amsler grid), central scotoma. Subretinal haemorrhage, exudates, oedema.
  • Symptoms: ↓ central vision (faces blur, reading difficult), distortion, missing patches
  • Peripheral vision preserved — patient can still walk around
  • Risk factors: age >50, smoking (strongest modifiable), family Hx, female, white, hypertension, hyperlipidaemia, low antioxidant diet, blue light?
🚨Red Flags
  • Sudden central distortion / visual loss in elderly — wet AMD until proven otherwise · same-week ophthalmology
  • Bilateral wet AMD risk — when one eye affected, monitor other eye intensively (Amsler grid daily)
  • Functional impairment — driving, falls, depression, social isolation
  • Submacular haemorrhage — refer urgently, may need surgical evacuation
  • Overlap with diabetes / other cause of ↓ vision — careful workup
🧪Investigations
  • Bedside: visual acuity (each eye separately), Amsler grid (distortion), fundoscopy
  • OCT — macular thickness, sub-/intra-retinal fluid, drusen
  • Fundus fluorescein angiography — confirm wet AMD, identify neovascular complex
  • Why: Distinguish dry vs wet (treatment differs), monitor progression, identify potentially reversible wet AMD
💊Management (NICE)
NICE NG82:
  • Dry AMD:
    • No specific treatment
    • AREDS-2 supplements if intermediate: vitamin C, E, lutein, zeaxanthin, zinc, copper · ↓ progression to advanced disease ~25% (note β-carotene removed — ↑ lung cancer in smokers)
    • Stop smoking · Mediterranean diet · UV protection
    • Visual aids: magnifiers, large-print, audiobooks · low vision clinic
  • Wet AMD:
    • Intravitreal anti-VEGF first line:
      • Ranibizumab (Lucentis) monthly
      • Aflibercept (Eylea) — Q4–8 weeks, longer durability
      • Bevacizumab (Avastin, off-label) — cheaper alternative
      • Faricimab — newer dual pathway
    • Photodynamic therapy (verteporfin) — historical, occasionally used
    • Refer to ophthalmology <1 week of new wet AMD symptoms — vision loss ongoing without treatment
  • Counselling: reassure peripheral vision preserved, partial sight registration, RNIB, social services
  • Driving: DVLA notification — 6/12 vision, fields
  • Lifestyle: stop smoking (strongest evidence), Mediterranean diet, omega-3, regular exercise, sun protection
OphthalmologyRed eye — conjunctivitis vs serious causes
Common: bacterial / viral / allergic conjunctivitis. Sinister red eyes: AACG, anterior uveitis, scleritis, keratitis (incl. herpes), endophthalmitis, orbital cellulitis.
❓Key Questions
  • "When did the eye become red? One or both?"
  • "Is there discharge — sticky/yellow or watery?"
  • "Any pain, or just gritty/itchy?"
  • "Has your vision changed?"
  • "Sensitivity to light?"
  • "Recent cold or sore throat?"
  • "Do you wear contact lenses? Have you slept in them?"
  • "Any history of cold sores / chickenpox / shingles?"
  • "Any joint pain, back stiffness, IBD, sarcoidosis?" (uveitis)
  • "Any recent eye surgery, trauma, or new eye products?"
  • "Hayfever or asthma?"
🔍Signs & Symptoms
  • Bacterial conjunctivitis: sticky purulent discharge, eyes glued shut on waking, both eyes (often one then other), no visual loss, no pain · S. aureus, H. influenzae, S. pneumoniae
  • Viral conjunctivitis: watery discharge, gritty / foreign body sensation, often bilateral, often follows URTI, palpable preauricular node (adenovirus)
  • Allergic conjunctivitis: bilateral, intense itching, watery, "cobblestone" papillae on tarsal conjunctiva, atopic Hx
  • Anterior uveitis: unilateral, pain, photophobia, ↓ vision, small pupil, ciliary flush, hypopyon · ankylosing spondylitis, IBD, sarcoidosis · refer ophth
  • Keratitis (esp. HSV): dendritic ulcer on fluorescein staining · do not give topical steroid alone · refer same-day
  • Scleritis: deep boring pain (worse at night, wakes from sleep), bluish hue · associated with RA, vasculitis · same-day ophth
  • Endophthalmitis: recent eye surgery / trauma + pain + ↓ vision + hypopyon · emergency
  • Orbital cellulitis: eye pain on movement, proptosis, ↓ vision, fever — emergency
🚨Red Flags
  • Visual loss — never just conjunctivitis; refer same-day ophth
  • Severe pain (especially boring / waking from sleep) — scleritis, AACG, endophthalmitis
  • Photophobia — uveitis, keratitis, meningitis
  • Fixed dilated pupil — AACG
  • Dendritic ulcer on fluorescein — HSV keratitis · NO STEROIDS alone
  • Hypopyon — uveitis / endophthalmitis · admission
  • Proptosis / pain on eye movement / ↓ vision in child — orbital cellulitis
  • Contact lens wearer with red eye — assume bacterial keratitis until proven otherwise · same-day ophth
🧪Investigations
  • Bedside: visual acuity (always), pupil reactions, fluorescein staining (corneal abrasion / dendrite), eyelid eversion (foreign body)
  • Slit lamp: AC cells/flare (uveitis), corneal infiltrate (keratitis), hypopyon
  • Swab: conjunctival swab + PCR for HSV / VZV / chlamydia / gonorrhoea
  • Bloods: HLA-B27, ANA, RF, ACE, syphilis if recurrent uveitis
  • Why: Distinguish conjunctivitis (benign) from sinister red eyes (sight-threatening); guide pathogen-specific treatment
💊Management (NICE)
NICE CKS / RCOphth:
  • Bacterial conjunctivitis: often self-limiting (60% resolve in 5 days). Chloramphenicol 0.5% drops 2-hourly first 2 days then QDS, OR 1% ointment QDS for 5–7 days. Fusidic acid alternative if pregnant.
  • Viral conjunctivitis: supportive (cool compress, lubricants), good hand hygiene (highly contagious 10–14 days). Avoid contacts, share towels.
  • Allergic: trigger avoidance · cool compress · topical antihistamine (azelastine) · mast cell stabiliser (sodium cromoglicate) · oral antihistamine if severe
  • Chlamydial / gonococcal: systemic abx — ceftriaxone 1 g IM (gonorrhoea) + azithromycin 1 g PO (chlamydia) + partner notification
  • Neonatal conjunctivitis (ophthalmia neonatorum): emergency · gonococcus / chlamydia / HSV · IV antibiotics · refer paediatrics + ophth
  • Anterior uveitis: topical steroid (prednisolone) + cycloplegic (cyclopentolate to relieve pain + prevent posterior synechiae) — under ophthalmology · investigate for systemic cause
  • HSV keratitis: aciclovir ointment 5×/day for 7–14 days · DO NOT give topical steroid alone (worsens) · refer same-day
  • Scleritis: oral NSAID + systemic immunosuppression · ophthalmology + rheum
  • Endophthalmitis: intravitreal antibiotics · vitrectomy · emergency
  • Orbital cellulitis: IV co-amoxiclav · CT orbit · ENT + ophth · drain abscess if needed
General Presentations — History & Red Flags (65 conditions)
CardioRespiratoryChest Pain
❓Key Questions
SOCRATES (site, onset, character, radiation, associations, timing, exacerbating/relieving, severity) · Radiation to arm, jaw, or back · Pleuritic? (worse on inspiration) · Associated: SOB, diaphoresis, nausea/vomiting · Palpitations · Positional change (worse lying flat → pericarditis) · Relieved by GTN? By antacids? · Exertional vs rest pain
🚨Red Flags
🚨 Crushing central pain + radiation to jaw/arm → STEMI/ACS
🚨 Tearing/ripping pain radiating to back → aortic dissection
🚨 Haemoptysis + pleuritic pain + DVT risk factors → PE
🚨 Hypotension + raised JVP + muffled heart sounds → cardiac tamponade
CardioEndocrinePalpitations
❓Key Questions
Onset, duration, frequency of episodes · Regular vs irregular (ask patient to tap out the rhythm) · Sudden start/stop vs gradual onset · Associated chest pain, SOB, syncope, presyncope · Thyroid symptoms (heat intolerance, weight loss, tremor) · Known structural heart disease · Pregnancy
🚨Red Flags
🚨 Palpitations + syncope/near-syncope → life-threatening arrhythmia
🚨 FHx sudden cardiac death in young patient → channelopathy (LQTS, Brugada)
🚨 Palpitations + exophthalmos + weight loss → thyrotoxicosis
🚨 Irregular + fast + SOB → AF with rapid ventricular response
CardioNeurologySyncope / Collapse
❓Key Questions
Prodrome: nausea, sweating, greying vision (vasovagal) vs none (cardiac) · Precipitant: prolonged standing, pain, heat, micturition, defaecation · Position at collapse (supine = cardiac until proven otherwise) · Duration of loss of consciousness · Witnessed: jerking, incontinence, tongue bite → seizure? · Recovery: rapid (vasovagal) vs prolonged post-ictal confusion · Preceding palpitations or chest pain · Exercise-related collapse
🚨Red Flags
🚨 Syncope during exertion → HOCM or aortic stenosis
🚨 No prodrome + collapse while supine → cardiac arrhythmia
🚨 Prolonged LOC + post-ictal confusion → seizure (not syncope)
🚨 New onset in >60yo → cardiac cause until proven otherwise
CardioRespiratoryHeart Failure Symptoms
❓Key Questions
Dyspnoea: exertional, NYHA class (I–IV) · Orthopnoea: number of pillows needed · Paroxysmal nocturnal dyspnoea (woken gasping from sleep) · Ankle swelling: bilateral, pitting, extent · Weight gain (fluid retention) · Fatigue / reduced exercise tolerance · Palpitations (arrhythmia as cause or consequence) · Known cardiac history: IHD, HTN, valvular disease, AF
🚨Red Flags
🚨 Acute severe SOB + pink frothy sputum → acute pulmonary oedema
🚨 New onset AF + rapid deterioration → decompensated HF
🚨 Bilateral leg oedema + raised JVP + basal crackles → clinical HF
🚨 Syncope + exertional dyspnoea → severe aortic stenosis
CardioRespiratoryDVT / Venous Thromboembolism
❓Key Questions
Unilateral leg swelling, pain, tenderness, warmth, erythema · Pleuritic chest pain, haemoptysis, SOB (PE features) · Recent immobility: long-haul travel, hospitalisation, surgery · OCP / HRT / hormone therapy use · Pregnancy or recent delivery · Known thrombophilia (factor V Leiden, antiphospholipid syndrome) · Active malignancy · Recent trauma or fracture to affected limb
🚨Red Flags
🚨 Haemodynamic compromise + PE signs → massive PE (obstructive shock)
🚨 Bilateral leg swelling + SOB in pregnant woman → PE until proven otherwise
🚨 DVT + livedo reticularis + recurrent miscarriage → antiphospholipid syndrome
RespiratoryCardioShortness of Breath (Acute)
❓Key Questions
Onset (sudden vs gradual) · At rest or exertional (NYHA grade) · Orthopnoea / PND · Wheeze or stridor · Cough — productive, haemoptysis · Pleuritic chest pain · Ankle swelling / weight gain · Recent infection / fever
🚨Red Flags
🚨 Sudden onset + pleuritic pain + haemoptysis → PE
🚨 Stridor → upper airway obstruction (epiglottitis, anaphylaxis)
🚨 Bilateral crackles + orthopnoea + S3 → acute pulmonary oedema
RespiratoryGICough
❓Key Questions
Productive vs dry; colour and quantity of sputum · Haemoptysis · Worse at night / early morning → asthma · Triggered by cold, allergens, exercise → asthma · Associated wheeze, SOB · Post-nasal drip / nasal symptoms → UACS · Heartburn / regurgitation → GORD-related cough
🚨Red Flags
🚨 Haemoptysis + weight loss + smoking → lung cancer
🚨 Haemoptysis + fever + night sweats + TB risk → TB
🚨 Stridor with cough → upper airway obstruction
🚨 Progressive cough + fine basal crackles + clubbing → IPF / asbestosis
RespiratoryGPWheeze / Asthma (Adult)
❓Key Questions
Onset and duration of current episode · Wheeze: inspiratory vs expiratory · Triggers: allergens, exercise, cold, NSAIDs, beta-blockers · Nocturnal symptoms / early morning dip · Previous asthma diagnosis, PEFR trends · Frequency of reliever use (>3x/week = uncontrolled) · Preventer inhaler compliance and technique · Previous A&E attendances / hospital admissions / ITU
🚨Red Flags
🚨 Unable to complete sentences in one breath → acute severe asthma
🚨 Poor respiratory effort + exhaustion → near-fatal asthma
🚨 New wheeze in >50yo + smoking → exclude lung cancer/COPD first
RespiratoryCardioHaemoptysis
❓Key Questions
Amount: streaking vs frank blood vs massive (>200ml) · Bright red vs dark blood · Mixed with sputum or pure blood · Duration and frequency · Associated: cough, SOB, chest pain, fever · Pleuritic pain (PE/pneumonia) · Weight loss, night sweats, anorexia · Recent infection / travel
🚨Red Flags
🚨 Massive haemoptysis (>200ml/24h) → airway emergency
🚨 Haemoptysis + weight loss + smoking → bronchogenic carcinoma
🚨 Haemoptysis + fever + night sweats + TB risk → TB
🚨 Haemoptysis + pleuritic pain + DVT risk → PE
GIObsAbdominal Pain
❓Key Questions
SOCRATES (site, onset, character, radiation, associations, timing, exacerbating/relieving, severity) · Location and radiation (epigastric→back = pancreatitis; RIF = appendicitis; loin to groin = renal colic) · Onset: sudden vs gradual · Nausea, vomiting, diarrhoea, constipation, PR bleeding · Last bowel opening, change in bowel habit · Anorexia, weight loss · Urinary symptoms (dysuria, haematuria, frequency) · Menstrual history, LMP, possibility of pregnancy
🚨Red Flags
🚨 Sudden severe pain + peritonism (rigid abdomen) → perforation / mesenteric ischaemia
🚨 Pulsatile abdominal mass + pain → ruptured AAA
🚨 Positive pregnancy test + unilateral pain + vaginal bleeding → ectopic
🚨 Anorexia + weight loss + change in bowel habit + age >50 → colorectal cancer
GIGPDyspepsia / GORD
❓Key Questions
Site: epigastric, retrosternal · Character: burning, gnawing, pressure · Relationship to meals (worse after = GORD; better after = duodenal ulcer) · Nocturnal symptoms / woken from sleep · Regurgitation of acid/food · Dysphagia or odynophagia · Nausea, vomiting · Weight loss, anorexia (alarm features)
🚨Red Flags
🚨 Dyspepsia + dysphagia + weight loss in >55yo → 2WW upper GI endoscopy
🚨 Dyspepsia + melaena / haematemesis → upper GI bleed
🚨 Persistent vomiting + weight loss → gastric cancer
🚨 Epigastric pain + new anaemia + age >55yo → urgent investigation
GIObsNausea & Vomiting
❓Key Questions
Onset, duration, frequency · Character: bilious, blood-stained (haematemesis), faeculent · Associated abdominal pain, diarrhoea · Weight loss · Headache, visual disturbance (raised ICP) · LMP / possibility of pregnancy · Recent travel / food history (infective gastroenteritis) · Vertigo / tinnitus (labyrinthitis/Menière's)
🚨Red Flags
🚨 Haematemesis (blood in vomit) → upper GI bleed emergency
🚨 Faeculent vomiting → bowel obstruction
🚨 Vomiting + headache + papilloedema → raised ICP
🚨 Vomiting + severe dehydration + ketones in diabetic → DKA
GIGPDiarrhoea
❓Key Questions
Frequency, consistency (Bristol stool chart), volume · Blood or mucus in stool · Nocturnal diarrhoea (always suggests organic cause) · Urgency / faecal incontinence · Associated abdominal pain (IBD, IBS) · Weight loss · Recent travel / food history (infective)
🚨Red Flags
🚨 Blood + mucus + diarrhoea + fever → infective colitis or IBD flare
🚨 Chronic diarrhoea + weight loss + age >50yo → colorectal cancer
🚨 Diarrhoea + recent antibiotics + healthcare contact → C. difficile
🚨 Profuse watery diarrhoea + dehydration → cholera / ETEC
GIGPRectal Bleeding / PR Bleed
❓Key Questions
Bright red vs dark/melaena · Blood mixed with stool or separate / on paper / in pan · Associated mucus, tenesmus · Change in bowel habit (constipation, diarrhoea, narrow stool calibre) · Abdominal pain · Weight loss, anorexia · Anal pain on defaecation → fissure; painless bleeding → haemorrhoids vs cancer · Previous colonoscopy
🚨Red Flags
🚨 Change in bowel habit + PR bleed + weight loss in >50yo → colorectal cancer
🚨 Profuse dark PR bleed with haemodynamic instability → lower GI haemorrhage
🚨 PR bleed + mucus + tenesmus + rectal mass → rectal carcinoma
🚨 Melaena (dark tarry stool) → upper GI bleeding source
GIEndocrineJaundice
❓Key Questions
Dark urine + pale stool + itch → obstructive jaundice · Fever + RUQ pain + jaundice = Charcot's triad → cholangitis · IV drug use, tattoos, sexual history → hepatitis risk · Recent travel (hepatitis A) · Weight loss, anorexia → malignancy · Painful vs painless (painless = pancreatic head cancer until proven) · Blood transfusions
🚨Red Flags
🚨 Painless progressive jaundice in >60yo + weight loss → pancreatic cancer
🚨 Fever + rigors + jaundice → ascending cholangitis (surgical emergency)
🚨 Fulminant liver failure: encephalopathy + coagulopathy → liver transplant centre
🚨 Jaundice + haemolysis in young patient → Wilson's / hereditary spherocytosis
GINeurologyDysphagia
❓Key Questions
Solids only vs solids and liquids (solids only = mechanical; both = motility) · Progressive vs intermittent · Level of sensation of hold-up · Painful swallowing (odynophagia) · Weight loss / anorexia · Regurgitation of undigested food vs vomiting · Heartburn / acid reflux history · Change in voice / hoarseness
🚨Red Flags
🚨 Progressive dysphagia to solids then liquids + weight loss → oesophageal carcinoma
🚨 Dysphagia + iron deficiency anaemia in middle-aged woman → Plummer-Vinson
🚨 Sudden complete dysphagia to solids → food bolus obstruction
🚨 Hoarseness + dysphagia → recurrent laryngeal nerve involvement
GIEndocrineWeight Loss (Unintentional)
❓Key Questions
Amount lost and timeframe (>5% body weight in 3 months is significant) · Appetite: increased (hyperthyroid, DM) vs decreased (malignancy, depression) · Malabsorption: loose stools, steatorrhoea · Dysphagia, dyspepsia, abdominal pain · Change in bowel habit, PR bleeding · Polyuria, polydipsia → diabetes · Heat intolerance, palpitations, tremor → hyperthyroidism · Night sweats, lymphadenopathy, fever → lymphoma
🚨Red Flags
🚨 Unintentional weight loss >5% in 3 months → always investigate for malignancy
🚨 Weight loss + haemoptysis + smoking → lung cancer
🚨 Weight loss + PR bleeding + change in bowel habit → colorectal cancer
🚨 Weight loss + polyuria + polydipsia → uncontrolled DM (especially T1)
DermatologyRheumatologyRash — Assessment
❓Key Questions
Distribution: localised vs widespread; flexures vs extensors · Onset and evolution (where did it start? how did it spread?) · Morphology: macular, papular, vesicular, pustular, urticarial · Colour and any changes over time · Itch (pruritus): severity, time of day · Blister formation / skin peeling · Mucosal involvement (mouth, eyes, genitals) · Preceding infection / fever / sore throat
🚨Red Flags
🚨 Non-blanching purpuric/petechial rash + fever → meningococcal sepsis
🚨 Widespread blistering + mucosal involvement → Stevens-Johnson syndrome / TEN
🚨 Drug rash + facial oedema + lymphadenopathy + fever → DRESS syndrome
🚨 Butterfly rash on face + joint pain + photosensitivity → SLE
DermatologyChanging Skin Lesion / Mole
❓Key Questions
ABCDE: Asymmetry, Border irregularity, Colour variation, Diameter >6mm, Evolution · Duration: how long present? rate of change? · Bleeding, crusting, ulceration · Itch or pain · Sun exposure history (UV, sunbed use) · Previous skin cancer / mole removal · Immunosuppression (transplant, HIV, steroids) · Skin phototype (Fitzpatrick I–II at highest risk)
🚨Red Flags
🚨 Irregular border + multicoloured + >6mm + evolving → suspected melanoma (2WW referral)
🚨 Non-healing ulcer on sun-exposed skin → SCC
🚨 Pearly nodule with telangiectasia on face → BCC
🚨 Rapidly growing firm nodule in elderly → Merkel cell carcinoma
NeurologyHTNHeadache
❓Key Questions
Onset: sudden ('thunderclap') vs gradual · Site: unilateral, bilateral, occipital · Character: throbbing, pressure, stabbing · Severity (1–10) · Associated: nausea/vomiting, photophobia, phonophobia · Visual aura, transient vision loss · Fever, neck stiffness, rash · Systemic: weight loss, jaw claudication, scalp tenderness (>50yo → GCA)
🚨Red Flags
🚨 Thunderclap onset = 'worst headache of life' → SAH until proven otherwise
🚨 Fever + neck stiffness + non-blanching rash → meningococcal meningitis
🚨 New headache in HIV/immunosuppressed → opportunistic infection (cryptococcus)
🚨 Scalp tenderness + jaw claudication in >50yo → GCA (risk of permanent blindness)
NeurologyPaediatricsSeizure
❓Key Questions
Witnessed account: before, during, and after? · Prodrome or aura (smell, déjà vu, fear, visual symptoms) · Loss of consciousness? Duration? · Convulsive movements: tonic-clonic vs focal · Tongue biting (lateral = epileptic; tip = vasovagal) · Incontinence (bladder/bowel) · Post-ictal period: confusion, drowsiness, Todd's palsy · Previous seizures / known epilepsy
🚨Red Flags
🚨 Status epilepticus (>5 min or no recovery between seizures) → medical emergency
🚨 First seizure in adult >30yo → brain tumour until proven otherwise
🚨 Seizure + fever + neck stiffness → meningitis/encephalitis
🚨 Seizure in pregnancy → eclampsia
NeurologyCardioTIA / Stroke Symptoms
❓Key Questions
FAST: Face drooping, Arm weakness, Speech difficulty, Time of onset · Exact time symptoms started (crucial for thrombolysis/thrombectomy window) · Visual loss: amaurosis fugax (curtain), homonymous hemianopia · Ataxia, dysdiadochokinesia → posterior circulation · Vertigo + diplopia + dysphagia → posterior circulation TIA · Headache at onset (haemorrhagic stroke) · Cardiac risk factors: AF, HTN, DM, hyperlipidaemia, smoking
🚨Red Flags
🚨 Ongoing neurological deficit → stroke: immediate stroke team activation
🚨 TIA: ABCD2 score ≥4 → same-day specialist review
🚨 Headache at onset of neurological deficit → haemorrhagic stroke
NeurologyRheumatologyWeakness / Motor Deficit
❓Key Questions
Distribution: unilateral, bilateral, proximal, distal · UMN features (spastic, brisk reflexes, upgoing plantars) vs LMN (flaccid, wasting, fasciculations) · Onset: sudden (vascular/demyelination) vs gradual (tumour/MND) · Progression: stepwise, relapsing-remitting, progressive · Associated sensory symptoms (paraesthesia, numbness) · Bladder/bowel involvement (cord compression → emergency) · Cranial nerve involvement (diplopia, dysphagia, dysarthria) · Fatiguability (worse as day progresses → myasthenia gravis)
🚨Red Flags
🚨 Acute bilateral leg weakness + bladder/bowel dysfunction → spinal cord compression (emergency MRI)
🚨 Ascending weakness + areflexia post-infection → Guillain-Barré syndrome
🚨 Fatigable ptosis + diplopia + bulbar symptoms → myasthenia gravis
🚨 Progressive painless weakness + fasciculations + no sensory loss → MND
NeurologyPsychiatryMemory Loss / Dementia Symptoms
❓Key Questions
Onset and progression (sudden = vascular; gradual = Alzheimer's) · Short-term vs long-term memory affected · Word-finding difficulty (dysphasia) · Visuospatial problems (getting lost, driving accidents) · Executive dysfunction (planning, organising) · Personality / behavioural change (FTD) · Visual hallucinations (DLB) · Fluctuating cognition (DLB)
🚨Red Flags
🚨 Rapid cognitive decline over weeks-months → CJD / autoimmune encephalitis
🚨 Dementia + new focal deficit → stroke / subdural haematoma
🚨 Memory loss + raised ICP symptoms → brain tumour
🚨 Confusion + urinary incontinence + gait disturbance → normal pressure hydrocephalus
NeurologyDiabetesPeripheral Neuropathy
❓Key Questions
Distribution: glove-and-stocking (symmetric) vs mononeuropathy vs mononeuritis multiplex · Character: numbness, tingling, burning, lancinating pain · Motor involvement: foot drop, weakness · Onset and progression · Diabetes (most common cause) — duration, glycaemic control · Vitamin B12 deficiency: diet, metformin use, gastric surgery · Chemotherapy (cisplatin, vincristine) · Kidney/liver disease
🚨Red Flags
🚨 Acute rapidly progressive neuropathy + areflexia post-infection → Guillain-Barré
🚨 Painful neuropathy + purpuric rash + hepatitis C → cryoglobulinaemic vasculitis
🚨 Mononeuritis multiplex → vasculitis / diabetes / sarcoidosis
🚨 Neuropathy + weight loss → paraneoplastic neuropathy
ObsBleeding in Late Pregnancy (>20wk)
❓Key Questions
Gestation · Painless vs painful bleeding (key differentiating question) · Amount and colour (fresh red vs dark altered blood) · Fetal movements since bleeding started · Contractions / uterine tenderness · Previous Caesarean section / uterine surgery → placenta praevia/accreta risk · Known placenta position from booking ultrasound · History of trauma
🚨Red Flags
🚨 Painless fresh red bleeding → placenta praevia (do NOT perform VE)
🚨 Painful constant bleeding + tender rigid uterus → placental abruption
🚨 Bleeding + hypertension + epigastric pain + thrombocytopaenia → HELLP syndrome
🚨 Any APH with fetal compromise → emergency delivery
ObsHTNPre-eclampsia / Hypertension in Pregnancy
❓Key Questions
Gestation · Headache: frontal or occipital, severity · Visual disturbances: flashing lights, blurred vision, scotomata · Epigastric / RUQ pain → HELLP · Oedema: facial, hands (non-dependent = significant) · Reduced or absent fetal movements · Previous hypertension / pre-eclampsia · Booking BP
🚨Red Flags
🚨 Severe headache + visual disturbance + HTN → impending eclampsia
🚨 Epigastric pain + elevated transaminases + thrombocytopaenia → HELLP
🚨 Seizures in pregnancy → eclampsia (give MgSO₄ immediately)
🚨 BP ≥160/110 unresponsive to treatment → hypertensive emergency
ObsLabour and Antenatal Concerns
❓Key Questions
Gestation · Regular vs irregular contractions (frequency, duration, intensity) · Rupture of membranes: time, colour (clear vs meconium-stained) · Fetal movements (normal, reduced, absent) · Bleeding (show vs significant APH) · Pain: regular cramping vs constant (abruption) · GBS status (Group B Streptococcus swab result) · Previous pregnancy complications / mode of delivery
🚨Red Flags
🚨 Meconium-stained liquor → fetal distress, prepare paediatric team
🚨 Absent fetal movements → urgent CTG / assessment
🚨 Cord prolapse → emergency delivery
🚨 Constant abdominal pain + bleeding → placental abruption
GynaeSexual HealthVaginal Discharge
❓Key Questions
Colour, consistency, volume, odour · Itch: vulval pruritus → candida · Fish-like odour → bacterial vaginosis · Frothy yellow-green → trichomonas · Mucopurulent → gonorrhoea / chlamydia · Postcoital / intermenstrual bleeding (cervicitis, ectropion, cancer) · Dyspareunia / pelvic pain → PID · UPSI history / last STI screen
🚨Red Flags
🚨 Discharge + deep dyspareunia + pelvic tenderness + fever → PID
🚨 Postcoital bleeding + discharge in >35yo → cervical cancer
🚨 Offensive discharge + fever + recent TOP/IUCD insertion → endometritis
🚨 Contact bleeding + mucopurulent discharge → STI (chlamydia/gonorrhoea)
GynaeEndocrineAbnormal Uterine Bleeding
❓Key Questions
Menstrual cycle: frequency, duration, regularity · Heaviness: pad/tampon use, flooding, clots · Intermenstrual bleeding (IMB) · Postcoital bleeding (PCB) · Postmenopausal bleeding (PMB) · Dysmenorrhoea: primary vs secondary · Pelvic pain / pressure → fibroids / adenomyosis · Bloating, urinary symptoms → endometriosis
🚨Red Flags
🚨 Postmenopausal bleeding → endometrial cancer until proven otherwise
🚨 IMB/PCB in >35yo → cervical cancer
🚨 Heavy bleeding + pallor + haemodynamic instability → urgent transfusion
🚨 Pelvic pain + abnormal bleeding + cervical excitation → PID / ectopic
GynaeGIPelvic Pain
❓Key Questions
Onset and duration (acute vs chronic >6 months) · Cyclical vs non-cyclical · Relationship to menstrual cycle · Dysmenorrhoea: primary vs secondary (endometriosis, fibroids) · Deep dyspareunia → endometriosis · Dysuria, frequency → UTI / interstitial cystitis · Bowel symptoms: bloating, constipation, diarrhoea → IBS / IBD · Vaginal discharge, fever → PID
🚨Red Flags
🚨 Acute severe pelvic pain + amenorrhoea + vaginal bleeding → ectopic
🚨 Fever + pelvic tenderness + cervical excitation → PID (risk of infertility)
🚨 Pelvic pain + adnexal mass + post-menopausal → ovarian cancer
🚨 Acute urinary retention + pelvic mass → large fibroid / ovarian cyst
MSKRheumatologyBack Pain
❓Key Questions
Site: cervical, thoracic, lumbar, sacral · Onset: acute vs chronic (>3 months) · Radiation: sciatica pattern (leg pain below knee, dermatomal) · Neurological: leg weakness, numbness/paraesthesia · Bladder/bowel dysfunction → cauda equina screen · Morning stiffness >1 hour → inflammatory (ankylosing spondylitis) · Worse with rest → inflammatory; worse with movement → mechanical · Trauma history
🚨Red Flags
🚨 Saddle anaesthesia + bladder/bowel dysfunction → cauda equina (surgical emergency)
🚨 Back pain + fever + raised CRP/WCC → discitis / epidural abscess
🚨 Progressive back pain + weight loss in >50yo → spinal metastases
🚨 Back pain + new neurological deficit → cord compression
MSKRheumatologyKnee Pain
❓Key Questions
Mechanism: traumatic vs atraumatic; acute vs chronic · Location: medial, lateral, anterior, posterior · Locking → meniscal tear · Giving way → ACL / patellofemoral syndrome · Swelling: immediate (haemarthrosis = ACL/fracture) vs delayed 24–48h (effusion = meniscal) · Morning stiffness duration → OA vs RA · Clicking, crepitus · Age and activity level
🚨Red Flags
🚨 Hot swollen joint + fever → septic arthritis until proven otherwise (surgical emergency)
🚨 Acute haemarthrosis in young athlete → ACL rupture
🚨 Monoarthritis in sexually active young adult → reactive / gonococcal arthritis
🚨 Night pain + bone pain at rest in child/young adult → malignancy
MSKRheumatologyHip Pain
❓Key Questions
Site: groin (true hip joint) vs lateral (trochanteric bursitis) vs posterior (referred from spine) · Onset: acute (fracture, septic) vs insidious (OA) · Trauma / mechanism of injury · Inability to weight bear · External rotation and shortening of limb (NOF fracture) · Groin pain on internal rotation → hip joint pathology · Morning stiffness >1 hour → inflammatory · Limp and reduced ROM
🚨Red Flags
🚨 Elderly patient + fall + externally rotated shortened leg → NOF fracture (surgical emergency)
🚨 Child with hip pain + limp + fever → septic arthritis of hip (paediatric emergency)
🚨 Sudden severe hip pain + steroid use → avascular necrosis
🚨 Hip pain + weight loss + >50yo → metastatic bone disease
RheumatologyMSKJoint Pain / Polyarthritis
❓Key Questions
Number of joints: monoarthritis (1), oligoarthritis (2–4), polyarthritis (≥5) · Distribution: small joints hands/feet (RA), large joints (OA/reactive), DIP (psoriatic/OA) · Symmetrical vs asymmetrical · Swelling, warmth, erythema · Migratory vs additive pattern · Skin changes: psoriasis, rash, nodules · Preceding infection (pharyngitis, diarrhoea, STI → reactive arthritis)
🚨Red Flags
🚨 Acute monoarthritis + fever → septic arthritis (emergency joint aspiration)
🚨 Monoarthritis + crystals on aspiration → gout (urate) or pseudogout (pyrophosphate)
🚨 Polyarthritis + butterfly rash + photosensitivity → SLE
🚨 New polyarthritis + rheumatoid factor + anti-CCP → RA (early DMARD referral)
ENTEar Pain (Otalgia)
❓Key Questions
Unilateral vs bilateral · Duration · Discharge: type (purulent, bloody, watery → CSF), odour · Hearing loss · Tinnitus · Vertigo / dizziness · Facial weakness → cholesteatoma / malignant OE · Preceding URTI / swimming / foreign body
🚨Red Flags
🚨 Otalgia + facial nerve palsy + vesicles → Ramsay Hunt syndrome
🚨 Foul-smelling discharge + hearing loss + granulation tissue → cholesteatoma
🚨 Otalgia in elderly diabetic + granulation tissue → malignant otitis externa (Pseudomonas)
🚨 Blood / CSF discharge after head trauma → base of skull fracture
ENTPaediatricsSore Throat / Tonsillitis
❓Key Questions
Duration · Difficulty swallowing (odynophagia), trismus (difficulty opening mouth) · Muffled 'hot potato' voice · Drooling · Neck swelling / lymphadenopathy · Fever, rigors · Rash (scarlet fever / EBV rash) · Ear pain (referred)
🚨Red Flags
🚨 Trismus + unilateral peritonsillar swelling + deviated uvula → quinsy (peritonsillar abscess)
🚨 Drooling + stridor + tripod posture → epiglottitis (airway emergency)
🚨 Sore throat + widespread lymphadenopathy + splenomegaly → EBV (AVOID amoxicillin)
🚨 Neck swelling + trismus + unwell → parapharyngeal / retropharyngeal abscess
ENTNeurologyDizziness / Vertigo
❓Key Questions
True rotational vertigo vs light-headedness vs disequilibrium · Duration (seconds → BPPV; minutes–hours → Menière's; days → labyrinthitis) · Triggered by position change → BPPV (Dix-Hallpike test) · Associated hearing loss + tinnitus → Menière's triad · Nausea / vomiting · Neurological symptoms: diplopia, dysarthria, dysphagia, ataxia, facial numbness → central · Cardiovascular: palpitations, postural symptoms · Recent viral illness → viral labyrinthitis
🚨Red Flags
🚨 Vertigo + new neurological deficits → cerebellar stroke / posterior circulation TIA (HINTS exam)
🚨 Sudden unilateral hearing loss + vertigo → vestibular neuritis vs infarct
🚨 Progressive unilateral hearing loss + tinnitus → acoustic neuroma
🚨 Vertigo + occipital headache → posterior fossa lesion
ENTEndocrineNeck Lump
❓Key Questions
Site: anterior triangle, posterior triangle, midline · Duration and rate of change · Painful vs painless (painless = more sinister) · Moves on swallowing → thyroid / thyroglossal cyst · Moves on tongue protrusion → thyroglossal cyst · Throat / mouth symptoms (primary cancer) · Hoarseness, dysphagia · B symptoms: fever, night sweats, weight loss → lymphoma
🚨Red Flags
🚨 Painless, hard, fixed neck lump + B symptoms in adult → lymphoma
🚨 Neck lump + ipsilateral throat symptoms + smoking/alcohol → head and neck cancer
🚨 Rapidly enlarging neck lump + fever + toxicity → deep space neck infection
🚨 Neck lump + exophthalmos + palpitations → thyroid goitre with hyperthyroidism
EmergencyDermatologyAnaphylaxis
❓Key Questions
Trigger: food (nuts, shellfish, eggs), medication, insect sting, latex, contrast · Time from exposure to symptoms onset · Urticaria / angioedema · Stridor / hoarseness (upper airway oedema) · Wheeze / SOB (bronchospasm) · Hypotension / dizziness / collapse · GI: nausea, vomiting, abdominal pain · Previous anaphylaxis episodes
🚨Red Flags
🚨 Stridor + airway oedema → immediate IM adrenaline 0.5mg 1:1000
🚨 Hypotension + collapse → anaphylactic shock — ABCDE emergency
🚨 Biphasic reaction (recurrence 1–72h after initial) → observe minimum 6h
🚨 Patient on beta-blockers → refractory anaphylaxis, may need glucagon
EmergencyRenalSepsis Recognition
❓Key Questions
Source of infection: chest, urine, skin, abdomen, meningism, line/catheter · Fever or hypothermia · Rigors · Confusion / altered consciousness (new) · Oliguria / reduced urine output · Mottled / cyanotic skin · Immunocompromised: steroids, chemotherapy, HIV, post-splenectomy · Recent surgery / procedure / hospitalisation
🚨Red Flags
🚨 Hypotension + organ dysfunction → septic shock (mortality >40%)
🚨 Non-blanching rash + sepsis → meningococcal sepsis — IM benzylpenicillin immediately
🚨 Lactate >2 mmol/L → seek source, resuscitate aggressively
EmergencyMSKTrauma Assessment (ABCDE)
❓Key Questions
Mechanism: RTA, fall, penetrating, assault (MOI guides expected injuries) · Speed / height / type of impact · Airway: speaking? stridor? GCS? · Breathing: bilateral chest movements? tracheal deviation? · Circulation: external haemorrhage? haemodynamically stable? · Disability: GCS, pupils, focal neurological deficits · Exposure: other injuries, environment (hypothermia) · Protective equipment used (seatbelt, helmet)
🚨Red Flags
🚨 Tracheal deviation + absent breath sounds + hypotension → tension pneumothorax (needle decompression)
🚨 Haemodynamic instability + abdominal pain → haemoperitoneum (FAST scan)
🚨 GCS ≤8 → intubation and neuroprotection
🚨 Cervical tenderness after trauma → C-spine immobilisation until cleared
EmergencyRenalAcute Kidney Injury (AKI)
❓Key Questions
Pre-renal clues: vomiting, diarrhoea, bleeding, poor fluid intake, sepsis, HF · Intrinsic renal: nephrotoxins (NSAIDs, gentamicin, contrast, ACEi/ARBs), glomerulonephritis symptoms · Post-renal (obstructive): poor urine stream, hesitancy, enlarged prostate, pelvic malignancy · Oedema · Nausea, vomiting, confusion (uraemia) · Baseline renal function (known CKD) · Diabetes, hypertension (CKD risk factors)
🚨Red Flags
🚨 Anuria → complete obstruction or cortical necrosis — emergency
🚨 AKI + hyperkalaemia (K >6.5) → cardiac arrest risk — ECG + immediate treatment
🚨 AKI + pulmonary oedema + oliguria → fluid overload in AKI
🚨 AKI + loin pain + haematuria + large kidneys → obstruction / RPGN
DiabetesEndocrineDiabetic Ketoacidosis (DKA)
❓Key Questions
Known T1DM or T2DM on SGLT2 inhibitor · Polyuria, polydipsia, nocturia (hyperglycaemia) · Nausea, vomiting, abdominal pain (ketoacidosis) · Fruity / pear-drop breath (ketones) · Kussmaul breathing (deep sighing respirations) · Dehydration: thirst, dry mucous membranes · Precipitant: infection (most common), missed insulin, surgery, MI · Recent blood glucose readings
🚨Red Flags
🚨 Kussmaul breathing + fruity breath + hyperglycaemia + ketones → DKA — start FRIII protocol
🚨 Cerebral oedema in DKA (headache, deteriorating GCS) → slow correction of osmolality
🚨 Hypokalaemia during DKA treatment → cardiac arrest risk
🚨 HONK/HHS (high glucose, no ketones, very dehydrated, elderly T2DM) → different protocol
DiabetesMSKDiabetic Foot
❓Key Questions
Pain or painlessness (neuropathic → loss of protective sensation) · Ulcer characteristics: site, depth, discharge, slough, exposed structures · Peripheral sensation: monofilament test result · Peripheral pulses: dorsalis pedis, posterior tibial · Skin: temperature, colour, hair loss, dry skin · Charcot joint: hot, swollen, neuropathic (may be painless) · Duration of diabetes and glycaemic control (HbA1c) · Previous foot problems / amputations
🚨Red Flags
🚨 Deep ulcer + fever + cellulitis + exposed bone → diabetic foot osteomyelitis (urgent ortho/vascular)
🚨 Absent pulses + cold foot + non-healing ulcer → critical ischaemia
🚨 Hot swollen foot in insensate diabetic → Charcot neuroarthropathy vs septic arthritis
🚨 Rapidly spreading cellulitis + crepitus + gas on X-ray → necrotising fasciitis (emergency)
DiabetesEndocrineNew / Uncontrolled Diabetes
❓Key Questions
Polyuria, polydipsia, nocturia (osmotic symptoms) · Weight loss (T1DM catabolism) · Fatigue · Blurred vision (osmotic lens changes) · Recurrent infections: thrush, UTIs, skin infections · Acanthosis nigricans (insulin resistance / T2DM) · Obesity / metabolic syndrome features
🚨Red Flags
🚨 New diabetes + weight loss + young age → T1DM, check for DKA urgently
🚨 New diabetes + osmotic symptoms + ketones + vomiting → DKA
🚨 Steroid-induced hyperglycaemia in inpatient → can become severe rapidly
🚨 New T2DM + haemoptysis / weight loss → consider underlying malignancy (pancreatic CA)
HTNCardioHypertension Assessment
❓Key Questions
Duration known / incidental finding vs symptomatic · Symptoms of end-organ damage: headache, visual changes, SOB, chest pain, ankle swelling · Previous BP readings (home vs clinic vs ambulatory) · Secondary HTN: episodic headache + palpitations + sweating → phaeochromocytoma · Muscle weakness + polyuria → Conn's syndrome (hyperaldosteronism) · Renal symptoms: haematuria, oedema, frothy urine · Cardiovascular risk factors: DM, hyperlipidaemia, smoking, age
🚨Red Flags
🚨 BP >180/120 + symptoms (headache, visual change, chest pain, confusion) → hypertensive emergency
🚨 Episodic HTN + headache + palpitations + sweating → phaeochromocytoma
🚨 HTN + hypokalaemia + low renin → primary hyperaldosteronism (Conn's)
ElderlyNeurologyFalls in the Elderly
❓Key Questions
Circumstances: where, when, what activity at time of fall · Prodrome: dizziness, palpitations, chest pain, visual change · Loss of consciousness? Witnessed? · Intrinsic factors: gait/balance, visual impairment, cognitive impairment · Extrinsic/environmental: rugs, stairs, poor lighting · Previous falls · Ability to get up after fall (long lie → rhabdomyolysis, hypothermia) · Incontinence with fall → syncope vs urgency
🚨Red Flags
🚨 Fall + long lie (>1 hour) → rhabdomyolysis, dehydration, pressure injuries
🚨 Fall + hip pain + externally rotated leg → NOF fracture (surgical emergency)
🚨 Recurrent falls + new confusion → subdural haematoma
🚨 Fall + syncope + no prodrome → cardiac arrhythmia
ElderlyNeurologyConfusion / Delirium (Acute)
❓Key Questions
Baseline cognition (ask carer/family — crucial) · Onset: acute (hours/days) vs chronic (dementia) vs acute on chronic · Fluctuating course (delirium hallmark) · Hyperactive (agitated, hallucinating) vs hypoactive (quiet, withdrawn — often missed) · Infection source: chest, urine, wound, line · Urinary retention (very common cause in elderly men) · Metabolic: glucose, electrolytes, renal/liver function · Head injury or fall preceding confusion
🚨Red Flags
🚨 Acute confusion + fever + neck stiffness → meningitis / encephalitis
🚨 Acute confusion + focal deficit + headache → stroke / intracranial bleed
🚨 Delirium + urinary retention → catheterise and treat UTI
🚨 Confusion + hypothermia + hypotension in elderly → sepsis
PaediatricsEmergencyFebrile Child
❓Key Questions
Duration of fever · Height of temperature and pattern · Rash: type, distribution, blanching vs non-blanching · Behaviour: inconsolable crying, abnormally quiet, unresponsive · Feeding and wet nappies (hydration status) · Respiratory symptoms: cough, wheeze, stridor · Ear pulling / discharge → otitis media
🚨Red Flags
🚨 Non-blanching petechial/purpuric rash + fever → meningococcal sepsis (immediate treatment)
🚨 Bulging fontanelle in infant → raised ICP/meningitis
🚨 Neck stiffness + photophobia + fever → meningitis
PaediatricsRespiratoryWheeze / Asthma (Child)
❓Key Questions
Frequency and pattern of episodes · Nocturnal symptoms / early morning (asthma typical) · Triggers: infections, allergens, exercise, cold · Severity: hospital admissions, ITU, OCS courses · Interval symptoms between episodes · Reliever inhaler frequency · Atopic history: eczema, hay fever, food allergy
🚨Red Flags
🚨 Unable to speak in single words → acute severe asthma
🚨 Sudden onset unilateral wheeze + choking episode → foreign body aspiration
🚨 Recurrent chest infections + failure to thrive + wheeze → cystic fibrosis
PaediatricsGIAbdominal Pain in a Child
❓Key Questions
Location: periumbilical → appendicitis (migrates to RIF); central colicky → intussusception · Onset and duration · Character: colicky (obstruction/intussusception) vs constant (peritonism/appendicitis) · Vomiting: bilious (obstruction) vs non-bilious · Diarrhoea or constipation · Blood in stool: red-currant jelly → intussusception · Fever
🚨Red Flags
🚨 Bilious vomiting in neonate → malrotation / volvulus (surgical emergency)
🚨 Red-currant jelly stool + colicky pain + sausage mass → intussusception
🚨 Periumbilical pain migrating to RIF + guarding → appendicitis
🚨 Abdominal pain + pallor + scrotal swelling in boys → testicular torsion
PaediatricsDermatologyRash in a Child
❓Key Questions
Distribution and morphology · Blanching vs non-blanching (critical distinction) · Fever and general appearance (well vs unwell) · Contact with other sick children / school absence · Vaccination history (measles, meningococcal, varicella) · Itch (urticaria, eczema, chickenpox) · Timing relative to medication / food introduction · Mouth / mucous membrane involvement
🚨Red Flags
🚨 Non-blanching purpuric rash + fever + unwell → meningococcal sepsis (IM benzylpenicillin)
🚨 Rash + mucosal involvement + drug history → Stevens-Johnson syndrome
🚨 Palpable purpura on buttocks/legs + abdominal pain + joint pain → HSP (IgA vasculitis)
🚨 Vesicular dermatomal rash in child → herpes zoster (consider immunodeficiency)
RenalGynaeUrinary Tract Symptoms / UTI
❓Key Questions
Dysuria, frequency, urgency · Haematuria · Suprapubic pain (cystitis) vs loin/flank pain + fever (pyelonephritis) · Systemic: fever, rigors, nausea → upper UTI · Confusion in elderly (atypical UTI presentation) · Catheter in situ · Previous UTIs: frequency, organisms, sensitivities · Pregnancy (asymptomatic bacteriuria must be treated)
🚨Red Flags
🚨 Loin pain + fever + rigors → pyelonephritis: IV antibiotics if severe
🚨 Urinary symptoms + pregnancy → treat asymptomatic bacteriuria (preterm labour risk)
🚨 Recurrent UTI in male → prostate pathology / structural abnormality
🚨 Catheter-associated UTI + sepsis → urological emergency
RenalHTNChronic Kidney Disease (CKD)
❓Key Questions
Nausea, vomiting, anorexia (uraemia) · Fatigue (anaemia of CKD) · Pruritus (uraemic) · Oedema: ankle, periorbital (nephrotic range proteinuria) · Dyspnoea (fluid overload / uraemic pericarditis) · Confusion (uraemic encephalopathy) · Bone pain / fractures (renal osteodystrophy) · Blood pressure control
🚨Red Flags
🚨 CKD + hyperkalaemia → arrhythmia risk — ECG, dietary restriction, medication review
🚨 CKD stage 5 + uraemic symptoms → urgent dialysis initiation
🚨 CKD + haemoptysis + haematuria → Goodpasture's / GPA
🚨 Rapidly progressive renal failure + haematuria → RPGN (crescentic GN) — urgent biopsy
PsychiatryElderlyDepression
❓Key Questions
Core: low mood (most of day, most days) and/or anhedonia · Duration ≥2 weeks · Sleep disturbance (initial, middle, terminal insomnia or hypersomnia) · Appetite and weight change · Energy and fatigue · Concentration and memory · Psychomotor retardation or agitation · Guilt, worthlessness, hopelessness
🚨Red Flags
🚨 Active suicidal ideation with plan and intent → urgent psychiatric review
🚨 Psychotic features (nihilistic/guilty delusions, hallucinations) → severe depression
🚨 Postnatal depression + psychotic features → postnatal psychosis (emergency)
🚨 Severe weight loss + refusal to eat/drink → hospitalisation
PsychiatrySuicide Risk Assessment
❓Key Questions
Current thoughts of self-harm or suicide · Intent — how serious? · Plan — specific method in mind? · Protective factors: children, religious beliefs, future plans · Previous attempts (most significant single risk factor) · Method and outcome of previous attempts (high lethality = high risk) · Precipitating factors: loss, anniversary, relationship breakdown · Hopelessness (strongest single predictor of completed suicide)
🚨Red Flags
🚨 Active plan + access to means + intent → emergency psychiatric review
🚨 Previous near-lethal attempt → highest future risk category
🚨 Hopelessness is the single strongest predictor of completed suicide
🚨 Isolated, male, alcohol-dependent, chronic pain → high-risk demographic
PsychiatryPsychosis / Mania
❓Key Questions
Positive symptoms: hallucinations (auditory, visual, tactile), delusions (persecutory, grandiose, referential) · Negative symptoms: flat affect, alogia, avolition, social withdrawal · Thought disorder: disorganised thinking, thought insertion/withdrawal/broadcasting · Manic symptoms: elevated mood, decreased sleep need, grandiosity, pressured speech, impulsivity · Insight — does the patient believe they are unwell? · Onset and duration · Substance use (cannabis, amphetamines, cocaine) · Medical causes: steroids, thyroid, delirium
🚨Red Flags
🚨 First episode psychosis with risk to self/others → inpatient admission likely
🚨 Command hallucinations to harm self or others → urgent risk assessment
🚨 Mania + severe disinhibition + reckless behaviour → emergency
🚨 Sudden onset + confusion + visual hallucinations → delirium (always exclude organic)
PsychiatryCardioAnxiety / Panic Disorder
❓Key Questions
Physical symptoms during attacks: palpitations, tremor, sweating, SOB, chest tightness · Cognitive: fear of dying, fear of losing control, derealisation/depersonalisation · Duration and frequency of attacks · Triggers vs spontaneous (panic disorder = spontaneous) · Agoraphobia: avoidance of situations where escape is difficult · GAD: persistent worry across multiple domains · OCD: obsessions + compulsions · PTSD: trauma history, flashbacks, hypervigilance, nightmares
🚨Red Flags
🚨 Anxiety + palpitations + episodic hypertension + sweating → phaeochromocytoma
🚨 Anxiety + weight loss + heat intolerance + tremor → hyperthyroidism
🚨 Panic attacks + active suicidal ideation → urgent psychiatric review
🚨 Severe agoraphobia + inability to leave home → significant functional impairment
PsychiatryGISubstance Misuse / Alcohol
❓Key Questions
CAGE questionnaire (Cut down, Annoyed, Guilty, Eye-opener) · Units per week, pattern of drinking · Dependence features: morning drinking, withdrawal symptoms (tremor, sweats, seizures) · Last drink / last use · Withdrawal history: previous seizures, DTs · Impact: work, relationships, finances, legal · Hepatic symptoms: jaundice, abdominal pain, haematemesis · Overdose history / polydrug use
🚨Red Flags
🚨 Alcohol withdrawal + tremor + sweating → seizure risk: start benzodiazepine treatment
🚨 Confusion + hallucinations + tremor → delirium tremens (DTs) — medical emergency
🚨 IV drug use + fever + heart murmur → infective endocarditis
🚨 Opioid overdose: pinpoint pupils + reduced consciousness + respiratory depression → naloxone
Sexual HealthGynaeSTI Symptoms / Sexual History
❓Key Questions
Vaginal/urethral discharge: colour, consistency, odour · Dysuria (urethritis → gonorrhoea/chlamydia) · Genital ulcers / sores (painful = herpes; painless = syphilis) · Genital lumps / warts · Pelvic pain / deep dyspareunia → PID · Systemic: fever, rash, joint pains (disseminated gonococcal infection) · Anal symptoms: discharge, pain, bleeding (proctitis) · Full sexual history: gender of partners, number, condom use, type of sex
🚨Red Flags
🚨 Genital ulcer + rash on palms/soles + lymphadenopathy → secondary syphilis
🚨 Discharge + pelvic pain + fever + cervical excitation → PID (infertility risk)
🚨 HIV risk + seroconversion illness: fever + rash + lymphadenopathy → urgent HIV test
🚨 Painless genital ulcer + inguinal lymphadenopathy → primary syphilis (high infectivity)
Sexual HealthGynaePelvic Inflammatory Disease (PID)
❓Key Questions
Lower abdominal / pelvic pain (bilateral) · Vaginal discharge: mucopurulent · Deep dyspareunia · Fever, rigors · Irregular bleeding / IMB · Recent UPSI or new sexual partner · IUD insertion (risk highest in 3 weeks post-insertion) · Recent gynaecological procedure (ERPC, hysteroscopy)
🚨Red Flags
🚨 PID + positive pregnancy test → ectopic until proven otherwise
🚨 PID + tubo-ovarian abscess → IV antibiotics +/- surgical drainage
🚨 Recurrent PID → bilateral tubal damage → infertility (discuss explicitly)
🚨 PID + RUQ pain → Fitz-Hugh-Curtis syndrome (perihepatitis)
Sexual HealthGynaeContraception Counselling
❓Key Questions
Current contraception and compliance · Reason for review: side effects, method failure, switching, new prescription · LMP and current pregnancy status · UPSI in last 72–120h (emergency contraception) · Smoking status and age (combined pill contraindications) · BP (combined pill contraindication if >140/90) · BMI · History of VTE, migraine with aura, breast cancer → combined pill contraindications
🚨Red Flags
🚨 Migraine with aura + combined OCP → 2x increased stroke risk — switch to POP/LARC
🚨 UPSI >120h → IUD more effective than oral emergency contraception
🚨 OCP + enzyme-inducing drugs (rifampicin, carbamazepine) → contraceptive failure
🚨 Combined pill + smoker >35yo → high cardiovascular risk — switch method
EndocrineCardioThyroid Disease
❓Key Questions
Hypothyroid: weight gain, cold intolerance, constipation, dry skin/hair, fatigue, low mood, bradycardia · Hyperthyroid: weight loss, heat intolerance, diarrhoea, sweating, palpitations, tremor, anxiety · Neck swelling / goitre · Eye symptoms: exophthalmos, diplopia, lid lag → Graves' disease · Pressure symptoms: dysphagia, dyspnoea, hoarseness → goitre · Pregnancy: postpartum thyroiditis · Previous thyroid treatment (surgery, radioiodine) · Neck irradiation history → malignancy risk
🚨Red Flags
🚨 Thyroid storm: fever + tachycardia + confusion + hyperthyroid → ITU emergency
🚨 Myxoedema coma: hypothermia + bradycardia + decreased consciousness → IV T3/T4 + steroids
🚨 Goitre + dysphagia + hoarseness + weight loss → thyroid cancer
🚨 Hyperthyroidism + pregnancy → fetal tachycardia if untreated
EndocrineElderlyHypothyroid / Hyperthyroid Focused
❓Key Questions
Energy levels and fatigue · Weight change with stable/changed appetite · Cold vs heat intolerance · Bowel habit: constipation (hypo) vs diarrhoea (hyper) · Skin/hair: dry, coarse, hair loss (hypo) vs fine, sweaty (hyper) · Pulse rate (bradycardia hypo vs tachycardia/AF hyper) · Mood: depression (hypo) vs anxiety/irritability (hyper) · Tremor (hyperthyroid)
🚨Red Flags
🚨 New AF in elderly → always check TFTs for hyperthyroidism
🚨 Hypothyroidism + lithium/amiodarone → drug-induced hypothyroidism
🚨 Hypothyroidism in pregnancy → fetal neurodevelopmental risk if untreated
🚨 Hyperthyroidism + weight loss + dysphagia → thyroid malignancy with goitre

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49 cards
Physical Examination Checklists — Dundee Guide 2024-25 (22)
General📋 General Examination / Vital Signs
Start every examination: Infection control → Introduce self → Identify patient → Explanation and consent → End-of-bed assessment.
StepWhat to Assess
End-of-bedLevel of distress, drowsiness, pallor, cyanosis, jaundice, sweating. Look at bed environment: O2, IV…
HandsWarmth, colour, peripheral cyanosis, capillary refill time (<2s), bruising, tar staining. Nails: finger…
Pulse & RRRadial pulse: rate, volume, character, rhythm. Respiratory rate: count for 30s × 2.
FaceEyes: conjunctival pallor, scleral jaundice, corneal arcus. Mouth: central cyanosis, dentition, angular…
Neck lymph nodesFrom behind: submental → submandibular → anterior triangle → posterior triangle → pre/post-auricular →…
LegsColour, swelling, scars.
Vital Signs (BP)Patient seated, arm at heart level. Estimate systolic by palpating radial. Auscultate brachial: systolic =…
ClosureExplain and document findings. Thank patient. Infection control.
Cardio❤️ Cardiovascular System Examination
StepDetails
IntroductionInfection control, introduce self, identify patient, explanation and consent.
End-of-bedDistress, pallor, cyanosis, diaphoresis. Bedside: O2, IV lines, cardiac monitor, GTN spray, ECG electrodes.
HandsWarmth, colour, peripheral cyanosis, CRT (<2s), pale palmar creases. Tar staining, finger clubbing,…
Pulse (radial)Rate, volume, character, rhythm. Radio-radial delay (aortic dissection). Collapsing/bounding pulse (AR, AV…
Blood PressureBoth arms — if >15 mmHg difference: repeat and use arm with higher reading. Consider lying + standing…
ElbowsElbow xanthomata (hypercholesterolaemia).
FaceEyes: conjunctival pallor, corneal arcus, xanthelasma. Malar flush (mitral stenosis). Mouth: central cyanosis.
JVPPatient at 45°, facing left. Measure vertical height from sternal angle to top of internal jugular…
Carotid arteriesPalpate right then left separately — NEVER simultaneously (vagal risk). Character: slow-rising (AS),…
Precordial inspectionChest deformity, scars (median sternotomy, CABG harvest, pacemaker), visible pulsations, pacemaker box.
Precordial palpationApex beat: normal 5th ICS mid-clavicular line; displaced = cardiomegaly. Heaves: left parasternal (RVH),…
AuscultationFour areas: Aortic (2nd R ICS), Pulmonary (2nd L ICS), Tricuspid (4th L ICS), Mitral (apex). Use diaphragm…
Lung basesBibasal crepitations (pulmonary oedema).
SacrumCheck for sacral oedema (CCF — especially bed-bound).
LegsPitting oedema (press tibia 10s), colour, temperature, venous graft scars.
ClosureExplain and document findings. Thank patient. Infection control.
⭐ OSCE Presentation: "On examination, [patient] appeared [well/unwell]. Pulse [X] bpm [regular/irregular]. BP [X/Y] in both arms. JVP [elevated/normal]. On auscultation I heard [murmur details / normal heart sounds]." Murmur grades: 1=barely audible → 6=heard without stethoscope.
Respiratory🫁 Respiratory System Examination
StepDetails
IntroductionInfection control, introduce self, identify patient, explanation and consent.
End-of-bedDistress: SOB? Accessory muscles? Complete sentences? Bedside: oxygen mask/flow rate, nebulisers,…
HandsWarmth, colour, peripheral cyanosis, CRT, thin skin (steroid use). Tar staining, finger clubbing…
Pulse & RRRadial pulse: rate, volume, rhythm. RR: count for 30s × 2 (normal 12–20/min).
FaceEyes: conjunctival pallor. Mouth: central cyanosis (blue tongue), pursed-lip breathing (COPD).
Neck lymph nodesFrom behind: systematically through all regions comparing sides.
JVPElevated in cor pulmonale (right HF secondary to lung disease).
Chest inspectionSitting forward, adequately exposed. Shape: barrel chest (COPD), pectus excavatum/carinatum, scoliosis.…
Chest palpationTrachea: central or deviated? (Away from effusion/tension, toward collapse/fibrosis.) Expansion: hands…
Chest percussionStart apices, move inferiorly. Compare same level both sides. ALL areas: anterior, posterior, lateral.…
Chest auscultationBoth fields, apex to base, anterior + posterior + lateral. Full inspiration–expiration cycle at each…
Additional testsTactile vocal fremitus (increased over consolidation, decreased over effusion). Vocal resonance: "Say 99"…
LegsPitting oedema (cor pulmonale/PE), signs of DVT.
ClosureExplain findings, document. Thank patient. Infection control.
⭐ OSCE Presentation: "Trachea [central/deviated to X]. Percussion [dull/resonant/hyper-resonant] at [location]. Auscultation: [breath sounds + added sounds] at [location]."
GI🫃 Gastrointestinal System Examination
StepDetails
IntroductionInfection control, introduce self, identify patient, explanation and consent.
End-of-bedPain, sweating, drowsy, jaundiced, pale? IV fluids, NG tube, drain, stoma bag, urine output.
HandsPalmar erythema (liver disease). Clubbing (IBD/cirrhosis/coeliac), koilonychia (iron deficiency),…
FaceEyes: conjunctival pallor, scleral jaundice, corneal arcus, Kayser-Fleischer rings (Wilson's). Mouth:…
NeckVirchow's node (left supraclavicular = gastric cancer — Troisier's sign).
Abdominal inspectionLying supine, adequately exposed, ask if any pain. Distension (6 Fs: fat, fluid, flatus, faeces, fetus,…
Abdominal palpationPatient supine, knees slightly bent, arms by sides. Begin away from pain — superficial then deep palpation…
OrganomegalyLiver: Start RIF, move up 2cm increments on inspiration — use radial edge of index finger to "scoop" upwards. Spleen: Start RIF, move to LUQ; roll patient right if not felt. Kidneys: Bimanual ballottement. Aorta: Epigastrium — expansile pulsatile mass = AAA.
PercussionLiver: percuss up from RIF in MCL; down from 5th ICS. Spleen: RIF to LUQ. Shifting dullness for ascites:…
AuscultationBowel sounds up to 2 minutes. Normal: intermittent gurgling. Increased/tinkling (SBO), absent…
Groin herniasExamine if indicated — cough test.
LegsBruising (liver disease), oedema (hypoalbuminaemia), muscle wasting.
ClosureState: "I would offer a PR examination as part of complete GI assessment." Document. Thank patient.
Renal🫘 Renal & Urology Examination
StepDetails
IntroductionInfection control, introduce self, identify patient, explanation and consent.
InspectionLying supine, abdomen exposed. Scars: flanks (nephrectomy), iliac fossa (renal transplant — right or…
PalpationSuperficial then deep — all nine regions. Kidneys: bimanual ballottement (hand in flank + hand on anterior…
PercussionLiver, spleen. Bladder: percuss upper abdomen down to symphysis pubis.
Ascites assessmentPercuss midline to flank; shifting dullness if positive.
AuscultationBowel sounds. Renal, aortic, hepatic bruits.
ClosureState: "I would check urine dipstick, BP, and fluid balance chart." Thank patient. Infection control.
Neurology🧠 Neurological — Upper Limb Examination
Equipment: Tendon hammer, 128Hz tuning fork, cotton wool, neurotips.
StepDetails
InspectionTremor (resting/postural/intention), muscle wasting, fasciculations, scars, neurofibromas. Arms…
ToneFlex and extend arm at elbow — slowly and quickly. Supinate wrist slowly and quickly. Spasticity =…
Power (MRC 0–5)Shoulder abduction/adduction (C5), elbow flexion (C5/6) + extension (C7), wrist flexion (C7) + extension…
ReflexesBiceps (C5/6), triceps (C7), supinator (C6). Reinforcement (Jendrassik) if absent. Grade: - absent, +/-…
SensationPain (neurotips, eyes open), light touch (cotton wool, eyes closed), temperature (cold tuning fork).…
ClosureExplain findings. Thank patient. Infection control.
UMN vs LMN: UMN = increased tone (spasticity), hyperreflexia, extensor plantar, clonus, weakness. LMN = decreased tone, hyporeflexia, wasting, fasciculations, flexor plantar.
Neurology🧠 Neurological — Lower Limb Examination
StepDetails
InspectionCatheter, skin lesions, muscle wasting, neurofibromas, scars, fasciculation, tremor.
ToneRoll each leg slowly and quickly; flex and extend knee. Clonus: dorsiflex ankle with knee flexed — >3…
Power (MRC)Hip flexion/extension, knee flexion/extension, ankle plantar flexion/dorsiflexion, ankle…
ReflexesKnee (L3/4), ankle (S1/2), plantar response (S1/2). Babinski: up-going = UMN lesion; down-going = normal.
SensationL2 anterior lateral thigh, L3 anterior medial thigh, L4 anterior medial calf, L5 anterior lateral…
GaitObserve standing and walking: pace, symmetry, arm swing, turning. Heel-to-toe (cerebellar). Romberg's test…
ClosureExplain findings. Thank patient. Infection control.
Neurology🧠 Cranial Nerves Examination
Equipment: Snellen chart, Ishihara chart, eye cover, pen torch, ophthalmoscope, red pin, tendon hammer, 512Hz tuning fork, neurotips, cotton wool, tongue depressor.
NerveExamination
CN I — OlfactoryAsk about smell changes; smell identification test if needed.
CN II — OpticVisual acuity (Snellen), colour vision (Ishihara), visual fields (confrontation with pin/finger),…
CN III/IV/VIResting gaze: ptosis (III), nystagmus. Eye movements in H-formation. Saccadic movements.
CN V — TrigeminalLight touch: ophthalmic (forehead), maxillary (cheek), mandibular (jaw). Muscles of mastication (clench…
CN VII — FacialRaise eyebrows (frontalis), close eyes tightly (orbicularis oculi), show teeth, smile, puff cheeks. UMN:…
CN VIIIWhisper test (mask other ear). Rinne: BC on mastoid then AC in front of ear — ask which is louder. Weber:…
CN IX/XAsk to cough, swallow, say "ahhh"; watch soft palate movements. Uvula deviates away from CN X lesion.
CN XISCM: turn head against resistance. Trapezius: shrug shoulders against resistance.
CN XIIInspect tongue: wasting, fasciculations. Protrude tongue — deviates toward LMN lesion.
ClosureExplain findings. Thank patient. Infection control.
MSK🦴 MSK — Spine Examination
StepDetails
IntroductionInfection control, introduce self, identify patient, explanation, consent, check for discomfort.…
InspectionFrom behind: head position, shoulder heights, thoracolumbar scoliosis (standing + bending forward). From…
PalpationSupraclavicular (cervical ribs, lymphadenopathy). Midline: cervical to lumbar spinous processes (step =…
Movement (active)Cervical: flexion, extension, lateral flexion ×2, rotation ×2. Lumbar: flexion ("touch your toes"),…
Special testsSchober's: mark 10cm above and 5cm below S2; normal expansion >5cm (reduced in AS). Straight leg raise…
ClosureExplain findings. Thank patient. Infection control.
MSK🦴 MSK — Hip Examination
StepDetails
IntroductionInfection control, introduce self, consent, check discomfort. Expose adequately (underwear below waist).
InspectionStanding: quadriceps/gluteal/hamstring bulk; gait (antalgic, Trendelenburg, stiff). Lying: position,…
PalpationGreater trochanter (bursitis). Groin — midline and medially.
MovementFlexion 100–130° (active and passive). Internal rotation passive (15°). External rotation passive (40°).…
Special testsTrendelenburg: stand on each leg — pelvis drops on opposite side = weak abductors. Limb length: true (ASIS…
ClosureExplain findings. Thank patient. Infection control.
MSK🦴 MSK — Knee Examination
StepDetails
IntroductionInfection control, introduce self, consent, check discomfort. Expose knees adequately.
InspectionStanding: valgus (knock-knee), varus (bow-leg), quadriceps/hamstring bulk, Baker's cyst (popliteal fossa).…
Palpation (knee flexed)Temperature. Tibial tuberosity, patella tendon, medial/lateral joint lines and collateral ligaments.…
MovementFlexion 0–140° (feel for crepitus). Extension ± heel height testing.
Special testsEffusion: medial gutter sweep (small) or patella tap (large). Meniscal: Steinman/McMurray's test.…
ClosureExplain findings. Thank patient. Infection control.
MSK🦴 MSK — Shoulder Examination
StepDetails
InspectionAnteriorly: shoulder contour, deltoid/trapezius bulk, SC joint, AC joint, clavicle, scars. Laterally:…
PalpationSC joint, clavicle, AC joint, acromion. Long head of biceps. Scapula (spine and body).
MovementTest active movement first. If reduced, check passive (to distinguish weakness from stiffness). External…
Special testsRotator cuff / ACJ: painful arc on abduction (impingement), Hawkins-Kennedy (impingement), Scarf test (ACJ…
ClosureExplain findings. Thank patient. Infection control.
MSK🦴 MSK — Hand & Wrist Examination (RA/OA)
StepDetails
Inspection (Hand)Skin: sclerodactyly, steroid signs. Nails: psoriatic pitting, onycholysis, nail fold infarcts.…
Inspection (Wrist)Dorsal and volar aspects. Deformity, swelling, scars. Ask to open/close fist — reduced range, triggering,…
PalpationWarmth at wrist and MCPs. Squeeze MCPs (tenderness). Bimanual palpate swollen joints…
MovementHand: finger flexion/extension/abduction, thumb opposition. Wrist: flexion 80°, extension 90°, radial…
FunctionPincer grip (pick up coin), tripod grip (hold pen), power grip (squeeze fingers), hook grip. "Can you do…
Special testsDe Quervain's: Finkelstein/Eichhoff. Scaphoid fracture: scaphoid compression (anatomical snuff box…
ClosureState: "I would check elbows for rheumatoid nodules, eyes for episcleritis." Thank patient. Infection control.
MSK🦴 MSK — Elbow / Ankle / Foot Examination
Elbow:
StepDetails
InspectionDeformity. Carrying angle. Effusion (lateral swelling), bursitis (olecranon), gouty tophi, psoriatic…
PalpationOlecranon, lateral/medial epicondyle, radial head. Between bony contours. Collateral ligament testing.
MovementFlexion 0–145°. Hyperextension >10° = hypermobility. Pronation 0–85°, supination 0–90°.
Special testsTennis elbow (lateral epicondylitis). Golfer's elbow (medial epicondylitis). Tinel's at cubital tunnel…
Ankle & Foot:
StepDetails
InspectionFootwear for orthosis/wear. Standing (front, side, back): swelling, nail changes, bruising, hallux valgus,…
PalpationLateral malleolus and ligament complex. Anterior joint line. Medial malleolus and deltoid ligament.…
MovementDorsiflexion (15°), plantar flexion (45°). Inversion (20°), eversion (10°). Metatarsal phalangeal movement.
Special testsGrind test (OA metatarsophalangeal). Anterior drawer (ligament instability). Mulder's click (Morton's…
Endocrine🧪 Endocrine — Thyroid Examination
StepDetails
GeneralAffect: nervous/irritable (hyper) or depressed/slow (hypo). Nails: brittle/onycholysis/acropachy (hyper).…
Neck inspectionFront and both sides. Symmetry. Movement on swallowing (ask patient to hold mouthful of water, then…
Neck palpationFrom behind: fingertips of both hands. Thyroid: size, symmetry/asymmetry of lobes, tenderness, movement,…
AuscultationThyroid bruits (increased vascularity in Graves').
Lower limbsPretibial myxoedema (Graves'). Proximal myopathy (stand from seated without hands). Slow-relaxing reflexes…
ClosureExplain findings. Thank patient. Infection control.
Endocrine🧪 Endocrine — Diabetes Lower Limb Examination
StepDetails
InspectionRemove shoes and socks; expose to knee level. Inspect legs AND all surfaces of both feet, including heels,…
PalpationTemperature (cold = ischaemic). Sweating (autonomic). Peripheral pulses: posterior tibial (2cm behind +…
Sensation10g monofilament: 5 points on each foot (avoid calluses/ulcers). Apex of 1st and 3rd toes. Metatarsal…
FootwearSuitability of shoes. Unusual/asymmetrical wear patterns.
ClosureState: "I would also check vibration (128Hz), proprioception, and perform ABPI if vascular disease…
⭐ Wagner classification: 0=pre/post-ulcerative, 1=superficial, 2=deep to tendon/capsule, 3=deep with abscess/osteomyelitis, 4=partial gangrene, 5=full foot gangrene.
Haematology🩸 Haematology System Examination
StepDetails
Hands and skinKoilonychia (iron deficiency), pale palmar creases (anaemia), petechiae, purpura, jaundice (haemolysis).
FaceEyes: conjunctival pallor, scleral jaundice. Mouth: angular stomatitis, blood blisters, ulcers,…
Lymph nodes (Neck)From behind: submental, submandibular, anterior/posterior triangle, pre/post-auricular, occipital,…
Lymph nodes (Axillary)Right axilla with left hand, left axilla with right hand. Palpate medial, anterior/posterior walls, apex.
Lymph nodes (Inguinal)Horizontal (below inguinal ligament), vertical (along saphenous vein). Epitrochlear and popliteal if…
AbdomenInspection: scars, distension, bruising, petechiae. Palpation: liver (hepatomegaly), spleen…
Legs/anklesAnkle petechiae. DVT signs: swelling, colour, distended veins, pitting oedema, tenderness, temperature,…
ClosureExplain findings. Thank patient. Infection control.
Dermatology🎭 Dermatology — Rash & Skin Lesion Examination
Rash Examination — use Distribution → Configuration → Morphology:
StepDetails
DistributionSymmetry (bilateral/unilateral). Localised or generalised. Sites: extensor (psoriasis), flexural (eczema),…
ConfigurationDiscrete (separate), coalescing (joining), confluent (whole area), grouped (herpes zoster), annular…
MorphologyPrimary: macule (flat <1cm), patch (flat >1cm), papule (raised <1cm), plaque (flat-topped…
Skin Lesion — ABCDEA=Asymmetry (shape/colour across axes). B=Border irregularity (jagged/irregular = concerning). C=Colour…
ClosureExplain findings. Thank patient. Infection control.
⭐ Non-pigmented lesions: describe by colour, size, morphology, border definition, and secondary changes. Don't just say "a red rash."
Ophthalmology👁️ Ophthalmology Examination
StepDetails
Visual acuitySnellen chart at 6m (or 3m reduced); with/without correction. 6/6 = normal. <6/6: use pinhole (corrects…
Visual fieldsConfrontation: finger/moving target in four quadrants, compare to your own. Bitemporal hemianopia =…
Direct ophthalmoscopyDim lighting; pupil dilation if appropriate. Dial 0, fundal reflex from 1m. +10 lens to focus anteriorly,…
Slit lampSystematic from outside in: lids/lashes, conjunctiva, sclera, cornea, anterior chamber, iris, pupil, lens.…
ClosureExplain findings. Thank patient. Infection control.
GI👂 ENT — Ear (Otological) Examination
StepDetails
InspectionErythema, swelling, pre/post-auricular scars, discharge.
PalpationMastoid tenderness (mastoiditis). Tragus tenderness (otitis externa).
OtoscopyHold like a pen. Right hand for right ear, left for left. Adults: pull pinna upwards and backwards.…
Hearing — free fieldArm's length, mask one ear, whisper numbers to other. If unable to hear whisper, gradually increase volume.
Rinne test512Hz fork on mastoid process then in front of external canal. Ask which is louder. AC>BC = normal or…
Weber test512Hz fork on forehead centrally. Lateralises to deaf ear = conductive loss. Lateralises to good ear = SNHL.
Extra testsBalance assessment: Romberg test.
ClosureExplain findings. Thank patient. Infection control.
Tuning fork interpretation: Normal = Rinne +ve both, Weber central. Unilateral conductive = Rinne -ve affected side, Weber to affected side. Unilateral SNHL = Rinne +ve both, Weber to unaffected side.
Psychiatry🧠 Psychiatry — Mental State Examination (MSE)
DomainAssessment Points
Appearance & behaviourAppearance: age vs actual, build, dress (appropriate to climate/culture?), self-neglect, posture, facial…
SpeechRate (fast=mania, slow=depression), rhythm, volume, spontaneity. Pressure of speech (cannot interrupt),…
Mood & affectMood (subjective): "How would you describe your mood today?" Affect (objective): neutral/euthymic,…
ThoughtsForm: tempo (flight of ideas=mania; poverty=depression/schizophrenia), blocking, loosening of…
PerceptionHallucinations (type and modality), illusions, depersonalisation, derealisation.
CognitionOrientation (time, place, person). Concentration (serial 7s). Memory (registration, short-term,…
InsightDoes patient believe they are unwell? Willing to accept treatment? Full / partial / absent insight.
ClosureThank patient, document consent, infection control.
⭐ Risk assessment: static factors (past attempts, male sex, older age, isolation) vs dynamic factors (current intent, plan, means, hopelessness, recent loss). Dynamic factors are what you act on.
O&G🤰 Breast & Pregnant Abdomen Examination
Breast Examination: Triple assessment = Clinical exam + Imaging (USS <35y, mammogram >35y) + Biopsy (core/FNA).
StepDetails
IntroductionInfection control, introduce self, identify patient. Explanation, consent, chaperone, privacy.
Inspection (sitting)Hands by side: asymmetry, scars, skin/tissue retraction, visible lump, peau d'orange, nipple inversion,…
Breast palpationPatient supine at 35–45°, arms raised. All four quadrants + axillary tail. Any mass: number, site, size,…
Axilla palpationLeft hand for right axilla, right for left. Palpate medial/anterior/posterior walls, apex. Nodes: number,…
⭐ Cancer red flags: hard, irregular, fixed, painless lump; skin tethering; peau d'orange; bloody nipple discharge; axillary lymphadenopathy.
Pregnant Abdomen Examination:
SFH measurementUlnar border of left hand to locate fundus; locate upper border of symphysis pubis. Measure in cm (≈…
PalpationFundus: determine upper pole. Lateral: fetal lie (longitudinal/oblique/transverse), back (firm/smooth),…
Fetal heartDoppler or Pinard horn; aim between fetal shoulders on back. Normal FHR: 110–160 bpm.
NICE Management Cards (27 conditions)
CardioACS (STEMI/NSTEMI/Unstable Angina)

ACS (STEMI/NSTEMI/Unstable Angina)

cardio▼
Presentation
Central crushing chest pain radiating to L arm/jaw, sweating, nausea, SOB >20 min. Risk factors: age, smoking, DM, HTN, hyperlipidaemia, FHx <65y.
Investigations
12-lead ECG within 10 min (ST elevation/depression/T inversion/new LBBB); serial troponin at 0 and 3h; FBC, U&
Management (NICE)
⭐ OSCE Focus
Say: "Crushing central chest pain radiating to jaw — ACS until proven otherwise. IV access, ECG, aspirin 300mg chewed, GTN, O2 if desaturating, call cardiology for PCI."
CardioAtrial Fibrillation (AF)

Atrial Fibrillation (AF)

cardio▼
Presentation
Palpitations, breathlessness, fatigue, dizziness, syncope; often incidental in elderly.
Investigations
ECG (diagnosis); FBC, U&E, TFTs, glucose, LFTs, clotting; echo (structural cause and LA size); CXR.
Management (NICE)
Rate vs rhythm control. Rate: bisoprolol or diltiazem first line. Rhythm (young, symptomatic, reversible cause): flecainide/cardioversion/ablation.
⭐ OSCE Focus
Know CHA2DS2-VASc off by heart: CCF(1), HTN(1), Age≥75(2), DM(1), Stroke/TIA(2), Vascular disease(1), Age 65-74(1), Sex female(1). Always mention anticoagulation decision.
CardioHeart Failure (HFrEF/HFpEF)

Heart Failure (HFrEF/HFpEF)

cardio▼
Presentation
SOB on exertion, orthopnoea, PND, ankle swelling, fatigue. Acute: frothy pink sputum = pulmonary oedema.
Investigations
ECG; CXR (Alveolar oedema, B-lines Kerley, Cardiomegaly, upper lobe Diversion, pleural Effusions); NT-proBNP >
Management (NICE)
HFrEF (EF <40%): ACEi/ARB + β-blocker + MRA (spironolactone) + SGLT2-i (dapagliflozin); loop diuretic for symptom relief. Consider CRT/ICD if EF <35%. HFpEF: diuretics + treat cause.
⭐ OSCE Focus
Acute pulmonary oedema management. Always ask about daily weight monitoring. Classify by NYHA grade.
CardioHypertension

Hypertension

cardio▼
Presentation
Usually asymptomatic; headache, epistaxis, visual changes if severe.
Investigations
ABPM (or HBPM): average ≥135/85 = stage 1, ≥150/95 = stage 2. Urinalysis, U&E, eGFR, lipids, HbA1c, ECG, QRISK3.
Management (NICE)
Stage 1 + <80y + end-organ damage/CV risk: treat. <55y or DM: ACEi/ARB first line. ≥55y or Black African/Caribbean: CCB (amlodipine) first line. Step 2: combine.
⭐ OSCE Focus
Malignant HTN = >180/120 + end-organ damage (papilloedema, encephalopathy, ACS, AKI) → admit, do NOT drop BP too quickly. Confirm with ABPM before treatment.
CardioDVT / Pulmonary Embolism

DVT / Pulmonary Embolism

cardio▼
Presentation
DVT: unilateral swollen painful calf, erythema, warmth. PE: pleuritic chest pain, SOB, haemoptysis, collapse.
Investigations
Wells score. If likely: proximal leg USS/CTPA. Unlikely: D-dimer (negative excludes; positive → imaging). ECG (S1Q3T3, RBBB, si…
Management (NICE)
DOAC (apixaban or rivaroxaban) for 3/12 (provoked) or ≥6/12 (unprovoked/ongoing risk). Warfarin or LMWH if contraindicated. Massive PE + haemodynamic collapse → thrombolysis (alteplase). NICE NG158.
⭐ OSCE Focus
Virchow's triad: hypercoagulability, stasis, endothelial injury. Always ask about recent surgery, travel, malignancy, COCP, FH.
RespiratoryAsthma

Asthma

resp▼
Presentation
Intermittent SOB, wheeze, cough (often nocturnal), chest tightness. Triggers: allergens, exercise, cold, NSAIDs. Diurnal variation. Atopy.
Investigations
Spirometry: obstructive (FEV1/FVC < 0.7), reversibility > 12% with bronchodilators. FeNO ≥40 ppb supports eosinophilic in…
Management (NICE)
Chronic (BTS/SIGN/NICE NG80): SABA (salbutamol) PRN → add low-dose ICS → add LABA → increase ICS/add LTRA.
⭐ OSCE Focus
Life-threatening features: PEF <33%, sats <92%, silent chest, cyanosis, exhaustion, arrhythmia, confusion, hypotension. Say these aloud in the exam.
RespiratoryCOPD

COPD

resp▼
Presentation
Chronic productive cough, SOB on exertion, frequent chest infections, smoking history >20 pack-years.
Investigations
Post-bronchodilator spirometry: FEV1/FVC < 0.7 (fixed). GOLD staging by FEV1%. CXR hyperinflation, bullae. ABG if sats < …
Management (NICE)
All: smoking cessation (most important), flu + pneumococcal vaccines, pulmonary rehab. Stable: SABA/SAMA PRN. If steroid-responsive features: LABA+ICS. Otherwise: LABA+LAMA then triple therapy.
⭐ OSCE Focus
Do NOT give uncontrolled high-flow O2 → reduces hypoxic drive. Aim sats 88–92% in known retainers. Use Venturi mask with specified FiO2.
RespiratoryCommunity-Acquired Pneumonia (CAP)

Community-Acquired Pneumonia (CAP)

resp▼
Presentation
Fever, productive cough (rusty in pneumococcus, green/purulent), pleuritic chest pain, SOB, rigors.
Investigations
CURB-65 score; CXR (consolidation); FBC, CRP, U&
Management (NICE)
CURB-65 0–1: home, amoxicillin 500mg TDS × 5 days PO. Score 2: hospital, amoxicillin + clarithromycin.
⭐ OSCE Focus
CURB-65: Confusion(1), Urea >7(1), RR ≥30(1), BP <90/60(1), Age ≥65(1). Ask about travel (Legionella), bird contact (Chlamydia psittaci), HIV risk, immunosuppression.
GIUpper GI Bleed (PUD/Varices)

Upper GI Bleed (PUD/Varices)

gi▼
Presentation
Haematemesis, coffee-ground vomit, melaena; may present with collapse, tachycardia, hypotension.
Investigations
Glasgow-Blatchford score; FBC, U& E (raised urea), LFTs, clotting, crossmatch 2–4 units
Management (NICE)
⭐ OSCE Focus
Rockall score for rebleed/mortality risk. Stop NSAIDs/anticoagulants. Test + treat H. pylori after bleeding settles (eradication reduces recurrence).
GIInflammatory Bowel Disease (UC/Crohn's)

Inflammatory Bowel Disease (UC/Crohn's)

gi▼
Presentation
UC: bloody diarrhoea, mucus, urgency, tenesmus, relapsing-remitting. Crohn's: abdominal pain, weight loss, diarrhoea, fistulae, perianal disease.
Investigations
FBC, CRP, U& E, ferritin, B12, folate, albumin; faecal calprotectin (raised)
Management (NICE)
Induce remission: mesalazine (UC), steroids, biologics (infliximab, adalimumab). Maintain: mesalazine, azathioprine, biologics.
⭐ OSCE Focus
Truelove & Witts criteria for severe UC. Always ask about extra-intestinal manifestations. Fistulae/perianal disease = Crohn's until proven otherwise.
GIAcute Pancreatitis

Acute Pancreatitis

gi▼
Presentation
Severe epigastric pain radiating to back, vomiting. I GET SMASHED: Idiopathic, Gallstones, Ethanol, Trauma, Steroids, Mumps, Autoimmune, Scorpion, Hypercalcaemia/triglycerides, ERCP, Drugs.
Investigations
Amylase/lipase > 3× ULN; FBC, U&
Management (NICE)
Aggressive IV fluid resuscitation (Hartmann's); adequate analgesia (morphine); O2; NG if vomiting; nil-by-mouth initially; early enteral nutrition via NG tube; ITU if severe.
⭐ OSCE Focus
Complications: necrosis, pseudocyst, abscess, ARDS, AKI, hypocalcaemia, chronic pancreatitis, DM. Atlanta severity criteria.
EndocrineType 2 Diabetes Mellitus

Type 2 Diabetes Mellitus

endocrine▼
Presentation
Polyuria, polydipsia, weight loss, fatigue, recurrent infections, blurred vision; often asymptomatic.
Investigations
HbA1c ≥48 mmol/mol diagnostic on 2 occasions (if asymptomatic). Fasting glucose ≥7 or random ≥11.1 mmol/L.
Management (NICE)
Lifestyle modification first; metformin first-line (if eGFR ≥30). If ASCVD/CKD/HF: add SGLT2-i (empagliflozin/dapagliflozin). GLP-1RA if BMI >35 or significant CVD risk.
⭐ OSCE Focus
Always do a foot exam on any DM OSCE station. DKA can occur on SGLT2-i (euglycaemic DKA). Know HbA1c diagnostic thresholds off by heart.
EndocrineDKA

DKA

endocrine▼
Presentation
Polyuria, polydipsia, weight loss, vomiting, abdominal pain, Kussmaul breathing, acetone breath, drowsy.
Investigations
Capillary glucose > 11 (or known DM); blood ketones ≥3.0
Management (NICE)
ABCDE. 0.9% saline 1L stat; replace over 24h per JBDS protocol. Fixed-rate IV insulin 0.1 units/kg/hr. Add K+ when K+ <5.5 mmol/L.
⭐ OSCE Focus
Always ask for the precipitant — infection, non-compliance, new diagnosis, MI, stress. Monitor K+ closely — DKA causes hypokalaemia as insulin drives K+ into cells.
NeurologyStroke / TIA

Stroke / TIA

neuro▼
Presentation
Sudden focal neurological deficit: unilateral weakness, facial droop, dysphasia, visual loss, vertigo, ataxia.
Investigations
Non-contrast CT head immediately (exclude haemorrhage). ECG (AF), glucose, FBC, U& E, coag, lipids, HbA1c, carotid Doppler,…
Management (NICE)
Ischaemic <4.5h: alteplase if no contraindications + aspirin 300mg 24h later. Thrombectomy <6h (or <24h with perfusion mismatch).
⭐ OSCE Focus
TIA: ABCD2 score + aspirin 300mg + urgent specialist review <24h. Driving: must not drive for 1 month after stroke; inform DVLA. Time is brain — thrombolysis window 4.5h.
NeurologyEpilepsy / First Seizure

Epilepsy / First Seizure

neuro▼
Presentation
Loss of consciousness, tonic-clonic movements, tongue biting, incontinence, post-ictal confusion.
Investigations
ECG (long QT, Brugada), glucose, Na, Ca, Mg, FBC, CRP, tox screen; EEG; MRI brain (first seizure in adult).
Management (NICE)
First seizure: no driving for 6/12; no AED until diagnosis confirmed. Focal: lamotrigine. Generalised: sodium valproate (NOT in women of childbearing potential — use lamotrigine/levetiracetam).
⭐ OSCE Focus
Driving: must inform DVLA. Group 1 (car/motorcycle): seizure-free 12 months. Group 2 (HGV/bus): seizure-free 10 years. Lamotrigine NOT sodium valproate for women of childbearing age.
NeurologyMeningitis (Bacterial)

Meningitis (Bacterial)

neuro▼
Presentation
Fever, headache, photophobia, neck stiffness, non-blanching rash (meningococcal), altered mental state.
Investigations
Blood cultures ×2, FBC, U& E, CRP, clotting, glucose; LP after imaging if safe. CSF: ↑WCC (neutrophils in bacterial), ↑prot…
Management (NICE)
GP: IM/IV benzylpenicillin 1.2g IMMEDIATELY if non-blanching rash or high suspicion, then blue-light transfer.
⭐ OSCE Focus
Close-contact prophylaxis with ciprofloxacin within 24h for household contacts. Public Health notification (notifiable disease). Dexamethasone reduces neurological sequelae.
NeurologySepsis

Sepsis

neuro▼
Presentation
Any infection + organ dysfunction (NEWS ≥5, hypotension, confusion, oliguria, raised lactate).
Investigations
Sepsis Six within 1 hour. FBC, CRP, U& E, LFTs, glucose, lactate, clotting, cultures ×2. Source: CXR, urinalysis, wound swabs.
Management (NICE)
⭐ OSCE Focus
qSOFA: RR ≥22, altered mental state, SBP ≤100 (2/3 = high risk). State "I would activate the sepsis six pathway." Lactate >2 mmol/L = high risk even without obvious hypotension.
MSKRheumatoid Arthritis

Rheumatoid Arthritis

msk▼
Presentation
Symmetrical polyarthritis of small joints (MCP, PIP, MTP, wrist), morning stiffness >30 min, fatigue. Extra-articular: lung, eye, skin nodules.
Investigations
Anti-CCP + RF + raised CRP/ESR; FBC (anaemia of chronic disease); X-ray hands (periarticular osteopenia, erosions, joint-space …
Management (NICE)
Early MDT referral within 3 weeks of presentation (NICE NG100). DMARDs: methotrexate first line + folic acid; add sulfasalazine/hydroxychloroquine. Steroids for flares.
⭐ OSCE Focus
DAS28 to monitor disease activity. Counsel on: pregnancy planning (MTX teratogenic — stop 3 months before), alcohol limits, regular LFT monitoring, infection risk.
MSKGout

Gout

msk▼
Presentation
Acute red hot painful monoarthritis, classically 1st MTP (podagra). Triggers: alcohol binge, diuretics, dehydration, red meat.
Investigations
Synovial fluid: negatively birefringent needle-shaped urate crystals. Serum urate (may be normal during acute attack). X-ray: e…
Management (NICE)
Acute: NSAID (naproxen 500mg BD) or colchicine 500mcg BD–QDS or short steroid course.
⭐ OSCE Focus
Lifestyle: ↓alcohol, ↓red meat, ↓fructose, ↑water, weight loss, stop thiazide diuretics if possible. Do NOT start allopurinol during an acute attack.
RenalAcute Kidney Injury (AKI)

Acute Kidney Injury (AKI)

renal▼
Presentation
Reduced urine output, oliguria/anuria, uraemic symptoms (confusion, pruritus, nausea).
Investigations
Creatinine ↑≥26 µmol/L in 48h OR ≥1.5× baseline in 7 days OR urine output < 0.5 mL/kg/h for 6h. Urinalysis, U& E, Ca, PO…
Management (NICE)
STOP-AKI: Stop nephrotoxins (NSAIDs, ACEi/ARB, aminoglycosides, contrast, diuretics if hypovolaemic). Treat sepsis. Optimise volume and BP. Prevent complications.
⭐ OSCE Focus
Always record urine output and check creatinine trend. Hyperkalaemia (K >6.0): ECG immediately → calcium gluconate → insulin-glucose → salbutamol → dialysis.
PsychiatryDepression

Depression

psych▼
Presentation
Low mood, anhedonia, anergia ≥2 weeks. Poor sleep (early morning waking), appetite change, weight change, poor concentration, worthlessness, hopelessness, suicidal ideation.
Investigations
PHQ-9 score; TFTs, FBC, B12, folate, U&E, glucose, LFTs; consider HIV/syphilis.
Management (NICE)
Mild: watchful waiting, guided self-help (CBT-based), exercise prescription, sleep hygiene. Moderate/severe: SSRI (sertraline 50mg first-line) + CBT/IPT.
⭐ OSCE Focus
Safety-net: crisis team number, Samaritans 116 123, Shout 85258. Assess and document risk every contact. Consider children's safeguarding if parent. Always screen for bipolar before starting antidepressants.
ObsPre-eclampsia

Pre-eclampsia

obs▼
Presentation
New HTN ≥140/90 after 20 weeks + proteinuria or other end-organ dysfunction. Headache, visual disturbance, epigastric pain, sudden oedema.
Investigations
BP, urinalysis (PCR/ACR), FBC (thrombocytopenia), U& E, LFTs (raised transaminases), uric acid, clotting; PlGF
Management (NICE)
Admit if severe (BP ≥160/110 or symptoms). Antihypertensives: labetalol first-line (nifedipine if asthma), hydralazine IV if severe.
⭐ OSCE Focus
HELLP: Haemolysis, Elevated Liver enzymes, Low Platelets — serious complication requiring immediate delivery. Eclampsia = seizures in pre-eclampsia → Mg sulfate + delivery.
PaediatricsBronchiolitis (RSV)

Bronchiolitis (RSV)

paeds▼
Presentation
Infant <1 year — coryza then cough, wheeze, SOB, poor feeding, apnoea. Peak at 3–6 months, winter.
Investigations
Clinical diagnosis. NPA for RSV if admitted. Capillary gas if severely unwell.
Management (NICE)
Mainly supportive: O2 if sats <92% (nasopharyngeal if needed), NG feeds if not taking orally, minimal handling. No routine antibiotics, steroids, or salbutamol (NICE NG9).
⭐ OSCE Focus
Admit criteria: <8 weeks old, dehydration, sats <92%, grunting, severe distress, social concerns. Discuss with parents: self-limiting illness, home monitoring.
ElderlyFalls in the Elderly

Falls in the Elderly

elderly▼
Presentation
Recurrent falls with or without LOC. Multifactorial: postural hypotension, gait/balance problems, medications, cognitive impairment, environmental hazards.
Investigations
Timed-up-and-go, 180° turn test. ECG (AF, LQT), lying-standing BP (postural hypotension), U& E, glucose, FBC, calcium, B12,…
Management (NICE)
⭐ OSCE Focus
Always ask about fear of falling (major barrier to rehabilitation), sleeping tablets, alcohol, vision problems. STOPP/START criteria for medication review.
ElderlyDelirium

Delirium

elderly▼
Presentation
Acute onset fluctuating confusion with disturbance of consciousness/attention/cognition. Hyperactive (agitation) or hypoactive (withdrawn — often missed).
Investigations
Screen for cause: Pain, Infection (urine dip, CXR, blood cultures), Nutrition/dehydration, Constipation, Hypoxia, Endocrine (Na…
Management (NICE)
⭐ OSCE Focus
Distinguish from dementia: delirium = acute onset + fluctuating attention; dementia = chronic + progressive + memory predominantly. Delirium on background of dementia is common and has worse prognosis.
DermatologyEczema

Eczema

derm▼
Presentation
Itchy, erythematous, dry, scaly skin. Flexural distribution in children (antecubital/popliteal fossae, wrists, neck). Trigger identification essential.
Investigations
Clinical diagnosis. Consider skin swabs if infected. Patch testing if contact dermatitis suspected. FBC, IgE, RAST if severe.
Management (NICE)
Emollients: generous and frequent application (cornerstone of treatment).
⭐ OSCE Focus
Always ask about triggers (soap, detergents, dust mites, pets, food, stress), sleep disturbance, school/work impact. 2-week trial of bath emollient + steroid before escalating.
DermatologyPsoriasis

Psoriasis

derm▼
Presentation
Well-demarcated erythematous scaly plaques, extensor surfaces (elbows, knees), scalp, lumbosacral. Nail pitting, onycholysis, salmon patch. Auspitz sign (pinpoint bleeding on scale removal).
Investigations
Clinical diagnosis. RF negative. Anti-CCP negative (unlike RA). X-ray: "pencil in cup" deformity in PsA.
Management (NICE)
Emollients. Topical: vitamin D analogue (calcipotriol) ± topical steroid. Phototherapy (UVB). Systemic: methotrexate, ciclosporin, acitretin.
⭐ OSCE Focus
30% risk of psoriatic arthritis. Cardiovascular comorbidity is increased. Ask about nail changes, joint involvement, family history.

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