Consultation Station Notes 20220919

Consultation Station Notes
Contents
Strategy and preparation.......................................................................................................................4
Consultation station template...........................................................................................................7
Common sense management..........................................................................................................10
Comms – Sexual history...................................................................................................................10
Ethics/Practice-based Adult/Geriatric/Paediatric, Acute/Emergency vs. Chronic/Preventive/Palliative
.............................................................................................................................................................11
Comms - Breaking bad news............................................................................................................11
Comms/Ethics – Medical error/Open disclosure.............................................................................14
Care issues.......................................................................................................................................15
Ethics - Elder Neglect/Abuse........................................................................................................15
Ethics/Law – Spousal abuse/domestic violence...........................................................................17
Ethics – Treatment refusal...........................................................................................................18
Lab results...........................................................................................................................................21
Lab – Raised Cr/drop in eGFR, AKI vs AoCKD...............................................................................22
Lab - Proteinuria..........................................................................................................................25
Non-specific/general symptoms..........................................................................................................25
Symptom - Fatigue/tiredness or weakness..................................................................................25
Geriatric...............................................................................................................................................28
Symptom – Functional decline or cognitive impairment/memory loss.......................................28
Symptom – Delirium....................................................................................................................29
Symptom – Dementia/Cognitive impairment/Memory loss........................................................29
Symptom – Falls and instability...................................................................................................29
Symptom – Urinary incontinence................................................................................................30
Adult....................................................................................................................................................30
Cardiovascular Acute/Emergency vs. Chronic/Preventive/Palliative...............................................30
Symptom/sign – New hypertension............................................................................................30
Condition – Hypertension............................................................................................................35
Respiratory Acute/Emergency vs. Chronic/Preventive/Palliative....................................................35
PE – Crepitations..........................................................................................................................35
PE – Pleural effusion....................................................................................................................37
PE – Pneumonectomy/lobectomy scar........................................................................................38
Condition – COPD........................................................................................................................38
Condition – Asthma.....................................................................................................................39
Condition – Smoking cessation....................................................................................................43
Gastrointestinal Acute/Emergency vs. Chronic/Preventive/Palliative.............................................43
Symptom - Acute abdominal pain...............................................................................................43
Renal & Urology Acute/Emergency vs. Chronic/Preventive/Palliative)...........................................48
Neurology Acute/Emergency vs. Chronic/Preventive/Palliative......................................................48
Symptom - Headache..................................................................................................................48
Symptom – Syncope....................................................................................................................54
Condition – Seizures/Epilepsy......................................................................................................54
Symptom – Weakness or difficulty walking.................................................................................57
Symptom – Weakness hemiparesis.............................................................................................62
Symptom/sign – LMN 7 palsy......................................................................................................62
Chronic – Post-stroke...................................................................................................................63
Symptom – Weakness paraparesis..............................................................................................68
Symptom – Weakness footdrop..................................................................................................68
Symptom – Tremors and incoordination.....................................................................................68
Syndrome/Chronic – Parkinsonism..............................................................................................71
Symptom – Numbness and paraesthesia.....................................................................................78
Psychiatry Adult/Geriatric/Paediatric, Acute/Emergency vs. Chronic/Preventive/Palliative...........83
Syndrome – Depression...............................................................................................................83
Musculoskeletal/Rheumatology Adult/Geriatric, Acute/Emergency vs.
Chronic/Preventive/Palliative..........................................................................................................84
Symptom – Lower back pain........................................................................................................84
Symptom – Hip pain....................................................................................................................86
Symptom – Knee pain..................................................................................................................87
Symptom – Shoulder pain...............................................................................................................91
Dermatology Adult/Geriatric, Acute/Emergency vs. Chronic/Preventive/Palliative........................91
Symptom/sign – Mole/skin lesion...............................................................................................91
Condition – Eczema.....................................................................................................................94
Endocrine Adult/Geriatric, Acute/Emergency vs. Chronic/Preventive/Palliative.............................94
Type 2 diabetes mellitus..............................................................................................................94
Haematology Adult/Geriatric, Acute/Emergency vs. Chronic/Preventive/Palliative.......................96
Infectious diseases Adult/Geriatric, Acute/Emergency vs. Chronic/Preventive/Palliative...............96
Admin - Pre-travel advice............................................................................................................96
Male reproductive system Adult/Geriatric, Acute/Emergency vs. Chronic/Preventive/Palliative. 102
Female reproductive system Adult/Geriatric, Acute/Emergency vs. Chronic/Preventive/Palliative. 104
Gynaecology..................................................................................................................................104
Lab – Abnormal cervical cancer screening.................................................................................104
Symptom – Vaginal discharge....................................................................................................104
Symptom - Dysmenorrhoea.......................................................................................................107
Symptom – AUB Menorrhagia...................................................................................................112
Symptom – Primary amenorrhoea............................................................................................116
Symptom – Secondary amenorrhoea........................................................................................116
Symptom – Subfertility..............................................................................................................116
Management – Contraceptive counselling................................................................................120
Obstetrics......................................................................................................................................120
Condition - GDM Gestational Diabetes Mellitus........................................................................120
Paediatric...........................................................................................................................................122
Cardiovascular Adult/Geriatric, Acute/Emergency vs. Chronic/Preventive/Palliative...................122
Sign - Paediatric murmur...........................................................................................................122
Respiratory Acute/Emergency vs. Chronic/Preventive/Palliative..................................................125
Symptom – Wheezing................................................................................................................125
Gastrointestinal Acute/Emergency vs. Chronic/Preventive/Palliative...........................................128
Renal & Urology Acute/Emergency vs. Chronic/Preventive/Palliative).........................................128
Neurology Acute/Emergency vs. Chronic/Preventive/Palliative....................................................128
Preventive – Routine developmental assessment.....................................................................128
Symptom – Failure to thrive......................................................................................................131
Symptom – Speech delay...........................................................................................................131
Eye Adult/Geriatric/Paediatric, Acute/Emergency vs. Chronic/Preventive/Palliative...................133
ENT Adult/Geriatric/Paediatric, Acute/Emergency vs. Chronic/Preventive/Palliative...................133
Musculoskeletal/Rheumatology, Acute/Emergency vs. Chronic/Preventive/Palliative.................133
Dermatology Adult/Geriatric, Acute/Emergency vs. Chronic/Preventive/Palliative......................133
Endocrine Acute/Emergency vs. Chronic/Preventive/Palliative....................................................133
Haematology Acute/Emergency vs. Chronic/Preventive/Palliative...............................................133
Infectious diseases Acute/Emergency vs. Chronic/Preventive/Palliative......................................133
Symptom – Acute fever in child.................................................................................................133
Male reproductive system Adult/Geriatric, Acute/Emergency vs. Chronic/Preventive/Palliative. 136
Eye Adult/Geriatric/Paediatric, Acute/Emergency vs. Chronic/Preventive/Palliative.......................136
Symptom – Vision loss...............................................................................................................136
Symptom – Ptosis?....................................................................................................................138
ENT Adult/Geriatric/Paediatric, Acute/Emergency vs. Chronic/Preventive/Palliative.......................138
Symptom – Hearing loss............................................................................................................138
General and communications
Strategy and preparation
Station format: 4min reading, 15min consult (5-6min history +/- 4-5min PE + invx, 3-5min problem
definition + management plan), 1min clarification
Goals and time allocation: Identify issues for management (reading CI Candidate Instructions, Hx,
PE/scores/Invx) – 10-11min. Enumerate issues/manage each issue/summarize (4-5min).
Reading time
Routine - Start timer. Count number of pages. SCHEDULED or UNSCHEDULED visit! Back to
front/chronological order. Draw up 9 boxes, fill in Name/age/sex, scheduled/unscheduled, A Dr’s
agenda/chronics, S Ddx for complaints, BPS + Bucket list; O Chap + BMI/T not done + important PE +
Score + Stat invx Na K Cr X-rays; P Meds to change, Prev, Definitive mx. Stop timer at 3:50, reset,
start, knock on door.
Information in CI is reliable as if clinical notes, but if it sounds weird, verify it (e.g. notes say asthma
but history sounds like COPD)
CI clues
Age/sex
Teenager – Overbearing parent?
Female teen – Eating disorder, underage sex?
Female in 30s, statins – Fertility issue, thyroid?
PMH
Repeated visits 2 or more for same complaint – Poor control?
Eczema – steroids?
Drugs
Statins – Pregnancy?
Opioids e.g. tramadol, codeine – Opioid use disorder?
BMI – Obese/Cushing’s syndrome? BP high – Drug side effect/poor control?

S RFE Name/Age/Sex A
Co-morbidities + Career screen Acute RFEs Patient’s RFEs
- Symptom/Lab result
BIOMEDICAL Acute RFE (symptom, lab result) - Collect medication
PMHx 1. COMPLAINT HOPC – On The. SRCT. ERA. - Chronic follow-up
Drugs medication list/ TCM OTC So Far ICE/worry
supplements / Alcohol/ Smoking/ - Onset, Triggers
Recreational drugs - Site/Radiation, Character,
Drug allergies/allergy to other substances Timing/progression
FHx - Exacerbating/Relieving
- Associated
SOCIAL - WAHSADE - Severity/Functional impact
- Work/Hobbies 2. COMPLICATIONS of disease
- Accounts – Financial difficulties - Functional, Psychosocial, Biomedical
- Home/Caregiver – Live with/housing type 3. COURSE
- Smoking - Seen dr, investigations, treatment,
- Alcohol response, follow-up
- Diet – Tell me about diet bf to dinner 4. CAUSE – DQ Direct Questioning with
- Exercise PMH, symptoms/SR, RF, tests done
- Primary/idiopathic causes
- Secondary causes – Drugs/iatrogenic
PSYCHO then Systems review head to toe OR
- PHQ2 (depressed, anhedonia) VITAMINC
- GAD2 (anxious, unable to stop worrying) - Risk factors (travel/contact/sex,
- Suicide occupation, FHx)
5. Contraindications to treatment
- allergies, PMH
Other bucket lists by age/sex profile Chronic RFEs Doctor’s agenda
- Acute/chronic/recurrent symptom
Child - BIG Chronic - Chronic follow-up
Birth FHx 1. Chronic CONDITION/COURSE/CAUSE if - Preventive
Immunization equivocal
Growth and Development - When and how diagnosed,
investigations, treatment/response,
Adolescent - HEADDSSS follow-up
Home 2. CONTROL/checking
Education/Employment - How has it been since last visit?
Activities 3. COMPLIANCE, Competence/ Crisis
Diet management, COMPLICATIONS of
Drugs/Drink/Smoking treatment,
Sex/Puberty - Compliance to
Sleep follow-up/meds/diet/exercise, reasons for
Suicide/Safety/Depression failure e.g. cost/cognition/caregiver
burden
4. Other CAUSES of poor
Female - MSOU control/triggers/Co-morbidities
Menses 5. COMPLICATIONS of disease
Sex
Obstetric/Plan fertility or contraception
Urogynae
Elderly – FFI MMB C

Function/ADLs
Falls
Incontinence
Memory/Mood/Behaviour + Caregiver
O P
PE Invx PLAR.TMS.RNT.P
Handrub. Chaperone. Previous - Pharm
BMI + wt/ht/OFC centiles/trend Stat - Lifestyle/Non-pharm
Vitals T/SpO2/RR/HR/BP - UPT, urine dipstick/UFEME - A&E/Referral
Sitting (peripheries/hands rheum, HEENT, - ECG - TCU/Monitoring/Safety net red flags and
thyroid and cervical LN, UL neuro) - X-rays SOS
Standing - Labs: serum bilirubin, glucose/A1c, - Refer, Notify, Trace contacts
Walking Cr/K/Na, FBC, ESR
Supine 45deg on couch (CVS, LL) Send off
Sitting up on couch (Resp) - LFT, T4/TSH, CK
Supine flat on couch (Abdo, LL Prev med
- fasting lipids/glucose - Vaccines (catch up, HPV,
neuro/MSK). Handrub.
MSE influenza/PPSV23/PCV13)
- Screening (BMD, FIT/cervical/MMG, CV)
======
History
Handrub
Elicit all RFEs + basic clarification. “How may I help you today? Besides this, is there anything else you
are worried about?
Screen PMH and Drugs/Smoking/Alcohol, Occupation. “Before I ask about these problems, check
past medical history. Besides X and Y and Z, do you have any other long-term medical problems? Any
others? What medications are you taking, do you have the list with you? ...explore… Any traditional
medications/OTC medications/supplements? …explore… Do you smoke? …explore… Do you drink
alcohol? …explore… What are you working as?”
***Main active column is “Assessment/Problem List”
- While reading Candidate Instructions CI, add acute, chronic and preventive problems identified to
problem list (Dr’s agenda)
- Write down VERBATIM + number ALL RFEs Reasons for Encounter (patient’s agenda) in Problem list
- If significant positive symptoms, co-morbidities or drugs identified in history, add to problem list for
exploration
- When acute/diagnostic problem addressed, add bullet point/s for underlying causes below
- When chronic problem explored, tick if good control or add bullet points if problems identified e.g.
compliance issues, underlying financial issues
***Try not to refer to your 9 boxes unless for writing down Problem List or if mind really blank.
Focus on eye contact, picking up patient cues and responding to patient cues. At most, tick off
history/examination items prepared during 4min reading.
Contraindications to treatment: Drug allergies. Hormones, TXA - CV risk factors (DHL/IHD/stroke,

smoking/alcohol), DVT/PE. NSAIDs - PMHx asthma, renal impairment, gastritis.
~~~~~
Patient cues and reflex response
Symptom
RFE Symptom – Onset when did this problem start, acute or chronic; first time or recurrent; any
Trigger? What do you mean by this symptom – exact Site point out/Radiation, Character? How is it
affecting your daily routine/mood? … Add to Problem List … return later Tell me more about this
symptom? Most recent episode from beginning to end?
RFE Lab test result – Why did you go for this test? Any symptoms – explore acute complications also?
Any previous result before this?... Add to Problem List… return later to explore underlying Cause. “I’ll
need to ask you more about your medical and social history to help clarify what the tests could
mean, and advise what steps to take next.”
RFE “Collect medicine” (possible hints: Corticosteroid overuse and complications, Opiate use
disorder) – What medication name and dose/have prescription or picture? Why are you taking it?
How long and how often/how much are you taking? … Add to Problem List.
RFE ICE “Worried about having condition X” – Why are you worried about this? How is it affecting
your daily routine/mood?... Add to Problem List.
PMH Condition not given in CI especially in young patient – Add to problem list then explore fully…
Tell me more about this condition? Condition when/how diagnosed with problem, tests done,
treatment given, follow up? Control – current symptoms or acute complications, exacerbations?
Compliance/competence/crisis management, side effects of treatment non-pharm and pharm?
Causes of poor control? Chronic complications of disease bio and psychosocial?
Drug/Alcohol/Smoking/TCM e.g. – When started, why, how often? Temporal relation to symptom?
Aware it might be contributing, consider stopping? What happens if you stop any withdrawal? … Add
to problem list
- Smoking – Do you smoke/When did you start/What kind cigarettes or rolled/How many in a day?
Are you aware it may be causing/worsening your medical problem? Would you consider quitting in
next 1 month or 6 months?
- Alcohol – Do you drink alcohol/What kind/How often and how much? Have you had more than 4-5
drinks at one go in last 1 year? CAGE – Ever felt need to cut down, annoyed when criticized, guilty,
need to drink as eye-opener?
~~~~~
By 5:30 mark, start examination regardless if history finished. Can continue social history while
taking BP.
Formulate approaches. For each question, consider “Why ask this?”
PE
Equipment: On me – Stethoscope, watch, pentorch, measuring tape. Provided – BP cuff,

otoscope/ophthalmoscope, tendon tapper. In bag – orange stick, Cotton wool, red hatpin, paeds kit.
Handrub!
If neuro examination needed, take out tendon tapper and neuro kit and put on table in front of
patient, open up.
Request chaperone if undressing upper body, examining abdomen, genitals or buttocks.
Request BMI/weight/height, health booklet or growth chart for plotting. Verbalize checking vitals
(hopefully they give and tell you to skip). Follow basic template and technique but skip unnecessary
steps (plan approaches for each kind of station). RFE will tell you whether need a lot of PE (in
reasonable clinical practice). Charts are available but don’t have to use (Can use clinical assessment
instead e.g. don’t need to know cut off for PHQ9, can use clinical assessment for GAD)
Peripheries/Hands + HEENT
Neck for goitre (Thyroid: Look/swallow, feel goitre) and cervical LN
Neuro: Pronator drift, dysmetria, power, gait
CVS: precordium + pedal oedema
Lungs: back chest inspect, expansion, auscultate; palpate cervical lymph nodes; front - inspect apex
beat, palpable P2, auscultate apices and axillae
Abdomen: lie flat, liver, cervical lymph nodes
DFS: inspect for ulcers/calluses/deformity, palpate pulses, screen pinprick/vibration sense
Handrub!
MSE: ASEPTIC Appearance/Behaviour, Speech, Emotion/affect mood, Perception hallucinations,

thought process, insight, cognition
Invx
Stat tests are usual polyclinic (pulse oximetry, HbA1c/capillary glucose, FBC/ESR, serum bil, INR, ECG,
urine microscopy, UPT, CXR/all x-rays) + Na/K/Cr. Know SB cut-offs for phototherapy? Other tests
e.g. TFT can offer and TCU to review.
Previous invx – “Do you have any previous blood tests/ECGs/x-rays/spirometry?”
Problem list
Do not hide diagnosis from patient. List all problems at once then elicit patient ICEKAPS + go into
detail. “I think you have the following problems: Firstly, 1. Poorly-controlled diabetes due to not
taking your medications and not exercising. This may be caused by the second problem, which is 2.
Major Depressive Disorder, which may have been triggered by the loss of your wife. Have you heard
about Major Depressive Disorder, what do you understand about it?”
Management
Broad overview -“To treat your problem, we can use lifestyle measures or medications. Medications
are… specify indication, drug name dose frequency duration, side effects to watch for. Lifestyle
measures are… For preventive care, arrange vaccinations for X if you haven’t done them and
screening tests for Y.”
Patient-centred (e.g. need to exercise but OA knees hence consider swimming). Must know clinical
reasoning behind management (not just because it is guideline, or only medication available at
institution if inferior)
Cut losses (better borderline than fail) – If unsure of medication dosage, only mention medication
name to patient and wait to be asked during 1min clarification, then say unsure of dose, will look up.
Try to leave last 1min to summarize issues and plan “Let’s summarize again. Your problems are A, B
and C. We will start medications and physio/exercise and review you again in 2 weeks.”
======
1min clarification common questions:
“What were your examination findings?”
“What was the mental state examination?”
=====
Practice
Do 2 patients in exam style every day. Handrub at start, before examination, after examination, after
consult.
Prep charts/scores as Epic templates. Can use clinical assessment instead e.g. don’t need to know
cut off for PHQ9, can use clinical assessment for GAD
Request vitals, height weight and BMI
All other x-rays also available as stat. Exam stat tests vs. actual stat tests – CLM has no stat Na/K/Cr.
Other tests – can offer and review another day. ???Know SB cut offs for phototherapy???
Look up guidelines after each case
Consultation station template
ACUTE RFE:
1. COMPLAINT HOPC – On The. SRCT. ERA. So Far
Onset, Triggers
Site/Radiation, Character, Timing/progression
Exacerbating/Relieving
Associated
Severity/Functional impact
2. COMPLICATIONS of disease
Functional
Psychosocial
Biomedical
3. COURSE
4. CAUSE – DQ Direct Questioning with PMH, symptoms/SR, RF, tests done
Primary/idiopathic causes
Secondary causes – Drugs/iatrogenic then Systems review head to toe OR VITAMINC
Risk factors (travel/contact/sex, occupation, FHx)
allergies, PMH
~~~~~
CHRONIC RFE:
1. Chronic CONDITION/COURSE/CAUSE if equivocal
When and how diagnosed, investigations, treatment/response, follow-up
2. CONTROL/checking
How has it been since last visit?
3. COMPLIANCE, Competence/ Crisis management, COMPLICATIONS of treatment,
Compliance to follow-up/meds/diet/exercise, reasons for failure e.g. cost/cognition/caregiver

burden
4. Other CAUSES of poor control/triggers/Co-morbidities

5. COMPLICATIONS of disease
Common sense management

Adherence to medication
- Simplify complex regimens – Once daily dosing, avoid halving medications (or offer pill cutter)
Comms – Psychiatric history

Intro “I see that you are going through a lot. Sometimes it affects our mood.”
PHQ2 - “Do you feel depressed? Have you lost interest or pleasure your daily activities?
GAD2 – “Are you constantly anxious or nervous about all kinds of things? Not able to stop
worrying?”
Suicide/Homicide – “Thought that life is not worth living or taking your own life/hurting
yourself/hurting someone else? Action - Have you tried doing so? Intent currently? Plans? Protective
factors – what would keep you from harming yourself/harming others?
Comms – Sexual history

Intro and Warning shot “When was your LMP? Is the interval between the first day of each cycle
regular/how long is it in between? Are you in any relationship, any husband/boyfriend/girlfriend,
how long? I’ll need to ask some sensitive details about your sexual history which may be relevant to
your symptoms, if it’s okay with you.”
1. Past encounters “Had any sexual intercourse? Since last menses/When was last sexual
intercourse? Last one before that?”
2. Partners “Besides your husband/current partner, have you had any other partners before? How
many? Male/female?”
3. Practices “What kind of sex? Vaginal/oral/anal?
4. Protection + Pregnancy Prevention/Pregnancy/Plans Pregnancy “Use any protection, condom?

Any method to prevent pregnancy, previous pregnancy or planning for pregnancy?”
5. Past STI and current symptoms, Pap smear “Any previous STI? Vaginal discharge, itch, ulcer, rash?
Previous Pap smear/cervical cancer screening?”
Comms – Adolescent/Teenager
Ref: NUP bridging case 112, 126
Overbearing parent + reticent teen
Came alone or anyone accompanying?
If coming with parent: “Is this your mother? [address both] How can I help you today?”
If mother replies: “Is there anything else you are worried about? Tell me more about problem 1.
Johnny, is that correct, can you tell me about it?”
If mother keeps interrupting and teenager reticent after 1 try, request parent “I see. Mummy, would
it be okay if I speak to Johnny alone and examine him for a while you wait outside first? After that
we can get you come back in to discuss my assessment if Johnny is comfortable to share.”
History-taking
Replace SHx with HEADDSSS (home, education/employment, activities, drugs/drinks/smoking, diet,

sleep, sex/puberty, suicide/depression/safety)
Intro “Like to ask some questions about your background so can get to know you and understand
your problems better.”
- Home – Can you tell me about your home situation? Whom do you live with, where? What do you
parents do, what do your siblings do? How are you relationships with your family, whom can you
talk with?
- Education/Employment – Can you tell me about school? Where do you study, what level/stream?
What are subjects are you good at/not so good at? How are your grades? Are you doing any jobs
outside, what?
- Activities – What CCAs are you in, do you enjoy them? What do you/your friends do like to do for
fun?
- Diet. Can you tell me about what you usually eat in a day, from morning to evening?
- Drugs/Drinks/Smoking – Some teenagers experiment with things like smoking and drinking. Do any
of your friends smoke? How about you? Family members smoke? Drink alcohol? Tried drugs?
- Sex/Puberty/Menarche – Have you started to have menses/how are menses? Many teens become
interested in romantic relationships, are you in any relationship? Can you tell me about your
relationship? Have you had any kind of sexual intercourse?
- Sleep – Can you tell me about your sleeping habits? What time do you go to sleep, wake up, why?
Feel refreshed in mornings?
- Suicide/Depression/Safety – Feel depressed, lost interest, constantly worrying? Ever thought of

ending your life or harming yourself?
Comms - Paediatric
May be similar to Adolescent/teenager
BIGHEADDSSS – Birth and FHx, immunizations, growth and development
Birth + FHx: FTNVD? Antenatal issues, neonatal issues?, FHx of conditions/consanguinity
Immunizations – Up to date?
Growth and development – Normal growth and development history? Check centiles and plot
growth chart
Explore social history – Any recent change at Home, School?

Comms - Breaking bad news
Ref: NHGP PREPP 2019 case 25, NHGP seniors
Stems:
Hep B – 28F did bloods for STD screening last week, Hep B positive.
HIV positive
Cancer
***Don’t get thrown off by patient’s anxiety wanting to know results, try to stick to plan (Hx/PE/Invx
then Mx) if possible
“I understand you must be anxious to know the results, not to worry I will explain in detail to you,
but need to understand your medical history and social background first so I can better advise you
what the results mean and how to proceed.”
***But WRITE DOWN any patient cues including social under A/Problem List e.g. “Beautician”,
“worried about informing boss”, “worried about informing partner”
Then go through approach to results (hx bio psycho social), PE/Invx before breaking news
- Hx: Reason tests were done? Systems review for symptoms, Risk factors for condition,
Occupational hx (HCW?) and social hx (marriage/plans for conception)
- PE/Invx
Problem List and Management Plan – SPIKES framework
Set “Before I explain your results, is there anyone who came with you today? Is your partner/family
member here with you? Would you like them to be present?”
Perception explore “What do you understand about the blood tests so far/what do you think has
caused your symptoms? What do you understand about Hepatitis B?”
Invitation to share request/fire warning shot “I’m afraid the results are not so good. [pause]”
Knowledge-share – Keep it simple! “The normal range for the blood test is between A to B, but your
results is C, which is 3x of normal. This means that you have [condition].” Or “The blood test shows
that you have Hepatitis B infection/HIV infection.” Or “The scan shows a growth in the lungs that is
possibly cancer.” [pause]
Explore/Empathize “How are you feeling right now?” + NURSE “I see that you are very worried. I
understand it must be very distressing to hear this news. I want to help and support you in any way I
can as your family doctor.”
Support – Management. “Is it okay if I tell you more about the condition and discuss what we can
do?”
- Patient education on condition and possibility of treatment, maintain hope
Bio
- Refer to specialist urgently (1wk) for further tests/scans and medication for treatment
- Other screening/investigations e.g. Hep A, Hep B/Hep C, syphilis
Psychosocial/emotional support – Inform family? Refer psychologist, support group. Refer MSW.
Public health/Legal
- Notification/contact tracing, confidentiality vs. legal requirement to inform partner (HIV). Why
should inform/screen, offer to help inform together.
- Prevention of ID transmission, safe sexual practices
Newly-diagnosed Hep B
Hx: RFE, other concerns. “I understand you must be anxious to know the results... [spiel]” Confirm
patient ID. Symptoms of jaundice/liver failure. Risk factors (FHx, sexual promiscuity,
IVDA/tattoos/transfusion). Occupational (HCW) and social hx (marriage/plans for conception).
PE: BMI + weight loss, Vitals + temp. Jaundice/pallor, chronic liver disease, liver failure. Abdo for
hepatosplenomegaly.
Invx: Stat – KIV UPT. Future – LFT, AFP.
Mx:
- SPIKES. Pt education + bio mx “Hepatitis B is a virus that infects that liver, may be spread from
mother to child, sex or blood e.g. needles/tattoos. Need to repeat test (HBsAg) 6mth to confirm
whether acute or chronic. Acute body has chance of clearing infection, chronic risk of developing
complications e.g. liver scarring/hardening, liver cancer; need long-term follow-up with blood tests
and scans to monitor.” Offer Hep A vaccination, screen for other STIs (gonorrhoea, chlamydia) and
repeat HIV screen due to window period (3mth), Pap smear.
- Refer psychologist if depressed.
- “Result is confidential I will not inform employer or boyfriend without your permission, but may
want to inform employer, avoid invasive work as spreads through blood; squeezing blackheads okay.
Should also inform boyfriend as can spread through sex, need to screen if he has Hep B and
vaccinate if not immune, meantime use condom or abstain. Won’t affect fertility/pregnancy/delivery
but baby needs Hep B vaccine and immunoglobulin at birth.”
- Prevent spread – Use condom meantime. No sharing toothbrushes/razors, cover open wounds,
clean blood spill with bleach, no organ donation. Not transmitted through food/utensils.
HIV **Confirm patient ID. Ensure 4th gen EIA/ELISA confirmed with Western blot.
Hx: RFE, other concerns. “I understand you must be anxious to know the results... [spiel]”. Symptoms
of acute seroconversion, AIDS. Risk factors – Sexual history (sexual promiscuity, Previous
STIs/screening) and other risk factors (IVDA/tattoos/transfusion). Occupational (HCW) and social hx
(marriage/plans for conception).
PE: BMI + weight loss. Eye - Icterus (hepatitis), eye signs of CMV. Mouth – Oral thrush, colds ores.
Cervical lymphadenopathy. Skin rashes. Auscultate lungs (TB, PCP). Abdomen –
Hepatosplenomegaly. Offer to examine genitalia for ulcers/discharge.
Mx:
- SPIKES – “The blood tests show you have HIV infection.” “HIV virus spread through blood,
nowadays if detected early there is good treatment that can prevent complications, prolong life to
normal expectancy, prevent spread.” Refer ID fast track within 1wk for blood tests KIV anti-retroviral
therapy. Screen for other STIs e.g. Hep B, syphilis, gonorrhoea/chlamydia.
- If depressed – “As your family doctor I want to support you in any way possible.” Refer
psychologist/Psy? Refer to support group? Meds very affordable subsidised? Contact Action for AIDS
for help.
- Legally required to notify MOH, ??jobs with invasive procedures, legally required to notify partner
“By Singapore law you are required to inform your sexual partner that you have HIV. I understand
you must be worried that he will not take it well, but I’m sure you want to protect his health as well.
He will need to get tested and treated if he has HIV. It is better that you inform him rather than he
finds out without warning when MOH does contact tracing.”
- Prevent spread – Meantime abstain, use condom. Remember legally required to inform any
partner of HIV status.
Cancer
Hx: Confirm patient ID. RFE, other concerns. “I understand you must be anxious to know the
results... [spiel]”. Symptoms of cancer local and systemic. Risk factors. Occupational and social hx.
PE:
Mx:
- SPIKES – “The scan shows a growth in the lungs that is possibly cancer.” “There is treatment
available for many cancers, but we will need to do further scans and tests to find out the stage.”
Refer specialist direct access 1-2wk.
- If depressed - “As your family doctor I want to support you in any way possible.” Refer
psychologist/Psy? Refer to support group? Refer MSW.
Comms/Ethics – Medical error/Open disclosure

Ref: NHGP seniors
Ethical principles: Truth-telling, collegiality
Confirm patient name and NRIC “Before I go on to discuss your results, may I confirm your name and
NRIC?”
Get history/PE and Invx in usual manner “I’ll explain the results in detail to you, but need to
understand your medical history and social background first so I can better advise you what the
results mean and how to proceed.”
SPIKES to break bad news – as above.
e.g. Missed abnormal result “What I can see is that the Pap smear/X-ray done last year was not
normal and it shows abnormal cells/a mass. I am concerned whether this could be related to the
symptoms you are having of weight loss/PV bleeding/breathlessness.”
ABC
Apologize + Acknowledge or NURSE
- “I am so sorry that you were not told about this earlier/I am sorry that you were given a medication
you are allergic to.”
- NURSE Name “I can see that this is making you distressed and worried.” Understand/Respect “I
understand it must be very stressful for you to be going through this situation/it is a lot to take in.”
Support “I want to help in any way I can.” [Explore “How are you coping with this?”]
[Bring patient back]
Check with colleague + Correct safety lapses + Comfort of patient
- “I do not know what exactly happened in the process of reviewing the results, but I will definitely
find out so I can give you an answer.” Or “I cannot comment on the other doctor’s management as I
was not present during the consult and he may have had reasons for managing your condition this
way, but I will check with him when he is back.”
- “Please be assured we take your feedback seriously and I will bring it up to our management and
we will improve our workflow so similar problems don’t happen again. (e.g. ensure drug allergies are
always checked, ensure abnormal results are always highlighted and patient recalled to discuss) May
I update you when I next see you on what we have found out and the steps we are taking to prevent
it happening again?”
- “At this point I also want to help you get better and feel more comfortable/I want to make sure we
assess your health condition in detail and treat it in the best way possible. I will personally call the
specialist to see you urgently within the next few days.”
Ethics/Practice-based
Care issues
Can patient be cared for 1. At home? 2. With community support? 3. Needs institutionalization?
What type of care? Medical/nursing? IADLs? BADLs? Respite care for caregivers? Specialized e.g.
Dementia, Palliative?
Financial assistance needed? For what? Medical bills? General?
Ethics - Elder Neglect/Abuse
Ref: NUPBridging Case 110, NHGP seniors, Julio
Stem: Elderly with b/g Alzheimer’s dementia + poorly-controlled chronic DHL due to non-adherence
to visits/medications comes with caregiver son. “Come to collect meds… not sure of
dosage/frequency.”
Look for complications e.g. hypoglycaemia, falls
Rule out abuse (examine for bruises, fractures etc.)
Determine how cooperative caregiver is, offer help
Refer/report if necessary
Subjective
Corroborative history – “Maybe patient can tell me what you remember about the history, and son
can add on anything she might miss out, is that okay?
Adherence to medications – “Sometimes people miss out or forget to take their medications? How
do you remember to take your medications each day? How often do you miss taking your tablets?
How often do you miss injecting insulin? Why do you think it happens?”
Elderly screen for function and complications:
Function BADLs + IADLs – What do you usually do in the daytime? DEATH Dressing? Eating feeding
herself? Ambulate walk by herself at home/outside, Transfer to chair? Toilet use by herself? Hygiene
shower herself? SHAFTT Shopping buy food/groceries for self? Housework? Accounting handle own
bills/bank statements? Food prepare/buy for herself? Telephone use to call friends/family?
Transport take bus by herself?
Memory/Mood/Behaviour – Memory problems? Feel down/depressed/hopeless, lost
interest/pleasure in doing things? Any disruptive behaviour? Apathy Affect Aggression
Psychosis/Hallucinations+ delusions Agitation
Falls – Fallen in last 1 year?
Incontinence – Control bladder? Bowels? Accidents?
Caregiver – Is there caregiver to help her in daytime? How are you coping? Elder abuse – Feel safe at
home? Any one hurt you/scolded or threatened you/made you do things you don’t want to/taken
your things without asking?
Other SHx – WASHED Working now/previously? Whom do you live with/where, how are things at
home? Any financial difficulties? Smoke now/smoked before, take alcohol now/before? What kind of
exercise do you do? Tell me what you usually eat starting from breakfast to night-time.
Finances
Objective
PE
BMI/trend if available, Vitals Temp BP/HR
Mental status AMT (highest education level?) + prepare MSE script in case examiner asks ASEPTIC
“Poorly-kempt appearance with fair eye contact normal behaviour, speech normal rate and content,
mood euthymic affect reactive, no hallucinations or delusions, normal thought content process,
good insight, cognition was oriented to place and person but not time AMT was 5/10”
General – hygiene, nutritional status
HEENT pallor, hydration, dental hygiene
Chest/abdo/limbs - wounds, bruises, fractures. For chronic illness - lipodystrophy
Gait/TUG
Footwear
Invx
Previous labs, up to date for chronic control? HbA1c/random capillary blood glucose (last meal?)
FBC (anaemia, TW), Na/K/Cr (electrolyte imbalance/malnutrition)
UFEME
Non-stat - ?alb
Assessment and Plan

State medical issues – “Has poor control of DM because not taking insulin + healthy meals, unable to
do so himself due to dementia, has financial difficulties with medication”
Manage medical side – “Can switch to simpler dosing regimen to reduce number of injections
needed”
Acknowledge challenges of caregiving + State social/caregiving issue – “it can be very difficult and
stressful to care for persons with dementia/special needs” + “concerned that patient may not be
receiving level of care he needs, at risk of chronic illnesses worsening if doesn’t have someone
around to give her daily supervision and help, or may endanger own safety if left alone at home”
Caregiver ICEKAPS – “Is that something that worries you also?”
If acknowledges – “What avenues of help have you tried so far? Applied for full-time caregiver? Can
apply for community services and help schemes under AIC Agency for Integrated Care, get MSW or
FSC to advise you in detail. Some schemes that may be helpful to you are…”
- Medical and ADL care: At home - FDW grant, home nursing help with insulin injection, meals-on-
wheels; In community - Dementia day care, respite care services
- Financial: MSW/AIC/FSC for subsidies on medications use

Medisave/Medifund/Elderfund/Medication Assistance Fund, etc…
- Caregiver support: Support groups
If signs of abuse – “Will need to refer to A&E for full assessment. Hope you understand will also need
to report to police.”
If doesn’t acknowledge – “Would like to refer you to MSW/FSC to help look into your case
social/financial issues see how to help.”
TCU
Summarize
Ethics/Law – Spousal abuse/domestic violence

Ref: NUP bridging case 111
Stem
38yo F, no PMH, unscheduled. Comes asking to learn about tubal ligation. Dx: Hidden issue of
domestic abuse and marital rape. Must also address RFE about contraception.
Subjective
As per contraceptive counselling approach then
Explore RFE “What do you understand about tubal ligation? Why do you want this form of
contraception in particular?”
Warning shot – “Need to ask some sensitive questions as I want to make sure you are about your
safety.”
Intimate Partner Violence/Domestic Violence – “Do you feel safe at home, why not? Is
anyone/partner hurting you physically? Sex without consent? Making you do things you don’t
want?”
Assess safety to return – “If you were to go back home after this, do you think you may get hurt
again? Do you have a place or person you can go to if you need to get away?”
Objective
Examine rest of body for injuries to document.
Can ask about any injuries to genitals. May not need to examine if rape committed within 72hours as
should refer to A&E instead for Rape Kit Examination.
UPT if sexual intercourse (?to document, prescribe contraception)
Assessment and Plan
Marital rape/non-consensual sex – If within 72 hours of assault, refer to A&E for Rape Kit
Examination. Offer emergency contraception. Offer resources like AWARE (Association of Women
for Action and Research Duty) Sexual Assault Care Centre and Samaritans of Singapore emotional
helpline 1-SOS if having suicidal/self-harm thoughts. Doctor’s duty to report possible crime under
Criminal Procedure Code section 424 (no immunity in marital rape since repeal 2020) but assure
victim police report is confidential, police are trained to handle matter sensitively, will decide
whether or not to investigate as a criminal offence depending on circumstances of case.
Domestic abuse/Non-accidental injuries – Advise Non-accidental injuries Victim can apply for PPO
Personal Protection Order, encourage to report to police. Doctor’s duty to report potential abuse,
assure as above.
Ethics – Treatment refusal

References: NHGP seniors, Julio, NUP CPG/AFP, Patient History
Ddx of complaint
General approach to management of treatment refusal
Balance between beneficence/non-maleficence and patient autonomy
Explore ICE, address
Explain consequences of refusal
Ensure able to URWC

S A
Acute symptom Issues:
Handrub! (SPIKES)
Complaint/RFE+HOPC - “How may I help you today/how Summary +
have you been since your last visit? Besides coming to see Any other concerns
your results, is there anything you are worried about?”…
“Tell me more about your [symptom]. When did you first
notice it? Was there anything that brought it on? Tell me
about the most recent episode from beginning to end. ...
What makes it worse? What makes it better?
Cause/DQ for red flags + Ddx
Course - “Have you had previous similar episodes? Have you
seen other doctors for it? What tests have been done? What
treatment has been tried? How is the response to
treatment?”
Complications/Function - “How has it affected your daily
life?”
Lab result
Complaint - “Why were these tests done, were you worried
about anything that caused you to do the tests?”
Cause/Ddx + PMH/social - “I’ll need to ask you more about
your medical and social history to help clarify what the tests
could mean, and advise what steps to take next.”
treatment?”
Complications
Chronic condition
Cause/initial diagnosis + Course
Control/checking + compliance/adherence/reasons +
competence/technique + crisis management
Causes/triggers
Complications of disease and treatment + co-morbidities
Bucket list
PMHx - “What other past medical conditions do you have?”;
Drugs/allergies - “What long-term medications are you
taking now? Do you take any traditional medications? Over
the counter medications? Supplements?”; FHx - “Does
anyone in the immediate family have…”
Social history WASHED Work/Accounts Home Alcohol
Smoking Exercise Diet + Function/ICE - “How has this
affected your lifestyle and daily activities? What are you
working as/studying/how are things? How are things at
home/whom do you live with/what kind of housing do you
stay in? Do have any financial problems? Do you smoke/how
much in a day/how many years/would you consider
quitting? Do you drink alcohol/how much/how often more
than 4 drinks in past year? Tell me about what you eat in a
day from breakfast to dinner. What exercise do you do?
What are worries you most about it?”
Psy Depressed/anhedonia/anxious - “How is your mood/do
you feel depressed? Have you lost interest or pleasure your
daily activities? Do you constantly worry about all kinds of
things?”
Add-ons for various population groups

Female: Add to PMH - menstrual, sexual +
contraceptive/STIs, urogynae
Child: Add after PMH - perinatal/birth, growth/development,
vaccinations, puberty/menarche
Adolescent: Replace SHx with HEADSSS
- Home – Whom do you live with? How are you relationships
with your family? Whom can you talk with?
- Education/Employment – Tell me about school. What are
you good at/not so good at?
- Activities – What do you/your friends do like to do for fun?
- Drugs/Drinks/Smoking – Do any of your friends drink
alcohol? Smoke? Take drugs? How about you?
- Sex/Puberty/Menarche – Have you started to have
menses? Many teens become interested in relationships, are
you in any relationship? Can you tell me about your
relationship? Have you had any kind of sex?
- Suicide/Depression/Safety – How is your mood? Have you
ever thought of ending your life or harming yourself?
Elderly: Complications or Function - falls, incontinence,
dementia
Legal: driving, underage smoking/alcohol/sex, notifiable
disease
AOB - “Is there anything else you are worried about?”

O P
PE - “I’ll need to examine you now.” Broad overview
Equipment: On me – Stethoscope, watch, pentorch, -“Recommendations to help treat
measuring tape. Provided – BP cuff, your problem are further
otoscope/ophthalmoscope, tendon tapper. In kit – orange investigations, lifestyle measures,
stick, Cotton wool, red hatpin, paeds kit. medications, follow-up plan”
Other primary care invx
Handrub! Non-pharm
BMI, vital signs + SpO2. Paeds – Growth chart in health Pharm + ADRs
booklet. Ref/TCU/red flags
Pallor Handrub!
Lungs: back chest inspect, expansion, auscultate; palpate
cervical lymph nodes; front - inspect apex beat, palpable P2,
auscultate apices and axillae
Thyroid: Look/swallow, feel goitre
MSE: ASEPTIC Appearance/Behaviour, Speech,
Emotion/affect/mood, Perception hallucinations, thought
process, insight, cognition
DFS: inspect for ulcers/calluses, palpate pulses, numbness,
vibration sense
Handrub!
Stat invx - “I would like to do some simple tests to help us Preventive care
find out what’s causing your problem.” Vaccinations (influenza,
Previous invx – “Do you have any previous blood PPSV23/PCV13, HPV), Screening
tests/ECGs/x-rays/spirometry?” (BMD, FIT, metabolic,
MMG/cervical)
Common diagnoses and management
Diagnosis Management
Diagnosis Broad overview -“Recommendations to help
Features treat your problem are further investigations,
lifestyle measures, medications, follow-up
plan”
Non-pharm
Pharm + ADRs
Ref/TCU/red flags
Lab results
Lab – Raised Cr/drop in eGFR, AKI vs AoCKD

Ref: NHGP PREPP 2019, NHGP seniors, Julio, NUP renal dose adj
Stem – 68/Chi/M DHL for chronic review, Cr rise from 100 to 195 over 1 year + uACR over detection
limit. When asked has been taking paracetamol for back pain. Dx: Multiple myeloma.
Causes of renal impairment

Pre-renal
- GI loss (diarrhoea, vomiting), insensible loss (exercise/heat stroke)
- Drugs: Diuretics
- Sepsis
Renal
- Drugs – ACEI/ARB, allopurinol, NSAIDs, aminoglycosides, IV contrast
- Vascular: Vasculitis e.g. Haemolytic Uraemic Syndrome, renal vein thrombosis
- Infection: Pyelonephritis
- Autoimmune/inflammation (glomerulonephritis)
- Neoplasm: Multiple myeloma
- Congenital: ADPKD
Post-renal
- BPH
- Stones, strictures
Subjective
Cause
2. Co-morbidities
- Screen for PMH – DM, hypt, lipids?
- DHx – medication list, new meds/change in dosage?
1. Complaint + complications
- Baseline Cr/eGFR, trend? K? uACR/PCR? Weight?
- Symptoms of renal failure - Decreased urine output? SOB, LL swelling, fatigue/lethargy? (Fluid
overload)
3. Cause
Why was lab test done?
Pre-renal
- Diarrhoea, vomiting? (GI loss)
- Recent infection, fever? (sepsis)
- Strenuous exercise/heat injury? (insensible loss)
- New BP medication or for passing urine? (diuretics, ACEI/ARB)

Renal
- Drugs: Gout medication? (allopurinol) Pain medication? (NSAIDs) Antibiotics for infection?
(aminoglycosides, sulfonamides)
- Infection: Dysuria, frequent urination less than 2hr, cannot delay/postpone urination, loin/flank
pain, fever? (UTI, pyelonephritis)
- Autoimmune/inflammation: Haematuria, bubbles/frothy urine, Joint pain, rashes/ulcers?

(glomerulonephritis)
- Neoplasm: Night sweats, LOW, LOA, bone pain? (Multiple myeloma)
- Congenital: FHx of high BP, early stroke? (ADPKD)
Post-renal
- Obstruction: Weak urine stream, urine stream stops and starts, strain to pass urine, incomplete
emptying? (BPH)
- Stones: Blood in urine/Gross haematuria, Loin to groin pain?
4. Course
- Seen Dr/Renal already? Invx done bloods, biopsy? Admission/hospitalization?
5. Complications – covered under complaint
6. Concerns
Bucket list BPS
Objective
PE
BMI, weight trend gain/loss? Vitals Temp, HR/BP
Supine flat 1 pillow
General – Respiratory distress, sallow complexion
Peripheries – Clubbing, leukonychia, scratch marks, AVF
Eyes – Pallor
Mouth – Mucous membranes moist?
Abdo: Renal transplant scar, enlarged liver, ballotable kidney
Supine 45deg
CVS: JVP, apex beat, S1/S2/additional sounds/murmurs (fluid overload)
Resp: Posterior auscultation for creps (fluid overload)

Sacral oedema (Fluid overload)
Legs: Pitting oedema (fluid overload)
Invx
Stat – Na/K/Cr eGFR, FBC, UFEME, KIV ECG if hyperkaleamia
Send off – KIV Calcium panel
Assessment and Plan
General: Pharm - Stop nephrotoxic drugs, renal adjust dosages. Non-pharm – Hydrate. TCU Referral:
If reversible cause identified, treat and hydrate, repeat Cr. If 30% rise in Cr over 2wk without
reversible cause, refer Renal.
Common renal adjustments
Metformin – CKD3B 1000mg/day, CKD4 stop.
Empagliflozin – ???
Sitagliptin – CKD3B 50mg OD, CKD4 25mg OD
ACEI/ARB – Adjust only if rise >30% from baseline - If newly initiated and, stop and refer Renal TRO
RAS; if increased dose, decrease to previous dose.
Hydrochlorothiazide – CKD4 ineffective so change to loop diuretic.
Spironolactone – CKD4 avoid.
Atenolol – CKD4 50mg OD, CKD5 stop.
Fenofibrate – CKD4 stop.
Warfarin – No adjustment, titrate to INR.
Apixaban – CKD3B (2 of 3 age 80 or older, bodyweight 60kg or less, Cr 133umol/L or more) halve to
2.5mg BD, CKD4 same, CKD5 avoid
Rivaroxaban – CKD3B reduce to 15mg OD, CKD4 same, CKD5 avoid
Allopurinol – CKD4 100mg OD, CKD5 stop.
Colchicine – CKD4 For prophylaxis 0.5mg 3x/wk.
Alendronate/risedronate – Contraindicated in CKD4.
Paracetamol – CKD4 no adjustment, CKD5 1000mg TDS.
Tramadol – CKD4 BD dosing max 100mg/day.
Cetirizine – CKD4 5mg OD.
Gabapentin – CKD4 max 600mg/day, CKD4 max 300mg/day.

Amoxicillin – CKD4 500mg BD, CKD5 500mg OD
Augmentin – CKD4 625mg BD, CKD5 625mg OD
Clarithromycin – CKD4 250mg BD
Nitrofurantoin – CKD4 contraindicated.
Acyclovir – CKD4 (CrCl 25 or below) zoster 800mg TDS, CKD5 zoster 200mg BD
Lab - Proteinuria
Non-specific/general symptoms
Sx – Collect medication
Ddx
Complications of steroid overuse – Cushing syndrome,
Opioid use disorder
Subjective
RFE/complaint – Collection medication
- Character: Which medication? Taking for what reason, old problem or new problem?
- Onset/duration: Taking how long, more than 14 days?
- Severity: Taking how much, how often? Go to other clinics to collect? Used for non-medical
reasons? Withdrawal/Dependency - Do you think you might be dependent on it, Need to take more
and more, If not taking/cut down what happens any Withdrawal symptoms? Overdose - Ever took
too much?
Symptom - Fatigue/tiredness or weakness

Ref: NUP bridging case 125, NHGP seniors
Stem – 56/Chi/F housewife tired x 6mth. Dx: PMR (proximal weakness stiffness aching.
Causes
Neuro causes (objective muscle weakness generalized or localized) - Autoimmune (Myasthenia

gravis) etc.
MSK causes (pain, stiffness) - Osteoarthritis, inflammatory arthritis/rheumatological/autoimmune

(RA, SLE, Dermatomyositis/polymyositis), deconditioning, fibromyalgia/chronic fatigue syndrome
Non-neuro causes (Generalized weakness/tiredness but no objective muscle weakness)
Drugs – Alcohol, Beta-blockers, sedatives, antihistamines
Cardio (CCF)
Respiratory (COPD/Asthma, ILD, OSA)
Metabolic/Endocrine/Electrolytes (Hypothyroidism/hyperthyroidism/periodic paralysis, DM, adrenal

insufficiency, renal impairment, electrolytes, liver impairment)
Haem (Anaemia, haem malignancy)
Infection (TB)
Neoplasm (malignancy)
Psy (Depression).
Subjective
Comorbidities - Screen PMH (DM, heart, kidney, liver, cancers) and DHx (medication list)
Complaint SRSOTCTERA
- Site/Character/Associated – What do you mean by tiredness/fatigue? Any examples of tiredness,

baseline function? Any objective muscle weakness, where/difficulty with what kind of activities? Any
pain/stiffness, where, duration?
- Onset/duration/Timing/progression – New onset or recurrent, duration? Sudden or gradual? Same

throughout day/worse at end of day? (myasthenia gravis)
- Trigger?
- Exacerbating – Exertion? Fatiguability – repeated use? (myasthenia gravis)
- Relieving – Rest? (myasthenia gravis)
Cause – PMH, SR, Risk factors BPS
- Neuro (objective muscle weakness generalized or localized) – Muscle weakness, eyelids

drooping/double vision, fatiguability worse with exercise and as day progresses? (myasthenia gravis)
- MSK (pain, stiffness) – Joint pain? (Osteoarthritis) Joint swelling, rashes, dry eyes, dry mouth/ulcers,
hair loss, FHX of autoimmune conditions (inflammatory arthritis/rheumatological/autoimmune)
Muscle aches, headache, sore throat? (fibromyalgia/CFS)
Non-neuro causes (Generalized weakness/tiredness but no objective muscle weakness)
Drugs – Medication list? TCM, OTC? Alcohol, illicit drugs?
Cardio – PMH heart problem, SOB/orthopnoea, leg swelling, decreased effort tolerance/walking
distance? (e.g. CCF)
Respiratory – PMH lung problem, SOB, chronic cough/sputum, wheezing, smoking (e.g.
COPD/Asthma, OSA, ILD)? Snoring, daytime sleepiness/morning headache, observed apnoea/restless
at night? (OSA)
Metabolic/Endocrine/Electrolytes/Nutrition – Weight gain, cold intolerance, constipation?

(Hypothyroidism) Weight loss, heat intolerance, tremors, diarrhoea, waking up unable to move?
(hyperthyroidism/periodic paralysis) Polyuria, polydipsia, polyphagia, weight loss (DM) Postural
giddiness, loss of appetite, salt craving? (adrenal insufficiency) Decreased urine output, LL swelling,
abdominal distension (Renal failure) Diarrhoea/vomiting/Jaundice/change in diet? (electrolytes, GI,
liver)
Haem – Giddiness, exertional SOB/decreased effort tolerance, PR bleeding/melaena/PV bleeding,

Fhx of anaemia/cancers? (Anaemia, haem malignancy)
Infection – Fever? Night sweats? Cough/ST? Contact with sick persons/TB/travel/sexual hx?
Neoplasm – PMHx of cancers, LOW/LOA, FHx of cancers, smoking, cancer screening done?
(malignancy)
Psy/Social – Recent stressors work/home/relationships, feel safe at home? Depressed mood,

anhedonia/loss of concentration, difficulty sleeping, suicidal? (Depression) Constant worrying,
cannot stop, all kinds of things? (anxiety)
Complications
- Function: How affected daily routine? Mobility, falls? BADLs/IADLs, falling asleep driving? Work,
home? Home environment?
- Psy: Affected mood? Suicide, Alcohol?
Concerns – ICEKAPS
Contraindications to treatment
Bucket lists
BPS
Objective
PE
BMI, weight and trend gain/loss. Vitals Temp, HR/BP. If suspecting resp, SpO2/RR.
Chaperone for later part need to expose
Seated
General – Cachexia, rash
Eyes/face – Ptosis, proptosis, pallor, EOM, lid lag. If suspecting MG KIV fatiguability + count to 10
Nose: Nasal turbinates
Mouth: Tonsillar hypertrophy (OSA)
Neck – Goitre swallow please, cervical lymphadenopathy
Hands – Clubbing, tremor
UL neuro - hand dance, KIV screen dysmetria. Skip tone/power. UL power proximal/distal + check
ROM. If suspecting MG KIV fatiguability.
Gait “See you walk to bed”
Supine 45deg.
If objective weakness, KIV LL neuro power proximal/distal + check ROM. Expose “Roll up pants”
screen power proximal/distal.
CVS: Expose “Take off shirt.” JVP, palpate apex beat and P2, auscultate heart
Resp: Posterior auscultation
KIV Supine flat for abdo: masses, organomegaly
Calves and pedal oedema.
Prep MSE spiel.
Offer – KIV measure neck circumference for OSA (.
Invx
Stat – FBC, ESR, Na/K/Cr, capillary glucose
Send off – TFT. KIV CK, RF, LFT. KIV Fasting glucose/lipids for CVRF.
Assessment and Plan
Polymyalgia Rheumatica. Age 50 or older, bilat aching/morning stiffness 2wk, 2 of 3 regions

neck/torso shoulders/proximal arm hip/proximal thigh, raised ESR 40mm/hr or more. Pharm – Low
dose prednisolone 15mg OD (?0.25mg/kg/day), ADRs …, expected response – Rapid after 1 st dose.
Refer/TCU – Refer Rheum, meantime TCU 2wk review symptoms.
OSA. STOPBANG 5 or more high risk (Snore loudly, Tired/sleepy in daytime, Observed stop
breathing/choking in sleep, Pressure high BP, BMI more than 35, Age older than 50, Neck
circumference more than 40cm, Gender male). Invx – Refer ENT for sleep study/polysomnography
(AHI Apnoea-Hypopnea index 15 or more per hour). Conservative – Weight loss, sleep lateral
position tennis ball in pyjama shirt, stop smoking/alcohol. Invasive - KIV CPAP (Advantages –
Improves sleep/QOL, lowers BP, lowers risk of CVA/arrhythmia/CV events) or mandibular
advancement devices/tongue-retaining devices. Surgery – If obese KIV refer Bariatric Surgery;
insufficient evidence for ENT surgeries. Legal – Fitness to drive may need to stop if keep dozing off.
Hypothyroidism – Mx accordingly.
Depression - Mx accordingly.
Anaemia – Work up cause.
Symptom – Lower limb swelling

Causes of lower limb swelling
Unilateral
V - Deep vein thrombosis, Chronic venous insufficiency
I – Cellulitis
T – Compartment syndrome, ruptured Baker’s cyst
N – Lymphoedema (pelvic tumour, previous lymph node dissection/radiation)
Bilateral
Above causes of unilateral swelling
Drugs: Calcium channel blockers (amlodipine/nifedipine), thiazolidinediones, fenfluramine (weight

loss)
CVS: Congestive cardiac failure, cor pulmonale
Resp: Obstructive sleep apnoea
Liver/GI: Liver cirrhosis/chronic liver failure, protein-losing enteropathy/malabsorption
Renal: Nephrotic syndrome, chronic kidney disease
O&G: Pregnancy
Endocrine: Hypothyroidism, pretibial myxoedema from Graves’ disease
Subjective
Concerns
- Why worried about lower limb swelling? How has it affected daily routine/function?
Co-morbidities + career
- PMH - Other PMH besides listed? DHx – Medication list, recent changes? Smoke, drink? What
work/activities, manage daily self-care activities, able to walk well?
Complaint SRSCOTETRFA
- Site: Show me where you think is swollen? Which leg or both?
- Severity: How far up does it go? Periorbital swelling/facial swelling, abdominal

distension/anasarca? (systemic causes)
- Character: Pitting/indent when press on it?
- Onset/duration/Time/progression: First time or recurrent? How long? Sudden <72hours or

gradual? Same throughout day or intermittent? Improving or getting worse or stable?
- Exacerbating: Worse at end of day/better with elevation (CCF, CVI)?
- Triggering: Trauma? Started after taking new meds e.g. CCB?
- Relieving: Better with limb elevation? (CCF, CVI) Better at end of day? (Renal)
- Associated: Pain? Redness? Fever? (cellulitis) SOB? (CCF, DVT)
Cause
Unilateral
- V: DVT – Previous DVT blood clots in legs, recent surgery/immobilization/long-haul flight in 4wk,
cancer, OCP use? Chronic venous insufficiency - Prominent veins, ulcers, skin discolouration? Worse
with prolonged standing?
- I: Cellulitis - Redness, pain, fever? Open wounds?
- T: Compartment syndrome – Trauma to leg? Recent exercise?
- N: Lymphoedema - Previous surgery/radiation to pelvis? Abdominal mass, Haematuria blood in

urine, weight loss/loss of appetite?
Bilateral
- Drugs: Newly started CCB (amlodipine, nifedipine), diabetic medication (thiazolidinediones), weight
loss medication?
- CVS: CCF - History of heart failure/ischaemic heart disease? CP/SOB, palpitations? Orthopnoea lying
flat, PND waking from sleep due to breathlessness?
- Liver/GI: Cirrhosis - History of liver problem e.g. cirrhosis, hepatitis? Jaundice? Protein-losing
enteropathy – Diarrhoea?
- Renal: Nephrotic syndrome – Frothy urine? CKD – Oliguria passing less urine?
- O&G: Pregnancy – LMP?
- Endocrine: Hx of thyroid problem? Hypothyroid – Weight gain, cold intolerance, lethargy,

constipation/menorrhagia? Graves disease – Weight loss increased appetite, heat intolerance,
tremors/palpitations?
Course
- Seen dr, investigations done, treatment tried, response?
Complications
- Bio: DVT – Exertional SOB/palpitations, haemoptysis?
- Function/Social: Affected daily routine, job? Finances?
- Psych: Feel depressed/anxious, suicidal?
- Allergy/adverse reaction to previous medications
Objective
PE
BMI, weight trend gain/loss? Vitals – Temperature (cellulitis/infection), BP/HR, KIV SpO2/RR
Seated
General inspection: Respiratory distress?
Hands: Clubbing, stigmata of chronic liver disease, AVF
Face: Sallow complexion? (CKD)
Eyes: Pallor, icterus
Mouth: Hydration
Neck: Goitre swallow, palpate
Standing:
Legs: Erythema, varicose veins/venous ulcers/hyperpigmentation/lipodermatosclerosis (CVI), Baker’s

cyst
Supine 45deg
Heart: Raised JVP, displaced apex beat, S3? (CCF)
Sitting up
Lungs: Crepitations, pleural effusion
Supine flat
Abdo: Distension, hernia, pelvic masses, nodular liver (cirrhosis), splenomegaly (chronic liver
disease), KIV shifting dullness and sacral oedema.
Legs: Warmth, tenderness/supple, pitting oedema level, measure calf circumference 10cm below
tibial tuberosity for asymmetry more than 3cm. Check DP and PT for concurrent peripheral arterial
disease.
Offer to check pelvic lymph nodes and DRE.

Invx
Stat:
KIV ECG if abnormal vital signs or suspecting PE, CCF/cor pulmonale. KIV CXR if SOB (cardiomegaly,
CCF signs). KIV X-ray tib/fib if signs if signs of injury.
Urine dipstick + microscopy for proteinuria, haematuria
FBC (anaemia, infection), Cr/Na/K (CKD)
Send off
uACR for proteinuria, LFT for low albumin and transaminitis, TFT for
hypothyroidism/hyperthyroidism
Assessment and Plan
DVT: Refer A&E stat KIV for US venous doppler and anticoagulation.
Cellulitis: Cloxacillin 1/52, TCU 1/52 to review. Elevate.
CVI: Compression stockings if pulses normal.
CCF: Refer for echocardiogram. Start diuretics for symptom relief.
Cirrhosis: Refer Gastro for US HBS
Calcium channel blockers: Switch to other antihypertensive or reduce dose + add another, chart
home BP and TCU for response 2weeks. (**Not add diuretic, does not help CCB-induced oedema)
Geriatric
Symptom – Functional decline or cognitive impairment/memory loss
Ref: NUP Bridging Case 108
Stems:
More forgetful, less talkative
Deterioration in previously well-controlled chronics

General approach
Rule out delirium
Rule out depression
Dementia – Rule out secondary causes
Subjective
HOPC – Functional decline
Premorbid personality – What was he like before?
Onset and time course – When did he change? Acute or gradual? Stepwise?
Precipitating factor – Anything happened before change noticed?
Based on above, proceed down track of 1. Delirium 2. Depression 3. Dementia
Symptom – Delirium
Drugs – New medications?

Trauma/fall/head injury?
Infection – Fever? Admission to hospital?
Symptom – Dementia/Cognitive impairment/Memory loss

Symptom – Falls and instability
Causes
Predisposing
Intrinsic
Stroke
Parkinsonism
Cerebellar dysfunction
Visual impairment
Postural hypotension
Extrinsic
Symptom – Urinary incontinence
Overactive bladder
Adult
Cardiovascular Acute/Emergency vs. Chronic/Preventive/Palliative
Symptom/sign – New hypertension
Ddx of complaint
General approach to diagnosis and management of complaint
Complaint - Confirm present finding of hypertension + chronicity
Complications - If grade 3 or higher, evaluate if hypertensive emergency (end-organ damage) or

urgency
Cause – 1. Known hypertension: Non-compliance? Resistant hypertension? 2. First presentation or

resistant: Secondary hypertension (suspect if young etc.) vs. essential
Ddx of secondary hypertension
Drugs: Alcohol/smoking?
Endocrine
S A
Handrub! (SPIKES)
have you been since your last visit? Besides high blood Any other concerns
pressure, is there anything you are worried about?”… “Tell
me more about your blood pressure issue.
Confirm present finding of hypertension + chronicity – Had
high BP before? Any home BP monitoring?
Complications/Function
If grade 3 or higher, evaluate if hypertensive emergency
(end-organ damage) or urgency
CNS – Weakness in arms or legs? Numbness? Noticed face
drooping? Difficulty speaking clearly? Blurring of vision?
CVS – Chest pain? Breathlessness? Breathless lying down/
how many pillows/woken from sleep because breathless?
Renal – Frothy urine? Blood in urine? Flank pain???

1. Known hypertension: Non-compliance? Resistant
hypertension? 2. First presentation or resistant: Secondary
hypertension (suspect if young etc.) vs. essential
Drugs – Corticosteroid intake/weight gain? (corticosteroids)
Runny nose medication?
(decongestants/sympathomimetics) TCM?
Renal:
Endocrine: Heat intolerance/tremors/palpitations/weight
loss? (hyperthyroidism) ???hypothyroidism? Episodic
headaches/sweating/palpitations? (phaeochromocytoma)
Neuro/ENT – Told you snore loudly at night? Sleepy in
daytime? (OSA)
Essential hypertension – Weight/height/BMI? FHx of
hypertension? Diet history – Tell me about what you usually
eat starting from morning to night time. Exercise history –
What do you do for exercise?

treatment?”
Chronic condition
Causes/triggers
Bucket list
the counter medications? Supplements?”
FHx - “Does anyone in the immediate family have high blood

pressure?”

things?”

Female: Add on before PMH – Gynae/Menstrual/Obstetric,
Sexual + contraceptive/STIs, Urogynae
Adolescent: Add after SHx - HEADSSS
dementia
disease

O P
Handrub! Non-pharm
Ask Pharm + ADRs
BMI. Paeds – Growth chart in health booklet.. Ref/TCU/red flags
Sitting in chair Handrub!

Vital signs – Recheck manual BP (confirm hypertension) in
both arms (coarctation of aorta, aortic dissection),
temperature (fever)
Hands – tremor/sweaty palms (hyperthyroidism), pulse
(hyperthyroidism), unequal pulses/radio-radial delay
(coarctation of aorta, aortic dissection), Pronator drift
(stroke), dysmetria (stroke)
Neck – Goitre (hyperthyroidism) swallow
Gait – “Can I see you walk to the bed?” (stroke)
Lying 45deg
General syndromic – moon facies/buffalo
hump/supraclavicular fat pad/striae (Cushing’s syndrome),
dry skin peaches and ceram/loss of outer third of eyebrow
(hypothyroidism)
CVS: JVP, Apex beat displacement (LVH), heart
sounds/murmurs (heart failure), carotid bruit
Lungs: Basal crepitations(heart failure)
Lying flat
Abdomen: ballot kidneys, bruits 3cm superior and laterael to
umbilicus (renal artery stenosis)
Sitting
Fundoscopy (Papilloedema, hypertensive retinopathy)
Handrub!
Stat invx - “I would like to do some simple tests to rule out Preventive care
serious conditions and possible underlying causes of your Vaccinations (influenza,
high blood pressure.” PPSV23/PCV13, HPV), Screening
ECG (LVH) (BMD, FIT, metabolic,
UFEME (protein, blood, casts, glucose) MMG/cervical)
Cr (AKI/CKD), K/Na (hyperaldosteronism?)
Previous invx – “Do you have any previous blood

tests/ECGs/x-rays/spirometry?”
Hypertensive emergency Broad overview -“Recommendations to help
plan”
Non-pharm
Pharm + ADRs
Ref/TCU/red flags
Hypertensive urgency Broad overview -“Recommendations to help
plan”
Pharm + ADRs
Restart old medications or start new one
Side effects
Non-pharm
Monitor home BP

Fasting glucose, lipids, uACR
Ref/TCU/red flags
- TCU 2 days to review BP
- Go to A&E if
weakness/numbness/slurring/blurring of vision,
chest pain/breathlessness
Secondary hypertension – Renal artery stenosis Broad overview -“Recommendations to help
plan”
Non-pharm
Pharm + ADRs
Ref/TCU/red flags
- Refer Gen Med/Renal for US doppler renal
arteries + other secondary hypertension
workup
Secondary hypertension – Phaeochromocytoma Broad overview -“Recommendations to help

plan”
Non-pharm
Pharm + ADRs
CCB. No atenolol!
Ref/TCU/red flags
- Refer Gen Med/Renal for US doppler renal
arteries + other secondary hypertension
workup
Condition – Hypertension
Concerns
Co-morbidities, Career
Screen for other PMH, DHx – medication list and recent changes, smoke/drink, job, ADLs, caregiver
Complaint/condition, Cause, Course
- When/how diagnosed?
Control/checking, Compliance (to follow up/meds/diet/exercise, reasons cost/cognition/caregiver

burden), Competence, Crisis management, Complications of treatment
- Control: Home BP?
- Compliance: How often miss meds? Diet? Exercise?
- Complications of treatment: Postural giddiness? Ankle oedema? Dry cough?
4. Causes (triggers)
5. Complications of disease, co-morbidities
- Heart failure - Exertional symptoms? Stroke - Weakness, numbness? Falls?
6. Concerns
Respiratory Acute/Emergency vs. Chronic/Preventive/Palliative

PE – Crepitations
Ref: NUP bridging resp 202200804
Ddx of crepitations
Change with coughing – Bronchiectasis (bibasal coarse, normal expansion/percussion/vocal

resonance), consolidation (reduced chest expansion/percussion dullness, BRONCHIAL breath sounds
+ INCREASED vocal resonance), collapse/atelectasis (reduced chest expansion/percussion dullness,
REDUCED breath sounds + REDUCED vocal resonance, +/- tracheal deviation or apex beat deviation)
Don’t change with coughing – ILD (bibasal fine Velcro-like end-inspiratory, normal
expansion/percussion/vocal resonance).
With expiratory rhonchi - ?
Aetiology of ILD
Secondary
- Drugs, iatrogenic, poisoning: Drugs methotrexate/amiodarone/nitrofurantoin/bleomycin, radiation,
asbestosis (lower lobe)/silicosis/pneumoconiosis (upper lobe)
- Infection: TB (upper lobe)
- Autoimmune: RA/SLE/Scleroderma (lower lobe), Ankylosing Spondylitis (upper lobe)
- Infiltrative: Sarcoidosis
Idiopathic Pulmonary Fibrosis
Objective
BMI + weight trend, Vitals Temp, RR/SpO2, HR/BP
Chaperone + Expose “Request a chaperone. Going to examine your lungs, will need you to take shirt
off.”
Supine 45deg.
General inspection foot of bed. Environment sputum mug/suction pot, inhalers. Respiratory
distress/tachypnoea/accessory muscles. Chest scars and tubes. Excursion “Take 2 deep breaths all
the way in and out” for symmetry look at lower part of chest.
Peripheries. Hands clubbing + Schamroth’s, asterixis, palmar erythema, tar stains, pulses. Skip HPOA.
Eyes pallor + Horner’s, face polycythaemia. Mouth central cyanosis. Neck JVP, tracheal deviation.
Chest anterior (signs rarely in front, move fast). Inspect lift arms and pendulous breasts for scars esp
chest tube in triangle of safety. KIV skip Palpate chest expansion “breathe out all the way” thumbs
close but not touching “deep breath in through mouth” for normal excursion 5cm? KIV skip Percuss.
Auscultate lungs S-shape from top then heart for loud P2. Skip vocal resonance. Palpate P2 and apex.
Sitting up – Hug pillow or cross arms over chest. Use peg to clip clothes if patient does not take off
shirt.
Chest posterior. Inspect for scars esp triangle of safety. KIV skip Palpate chest excursion. KIV percuss
from top S-shape. Auscultate from bases upwards S-shape “deep breaths through mouth. Breathe in
all the way, breathe out”. Vocal resonance.
Cervical lymph nodes.
Peripheries – Pedal oedema, clubbing.
Prep presentation of PE
Bronchiectasis: Bibasal coarse inspiratory crepitations whose characteristics change with coughing,
+/- expiratory rhonchi. Chest expansion equal bilaterally, percussion note normal, vocal resonance
normal. Not in respiratory distress, RR 16 breaths/min; fingernail clubbing present, trachea central,
apex beat not deviated; notice use of sputum mug. Complications: No signs of respiratory failure,
pulmonary hypertension/cor pulmonale. Aetiology: No dextrocardia to suggest Kartagener’s
syndrome. Request: Check vital signs, examine sputum mug, perform bedside spirometry. Diagnosis:
Bronchiectasis affecting bilateral lower lobes. Possible aetiologies: Generalized vs. local (generalized:
post-infection e.g. recurrent pneumonia/measles/TB/ABPA, congenital e.g. cystic
fibrosis/Kartagener’s syndrome, immunodeficiency e.g. hypogammaglobulinaemia, traction fibrosis
from ILD; localized: luminal blockage, intra-mural blockage, extramural blockage).
ILD: bibasal fine/Velcro-like end-inspiratory crepitations whose characteristics do not change with
coughing, Chest expansion equal bilaterally, percussion note normal, vocal resonance normal. Not in
respiratory distress, RR 16 breaths/min, fingernail clubbing present, trachea central/deviated from
traction fibrosis, apex beat not deviated; notice use of inhalers, supplementary O2. Complications:
No signs of respiratory failure (e.g. acrocyanosis, resting hypoxaemia), pulmonary hypertension/cor
pulmonale. Aetiology: No peripheral stigmata of rheumatological disease (e.g. RA/SLE). Request:
Check vital signs, perform bedside spirometry, obtain drug and occupational hx.
- Diagnosis: Interstitial lung disease affecting bilateral lower lobes/upper lobes.
Invx
Peak expiratory flow meter
Stat – CXR (Bronchiectasis confirm diagnosis – ring shadows, tram lines), extent, complications e.g.
pneumonia/abscess), lung function test (obstructive pattern). ILD reticular, nodular shadowing (early
findings non-specific; late findings include bilateral lower zone reticular infiltrates, hazy opacities.
Low inspiratory lung volumes).
Send off – Spirometry. KIV refer Resp for HRCT thorax (findings ILD – bilateral reticulation/ground-
glass and honeycomb appearance in lung peripheries and lower lobes i.e. interstitial pneumonia).
KIV Echo for pulmonary hypertension.
Assessment and Plan
Bronchiectasis. Non-pharm – patient education, smoking cessation, vaccines, chest physio; Pharm –
bronchodilators; Surgery – lobectomy/pneumonectomy/transplant.
PE – Pleural effusion
Aetiology of pleural effusion
Infection: Parapneumonic, pleural TB/TB pleuritis.
Neoplasm: Malignancy
Prep presentation of PE
Reduced chest expansion on right side, stony dullness to percussion, reduced breath sounds,
reduced vocal resonance over right lower hemithorax. Not in respiratory distress, RR 16
breaths/min. No finger clubbing, trachea central, apex beat not deviated. Treatment: No scars,
supplemental O2, IV antibiotics. Complications: No signs of respiratory failure. Aetiology:
Rheumatological disease e.g. RA/SLE (peripheral stigmata arthropathy), Malignancy (nicotine
staining, cervical lymphadenopathy, Horner syndrome), pedal oedema. Request: Vital signs.
- Diagnosis: Right-sided pleural effusion. Possible aetiologies: Parapneumonic effusion, malignant

pleural effusion, rheumatological disease; (others - chronic liver disease, nephrotic syndrome, CCF,
hypothyroidism). Differential diagnoses: Fibrothorax (from haemothorax, asbestosis, old TB, old
empyema), lung collapse.
Invx
Stat – CXR (confirm diagnosis, extent, complications e.g. mediastinal shift)
Send off - Pleural fluid for pleural protein and LDH + compare serum (Light’s criteria for exudate any
1 of 3, sensitive not specific), cell count and type, pH, smears/culture, cytology.
PE – Pneumonectomy/lobectomy scar
- PE: Left thoracotomy scar, reduced chest expansion on left, dullness to percussion, absent
(pneumonectomy)/reduced (lobectomy) breath sounds and vocal resonance over left
hemithorax/upper or lower left hemithorax. Trachea deviated to left (upper lobectomy), apex beat
deviated to left (lower lobectomy), no evidence of finger clubbing. Not in respiratory distress, RR 16
breaths/min. Complications: No signs of respiratory failure. Treatment: Not on supplemental O2,
inhaler, sputum mug. Aetiology: Bronchiectasis (coarse crepitations), COPD (rhonchi), malignancy
(nicotine stains, cervical lymphadenopathy, Horner syndrome). Complete: Vital signs.
- Diagnosis: Left-sided pneumonectomy/lobectomy. Possible aetiology: Localized bronchiectasis,

malignancy, infective e.g. lung abscess/mycetoma; others – TB, COPD (lung volume reduction
surgery), trauma.
Condition – COPD
Ref: NHGP seniors, NUP bridging case 82
Stems
Acute complications of COPD e.g. pneumothorax
Poorly-controlled COPD
COPD inappropriately on ICS
COPD misdiagnosed as asthma
Chronic COPD for fitness to fly/pre-travel advice.
Subjective
Concerns
- RFE, why worried about this, how affected daily routine/work

- Current acute exacerbation symptoms increased SOB/sputum volume/change in sputum colour?
Co-morbidities and career
- Screen other PMH, DHx medication list and changes, Smoking and stage of change, alcohol, job,
ADL and ambulation status
Complaint/Condition diagnosis, cause
- When diagnosed and how? Spirometry done and last one?
- If unconfirmed diagnosis, ddx of presenting symptom e.g. chronic cough, SOB.
- Acute SOB/cough. Resp – V Pulmonary embolism (surgery/immobility/travel), I Pneumonia (fever,

purulent sputum), T Pneumothorax (SOB, trauma). CVS – AMI (chest pain), CCF (orthopnoea/PND, LL
swelling)
- Chronic SOB/cough. Resp - TB/lung cancer (fever, haemoptysis, night sweats, LOW?),
bronchiectasis. CVS – CCF/cor pulmonale (orthopnoea/PND, LL swelling). Haem – Anaemia
(fatigue/reduced ET, PR bleeding?)
- Underlying causes of COPD: Smoking? Occupational exposure? Fhx/alpha1 antitrypsin deficiency?
Course and Control and Compliance
- Control – Exacerbations/steroids 2 or more or hospitalization 1 in last 1 year, intubations? Current

functional status MMRC? (mMRC 0-4 0. breathless on strenuous exercise, 1. Breathless walking
uphill/hurrying, 2. Breathless level ground/own pace more than 100m, 3. Breathless after 100m level
ground, 4. Breathless dressing/cannot leave house)
- What treatment on? Medications, LTOT, surgery? Quit smoking attempts, influenza/pneumoccal
vaccines, exercise therapy?
- Compliance preventer/reliever and why not compliant?
Competence, crisis management
- Inhaler technique? Have COPD action plan?
Complications of treatment
- Inhaled steroids – oral thrush? Oral steroids – Cushing’s?
- Anticholinergics – dry mouth/gluacoma/urinary retention/constipation
Other causes of poor control
- Triggers – smoking/2nd hand smoke, respiratory infections, occupation/environment e.g.

construction work/mining. (Not allergic unlike asthma).
Complications of disease/co-morbidities
- Bio: Pneumothorax (sudden SOB), Cor pulmonale (orthopnoea/PND/LL swelling), Lung cancer
(haemoptysis, LOW/LOA), osteoporosis
- Psy: Depression, anxiety

- Social: Functional impairment, job, finances, home situation/caregiver, home environment (lift
landing)
Objective
PE
BMI/wt and trend. Vitals – Temp, RR/SpO2, BP/HR, bounding pulse
Sitting
General inspection: Respiratory distress (tachypnoea, accessory muscles), colour

(cyanosed/polycythaemia). Peripheries: Clubbing/tremor, asterixis (respiratory failure). Face:
Plethora. Eyes: Pallor/polycythaemia. Mouth: Central cyanosis.
Neck: Tracheal deviation, cervical lymph nodes.
Supine 45deg
Anterior chest. Lungs: Symmetry of chest expansion, scars, KIV expansion (reduced) x 1 percuss
(hyperresonance), auscultate. Heart: Raised JVP/displaced apex beat/parasternal heave/loujd P2
(pulmonary hypertension, cor pulmonale), S1/S2 and loud P2.
Sitting up
Posterior chest. Neck: Cervical lymph nodes if not done. Lungs: Chest expansion x 1, auscultate from
bases up for wheeze/creps, percuss for hyperresonance.
Legs: Pedal oedema (cor pulmonale).
- PE: Bilateral chest hyperinflation + reduced chest expansion, hyperresonant percussion note + loss
of liver and cardiac dullness, bilateral expiratory rhonchi + prolonged expiratory phase. Vocal
resonance normal. Trachea central, apex beat not deviated, no finger clubbing. Not in respiratory
distress, RR 16 breaths/min. Complications: No signs of respiratory failure, pulmonary
hypertension/cor pulmonale. Treatment: Not on supplemental O2, no inhalers. Aetiology: Nicotine
staining of fingers. Complete: Vital signs, bedside spirometry.
Invx
Stat – SpO2. CXR if suspecting infection/lung cancer, KIV ECG TRO AMI and check for prolonged QTc
(???CCF). KIV FBC (infection, anaemia/polycythaemia).
Send off/arrange - Spirometry/Lung function test (to confirm obstructive pattern/irreversibility,

severity) if no previous/recent. Diagnostic criteria [ite 2021, 2019]: Irreversible obstructive
pulmonary defect i.e. Post-bronchodilator FEV1/FVC *absolute value* < 0.70 [GOLD] or below LLN
(ATS), not reversible i.e. FEV1 percentage change less than 12% or FEV1 absolute change less than
0.2L. Severity - GOLD grade By FEV1 *percentage* of predicted 1 Mild, 2 moderate, 3 severe, 4 very
severe - >80%, 79% or less, 49% or less, 29% or less.
KIV ABG, sputum culture/AFB smear, CT chest.
Assessment and management
Acute exacerbation of COPD. Dx moderate-severe exacerbation Anthonisen criteria 2 of 3

SOB/sputum volume/sputum purulence (if 1 of 3 just increase bronchodilators but no Abx or
prednisolone). Supplemental O2 level keep above 90% (88-92%?), caution with higher levels to avoid
suppressing respiratory drive. Nebulized salbutamol:ipratropium:NS 1:2:1. PO prednisolone 40mg
OD x 5-7 days (for all patients GOLD grade 3 and below; improve FEV1, oxygenation, recovery time,
reduce length of hospitalization). Antibiotics e.g. ciprofloxacin 500mg BD 1/52 (cover Pseudomonas
aeruginosa) or amoxicillin/clavulanate 625mg BD x 1/52 (if QTC prolonged); low risk (not age 65 and
above, GOLD grade 3 and below, exacerbations 2 or more per year, heart disease) can give
clarithromycin 500mg BD x 1/52 or doxycycline (cover Streptoccous pneumoniae, Haemophilus
influenzae, Moraxella catarrhalis). TCU 2 days review symptoms.
New diagnosis of COPD.
Diagnosis + pt education “You have COPD, have you heard of it? What do you understand about it?
COPD is condition of chronic airway inflammation, poorly reversible with bronchodilator therapy,
caused by chronic smoking. Goals of treatment to improve SOB symptoms, prevent/reduce
hospitalizations, slow disease progression/decrease mortality. Treatment will be medication and
lifestyle/non-medication + vaccinations”
Invx: Refer for Spirometry if not done. “After this I want you to do formal COPD Assessment Test
score to grade your symptoms, however based on your history, considered multiple exacerbations
and mild/moderate-severe symptoms”. Classify GOLD group for initial management by
exacerbations/hospitalizations + severity of symptoms (cough/dyspnoea CAT 0 to 40 or mMRC 0-4 0.
breathless on strenuous exercise, 1. Breathless walking uphill/hurrying, 2. Breathless level
ground/own pace more than 100m, 3. Breathless after 100m level ground, 4. Breathless
dressing/cannot leave house). mMRC 2 or more/CAT 10 or more = Group C or D (C = no
hospitalization, 1 or less exacerbation in last year; D = hospitalization or 2 or more exacerbations e.g.
need steroids). mMRC <2/CAT <10 = Group A or B (A = no hospitalization, 1 or less exacerbation in
last year; B = hospitalization or 2 or more exacerbations).
Pharm – Bronchodilators:
Initial treatment [ite 2020, 2019]. GOLD group A – SAM/SABA; group B – LAMA (Incruse
Ellipta/umeclidinium 1puff OD or Spiriva Respimat/tiotropium) or LABA (salmeterol, vilanterol) KIV
LAMA+LABA (Anoro/umeclidinium+vilanterol); group C – LAMA KIV LAMA+LABA or ICS+LABA; group
D – LAMA+LABA KIV LAMA and ICS+LABA (improves lung function, health status, reduces
exacerbations but not all-cause mortality) or ICS+LABA alone (if more exacerbations).
ADRs – LAMA – palpitations, narrow angle glaucoma, urine retention. LABA – palpitations,
hypokalaemia.
Asymptomatic [ite 2020] - Do not give pharmacotherapy to asymptomatic individual with spirometry
findings of airflow obstruction! (does not prevent future respiratory symptoms or reduce decline in
lung function).
Non-pharm [ite 2019]
- Smoking cessation (reduce lung function decline) – If pre-contemplation, suggest cutting down and
arrange follow-up/refer
- Regular exercise/physical activity KIV refer pulmonary rehabilitation in hospital
- Written COPD Action Plan (reduces respiratory-related hospital admission). If asked: Green zone,
Yellow, Red Zones; Green zone = usual level of SOB/cough/sputum/effort tolerance, continue regular
inhalers +/- home LTOT + regular exercise + avoid smoking; Yellow = more
SOB/cough/sputum/decreased ET, add reliever KIV start prednisolone and antibiotic + arrange to see
doctor; Green = Very SOB affecting sleep/haemoptysis/confused, call ambulance 995 to hospital +
take above meds.
Prev: Influenza yearly + complete pneumococcal vaccine (Below age 65 give PPSV23 once; age 65
and above give PCV13 once at least 1yr from previous PPSV23, then another PPSV23 at least 1yr
from previous PCV13 and 5yr from previous PPSV23).
TCU ?3mth for follow-up
Chronic follow-up for COPD, poorly-controlled
Pt education and non-pharm/prev as above, plus escalation/de-escalation of therapy: (for

exacerbations [ACG 2018 + GOLD 2021]) monotherapy with LAMA (tiotropium) or LABA (salmeterol)
 dual therapy LAMA + LABA  (if still having exacerbations or asthma/COPD overlap/eosinophil
100 or more, add ICS) triple therapy LAMA + LABA + ICS OR (if eosinophils 300 or more OR
eosinophils 100 or more AND hospitalization/2 exacerbations) switch to LABA+ICS  Refer Resp add
azithromycin (smokers) or roflumilast (GOLD grade 3 or 4 + chronic bronchitis)
If inappropriately on monotherapy with ICS (increased pneumonia risk, does not improve mortality
or prevent long-term decline of FEV1), stop or change.
KIV refer Resp for LTOT Long-term oxygen therapy 15hr or more per day (Indications [ite 2020]:
Hypoxaemia i.e. resting SpO2 88% or lower or arterial PaO2 <55mmHg), CTVS for lung reduction
surgery/lung transplant.
Fitness to fly/Pre-travel advice – see Pre-travel advice section on assessment for fitness. Also give
DVT prevention advice for long-haul flight.
Condition – Asthma
Ddx of complaint
S A
Handrub! (SPIKES)
treatment?”
life?”
Lab result
treatment?”
Complications
Chronic condition
Symptom control
- “How is your asthma?”
- GINA in logical order/order of yield is DRNA:
1. Day symptoms – “Currently (meaning in the last 4 weeks),
how many times a week do you have asthma symptoms?” (1
point for 3 or more times; for age 5 and young, 2 or more
times)
2. Reliever use – “How many times a week do you have to
use your Ventolin/take additional puffs of Symbicort on top
of your regular dose?” (1 point for 3 or more times; for age 5
and young, 2 or more times) + add on “Do you use up 1
canister of Ventolin in less than 2 months?” (Risk factor for
adverse outcomes)
3. Night symptoms – “Been woken up from sleep due to
asthma symptoms (or coughing)?” (1 point for yes)
4. Activity restriction – “Have difficulty doing your daily
activities at work/school/home (or play less than other
children) because of asthma?” (1 point for yes)
Total up – 3 or more
Risk factors
- SABA use excessive + no preventer/non-adherence
- Exacerbation in last 1 year – “In last 1 year, had to go to the
clinic or hospital for asthma flare up?”
- Intubation or ICU admission – “Had a breathing tube put
into your airway because of asthma before? Been admitted
to ICU because of asthma before?”
- Smoke exposure – “Have you smoked before? Does anyone
at home smoke?”
Causes/triggers
Bucket list
stay in? Do you smoke/how much in a day/how many
years/would you consider quitting? Do you drink
alcohol/how much/how often more than 4 drinks in past
year? Tell me about what you eat in a day from breakfast to
dinner. What exercise do you do? What are worries you
most about it?”
things?”
dementia
disease

O P
Handrub! Non-pharm
Pallor Handrub!
vibration sense
Handrub!
PPSV23/PCV13, HPV), Screening
Previous invx – “Do you have any previous blood tests/ x- (BMD, FIT, metabolic,
rays/spirometry?” MMG/cervical)
plan”
Non-pharm
Pharm + ADRs
Ref/TCU/red flags
Condition – Smoking cessation

Ref: NUP bridging 2022 case 122
Short ABC
Assess smoking – Do you smoke? How much?
Assess stage of change + Assess nicotine dependence
Nicotine dependence – <1. Number of cigarettes as above> 2. First cigarette after waking 3. Hate to
give up first cigarette. KIV the rest 4. Smoke more in morning 5. Smoke in places forbidden
church/library 6. Smoke when sick in bed
Brief manage. Pt education smoking harmful making your condition worse, should change, refer HPB
IQUIT or at least cut down 1 stick/day, follow-up.
Longer 5As
Gastrointestinal Acute/Emergency vs. Chronic/Preventive/Palliative

Symptom - Acute abdominal pain
Ddx of complaint
Clarify nature of pain – SOCRATES
DQ/systems review for red flags and differential diagnosis
S A
Handrub! (SPIKES)
SRSOTCTERA
***Site/Radiation clarify++ – “Can you point where you feel
the pain? Is it more at the upper/centre part/lower part of
your tummy? Is it more at the middle part/right side/left
side? Does it travel anywhere else/can you point where it
travels to? Is it more at the upper or lower part?”
Severity – “How bad on scale from 0 to 10?”
Onset/duration/Timing/frequency – “How did it first start?
Sudden or gradual? Constant or intermittent?”
Character – “What does it feel like? Sharp/dull/pulling?”
Trigger – Anything triggered it off, NSAIDs/steroids, spicy
food, irregular meals?
Exacerbating/Relieving – “What makes it worse? Anything
makes it better?”

Associated symptoms
Epigastric
-
RIF
- Systemic: Fever?
- Gynae (ectopic pregnancy, ovarian cyst torsion/rupture):
Need to ask all my patients hope you don’t mind, are you in
any relationship? Sexually active? When was LMP/Menses
regular/cycle? Any SI after that/Protection? Any abnormal
PV bleeding? PV discharge? Previous STI? Other partners?
- GI (appendicitis): Nausea/vomiting/haematemesis?
Diarrhoea/constipation? PR bleed/melaena? Jaundice?
Heartburn? Acid brash?
- GU (UTI, renal colic): Dysuria? Urgency? Frequency? Gross
haematuria? Flank pain?

treatment?”
life?”
Lab result
treatment?”
Complications
Chronic condition
Causes/triggers
Bucket list
things?”

dementia
disease

O P
Non-pharm
Pharm + ADRs
Ref/TCU/red flags
Handrub!
Chaperone! Handrub!
BMI. Paeds – Growth chart in health booklet.

vital signs
Sitting at chair
Eyes: Pallor, icterus
Mouth: Tongue (hydration)
Lying flat on bed

Abdomen: Tenderness/location, guarding/rebound
Sit up for renal punch.

vibration sense
Handrub!
FBC (leucocytosis, neutrophilia/left shift) PPSV23/PCV13, HPV), Screening
UPT (pregnancy) (BMD, FIT, metabolic,
Urine microscopy (RBCs, WBCs) MMG/cervical)
Previous invx – “Do you have any previous blood

tests/ECGs/x-rays/spirometry?”

plan”
Non-pharm
Pharm + ADRs
Ref/TCU/red flags
Surgical abdomen Broad overview -“Recommendations to help
treat your problem are further investigations,
Tenderness, guarding/rebound lifestyle measures, medications, follow-up
plan”
Patient comms
- Explain serious condition, provisional
diagnosis (e.g. appendicitis), treatment
(immediate surgery or CT scan to confirm)

Non-pharm
Pharm + ADRs
Ref/TCU/red flags
-
Acute appendicitis Broad overview -“Recommendations to help

treat your problem are further investigations,
Alvarado score lifestyle measures, medications, follow-up
plan”
Non-pharm
Pharm + ADRs
Ref/TCU/red flags
GERD
Signs/symptoms: Heartburn sensation, regurgitation.
Mx: Non-pharm - Small meals, avoid meals 2hr before sleep, elevate head when sleeping, lose
weight, stop smoking.
Renal & Urology Acute/Emergency vs. Chronic/Preventive/Palliative)

Sx – Hyponatraemia (lab)
Ref: NHGP seniors
Causes of hyponatraemia
Hypovolaemic, hypervolaemic, euvolaemic

Rule out spurious causes (see other lab tests) – hyperglycaemia, hyperlipidaemia, high protein
Hypovolaemic
- GI loss: vomiting/diarrhoea
- Renal loss: Diuretics thiazide or loop
Hypervolaemic
- Cardio: CCF
- Liver/GI: Liver cirrhosis
- Renal: Renal failure
Euvolaemic
- Primary polydipsia or reduced solute intake
- SIADH secondary to Drugs (SSRIs) or recent surgery, Infection (pneumonia), Malignancy (e.g. lung)
- Endocrine: Hypothyroidism, Adrenal insufficiency
Complications of hyponatremia
Neuro - Confusion, seizures
Subjective
RFE
Complaint
- Why were tests done? Other tests together e.g. glucose, lipids? Workup done e.g. serum and urine
sodium and osmolality
- Symptoms of hyponatraemia: Non-specific – Lethargy, nausea; Neuro - Giddiness/unsteady gait,

confusion, seizure?
Co-morbidities
- PMH – DM, malignancy? Drugs, TCM, supplements?
Cause
Spurious
- Hyperglycaemia - Known DM, polyuria/polydipsia/LOW?
Hypovolaemic
- GI losses – Nausea/vomiting?
- Renal losses – Taking thiazide or loop diuretics, increased urination?
Hypervolaemic
- CCF – Known heart failure, reduced ET/Orthopnoea/PND/LL swelling?
- Liver cirrhosis – Known liver cirrhosis?
- Renal – Known renal failure/dialysis, reduced urine output?
Euvolaemic
- Primary polydipsia or low solute intake – Excessive fluid intake? Poor oral intake, low salt diet?
- SIADH: Drugs – SSRIs, recent surgery? Infection – Recent lung infection, fever, cough, sputum?
Malignancy – Known cancer, LOW/LOA, headache/diplopia?
- Endocrine: Hypothyroid – Known hypothyroidism, neck swelling, weight gain, cold intolerance,
lethargy, constipation? Adrenal insufficiency – Long-corticosteroid intake or TCM?
Objective
PE
Wt and trend, BP/HR
Sitting
General inspection: Mental status
Hands: Skin turgor, capillary refill time
Mouth: Tongue mucosa for hydration status
Neck: Goitre
Supine 45deg
Cardio: JVP, apex beat
Lungs: Creps
Legs: Pedal oedema
Invx
Stat: capillary glucose, Urea (calculate serum osmolality = 2 x Na + glucose + urea; hyperosmolar if
Sosm >295, hypoosmolar if Sosm < 275). CXR if symptoms of lung ca.
Send off: Venous glucose, lipids; urine sodium and urine osmolality, TFT, cortisol
Assessment and Plan

Hypovolaemic. If symptomatic, refer A&E for IV volume and sodium replacement and close
monitoring. Treat underlying cause e.g. GE, stop diuretics.
Hypervolaemia. Treat CCF – Fluid restrict, diuretics, optimize CCF treatment.
SIADH. Fluid restrict 800ml/day, KIV sodium tablets if persistent. Investigate and treat underlying
cause – stop offending drug, treat pneumonia with antibiotics, CXR/CT thorax for lung cancer, treat
hypothyroidism.
Neurology Acute/Emergency vs. Chronic/Preventive/Palliative

Symptom - Headache
References: NHGP seniors, NUP bridging case 112, Julio, NUP CPG/AFP, Patient History
Ddx of complaint
By profile
Young: Migraine, tension-type headache
Elderly/CV risk: Stroke, giant cell arteritis/temporal arteritis
Overweight: OSA, benign intracranial hypertension
Pregnant: Pre-eclampsia, cerebral venous thrombosis, migraine
By ICHD-3
Primary headache + cep…: Migraine, tension-type headache, cluster headache
Others: MOH Medication-Overuse Headache
Secondary headache: Brain/Intracranial (Vascular intracranial haemorrhage/giant cell arteritis,

Infective meningitis/encephalitis/brain abscess, Trauma, Autoimmune GCA, Metabolic
OSA/pregnancy, Neoplasm meningioma/pituitary tumour/metastatic cancer), Eye (glaucoma), ENT
(sinusitis), Teeth/Jaw (dental caries/abscess/TMJ dysfunction), Neck (cervicogenic
headache/spondylosis/whiplash)
Subjective
RFE - “How may I help you today? Anything else worried about?”
Comorbidities – Screen PMHx and DHx “Before I ask about that, any past medical conditions? Any
long term medications?”
Complaint/HOPC “Tell me more about your headache. First time or recurrent? Tell me about the
most recent episode from beginning to end.”
SRSCOTETRA
Site/Radiation – Where do you feel it? (unilateral migraine/cluster, bilateral tension-type)

Severity – On a scale of 0 to 10, how bad? Worst headache of your life? (SAH)
Character/Associated – Can you describe what it feels like? (throbbing migraine, pressing/tightness
tension) When it comes, any other symptoms – feel like vomiting, pain with bright lights loud
sounds, warning symptoms like bright dark spots in vision tingling? (nausea/photophobia
phonophobia/aura in migraine) eye pain tearing/nose blocked runny (cluster headache?)
Onset/duration/Timing/frequency – New or recurrent? Started very suddenly or gradual onset,

maximum intensity from start? (SAH) How often/how many times in a month? (chronic daily?)
Exacerbating – When is it worse, or what makes it worse? (early morning/lying flat/coughing-

sneezing raised ICP, bright lights/loud noises/exertion migraine)
Triggers – Anything triggered it off? How is sleep been? Any increased stress lately, why, how to
manage? How are things at home/school?
Relieving – What makes it better? How much medication, how often in a week? (medication-
overuse)
Associated symptoms - Secondary causes red flags
Brain
D – New medications recently? Alcohol, smoking, illicit drugs?
V, N - Weakness in limbs, Numbness, Difficulty speaking clearly, Double vision, blur vision? (stroke,
SOL)
I – fever, Neck stiffness? (meningitis/encephalitis/abscess)
N - Worse on waking in the morning, on coughing/sneezing? Lost weight/appetite? (SOL)
T – Hit head? (trauma, ICH)
A – Jaw pain when eating, episodes of vision loss? (temporal arteritis)
M – Snore loudly, tired in daytime, partner seen you stop breathing at night? (OSA) LMP, pregnant?
(pre-eclampsia)
Extracranial
Eye - Eye pain, blur vision? (glaucoma)
ENT – Blocked/runny nose, atopy history, pain over cheeks and sinuses? (AR, sinusitis) Snore loudly,
tired in daytime, partner seen you stop breathing at night? (OSA)
Neck – Neck pain stiff, pain shooting down arms? (cervicogenic)
Course - “Have you had previous similar episodes? Have you seen other doctors for it? What tests
have been done? What treatment has been tried?”
How are your symptoms after treatment?
Complications
- Psy: How affected sleep, mood? Depressed, lost interest pleasure in activities? Constantly worrying
about everything cannot stop?
- Function - How has it affected daily routine? What work/impact, affected school grades, hobbies?
Relationships? Finances?
Contraindications to treatment – Asthma/COPD? (NSAIDs, beta-blockers) gastritis, renal

impairment? (NSAIDs)
Bucket lists BPS
PMHx - “What other past medical conditions do you have?”
Hypertension?
Drugs/allergies - “What long-term medications are you taking now/Do you have a medication list?
Do you take any traditional medications? Over the counter medications? Supplements?”
FHx - “Does anyone in the immediate family have…”
Social history WASHED Work/Accounts Home Alcohol Smoking Exercise Diet + Function/ICE - “How
has this affected your lifestyle and daily activities? What are you working as/studying/how are
things? How are things at home/whom do you live with/what kind of housing do you stay in? Do you
smoke/how much in a day/how many years/would you consider quitting? Do you drink alcohol/how
much/how often more than 4 drinks in past year? Tell me about what you eat in a day from
breakfast to dinner. What exercise do you do? What are worries you most about it?”
Psy Depressed/anhedonia/anxious - “How is your mood/do you feel depressed? Have you lost
interest or pleasure your daily activities? Do you constantly worry about all kinds of things?”
Female: menstrual, contraceptive + sexual, urogynae
Adolescent: HEADSSS, puberty/menarche
Child: perinatal, growth, development, vaccinations, puberty/menarche
Elderly: falls, incontinence, dementia
Legal: driving, underage smoking/alcohol/sex, notifiable disease
Objective
PE - “I’ll need to examine you now.” Handrub!
BMI and centiles/trend (OSA, neoplasm), vital signs – Temperature (infection), BP (uncontrolled
HTN; before preventive meds)
Neuro (stroke, SOL)
- UL: Pronator drift, dysmetria, power

- Gait “See you walk/I see that you are walking steadily.”
- Eyes – Can see clearly? All? Pupils turn off lights. EOM.
- CN VII
Fundoscopy for papilloedema (raised ICP)
C-spine flexion/extension (meningism)
C-spine lateral flexion, palpate spinous processes for tenderness (cervicogenic)
Special selective
Palpate temporal artery in front of tragus + temporal region (thickened and tender in temporal
arteritis/GCA)
Tap index+middle over frontal x 2 + cheek x 2 (sinusitis)
Mouth for tonsillar hypertrophy/Mallampati score, nose for deviated nasal septum/engorged
turbinates, measure neck circumference (OSA, AR)
Palpate rotating index+middle for tenderness at frontalis/temporalis/masseter/trapezius (tension

headache)
Handrub!
Invx “I would like to do some simple tests to help us find out what’s causing your problem.”
Stat - If fever/neck stiffness, FBC raised TW (infection). If suspecting GCA, ESR (raised in temporal
arteritis/GCA). If neck pain, X-ray C-spine (cervicogenic headache)
Assessment and Plan
General Avoid triggers - Sleep hygiene
Stress management
Headache diary – frequency, identify other
triggers, frequency of medication use
Red flags – Come back early if worsening

headache/change in character. Go to A&E if
thunderclap/worst headache of life,
weakness/numbness/slurring/double vision.
Migraine without aura Broad overview -“Recommendations to help
5 or more episodes + duration 4-72h + 2 of 4 treat your problem are further investigations,
unilateral/throbbing-pulsating/moderate- lifestyle measures, medications, follow-up
severe/aggravated by physical activity + ?2 of 4 plan”
nausea/vomiting/photophobia/phonophobia Other primary care invx
(relieved in dark quiet room, with sleep) Non-pharm
Avoid triggers – sleep hygiene, stress
Migraine with aura management (time management, mindfulness
Preceding aura (visual scotoma/bright spots, exercises), regular exercise and meals
tingling) Headache diary frequency, response
Avoid medication overuse
Pharm + ADRs
Abortive therapy
Paracetamol 1000mg QDS-PRN
NSAIDs e.g. Naproxen 550mg BD-PRN
If nausea: IV metoclopramide or IM
promethazine
Triptans e.g. Sumatriptan 50mg once + repeat
in 2hr; CI IHD, uncontrolled HTN, pregnancy;
ADR: giddiness, nausea/vomiting, transient
increased BP
Preventive therapy
Indications: 1. Frequent 3 or more/month 2.
significant disability diminished QOL 3.
Contraindication/severe ADR to/failure of acute
therapies 4. Risk of medication-overuse
headache 5. ?Menstrual migraine
Beta-blocker Propranolol 20mg BD or
metoprolol
Amitriptyline
Topiramate
Ref/TCU/red flags
Tension-?type headache Broad overview -“Recommendations to help
10 or more episodes + duration 30min to 7days treat your problem are further investigations,
+ 2 of 4 bilateral/pressing tightness lifestyle measures, medications, follow-up
band-like/mild-moderate/not aggravated by plan”
physical activity + NO Other primary care invx
nausea/vomiting/photophobia/phonophobia Non-pharm
(preceded by stress)
Pharm + ADRs
Abortive
Paracetamol
NSAIDs
Combination caffeine/ibuprofen
Preventive
Amitryptiline
Ref/TCU/red flags
Cluster headache Broad overview -“Recommendations to help
5 or more episodes + duration 15min-6hr treat your problem are further investigations,
unilateral-oribtal-supraorbital-temporal severe lifestyle measures, medications, follow-up
+ 1 of 7 conjunctival injection/tearing/eyelid plan”
oedema/miosis/forehead sweating/nasal Other primary care invx
congestion/restlessness Non-pharm
Pharm + ADRs
Beta-blockers or lithium
Ref/TCU/red flags
Medication-Overuse Headache Broad overview -“Recommendations to help
Pre-existing headache disorder 15 or more treat your problem are further investigations,
days/month + medication intake 10 or more lifestyle measures, medications, follow-up
days/month (non-opioid 10 more days, ?? plan”
opioid 15 or more days) + duration 3 months or Other primary care invx
more Non-pharm
Patient education – worsened by overuse of
analgesia
Discontinue offending medication abruptly.
Advise headaches will get worse before
improving.
Pharm + ADRs
Bridge with other medication e.g.
NSAIDs/steroids, KIV preventive therapy for
migraine
Ref/TCU/red flags
Follow-up in 2 weeks?
OSA and AR Non-pharm
STOPBANG 5 or more high risk – Snoring, Patient education – OSA, have you heard of it?
Tiredness daytime/unrefreshed sleep, Tongue and soft tissue around airway blocking
Observed apnoea/choking/gasping for air at during sleep. Risk of accidents with
night; Pressure hypertension, BMI >35, Age > driving/operating heavy machinery when
50, Neck circumference >40cm, Gender male sleepy
Sleep in lateral position, sew tennis ball into
Ddx: Thyroid mass pyjama shirt
Complications + co-morbidities: Weight loss through diet and exercise
driving/operative heavy machinery accidents, Stop smoking, avoid alcohol and sedating
DM/HTN/lipids/obesity/fatty liver, AMI/stroke, medications (antihistamines, BZD, opiates,
depression antidepressants);
Smoking/alcohol
Pharm + ADRs
PE Intranasal corticosteroids for AR
BMI >35kg/m2, BP high
Mouth for Mallampati score and tonsillar Ref/TCU/red flags
hypertrophy (open mouth stick out tongue do Refer ENT for sleep study/polysomnography
not say ah), nose for deviated nasal septum, TCU appropriately
measure neck circumference
KIV CVS for raised JVP, loud palpable P2 + Prev - Screen FPG, lipids (co-morbids)
parasternal heave (pulmonary hypertension)
Invx: Future - Screen FPG, lipids (co-morbids),

TFT (ddx/aetiology)
Temporal arteritis/Giant Cell Arteritis Broad overview -“Recommendations to help
Pathology: Vasculitis of large to medium-sized treat your problem are further investigations,
vessels lifestyle measures, medications, follow-up
Features: Age >50 (peak in 60s), temporal plan”
pain/jaw claudication, visual disturbances
(temporary vision loss or curtain), fever/LOW, Ref/TCU/red flags
a/w polymyalgia rheumatica (aching + morning Refer to A&E stat. Explain medical emergency
stiffness shoulder neck hips) high risk of stroke or vision loss. Likely admitted
to Rheumatology for temporal artery biopsy to
PE confirm diagnosis, prednisolone to treat
Palpate temporal artery in front of tragus + inflammation.
temporal region (thickened and tender in
temporal arteritis/GCA) Non-pharm
KIV carotid bruit, CV for aortic regurgitation Pharm + ADRs
murmur (secondary dilatation from ascending
aortic aneurysm)
Stat invx
FBC, ESR raised
Symptom – Syncope
Ref: NHGP seniors, Julio
- LOC – Tell me what happened before, during and after the episode. Witnessed? Pre-ictal, ictal,
post-ictal events? Seizure vs. syncope Sheldon score (Seizure - LOC after emotional stress; abnormal
behaviour i.e. unresponsive, unusual posture/limb jerking, head turning to one side, amnesia;
tongue bitten, post-ictal confusion; Syncope – Presyncopal giddiness, sweating/diaphoresis,
triggered by prolonged standing/sitting).
- Onset/duration/Time course/progression: First episode or recurrent?
If diagnosis not confirmed,
Neuro: Weakness, numbness, speech slurring, blurring of vision? (stroke)
Febrile fit – Fever.
Drugs, alcohol
Metabolic: Poor oral intake, use of OHGA/insulin? (hypoglycaemia, hyponatraemia)
Epileptic syndrome – Childhood hx of jerking limbs/spilling milk or food when waking in morning
‘flying cornflakes’/blanking out, learning disabilities. Fhx of epilepsy.
Brain
Condition – Seizures/Epilepsy
Ref: NUP bridging 2022 case, prog b neuro 20220813
Stem:
30yo female, b/g stable epilepsy since childhood on lamotrigine, unscheduled. P/w LOC; other
concerns family planning/pregnancy. Dx: Breakthrough seizure secondary to stress and alcohol use.
20yo female, no known hx of epilepsy but actually had childhood myoclonic episodes, unscheduled.
P/w LOC. Dx: First seizure, has underlying Juvenile Myoclonic Epilepsy.
Subjective
1. Co-morbidities
- Screen for PMH, Known seizures/epilepsy?
- DHx – medication list?
2. Complaint, Cause – Current symptoms and ddx if not confirmed
- LOC – Tell me what happened before, during and after the episode. Witnessed? Pre-ictal, ictal,
post-ictal events? Seizure vs. syncope Sheldon score (Seizure - LOC after emotional stress; abnormal
behaviour i.e. unresponsive, unusual posture/limb jerking, head turning to one side, amnesia;
tongue bitten, post-ictal confusion; Syncope – Presyncopal giddiness, sweating/diaphoresis,
triggered by prolonged standing/sitting).
- Onset/duration/Time course/progression: First episode or recurrent?
If diagnosis not confirmed,
Neuro: Weakness, numbness, speech slurring, blurring of vision? (stroke)
Febrile fit – Fever.
Drugs, alcohol
Metabolic: Poor oral intake, use of OHGA/insulin? (hypoglycaemia, hyponatraemia)
Epileptic syndrome – Childhood hx of jerking limbs/spilling milk or food when waking in morning
‘flying cornflakes’/blanking out, learning disabilities. Fhx of epilepsy.
Brain
3. Condition/Diagnosis, Course
4. Control/checking, Compliance (to follow up/meds/diet/exercise, reasons cost/cognition/caregiver

burden), Competence,
5. Causes (triggers) of breakthrough seizure
- Non-compliance to medication/missed doses, underlying social problems or stressors? Recent

change in dosage?
- Drugs: Alcohol use/overuse? New medication/supplements?

- Infection: Fever, intercurrent illness?
- Metabolic/Endocrine: Poor oral intake? (Hypoglycaemia, hyponatraemia)
- Emotional stress, sleep deprivation
- Flashing lights/video games
6. Complications of treatment, Crisis management
6. Complications of disease, co-morbidities
7. Concerns
- Pregnancy/family planning, LMP?
Objective
PE
If posturally-related, start postural BP at 5min.
BMI weight/height. Vitals – Temp (infection), pulse HR/BP
Sitting
General inspection: Skin for neurocutaneous syndromes (neurofibromas, portwine stain of Sturge
Weber syndrome, angiofibromas of tuberous sclerosis)
UL neuro: Hand dance (pronator drift), dysmetria KIV dysdiadochokinesia. UL tone, reflexes, power.
KIV pinprick.
KIV CN: Eyes, CN 5, CN 7. Mouth for tongue bite. Head for injuries.
Gait “See you walk to the bed.”
Supine 45deg.
KIV Cardiovascular: Heart sounds, murmur AS, carotid bruit. Lungs for creps.
Invx
Stat – Capillary glucose (hypoglycaemia), FBC (infection), Na/K/Cr (electrolyte disturbances). ECG
(arrhythmia). UPT if possibly pregnant.
Send off – Ca/Mg/PO4, LFT.

Assessment and Plan
Breakthrough seizure - General. Refer/Red flags – Refer Neuro 1-2weeks with memo. To A&E if
recurrent breakthrough seizures, focal neurological symptoms e.g. weakness.
First presentation seizure – General. Refer Neuro fast track 1-2wk (may arrange MRI, EEG). Safety
advice – Avoid driving, swimming/heights or doing things alone.
Driving. Not allowed for confirmed epilepsy (i.e. recurrent including scar epilepsy). If seizures for
other reasons but on AED, check Fitness to Drive guidelines.
Family Planning/Contraception/Pregnancy. Levereticam/Keppra, Lamotrigine, Carbamazepine have

lowest risk of foetal malformation but still present 3% (also neurodevelopmental issues,
pregnancy/labour), valproate has highest risk. Epilepsy may have genetic predisposition. However,
poorly-controlled seizures are worse for baby (IUGR). Refer Neuro specialist to discuss risks and
benefits. Start folic acid supplements 5mg OD. Monitor FBC for thrombocytopaenia, LFT for liver
impairment. Contraception: Avoid COCPs (interaction with AEDs hepatic inducers reduced efficacy of
oestrogen-containing contraceptives). Reversible short-term e.g. barrier, IM depot provera vs. long-
term IUCD Mirena/Copper.
Non-adherence. Address underlying social issues.
Alcohol. Screen 4 drinks KIV CAGE. Stop alcohol (no safe limit esp in epilepsy)
Stress/sleep deprivation. Stress management/time management KIV refer psychologist for coping
strategies + MSW for social issues, sleep hygiene and regular sleep pattern.
Symptom – Weakness or difficulty walking

Ref: NHGP seniors, Julio, Baliga/Jansen Koh, Prog B neuro workshop
Stem:
Difficulty walking, weakness since teenage years. Dx: (Charcot Marie Tooth i.e. HSMN)
Causes of weakness – Localization and aetiology
Localization Pattern of weakness Aetiology Associated symptoms

Non-neurological
causes
Brain
- Extrapyramidal
- Cerebellar
- Corticospinal UMN
- Cortex
- Subcortex
- Corticospinal LMN
- AHC
- Radicle
- Plexus
- Peripheral
neuropathy
(polyneuropathy)
- Mononeuropathy
- NMJ
- Muscle
General approach
Localized/patterned weakness or not? If not, rule out cerebellar syndrome and Parkinsonism.
Objective muscle weakness or not? (Neurological axis vs. other systems/psy)
Localization of weakness - Neurological axis UMN vs LMN (AHC, root, nerves, peripheral nerves,
NMJ, muscle)
If localized, left-right asymmetrical or symmetrical? If asymmetrical, hemiparesis or monoparesis?

(stroke vs. AHC Polio/peripheral nerve)?
If localized left-right symmetrical, global or proximal or distal? (cervical myelopathy/spinal cord vs.
NMJ/myopathy vs. AHC/peripheral neuropathy – proximal on axis affects distal muscles)?
UMN or LMN or mixed/spastic or flaccid or mixed (cervical myelopathy vs. spinal cord compression
vs. AHC MND Motor Neurone Disease)?
Sensory involvement (UMN/neuropathy vs. AHC/NMJ/myopathy)?
Other neuro symptoms bowel bladder? (cortex, subcortex, cauda equina)
Aetiology of weakness
DVITAMINC
Generalized weakness/tiredness but no objective muscle weakness - Non-Neuro causes. Cardio

(CCF), Respiratory (COPD/Asthma, OSA, ILD), MSK (osteoarthritis, inflammatory
arthritis/rheumatological, deconditioning, fibromyalgia), Metabolic/Endocrine/Electrolytes
(Hypothyroidism/hyperthyroidism/periodic paralysis, DM, renal impairment, cachexia), Haem
(Anaemia, haem malignancy), Infection, Neoplasm (malignancy), Psy (Depression).
Generalized objective muscle weakness Neuro and Non-neuro causes: Neuro causes - Autoimmune
(Myasthenia gravis). Non-neuro causes - Metabolic/Electrolytes/Endocrine/Nutrition (periodic
paralysis), Neoplastic (cachexia).
Localized objective muscle weakness – Neuro causes as below.
Localized symmetrical global – cervical myelopathy/Spinal cord compression: Trauma/Degeneration

(PID, spinal stenosis, spondylolisthesis, spondylolysis), Vascular (aneurysm, spinal artery occlusion),
Infection (vertebral abscess), Neoplasm (metastatic ca, primary
meningioma/neurofibroma/ependymoma/glioma)
Localized symmetrical distal – neuropathy (sensory involvement), myopathy (no sensory

involvement). Peripheral neuropathy – Drugs (alcohol, isoniazid/ethambutol, chemotherapy),
Nutrition (B12 deficiency), Metabolic (DM, renal failure), Autoimmune (Guillain-Barré
Syndrome/CIDP Chronic Inflammatory Demyelinating Polyneuropathy), Neoplasm (Carcinomatous).
Localized symmetrical proximal – NMJ, myopathy: NMJ – Autoimmune (Myasthenia gravis).
Myopathy – Drugs (Steroids, statins), Electrolyte (hypokalaemia, hyponatraemia, hypocalcemia),
Endocrine (Hyper/hypothyroidism, Cushing syndrome, acromegaly), Autoimmune
(Dermatomyositis/Polymyositis), Neoplasm (Carcinomatous), Infection (viral/bacterial myositis)
Subjective
Screen PMH and DHx
Complaint: Weakness or difficulty walking.
- Site/characterization (Pattern of weakness/localization) – What do you mean by weak, some

examples where felt weak? Difficulty getting up from sitting/squatting, going up stairs, reaching
overhead? (Proximal weakness) Falling to one side? (corticospinal, ataxia, Parkinsonism) Which part
is weak, can point out? Generalized or weak in legs/upper limbs or one side? (global vs. paraparesis
vs. hemiparesis)
- Onset/duration, Time course, progression (aetiology) – New or recurrent? Sudden or subacute or

gradual progressive? (vascular vs. autoimmune/congenital) Diurnal variation – constant or worse
end of day? (myasthenia gravis) Self-resolved or residual weakness? (TIA vs. stroke)
Cause (localization) - Associated symptoms
- Loss of sensation/numbness/paraesthesia or no, to what level? (UMN cortex to spinal

cord/radiculopathy/peripheral neuropathy/mononeuropathy vs. AHC/NMJ/myopathy)
- Slurring of speech, blurring of vision, difficulty swallowing? Headache? (UMN e.g. stroke)
- Tremor, slow movement? (Parkinson’s disease)
- Back pain? (spinal stenosis, cord compression, PID) Injury to back or head?
- Urinary or faecal incontinence? (autonomic)
Cause (Aetiology) – SR, PMH, DHx, FHx

- PR bleed/melaena? (anaemia) fever? (infection) Previous cancers, Weight loss/appetite loss, bone
pain/night pain? (neoplasm/malignancy)
- PMH DHL, smoking/alcohol? (stroke) thyroid problems, kidney problems? (metabolic/endocrine)
- Alcohol? New medications/TCM/supplements? Steroids, statins? (drugs)
- FHx IHD/stroke? Neuromuscular disorders? Thyroid problems?
Course - “Have you had previous similar episodes? Have you seen other doctors for it? What tests
have been done? What treatment has been tried? How is the response to treatment?”
Complications/function – Medical and social
- Falls/instability, immobility?
- Functional/social impairment – How affected daily routine? BADLs Self-care, IADLs? What job, how
affected? Who is at home, how affected home/family?
Objective
PE
BMI, pulse/HR, BP
Chaperone “Request for a chaperone”
Seated
- Environment (wheelchair, walking aid, splint)
- Note speech. Inspect face (ptosis, temporalis masseter wasting, facial asymmetry), limb
posture/wasting.
– Hand dance (pronator drift, wrist drop, finger tapping/myotonia, cerebellar dysmetria KIV
dysdiadochokinesia) KIV power proximal/distal + fatiguability one side OR full UL tone, reflexes KIV
Hoffmann (UMN or LMN?), power, sensation pinprick (sensory involvement?)
- If suspecting cervical myelopathy, KIV C-spine ROM and tenderness.
- If suspecting myopathy, KIV CN: Eye group KIV fatiguability + count to 10 (myasthenia gravis). Face
group. KIV lower CN if UMN signs. Special tests – KIV percussion myotonia (myotonic dystrophy).
Gait – “Are you able to walk? See you walk to bed.” For high steppage (footdrop i.e. dorsiflexor
weakness), circumduction (UMN weakness of hip flexors).
Supine 45deg
LL – Expose “Ideally need to remove trousers but for purposes of modesty could you roll up your
pants to mid-thigh.” Inspect at foot of bed posture/wasting/skin changes (wasting – chronic LMN;
contracture – chronic UMN) + screen footdrop, tone hip roll and passive rigidity and leg lift, reflexes
KIV clonus if hyperreflexic + Babinski touch 1 st MTPJ, power. Skip heel-shin up in air touch finger then
knee then slide down then up in air. Sensation pinprick dermatomes L2 L3 medial knee L4 L5 SPN
lateral leg DPN webspace S1 lateral heel, KIV proprioception “moving your big toe this is up this is
down, close your eyes tell me up down or don’t know” x 2 of 3.
Prep presentation of PE findings: Lesion - Flaccid tetraparesis predominantly distal weakness with
accompanying sensory deficits, chronic. Localization: Peripheral neuropathy. Functional status:
Impaired mobility.
Invx
Stat: random capillary glucose, FBC, Na/K/Cr, KIV ESR, ECG. KIV X-ray lumbar spine or C-spine.
KIV send off labs – TFT, B12/folate, CK, VDRL, HIV, ANA
KIV refer ED/Neuro for: CT brain TRO haemorrhagic stroke, MRI brain, lumbar puncture.
KIV for aetiology of stroke: echo for emboli, carotid digital subtraction angiography
Management
Acute stroke/TIA
ABC
Referral: For stroke - Refer A&E, admit to stroke unit. For TIA – Refer A&E if ABCDE > …?
CT brain TRO haemorrhagic stroke then MRI brain diffusion-weighted imaging to confirm diagnosis
and type, complications e.g. hydrocephalus.
Haemorrhagic stroke: KIV craniotomy to evacuate bleed
Ischaemic stroke
- If less than 3hr of onset of ischaemic stroke (SG guidelines within 4.5hr still beneficial), KIV
thrombolysis/reperfusion therapy with IV recombinant tPA Tissue Plasminogen Activator (e.g.
alteplase). Use NIHSS National Institute of Health Stroke Scale.
- Permissive hypertension keep BP <220/120 (<185/110 if tPA candidate), control blood sugar, treat
fever/seizures
Chronic management
Other workup for aetiology/risk factors: Labs – FBC (poylcythaemia), coagulation profile, electrolytes
(hyponatraemia). ECG for AF, AMI. 2Decho for emboli, carotid imaging (duplex US or DSA Digital
Subtraction Angiography) and transcranial Doppler. Young stroke workup: autoimmune (ESR, ANA,
dsDNA, anticardiolipin IgM/IgG), prothrombotic (protein C, S, antithrombin III, factor V Leiden),
homocysteine, VDRL
Patient education
Multidisciplinary team for PT/OT/ST
Pharm: Antiplatelets aspirin, clopidogrel; anticoagulation.
Control risk factors – Stop smoking, control DHL
Treat underlying cause e.g. carotid stenosis severe 70% + symptomatic (had TIA) - refer KIV CTVS KIV
for carotid endarterectomy
Symptom – Weakness hemiparesis

Symptom/sign – LMN 7 palsy
Ref: Prog B neuro 20220806 and 20220813
Stem: Facial drooping or hearing loss.
Causes – Localization + aetiology
- Isolated LMN7: Viral Zoster, Idiopathic Bell’s palsy
- CP angle tumour: Vestibular Schwannoma/acoustic neuroma
- Diffuse: NPC.
Subjective
Objective
Vitals – Temp, HR/BP
General inspection for ptosis, facial asymmetry, limb posture/wasting.
CN examination 2 to 12 screen + detailed CN 5, 7, 8.
- CN 2 to 6 Screen vision count fingers, can see clearly all of me? Pupils dim lights check anisocoria
from afar reflexes from afar come in RAPD count of 3 skip near accommodation “look at wall, now
look at finger”. EOM and nystagmus (cerebellar).
- CN 5 sensation pinprick normal first then affected, motor power.
- CN 7 power. Go behind to look for surgical scars/radiotherapy at occiput/behind ear.
- CN 8 “do you hear this? Now close your eyes raise your left hand if you hear it on left and right
hand if you hear it on right. Equally loud both sides?” KIV Weber on vertex + left hand
counterpressure “raise your hand if you hear a sound louder on the right”. Rinne + left hand
counterpressure on top. KIV otoscopy if hearing loss.
- CN 9-12 screen open mouth, say ah, stick out tongue, turn head to look left “keep it there, resist
my movement” turn head to look right. Shrug shoulders.
UL pronator drift, cerebellar dysmetria KIV dysdiadochokinesia, KIV power proximal/distal.
Chronic – Post-stroke
Ref: Look and Proceed, Baliga/Jansen Koh, NHGP seniors, Julio
About strokes
Syndromes
Subcortical/lacunar stroke – pure motor 50%, pure sensory 5%, mixed motor and sensory 35%, ,
ataxic hemiparesis (10%), clumsy hand-dysarthria syndrome (rare)
ACA Anterior Cerebral Artery: Frontal lobes i.e. AMS, impaired judgment, gait apraxia; contralateral
LOWER limb weakness + hypoaesthesia
MCA Middle Cerebral Artery: Gaze preference towards side of lesion, ipsilateral hemianopsia,
agnosia, receptive/expressive aphasia if dominant lobe + contralateral hemiparesis + hypoaesthesia
PCA Posterior Cerebral Artery: AMS, altered memory, cortical blindness/homonymous hemianopsia,
visual agnosia.
Vertebro-Basilar Artery Occlusion: Cranial nerve/brainstem and cerebellar deficits – Visual field
deficits, diplopia/nystagmus, ipsilateral loss of sensation pain and temperature, vertigo,
dysarthria/dysphagia, syncope, ataxia + contralateral loss of sensation pain and temperature.
Short case
Stem: Pt presented with one-sided weakness.
General approach
Pick up hemiparesis
Localize stroke - Brainstem, subcortical, cortical
Look for possible aetiology – embolic (AF, heart murmur), thrombotic (carotid bruit,
xanthelasmata/xanthomata)
Rule out ddx of stroke e.g. SOL (papilloedema)
Routine
Seated
Inspect for facial asymmetry, posture UL flexed, LL extended.
Pronator drift – Localize which side is weak
Gait – “Are you able to walk?”
Seated on wheelchair/on couch 45 deg
Upper limbs: Inspect for wasting and posture. Tone for spasticity. Reflexes for hyperreflexia. Power.
If power 4 or more, test for dysmetria and dysdiadochokinesia (ataxic hemiparesis). ?Skip sensory
testing.
Lower limbs: Inspect for wasting and posture. Tone for spasticity and clonus. Reflexes for
hyperreflexia and upgoing plantars. Power. Skip cerebellar, skin sensory testing (does not contribute
much to localization).
On couch sitting up
Eyes: Pupils, EOM for contralateral CN III palsy (brainstem stroke/Weber syndrome), contralateral
CN VI and LMN VII palsy (brainstem stroke/Millard-Gubler syndrome).
Face: CN VII for ipsilateral UMN VII (subcortical/lacunar stroke). CN V for sensation – light touch, KIV
pinprick if light touch not affected).
Cortical signs: Gaze preference, visual neglect – “Look straight at my eyes while I move my fingers.
Which side is moving?”. Visual fields for homonymous hemianopia. Ask questions to check for
aphasia (dominant lobe involved).
On couch 45deg
Check pulse (AF)
Auscultate carotids (bruits), heart (murmurs)
Check peripheries for tar stains (smoking), xanthomata/xanthelasmata (atherosclerosis), DM

dermopathy (DM)
Function: UL function, pressure sores, NG tube (swallowing dysfunction), urinary catheter (?

autonomic dysfunction).
Complete: BP (hypertension), urinalysis (DM), fundoscopy for papilloedema (SOL)
Presentation
Lesion: Left hemiparesis
Findings: UMN signs increased tone, hyperreflexia, upgoing plantars on left + UL weakness affecting
extensors more than flexors and LL weakness affecting flexors more than extensors
Localization: Level of lesion is Subcortical? Cortical? At brainstem?
Aetiology: Could be thrombotic or haemorrhagic. No AF or murmur to suggest embolic stroke.
Ddx: Neoplasm (SOL of brain), infection (abscess, meningoencephalitis), metabolic/toxic

(hypoglycaemia, hyponatremia), seizures.
Functional status: Function limited by hemiparesis – unable to walk.
Complications: Pressure sores.
Consultation
Stems
- Post-stroke follow-up +/- driving
- TIA +/- driving
General approach for chronic presentation (for acute see “symptom – weakness”)
Identify underlying causes and risk factors, control
Identify complications of treatment
Identify complications of stroke – medical, psychiatric, functional (BADLs/IADLs), social including

driving, finances, caregiver
Subjective
Screen PMH + DHx
Diagnosis
- Symptoms: Weakness/numbness of limbs and face? Difficulty with speaking clearly? Loss of vision
(amaurosis fugax)?
- Time course/progression/persistent deficits (Stroke or TIA?)
Cause
- Neuro told you underlying cause of stroke/scans done?
- Headache/seizures/LOC? (haemorrhagic stroke)
- Irregular pulse/heart scan/on warfarin? (AF, murmur)
- Have DHL? Smoking/alcohol?

Control of risk factors, compliance – How is BP? Sugar? Cholesterol? Still smoking/drinking? How
taking medications/how often missed/problems taking? Physio/exercise?
Complications of treatment
- Anticoagulation - Bleeding/bruising?
- NGT – Blockage? Aspiration?
Complications of stroke
- Medical: Pressure ulcers? Pneumonia/UTI? DVT/PE? AMI?
- Psychiatric: Mood depressed/anhedonia? Memory loss?
- Functional/Occupational: DEATTH SHAFTT How affected daily routine – handedness/need help with
daily activities? Able to walk/need aid/Falls? Swallowing problems? Bladder/bowel incontinence?
How affected work? Do you drive?
- Social: Who is there at home? Who is caregiver/how coping/family support? (caregiver

competence, caregiver stress) How is home environment/type of housing/lift
landing/stairs/toilets/grab bars? How is financial situation?
Objective
PE
BMI. Pulse regularity/BP
Seated
UL: Pronator drift. Skip tone/reflexes. Power. Function - Comb hair, open bottle, pick up coin.
CN: CN VII if facial droop/swallowing impairment
Gait “See you walk to the bed.”
Lying 45deg
Heart: Auscultate for murmurs, carotid bruit
Lungs: Sit up check auscultate for atelectasis, aspiration pneumonia
Sacrum: check for sacral sores
Peripheries check for bruising, pallor
Invx
Stat - INR, HbA1c/glucose, FBC if on aspirin/warfarin, Na/K/Cr if on HTN meds. KIV ECG if AF
unknown/tachycardic
Chronic send off: lipid panel, urine ACR

Management
Medical
Control CV risk factors
- Stop smoking, alcohol
- control DHL – Target BP <140/90 (post-stroke 3 days); arrange DFS/DRP
- Preventive Care – Vaccinations
Treat underlying causes e.g.
- AF: If CHA2DS2VASc score (chart number 3; ) = 1 or more, anticoagulate. CHA2DS2VASc = CCF,

Hypertension, Age 75 or more (2 points) or age 65 or more (1 point), DM, Stroke/TIA (2 points),
Vascular disease, Sex category female. Check for contraindications to NOAC – prosthetic heart
valves, moderate-severe MS; check for bleeding risk HASBLED (chart number 5; Hypertension,
Abnormal liver function 1 kidney function 1, Stroke, Bleeding, Labile INR, Elderly > 65yo, Drugs 1
alcohol 1). Preferred agent NOAC (advantages – more effective in stroke prevention, no frequent
blood-taking for monitoring, less interaction with food/drugs; disadvantage – expensive). Warfarin
target INR 2-3 (if MVR/AVR, target 2.5-3.5); advantages – cheap; disadvantages – frequent blood-
taking, food/drug interactions.
Function - Multidisciplinary team
- PT/OT/ST for rehab – PT strengthening exercises, mobilization; OT for ADLs, home environment
assessment/modification; ST for swallowing, speech
- Community resources: Refer to Day Rehab Centre or social daycare
- Home environment modification for fall prevention – HDB EASE Enhancement for Active SEniors
programme provides subsidies for home enhancement; install ramp for home entrance, grab bars,
anti-slip treatment for bathroom
- Caregiver training, stress management, support group
Driving:
Post-stroke – Group 1 resume driving 1mth after if no weakness, otherwise refer DARP Driving
Assessment and Rehabilitation Programme. Group 2 resume driving after 1yr + DARP and Neuro
clearance
Post-TIA – Group 1 single TIA resume driving after 1mth if no weakness, multiple resume driving
after 6mth if no weakness. Group 2 single resume driving after 6mth if no weakness, multiple after
1yr + Neuro clearance.
Treat complications
- Post-stroke depression. Non-pharm: Engage family, refer psychologist for counselling. Pharm: SSRI
fluoxetine 10mg OM. Advantages – reduce depression, improves neuro functioning, independence in
ADLs. ADRs – nausea/abdo discomfort/diarrhoea, decreased libido, small increased risk of ICH, black
box warning for younger age group suicidal ideation. TCU 2wk to review.
Symptom – Weakness paraparesis

Symptom – Weakness footdrop
Symptom – Tremors and incoordination
Ref: NHGP seniors, Julio
Stem:
1. Acute tremors. Job issues.
2. Fall, tremors. Dx: Parkinson’s disease.
Causes of tremors - SR
Drugs: Alcohol/illicit drug withdrawal. OHGAs, beta-agonists, sympathomimetics, weight loss pills,
caffeine. Drug-induced PD (antipsychotics, antiemetics), cerebellar (phenytoin, lithium, valproate)
Neuro: Parkinsonism/Wilson’s disease, stroke, Cerebellar syndrome
Endocrine: Hypoglycaemia, Thyrotoxicosis
Psy: Psychogenic tremor/Anxiety
Idiopathic: Essential tremors, physiological tremors

Subjective
2. Co-morbidities
- Screen for PMH: Parkinson’s disease? Thyroid disease? Asthma/COPD? (beta agonists)
- DHx – medication list?
1. Complaint (SRSOTCTERA)
- Site: Unilateral/bilateral? (Parkinsonism vs. others) UL/trunk/voice? (essential)
- Onset/duration/Timing/Progression: When, how long? New or recurrent? Acute or gradual? Same

through day or provoked? Getting worse? (Parkinsonism)
- Character: Resting vs. action, intention, postural? (Parkinsonism vs. others, cerebellar) involuntary
purposeless movement fidgety? (chorea)
- Triggers: Hunger? (hypoglycaemia) Stop alcohol? (alcohol withdrawal, essential tremors)

Stress/anxiety, caffeine? Fine movements?
- Exacerbating: Stress/anxiety, physical exertion, caffeine? (physiological) Distraction?

(Parkinsonism)
- Relieving: Rest/action? Alcohol? (essential tremor) Distraction? (psychogenic)
- Associated symptoms: Weakness/numbness/difficulty speaking clearly, BOV/diplopia? (stroke)

Unsteady gait? (cerebellar syndrome) Slow movements, stiffness, falls, memory loss? (Parkinsonism)
3. Cause – PMH, symptoms/SR, RF BPS, screening/invx. Systems review
- Drugs: Alcohol intake, illicit drugs? (alcohol withdrawal) DM medications (OHGAs), asthma
medications (beta-agonists), OTC flu medications (sympathomimetics), weight loss pills, caffeine?
Epilepsy drugs (cerebellar), psy drugs (Parkinsonism)?
- Neuro: Slow movement/falls/memory loss, FHx of Parkinsonism/liver disease? (Parkinsonism) PMH

stroke, weakness/numbness slurring, CV risk factors DHL/smoking? (stroke) Unsteady gait?
(Cerebellar syndrome)
- Endocrine: On insulin/OHGAs, hunger pangs when missed meals, cold sweats? (Hypoglycaemia)
weight loss/increased appetite, heat intolerance, palpitations, loose stools, insomnia?
(hyperthyroidism)
- Psy: Constant worrying unable to stop, panic attacks? (Anxiety)
- Idiopathic: FHx of essential tremor? (Essential tremors) Worse with caffeine/physical exertion
/emotional stress, excessive alcohol use? (physiological tremors)
4. Course
- Seen doctor? Invx? treatment, response?
5. Complications (treatment/disease, medical/functional/social)
- Function: Falls in last 1 yr, ambulation need walking aid, immobility? Hand dominance? How
affected daily routine, BADLs/IADLs – handwriting, drinking water, putting on makeup? What work
(pilot, surgeon?), impact, hobbies? Home? Home environment?
6. Concerns
- PMH asthma/COPD? (beta-blockers)
Objective
PE
BMI, weight trend for loss (hyperthyroid, drugs). Vitals – Temp, pulse + HR/BP KIV postural BP for
Parkinsonism
Sitting
Environment: Walking aid, shoes
General inspection: Anxious, hyperthyroid, resting pill-rolling tremor (Parkinsonism)
Eyes: Exophthalmos/lid retraction (Graves’ disease/hyperthyroidism), jaundice
Face: hypomimia (Parkinsonism), facial asymmetry (CN 7).

KIV CN EOM for Parkinson’s plus.
Neck: Goitre “swallow saliva”
Hands/UL neuro: Thyroid acropachy. Hand dance – postural tremor with paper, finger apposition for
bradykinesia. Dysmetria KIV dysdiadochokinesia. Tone – lead-pipe, cogwheel rigidity. KIV reflexes,
power proximal/distal.
Gait – Ataxic, Parkinson’s (stooped posture, slow ignition, shuffling, reduced arm swing, turning en
bloc)
KIV function – Open cap, take out coin, write name on paper.
Invx
Stat: capillary glucose. KIV ECG.
Previous tests/send off – TFT. KIV LFT (Wilson’s disease). KIV refer Neuro/ED for brain imaging if
suspecting cerebellar disease.
Assessment and Plan
Drug-induced. Stop offending drug.
Parkinsonism. See Parkinsonism.
Thyrotoxicosis.
Essential tremors. AD Autosomal Dominant inheritance, present in midlife peaks at age 70. Non-
pharm – Avoid caffeine and overuse of sympathomimetics. Pharm – Beta-blockers e.g. Propranolol
20mg BD (?60mg TDS to 320mg TDS; CI: asthma/COPD, heart block ADR: postural hypotension,
fatigue, erectile dysfunction). Alternatives – Gabapentin, topiramate. TCU 2w review.
Medicolegal aspect. Discuss job with employer.
Syndrome/Chronic – Parkinsonism
Ref: Look and Proceed, Baliga/Jansen Koh/James Loo, NHGP seniors, Julio
About Parkinsonism
Diagnostic criteria
UKPDS Brain Bank clinical diagnostic criteria for Parkinson’s Disease:

1. Parkinsonism: ATRP Akinesia/bradykinesia + 1 or more of Tremor rest 4-6Hz, Rigidity, Postural
instability
2. Exclude Parkinson-plus features early in course and secondary causes, negative/poor response to
levodopa
3. Supportive features: Unilateral onset/asymmetrical, rest tremor, levodopa responsive, progressive

over 10 or more years
Hoehn-Yahr stage 1 to 5 of severity – Unilateral parkinsonism to bedbound/wheelchair-bound.
Ddx – Vascular Parkinsonism/stroke, NPH
Aetiology of Parkinsonism
A. Parkinson’s Disease/idiopathic
B. Parkinson-plus syndromes:
- PSP Progressive Supranuclear Palsy - vertical gaze palsy falls going downstairs/cannot read
newspaper, postural instability/early falls within 1 st year due to axial rigidity (vs idiopathic PD usually
3yr), frontal lobe signs
- MSA Multiple System Atrophy (cerebellar signs, autonomic postural hypotension/urinary

incontinence or retention/erectile dysfunction, corticospinal hyperreflexia upgoing plantars)
- CBGD Cortico-Basal Ganglionic Degeneration (limb apraxia/alien limb syndrome, dystonia)
- Diffuse Lewy Body Dementia (cognitive impairment, neuropsychiatric)
C. Secondary causes:
Drug-induced (antiemetics e.g. metoclopramide, phenothiazines e.g. prochlorperazine, neuroleptics

e.g. chlorpromazine/trifluoperazine, lithium, recreational MPTP), alcohol, carbon monoxide
poisoning
Vascular: Anoxic brain damage/ischaemic encephalopathy, Atherosclerosis/”Vascular Parkinsonism”
Infection: Post-encephalitis, HIV
Trauma: Repeated head injury
Neoplasm: Frontal meningioma
Congenital/genetic: Wilson’s disease (young), Huntington’s disease
Complications
Of treatment:
- Levodopa DDDOOPA Dystonia/Dyskinesia, Depression, On-off motor fluctuations/wearing Off

phenomenon, Postural hypotension, Abdominal nausea/constipation
- Dopamine agonists (bromocriptine, ropinirole, pramipexole) – Hallucinations/psychosis, nausea
- Anti-cholinergics (benzhexol/trihexyphenidyl , benztropine) – Blurring of vision, dry mouth, urinary

retention, constipation, giddiness/confusion
Of disease:
Motor - Recurrent falls/instability, immobility, swallowing difficulty.
Non-motor – Sleep disturbances; Neuropsychiatric dementia, depression, psychosis; Autonomic

postural hypotension, constipation, urinary retention or overflow incontinence, erectile dysfunction
Short case
Stem: Patient with recurrent falls. Examine the upper limbs/Examine the gait/Examine the lower
limbs/Examine the face.
General approach
Pick up signs of Parkinsonism
Rule out Parkinson’s plus syndromes, secondary aetiologies (Wilson’s disease)
Look for complications of treatment (dyskinesia)
Determine impact on function (writing)
Examination routine
Seated
General inspection: Environment – Walking aid. Face - Hypomimia/mask-like facies (fixed stare,
infrequent blinking, ironed-out wrinkles, drooling). Hands – Unilateral resting pill-rolling tremor.
Upper limbs: Hand dance - pronator drift (stroke), wrist dorsiflexion for weakness (stroke), finger
apposition (thumb to index) for bradykinesia (Parkinsonism). Tone lead-pipe, cogwheel rigidity -
flex/extend wrist not circumduct; accentuate by moving contralateral arm up and down. +/- Reflexes
for hyperreflexia and upgoing plantar response (MSA Multi-System Atrophy). +/- Power. Cerebellar
screen for dysmetria (MSA).
Face/CN: Inspect - Seborrheic dermatitis of face. Eyes – Kayser-Fleischer rings (Wilson’s disease),
EOM and vertical movements for impaired vertical gaze down/up, if unable to do overcome by
vertical Doll’s reflex (PSP Progressive Supranuclear Palsy); close eyes for blepharospasm. Glabellar
tap/Myerson’s sign – “Going to stand behind you and tap between your eyes; look straight ahead at
the wall.”
Gait – Decreased arm swing, stooped posture, difficulty initiating gait, shuffling +/- festinating gait
(catch up with centre of gravity), turning en-bloc/in numbers (Parkinsonism). Apraxic gait (NPH?).
Complete: Examine gait if not done, handwriting/button – micrographia, ask questions to assess
speech – monotonous speech. Postural BP – orthostatic hypotension (MSA). AMT for cognitive
impairment (Lewy-Body Dementia, Idiopathic/Parkinson’s Disease, PSP, Wilson’s disease, CJD). Ask
history – falls/instability, drug history for drug-induced Parkinsonism, FHx for Wilson’s disease.
Presentation
Lesion: “Parkinsonism”
Findings: “Hypomimia, asymmetrical resting pill-rolling tremor, lead-pipe rigidity at elbow +

cogwheel rigidity at wrist, bradykinesia, reduced arm swing difficulty initiating shuffling gait turning
en bloc”
Aetiology: “Possible aetiology is Parkinson’s Disease/idiopathic. No features of Parkinson’s plus

syndromes such as vertical gaze palsy (PSP), upgoing plantar response or cerebellar signs (MSA).”
Complications and function: “Disabled by severe bradykinesia. No dyskinesias from levodopa

therapy.”
Consultation approach
Stem: Frequent falls.
Subjective
Screen for PMH (DHL, schizophrenia), DHx (anti-emetic, anti-psychotic, recreational drugs like
MPTP), alcohol use
Diagnosis – Symptoms (A + TRP), onset/time course
- HOPC: 1st time or recurrent? Fall hx Pre-fall weakness/giddiness? During fall MOI – Tripped? Post-
fall injuries? Screen for other intrinsic causes of falls e.g. vision? Screen for extrinsic causes e.g.
environment?
Cause – Rule out secondary Parkinsonism and Parkinson-plus
- Parkinson-plus and mimics – Vertical gaze palsy cannot see stairs/read bottom of newspaper,
falls/instability early within 1st year? (PSP) Postural giddiness? (MSA-P, MSA-C) Memory problems,
sleep disturbances, hallucinations? (LBD) Alien limb? (CBGD) Memory problems, walking difficulties,
urinary incontinence/retention? (NPH) Repeated strokes and stepwise progression – condition
worsened sharply after each stroke? Predominantly lower limb symptoms? (vascular parkinsonism)
- Drugs – Took any new medications for vomiting or psychiatric medication before it started e.g.
metoclopramide, chlorpromazine? MPTP?
- Infection – Brain infection before?
- Trauma – Repeated head injuries?
- Congenital – Liver problems/Family history of Wilson’s disease? Huntington’s disease?
Course – Followed up with Neuro? Done scans/tests? Given medication/therapy? Response to

medication?
Compliance – Medication list, taking on time/missed medication? Taking correctly empty stomach
30-60min before meal?
Complications of treatment:
- Levodopa DDDOOPA Dystonia/Dyskinesia – Involuntary abnormal movements? Depression –

Depressed mood? On-off motor fluctuations/wearing Off phenomenon – On and off freezing/slow
movement less than 4 hours after last dose of meds? Postural hypotension – Giddiness when
standing up? Abdominal - nausea/constipation?
- Dopamine agonists (bromocriptine, ropinirole, pramipexole) – Hallucinations/psychosis? nausea?
- Anti-cholinergics (benzhexol/trihexyphenidyl , benztropine) – Blurring of vision? dry mouth? urinary

retention? Constipation? Giddiness/confusion?
Complications of disease:
- Motor – Falls in last 1 year/how many? Fear of falling? Immobile because of fear? Swallowing
difficulty?
- Non-motor – Sleep disturbances? Dementia – Memory loss? Depression – Mood down? Psychosis –
hearing/seeing things not there? Autonomic - postural giddiness? Constipation? urinary retention or
overflow incontinence? erectile dysfunction – problems with sex?
Co-morbidities – if not screened above.
<start taking postural BP here seated, then stand and continue SHx>
ICEKAPS – Patient’s understanding of disease (progressive)?
SHx
- Other psychosocial impact – Affected ADLs, work, home life/family? Finances? Mood?
- Home – Type of housing? Lift-landing? Home modification?
- Caregiver stress?
- End-of-life plans?
Objective
PE
Postural BP seated, stand <take ICEKAPS and social history>

General inspection: Face - Hypomimia/mask-like facies. Hands – Unilateral resting pill-rolling tremor,
limb posture (ddx stroke/vascular parkinsonism, MSA).
Standing
Face/CN: Inspect - Seborrheic dermatitis of face. Eyes – Kayser-Fleischer rings (Wilson’s disease),
EOM and vertical movements for impaired vertical gaze down/up, if unable to do overcome by
vertical Doll’s reflex (PSP Progressive Supranuclear Palsy); close eyes for blepharospasm. Glabellar
tap/Myerson’s sign.
Gait “See you walk to the bed, turn around, walk back and sit down.”
Seated
Upper limbs: Hand dance - pronator drift, finger apposition (thumb to index) for bradykinesia
amplitude decreasing when fast is positive. Tone lead-pipe, cogwheel rigidity (more common) -
accentuate by moving contralateral arm up and down. Comment on power “Able to lift up arms so
good anti-gravity power”. Cerebellar screen for dysmetria.
Invx
FBC, UFEME (multiple myeloma etc)
Assessment and Plan
Diagnosis/Problem Management
Parkinson’s Disease – new diagnosis Patient education
- Diagnosis – “Likely Parkinson’s Disease –
progressive condition caused by degeneration
of part of the brain (substantia nigra) affecting
movement”
- goals of care – control motor and non-motor
symptoms, improve QOL quality of life, prevent
falls and maintain independence in mobility
and ADLs
Invx and Referral

Refer Neuro for investigations if symptoms not
atypical of idiopathic PD - Brain imaging (rule
out NPH, multi-infarct syndrome, Parkinson
plus)
If young, rule out Wilson’s disease – refer Eye
for slit lamp examination (Kayser Fleischer
rings), Neuro for serum caeruloplasmin and 24h
urine copper
Multidisciplinary refer to PT/OT/ST
If end-stage, refer Palliative care
Motor symptoms
Non-pharm
PT/OT for exercise therapy/gait training,
mobility aids
ST for speech quality, dysphagia, KIV tube
feeding
Pharm
Bradykinesia – Levodopa + decarboxylase
inhibitor e.g. benserazide/Madopar 62.5mg TDS
(titration: increase 62.5mg max 250mg TDS KIV
Madopar HBS long-acting for night; admin: take
30min before food empty stomach; golden
period of effectiveness is 10yr). Others:
carbidopa/Sinemet. ADRs: DDDOOPA
dyskinesia abnormal involuntary movement,
on-off freezing/slow movement when
medication wearing off, postural hypotension,
nausea
- Dopamine agonists e.g. bromocriptine,
ropinirole, pramipexole. Population: Younger
age <65yo, mild disease. ADR:
nausea/constipation, insomnia, hallucinations.
- Others MAOI e.g. selegiline, COMT inhibitors
e.g. entacapone, antiviral amantadine
Tremor – Anticholinergics
(benzhexol/trihexyphenidyl 2mg BD,
benztropine 2mg BD). ADR: Blurring of vision,
dry mouth, urinary retention, constipation,
giddiness/confusion
Surgical
Refer NNI for deep brain stimulation or lesion
surgery (thalomotomy or pallidotomy)
Non-motor
Sleep disturbances – Sleep hygiene
Neuropsychiatric dementia – Donepezil,
rivastigmine
Depression – SSRI (CI with selegiline –
serotonergic crisis) or amitryptiline
Psychosis – Clozapine (ADR: leukopenia),
quetiapine. NOT olanzapine
Autonomic postural hypotension –
Fludrocortisone (ADR: hypertension,
hypokalemia, ankle oedema)
Constipation – Lactulose
Nausea – Domperidone
Erectile dysfunction – Sildenafil (ADR: priapism,
headache/blue vision/flushing, cardiac
arrest/hypotension)
TCU
TCU 1wk to review side effects, titrate dose
Levodopa side effects Dyskinesia – Reduce dose, increase frequency.
Inform Neuro KIV add amantadine.
Wearing Off – Increase frequency BD to TDS,
reduce dose slightly/keep same dose, avoid
high protein meals 30-60min after meds
Postural hypotension – Adequate
hydration/increase salt intake, get up slowly,
countermanoeuvres leg crossing/squatting,
devices stockings; Pharm 1st line
Fludrocortisone 50mcg OD (max 300mcg OD),
2nd line midodrine 10mg OD
Abdominal – Nausea domperidone (low risk of
extrapyramidal side effects), constipation
Lactulose
Symptom – Numbness and paraesthesia

Ref: NUP bridging case 122, prog B neuro, NHGP seniors
Stem:
55/Mal/M b/g poorly-controlled/defaulting DM lipids, unscheduled visit for numbness/paraesthesia

in feet. Dx: Diabetic peripheral neuropathy, poorly-controlled DM non-adherence due to social
issues.
Causes - Localization of numbness/paraesthesia
Localization Pattern of weakness Aetiology Associated symptoms

Non-neurological V: PVD Peripheral
causes Vascular Disease
M: Hypoglycaemia
Psy: Anxiety/Panic
attacks
Brain Unilateral V: Stroke/TIA
Trauma: ICH
Neoplasm: SOL,
metastases
Primary: Migraine,
migraine with aura
Bilateral I: Meningitis
A: Multiple sclerosis
Spinal cord – Spinal T/D: Spondylosis
stenosis
Nerve root – T/D: PID
Radiculopathy
Plexus – Brachial T: Trauma
plexus / Lumbosacral C: Erb’s palsy
plexus
Peripheral nerve Glove and stocking Peripheral neuropathy
(polyneuropathy) - Common: DM,
alcohol, B12
deficiency
- D: Alcohol,
Metformin, isoniazid /
ethambutol /
metronidazole
- A: GBS / AIDP / CIDP
- M: DM, CKD, B12
deficiency
- N: Cancer
- C: CMT / HSMN
Mononeuropathy Median nerve Carpal tunnel
- Nerve entrapment Ulnar nerve syndrome
- Mononeuritis Radial nerve - Idiopathic + risk
multiplex factors: Pregnancy, Hx
of wrist fracture /
repetitive strain /
vibrating tools
- D: Drugs
- A: RA
- M: Pregnancy, DM /
obesity,
hypothyroidism,
acromegaly
Mononeuritis
multiplex
- Common: DM
- A: RA, SLE,
Vasculitis /
polyarteritis nodosa
- M: DM
- N: Lymphoma /
leukaemia direct
involvement,
paraneoplastic
syndrome,
amyloidosis
Subjective
2. Co-morbidities
- Screen for PMH (DM)

- DHx – medication list, new meds? (metformin, chemotherapy) alcohol, smoking?
1. Complaint (SRSOTCTERA) - Localization
- Site/Radiation: Where is numbness/tingling, can point out? One side or both sides, Hands – which
peripheral nerve distribution, LL – Stocking distribution? Radiation from neck?
- Onset/duration/Timing/progression: When started/How long? New or recurrent? Sudden or

gradual? Constant or intermittent, same through day or worse at night? Same or getting worse?
- Character: Numbness / sensory loss? Pain, burning / electric-shock, shooting, stabbing?
- Triggers
- Exacerbating: At night / on waking / using vibrating tools (carpal tunnel syndrome), turning neck
(cervical spondylosis)
- Relieving: Shaking hands out? (CTS / entrapment neuropathy) Analgesics for pain?
- Associated: Weakness, where? Difficulty speaking clearly, difficulty swallowing, double vision?
(Brain) Recurrent pounding headache, nausea, photophobia/phonophobia, flashing lights?
(migraine) Neck, Loss of balance, walking on cotton wool? Back pain, radiation down lower limbs,
bladder or bowel incontinence? (spinal) Leg pain worse with walking, Smoking? (vascular
claudication)
3. Cause/Aetiology – PMH, symptoms/SR, RF BPS, screening/invx
- DVITAMINC or Systems review head to toe, Risk factors (travel/contact/sex, FHx),
- Drugs: Alcohol? Metformin, chemotherapy? TB medications (Isoniazid, ethambutol) or antibiotics

(metronidazole)?
- Infection: Hx of brain infection? (meningitis) Risk factors for infection including STIs – multiple sex
partners, CSW? (HIV, syphilis)
- Trauma: Injury to neck/back? Hx of wrist fracture, repetitive strain / chronic vibration, prolonged
cold exposure?
- Autoimmune: Recent URTI? Joint pain, rashes/ulcers? (vasculitis)
- Metabolic/Endocrine/Electrolytes/Nutrition: Hx of DM/smoking? (DM) Weight gain, cold

intolerance, lethargy, constipation, oedema? (hypothyroidism) Change in facial features, change in
glove size, headache? (acromegaly) Kidney problems? (Renal failure) Metformin 4mth or more,
vegan? (B12/folate deficiency)
- Neoplasm: Hx of cancer, LOW/LOA?
- Congenital: FHx of nerve problem? (Charcot Marie Tooth)
- Psy: Anxious, panic attacks?
4. Course (prev episodes, invx, treatment, response)
- Seen doctor? Invx blood tests, NCS/EMG? Medications?
- Psy: Affected sleep, mood? Anxiety?

- Function/Occupation/Social: If UL involved, handedness? How affected daily routine, ADLs/IADLs?
What work/impact on job, hobbies, home, finances?
6. Concerns
- ICEKAPS understanding of condition? Expectation of treatment?
Bucket list general
Contraindications to treatment – Allergies, PMH
PMH, Drugs TCM OTC/Alcohol/Smoking/illicit drugs, FHx
SHx WASHED (work/hobbies, accounts, smoking/alcohol, home, exercise, diet)
Psych PHQ2 (depressed, anhedonia), GAD2 (anxious, unable to stop worrying)
Objective
PE – Peripheral neuropathy LL
BMI + weight trend, Vitals Temp, HR/BP
Chaperone + Expose “Request a chaperone. Need to take off socks and shoes, ideally remove pants
but for purposes of modesty will ask you to roll up your pants to mid-thigh.”
Environment – Walking aids, footwear (fitting size, covered, asymmetrical wear and tear)
General inspection: Anxious appearing, acromegalic facies.
Sitting: KIV screen neck AROM (lateral flexion, flexion/extension) if suspecting cervical myelopathy.
KIV goitre “swallow”. KIV pronator drift.
Romberg. Gait - “See you walk to door, turn around, walk to couch.” High-stepping (footdrop ankle
dorsiflexor weakness), broad-based.
Supine 45deg
Foot + LL neuro: Inspect – Skin changes macerated skin fissures/erythema/calluses/gangrene, bony

deformities Charcot foot. Screen footdrop KIV SLR. Vascular – Pink, temperature, pulses DP and PT.
KIV tone. Reflexes – Diminished ankle jerk, skip clonus. Power – Distal weakness. Skip heel-shin.
Sensation – Pinprick demonstrate on back of hand then forehead “this should feel like a sharp
poking” <dermatome L2 to S1 KIV skip if pressed for time> then stocking neuropathy “is it sharp?”;
proprioception IPJ big toe “I’m going to move your toe - this is up, this is down. Tell me up, down or
don’t know?” KIV vibration 128Hz if proprioception normal. KIV monofilament if have time.
PE – CTS
BMI, weight trend. Vitals – Temp, HR/BP
Sitting
General inspection: Anxiety, acromegalic facies
Neck: Goitre “Swallow”. C-spine ROM, tenderness, Spurling
Screen pronator drift, wrist drop + cross fingers + OK sign
UL neuro: Tone, reflexes, power
Then hand power + sensation + special tests: Scree
Peripheries for Dupuytren contracture, parotidomegaly (alcohol), DM dermopathy
Invx
Stat – HbA1c/capillary glucose, Na/K/Cr, FBC for macrocytic anaemia. KIV X-ray C-spine (chronic neck
pain ?spondylosis) or lumbar spine.
Send off – TFT, B12/folate.
KIV refer for nerve conduction study (reduced or absent SNAPs sensory nerve action potentials,
prolonged latency), MRI spine
Assessment and Plan
Diabetic peripheral neuropathy. Control DM and risk factors. Non-pharm: Foot care advice – avoid
going barefoot wear proper footwear fitting covered shoes/socks, test bathwater temperature, trim
toenails remove sharp edges, check feet daily + regular DFS. Pharm: For neuropathic pain –
Gabapentin 100mg ON (Disadvantages: Sedation avoid driving/heavy machinery, Slow onset 2mth
for good effect), pregabalin 75mg OM (Disadvantages – Expensive), amitriptyline 10mg OM
(Disdavantages – sedation, anticholinergic effects? CV risk? Slow onset 6wk for good effect),
venlafaxine 37.5mg OD (Advantages rapid onset 1wk for good effect max effect 6wk). Referral/TCU:
KIV refer Neuro for NCS, chronic pain specialist for TENS, lignocaine injection, spinal stimulation. TCU
2-4weeks to titrate neuropathic pain meds.
Carpal tunnel syndrome. Conservative – Activity modification, reduce repetitive wrist movements,
night splinting. Invasive – Refer Hand KIV steroid injection, carpal tunnel release.
Psychiatry Adult/Geriatric/Paediatric, Acute/Emergency vs.

Chronic/Preventive/Palliative
Syndrome – Depression
Ref: NUP Bridging Case 108, NHGP seniors, Julio
Stem:
Low mood, loss of interest
Elderly presenting with functional decline or forgetfulness
Subjective
If elderly, rule out delirium
Screen PHQ2 for low mood and/or anhedonia and duration – Mood down/depressed/hopeless? Less
interest/pleasure in doing things/usual activities?
Elicit predisposing (premorbid personality/previous episodes), precipitating/perpetuating factors –

Recent events in family/home/work? Loss of loved one?
Elicit impairment in social and occupational functioning: BADLs – care for self? IADLs – manage bills,
take public transport? Safety?
Elicit other PHQ9 symptoms + score severity at the same time (chart no. 8) – SIGECAPS Sleep had
trouble falling asleep/staying asleep/early morning wakening/sleeping too much?, Interest (as
above), Guilt feel bad about self/let others down?, Energy little/tired?, Concentration trouble
focussing on daily activities?, Appetite poor/lost weight/overeating?, Psychomotor moving/speak
slowly or more restless than usual noticeable to others?, Suicide – felt life not worth living/better off
dead?
Suicide risk assessment active/passive, low/moderate/high risk, protective factors – Previous

attempt, Thought, intent, plan, Protective factors
Rule out mania; anxiety – anxious constantly? Unable to stop worrying?; psychosis
Rule out drugs and organic illness – New medications/alcohol/illicit drugs?
ICEKAPS
Objective
PE
BMI + weight trend, Vitals BP HR
Gait by observation
Prepare MSE for 1min clarification – ASEPTIC “Elderly gentleman Appears well-kempt in t-shirt and
long pants eye contact reduced behaves appropriately, Speech gives short answers relevant,
Emotion mood depressed tearful affect blunted/reactive smiles appropriately, Perception no
hallucinations, Thought no delusions normal content and process, Insight good, Cognition intact.”
Invx
PHQ9 for severity of depression (done above)
AMT
Labs: Stat - FBC, Na; Subsequent for reversible causes of cognitive impairment – TFT, B12, Calcium,
LFT
Management
Refer – Psychiatry if severe. Psychologist for psychotherapy/CBT. MSW for financial concerns
Non-pharm
Patient education
Social support – Family members, befriender service
Stress management – refer counsellor/psychologist for mindfulness, exercise
Pharm
If PHQ9 moderate severity (xx?), offer SSRIs
TCU/red flag return advice - TCU 2weeks review SSRI side effects. 1-SOS hotline. Anticipate triggers
that precipitate poor mood (death anniversary, objects/places that remind about loss of loved one)
Chronic – Opioid/substance use disorder
Ref: NUP bridging case 99, uptodate, MOH CPG Opioids 2021
Stem
Chronic back pain/knee pain (non-cancer) came to collect opioid medication e.g. codeine, tramadol,
oxycodone.
Chronic cough came to collect Procodin/Dhasedyl.
General approach
Suspect opioid use disorder: In requesting for opioids, doctor hopping
Assess opioid dependence (tolerance, withdrawal symptoms on discontinuation)
Assess willingness for treatment, type of treatment (previous treatment, patient preference)
Diagnosis – DSM-5 for Opioid Use Disorder
- Problematic pattern of opioid use
- Duration over 12months
- Causing clinically-significant impairment or distress
- Features 2 or more of: 1. large amounts + tolerance, unable to cut down, 2. craving/withdrawal
symptoms 3. Significant time spent obtaining/recovering from effects 4. affects obligations
work/school/home or social/occupational/recreational activities 5. continues despite recurrent
problems or physically hazardous
Subjective
RFE – Collect medication
HOPC
- Character: Which medication? Taking for what reason, old problem or new problem?
- Onset/duration: Taking how long, more than 14 days?
- Severity: Taking how much, how often? Go to other clinics to collect? Used for non-medical
reasons?
Complications
- Withdrawal/Dependency: Do you think you might be dependent on it? Need to take more and
more? If not taking/cut down, what happens? Withdrawal symptoms - Neuro
restlessness/anxiety/insomnia; MSK – Myalgia; Skin – Sweating; Eye lacrimation/pupil dilation; GI
nausea/vomiting/abdominal cramping/diarrhoea?
- Overdose: Ever took too much?
- Neuro: Drowsiness? Falls?
- GI: Constipation?
- IVDA – Infective endocarditis?
Co-morbidities
- PMH: OSA/obesity, liver impairment, renal impairment?
- DHx: Medication list, Use of other substances medication (BZD), alcohol, smoking, recreational
drugs?
- Psy: MAPSO. Mood mood/anhedonia, reason, suicidality? Anxiety? Psychosis hallucinations?

Substance use? Organic and others i.e. medical.
Concerns
- Impact of pain on daily routine/work? Expect zero pain, why?
- Other analgesics tried?
- Contraindications to NSAIDs/coxibs asthma, gastritis, renal impairment
Complete BPS history especially social background
- Occupation – driving, heavy machinery?
Objective
PE
Complications – acute intoxication (sedation, slurred speech, pinpoint pupils, respiratory depression)
withdrawal. Co-morbidities – IV or nasal drug use.
BMI and trend, vitals Temp/BP/HR, respiratory rate for resp depression < 8/min
General: Cachexia
Peripheries: IVDA track marks, self-harm scars
Eyes: Pinpoint pupils,
ENT: Nasal septum deviation/perforation
KIV heart murmur
Abdomen: Faecal loading, KIV DRE
MSE: A - Kempt/eye contact/psychomotor retardation; S – Reserved; E – Flattened affect, depressed

mood, congruent; P- Auditory or visual hallucinations; T – Suicidal ideation, delusions; I – Insight; C.
Invx
Scores – PHQ9
Stat – X-rays of painful areas. ECG for prolonged QTc. Cr for renal impairment.
Send off – LFT for liver dysfunction, screen IVDA for blood-borne viruses HIV/Hep B/Hep C.
Assessment and Plan
Chronic pain. Patient education – Expectation of painkillers to alleviate symptoms but not zero pain,
not treat underlying condition.
Opioid Use Disorder. Patient education and MI - Opioid use disorder, heard of it? Tolerance (Using
too much too frequently making it less effective in long run, need more and more to achieve same
effect) and withdrawal (effects on body when stopped). Opioids inappropriate for mild non-cancer
pain, codeine lack of evidence in reducing severity/frequency of cough and should not be continued
more than 1mth risk of dependence. Stage of change? Referral/notification – Refer to Addiction
Specialist/Psychiatrist at NAMS National Addictions Management Service for detoxification,
addiction counselling/psychotherapy treatment, self-help/support groups Narcotics Anonymous,
MSW, KIV medications. Report to CNB Central Narcotics Bureau and MOH Ministry of Health within
7 days through eNOTIF (regulation 19 of Misuse of Drug Regulations) – “Obliged to inform MOH and
CNB, purpose is to help you, not saying that you are drug addict but to give you support you need to
cut down”. Pharm – KIV opioid antagonist (naltrexone) while undergoing detoxification. Manage
pain - No opioids for pain, offer non-opioid alternatives according to WHO analgesic ladder e.g.
regular paracetamol, NSAIDs (e.g. PO diclofenac, IV ketorolac)/coxibs (etoricoxib), neuropathic pain
e.g. gabapentin; non-pharm e.g. ice pack/heat pack, physiotherapy/exercise, acupuncture; KIV refer
Chronic Pain Specialist. Manage co-morbidities – Smoking cessation, alcohol cessation advice.
Manage other complications – Anxiety/insomnia (hydroxyzine), Constipation (lactulose regular
dose), nausea (metoclopramide, promethazine). TCU/Red flags – Will need treatment and follow-up
6-12 mth. Red flags of overdose (drowsy, respiratory depression) and interaction with other
medications (BZD, sedative). Prev – Hep A and B vaccination.
Syndrome – Eating disorder

Stem
Parent concerned about weight loss and restricted eating habits
Teenage female with absent/irregular menses
Teenage female with stress fracture
Teenage female with constipation
Ddx of eating disorder
Primary eating disorder

- Anorexia Nervosa (restrictive type). DSM5 criteria: A. Restricted energy intake + low bodyweight B.
Fear of gaining weight intense OR behaviour interfering with weight gain C. Disturbance in
bodyweight experience/self-evaluation. Type – binge eating-purging type (recurrent binge eating
vomiting laxatives diuretics in last 3mth) vs. restricting type (none). Severity – Mild moderate severe
extreme - BMI 17 or more 16 15 below 15. Remission - partial or full.
- Bulimia Nervosa (increased food intake, compensatory behaviour vomiting/laxatives/diruetics, self-

image affected, duration 3mth)
- Female athlete triad (disordered eating, amenorrhoea, osteoporosis)
Secondary causes of weight loss
- Metabolic/endocrine: DM (polyuria, polydipsia), hyperthyroidism (tremors, heat intolerance)
- Nutritional/GI e.g. malabsorption/IBD (diarrhoea, PR bleeding, night blindness, numbness)
- Neoplasm: Malignancy (LOA + LOW, FHx of cancers?)
Complications of eating disorder/co-morbidities
- Female Athlete Triad – Amenorrhoea, Osteoporosis/Fragility fractures
- Cardiovascular: Bradycardia/arrhythmias, hypotension/postural hypotension
- Metabolic/endocrine/nutritional: Electrolyte imbalance hypokalaemia, refeeding syndrome
- Derm: Hair loss, dry skin
- Psy: Depression, anxiety, suicidal ideation
Subjective
HOPC restrictive eating/weight loss – “tell me more about eating habits” + SRSCOTETRFA
- Severity – How much weight loss/duration/intentional? Dietary habits?
- Characterize – Restrictive eating? Binge eating and purging/laxatives/diuretics?
Cause
Primary Eating Disorder. SCOFF 2 or more – Sick make self vomit because full Control lost over eating
Over 3mth lost 6kg F fat feel fat F food controlling food dominates life.
- Anorexia Nervosa. Low weight: Weight, height, BMI? Weight loss, intentional? Fear of gaining
weight – Fear gaining weight/why precipitating events unkind comments? Distorted perception
undue influence on self worth - Ideal weight to you? Restrictive eating: Diet – Can you tell me what
you eat in a day from breakfast to evening time? Any weight loss pills/binging/purging/use laxatives
to get diarrhoea/? Exercise – tell me about what you do for exercise… TFITR type, frequency,
intensity, time, rest/recovery? Fhx of eating disorders, psychiatric conditions.
- Bulimia Nervosa.
Secondary causes of weight loss

- Met/Endo: DM – polyuria, polydipsia? Hyperthyroidism - Increased appetite, heat intolerance
tremors, palpitations?
- Nutrition/GI: IBD – bloody diarrhoea, oily floating stools?
- Neoplasm: Malignancy – LOA, fever/sweating at night, swollen lymph nodes, Fhx of cancers?
Complications, co-morbidities
- Female Athlete Triad (Disordered eating, amenorrhoea, osteoporosis): Amenorrhoea/Menstrual hx

– LMP… Tell me about menses… regular? Romantic relationship, sexual intercourse? Confirm dx –
Exercise/competitive sports? Ddx for amenorrhoea screen headache, milky breast discharge, hot
flushes? Osteoporosis/fragility fractures – Any fractures before?
- Cardiovascular: Arrhythmia – Irregular heartbeat? Hypotension/postural drop – Giddiness with

postural change?
- Metabolic/Electrolytes
- Derm: Dry skin? hair loss?
- Psy: Depressed, anxious, suicidal?
Course
- Seen doctor, tests done, treatment tried?
Objective
PE
Chaperone
BMI weight centile/trend (severity - 17 16 15 below). Vitals – Temperature, postural BP (for drop SBP
>20mmHg DBP > 10mmHg HR change > 20bpm), HR (bradycardia)
General inspection: Thin habitus, lanugo hair/hair loss/dry skin, goitre
Peripheries: Tremors. Russell’s sign calluses on dorsum of hand (bulimia). Scars from cutting/self-
harm.
Eyes: Pallor
Tongue: Hydration
Neck: Goitre – swallow, palpate
Legs – Pitting oedema (hypoalbuminaemia)
KIV Cardiovascular: Mitral valve prolapse??
Invx
Stat: UPT if LMP delayed/unprotected sex. X-ray if suspected fracture. FBC (anaemia), Na/K/Cr
(hyponatremia/hypoklaemia), capillary glucose (hypoglycaemia). ECG (bradycardia, prolonged UTC)
Send off: TFT, LFT and albumin, calcium/phosphate/vit D/BMD if amenorrhoea > 9mth
Assessment and Plan
Anorexia Nervosa. Dx/Pt education/multidisciplinary – have you heard of it, what do you
understand? Weight actually low for age/sex. Elicit concerns e.g. competition, explain too rapid
weight loss causing bone problem cannot compete. Offer to speak to parent, need Family-based
therapy. Referral – Refer to A&E for hospitalization if 1. haemodynamically unstable (hypothermia T
<35deg C, bradycardia <40-50bpm, BP <80-90/60 or giddy, postural drop 10-20mmHg or 20bpm
increase), 2. severe underweight BMI <15 or less than 70-75% ideal bodyweight or food refusal or
failure to respond to outpatienct 3. 2. ECG prolonged QTc 500ms or longer 4. dehydration/serious
electrolyte disturbance K <3.2 /hypoglycaemia 5. moderate-severe refeeding syndrome marked
oedema or phosphorus < 2mg/dL). Refer Paeds Psy/Eating Disorder clinic early 2weeks, TCU 1wk to
monitor electrolytes. Psychotherapy – Refer Psychologist for Family-based therapy or group-based
therapy. Lifestyle – Weight gain gradually increase intake + restrict strenuous exercise aim 0.5kg/wk
eventual goal 90% of expected weight for age/gender. Refer Dietitian will need 3 full meals +
structured snacking monitored by family or school nurse, add multivitamin + calcium vit D
supplements. Pharm – If co-morbid depression, consider SSRI; KIV refer psy for olanzapine. TCU –
Monitor progress for weight gain, resumption of menses.
Musculoskeletal/Rheumatology Adult/Geriatric, Acute/Emergency vs.

Symptom – Lower back pain
Ref: NHGP PREPP 2019, NUP bridging ortho 20220819
Stem – 68/Chi/M DHL for chronic review, Cr rise from 100 to 195 over 1 year + uACR over detection
limit. When asked has been taking paracetamol for back pain. Dx: Multiple myeloma.
Causes
Hip
SI joint (ankylosing spondylitis)
Lumbar spine
Complaint – SRSOTCTERA
- Site/Radiation – Where exactly, can point out? Radiation to legs, below knee?
- Severity – Pain score?
- Onset/duration/Timing/progression – New onset or recurrent? Acute or gradual/insidious? Same

throughout day or worse certain times, worse at night? Getting better/worse?
- Character – Sharp/dull?
- Triggers – Trauma, fall, heavy load, new activity?
- Exacerbating – Movement/change in position?
- Relieving – Rest? Medications?
- Associated symptoms/Red flags: Weakness, numbness? (radiculopathy) Urinary incontinence,

bowel incontinence? (
Causes – Associated symptoms/SR + PMH + RF BPS + Invx/screening
- Red flags: Fever, night sweats? (infection) Rest pain, night pain, LOW/LOA, PMH cancers?
Complications
- Function: How affected daily routine? Work, hobbies, home? Home environment?s
- Psy: Depressed?
Objective
PE
BMI, vitals Temp, HR/BP
Environment.
Chaperone + Expose “I’d like to request a chaperone for the examination. Ideally would like you to
change to an examination gown, but for purposes of modesty could you just take off shirt.” Running
commentary “I see your lower back is straightened out.”
Gait “See you walk from here to the spot next to the couch.”
Standing – Look from side, back (loss of lordosis from spasm, scoliosis, listing from spasm). Move -
Forward bend test “bend forward and try to touch the floor” (accentuate kyphoscoliosis, flat back
rather than rounded signifies spasm or intervertebral joint pathology). If suspecting ankylosing
spondylitis KIV Schober’s test. Extend (facet joint pathology). Lateral flexion “mirror me”.
Sitting. Move – Lateral rotation cross arms over chest and turn “mirror me” (thoracic spine
pathology).
Supine. Neuro LL – SLR. Inspect, KIV tone, KIV reflexes, power distal only or KIV from L2 to S1, skip
heel-shin, sensation pinprick. Vascular – Feel dorsalis pedis pulses. Screen hip with FADIR. Screen SI
joint with FABER figure of 4 (pain in buttock area is SI joint pathology, pain in groin is intra-articular
hip pathology).
Prone. Feel - Midline of spinous processes for step deformity/tenderness, paralumbar muscles L1 to
L5, buttock SI joint along the triangle lines “Going to press on above buttocks to check the sacro-iliac
joint”, ischial tuberosity “Going to press at the sitting bones”. Femoral stretch test (pain shooting
down front of thigh).
Invx
Stat – KIV X-ray lumbosacral spine (indications: red flags, duration?), pelvis AP. KIV FBC, ESR.
Send-off – KIV LFT.
Symptom – Hip pain
Previous trauma, Intake of steroids, diving? (AVN)
Symptom – Knee pain

Ref: NUP bridging 2022 case 131, NHGP seniors, NUP bridging ortho 20220819
Stem
- 58/Chi/F with 2 previous visits for eczema comes for unscheduled visit, complains of knee pain
3wk. By the way can get more meds standby for eczema? Dx: Referred pain from hip AVN secondary
to chronic steroid use for eczema
- Elderly with chronic bilateral mechanical knee pain. Dx: OA knee
- Young athlete with sudden knee pain and swelling. Dx: ACL tear.
Causes
General
Rule out referred pain from hip (fracture, AVN)
DVITAMINC
Trauma – Fracture, Haemarthrosis
Infection – Septic arthritis
Neoplasm – Cancer secondary/primary
Autoimmune/inflammatory – RA Rheumatoid Arthritis, Reiter syndrome
Metabolic (crystal arthropathies) – Gout, pseudogout
Degeneration/Overuse – Osteoarthritis
Traumatic/Degenerative/overuse conditions by anatomical location
- Anterior: PFOA PatelloFemoral OsteoArthritis, PatelloFemoral Pain Syndrome, patellar subluxation,

patellar tendinopathy, OSD Osgood Schlatter Disease
- Medial: Osteoarthritis knee, MCL Medial Collateral Ligament tear, Medial meniscus injury, pes
anserine bursitis
- Lateral: ITB IlioTibial Band syndrome, LCL Lateral Collateral Ligament tear, Lateral meniscus injury
- Posterior: Baker’s cyst, PCL Posterior Cruciate Ligament tear
By associated symptoms
- Fixed flexion deformity – Osteoarthritis, rheumatoid arthritis
- Locked knees – Meniscus tear, loose body
Subjective
Screen PMH and DHx

Complaint – Tell me more about knee pain
- ***Site/Radiation: Which knee or both; Other joints affected? (monoarthropathy vs.

polyarthropathy) Where exactly, can point out? (anterior, medial, lateral, posterior) Is there hip pain,
back pain, ankle pain? (referred pain from hip/back) Does pain travel anywhere else?
- Severity: Pain score?
- Onset, Timing, progression: When did it start? Had before? Sudden or gradual? Worse in morning
or end of day? (inflammatory vs. mechanical) Getting worse/better?
- Character: Describe what the pain is like? Similar to previous or different?
- Triggering: Fall, trauma, twisting injury, popping sound? (trauma – fracture, haemarthrosis,
ligament tear)
- Exacerbating: Anything makes it worse e.g. walking/stairs/squatting, getting up from prolonged

sitting, worse end of day? (OA)
- Relieving: Anything makes it better e.g. rest, medications? Does it go away completely?
- Associated symptoms: Swelling? (Haemarthrosis, septic arthritis, gout, RA) Redness? (inflammatory
causes septic arthritis, gout, RA) Fixed flexion? (OA, RA) Locking? (meniscus tear, loose body)
Cause – PMH, symptoms, risk factors
- Red flags: Fever/chills, night sweats? (septic arthritis) Hx of malignancy, Rest pain, night pain,
LOW/LOA,? (malignancy, infection) Morning stiffness >30min, joint swelling, rash, FHx of RA?
(inflammatory arthropathy e.g. RA)
- history of gout? Triggered by alcohol, red meat? (gout)
- knee
Course
- Seen doctor? Investigations X-ray MRI bloods? Treatment tried analgesia injections physio?
Complications
- How affected daily activities? Baseline? Mobility/walking aids/distance before pain felt? Falls?
Function BADLs and IADLs, work, home? Home environment – lift landing, steps?
- Psy
Contraindications to treatment: Allergies? Asthma/COPD, renal impairment, gastritis? (NSAIDs)
Concerns
Bucket list
Bio – PMHx (haemophilia), DHx/alcohol/smoking, FHx
Psy
SHx – WASHED
Objective
PE
BMI/weight + trend gain or loss? (obesity, Cushing syndrome). Vitals Temp, HR/BP
***Environment – Walking aid, shoes – Your usual shoes?
***Chaperone + Expose to underwear (see hip and whole posture of limb) “For this examination will
need you to remove your shoes and socks, and ideally your pants as well, but for the sake of
modesty perhaps you can roll up your pants above the knee level.” Running commentary “I see you
are limping.”
Gait – “See you walk to the spot next to the couch.” Antalgic, varus thrust? (OA)
Standing – Look front, side, back (quadriceps wasting, deformity/shortening, knees together for
genu varum OA knee or genu valgum risk factor for AKPS/PFPS, knee flexion from side due to
effusion or pain, Baker’s cyst). Move – If young, squat (anterior pain from PFOA/PFPS, medial/lateral
pain from meniscal injury).
Supine – With knees extended. Look for posture/shortening/deformity, quads wasting, erythema,
effusion. Screen hip+back with SLR passive, FADIR flex adduct across midline IR hip (intraarticular hip
pathology e.g. OA knee, AVN, labral tear)/FABER (intraarticular vs. SI joint pathology, KIV proceed
with hip examination (Move IR/ER/flex/abd/adduct, Feel tenderness groin/greater trochanter). Knee
Feel – Warmth with back of hand (infection/inflammatory/crystal), effusion patellar tap left hand
milk right index middle wiggle patella, effusion cross fluctuance push fluid medial lateral, effusion
bulge sweep medial to top and lateral then back, Clark’s test/patellar grind right hand under knee
“press down on my hand” left hand C-shape compress on quadriceps tendon and push down/left
right grind, retropatellar tenderness KIV patellar apprehension flex knee 30deg. Move - ROM knee
extension active “lift your leg and straighten your knee all the way” + passive if flexion deformity
(extensor lag vs. FFD) + compare to contralateral side; knee flexion active “bend your knee and pull
your heel into touch your buttocks” + passive if limited, compare to other side.
With knees flexed 90deg. Feel – Quads tendon and superior pole of patella (quadriceps
tendinopathy), inferior pole (patellar tendinopathy), tibial tuberosity (OSD), pes anserine insertion
1FB medial and inferior (pes anserine bursitis in post-menopausal); lateral joint line (OA, meniscus
tear), fibular head, LCL (LCL tear); medial joint line (OA, meniscus), medial femoral epicondyle medial
1/3, MCL (MCL tear).
KIV in young patient/trauma Special Tests – Sag sign, posterior drawer (PCL tear), anterior drawer
index fingers relax hamstrings thumbs straddle joint line pull with bodyweight (ACL tear),
Lachmann’s left hand hold thigh right hand hold proximal tibia 20deg feel for play OR modified
Lachmann’s sandwich thigh between examiner’s left thigh and left hand, valgus stress left heel of
palm lateral to knee right hand apply stress distal tibia for pain or gapping (MCL tear), varus stress,
McMurray.
(Skip these Special Tests) Lateral position – Noble’s test left thumb pressure over lateral femoral
epicondyle passively move knee between 0 to 30deg flexion (ITB friction syndrome), Ober’s test left
hand on iliac crest right hand passively move hip into flexion and adduct till knee touches table.
Prone position - Apley grind.
Invx
Stat – KIV X-ray knee, X-ray pelvis AP and hip lateral. KIV FBC (infection), ESR (infection).
Assessment and Plan
Hip fracture/AVN – Refer A&E for Ortho review KIV surgical intervention vs. conservative and NWB.
Trauma, ligament tears. Invx X-ray TRO fracture/loose body. RICE, knee brace, analgesia. Refer –
Physio, Ortho for MRI knee.
OA knee. Pharm – Diclofenac 25mg-50mg TDS-PRN for pain, +/- omeprazole cover. Non-pharm –
Activity modification (graded activity pace self, use lift avoid stairs), quads strengthening (SLR
sitting/lying 2-3 sets x 50 reps x 10s, wall slide half squat 2-3sets x 20 reps x 5s /refer physio, mobility
aid walking stick, lose weight. Fall prevention (proper walking shoes no slippers, keep floor tidy and
dry bundle wires, home modification grab bars non-slip tiles good lighting). Refer – Physio,
Orthopaedics KIV for surgical intervention.
OSD. ICE, analgesia. Continue physical activity as tolerated. If refractory, KIV refer Ortho for surgery
after closure of proximal tibial growth plate.
ITB syndrome. Acute – RICE, analgesia. Subacute – Exercise strengthening therapy, refer physio.
Graduated return to sport.
Symptom – Foot pain
Approach
Diagnosis – site is most important
Underlying causes
Ddx
Gout
Stress fracture
Subjective
RFE – Foot pain
Co-morbidities – Screen PMH, DHx, alcohol/smoke, occupation
HOPC Foot pain – “Tell me more about the pain” + SRSCOTETRA
S,R – Where, point out exactly? Travel anywhere else?
S – How bad 0 to 10?
C – What does pain feel like, sharp dull electrical current?
OT – Recurrent or new? Sudden onset or gradual? Constant or on and off, present at rest? Getting
worse better or same?
E – What makes it worse? Movement, exercise?
T – Anything triggered it off? Injury, new or increased exercise/activity – why more exercise?
R – What makes it better, rest?
F – How affected daily routine, work/school/hobbies?
A-…
Underlying cause
- Bio - ??
- Psychosocial – WASHED or HEADDSSS

W working as, how coping? A any financial difficulties? H tell me about home situation? S smoking?
A alcohol? E exercise? D tell me what you eat in a day from morning to evening?
H tell me about home situation… live with… relationship with family? E tell me about school
situation… how are grades… work part-time? A what CCA, do what for fun? Diet tell me what you
eat…? Drugs some experiment with smoking, you or friends… alcohol… drugs? Sex how are menses,
many interested in romantic relationships, you… any sexual intercourse…? Sleep tell me about your
sleeping habits…? Suicide feel depressed, lost interest, constantly worrying, life not worth living?
Assessment and Plan
Stress fracture. Evaluate for FAT/eating disorder/osteoporosis. ?NWB. Short leg cast/aircast boot +
refer Ortho fast track 1week. Analgesia.
Symptom – Shoulder pain
Dermatology Adult/Geriatric, Acute/Emergency vs. Chronic/Preventive/Palliative

Symptom/sign – Mole/skin lesion
Ddx of complaint
S A
Handrub! (SPIKES)
have you been since your last visit? Besides this, is there Any other concerns
anything you are worried about?”… “Tell me more about
your skin lesion. When did you first notice it?
Onset
Associated symptoms – Itching? Pain?

Red flags - Bleeding? Change in size/colour?

treatment?”
life?”
Lab result
treatment?”
Complications
Chronic condition
Causes/triggers
Bucket list
things?”

dementia
disease

O P
Handrub! Non-pharm
Pallor Handrub!
vibration sense
Handrub!
MMG/cervical)
plan”
Non-pharm
Pharm + ADRs
Ref/TCU/red flags
Condition – Eczema
Course
What treatment – topicals, **oral steroids, moisturiser? How frequent?
Endocrine Adult/Geriatric, Acute/Emergency vs. Chronic/Preventive/Palliative

Type 2 diabetes mellitus
Ref: NUP bridging case 122,
Subjective
Caught/initial diagnosis + Co-morbidities (Screen PMH + DHx) + Course
- Age of diagnosis? Osmotic symptoms? Lab test? Fhx of DM?
- Other PMH? Medication list, changes/when? Smoking, how much, consider quitting? Alcohol?
Control/checking + compliance/adherence/reasons + competence/technique + complications of

treatment + crisis management
- Control/checking: Last 3 HbA1c? Home glucose monitoring?
- Compliance: Taking oral medicines, insulin? How often missed, why? Diet – Tell me what you
usually eat in a day e.g. last 2 days from breakfast to evening, home cooked, sweet drinks, alcohol?
Exercise, how often, what, how long, how intense?
- Competence/complications of treatment/crisis management: Where injected, site rotation?

Hypoglycaemia – Low sugar readings, giddiness, hungry, cold sweats, tremors? How do you manage
hypoglycaemia symptoms?
Causes/triggers
- SHx: Occupation working hours/irregular/food options? Financial problem?
Complications of treatment and disease + co-morbidities
- Macrovascular: Hx of AMI/stroke/PVD? Exertional SOB, chest pain, weakness on one side,

numbness, leg pain on walking?
- Microvascular: Renal – Hx of kidney problem, Cr/eGFR, proteinuria? Eye – Hx of eye problem, DRP
done, blurring of vision? Foot – Open wounds/infection, amputation, DFS done, numbness?
Contraindications to treatment: Drug allergies. Hormones, TXA - CV risk factors (DHL/IHD/stroke,

Concerns ICEKAPS
Assessment and Plan
Treat other co-morbidities – Smoking cessation, reduce alcohol, control BP and lipids.
Diet issues. Pack simple meals from home instead of outside food, outside ask for less
condiments/sauces/sugar and low-fat, take brown rice. Offer dietitian referral for detailed diet
analysis and optimization.
Medication adherence. Simplify medication regimes to OD or BD. Use labelled medication

containers, set medication alarm on phone.
Irregular work schedule and financial issues. Refer MSW or Family Service Centre for financial
assistance. Take on assignments with similar timing, mutual exchange with colleagues for better
timing.
Pharm titration
Insulin. Glargine start 0.1U/kg OD
Ramadan management. Recommend against fasting if poorly-controlled DM or hypoglycaemia.

Medication adjustment.
Haematology Adult/Geriatric, Acute/Emergency vs. Chronic/Preventive/Palliative
Infectious diseases Adult/Geriatric, Acute/Emergency vs.
Admin - Pre-travel advice
References: NHGP seniors, Julio, Cheryl, NUP CPG/AFP, Patient History, NUP bridging case 82
Ddx of complaint
General approach to pre-travel advice
Travel itinerary
Previous travel history
Pregnancy status/PMH/drugs
Vaccinations
Diet restrictions + Social history
Subjective
Handrub!
Complaint/RFE+HOPC - “How may I help you today/how have you been since your last visit? Besides
coming for travel advice, is there anything you are worried about?”…
Travel itinerary – “Tell me more about your travel plans and itinerary.”
- Where? Time zone/flight duration/departure and arrival time? Urban or rural? What kind of
accommodation?
- Access to medical care/hospital/emergency facilities?
- When (ideally 6wk after)? How long?
- What activities?
High altitude? (+ how high/fast? Previous acute mountain sickness?)
Diving?
Wildlife?
Sex? (+ sexual history, previous HIV test/HIV symptoms fever sore throat lymphadenopathy rash,
PrEP taken before)
Previous travel history
Where have you travelled before? Encountered problems during travel?
Experience with activities/climbing? Experience taking malaria prophylaxis?

Bucket list
Pregnancy status
PMHx - “What other past medical conditions do you have?”
Control/checking + compliance/adherence/reasons + competence/technique + crisis management
Causes/triggers
Drugs/allergies - “What long-term medications are you taking now? Do you take any traditional
medications? Over the counter medications? Supplements?”; FHx - “Does anyone in the immediate
family have…”
“Are you allergic to any medications?”
Vaccinations - “Do you have your vaccination records with you?”
Social history
Diet – “Do you have any dietary restrictions?”
WASHED Work/Accounts Home Alcohol Smoking Exercise/Activities Diet + Function/ICE - “What are
you working as/studying/how are things? How are things at home/whom do you live with/what kind
of housing do you stay in? Do you smoke/how much in a day/how many years/would you consider
quitting? Do you drink alcohol/how much/how often more than 4 drinks in past year? What exercise
do you do/What do you do in your free time?”
Psy Depressed/anhedonia/anxious - “How is your mood/do you feel depressed? Have you lost
interest or pleasure your daily activities? Do you constantly worry about all kinds of things?”
Female: Add to PMH - menstrual, sexual + contraceptive/STIs, urogynae
Child: Add after PMH - perinatal/birth, growth/development, vaccinations, puberty/menarche

- Home – Whom do you live with? How are you relationships with your family? Whom can you talk
with?
- Education/Employment – Tell me about school. What are you good at/not so good at?
- Drugs/Drinks/Smoking – Do any of your friends drink alcohol? Smoke? Take drugs? How about you?
- Sex/Puberty/Menarche – Have you started to have menses? Many teens become interested in
relationships, are you in any relationship? Can you tell me about your relationship? Have you had
any kind of sex?
- Suicide/Depression/Safety – How is your mood? Have you ever thought of ending your life or
harming yourself?
Objective
PE - “I’ll need to examine you now.”
Handrub!
BMI, vital signs + SpO2. Paeds – Growth chart in health booklet.
Depending on PMHx
Pallor
+/- Resp
+/- Cardio
+/- MSK
Handrub!
Invx
Previous invx – “Do you have any previous blood tests/ECGs/x-rays/spirometry?”
Vaccination records – “Do you have your vaccination records with you?”
Stat invx - “I would like to do some simple tests to check control of your chronic condition.”
Assessment and Plan
General travel advice Get personal travel insurance
Check history of DVT/PE Vascular: DVT prevention on long flights
- Do calf muscles exercises/walk on plane, stay
hydrated, wear compression stockings
Infection control
- Resp: Wash hands frequently, wear mask,
follow local COVID19 regulations
- GI: Eat cooked food/pasteurised dairy
products (prevent GE, Hep A), drink bottled or
boiled water/avoid tap water or unfiltered
stream water, Avoid eating bushmeat (raw or
partially-processed meat from
bats/rodents/wild animals which can spread
zoonoses)
- Skin: Avoid close contact with stray/wild
animals (rabies), Avoid walking barefoot
(hookworm/strongyloides)/ swimming in
freshwater (schistosomiasis, leptospirosis,
amoebiasis, meliodosis)
Trauma/Motor vehicle accidents – Wear

seatbelt onboard travel
Sun protection – Wear long sleeves/pants + hat
+ sunglasses, use SPF30 sunblock
Rural areas Vaccinations
- Check CDC Yellowbook for required
vaccinations
- Catch-up routine vaccines, Influenza
- Yellow fever/Japanese encephalitis
- Hepatitis A and typhoid fever
- Rabies
Malaria prophylaxis
- Check CDC Yellowbook for malaria risk and
chloroquine-resistance
- Non-pharm: Wear long sleeves/pants/socks,
apply topical mosquito repellent (DEET to skin,
permethrin to clothing), sleep under mosquito
net treated with permethrin
- Pharm/chemoprophylaxis:
Doxycycline 100mg OM, start 1 day before + 28
days (1mth) after leaving malaria-prone area.
Malarone (Atovaquone-proguanil
250mg/100mg) 1tab OD, start 1 day before +
continue 7 days (1wk) after.
Mefloquine 250mg 1tab/week, start 2wk
before + continue 4wk (1mth) after. Safe for
pregnancy.
High altitude Non-pharm:
- Acclimatize by ascending 1500m weeks before
- Ascend gradually not more than 2800m first
day or 500m/day after 2500m, plan 1 extra day
acclimatization for every 1000m of height (i.e.
every 3rd day)
- Avoid alcohol (continue caffeine if regular
use), stay hydrated
- O2 supplementation 0.5-1L/min
-
Pharm prophylaxis against Acute Mountain

Sickness/HACE High Altitude Cerebral
Edema/HAPE High Altitude Pulmonary Edema:
- Acetazolamide/Diamox 125mg BD 1 day
before ascent, stop if on descent or after 2 days
at same elevation. Contraindication: Sulfa
allergy. ADR: Paraethesia, altered taste;
rashes/SJS-TENS, blood dyscrasia.
- Dexamethasone 4mg BD same day, stop if on
descent or after 2 days at same elevation. ADR:
Worsened DM control, PUD/GI bleed,
susceptibility to parasites, euphoria/mania.
Interactions: Tendon rupture with cipro.
Red flag advice

- Descend within 24hours if symptoms of AMS:
headache, fatigue, loss of appetite,
nausea/vomiting
Sex STI prevention
- Non-pharm: ABC
PrEP - Pharm/HIV PrEP Pre-Exposure Prophylaxis:
HIV status negative (test + symptoms) Check HIV/Hep B/Hep C status and renal
Hep B status known/vaccinated function first (contraindicated in CKD4, halve
Normal renal function frequency to 48hourly if CrCl 49 or below).
Females – Daily regime Truvada
(Emtricitabine/tenofovir) 1tab OD x 3wk before
and continued (achieve high concentration in
Invx: Check HIV status/Hep B/Hep C/Cr done cervix); Males – Daily regime Truvada 1tab OD x
previously 1wk before and continued OR event-driven
Stat Cr for renal function Truvada 2tab 24h before sex + 1tab OD x 2days.
- TCU 3months after PrEP
Condition – Pregnancy Air travel
- Safest in 2nd trimester (most obs emergencies
in 1st and 3rd trimester but not contraindicated)
- Commercial airlines allow flight up to 36wk
gestation (for singletons, else 32wk for
multiples). Give memo just in case after 28wk
(fit to travel, GA, EDD; dated within 10 days of
flight)
- DVT prevention – support stockings, exercise
calves/ambulate, keep hydrated
- Nausea – Pyrixodine 10mg TDS + doxylamine
Chronic disease – Type 1 DM General
- Hand carry (do not check in) DM meds (with
pharm labels)/needles + glucometer +
sweets/snacks for hypoglycaemia
- Wear covered well-fitting shoes
Air travel
- Travel memo to airline, inform airline staff DM
on insulin injection
- Watch diet on plane (avoid sweet snacks,
bring own), monitor glucose
Insulin adjustment
- Adjust if travelling more than 5 time
zones/hours eastward or westward. Eastward
shorter day (e.g. Australia because timezone is
ahead) so reduce insulin, westward longer day
(e.g. USA because timezone is behind) so
increase insulin
- Use basal-bolus strategy: Keep watch in
departure country timezone; Take full basal
dose before departure, Half basal dose at
lunch/dinner on board following departure
time, half basal dose 12hours later, full dose
next day following arrival time (if at least 12hr
since last dose). Give rapid-acting bolus with
on-board meals.
OHGA adjustment
- Follow departure country time + with meals,
omit dose if timing close.
Chronic disease – Asthma Hand carry (do not check in) inhaler + standby
prednisolone always
Control Memo to airline
For EIA, use 2 puff 15-30min? before exercise
Chronic disease – COPD If pneumothorax, no air travel for 2wk after
successful drainage/full lung expansion
History Refer Resp for walking test (50m/1 flight stairs)
Functional status – Can walk more than 100m + hypoxia challenge test
or climb stairs? Memo and make arrangements with airline for
Contraindications based on British/American supplemental O2 if in-flight PaO2 expected to
Thoracic Society guidelines - Previous fall below 50mmHg.
pneumothorax within last 2weeks
Chronic disease – Nephrotic syndrome No travel if currently symptomatic (risk of

thrombosis)
Type of nephrotic syndrome steroid-sensitive / General
steroid-dependent / steroid-resistant - Bring adequate medications + memo with
Current symptoms condition, crisis management in case of relapse
- Avoid crowded places (immunocompromised)
Vaccinations
- No live vaccines (yellow fever, MMR/V) while
on prednisolone
Monitoring and red flags

- Check weight and urine dipstick every 2-3 days
- If fever seek medical attention.
Chronic disease – Congenital heart disease If CCF/severe: no high altitudes, give

supplementary O2, have bracelet, ensure
Severity/CCF access to hospital
Chronic disease – Haemophilia No contact sports/high risk activities for trauma
Jet lag prevention General
- Exercise, rest, healthy diet, comfortable
clothes and shoes for flight; avoid large meals,
alcohol, caffeine
- Break up long flight with stopover. Sleep on
flight.
- Avoid critical decisions on arrival
Adjust body clock

- If travelling westward (longer day), sleep 1-
2hours later for a few days before; if eastward
(shorter day), sleep 1-2hours earlier
- Expose body to bright light in evening (if
westward longer day) or morning (if eastward
shorter day), shower
- Follow arrival location schedule/timings as
soon as possible
Pharm:
?PO melatonin 0.5mg on first few days
Male reproductive system Adult/Geriatric, Acute/Emergency vs.

Erectile dysfunction
- HOPC (Tell me more about your erectile dysfunction problem). Onset/triggers (When did you start
to notice it? Was there any trigger?) Characterise (No desire? Cannot penetrate? Cannot sustain?
Premature ejaculation?)
Causes
Drugs (What chronic medications are you taking? TCM/OTCs? Beta-blockers/thiazides? SSRIs?)
Cardiovascular disease (Besides the … which you are taking medications for, do you have other
medical problems? DHL/IHD/PVD – buttock/leg claudication? Smoking? Alcohol?)
Endocrine (Hypothyroidism – weight gain/cold intolerance/dry skin/constipation?

Hypogonadism/hyperprolactinaemia - Any known hormonal
problem/gynaecomastia/galactorrhoea/bitemporal hemianopia?)
BPH??
Neuro (LL weakness/numbness/saddle anaesthesia/bladder or bowel incontinence? Pudendal nerve

injury (Any injury to genital area? Surgery?)
Psychological (How has your mood been? Any stressors? How is your relationship?)
ICE (What worries you most about this?)
PE
BMI, BP/HR
Sitting
General – facial hair/muscle bulk, goitre
Visual fields (can see me clearly all of me?)
Standing
Lower back, sacrum
Supine
LL – Pulses, CRT, sensation, distal strength
Abdo – gynaecomastia/galactorrhoea
Penile shaft lesion
PR for BPH
Invx:
Stat – glucose/HbA1c
Issues - summarise
Other primary care invx: TFT, serum testosterone, screening lipids/glucose
Mx
Medication (PDE5 inhibitors) vs Lifestyle measures (lose weight, stop smoking/drinking, exercise, de-
stress, refer counselling)
PDE5 inhibitor: sildenafil. Contraindications: Nitrates. Take 50mg 30min-1hour before sex, avoid
fatty meals. Side effects: Blue vision, hypotension, priapism. (alternative – tadalafil 20mg 1-2hour
before sex, not affected by meal, no blue vision)
Female reproductive system Adult/Geriatric, Acute/Emergency vs.

Gynaecology
Lab – Abnormal cervical cancer screening
Ref: NUP bridging 2022
If HPV HR (non-16/18), call up lab to request to run reflex cytology on same sample.
Symptom – Vaginal discharge

Ref: NHGP seniors, NUP bridging 2022
Stem – 25yo/F p/w vaginal discharge.
Causes
Infective
- Cervicitis also: Gonorrhoea, Chlamydia
- Vaginitis only: Trichomonas, Bacterial vaginosis, Candidiasis
Non-infective: Irritant, Atrophic vaginitis
Physiological
Subjective
RFE + other worries
Screen PMHx and DHx
Complaint - Vaginal discharge
- Character: Colour/thickness? (Purulent gonorrhoea, fishy, greenish yellow frothy Trichomonas,

whitish curdlike Candida,) Odour?
- Onset/time course: Happened before? (recurrent infection) Varies with menstrual cycle?
(physiological)
Cause + complications – Associated symptoms and risk factors BPS

- SR + complications: Vaginal itch/burning/irritation? (vaginitis) dysuria? (urethritis) Fever/abdo
pain? (PID, tuboovarian abscess)
- Menstrual hx – LMP? (pregnant) Regular/usual interval? Flow? PCB/PMB/dyspareunia (cx)?
- Sexual hx – Relationship, how long? Past encounter? New sexual partners - new in last
3mth)/previous partners - multiple? Practices? Protection - no condom)/Pregnancy - IUCD in situ,
current pregnancy? Past STI or partner STI(risk factor)/Pap smear?
- Obs hx – Previous pregnancy?
- DHx – recent Abx use? (Candida) DM hx? (Candida) OCPs? Illicit drugs?
- PMH – DM?
- Psy – Mood, suicide
Course
- Seen dr? Done tests? Treatment tried?
Complications as above in SR
Other SHx – WASHED, HEADSS
Objective
PE
BMI + wt, vitals Temp, HR/BP
Request chaperone, “need to examine abdomen and private area”
Abdo: Tenderness/guarding, masses
VE and speculum: Get double pair of gloves, lubricant, speculum, swab stick. Vulvar erythema,
Cervical excitation, adnexal tenderness/masses. Speculum “insert this plastic device to see inside
vagina and neck of womb”, check for fistula, malignancy.
Invx
Take swab, send discharge for microscopy, pH, NAAT nucleic acid amplification test
Send Pap smear if not done.
Stat: UPT (at least offer). KIV FBC/ESR (infection), capillary glucose (DM).
Send off – Screen other STIs (blood for HIV/Hep B/syphilis, urine NAAT for gonorrhoea/chlamydia)
Assessment and Plan
General for all Advice
Avoid tight fitting underwear, use cotton not synthetic, avoid
vaginal douching and soaps/gels.
No evidence for probiotics.
Prev: Contraception/safe sexual practice (double Dutch OCP +

condom), HPV vaccine, Cervical screening, MMG/FIT/BMD
Emergency – PID Pelvic Referral – Refer A&E if suspicious, KIV for IV Abx and drainage.
Inflammatory Disease or TOA
Tubo-Ovarian Abscess
Special: Pregnancy Don’t treat non-STI vaginitis if asymptomatic.
Pharm
Metronidazole for Trichomonas and BV is safe
VVC – Give clotrimazole pessary only (no oral fluconazole).
Gonorrhoea Pt education. Invx – Screen other STIs including HIV/Hep

B/VDRL. Pharm – IM ceftriaxone 500mg once + PO
azithromycin 1g once empirical for Chlamydia (alternative:
doxycycline 100mg BD x 2wk?). Public health – Notify CDLENS
for contact tracing, treat all partners from last 2mth (60 days)
even if asymptomatic (write memo to Kelantan for STI
screening), abstain from sex till all partners treatment
completed.
Chlamydia Pt education. Invx – Screen other STIs. Pharm – PO
azithromycin 1g once (alternative: doxycycline 100mg BD x
2wk?); test of cure 5wk after completing treatment?. Public
health – Notify CDLENS for contact tracing, treat partners even
if asymptomatic (write memo to Kelantan for STI screening),
abstain from sex till both partners treatment completed.
Trichomonas Pt education. Invx – Screen other STIs. Pharm – PO
Discharge – Yellow-green, metronidazole 500mg BD x 1wk or PO metronidazole 2g once
frothy discharge, foul-smelling, (need systemic treatment not pessary because in Skene’s
vulvar itch, dysuria, dyspareunia glands; if recurrent, PO metronidazole 2g OD x 1wk); ADRs –
Invx: pH High >4.5, microscopy interacts with alcohol so abstain; Retest for clearance after
motile trichomonads 4wk. Public health – Notify CDLENS, advise inform partner to
screen and treat (male partner may be asymptomatic or have
mucopurulent urethral discharge, dysuria; write memo to
Kelantan for STI screening), abstain from sex till both partners
treatment completed.
Bacterial vaginosis Pharm – If symptomatic, PO metronidazole 500mg BD x 1wk

Discharge – Greyish, thin bubbly (alternative if allergic: clindamycin 400mg BD x 1wk; if
discharge, fishy odour, no recurrent, maintenance PO metronidazole 2g monthly AND PO
itch/pain fluconazole 150mg once); ADR – interacts with alcohol so
Invx: pH high > 4.5, microscopy abstain.
clue cells No need re-testing or treatment of sexual partners (not STI).
Candidiasis Pt education – May be related to Abx.
Discharge – White, thick curd- Pharm – Clotrimazole pessary 100mg ON x 6days or PO
like, non-offensive odour, vulvar fluconazole 150mg once (If recurrent, clotrimazole pessary
itch, dysuria, dyspareunia 100mg ON x 2wk or PO fluconazole 150mg every 3 days x 3
Invx: pH low <4.5, microscopy doses then maintenance fluconazole 150mg weekly x 6mth;
yeast/pseudohyphae ADRs – Clotrimazole weakens latex condoms.
Non-pharm – Perineal hygiene.
No need for re-testing or treatment of sexual partners (not STI)
Symptom - Dysmenorrhoea
Ddx of dysmenorrhoea (menstrual cramps)
Serious conditions: Ectopic pregnancy, miscarriage
Secondary
- Infection: STI/PID Pelvic Inflammatory disease
- Uterus: Endometriosis, Adenomyosis/fibroids
- Cervix: Cervical stenosis
- Pelvic congestion syndrome
Primary
Characterize pain especially timing (secondary vs. primary)
Rule out serious conditions
Rule out secondary causes
S A
Handrub! (SPIKES)
have you been since your last visit? Besides this, is there Any other concerns
anything you are worried about?”… “Tell me more about
your menstrual cramps.”
SRSCOTERA
***Site/Radiation clarify++ – “Can you point where you feel
the pain? Is it more at the upper/centre part/lower part of
your tummy? Is it more at the middle part/right side/left
side? Does it travel anywhere else/can you point where it
travels to? Is it more at the upper or lower part?” (Midline -
primary vs. iliac fossa - secondary, radiation to back in both
primary and secondary)
Severity – “How bad on scale from 0 to 10?”
Character/Associated
- “What does it feel like? Sharp/dull/pulling?”
- Any nausea/fatigue/headache/bloating/breast
tenderness?” (primary dysmenorhoea)
Onset/duration/Timing/frequency
- “How did it first start? New or recurrent occurs every
menstrual cycle, similar nature?” (ectopic vs.
dysmenorrhoea)
- “Sudden or gradual? Constant or intermittent?” (ectopic,
PID)
Exacerbating/Relieving – “What makes it worse? Anything
makes it better?”

- Menstrual history - LMP? (ectopic pregnancy, miscarriage)
Menarche? Usual menstrual cycle? Flow i.e.
menorrhagia/oligomenorrhoea? Bleeding in-between usual
cycle i.e. IMB? (endometriosis, adenomyosis)
Known endometriosis/adenomyosis/fibroids?
- Sexual history – Need to ask all my patients if any chance
of pregnancy. Are you in relationship? Sexually active/Had
sex since last menses/last two months? Partners – Who
with/anyone else? Practices – What kind?
Protection/Pregnancy prevention – condoms/birth control?
Past STIs/PID?
Post-coital bleeding?
Deep pain during sex i.e. dyspareunia? (endometriosis)
- Gynae/Obstetric history
Previous pregnancies/deliveries/miscarriages/abortions?
Secondary
Pain when passing motion i.e. dyschezia? Fhx
endometriosis? (endometriosis)
Fever? Foul-smelling vaginal discharge? Dysuria? (STI/PID
Pelvic Inflammatory disease)
If menorrhagia,
Bleeding/bruising elsewhere e.g. nosebleed, gum bleeding,
PR bleed/melaena? Fhx of bleeding disorders? (bleeding
diathesis?)
Cold intolerance? Fatigue? Constipation? Dry skin?
(hypothyroidism)

treatment?”
Complications/Function
Problems with trying to conceive? (subfertility)
Giddy/breathless /chest tightness/tired easily? (anaemia)
How are you coping with the pain/How has it affected your
daily life? Work/studies? Activities? Relationship/sex?
Sleep?” (impaired function)
How is your mood/depressed/loss interest? So bad that life
not worth living? Anxious? (psychosocial)
Bucket list
Female:
Gynae/Menstrual/Obstetric
Sexual + contraceptive/STIs
Urogynae

things?”
Smoking Exercise Diet + Function/ICE - “What are you
than 4 drinks in past year?”
Adolescent: Add after SHx - HEADSSS

Elderly: Complications or Function

- incontinence bladder/bowel issues?
disease

O P
Handrub! Chaperone! Non-pharm
BMI. Paeds – Growth chart in health booklet. Pharm + ADRs
Vital signs (hypotension in ectopic) Ref/TCU/red flags
Seated Handrub!
Eyes: Pallor
Lying flat
Abdomen: Tenderness/guarding/rebound, enlarged uterus
(fibroids/adenomyosis), adnexal masses (ectopic, PID,
fibroid)
VE - “Will need to examine your private area.” Double
gloves, lubricate, prep speculum and swab stick. Cervical
excitation (cervicitis/PID), adnexal tenderness (ectopic, PID)
Speculum – “Will insert this plastic speculum to better see
inside.” Check for discharge, send HVS High Vaginal Swab
Handrub!
Preventive care
Stat invx - “I would like to do some simple tests to help us Vaccinations (influenza,
find out what’s causing your problem.” PPSV23/PCV13, HPV), Screening
UPT (rule out pregnancy) (BMD, FIT, metabolic,
If menorrhagia, check FBC stat, send TFT later MMG/cervical)
Previous invx – “Do you have any previous ultrasound

scan/blood tests?”
Latter investigations – Arrange Transvaginal ultrasound

Primary dysmenorrhoea Broad overview -“Recommendations to help
plan”
Non-pharm
- Hot water bottle/heat to lower abdomen
- Exercise regularly
Pharm + ADRs
- NSAIDs
- Hormonal:
a. COCPs Combined Oral Contraceptive Pills.
MOA: Suppress ovulation/reduce menstrual
flow and contractions. Admin: Extended or
continuous administration e.g. 24/4
formulation
b. Others e.g. POP, depo-provera, Implanon,
Mirena
- Other
Ref/TCU/red flags
- Follow up after scans/in one month
Adenomyosis Broad overview -“Recommendations to help
plan”
Non-pharm
Conservative/Pharm + ADRs
NSAIDs for pain, tranexamic acid for heavy
bleeding
Mirena IUD (not copper IUCD – worsens
dysmenorrhoea; not OCP – limited efficacy
according to UpToDate)
Surgical
Fertility not desired - Hysterectomy
Fertility-preserving – Uterine artery
embolization
Ref/TCU/red flags
Pelvic Inflammatory Disease Broad overview -“Recommendations to help
plan”
Ref/TCU/red flags
Refer to ED KIV for hospitalization if red flags:
- Pregnancy
- Severe clinical illness (high fever, vomiting,
severe abdo pain) OR unable to take oral
medications OR no response/tolerance to oral
medications OR concern about adherence
- Pelvic abscess/Tubo-ovarian abscess OR
suspected alternate diagnosis (e.g. appendicitis,
ovarian torsion)
If not, consider outpatient

Pharm + ADRs
- IM ceftriaxone 500mg ONCE + PO doxycycline
100mg BD x 14 days (or azithromycin 1g
once/week x 14 days)
- If recent gynaecologic instrumentation within
3wk, add metronidazole 500mg BD x 14days (or
clindamycin 450mg QDS x 14days)
Counselling/Non-pharm
Patient
- Refrain from sex till treatment completed and
symptoms resolved
- Invx: Screen for other STDs, update vaccines
Hep B and HPV
- Safe sex practices in future
Partner – Advise all male sex partners in last 60
days to be examined for treatment regardless
of STI test results
Follow-up
- TCU 2-3days

plan”
Non-pharm
Pharm + ADRs
Ref/TCU/red flags
Symptom – AUB Menorrhagia

Ref: NUP bridging 2022, NHGP seniors
Stem – 47yo/F p/w menorrhagia, tiredness, saw A&E and Hb 9g/dL.
Normal menstruation
- Regular (+/-??), cycle 3wk+3days to 5 weeks (24 to 35 days)

- Duration: 2 to 7 days
- Flow: 80ml or less
Types of AUB Abnormal Uterine Bleeding
- Anovulatory (AUB-O Ovulary Dysfunction): Irregular or infrequent
- Ovulatory: Regular intervals, excessive volume or duration 8 days or more
Causes of AUB
By age group
- 20s: Miscarriage, anovulatory/PCOS, STI, thyroid, coagulopathy
- 40s: Cancer endometrial or cervical, STI, fibroids
- Post-menopausal: Cancer endometrial or cervical, atrophic vaginitis
By systems/anatomy – PPALMEI COON
Other systemic causes
- Drugs – Hormonal contraceptives (COCP, Depo Provera, Mirena IUD), anti-depressants, anti-
psychotics, anti-epileptics.
- Hypothyroidism / hyperthyroidism.
Structural
- Pregnancy/miscarriage
- Polyps – Endometrial polyps, cervical polyps/ectropion
- Adenomyosis
- Leiomyoma
- Malignancy and endometrial hyperplasia
Non-structural
- Coagulopathy
- Ovulatory dysfunction: Hypothalamus (Weight loss/gain/excessive exercise Female Athlete Triad,

severe medical illness, stress physical/emotional), Pituitary (neoplasm -
prolactinoma/craniopharyngioma, vascular - Sheehan’s syndrome), Ovaries (PCOS, Premature
Ovarian Failure, perimenopausal), Uterus (iatrogenic - Asherman syndrome adhesions/fibrosis)
- Iatrogenic IUCD
- Endometritis and infections: Endometritis/PID Pelvic Inflammatory Disease, cervicitis
- Not otherwise classified – Useless category for secondary causes!

Subjective
RFE + other worries
Screen PMHx (thyroid problems, bleeding problems), DHx (hormonal contraceptives/IUCD,

antidepressants, antipsychotics, antiepieptics)
Complaint
- Character/Severity, Onset/Time course
Detailed Menstrual Hx: LMP? (pregnancy) Previous menstrual pattern and current - regular/irregular,
usual interval/frequency/have menstrual diary or last dates? (normal ovulation vs. ovulatory
dysfunction; getting more irregular – perimenopausal)
Amount of blood loss - Spotting or many pads/clots? (spotting – cervix/lower genital tract e.g. polyp,
infection; heavy bleeding - uterus)
- IMB? (endometrial – polyps hyperplasia carcinoma endometritis PID; cervical -polyps, cancer,
cervicitis, ectropion; vaginal) PCB? (cervical causes e.g. cervical ca, polyps) PMB? (endometrial ca).
- COCPs/contraception use
- Associated symptoms/SR – Dysmenorrhoea? (endometriosis)
- Fever, pelvic pain, vaginal discharge? (endometritis/PID)
Sexual hx: Married or in relationship? Need to ask sensitive questions about sexual history as may be
relevant to your symptoms. Past sexual encounter? Partners? Practices? Protection/Pregnancies
prevention or plans? Past STI or partner, Pap smear?
Obstetric hx: Previous pregnancies/miscarriages/terminations?
Causes – PALMCOEIN. SR + RF BPS
- Other systemic causes
Drugs – Hormonal contraceptive pills/injections, or IUCD? Antiplatelts/anticoagulants? Anti-

depressants, anti-psychotics, anti-epileptics?
PMHx of thyroid problem, cold/heat intolerance? (hypothyroidism, hyperthyroidism) Bleeding

problems? (Coagulopathy)
- PALM: US scan done before, known PMH of fibroids/adenomyosis or endometriosis/thickened

endometrium? (structural - adenomyosis, fibroids, malignancy/endometrial hyperplasia)
- Malignancy and endometrial hyperplasia: Age 45 and above. Red flags - PMB/Weight loss/LOA?
Risk factors for endometrial Ca – Hormone replacement therapy or tamoxifen? BMI obese
>35/weight? FHx of endometrial ca or colorectal ca/HNPCC?
- Coagulopathy: Previous PPH Post-Partum Haemorrhage, bleeding from dental

procedures/surgeries? Frequent bruising, epistaxis/gum bleeding? FHx of bleeding disorders?
- Ovulatory dysfunction: Irregular menses? (Ovulatory dysfunction)

Weight gain/loss, exercise, stress, severe medical illness? (Hypothalamic)
Headache, BOV/tunnel vision, milky discharge from breast? (Pituitary - prolactinoma) Heavy
bleeding post-delivery? (Pituitary - Sheehan syndrome)
Hair on face/chest, acne, deep voice, obesity? (Ovarian - PCOS)
Age 40s-50s, Irregular less frequent bleeding, hot flushes/night sweats/palpitations/mood swings
irritability/insomnia? (Ovarian – Menopause, Premature Ovarian Failure)
Course
- Seen doctor? Invx done? Medications tried?
Complications
- Giddiness, SOB/CP? (anaemia)
- Fertility problems?
- Psy – How are you coping? Depressed/lost interest? Anxious?
- Social: How affected daily routine/activities, work/hobbies, relationships, sleep?
Bucket list
- Contraindications to treatment: Drug allergies. Hormones, TXA - CV risk factors (DHL/IHD/stroke,

- Smoking, alcohol? Finances?
Objective
PE
BMI/wt, vitals Temp HR/BP (unstable?)
Request chaperone – “Will need to examine your abdomen and private area.” Prepare gloves,
lubricant, speculum, Pap smear equipment.
Pallor, hydration
Neck – Goitre “Swallow saliva.”
Abdo – Scars, Enlarged uterus (uniform globular- adenomyosis; irregular – fibroids), adnexal masses,
tenderness.
VE/Speculum: Cervical excitation and adnexal tenderness, bimanual palpation for fibroids and
adnexal masses. Speculum for cervical lesions/polyps, IUCD thread, discharge.
Pap smear if not done, swabs if suspecting Gonorrhoea or Chlamydia.
Invx
Stat- UPT, FBC. If suspecting coagulopathy do PT/INR.

Future – If anovulatory bleeding, KIV hormonal tests TFT, prolactin, FSH/LH, estradiol/testosterone
(hyper/hypothyroidism, PCOS, premature ovarian failure). If age above 40 or risk factors for
malignancy/endometrial hyperplasia, refer Gyn for transvaginal US pelvis and endometrial sampling.
Assessment and Plan
Emergency - Symptomatic anaemia or active PV bleeding
Referral – To A&E KIV for PCT, admission.
Malignancy and endometrial hyperplasia - Age 45 and above (O&G book has age 40?) or risk factors
for endometrial Ca/hyperplasia
Referral – To Gynae for Transvaginal US pelvis and endometrial biopsy. If PMB – KIV US pelvis first
then sample if endometrium thickened in 1 st half of cycle
General.
Pharm: If dysmenorrhoea pain also, PO mefenamic acid 500mg TDS. PO norethisterone 10mg BD x
2wk (gyn says 6 weeks; if obese give TDS dose) to keep amenorrhoeic (MOA: Anovulation means no
corpus luteum to produce progesterone; oral progesterone stops lining proliferation but maintains
lining); alternatively Mirena/Levonorgestrel-releasing IUCD (ADR: 20% intermittent spotting 1 st 6mth,
50% amenorrhoea after 1yr; lasts 5 yr) or IM Depo-Provera 150mg q3mth (ADR: Irregular bleeding 1 st
3mth, abdo bloating/breast tenderness/weight gain water retention, depression). PO tranexamic
acid 1g TDS x 3 days to reduce menstrual flow (if VTE risk, give lower dose). Haematinics PO
Sangobion or PO Iberet.
Psychosocial support.
Non-pharm – MC, LD/avoid strenuous activity.
TCU and red flag advice.
STI – Treat STI, screen for other STIs. Notify, screen partner.
Prev – Contraception/family planning. HPV vaccination. Cervical screening. MMG/FIT/BMD/CV risk.
Structural lesion PAL Fibroids –
Ovulatory dysfunction -
Symptom – Primary amenorrhoea

Symptom – Secondary amenorrhoea
Symptom – Subfertility
Stem:
32yo female b/g lipids on statins, unscheduled visit. TTC 1yr. Dx: PCOS.
Causes of subfertility/infertility
Male factor
Erectile dysfunction causes. Drugs, alcohol, smoking. Medical causes. Trauma
Varicocele
Female factor
Anovulatory/Functional
- Other systemic causes: Hypothyroidism
- Hypothalamic: Stress, weight loss/excessive exercise
- Pituitary: Prolactinoma
- Ovarian: PCOS, Premature Ovarian Failure
Ovulatory/Structural
- Fallopian tube obstruction
- Uterine adhesions, fibroids, adenomyosis/endometriosis
- Cervix pathology
Subjective
2. Co-morbidities
- Screen for PMH, DHx – medication list, alcohol, smoking, illicit drugs? TCM/OTCs?
1. Complaint (SRSOTCTERA) – Subfertility
- Onset/duration: How long married, how long TTC? Previous marriages, previous
pregnancies/miscarriages/abortions for woman?
- Sexual History: “Need to ask sensitive details about sexual history to understand more about your
fertility problem.” Frequency, if not frequent why? (Confirmed subfertility – At least EOD SI or 2-
3x/week after end of menses unprotected x 12mth) Practices, problems e.g. dyspareunia,
penetration/ejaculation? (must be vaginal) Pregnancy prevention/Protection – condoms, OCPs,
IUCD? Any previous partners? Previous STIs or screening/Pap or Cervical screening and HPV vaccine?
- Started folic acid?
- Menstrual History: LMP? “Tell me about menses.” Regular, frequency/number of cycles per year,
menstrual diary/last dates? (<8 cycles/yr = PCOS) Menarche? IMB, PCB? Duration short/prolonged?
Flow light/heavy/clots? Dysmenorrhoea? (structural causes)
3. Cause – PMH, symptoms/SR, RF BPS, screening/invx

Female factor
- Ovulatory/Structural: Previous PID/surgical procedures on womb/reproductive organs? (adhesions)
- Anovulatory: Weight gain, cold intolerance, fatigue/lethargy, constipation? (Other systemic –

Hypothyroidism) Weight loss despite increased appetite, heat intolerance, diarrhoea,
tremors/palpitations? (Other systemic – Hyperthyroidism) Weight loss/dieting/exercise, stressors at
work/home? (Hypothalamic) Headache/giddiness, tunnel vision/double vision, milky discharge from
breasts? (Pituitary – Prolactinoma) Irregular menses, obese weight height BMI, excessive body hair
unwanted worsening, acne worsening bothersome, previous US ovariries? (Ovarian – PCOS) Irregular
menses, hot flushes, vaginal dryness, mood swings? (Ovarian – Premature ovarian failure)
Male factor – Partner here?
- Previous marriage/children?
- Problems with sustaining erection and penetration/premature ejaculation?
- PMH, obesity, surgery to reproductive organs? Drugs, alcohol, smoking? Stress? Occupation?
- Seen doctor? Invx - blood tests for hormonal levels, scans of reproductive system, sperm tests?
5. Complications medical/functional/social
- Psy: “Can be stressful psychologically.” Mood depressed, lost interest in activities/hobbies?

Anxious?
- Social: “Can affect relationship.” How is relationship? Finances?
6. Concerns
- ICEKAPS: What do you think is cause of subfertility? What are you most worried about? What
would you like me to do for you?
7. Contraindications to treatment/pregnancy
- Drug allergies? Current drugs need stopping – statins, glipizide, carbimazole.
- PMH – Chronic illnesses in detail e.g. DM (HbA1c should be < 6.5%), lipids. Previous panel tests.
Bucket list
SHx – Work, hobbies? Diet usually eat what, any exercise?
Objective
PE
Chaperone “Request for chaperone.”
BMI/ht/wt trend if not done (obese, underweight/anorexic). Vitals – Temp, Pulse HR/BP
Seated
Hands: Tremor, thyroid acropachy, sweaty palms/erythema

Face: Hirsutism, acne. Loss of eyebrows/dry skin.
Eyes: Pallor. Proptosis (go to side and top) KIV EOM and lid lag. Screen vision “Can see clearly all of
me?” KIV visual fields.
Neck: Acanthosis nigricans. Goitre “swallow” + palpate from behind.
KIV reflexes (delayed deep tendon reflexes), proximal myopathy for weakness.
Supine flat
Axilla for acanthosis nigricans.
Abdomen: Hirsutism, striae. Uterus (fibroids)
KIV VE: Cervical excitation, adnexal masses
KIV Speculum: Cervical growths. Pap smear if not done.
Invx
Stat: UPT if amenorrhoea. KIV HbA1c/capillary glucose (screen)
Send off: TFT, KIV arrange D21 progesterone, androgens. CVRF screening – lipids, FPG.
Assessment and Plan
General fertility and pre-conception advice: Regular SI 3x or more/week. Stop alcohol/smoking/illicit

drugs; start exercise and eat healthy balanced diet. Stop pregnancy-contraindicated drugs (e.g.
statins, glipizide, carbimazole). Start folic acid 400mcg OD. Screen for rubella/varicella immunity and
vaccinate.
PCOS. Diagnosis – Rotterdam criteria 2 of 3. Educate – Cysts in ovary from under-developed follicles.
Non-pharm: Weight loss, diet pack own food KIV refer dietitian, exercise moderate intensity aerobic.
Monitor menstrual calendar, manage stress. Pharm: Optimize chronics KIV metformin. Invx: Screen
FPG and lipids. Referral - Refer Gynae KIV US of ovaries if diagnosis not obvious,
clomiphene/letrozole for induction.
Indications for referral to Fertility specialist: 1. Age and duration (Age > 35,age >30 tried for 1yr, age
<30 tried for 2yr/total duration of subfertility 3yr) 2. Structural abnormality fibroids/endometriosis,
PID. 3. Premature ovarian failure. 4. Male – sexual dysfunction, hx of urogenital surgery, varicocele,
significant systemic illness.
What specialist may do: Blood tests (mid progesterone level 7 days before expecte pd period,
FSH/LH/prolactin/testosterone), scans (TVUS, hysterosalpingogram to look at Fallopian tubes),
seminal analysis (check sperm amount and quality) and male structural (hypospadias, varicocele)
and genetic syndromes. Treatment with clomiphene, gonadotropins, laparoscopic ovarian drilling in
PCOS, IUS/IVF.
Management – Contraceptive counselling
Stem
38yo F, no PMH, unscheduled. Comes asking to learn about tubal ligation. Dx: Hidden issue of
domestic abuse and marital rape. Must also address RFE about contraception.
Subjective
Screen PMH, DHx, alcohol, smoking
Gynae code and plans for future fertility
Contraceptive use history
Assessment and Plan
Wants long-term contraception as completed family. “Understand you have completed family and
looking for long-term pregnancy prevention. Several options – Irreversible (surgery for tubal ligation
for woman, vasectomy for men), reversible long-acting contraception (implant in womb with or
without hormones i.e. copper IUCD or Mirena, implant in arm i.e. Implanon, injection into muscle i.e.
Depo Provera). Do you have any preference?”
Obstetrics
Condition - GDM Gestational Diabetes Mellitus
Ref: NUP bridging 2022 with Pradip, NHGP seniors
Stem – 28/F G2P1, GDM found on screening comes for counselling. Did not screen during previous
pregnancy.
Subjective
RFE, other worries. “Understand you are anxious to know result, don’t worry will explain to you in
detail. Get more info about medical and social history so can advise you better.”
Screen PMH, DHx – Known DM?
Current SR – Any weight loss/polyuria/polydipsia/polyphagia?
Current pregnancy – Gestation. How are you feeling today? Alarm symptoms (PV bleed, leaking
liquor, contractions? FM?).
Past Obs hx – Previous pregnancies/termination/miscarriage/IUFD? Previous GDM/hypertension or

pre-eclampsia? Previous big baby/delivery complications?
Objective
PE
Baseline BMI, weight trend. Vitals Temp, BP/HR.
Abdo - SFH, FM, Doppler.
Invx
?Urine FEME (glucose, protein)
Assessment and Plan
Patient education
- Dx. “Normal range for GDM screen (3 pt OGTT) – fasting less than 5.1, after 1h less than 10.0, after
2h less than 8.5. Yours is above this range, means you have Gestational Diabetes.”
- Pathophysiology “Common condition, happens in 1/5 of women because placenta (organ that
supports baby) produces hormones that reduce body’s natural control of blood sugar.”
- Risks and importance of control
Maternal: 1. Pre-clampsia (high blood pressure and high urine protein in pregnancy needing earlier
delivery 2. Risk of DM after pregnancy and CV disease.
Obstetric/Foetal: “If sugar not controlled, risk of complications for pregnancy and baby - 1.
Macrosomia (big baby because sugar crosses into baby’s blood), 2.
Polyhydramnios/PPROM/PTL/chorioamnionitis (baby passes more urine, high water level in bag,
burst, infection), 3. Delivery complications poor progress/emergency LSCS or assisted delivery with
forceps vacuum/shoulder dystocia/hypoxic brain injury/Erb’s palsy (difficult delivery because of
baby’s size, need emergency Caesarean operation or forceps or vacuum to help pull out baby, baby’s
brain injured due to lack of oxygen, nerves in neck permanently injured due to positioning when
removing baby), 4. IUFD/stillbirth (higher chance of baby dying in womb)”. **Complications of foetal
anomalies and IUGR apply to pre-existing DM, not GDM.
Non-pharm
- 1st line treatment is lifestyle modification/diet control. Avoid sugary drinks and food and oily food,
refer dietitian/DNE to go through diet, exercise aerobic/heart-pumping at least 150min/week.
Monitor 7-point capillary glucose 2x/wk (pre and post bf/lunch/dinner, before bedtime), target pre-
meal 4.4-5.3 or less, 2h post-meal 5.5-6.7 or less (1h post-meal 7.8 or less).
Pharm
- Preferred is insulin (unless pre-existing DM on metformin, needle-phobia etc.). Dose: Start

insulatard 4U BD. Advantages: Fast onset and response, easier to titrate, protects baby’s size and
heart. ADRs: Completely safe for foetus (does not cross placenta, does not cause birth defects);
mummy monitor for hypoglycaemia (low blood sugar <4, giddy hungry hands shaking; if so take 3
sweets or half cup of sweet drink and recheck 15min, come back next day to see Dr).
- If pre-existing DM on metformin, continue; stop other OHGAs. Advantages: Safe based on current
studies. Disadvantages: No information about long-term effects of exposure on child.
- Post-natally stop all medications (sugar goes down after placenta out in majority of patients).
Referral and TCUs
- Co-managed with Obstetrics (no need for Endocrine unless pre-existing DM). Routine growth scan
at 32wk, additional follow-up scan at 36wk (monitor for macrosomia). Timing of delivery: Well-
controlled on diet – routine 40-41wk; on insulin or metformin – 38-39wk. Post-natal care: Stop
medications, recheck 2pt OGTT 6wk after delivery, future pregnancies need booking visit/1 st
trimester DM screen 2pt OGTT (risk of recurrent GDM 50%), screen DM yearly (risk of DM 7x normal
population).
Other prev
- Influenza and Tdap vaccination.
- Cervical cancer screening.
ACG guidelines for GDM screening
High-risk (previous GDM/big baby 4kg or more, age 40 or older, obese BMI 30 or more pre-
pregnancy/pre-DM/PCOS) - 1st trimester screen with 2pt OGTT. Cut-offs for pre-existing DM.
Universal screening - 24-28wk (2nd to 3rd trimester - gestational insulin resistance) with 3pt OGTT.
Cut-offs – fasting 5.1 or more, 1h 10.0 or more, 2h 8.5 or more.
Paediatric
Cardiovascular Adult/Geriatric, Acute/Emergency vs. Chronic/Preventive/Palliative
Sign - Paediatric murmur
Ddx of complaint
Innocent vs. pathological
- Innocent/Still’s murmur. PE: Grade 2 or less, Systolic Ejection/Cresc-decresc, Standing up/Valsalva

reduces intensity; no CCF/pulm hypt. Hx: No cyanosis, play less than others, poor feeding/FTT
S A
Handrub! (SPIKES)
treatment?”
life?”
Lab result
treatment?”
Complications
Chronic condition
Causes/triggers
Bucket list
things?”

dementia
disease

O P
Handrub! Non-pharm
Pallor Handrub!
vibration sense
Handrub!
MMG/cervical)
plan”
Non-pharm
Pharm + ADRs
Ref/TCU/red flags
Respiratory Acute/Emergency vs. Chronic/Preventive/Palliative

Symptom – Wheezing
Common exam scenarios
- Age under 5 with recurrent wheeze + strong atopic risk factors
- Age over 5 with recurrent wheeze
- Wheezing after feeding
Ddx of wheezing in child
Emergency: Anaphylaxis, Foreign body
Resp acute: Viral bronchiolitis/bronchitis
Resp chronic: Asthma, bronchopulmonary dysplasia/tracheomalacia, cystic fibrosis, primary ciliary

dyskinesia, immunodeficiency, bronchiolitis obliterans, mediastinal mass
ENT: chronic rhinosinusitis/PND, OSA, vocal cord dysfunction
GI: GERD
Cardio: Congenital heart disease
S A
Handrub! (SPIKES)
“Tell me more about your wheezing. When did you first
Confirm wheezing –
Onset - When did you first notice it? (since birth –
congenital cause, acutely – anaphylaxis/FB/infection, chronic
– asthma etc.
Timing/Triggers – What causes it to come on? (night/early
morning – asthma, exercise – EIA, persistent – congenital)
Exacerbating -
Relieving -

treatment?”
Previous episodes
Hospitalization/intubation
Investigations – Spirometry?
Management so far?

Do you have eye swelling? Rashes? (Anaphylaxis)
Swallowed or choked on something? (Foreign body)
Fever, cough, runny nose? (Viral bronchiolitis/bronchitis)
Worse at night/morning/exercise? Better in daytime/diurnal
variation/with inhalers? Allergic rhinitis/eczema/Fhx of
atopy? (Asthma)
Born premature? Present since birth? (bronchopulmonary
dysplasia/tracheomalacia) Noisy breathing when
eating/crying? Better with position change?
(tracheomalacia)
Recurrent/frequent fevers/infections? (cystic fibrosis,
primary ciliary dyskinesia, immunodeficiency)
Cough when feeding/vomiting after feeds? (GERD)
Born with heart condition? (Congenital heart disease)
LOW/poor growth? Lymph node swelling? (mediastinal
mass/tumour)

life?”
Growth affected?
Bucket list
Social history
things?”


O P
Handrub! Other primary care invx

BMI, HR/BP, RR + SpO2, Paeds – Growth chart in health (age 5 or older) Spirometry KIV
booklet. methacholine challenge
Atopy test/exercise test (for airway
Nose: pale swollen turbinates hyperreactivity)
Throat (recurrent wheezing in children
Lungs: inspect front/side respiratory distress, symmetry, <2yo not responding to
structural (increased AP diameter chronic hyperinflation, bronchodilators/corticosteroids)
pectus excavatum scoliosis), back inspect, expansion, 24-hr oesophageal PH monitoring
auscultate; palpate cervical lymph nodes; front – trachea,
JVP, apex beat, palpable P2, auscultate apices and axillae Non-pharm
Peripheries: Skin for eczema, legs for pedal oedema
Pharm + ADRs
Handrub! (suspected asthma) Trial regular
betamethasone dipropionate
50mcg 1puff BD (low-dose) +
salbutamol PRN x 2weeks
(suspected GERD) Empiric acid
suppression?
Ref/TCU/red flags
Handrub!
PPSV23/PCV13, HPV), Screening
CXR (FB, TB, structural abnormalities e.g. vascular rings) (BMD, FIT, metabolic,
If chronic/systemic symptoms, FBC (anaemia, MMG/cervical)
leukocytosis/leukopenia, eosinophilia – allergy/parasites)
plan”
Non-pharm
Pharm + ADRs
Ref/TCU/red flags
Gastrointestinal Acute/Emergency vs. Chronic/Preventive/Palliative

Sx – Recurrent abdominal pain
Ddx of acute abdominal pain
Surgical causes
Trauma: Intraabdominal solid organ laceration (liver, spleen)
GI: Appendicitis, Meckel diverticulitis, perforated viscus, malrotation with midgut volvulus,
incarcerated hernia, intussusception, adhesions with intestinal obstruction, bowel ischaemia/acute
mesenteric ischaemia, bacterial peritonitis
Uro: Testicular torsion
Gynae: Ectopic pregnancy, threatened abortion, Ovarian cyst torsion/rupture, PID.
Non-surgical
GI: GERD, gastritis/PUD, GE, constipation, lactose intolerance, malabsorption, mesenteric adenitis
Liver/HPB: Hepatitis, liver abscess, pancreatitis, biliary colic, cholecystitis, cholangitis
Uro: UTI, urolithiasis, ARU/distended bladder, obstructive hydronephrosis
Gynae: Dysmenorrhoea, Mittelschmerz, endometriosis
MSK: Haematoma.
Other: Endocrine – DKA. Autoimmune – HSP. Resp – pneumonia. CVS – Myocarditis. Haem – Sickle
cell crisis.
Ddx of chronic (2 months or more)/recurrent abdominal pain
Rule out acute abdomen causes as above
GI: GERD, gastritis/PUD/H pylori infection, Constipation colic, Malignancy, Inflammatory bowel
disease, Lactose intolerance/Food allergy/malabsorption/celiac disease, Functional abdominal pain
(including IBS, abdominal migraine, functional dyspepsia)
Liver/HPB: Chronic hepatitis, chronic pancreatitis, Biliary colic/chronic cholecystitis
Uro: Urinary tract infection, urolithasiis, hydronephrosis
Gynae: Dysmenorrhoea, endometriosis, Mittelschmerz, PID
Psychosocial – School avoidance
Concerns
- RFE, ICEKAPS
Comorbidities/Career
- PMH/DHx including TCM/OTCs. In school/childcare?
Complaint – OSR.CSF.TETRA
- Onset/duration: Currently ongoing? New or recurrent? If new, acute or gradual? If recurrent how
often, lasts how long each time?
- Site, Radiation: Where, point out? Anywhere else? (central/periumbilical safe) Radiation?
- Character
- Severity, Functional impact: Able to walk/play, eat, go to school? Well in-between? Wakes at night?
- Time course/progression: Getting worse/more frequent or better/less frequent?
- Exacerbating, Triggering, Relieving,
- Associated sx review: GI, constitutional, Uro, Gynae
Cause
- GI: Vomiting bloody bilious? Reflux? Diarrhoea/Constipation and baseline bowel habits (frequency,
form), reduced fibre/fluid intake and usual diet and reasons, poor toileting habits/watching mobile
phone/fear of public toilets, pain at anus? Red flags – PR bleeding/melaena? Risk factors – FHx of
IBD, coeliac disease? Bloating/flatulence?
- HPB: Jaundice, pale stools, tea-coloured urine, pruritis?
- Constitutional sx: Fever? Red flags – night sweats, LOW/LOA/change in growth trajectory? Risk
factors – travel, contact history, food ingestion?
- Uro: UTI – Dysuria, frequency, cloudy urine, gross haematuria? Testicular torsion – Testicle pain,
swelling?
- Gynae: PV discharge/PV bleed? LMP, menstrual history? Risk factors – Sexual history?
- MSK: Trauma to abdomen?
- Endocrine: DKA – Polyuria, polydipsia, polyphagia, LOW, FHx of DM? Hyperthyroid – Heat
intolerance, tremors? Hypothyroid – Cold intolerance?
- Autoimmune: Rashes, joint pain?
- Resp: Cough?
- Psychosocial: Recent changes at home/school e.g. parents divorced/arguing, moved house, started
kindergarten?
Course
- Seen dr, investigations done, treatment with laxatives, compliance, response?
Complications of treatment and disease
- Bio: Dehydration – Oral intake? Shock – Confused?
- Psychosocial: Affected daily routine, school/activities, friends, family, finances?
BIGHEADDSSS
Birth – Passed meconium stools within 1 st day?
Immunization
Growth and development – Dry by day and night? (normally daytime by age 2, night time by age 3?)
Home
Education
Activities
Diet
Drugs/alcohol/smoking
Sex/puberty
Sleep
Suicide/depression
Objective
PE – Rule out acute abdomen, testicular torsion. Look for complications e.g.
dehydration/hypotension.
BMI wt/ht centiles and trend, vitals T HR
General: Dysmorphism
Skin: Perfusion
Eyes: Pallor, jaundice
Mouth: Hydration, oral ulcers, Peutz-Jegher pigmentation
Neck: Goitre
Abdo: Scars, hernias, tenderness/guarding/rebound, masses, bowel sounds.
External genitalia: Testicular lie
Inspect perianal/perineal region for anal fissures
Invx
Stat - Urine dipstick/microscopy for blood, leucocytes nitrites in infection. KIV Na/K/Cr if concern for
dehydration/solute depletion, FBC if concern for infection. AXR Usually not indicated
Send off – KIV TFT, calcium
Assessment and Management

Constipation colic. Pt education. Non-pharm – Dietary fibre intake (more fruits and vegetables
colourful tasty), fluids, toileting habits (regular potty time after meals, foot support if feet dangling,
no distractions), diary of abdominal pain/stool amount/consistency. Pharm – Lactulose 0.5ml/kg BD
or PEG 0.5 to 1 sachet/day dissolved in 125ml of water. Duration proportionate to duration of
problem (weeks to months to wean off).
Recurrent abdominal pain. Tummy pain diary. Red flag advice. KIV refer for consideration of scopes.
Food allergy. Pt education, avoid triggers, read labels on packaged food/medications/vaccines,

prepare meals at home. Challenge test when older. May grow out of it.
Renal & Urology Acute/Emergency vs. Chronic/Preventive/Palliative)

Neurology Acute/Emergency vs. Chronic/Preventive/Palliative
Preventive – Routine developmental assessment
Sources: NHGP seniors.
Important problems by age
Growth, development, vaccinations
Newborn: Congenital abnormality, eye, heart, developmental dysplasia of hip
4mth: Gross motor issues, head lag
6mth-12mth:
18mth: Speech delay, autism
30mth: Speech delay, autism
48mth: Vision
History
Parental concerns, nutrition (feeding, PU and BO)
Health booklet for below
Birth and antenatal/perinatal history
- Siblings/Birth order? GA? (growth and vaccines by chronological age, development adjusted for
prematurity below 36weeks till age 2)
- mode of delivery? Apgar/perinatal events?
- Antenatal history – problems during pregnancy maternal/foetal?
- Postnatal hx – Screening tests normal?
past medical history
- Any past medical history so far?

Growth
- Weight, height, OFC tracking along centiles or change in centiles?
Development
- Milestones – able to do what, not able to do what?
- Gross motor: 1mth - Equal movements? (1mth) Lifts head momentarily when prone? (1mth); 4mth
- Lifts head 45 degrees when prone/ventral suspension + props up on forearms? (3mth, 3mth) No
more head lag (4mth) Lifts head 90 degrees when prone (5mth) Holds head steady in sitting position
(5mth) Rolls over. Bears weight on legs for few seconds (6mth); 6mth - Sits unsupported (6mth,
7mth); 12mth - Stands with support (9mth, 9mth) Pulls to stand (9mth, 10mth) Stands without
support, cruising (10-12mthm, 14.5mth); 18mth - Stoops to recover (15.5mth) Walks
well/independently (15mth, 16mth) Walks up steps with support not hand held (18mth, 21.5mth);
30mth - Walks down steps with support but not hand held (24.5mth)/ Walks up/downs stairs
alternate feet, runs well (30mth), Kicks ball forward (24mth, 26mth) Jumps up both feet off the
ground (24mth, 32.5mth) Balances each foot 1s (37mth); 4yr - Pedals tricycle (36mth, 41.5mth)
Hops (53.5mth) Balances on either foot for 5 seconds (36mth, 57mth).
- Fine motor: 1mth - Follows object to mid-line (1.5mth); 4mth - Follows object past mid-line?
(1.5mth, 2.5mth)/Follows object 180 degrees (4.5mth) Brings hands together at midline/hand regard
(3mth, 3.5mth) Unfists/Grasps rattle in hand (3mth, 4mth) Regards small object like raisin (5.5mth);
6mth - Reaches for object (6mth, 6mth) Looks for fallen object (7mth) Transfers objects from hand
to hand (6mth, 7.5mth); 12mth - Finger-Thumb grasp/immature pincer grasp (9mth, 10mth)/Mature
pincer grasp (12mth, 13.5mth) Bangs 2 cubes held in hands (9mth, 10.5mth); 18mth - Scribbles
(16mth) Builds tower of 2-3 cubes (17mth); 30mth - Builds tower of 4-6 cubes (24mth, 23-29mth)
Builds tower of 8-9 cubes (35.5mth) Copies straight vertical line (24mth, 38.5mth) Picks longer line
(46.5mth); Copies a circle (36mth, 47mth) Copies a cross (48mth, 50mth) Copies a square (48mth,
56mth) Draws person with 3 parts (57.5mth) Copies triangle (60mth).
- Hearing/receptive speech: 1mth - Responds to bell/Alerts to sound? (1mth); 4mth - Turns head to
sound at ear level 20cm out of sight (3mth)/Turns to sound that is out of sight (6mth, 7.5mth)
Follows 1-step command with gesture (12mth) Follows 1-step command without gesture (18mth)
Follows 2-step command (24mth) Follows 3-step command (36mth) Understands what/where
questions (48mth) Can follow rules (60mth).
- Expressive speech: 1mth - Vocalises/Coos (1.5mth, 1.5mth); 4mth - Laughs without being tickled
(3mth, 4.5mth); 6mth - Babbles non-specifically/Says single syllables e.g. Ba, da, ga, ma/Imitates
speech sounds (6mth, 10mth); 12mth – Papa mama non-specific (9mth)/Says papa mama specifically
(12mth, 14.5mth); 18mth - Points to 2 parts of own body (19mth) Says 3 words other than
Papa/Mama (12mth, 21mth) 10 words with meaning (18mth); 30mth - 2-3 word phrases (24mth,
27mth) 50-word vocabulary (24mth) Points to 2-4 pictures correctly (25.5-28.5mth) Names 2-4
pictures correctly (30mth-37mth) Knows age/name/sex (40mth) Rote counts to 10 (52mth) Knows
functions of objects (55.5mth) 3-4 word phrases (36mth) Correct
grammar/pronouns/plurals/prepositions, Names 3-4 colours (48mth, 63.5mth) Fluent speech/stories
(60mth) Places and counts blocks (64mth).
- Social: 1mth - Face regard (1mth) Spontaneous social smile (1mth); 4mth - Excites at a toy/familiar
pleasant situation(feeding/bathing) (3mth, 5.5mth); 6mth - Reacts to stranger/stranger anxiety
(6mth, 10mth); 12mth - Waves bye bye (9mth, 10.5mth) Claps hands (9mth, 11mth) Indicates wants
by gestures/pointing, has joint attention (12mth, 13.5mth); 18mth - Imitates household activities
(16mth) Drinks from a cup (12mth, 18.5mth); 30mth - Uses spoon (18mth, 22mth) Removes clothing
(24mth)/Puts on any clothing with help (34mth) Names friend (45.5mth) Pretend/Imaginative play
e.g. e.g. Drive cars/action figures/cooking/Comb doll’s hair (18mth, 24.5mth) Toilet-trained (36mth)
Brushes teeth with help (51mth) Dresses with no help (54mth) Brushes teeth with no help (69mth).
- Developmental regression – able to do previously but now cannot?
Vaccinations
- Up to date for age?
PE
Height/weight/OFC plot centiles on growth chart
Dysmorphism, neurocutaneous stigmata
Interaction with parent and doctor – Start by bribing with sticker.
Pre-schooler (walks) – DA by playing while seated, check eyes while seated, check on couch heart,
lungs, abdo
- Receptive speech (Upwards from 12mth i.e. walking): 1-step with gesture - Point + “Take the
sticker/bear” or “Give me a high five” or “Follow me squatting!” (12mth), “Where is mummy?” (joint
attention) + 1 step without gesture - “Pass the bear to mummy” (18mth), 2-step “touch your head,
then clap your hands” (2yr), on – “put the bear ON the truck” (30mth), under “put the bear UNDER
one truck, then pick up the other truck, then pass the truck to mummy” (3yr), between “put the bear
BETWEEN the 2 trucks” (4yr), before “BEFORE you pick up the truck, clap your hands” (5yr)
- Expressive speech (older child or younger child based on receptive speech level): Older child –
Narrate “Tell me what is happening in the picture” (4yr), Recount “Can you tell me the story again?
What did Peter and Mary do?” (5yr), 2 to 3 words “What is the boy doing?” (2-3yr). Younger child
(downwards) – 10 words picture book + “What is this? Where are your eyes/nose/mouth?” (18-2yr),
mama/papa meaningful “[to parent] What does he call you? [to child] Where is mama?” (12mth)
- Fine motor (older child or younger child based on walking 18mth): Older child (blocks, drawing) –
Draw arrangement then ask child to stack blocks as tower of 3/6/9 (18mth, 24mth, 30mth), 4-block
train (2.5yr), 3-block bridge (3yr), 3-step ladder (4yr), 4-step ladder (5yr). Crayon + paper draw out
pictures and ask child to copy scribble (18mth), vertical line (2yr), horizontal line (2.5yr), circle (3yr),
square/cross (4yr), triangle (5yr). Younger child (downwards) – Pincer grip/raking “Can he take these
biscuits? Pick up biscuit” (12mth/9mth), reach/transfer give bear then fire engine to same hand
(4mth/6mth)
Infant (doesn’t walk) – Examine fontanelles, eyes, heart/lungs on parent then on 360deg
examination on couch (supine, sitting, standing, prone)
Invx
18mth old – M-CHAT for autism, Vanderbilt
Management
Anticipatory guidance – vaccinations, development (upcoming milestones, future DA appointments)
Symptom – Failure to thrive

Symptom – Speech delay
General approach
Isolated speech or global developmental delay?
Primary or secondary?
Primary causes
Secondary causes
- Bio: Hearing impairment, brain injury (hypoxia, infection, spasticity, congenital), tongue tie
- Psy: Autism Spectrum Disorder
- Social: Neglect/decreased stimulation, excessive screen time
History
RFE, express sympathy “That must be very worrying for you”, screen for other RFE “Besides this is
there anything else you are worried about?”
Screen birth hx and PMH “Before I ask about the speech issue, birth history. Do you have health
booklet?”
- Siblings/Birth order? GA? Mode of delivery, Apgar, perinatal events “problems during delivery”?
Antenatal history “problems during pregnancy?”
- PMH Medical illnesses so far? DHx Medications?
- growth normal?
- had all vaccines?
HOPC “Tell me more about speech issue”
- extent (receptive or expressive), severity (milestones attained, cannot do)
- onset/time course/regression “When first noticed? When first able to say papa mama?”
developmental regression “Able to say things but now cannot?”
Other developmental domains – social, gross motor, fine motor

Cause (secondary)
Hearing - Hearing screen normal? Turn to sound behind?
Brain – Infection/fever during pregnancy? Prolonged delivery? Previous infection/trauma/seizures?
Mouth – Tongue tie problems latching/swallowing? Problems talking?
Autism – Non-verbal communication (AUT Abnormal understanding? U? T?) + repetitive behaviours

(ISTI I Stereotyped? Trains fixation? In?), FHx of autism?
Social – Main caregiver/language? Parents working? Talk/read together? Screen time?
Course
Seen doctor? Tests done? Therapy?
Complications
Impact on school? Impact on family?
PE
Height/weight/OFC plot centiles on growth chart
Dysmorphism, neurocutaneous stigmata
Interaction with parent and doctor
Pre-schooler (walks) – DA by playing while seated, neuro by observation, check while

seated/standing hearing, tongue, otoscopy
- Receptive speech (Upwards from 12mth): 1-step with gesture - Point + “Take the bear” or “Give me
a high five” or “Follow me squatting!” (12mth), “Where is mummy?” (joint attention) + 1 step
without gesture - “Pass the bear to mummy” (18mth), 2-step (2yr), on (30mth), under (3yr), between
(4yr), before (5yr)
- Expressive speech (older child or younger child based on receptive speech level): Older child –
Narrate “Tell me what is happening in the picture” (4yr), Recount “Can you tell me the story again?
What did Peter and Mary do?” (5yr), 2 to 3 words “What is Peter doing?” (2-3yr). Younger child
(downwards) – 10 words picture book + “What is this? Where are your eyes/nose/mouth?” (18-2yr),
mama/papa meaningful “[to parent] What does he call you? [to child] Where is mama?” (12mth)
Eye Adult/Geriatric/Paediatric, Acute/Emergency vs. Chronic/Preventive/Palliative
ENT Adult/Geriatric/Paediatric, Acute/Emergency vs. Chronic/Preventive/Palliative
Musculoskeletal/Rheumatology, Acute/Emergency vs. Chronic/Preventive/Palliative
Dermatology Adult/Geriatric, Acute/Emergency vs. Chronic/Preventive/Palliative
Endocrine Acute/Emergency vs. Chronic/Preventive/Palliative
Haematology Acute/Emergency vs. Chronic/Preventive/Palliative
Infectious diseases Acute/Emergency vs. Chronic/Preventive/Palliative
Symptom – Acute fever in child
Ddx of complaint
Cause – Systems review, examine
Complications – Feeding? Hydration? Activity?
S A
Handrub! (SPIKES)
treatment?”
life?”
Lab result
treatment?”
Complications
Chronic condition
Causes/triggers
Bucket list
things?”

dementia
disease

O P
Handrub! Non-pharm
Pallor Handrub!
vibration sense
Handrub!
MMG/cervical)
plan”
Non-pharm
Pharm + ADRs
Ref/TCU/red flags
Male reproductive system Adult/Geriatric, Acute/Emergency vs.
Eye Adult/Geriatric/Paediatric, Acute/Emergency vs.

Symptom – Vision loss
Ref: Prog B neuro workshop 20220813
Causes of monocular vision loss – Localization and aetiology
Eye – Retinal detachment
Optic nerve: Amaurosis fugax, temporal arteritis, optic neuritis from MS.
Brain (Cortical blindness): Posterior circulation stroke, migraine with prolonged aura
Subjective
2. Co-morbidities
- Screen for PMH
- DHx – medication list?)
1. Complaint (SRSOTCTERA) – Vision loss
- Site/Character: Unilateral or bilateral? Whole visual field or one part?
- Onset/duration, Timing, progression: New or recurrent? Acute or gradual? Getting worse?
3. Cause – localization. Associated symptoms.
- Floaters/flashing lights? (retinal detachment)
- Eye pain, jaw claudication/headache? (CRAO, temporal arteritis)
- Previous numbness/weakness? (MS)
- Difficulty speaking dysarthria, difficulty swallowing dysphagia, giddiness, hearing loss? (posterior
circulation stroke) Recurrent pounding headaches? (migraine)
3. Cause – PMH, symptoms/SR, RF BPS, screening/invx
- If lab, why done?
- DVITAMINC or Systems review head to toe
- Risk factors (travel/contact/sex, FHx)
- Drugs OCPs? (cause of young stroke)

6. Concerns
- ICEKAPS: Understanding of cause? Treatment expected?
- Allergies – aspirin?
Objective
PE
BMI, Vitals Temp pulse (AF?) HR/BP
Seated
Eye group in detail
- Pocket Snellen “cover your left eye with this piece while I hold the chart. Read the lowest line of
numbers that you can see.”
- Pupils anisocoria, reflexes, RAPD, near accommodation.
- Visual fields – Demonstrate 1 arm’s length “Cover your left eye with your left hand, look into my
right eye.” Check for central scotoma.
Fundoscopy for cherry red spot (CRAO), papilloedema (optic neuritis)
Screen CN 5, 7. Skip lower CN.
Hand dance pronator drift, dysmetria KIV dysdiadochokinesia, power KIV reflexes.
Gait “See you walk to bed”
Supine 45deg. Chaperone + Expose “Request a chaperone. Please take off shirt.”
Cardiovascular Pulse if not done. Auscultate heart sounds for murmurs, carotids for bruit.
Invx
Stat – Capillary glucose, ECG
Assessment and Plan
Amaurosis fugax. Refer A&E for CT brain
Young stroke/hypertension. Will need workup.

General. Driving – Legally cannot drive. Car left behind “I will help call next-of-kin or Automobile
Association.
Symptom – Ptosis?
ENT Adult/Geriatric/Paediatric, Acute/Emergency vs.

Symptom – Hearing loss

Consultation Station Notes 20220919

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Consultation Station Notes

Teenager – Overbearing parent?

Female teen – Eating disorder, underage sex?

Female in 30s, statins – Fertility issue, thyroid?

Repeated visits 2 or more for same complaint – Poor control?

Opioids e.g. tramadol, codeine – Opioid use disorder?

BMI – Obese/Cushing’s syndrome? BP high – Drug side effect/poor control?

Elderly – FFI MMB C

***Main active column is “Assessment/Problem List”

Contraindications to treatment: Drug allergies. Hormones, TXA - CV risk factors (DHL/IHD/stroke,

Patient cues and reflex response

Formulate approaches. For each question, consider “Why ask this?”

Equipment: On me – Stethoscope, watch, pentorch, measuring tape. Provided – BP cuff,

Request chaperone if undressing upper body, examining abdomen, genitals or buttocks.

Neck for goitre (Thyroid: Look/swallow, feel goitre) and cervical LN

Neuro: Pronator drift, dysmetria, power, gait

CVS: precordium + pedal oedema

Abdomen: lie flat, liver, cervical lymph nodes

DFS: inspect for ulcers/calluses/deformity, palpate pulses, screen pinprick/vibration sense

MSE: ASEPTIC Appearance/Behaviour, Speech, Emotion/affect mood, Perception hallucinations,

Previous invx – “Do you have any previous blood tests/ECGs/x-rays/spirometry?”

1min clarification common questions:

“What were your examination findings?”

“What was the mental state examination?”

Request vitals, height weight and BMI

Look up guidelines after each case

Consultation station template

1. COMPLAINT HOPC – On The. SRCT. ERA. So Far

Site/Radiation, Character, Timing/progression

4. CAUSE – DQ Direct Questioning with PMH, symptoms/SR, RF, tests done

Secondary causes – Drugs/iatrogenic then Systems review head to toe OR VITAMINC

Risk factors (travel/contact/sex, occupation, FHx)

1. Chronic CONDITION/COURSE/CAUSE if equivocal

When and how diagnosed, investigations, treatment/response, follow-up

How has it been since last visit?

3. COMPLIANCE, Competence/ Crisis management, COMPLICATIONS of treatment,

Compliance to follow-up/meds/diet/exercise, reasons for failure e.g. cost/cognition/caregiver

4. Other CAUSES of poor control/triggers/Co-morbidities

Common sense management

Comms – Psychiatric history

Comms – Sexual history

3. Practices “What kind of sex? Vaginal/oral/anal?

4. Protection + Pregnancy Prevention/Pregnancy/Plans Pregnancy “Use any protection, condom?

Overbearing parent + reticent teen

Came alone or anyone accompanying?

Replace SHx with HEADDSSS (home, education/employment, activities, drugs/drinks/smoking, diet,

- Suicide/Depression/Safety – Feel depressed, lost interest, constantly worrying? Ever thought of

BIGHEADDSSS – Birth and FHx, immunizations, growth and development

Birth + FHx: FTNVD? Antenatal issues, neonatal issues?, FHx of conditions/consanguinity

Explore social history – Any recent change at Home, School?

Problem List and Management Plan – SPIKES framework

- Patient education on condition and possibility of treatment, maintain hope

- Other screening/investigations e.g. Hep A, Hep B/Hep C, syphilis

- Prevention of ID transmission, safe sexual practices

Invx: Stat – KIV UPT. Future – LFT, AFP.

- Refer psychologist if depressed.

Comms/Ethics – Medical error/Open disclosure

SPIKES to break bad news – as above.

Apologize + Acknowledge or NURSE