Histories 10th Edition

Fast PACES
Academy for Doctors
Histories
DR IMRAN BABAR MRCP (UK)

10th Edition
FAST PACES Academy
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+923004507980 mrcpfast@gmail.com
Contents
Topic Page
1 History Taking Pattern 2
2 Abdominal Swelling 4
3 Ankle Swelling (PHTN) Young, Non- Smoker 5
4 Asymptomatic HTN 6
5 Breathlessness 7
6 Burning of Feet 8
7 Chest Pain 9
8 Cold and Painful Fingers 10
9 Acute confusion 11
10 Collapse 12
11 Chronic Confusion (Forgetfullness) 14
12 Chronic Cough 15
13 Diabetic Foot 16
14 Difficulty in walking 17
15 Dizziness OR Feeling Faint 19
17 Double Vision 20
18 Dysphagia 21
19 Epigastric Pain & Nausea 22
20 Facial Swelling 23
21 Funny Turns 24
22 Backache 25
23 Hemoptysis 27
24 Headache 28
25 Hoarse Voice 31
26 Hypercalcemia 32
27 Hyperlipidemia 33
28 Jaundice 34
29 JOINTS 36
30 Loin Pain 37
31 Loss of weight 38
32 Weight loss and Diarrhea 39
33 Lower GI Bleeding 41
34 Megaloblastic Anemia 42
35 Lump in the neck (Lymph Nodes) 43
36 Painful Shins (Erythema Nodosum) 44
37 Painful Shoulders 45
38 Palpitations 46
39 Pins and Needles (Peripheral Neuropathy) 47
40 Carpal Tunnel Syndrome 48
41 Polyuria 49
42 Pruritis 50
43 Purpuric Rash 51
44 Pyrexia 52
45 Renal Colic & Hematuria 53
46 Tiredness 54
47 Tremors 55
48 Visual Disturbance 56
49 Vomiting 57
50 Weakness of one Arm 58
51 Weight Gain 59
52 Wheeze 60
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1. History Taking Pattern
Introduction and Information sharing with the patient

Presenting Complaint
?????
Localization and ODPARA (History of Present illness)
What else?
Associated System
Differential Diagnosis Related Questions
Other information
P → Have you ever had similar complaints it the Past?

A → Do you have Allergy to any thing?
M → Do you have any other Medical problems like Diabetes, high Blood pressure, problem related to
Liver,kidney etc
M → Are you taking any Medicines? Which medicines? Can You please show me the List of medicines that
you are taking? (In which doses? For how long? Any particular side effects) Any other medicines not given by
the doctor?
Hugs → Have you ever been Hospitalized for any Medical or Surgical reason?
F → Any similar complaints in your other Family members? (Especially for communicable diseases)
Any other significant illness that runs in your Family? (Like DM, Heart problem, Kidney problem)
OB/Gynae Any problem related to monthly periods?
Sexual Hx (If required, optional, not required always) Is that allright if I ask you some personal questions?
Let me assure you what ever you tell me will be kept confidential.
Are you in relationship with someone?
Social History: (in detail)
 Job
 Living
 Daily activities
 Social and Financial support?
 How is affected in job,daily activities and how the family is affected?
 Smoking,Alcohol and other drugs if required
 Diet and exercise (Sometimes required)
 Driving…Do you Drive? Is that private vehicle or else?
 Travelling…Any recent Travel?
R.O.S…Now I am going to ask you few more questions which are not directly related to your problem but
sometimes helpful. Is that fine with You?
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Recap
After recap …Would you like to add anything else which I might have missed?
Idea
Concern Do you have any particular concern at the moment?
(Other possible questions ….Why you think like this? Did any one mention this possibility)
Explain
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2. Abdominal Swelling
4 Fs DD For Ascites
 Fluid (Ascites) 1. GIT

 Fat
 Flatus a. CLD
 Fetus
 Alcohol
Where exactly the swelling is?  Viral
Do you have swelling anywhere else?  Autoimmune
 Metabolic
For how long you have this?
 Vascular
Is it getting worse?  Medicines
What makes it better? b. Malignancy
What makes it worse? c. Malabsorption Syndrome

d. Budd Chiari Syndrome
GIT Also screening Questions for Hepatitis B and C and e. Pancreatitis
Autoimmune, Metabolic causes of CLD
2. Hypothyroid
General (Malignancy, TB, other autoimmune conditions)
Thyroid 3. Heart CCF and Cor-Pulmonale
Heart
4. Chest TB and Malignancy
Chest
Kidney 5. Kidney Nephrotic Syndrome
Joint
6. Joints SLE and RA
P
A
M
M (Methotrexate, Amiodarone, Phenytoin, INH etc)
Hugs
F
O
Sx (HIV, HBV, HCV)
Social
 Exposure to asbestos
 Alcohol
 I/V Drugs
 Smoking
Recap
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3. Ankle Swelling (PHTN) Young, Non- Smoker

Young non- smoker with complaints of SOB, Chest Pain and Secondary Causes of Pulmonary HTN
Ankle swelling
1. Chest
 Recurrent PE
SOB (Detail)  Chronic Conditions e.g Bronchiectasis
Chest pain (Detail) 2. Heart

 Congenital
Ankle swelling (Detail)  Valvular Problem
3. Joints
 SLE
 General  Scleroderma
 OSA (Obstructive Sleep Apnoea)
4. Medicine…Fenfluramine
 Joints
P 5. Sexual …HIV
A 6. Social …Job
M
M
Hugs
F
O
Social
R.O.S
Recap
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4. Asymptomatic HTN
Do you have any Symptoms like DD Of HTN
 Headache A. Primary
 Vision Problem
B. Secondary
 Chest Pain
 Difficulty in breathing White Coat HTN
 Pain in Legs especially on walking Glands
 Conns Syndrome
DD
 Cushing Syndrome
Do you feel anxious especially while visiting the doctors? (White
coat HTN)  Acromegaly
 Phaeochromocytoma
General
Glands Kidneys
Kidney  Diabetic Nephropathy

 APDK
P  GN
A
M
M Medicine
 Poor Compliance
Hugs
 Steroids,OCPs,NSAIDs
F
O
Social Family History…APKD
Pregnancy
R.O.S
Social …Alcohol, Cocaine

Recap
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5. Breathlessness
DD For SOB
SOB (Detail)
Heart
 IHD
 Cardiomyopathy
DD  Valvular
 Heart  Pericardial Disease
 Chest
Chest
 General  Pneumothorax
 Pleural effusion
 CNS
 Anemia  COPD
 Asthma
 Glands
 Bronchiectasis
 Kidney  Foreign body
 Psychological
 PE
 Pulmonary HTN
 Pneumonia
P  ILD
 Sarcoidosis
A  Malignancy
M CNS
 Myasthenia Gravis
M
 MND
 GBS
Hugs
Glands DM (DKA), Acromegaly, Hypothyroidism
Renal Failure
F
Psychological
O
Social
Social
R.O.S
Recap
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6. Burning of Feet
Where exactly the burning is in your feet? DD of Peripheral Neuropathy

Up to which level?
DM
Do you have burning anywhere else like in your hands?
General Malignancy
Any numbness Or Tingling? (Sensory)
Multiple Myeloma
Weakness or Cramps? (Motor)
Hypothyroidism
Any problem with your balance especially in darkness? (Balance or
GIT
gait)
 Vit. B12 Deficiency
 Autoimmune gastritis
Do you feel dizzy when you stand up quickly from sitting position?
(Autonomic)  Malabsorption syndrome
Kidneys CRF
 For how long you have this problem?
(Numbness,tingling,burning,pain etc) Joints RA and SLE
 Is it getting worse?
Medicines
 What makes it better?  IINH
 Chemotherapy
 What makes it worse?
 Nintrofurantoin
Family History HMSN

Associated cause like detail of DM if in history
Sexual history HIV
 General
Social History Alcohol and Nutrition
 Multiple Myeloma
 Thyroid
 GIT
 Kidneys
 Joints
P
A
M
M
Hugs
F
O
Social
R.O.S
Recap
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7. Chest Pain
Where exactly it is? DD of Chest Pain
For how long you have this?
How did it develop? Suddenly or gradually? Heart
What were you doing at that time (If sudden)  Pericarditis
What type of pain it is?  IHD
How intense on a scale of 1 to 10?  AS
Does it move anywhere else?
What makes it better? Aortic Dissection
What makes it worse? GERD

More on pressing or movement…Musculoskeletal
Lying flat…Pericardial Lungs

 Pleursy
On Exertion…IHD
 Pneumothorax
Eating…GERD  Pneumonia
Taking deep Breath in…PE  Malignancy

 PE
Coughing or sneezing…Spinal due to Mass or Disc herniation
 PHTN
DD
 Injury (Musculoskeltal) Chest
 Heart  Trauma
 Aortic Dissection  Post Herpetic Neuralgia
 GERD  Intervertebral Disc Disease
 Lungs  Spinal mass
 Spinal
 General
P
A
M
M
Hugs
F
O
Social
R.O.S
Recap
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8. Cold and Painful Fingers

In which Fingers you have this problem? DD
Where did it start first?
Joints
Any other part of body affected?
 RA
Any color changes? Which color changes?
 SLE
White, Blue or Red? In which fingers?
 Scleroderma
 For how long you have this problem?  Polymyositis
 Is it getting worse?  MCTD
 What makes it better?

General Myeloproliferative disorders
 What makes it worse?
Associated system like JOINTS Liver Cryoglobulinemia (Hepatitis B and C)
DD
Hypothyroidism
General
Any yellowness of your eyes? (Liver) Trauma

Cervical Myelopathy
Any Problem adjusting to temperatures?
Cervical Rib
Any injury to neck area before developing these symptoms?
Any Problem with movement of Neck like stiffness? Neurological e.g Carpal Tunnel Syndrome
Any numbness or tingling in your hands?

Medicines B – Blockers and Chemotherapy
Any Pain in Legs on walking?
P Drugs e.g Cocaine etc

A
M
M
Hugs
F
O
Social
 Jobs (Vibrating tools)
 Smoking
 Cocaine
R.O.S
Recap
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9.Acute confusion
Head injury
Infections (General)
 Meningitis / Encephalitis
 Abscess
 Pneumonia
 UTI
 Others
Stroke / TIA (CNS)
Metabolic (Other systems)
 CRF
 CLD
 COPD (CO2 retention)
 Electrolyte Imbalances
Endocrine problems DKA (Glands)
IHD
Stool Impaction
Urinary Retention
Drugs
Alcohol
 Intoxication
 Withdrawl
 Wernicke syndrome
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10. Collapse
Events Before Collapse
Please tell me what happened exactly? What were you doing at that time? Did you remember while
falling?
Any unusual symptoms before this? (Aura) Like
 Pre-syncope features like Light headedness, Darkening of vision/tunnel vision or any generalized
body weakness
 Blurring of vision,nausea and sweating (Autonomic)
 Chest pain or racing of heart? Difficulty in breathing? (Caridiac)
 Severe headache? (Subarachnoid hemorrhage)
 Seeing of unusual objects,abnormal smell Or ringing in the ears? (Epilepsy, seizures)
During the Event
Was there anyone around you? What did they tell?
Did you lose consciousness? (If yes) Was it Complete or incomplete? For about how long you might have
been remain unconscious?
Did any one tell you about any color changes of your skin? (Whie,Blue or Grey ) or Any shaking of your
body limbs (Seizures)
Post Recovery events
When you woke up Were you fully back to normal Or any confusion and sleepiness?Did you wet
yourself? Any wound on your tongue? Body Aches? Or Headache? Seizures
Did any one Checked your blood sugar level at that time? Hypoglycemia
Any problem with speech Or Weakness in body limbs? TIA or Stroke
Any Fever and Neck Stiffness? Meningitis
Fatigue or racing of heart on exertion? Anemia
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P
A
M
M
Hugs
F
O
Social
 Alcohol
 Cocaine
 Other recreational drug like amphetamines
 Night club
 Lack of sleep
R.O.S
Recap
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Features of syncope
Sudden collapse due to sudden transient loss of blood supply to the brain followed by complete recovery within
short time without any problems after the event like weakness or speech problem
It may be preceded by Pre-syncope features or not like Light headedness, Darkening of vision/tunnel vision or
generalized body weakness
It may also be preceded by Aura related to underlying type of syncope or not like Vasovagal (Autonomic e.g
blurriness,nausea,sweating etc)
OR
It can be preceded by triggers like
 coughing,sneezing etc (Situational)

 Neck movement (Carotid sinus hypersensitivity)
 Sudden standing (Postural)
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11. Chronic Confusion (Forgetfullness)

What do you mean by that? DD
How did it develop? For how long? Is it getting worse?
Injury Hematoma
Does he know about the problem?
What does he forget about? CNS
Does he know what day or time it is?  Alzeihemr’s Disease
Does he forget where he is?  Lewy body Dementia
Does he lose the way to his home?  Crutzfeld Jacob Disease
Does he forget the name of his family members?  Picks Disease
Any problem recalling present or past event?  Normal Pressure Hydrocephalus
What about his personal hygiene?
Any changes in his mood or behavior? Hypothyroidism
Does he see the objects which others don’t see?
Any injury to head before this? Liver Disease
CNS
General Kidney Disease
Depression
Thyroid Drugs…Alcohol
P
A Others
M
M
Hugs
F
O
Social
 Alcohol
 Recreational drugs
 Legal issues
 Lasting poser attorney
R.O.S
Recap
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12. Chronic Cough
ODPARAA DD of cough
Chest Chest
General  COPD, Asthma, Bronchiectasis, Foreign body
 Pneumonia, TB, Cancer, ILD, sarcoidosis
Heart  Chronic Pulmonary Embolism
GERD Heart
 CCF
ENT  Valvular
 Cardiomyopathy
P Medicines
A  ACE inhibitors, Amiodarone, Tamoxifen
M Dauxorubicin, Nitrofurantoin etc
M
GERD
Hugs
ENT
F  Chronic sinusitis
O  Allergic Rhinitis
Social
 Job, Previous job
 Living, any recent renovation at home
 Smoking
 Alcohol
 Others
R.O.S
Recap
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13. Diabetic Foot
Ulcer Management Plan

Gangrene
Charcot joint
General measures
What actually the problem is? Then  Patient’s Education and explanation of the
condition
 Sensory
 Avoidance of smoking
 Motor
 Balance  Reduction in alcohol intake
 Autonomic
 Pain in Legs on walking (PVD) MDC including
ODPARA  Diabetic clinic

 Dietitian
DM (Detail)
 Physical trainer
 Physician
P  Joint specialist
 Foot specialist
A
 Vascular surgeon
M (HTN,Cholesterol)  Foot specialist etc
M
Specific measures
Hugs Control of DM, BP and Fat levels with therapy
F (Important)
Social Smoking,Alcohol and other recreational drugs
R.O.S
Recap
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14. Difficulty in walking
What actually the problem is? DD of Flaccid Or Floppy Paraparesis

If weakness in which part? Weakness in any other part?
1.Proximal pattern
Stiff or Floppy
 Myopathy
ODPARA (Stiff or Spastic)  NMJ problems
Any Backache
Any injury 2.Distal pattern
Any swelling
Motor Neuropathy
Any other problem with legs (Sensory symptoms,Balance  GBS
problem, others)
 CIDP
CNS (Other questions)  Lead Poisoning
 Diphtheria
General
 Acute Intermittent porphyria
Cervical spine
 HNSN
Chest
GIT
P 3.Generalized
A Acute events
M
M  Cord Compression
 Transverse Myelitis
Hugs
 Infarction of the cord
F (Hereditary spastic paraparesis)
O Hypokalemia / Hyperkalemia
Sexual HIV and Syphilis

MND
Social Smoking and Alcohol etc
4.Asymmetrical
R.O.S
 Polio
 Radiculopathy
Recap
 Plexopathy
 Mononeuropathy
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Weakness of Proximal Group of Distal Weakness Generalized body weakness
Muscles
Muscular Dystrophy Myotonia Dystrophica Depression
Inflammatory conditions Inclusion body Myositis Malignancy

 Polymyositis
 Dermatomyositis Peripheral Motor Neuropathy CNS
 Polymyalgia Rheumatica  MG
HMSN  MND
Endocrine  Botulism
 Hyperthyroidism
 Hypothyroidism Endocrine
 Cushing Syndrome  DM
 Acromegaly  Addison’s Disease
Channelopathy Others
 MG  Hypokalemia
 LEMS  Organo-phosphorus poisoning
 Snake bite
Bones (Osteomalacia)
Drugs
 Steroid
 Statins
 Alcohol
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15. Dizziness OR Feeling Faint
What exactly the problem is?

Any problem with your Balance?
Do you feel yourself spinning in the space or the things spinning around you?
Any unusual symptoms before you collapse or having dizziness?
Aura (Autonomic, cardiac, epilepsy, subarachnoid haemorrhage etc)
Pre Event
During Event
Post Event
Do you get such symptoms during specific situations like while passing water works,coughing or sneezing etc?
(Situational)
Any such symptoms when you suddenly turn your Neck? (Carotid sinus Hypersensitivity)
Any problem when you suddenly stand up from sitting position? (Postural)
Hypoglycemia
Seizures
Stroke or TIA
Anemia
P
A
M
M
Hugs
F
O
Social Alcohol or Drugs etc
R.O.S
Recap
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16. Double Vision
What exactly the problem is? DD of Double vision

In which eye? In which direction? Extra Ocular Muscles
Any other problem with your eye like pain,decreased  Thyrotoxicosis
vision,problem recognizing the different colors etc  Myositis
 Chronic Progressive External
ODPARA Opthalmoplegia
Does it improve by closing of one eye (MS, Nerve) Channelopathy MG

Nerves
General and CNS (BIH,SOL,MS,MG)  Ischemic e.g DM, HTN
 Vasculitis e.g GCA, SLE
Flu like illness before this? (Miller Fischer)
Infective
Did you use any Cane foods before it develops? (Botulisum) BIH
SOL
Any Jaw Pain? (GCA) Miller Fischer
Botulism
Thyroid (Thyrotoxicosis)
Joints (SLE)
P
A
M—DM,HTN, IHD
M—Aminoglycosides, D-Penicillamine
Hugs
F
O
Social
 Smoking
 Alcohol
 Drugs
 Diet deficient in dairy products
 Exercise
R.O.S
Recap
ICE
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17. Dysphagia
Where exactly the food stucks? DD of Dysphagia

Which type of food you feel problem with? Solid,liquids Or
1.Oropharyngeal (CNS Causes)
both?
 Stroke
Any difficulty in starting your swallowing?
 MND
Any cough with swallowing?  MG
Any Pain during swallowing?  Parkinson’s Disease
Others
ODPARA  Globus Hystericus
 Pharyngeal Pouch
GIT and General 2.Esophageal
Inflammatory
Joints  GERD
 Drugs
 Eosinophilic Esophagitis
CNS
Infective
 Viral
Anemia…Racing of heart or SOB on walking  Fungal
Strictures
Candidiasis…Any white patch on your tongue?  Peptic
 Caustic
 Ischemic
Swelling in front of neck? Goiter
Motility Problem
 Scleroderma
 Achalasia
P
 DES
A  Dermatomyositis
M…DM
M…NSAIDs, Steroids
Others
Hugs  Rings
 Tumors
 Foreign body
F
O
Sexual…HIV
Social
 Smoking
 Alcohol
R.O.S
Recap
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18. Epigastric Pain & Nausea
L DD Of Epigastric Pain and Nausea:

O
Inflammatory
Q
I  APD
R
Dyspepsia
A
A  Pancreatitis
 Cholecystitis
GIT  IBD
General
Infective
Heart
 Ascending cholangitis
Chest  Acute viral Hepatitis
Psychological  Hepatic abscess
Malignancy Stomach, Liver, Gall bladder, Pancreas,

P Small bowel
A
M
M Ischemic IHD and Bowel Ischemia
Hugs
Drugs NSAIDs and Antibiotics
F
O
Social Alcohol
R.O.S
Recap
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19. Facial Swelling
Where exactly the swelling is? DD Of Facial Swelling

Anywhere else?
 Angioedema (Hereditary or acquired)
ODPARA
 Urticaria
Rash
Abdominal pain  SVC obstruction
SOB / Whistling
Did you ever collapse or not?  Hyperthyroid

General  Cushing syndrome
Glands  CCF
Thyroid (Hyper? Or Hypo? )
Cushing?  CLD
Heart  Nephrotic Syndrome

GIT
 Connective tissue disorders (Like SLE etc)
 Medicines (e.g ACE Inhibitors, Morphine etc)
Kidneys
Joints
Important…Epi Pen
P
A
M
M
Hugs
F
O
Sx
Social
R.O.S
Recap
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20. Funny Turns
What exactly the problem is? DD Of Funny Turns
Syncope → detail Hypoglycemia
ODPARA  Tight DM control

 Malignancy
DM → Detail  Insulinoma
 Glands (Adrenal Insufficiency, Panhypopituarism)
Tight control of Diabetes may be the problem so  CLD
explore in detail  CRF
 Post Prandial
General  Alcohol
 Factitious
Glands
Syncope
Post- Prandial Stroke or TIA
Seizures
GIT Anemia
Drugs
Liver Disease
Kidneys
P
A
M
M
Hugs
F
O
Social
R.O.S
Recap
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21. Backache
DD Of Backache
LOQIRAA
Local Causes Cord Compression due to
Local Causes  Tumor
 Injury  Trauma
 Weight lifting  TB
 Swelling  Abscess
 Problem with legs  Hematoma
o Cord compression
Other Local causes
o Disc Herniation
o Spinal stenosis  Spinal stenosis
 Intervertebral Disc Herniation
Seronegative (Stifness if lower backache)
 Cauda equina Syndrome
General  Spinal Strain
Multiple Myeloma
Seronegative Arthropathies (ARPE)
Paget’s Disease
 Ankylosing Spondylitis
Thyroid
 Reactive Arthritis
Breast  Psoriatic Arthritis
Chest  Enteropathic Arthropathy
GIT
General Malignancy, TB
Prostate if Male (metastasis) Multiple Myeloma
P Paget’s Disease
A Thyrotoxicosis (Osteoporosis)
M
M Prostate
Osteoprosis
Hugs
 Medicines e.g Steroids, Thiazide
F
diuretics
Obs /Gynae
 Early menopause
Social Driving and Travelling
 Oophorectomy
R.O.S  Smoking
 Diet deficient in Dairy products
Recap
 Lack of Exercise
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Features of multiple Myeloma
 Blurriness of vision
 Recurrent infections
 Fractures after minor injury
 Kidney Problems
 Hyper-uricemia
Features of Paget’s Disease

 Changes in hat size
 Hearing problem
Bowing of legs
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22. Hemoptysis
Hemoptysis or Hematemesis? DD of Hemoptysis

How much? Color? Lungs
Bleeding from any other site? Airways
Any injury before this?  Exacerbation of COPD
 Bronchiectasis
Chest  Foreign body
General  Procedure (Bronchoscopy)
ENT
Heart Parenchyma
Foreign body  TB
 Pneumonia
P  Cancer
A
M Blood channels
M  PE
Hugs  HHT
F
 Wegener’s Granulomatosis
O
 Good Pasture Syndrome
Social
 Other vasculitides
 Smoking
 Alcohol
Heart Mitral Stenosis
 Driving
 Travelling ENT
Bleeding disorders
R.O.S
Drugs Warfarin and Heparin

Recap Trauma
Idea
Concern
Explain
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23. Headache
LOQIRAA P
A
Aggravating factors
M—Blood disorders (Clotting disorders)
SOL Brain aggravated by Medicine
 Coughing  OCPs
 Sneezing  Calcium channel blockers
 Straining or Bending  Nitrates

 Analgesic overuse because of some other
Migraine problem like RA or OA
 Any specific Food or drinks like alcohol, cheese etc
 Lack of sleep
Hugs
 Fasting
F—Kidney problems in the family like APKD
 Exercise / Stress
O— Any recent Pregnancy because it ay cause
 Does Noise bother you?
Cerebral Venous Sinus thrombosis (CVT)
 Does Light bother you? Recurrent abortions may be related to
Antiphospholipid Syndrome with features of
Trigeminal neuralgia
migraine or CVT due to hypercoagulation
Aura Any unusual symptoms before this like visual, speech,
sensory or motor symptoms Sexual activity may cause Post-coital or
exercise induced headache
Trauma
Social Cocaine etc
Macro-adenoma
R.O.S
CNS and General
Depression (SIEG-CAPS) Recap
Meningitis
Idea
Occipital headache due to Cervical Spondylosis Concern
Explain
Carotid artery dissection
Giant Cell arteritis (If pain on side of Head or Temple)
Eye problems
Post Herpetic Neuralgia
ENT
APKD (Kidneys)
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FAST PACES Academy
How to ask Questions
Trigeminal neuralgia Sudden / Sharp triggered by chewing,
talking or shave?
Trauma Any Injury before this?
Macroadenoma If frontal Headache (Problem looking to

extremes)
Meningitis Fever and Stiffness in the neck?
Occipital headache due to Cervical Spondylosis

 Problem with movements of neck?
Carotid artery dissection Any sever Neck pain?
Giant Cell arteritis (If pain on side of Head or Temple)

 Any jaw pain?
Eye problems Pain, Redness,watering ,Discharge , Blurriness or

decreased vision?
(Cluster headache, Glaucoma, Infection, Cavernous sinus
thrombosis, GCA,BIH,SOL Brain etc )
Post Herpetic Neuralgia Any Rash on face
Kidneys
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FAST PACES Academy
DD of headache Headache with visual aura
 Migraine
Trauma  CVT
 Posterior cerebral circulation ischemia
Infection
 Meningitis Frontal Headache with vision problem on looking
 Encephalitis to sides
 Acromegaly
SOL Brain  Cushing disease
 Tumor  Non Functioning pituitary adenoma
 Abscess  MEN 1
 Tuberculoma
 Lymphoma Headache with Photophobia
 Migraine
Bleeding  Cluster headache
 Intracranial  Meningitis
 Subarachnoid hemorrhage
 Epidural hematoma Sudden onset Headache
 Subdural hematoma  Acute on chronic
 Subarachnoid hemorrhage
Blood vessels  Meningitis / Encephalitis
 CVT  Carotid / Vertebral artery dissection
 Posterior cerebral circulation ischemia
 Cavernous sinus thrombosis Facial headache
 GCA
Frontal Headache (Pituitary Macroadenoma)  Temporo-mandibular joint
e.g Acromegaly,Cushing disease, MEN 1 and Non  Post herpetic neuralgia
Functioning adenoma  Trigeminal neuralgia
 Toothache
Depression  Otitis Media
Cervical Spondylosis
Others
GCT
BIH
Eyes Uveitis, Glaucoma etc
Cluster headache
Post Coital headache or Exercise induced headache
Cough headache
Caffeine with drawl
Analgesic over use Headache
Medicines e.g CCB , Nitrates , OCPs etc
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FAST PACES Academy
24. Hoarse Voice

DD of Hoarseness
ODPARA
Sore throat Viral or Bacterial
Sore Throat
General Smoke Inhalation
Smoke inhalation GERD
GERD Cancer
Thyroid Hypothyroidism
Chest Pancoast Tumor in Lungs
Heart Mitral Stenosis
P Asthma Use of steroid inhaler

A
M
M
Hugs
F
O
Social— job Using voice e.g Announcement
R.O.S
Recap
I
C
E
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FAST PACES Academy
25. Hypercalcemia
Bones, Psychic Moans, Abdominal Groans & Renal Stones
Symptoms DD Of Hypercalcemia
 Bones
Malignancy
 Brain
 GIT  Breast
 Kidneys  Lung
General Malignancy and Multiple Myeloma  Prostate
 Hematological
Macroadenoma
 Any Frontal Headache  Multiple Myeloma
 Any Vision problem on looking to the extremes
MEN 1 (4 P’s)
Glands Any Swelling in front of your neck
 Pituitary Macroadenoma (Acromegaly)
(Medullary carcinoma of the thyroid)
 Parathyroid
Any sudden onset headache with sweating, flushing of
 Pancreatic cancer
face and racing of heart? (Phaeochromocytoma)
 Peptic Ulcers
Any problem adjusting to Temperatures

(Thyrotoxicosis) Thyrotoxicosis
Changes in hand size and feet size? (Acromegaly)

Chest
Chest
 Sarcoidosis
Heart  TB
 Cancer
P  Heart (Arrythmias due to Hypercalcemia)
A
M
M Medical problems
Hugs
Medicines Vitamin D analogues,Calcium supplements,
F
O Thiazide Diuretics
Social Diet, Exercise (Sedentary or immobile)
Social Increase intake of Milk and Dairy products

R.O.S
Recap
I
C
E
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FAST PACES Academy
26. Hyperlipidemia
Details of Lipids
Symptoms related to Vasculopathy Stroke, Eyes , IHD , CCF, Kidneys , PVD etc
OTHER RISK FACTORS
DM
HTN
Smoking
Hugs
Social
R.O.S
Recap
Idea
Concern
Explain
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FAST PACES Academy
27. Jaundice
Yellow Discoloration of any other part? P

A
ODPARA
M…Any clotting problem or Liver related
problem in the past
1.Post Hepatic Jaundice related Questions
M… Methotrexate, Amiodarone,
 Any Itching
Phenytoin, INH, Paracetamol etc
 Any Pale colored bowel works
 Any Dark colored water works Hugs... Medical or Surgical procedures
 Any fever or chills
Family Hx…Gilbert syndrome and other

2.Hepatic Causes Related Questions familial causes
General Questions
OBS /Gynae Pregnancy related e.g

Prodrome of acute viral hepatitis Any flue like illness before this?  IHC of Pregnancy
 AFL of Pregnancy
GIT Questions (CLD) and Hepatitis B and C Screening Questions
 HELLP Syndrome etc
Piercing,Tatooing Blood transfusions etc
Sx…Hepatitis B and C
Autoimmune Any white patches on your skin and Any joint pains
Social…Alcohol,Mushroom poisoning,
Metabolic
Swimming in pool etc
 Any darkening of skin Travelling...Viral hepatitis
 Any stiffness in limbs or shaking of your hands
 Any difficulty in breathing and whistling sound

Heart Any racing of your heart? Do you need to use extra pillows to
sleep?
Kidneys Any decrease volume of water works (Leptospirosis)
Budd Chiari Syndrome Ever had clot in the blood channels of your
legs or lungs
3.Pre Hepatic related Questions
Anemia Any Racing of your heart,Fatigue and difficulty in breathing

on exertion?
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FAST PACES Academy
DD of Jaundice
Painful Jaundice
 Acute Hepatitis
Alcohol
Viral
Drugs
 Biliary Colic
 Budd Chiari Syndrome
 CCF
 Metastatic
 Pancreatitis
Painless Jaundice
 Gilbert syndrome
 Hemolysis
 Cirrhosis
 Malignancy
Clues
PBC Middle aged female, Fatigue , pruritis , Malabsorption
Alcohol History and examination,Pain,Raised MCV and Neutrophilia
Acute Viral Prodromal flue like illness
Autoimmune Other autoimmune conditions,Fever, Arthralgia
Metabolic
Hemochromatosis
 Dark Skin, Joint replacement,DM , infertility
Wilson’s disease
 Extrapyramidal features
 Psychiatric problem
Alfa 1 anti trypsin deficiency

 Young,Non- smoker with COPD
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FAST PACES Academy
28. JOINTS
Symmetrical
1. Viral <6 weeks
2. SLE
3. RA
4. Vasculitis
5. Drug Induced Lupus
6. Psoriatic arthritis
Asymmetrical
1. Seronegative Arthropathies
2. Gout
3. Rheumatic Fever
4. Malignancy
Mono-articular
1. OA
2. Gout
3. Pseudo-gout
4. Septic
5. Malignancy
6. Trauma
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FAST PACES Academy
29. Loin Pain
LOQIRAA
Genitourinary Questions
BPH
Trauma
General
PAMM-Hugs-FOS
R.O.S
Recap
I
C
E
DD
1. Renal Stones
2. Renal Cancer
3. Pyelonephritis
4. Hydronephrosis
5. BPH
6. Trauma
7. Cyst Rupture
8. Blood clots
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FAST PACES Academy
30. Loss of weight
Weight loss schemes 1.With Good Appetite
GIT A.GI Causes

 Dieting
General
 Malabsorption syndromes
Glands
 Medicines e.g Laxatives
Heart
Chest B.Non GI Causes

 Exercise
Kidney
 Gland DM, Thyrotoxicosis, Pheochromocytoma
Connective Tissue Disorders
 Medicines Fenfluramine,Orlistat,Diuretics and

Anti thyroid medicines e.g Thyroxine
P
A
M
M 2.With Bad Appetite
Hugs A.GI Causes

 APD
F  Chronic infections
O
Social  IBD
 Malignancy of GIT
R.O.S
 Medicines
Recap
B.Non GI Causes
I
 Depression
C
E  Adrenal Insufficiency
 Malignanacy
 Chronic Infections
 Medicines e.g Antibiotics
 Smoking
 Alcohol
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FAST PACES Academy
31. Weight loss and Diarrhea
Weight loss detail
Details of diarrhea according to scheme
GIT
 Malabsorptio like Celiac Disease and Whipple’s Disease etc
 General
 Chronic Pancreatitis
 Crohn’s Disease
 Chronic infections TB and HIV etc
 Malignancy
 SIBO e.g Scleroderma etc
 Microscopic colitis (Usually middle aged lady with watery diarrhea but normal Colonscopy and diagnosis is
established on biopsy)
Glands Thyrotoxicosis and DM (Autonomic)
Joints
 Food allergy
 Allergy to medicines
 Eosinophilic gastroenteritis
 Lactose intolerance etc
M…Diabetes mellitus with diarrhea due to autonomic neuropathy
M…Medicines like Laxatives and antibiotics
Hugs Bowel surgery leading to SIBO and Radiation Enteritis
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FAST PACES Academy
F…Family history of celiac disease or IBD etc
Ob/Gynae
Social…Travelling diarrhea,Sexual History for HIV and others
R.O.S
Recap
Idea
Concern
Explain
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FAST PACES Academy
32. Lower GI Bleeding
What is the color? Questions

How much at a time?
Bleeding from any other site? Fissusre in ano Any pain on passing bowel works?
When you get this? Before, during or after bowel Haemorrhoids Any lump coming out of back passages?
works?
ODPARA Associated Questions of IBD and Celiac

 Redness or yellowness of eyes
Any pain on passing bowel works?  Ulcers in mouth
 Joint pain
Any lump coming out of back passages?  Rash
Other Malabsorption Questions (ADEK,Anemia ,

GIT and Associated Questions of IBD and Celiac Albumin)
General
Heart (AF → ischemic colitis)
DD of Lower GI Bleeding
P
A  Anal Fissure
M—Radiations
M  Hemorrhoids
Hugs  Collitis
o Diverticulitis
F
O o Infective
Sexual History o Inflammatory
Social History
o Ischemic
o Radiations
R.O.S
o Medicines e.g NSAIDs
Recap o Pseudomembranous
Idea
Concern  Malignancy
Explain
 Polyps
 Blood vessels Angiodysplasia,HHT,Drugs e.g

Warfarin etc
 CLD
 Procedures e.g Colonoscopy
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FAST PACES Academy
33. Megaloblastic Anemia
Anemia and Pancytopenia related Questions?

Difficulty in breathing, racing of heart or fatigue on walking? (Anemia)
Bleeding from nose, gums or any other site? Any rash? (Thrombocytopenia)
Any fever? (Neutropenia)
ODPARA
B-12 Deficiency Questions

 Any Yellowness of your eyes
 Soreness of Tongue
 Any Numbness or Tingling in fee?
GIT
 Automimmune gastritis (B 12 Deficiency)
 Malabsorption (Celiac)
 Ever had Worms in bowel works?
Kidneys (CRF and dialysis leading to loss of Folate)
Skin problem (Psoriasis leading to increased demand of Folate)
P
A
M
M— Sulfonamides, Phenytoin etc
Hugs—Stomach or Bowel surgery
F
O Pregnancy, Breast feeding
Sx
Social Alcohol, Do you take balanced diet including Meat, dairy products, any use of over cooked vegetables
R.O.S
Recap
I
C
E
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FAST PACES Academy
34. Lump in the neck (Lymph Nodes)
Where exactly the swelling is in your neck?

Do you have swelling anywhere else?
Does it move when you swallow?
Any problem due to swelling? like

 Any pain in it?
 Difficulty in swallowing?
 Difficulty in breathing?
 Problem with voice?
ODPARA
General
 Malignancy
 Metastatic
 Lymphoproliferative disorders
Sore Throat Viral (Non Specific),HIV,Infectious

mononucleosis
Thyroid
Chest…TB,Sarcoidosis , Cancer
GIT…Cancer
P
A
M
M
Hugs
F
O
Social
R.O.S
Recap
Idea
Concern
Explain
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FAST PACES Academy
35. Painful Shins (Erythema Nodosum)
Where exactly the rash is?

Anywhere else?
How does it look like?
Any problem with your rash like pain,itching, bleeding or discharge form it?
ODPARA
General …Malignacy ,Infections and inflammation
Sore Throat …Streptococcus
Chest
 Sarcoidosis
 TB
 Mycoplasma / Psittacosis
 Fungal
GIT… IBD
Skin.. Leprosy
P
A
M
M…OCPs,Sunlfonamides
Hugs
F
O
Social… Pets at home (cat scratch disease) and Travelling
R.O.S
Recap
Idea
Concern
Explain
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FAST PACES Academy
36. Painful Shoulders
LOQIRAA DD of Painful Shoulders
Any Stiffness? 1. Polymyalgia Rheumatica
2. Polymyositis / Dermatomyositis
Are they sore to touch?
Any Rash? Where? 3. Osteomalacia
Do you feel weakness while going upstairs?
4. Trauma
Any Injury to neck before this? 5. Cervical Spondylosis
Problem with movement of neck? 6. Hypothyroid
7. Fibromyalgia
Thyroid
8. Joints…RA and Ankylosing Spondylitis
Depression
Joints
P
A
M
M
Hugs
F
O
Social
R.O.S
Recap
Idea
Concern
Explain
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FAST PACES Academy
37. Palpitations
For how long? How frequent do you get that?

Sudden or gradual? If sudden…what were you doing at that time?
When you get that…Any specific situation or time?
For how long it remains there?
How does it feel like? Can you please tap for me?
Do you feel any Thumping in your chest? Regular or irregular? (If patient can’t tap then ask this)
Did you ever check your pulse at that time? If Yes…. How fast it was? Regular or irregular?
Heart …IHD ,Valvular , AS , HOCM , CCF etc
Lungs…PE ,COPD ,Asthma ,Chest infections
Chest wall…Injury, Operations
Food Pipe…GERD
Anxiety
Anemia
Glands
 Thyrotoxicosis
 DM
GIT…Electrolyte imbalances due to Gastroenteritis
Kidneys…Hyperkalemia
P
A
M
M e.g Beta agonist,Thyroxine etc
Hugs
F
O
Social History… Alcohol, Cocaine,Caffeine etc
R.O.S
Recap
Idea
Concern
Explain
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FAST PACES Academy
38. Pins and Needles (Peripheral Neuropathy)
In which feet the problem is?

In which part of your feet?
Up to which level?
Do you have such symptoms anywhere else?
Any numbness or tingling…Sensory
Any weakness or cramps…Motor
Balance problem especially with closed eyes or in darkness?
Any dizziness on standing up suddenly? Autonomic
ODPARA
DD
Diabetes (In detail)
General (Multiple Myeloma,other Malignancy)
Thyroid
GIT…Autoimmune Gastritis,Malabsorption syndrome (Celiac)
Kidney…Uremia
Joints…SLE,RA
P
A
M…Vitamin B 12 deficiency
M…INH,Nitrofurantoin,Chemotherapy
Hugs
F…HMSN
O
Sexual…HIV,Syphilis
Social…Alcohol,Diet deficient in dairy products
Recap
Idea
Concern
Explain
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FAST PACES Academy
39. Carpal Tunnel Syndrome
Where exactly the numbness is?

In which hand?
Which part of your hand?
Up to which level?
Do you have such symptoms in your feet or not?
Any other problem with your hands? Like Pain and weakness or wasting?
ODPARA
Trauma Any injury before this?
General Malignancy
Glands weight gain

 Acromegaly
 Cushing
 DM
 Hypothyroid
Kidneys…Dialysis
Joints…RA ,Gout
P
A
M
M
Hugs
F
Ob/ Gynae…Pregnancy
Social…Stone Cutter, Vibrating tools,Tractor use ( Farmer )
R.O.S
Recap
Idea
Concern
Explain
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FAST PACES Academy
40. Polyuria

DD
Approximately How much is the quantity?
What is the color? 1.Diabetes Inspidus (PTI VTI)
How much fluids you take daily?
 Postoperative
Which type of fluids you take?
 Trauma
 Infection
ODPARA
Hypercalcemia Bones,Psychic Moans, Abdominal groans and  Vascular events (Stroke)

Renal stones?
 Tumor
Any Injury to head before this?  Infiltrations e,g
CNS TB,Sarcoidosis,Haemochromatosis,Maligna
ncy
Panhypopituarism Questions
 GH
 Hypothyroid 2.DM
 Adrenal insufficiency
 Sexual Problem 3.Hypercalcemia
General 4.Psychogenic Polydypsia
Chest …TB, Sarcoidosis
P
A
M
M…Lithium,Glibenclamide
Hugs…Surgery, Radiations
F
O
Social
R.O.S
Recap
Idea
Concern
Explain
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FAST PACES Academy
41. Pruritis
Where exactly the itching is on your skin? Anywhere else?
ODPARA
Any one else at home have similar complaints? Scabies
General…Lymphoma
Polycythemia…Headache,Blurriness,Ringing in ears/vertigo
Glands…DM,Thyroid (Hyper OR Hypo)
Liver
 Obstructive
 PBC
 Hemochromatosis
 Cholestatic phase of acute viral hepatitis
 Pregnancy (IHC)
Kidney…Uremia
Joints
Psychological
P
A
M
M
Hugs
F
O
Sx HIV
Social…Occupation (Fiber glass) use of Soaps, Detergent, Washing liquids etc
R.O.S
Recap
Idea
Concern
Explain
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FAST PACES Academy
42. Purpuric Rash
Where exactly the rash is? P

Anywhere else? A
How does it look like?
Can you feel it? M -- Liver disease, Kidney disease
Does it disappear when you press it?
M --- Heparin, Aspirin , Warfarin ,Steroids
ODPARA
Hugs-- Radiation exposure
Any Bluish spots on your skin?
Bleeding from any part? F -- HHT, Bleeding disorders
Any difficulty in Breathing,Fatigue or Racing of heart on walking
(Anemia) OB/Gynae -- Recurrent abortions, Periods
Pregnacny induced Theombocytopenia ,TP,
DD Pre-eclampsia
ITP---Any Flue like illness before this?
Sx --- HIV, EBV
General --- Malignancy,Leukemias ,metastatic
Social -- Diet deficient in vitamin C
CNS --- TTP
R.O.S
GIT --- Henosch Schonlein Purpura
Recap
Liver --- CLD
Idea
Kidney --- HUS Concern
Explain
Joints -- SLE
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FAST PACES Academy
43. Pyrexia
For how long you have fever?
Do you check it? How high does it go?
Is it present all the time or comes and goes?
Any sweating or Chills?
Do you have any other symptoms with fever?
Have you had fever before travelling?
Did you visit your GP before travelling? Did you take any Vaccination before travelling?
Did you take any Malaria preventive medicine before that? For how long you took these medicines?
Infections
 CNS --- Meningitis, Encephalitis, Abscess
 ENT --- Otitis Media, Acute viral illness like
HIV,EBV
 Chest --- Pnumonia
 Heart--- Infective Endocarditis
 Liver --- Acute Hepatitis, Liver abscess
 GIT--- Enteric fever, Gastroenteritis
 Kidney--- Pyelonephritis
 Genitourinary ---UTI,PID
Joints-- RA,SLE,others
General --- Malignancy
Thyrotoxicosis
P
A
M
M
Hugs
F
O
Sx--- HIV, EBV, HCV , HBV
Social
Vaccines DPT, Polio, MMR ,Hepatitis
R.O.S
Recap
ICE
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FAST PACES Academy
44. Renal Colic & Hematuria
Pain— LOQIRAA
When you get bleeding? Before,During or After water works?
Bleeding from any other site?
Any injury before this? (e.g Catheter)
Any burning or pain while passing water works?
Ever passed stone?
BPH
General
CRF
Sore Throat
Chest --- Wegener’s Granulomatosis ,Good Pasture Syndrome
Joints – SLE
P
A
M— TB, Bleeding disorders
M— Warfarin,Cyclophosphamide , Others
Hugs
F APKD, Alport Syndrome
O
Sx
Social…Smoking, Heroin,Occupation Plastic ,Dye, Rubber etc
Travelling…Travelling to Egypt (Schistosomiasis)
R.O.S
Recap
Idea
Concern
Explain
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FAST PACES Academy
45. Tiredness
ODPARA
Associated
DD
Obstructive Sleep Apnoea…OSA
General…Malignancy, Infection
CNS…Myasthenia Gravis
Depression (SIEG CAPS)
Anemia
Sore Throat…Post Viral
Glands
 DM
 Addison’s Disease
 Acromegaly
 Hypothyroid
Heart… IHD, CCF, Infective Endocarditis
Chest …COPD, TB , Cancer , Pulmonary HTN etc
Kidneys…CRF
GIT
Joints
P
A
M
M
Hugs
F
O
Sx …HIV
Social..Travelling
R.O.S
Recap
ICE
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FAST PACES Academy
46. Tremors
In which hands?
Any other part is affected or not? like Head, Jaw, Feet etc
Where started first?
When you get tremors?
ODPARA
(Scheme to rule out Cerebellar Causes)
CNS (Tumor, Stroke, MS, FA ,Parkinson’s Plus

syndrome)
 Cerebellum and other causes of CNS which can
cause Tremors
General...Malignancy
Glands
 Thyrotoxicosis
 Hypothyroid
GIT… Malabsorption causing vitamin E deficiency
P
A
M
M
 Resting Tremors---Neuroleptics , Anti Psychotics
 Intentional intentional---Tremors Lithium,
Antiepileptics
 Others---Beta agonists ,Theophylline, Cyclosporin
Hugs
F
O
Social…Occupation Mercury exposure,Alcohol
Cocaine, Amphetamines
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FAST PACES Academy
47. Vision Problem
In which eye?
Any other problem with your eyes? like Double vision, problem with color vision?
Any Redness,watering discharge or Pain?
ODPARA
CNS
Giant Cell Arteritis
DM—Symptoms
Thyroid
R.O.S DD
P Local
A  Trauma
M  Infection
M  Cataract
 Glaucoma
Hugs
Retinal
F  Retinopathy
O  Optic Atrophy Ethambutol
Sx  Detachment
Social..Driving,Travelling  Retinal Pigmentation
Recap CNS
 MG
Idea
 BIH
Concern
 Tumors
Explain
 TIA
 Migraine
 Hyperviscosity
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FAST PACES Academy
48. Vomiting
DD
ODPARA
GIT
GIT  Esophagitis
 APD
General Malignancy
 Tumor
CNS
 Small bowel Crohn’s
Eyes  Hepatitis
ENT  Pancreatitis
 Gall stones
Glands..Addison’s Disease,DKA
 Acute gastroenteritis
CKD  Acute Enteric Fever
Psychiatric
General---Cancer
CNS---Raised ICP,Tumor , infection, SOL ,TB

P
A Eyes----Glaucoma
M
M---Antibiotic,Chemotherapy ENT--- Otitis Media,Labyrinthitis
Hugs---Radiation Glands
F CRF
O
Social---Alcohol Psychological
Recap
Idea
Concern
Explain
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FAST PACES Academy
49. Weakness of one arm
Where exactly the weakness is?
Do you have weakness anywhere else?
ODPARA DD
CNS  TIA/ Stroke

 MS
 Migraine
 Stoke / TIA
 SOL Brain  Epilepsy Todd’s Paresis
 Migraine
 Epilepsy  SOL Brain
Neck Pain (Carotid artery dissection)  Psychological Hysterical
Heart…AF, Infective Endocarditis , LVF
Blood clots in the blood channels of Legs or Lungs
P
A
M---DM, HTN, Fat Levels
M
Hugs
F---Stroke , MI , APKD
O
Social…Smoking ,Cocaine
R.O.S
Recap
Idea
Concern
Explain
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FAST PACES Academy
50. Weight Gain
Where exactly you are putting weigh in your body?
How much weight you have gained?Over how much time period?
Glands
 Cushing syndrome
 Acromegaly
 Hypothyroid
 Polycystic Ovarian Syndrome
Heart…CCF, Cor Pulmonale
GIT…Malabsorption leading to Hypoalbumenimia
Kidney…Nephrotic syndrome
M---Insulin,Sulfonylureas , OCPS, Steroids , TCA , Antipsychotics
Hugs
Social…Alcohol, Excessive Diet,Lack of Exercise
R.O.S
Recap
Idea
Concern
Explain
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FAST PACES Academy
51. Wheez
ODPARA
Chest
Heart
GERD
DD
 Occupational Asthma
 Churgh Strauss syndrome
 Foreign body
 Anaphylaxis
 CCF
 GERD
M…NSAIDs ,Aspirin ,B -Blockers
Hugs
Social…Occupation, Smoking
R.O.S
Recap
Idea
Concern
Explain
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FAST PACES Academy
Possible List of common cases
1. Acute confusion…UTI
2. Weakness…Stroke/TIA
3. Weakness in legs with paresthesizia…GBS
4. Memory problem …Transient Global amnesia
5. Fatigue and weigh loss…Infective endocarditis,SIADH with hyponatremia,malignancy,Adrenal insuffiency
6. Fatigue…anemia,OSA,Depression,Acute Renal failure
7. SOB with Joint pains…Sarcoidosis
8. Joint pains and painful rash..Sarcoidosis
9. SOB and Cough with history of breast cancer…Chemotherapy induced cardiomyopathy
10. Occupational asthma…work in paint factory or new bird at home etc
11. NSAIDs induced Renal Failure
12. Autoimmune disease like Type 1 DM and other autoimmune conditions like Adrenal insufficiency
13. Mechanical Backache with history of Malignancy
14. Subacute intestinal obstruction with previous history of Operation
15. Bilateral knee pains with stiffness…Possibility of RA
16. Side effects of many medicines
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FAST PACES Academy
Case 1
Dear Dr,
I would be grateful for your opinion on this 48‐year‐old lady who was diagnosed with Rheumatoid
arthritis 5 years ago. She has noticed increased swelling of her ankles for the last 2 months and has 3+
proteinuria on dipstick urinalysis today.
Scheme
Introduction Problem List
Presenting complaint--Ankle swelling
Please tell me more about it? (1st open ended question)
Localize (if not done by the patient)
Complete the ODPARA (Which is not told by the patient)
Do you have any other problems? (2nd open handed question)
Associated system (e.g kidneys related questions)
General Questions
DD (From top to toe)
o Thyroid
o Heart
o Chest
o GIT
Detail about RA (Previous details + current details + MCT/ overlap +Extra articular)
PAMM-Hugs-FOS
R.O.S (Sometimes not required)
Recap (3rd open ended question)
I
C
E
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FAST PACES Academy
Case 2
Dear Dr,
I would be grateful for your assessment of this 55‐year‐old man with poorly controlled diabetes. He has
previously been reluctant to attend a diabetic clinic. He is currently taking oral hypoglycaemic medication
and bendroflumethiazide. I feel he may need to start insulin soon. I calculated his body mass index today
at 36. His last HbA1C was 97 mmol/mol (11%).
Scheme
Presenting complaint
Detail about diabetes as given in symptoms notes
Detail about HTN and Bendroflumethiazide
Detail about obesity
M--HTN,Fat level,Heart disease, Kidney problem etc
M-- others
Hugs
F—DM,HTN,IHD etc
S Job, Living, Partner, How is affected? Smoking, Alcohol, Diet, Exercise
R.O.S (if required)
Recap
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FAST PACES Academy
Case 3
Dear Dr,
This 26‐year‐old female attended my surgery today complaining of difficulty walking that had come on
over a few days. On examination she has a markedly ataxic gait but no other abnormality. She has no
significant past medical history and takes only simple Analgesia for headaches. I would be grateful for
your urgent assessment.
Scheme
Presenting complaint
Localize
Complete the ODPARA
Do you have any other problems?
Associated system (CNS)
General Questions
Headache in detail
Other causes of cerebellar involvement (From top to toe)
 Anemia
 Thyroid
 GIT (Malabsorption of Vitamin E etc)
P
A
M---Medicines like anti epileptics
M---Medical problems like related to brain
Hugs
F---Family history e.g. ataxia telangiectasia

O
S----Alcohol, Malnutrition
R.O.S
Recap
I
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FAST PACES Academy
Case 4
Dear Dr,
Thank you for seeing this 35‐year‐old teacher urgently. I am concerned she has had a pulmonary embolus.
She developed central pleuritic chest pain during the course of yesterday; however, she has felt generally
unwell for a week. She was on the combined oral contraceptive pill until 1 year ago. She currently takes
fluoxetine for depression andnifedipine for Raynaud’s syndrome.
On examination she was a little breathless. Pulse 100 and BP 170/100. Chest clear.
Scheme
Presenting complaint-------Chest Pain
Tell me more about it
Complete the LOQIRA
Do you have any other problem?
Associated system-----Chest especially pulmonary embolism
Leg swelling + Risk factors for PE especially Pills
General Questions
DD
 Heart
 GERD
 Injury

Detail of Depression
Raynaud’s Phenomenon + Joint related questions as in notes
PAMM---Hugs----FOSS
Recap
I
C
E
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FAST PACES Academy
Case 5
Dear Dr,
I would be grateful if you would see this 22‐year‐old language student who has had persistent diarrhoea
since returning from Russia 2 months ago. Several of her friends on her trip also had diarrhoea whilst
abroad but unlike them her symptoms have not settled
with antibiotics.
Scheme
Presenting complaint------- Chronic Diarrhea
Please tell me more about it
Detail as in notes + GIT questions
DD
 General questions
 Thyroid
 Joints
P
A---Eosinophilic enteritis
M---DM,Celiac disease
M---Laxatives
Hugs
F---Celiac, IBD etc
O
So---Sexual history, Travel History
Recap
I
C
E
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FAST PACES Academy
Case 6
Dear Dr,
I would be grateful for your opinion on this 78‐year‐old man who has recurrent dizzy spells and on two
occasions he has blacked out at home. He had a pacemaker inserted 2 years ago following an episode of
heart block, which complicated an anterior myocardial infarction. I wondered if the pacemaker was
malfunctioning, though a recent check was satisfactory. His only other medical history is hypertension. In
the surgery today his pulse was 70 regular and BP 135/85
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FAST PACES Academy
Case 7
Dear Dr,
Thank you for seeing this 56‐year‐old businessman who came to see me because his wife was concerned
he looked a bit yellow. Apart from looking a little jaundiced there was no abnormality on physical
examination today. His liver function tests are deranged with an elevated ALT and bilirubin. Otherwise he
is well and only takes bendroflumethiazide for hypertension.
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FAST PACES Academy
Case 8
Dear Dr,
Thank you for seeing this 30‐year‐old shop assistant who complains of amenorrhoea for 6 months. She has
a history of manic depression for which she is under psychiatric review but is currently well and off
medication. A pregnancy test was negative. Her body mass index was calculated at 25.
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FAST PACES Academy
Case 9
Dear Dr,
We have had this 30‐year‐old man on our asthma clinic registry since he was a teenager although he has
never been very diligent about attending his appointments.
However, he now complains that his breathing has been getting very much worse over the last few months
and his symptoms are not controlled with Ventolin and Becotide.
I would be grateful for your opinion.
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FAST PACES Academy
Case 10
Dear Dr,
Many thanks for seeing this 20‐year‐old man who feels increasingly fatigued and unwell. On examination
he has bilateral cervical lymphadenopathy, which has been Increasing for at least 2 months. There are no
nodes elsewhere and there is no other
abnormality on physical examination.
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FAST PACES Academy
Case 11
Dear Dr,
This 66‐year‐old female has suffered two episodes of transient loss of consciousness.
Apart from these episodes she is in good health. Her medical history includes a Myocardial infarct 4 years
ago and mastectomy 9 years ago. She takes aspirin 75 mg od, atenolol 50 mg od and enalapril 10 mg od.
She is a non‐smoker. Physical examination of neurological and cardiovascular systems was normal with
blood pressure 110/65 mm Hg. An ECG showed sinus rhythm 60 bpm and inferior q‐waves from her
previous MI.
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FAST PACES Academy
Case 12
Dear Dr,
I would be grateful for your advice on this 40‐year‐old male who was diagnosed with antiphospholipid
syndrome following a pulmonary embolus 3 years ago. Long‐term anticoagulation with warfarin (target
INR 2.5) was advised then. Recently
he seems increasingly resistant to warfarin requiring doses of 15 mg daily. Despite this his INR is
frequently sub-therapeutic. In addition, on one occasion he has been admitted via A&E for INR > 20. I have
checked his antiphospholipid antibody levels
which remain greatly elevated and would be grateful for you advise on his management.
73

Histories 10th Edition

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Fast PACES

Academy for Doctors

DR IMRAN BABAR MRCP (UK)

Introduction and Information sharing with the patient

P → Have you ever had similar complaints it the Past?

 Fluid (Ascites) 1. GIT

What makes it worse? c. Malabsorption Syndrome

3. Ankle Swelling (PHTN) Young, Non- Smoker

Chest pain (Detail) 2. Heart

Do you have any Symptoms like DD Of HTN

Kidney  Diabetic Nephropathy

Social …Alcohol, Cocaine

Where exactly the burning is in your feet? DD of Peripheral Neuropathy

Family History HMSN

What makes it worse? GERD

Lying flat…Pericardial Lungs

Taking deep Breath in…PE  Malignancy

 Injury (Musculoskeltal) Chest

 Aortic Dissection  Post Herpetic Neuralgia

 GERD  Intervertebral Disc Disease

 Lungs  Spinal mass

8. Cold and Painful Fingers

 For how long you have this problem?  Polymyositis

 Is it getting worse?  MCTD

 What makes it better?

Associated system like JOINTS Liver Cryoglobulinemia (Hepatitis B and C)

Any yellowness of your eyes? (Liver) Trauma

Any numbness or tingling in your hands?

P Drugs e.g Cocaine etc

Stroke / TIA (CNS)

Metabolic (Other systems)

Endocrine problems DKA (Glands)

Events Before Collapse

Any unusual symptoms before this? (Aura) Like

 Blurring of vision,nausea and sweating (Autonomic)

 Chest pain or racing of heart? Difficulty in breathing? (Caridiac)

 Severe headache? (Subarachnoid hemorrhage)

 Seeing of unusual objects,abnormal smell Or ringing in the ears? (Epilepsy, seizures)

During the Event

Was there anyone around you? What did they tell?

Post Recovery events

Any problem with speech Or Weakness in body limbs? TIA or Stroke

Any Fever and Neck Stiffness? Meningitis

Fatigue or racing of heart on exertion? Anemia

It can be preceded by triggers like

 coughing,sneezing etc (Situational)

11. Chronic Confusion (Forgetfullness)

Ulcer Management Plan

ODPARA  Diabetic clinic

Social Smoking,Alcohol and other recreational drugs

What actually the problem is? DD of Flaccid Or Floppy Paraparesis

Sexual HIV and Syphilis

Muscular Dystrophy Myotonia Dystrophica Depression

Inflammatory conditions Inclusion body Myositis Malignancy

 Acromegaly  Addison’s Disease

What exactly the problem is?

Any unusual symptoms before you collapse or having dizziness?

Aura (Autonomic, cardiac, epilepsy, subarachnoid haemorrhage etc)