• Fever for 5 days
• Cough with sputum for 2 weeks
• Chest pain for 3 hours

History of Presenting Illness

• Exact site: central/suprapubic, right or left iliac fossa
• Character: dull aching, cramping, colicky, stabbing
• Severity and radiation: to back, groin, thigh or rectum
• Duration of each episode and whether it is progressively worsening
• Relation to menstrual flow: how many days before menses, during menses, and how many days after it
• Relieving/aggravating factors: analgesics, rest, movement, defecation, micturition, intercourse
• Associated symptoms: heavy menstrual bleeding, irregular bleeding, passage of clots, dyspareunia, infertility, dyschezia, constipation, diarrhoea, nausea/vomiting, fever, loss of weight.

• Number of attacks, time and place of onset
• Precipitating factor: standing for long time, pain, emotional stress, fasting, exertion, micturition
• Prodrome: dizziness, blurring of vision, nausea, sweating, palpitations, chest pain
• Complete loss of consciousness or near fainting, duration, fall/injury
• Tongue bite, abnormal movement, urinary/faecal incontinence
• Recovery: immediate or confusion/drowsiness afterward
• History of heavy vaginal bleeding, black stool, poor oral intake, vomiting/diarrhoea, pregnancy possibility, cardiac disease, epilepsy, or medication use.

Examination-style summary

A reproductive-aged woman presents with chronic cyclical lower abdominal pain for 1 year, occurring before and after menstruation, associated with curdy vaginal discharge and dysuria. She additionally developed recurrent syncope and breathlessness for 1 day. The differential diagnoses include secondary dysmenorrhoea due to endometriosis/adenomyosis, pelvic inflammatory disease or cervicitis/vaginitis with urinary infection; pregnancy-related causes, anaemia from abnormal uterine bleeding, and cardiopulmonary causes of syncope and dyspnoea must be urgently excluded.

Important viva point

History of Presenting Illness

Short presentation summary

A ___-year-old lady presented with chronic cyclical lower abdominal pain for over 1 year, occurring ___ days before menstruation and persisting for ___ days after menstruation, associated with curdy white vaginal discharge and dysuria for ___. She also developed recurrent syncope and breathing difficulty for 1 day.

1. Patient was apparently well ___ ago, then developed lower abdominal pain, gradual in onset, mainly at ___, cramping in nature, severity ___/10, radiating to ___, lasting ___ per episode.
2. Pain starts ___ days before menstruation, continues for ___ days after it, is aggravated by ___ and relieved by ___.
3. It is associated with ___ menstrual flow, ___ cycle regularity, dyspareunia ___, painful defecation ___, and low backache ___.
4. She also has curdy white per-vaginal discharge for ___, amount ___, odour ___, associated with vulval itching ___ and soreness ___.
5. Burning micturition started ___ ago, associated with frequency ___, urgency ___, suprapubic pain ___, loin pain ___, and fever ___ .
6. She had ___ episodes of syncope during the last 1 day, each lasting ___, precipitated by ___, preceded by dizziness ___, palpitation ___, sweating ___, and followed by ___ .
7. There was no tongue bite ___, abnormal body movement ___, urinary incontinence ___, or post-ictal confusion ___ .
8. Breathlessness began ___ ago, is present at rest/on exertion ___, and is associated with cough ___, wheeze ___, chest pain ___, palpitation ___, and haemoptysis ___ .
9. LMP was ___; menstrual period was missed ___; contraception used ___; pregnancy test ___ .
10. Relevant negatives: no fever (against acute PID), no heavy menstrual bleeding/passage of clots (against adenomyosis/fibroid), and no haematuria or loin pain (against upper UTI/urinary calculus).

1. Patient was apparently well 1 year back, then developed gradual-onset, intermittent, dull aching lower abdominal pain, mainly in the suprapubic region.
2. The pain starts 1-2 days before menstruation and persists for 1-2 days after cessation of flow; it is non-radiating and partially relieved by analgesics.
3. It is associated with dysmenorrhoea, low backache and dyspareunia, but there is no menorrhagia or intermenstrual bleeding.
4. She has curdy white, non-foul-smelling per-vaginal discharge with vulval itching and soreness.
5. She also has burning micturition with increased frequency and urgency, without loin pain or haematuria.
6. For the last 1 day, she has had recurrent brief episodes of syncope, preceded by dizziness, blurring of vision and sweating, especially while standing.
7. Each episode lasted for a few minutes, with spontaneous complete recovery and no post-ictal confusion.
8. There was no tongue bite, abnormal body movement, frothing from mouth, or urinary incontinence.
9. She has mild breathlessness on exertion, associated with generalized weakness, but no chest pain, palpitation, cough or haemoptysis.
10. There is no fever, vomiting, abdominal distension, significant weight loss, or previous similar illness.

• Against acute PID: no high-grade fever, chills, or acute severe lower abdominal pain.
• Against ectopic pregnancy: no amenorrhoea, per-vaginal bleeding, or sudden severe unilateral abdominal pain.
• Against renal stone/pyelonephritis: no colicky loin-to-groin pain, haematuria, or fever with chills.

1. Patient was apparently well 1 year back, then developed gradual-onset recurrent lower abdominal pain, dull aching in nature, mainly suprapubic, occurring before and persisting after menstruation.
2. Pain is associated with dysmenorrhoea, low backache and curdy white per-vaginal discharge with vulval itching.
3. She also complains of burning sensation during micturition, associated with increased frequency and urgency of urine.
4. For the last 1 day, she has had recurrent brief attacks of loss of consciousness, preceded by dizziness, blurring of vision and sweating, with spontaneous recovery.
5. There is no history of palpitation, chest pain or syncope during exertion.
6. There is no history of abnormal body movement, tongue bite, urinary incontinence, or post-ictal confusion.
7. She also complains of breathlessness for 1 day, not associated with cough, sputum, wheeze, haemoptysis or orthopnoea.
8. There is no history of fever with chills, loin pain, haematuria, severe vomiting, or per-vaginal bleeding.

• No palpitation, chest pain, exertional syncope: against cardiac arrhythmia/structural heart disease.
• No abnormal movement, tongue bite, incontinence, post-ictal confusion: against seizure.
• No pleuritic chest pain, haemoptysis, unilateral leg swelling: against pulmonary embolism.

• Recurrent syncope + breathlessness for 1 day
• Lower abdominal pain, vaginal discharge, and dysuria point separately toward a genitourinary cause, likely UTI with vulvovaginal candidiasis, but they do not by themselves strongly suggest seizure, pulmonary embolism, or heart disease.

1. Vasovagal syncope
   Considered because syncope is preceded by dizziness, blurring of vision and sweating, possibly triggered by pain, prolonged standing, or anxiety.
2. Anaemia-related presyncope/syncope
   Considered because breathlessness, weakness, dizziness and syncope can occur with significant anaemia. Ask specifically about menorrhagia, poor diet, pallor, melena, and chronic blood loss.
3. Dehydration or orthostatic hypotension
   Considered if there is poor oral intake, vomiting, diarrhoea, fever, reduced urine output, or syncope after standing.
4. Cardiac syncope/arrhythmia
   Considered only because syncope with breathlessness can be cardiac. It becomes more likely if there is exertional syncope, palpitation, chest pain, known heart disease, or family history of sudden cardiac death.
5. Pulmonary embolism
   It is an emergency differential in syncope plus sudden dyspnoea, but should only be emphasized if there are pleuritic chest pain, haemoptysis, tachycardia, hypoxia, unilateral leg pain/swelling, immobilisation, pregnancy/postpartum state, or OCP use.
6. Seizure
   Considered only if the “syncope” history suggests it, such as tonic-clonic movements, lateral tongue bite, urinary incontinence, prolonged unconsciousness, or post-ictal confusion.

• No history of menorrhagia, melena, or chronic blood loss, which argues against severe blood-loss anaemia.
• No history of vomiting, diarrhoea, poor oral intake, or postural dizziness, which argues against dehydration/orthostatic hypotension.
• No history of palpitation, chest pain, exertional syncope, or known cardiac disease, which argues against cardiac syncope.

HOPI

1. Patient was apparently well 1 year back, when she developed recurrent dull aching lower abdominal pain, mainly suprapubic, occurring before and persisting for a few days after menstruation.
2. Pain is associated with dysmenorrhoea and low backache, but there is no fever, foul-smelling discharge, dyspareunia, or abnormal vaginal bleeding.
3. She also complains of curdy white, non-offensive per-vaginal discharge associated with intense vulval itching and soreness.
4. She has burning micturition with increased frequency, urgency, and suprapubic discomfort.
5. There is no history of fever with chills, loin pain, nausea, vomiting, or haematuria.
6. For the last 1 day, she has had recurrent brief syncopal attacks preceded by dizziness and sweating, with spontaneous complete recovery.
7. There is no history of palpitation, chest pain, exertional syncope, abnormal body movement, tongue bite, urinary incontinence, or confusion after regaining consciousness.
8. She also complains of mild breathlessness for 1 day, without cough, wheeze, haemoptysis, orthopnoea, or pedal oedema.

Relevant negative points with appropriate differentials

• No fever with chills, loin pain, nausea or vomiting: against acute pyelonephritis.
• No colicky loin-to-groin pain or haematuria: against renal/ureteric calculus.
• No foul-smelling discharge, fever, dyspareunia or cervical-motion tenderness on examination: against pelvic inflammatory disease.
• No polyuria, polydipsia or weight loss: screen for diabetes mellitus, which can predispose to recurrent UTI and vulvovaginal candidiasis.
• No palpitation, chest pain or exertional syncope: against an important cardiac cause of syncope.

Cardiac arrhythmia causing cardiac syncope

There is no history of palpitation, chest pain, syncope during exertion, known heart disease, or family history of sudden cardiac death.

Recurrent syncope, possibly due to cardiac arrhythmia

• Chief complaint: Recurrent syncope for 1 day.
• Differential diagnosis: Cardiac arrhythmia causing syncope.
• Negative points: No palpitation, chest pain, exertional syncope, or known heart disease.

1. Pneumonia: HOPI, respiratory examination, CBC, CXR, sputum tests.
2. COPD exacerbation: HOPI including smoking and baseline symptoms, chest examination, ABG, CXR, spirometry.
3. Pulmonary tuberculosis: HOPI including cough duration, constitutional symptoms and contact history, examination, sputum GeneXpert/AFB, CXR.
4. Acute gastroenteritis: HOPI including stool and vomiting characteristics, dehydration assessment, abdominal examination, stool R/E and electrolytes.

• 8-line HOPI
• Expected general and systemic examination findings
• Relevant investigation findings
• Key negative points supporting/excluding appropriate differentials

Pneumonia: Bangladesh MBBS Ward Case Format

HOPI, 8 lines

1. Patient was apparently well ___ days ago, then developed sudden onset high-grade fever with chills and rigor.
2. Fever is continuous/intermittent, associated with sweating, headache, generalized body ache and weakness.
3. This was followed by cough, initially dry, later productive with yellowish/rusty sputum.
4. Sputum is moderate in amount, non-foul smelling and without haemoptysis.
5. Patient complains of right/left-sided pleuritic chest pain, increased by coughing and deep inspiration.
6. There is breathlessness of gradual onset, progressive in nature, initially on exertion and later at rest.
7. There is no history of cough for more than 2 weeks, evening rise of temperature, night sweats, weight loss or contact with a TB patient.
8. There is no history of wheeze, recurrent similar attacks, orthopnoea, PND, pedal oedema, aspiration, or recent hospital admission.

Expected examination findings

• Ill-looking, febrile, tachycardic, tachypnoeic
• Pallor may be present
• Cyanosis may be present in severe disease
• Oxygen saturation may be reduced
• No pedal oedema or raised JVP

• Reduced chest movement
• Increased tactile vocal fremitus
• Percussion note: dull
• Vocal resonance: increased
• Bronchial breath sound
• Increased vocal resonance and whispering pectoriloquy
• Fine inspiratory crepitations

Expected relevant investigations

Relevant negative points and differential diagnoses

• No chronic cough, evening fever, night sweats, weight loss, or TB contact: against pulmonary tuberculosis.
• No wheeze, long smoking history, chronic productive cough, or recurrent similar attacks: against acute exacerbation of COPD/asthma.
• No orthopnoea, PND, pedal oedema, raised JVP, or past cardiac disease: against left ventricular failure with pulmonary oedema.
• No haemoptysis, sudden-onset dyspnoea, pleuritic chest pain, leg swelling, immobilisation, or OCP use: against pulmonary embolism.

COPD with Acute Exacerbation: Ward Case Format

HOPI, 8 lines

1. Patient was apparently well ___ years back, then developed gradually progressive breathlessness, initially on exertion and now on minimal exertion.
2. Breathlessness is associated with chronic cough for several years, productive of scanty mucoid sputum, more marked in the morning.
3. The patient has a history of smoking/bidi smoking for ___ pack-years and continues/ceased smoking ___ years ago.
4. For the last few days, breathlessness has increased from the usual level and cough has become more frequent.
5. Sputum quantity has increased and changed from mucoid to yellowish/purulent, with/without fever.
6. There is associated wheeze, chest tightness, reduced exercise tolerance, and inability to lie flat due to breathlessness.
7. There is no history of haemoptysis, pleuritic chest pain, high-grade fever with rigor, or recent contact with a TB patient.
8. There is no history of episodic reversible breathlessness since childhood, atopy, orthopnoea, PND, pedal oedema, or known ischemic heart disease.

Expected examination findings

• Tachypnoea, tachycardia, use of accessory muscles of respiration
• Pursed-lip breathing, tripod position in severe exacerbation
• Cyanosis in advanced disease
• Low BMI, muscle wasting, or barrel-shaped chest
• Raised JVP and bilateral pedal oedema may occur in cor pulmonale

• Chest appears hyperinflated, with increased anteroposterior diameter
• Bilateral reduced chest movement
• Decreased tactile vocal fremitus and vocal resonance
• Hyper-resonant percussion note
• Diminished breath sounds
• Prolonged expiration with diffuse polyphonic rhonchi/wheeze
• Fine crackles may occur, but focal bronchial breathing suggests superadded pneumonia

Relevant investigations and expected findings

Relevant negative points and appropriate differential diagnoses

• No episodic attacks from childhood, no atopy, and no marked day-to-day variability of symptoms: against bronchial asthma.
• No high-grade fever, pleuritic chest pain, focal crepitations, bronchial breath sound, or focal opacity on chest X-ray: against superadded pneumonia.
• No chronic fever, night sweats, weight loss, haemoptysis, or TB contact: against pulmonary tuberculosis.
• No orthopnoea, paroxysmal nocturnal dyspnoea, pedal oedema, raised JVP, or basal fine crepitations: against left ventricular failure.

Decompensated HBV Cirrhosis with Oesophageal Varices and Diabetes Mellitus

HOPI, 8 lines

1. Patient is a known case of chronic hepatitis B infection with liver cirrhosis for ___ years and diabetes mellitus for ___ years, on regular/irregular treatment.
2. The patient developed progressive abdominal distension for ___, initially mild but gradually increasing, associated with bilateral pedal swelling and early satiety.
3. There is history of yellow discoloration of sclera and urine for ___, associated with anorexia, nausea, weakness and loss of weight.
4. There is history of haematemesis, consisting of fresh blood/coffee-ground material, and passage of black tarry stool, suggesting upper gastrointestinal bleeding.
5. Upper GI endoscopy revealed oesophageal varices; there is/was no history of repeated haematemesis after band ligation or beta-blocker treatment.
6. There is history of sleep disturbance, altered behaviour, disorientation, excessive drowsiness, or flapping tremor, suggesting hepatic encephalopathy.
7. There is no history of fever, abdominal pain or tenderness, which goes against spontaneous bacterial peritonitis; there is no reduction of urine output to suggest hepatorenal syndrome.
8. Diabetes is associated with polyuria, polydipsia, increased appetite/weight loss and variable glycaemic control; there is no history of alcohol intake, intravenous drug use, blood transfusion, or hepatotoxic drug intake.

Expected Examination Findings

General examination

• Ill-looking, cachectic patient
• Icterus, pallor due to chronic disease or blood loss
• Bilateral pitting pedal oedema
• Spider naevi, palmar erythema, leukonychia
• Muscle wasting, especially temporal wasting
• Scratch marks may be present
• Altered sensorium and asterixis (flapping tremor) if hepatic encephalopathy is present

Abdominal examination

• Distended abdomen with full flanks and everted umbilicus
• Positive fluid thrill and shifting dullness, indicating ascites
• Dilated superficial abdominal veins, possibly caput medusae
• Liver may be small and firm, with a sharp edge, or non-palpable in advanced cirrhosis
• Splenomegaly due to portal hypertension
• Umbilical hernia may be present in massive ascites
• Abdominal tenderness and fever suggest spontaneous bacterial peritonitis, not uncomplicated ascites

Other system examination

• Tachycardia and postural hypotension if recent variceal bleeding
• Basal crepitations or pleural effusion may occur in hepatic hydrothorax
• Peripheral neuropathy or diabetic foot changes may be present in diabetes mellitus

Expected Relevant Investigations

Relevant Negative Points and Appropriate Differentials

• No fever, diffuse abdominal pain, rebound tenderness, or worsening encephalopathy: against spontaneous bacterial peritonitis.
• No progressively painful hepatomegaly, marked weight loss, or rapidly increasing ascites: against hepatocellular carcinoma.
• No oliguria, rapidly rising creatinine, shock, vomiting, diarrhoea, or nephrotoxic drug use: against acute kidney injury/hepatorenal syndrome.
• No chronic alcohol intake: supports HBV as the major cause rather than alcohol-related cirrhosis.
• No melena, haematemesis, or postural dizziness at present: against active variceal haemorrhage, though varices remain present.

A known case of chronic hepatitis B-related decompensated liver cirrhosis with portal hypertension, ascites and oesophageal varices, associated with diabetes mellitus.

COPD with Acute Exacerbation

HOPI, 8 lines

1. Patient was apparently well 10 years back, then developed gradually progressive breathlessness, initially on exertion and later on minimal exertion.
2. It was associated with chronic cough, more marked in the morning, with scanty mucoid expectoration.
3. The patient has a long history of bidi/cigarette smoking and significant exposure to biomass fuel smoke.
4. For the last 5 days, breathlessness has increased beyond the usual level and is now associated with wheeze and chest tightness.
5. Cough has increased in frequency, with increased amount of sputum which has become yellowish and purulent.
6. There is no high-grade fever with rigor, pleuritic chest pain, or haemoptysis.
7. There is no history of cough for more than 2 weeks, evening rise of temperature, night sweats, weight loss, or contact with a patient with tuberculosis.
8. There is no history of orthopnoea, paroxysmal nocturnal dyspnoea, pedal oedema, palpitation, or chest pain.

Expected examination findings

• Tachypnoea, tachycardia, use of accessory muscles of respiration
• Pursed-lip breathing and tripod posture in severe exacerbation
• Cyanosis may be present
• Barrel-shaped chest and reduced body weight
• Raised JVP and bilateral pedal oedema may occur if cor pulmonale develops

• Bilaterally reduced chest expansion
• Hyper-resonant percussion note
• Decreased vocal fremitus and vocal resonance
• Diminished vesicular breath sounds
• Prolonged expiration
• Diffuse bilateral polyphonic rhonchi

Relevant investigation findings

• Pulse oximetry: reduced SpO₂
• CBC: neutrophilic leukocytosis if infective exacerbation; raised Hb/PCV in chronic hypoxaemia
• ABG: hypoxaemia, with hypercapnia and respiratory acidosis in severe exacerbation
• Chest X-ray: hyperinflated lung fields, flattened diaphragms, increased retrosternal air space, narrow vertical heart
• Sputum Gram stain/culture: possible infecting organism in purulent sputum
• ECG: P pulmonale, right-axis deviation, or right ventricular hypertrophy if cor pulmonale
• Spirometry after recovery: post-bronchodilator FEV1/FVC ratio less than 0.70, with reduced FEV1

Relevant negative points with D/D

• No childhood onset, atopy, seasonal variation, or marked day-to-day variability: against bronchial asthma.
• No high-grade fever, pleuritic pain, focal crepitations, bronchial breathing, or focal consolidation on X-ray: against pneumonia.
• No chronic fever, night sweats, weight loss, haemoptysis, or TB contact: against pulmonary tuberculosis.
• No orthopnoea, PND, pedal oedema, raised JVP, or basal fine crepitations: against left ventricular failure.

A chronic smoker with progressive exertional dyspnoea, chronic productive cough, and acute worsening of breathlessness with increased purulent sputum, suggestive of acute exacerbation of COPD.

Patient was apparently well until ___ years/months back, when he gradually developed breathlessness, initially on exertion and later on minimal exertion, associated with chronic cough and mucoid expectoration.

Patient gives history of long-standing gradually progressive breathlessness with chronic cough and expectoration.

For the last ___ days, there has been acute worsening of his usual breathlessness, with increased cough and increased purulence/quantity of sputum.

• COPD symptoms are usually long-standing, for months to years.
• If chronic bronchitis phenotype is present: productive cough for at least 3 months in each of 2 consecutive years.
• An acute exacerbation of COPD is a recent worsening of usual dyspnoea, cough, or sputum, commonly over a few days to 14 days.

He had chronic cough with expectoration and progressive exertional breathlessness for 3 years. For the last 5 days, there has been increased breathlessness, cough and purulence of sputum.

Expected Investigations: UTI with Vulvovaginal Candidiasis

If symptoms are recurrent or atypical

• NAAT for gonorrhoea/chlamydia if cervicitis/STI is suspected, such as mucopurulent discharge, postcoital bleeding, pelvic pain, or high-risk sexual history.
• USG KUB with post-void residual if recurrent UTI, haematuria, renal stone symptoms, obstruction, or persistent infection.
• HIV testing with informed consent if recurrent/severe candidiasis or other risk factors for immunosuppression.

Urine R/E, urine culture and sensitivity, vaginal swab microscopy with 10% KOH mount, vaginal pH, CBC, RBS/HbA1c, serum creatinine, and urine pregnancy test.

Better HOPI

1. Patient was apparently well 5 days back, when she developed burning sensation during micturition, which was gradual in onset and progressively increased.
2. It was associated with increased frequency and urgency of micturition, with suprapubic discomfort.
3. She also developed curdy white, non-foul-smelling per-vaginal discharge associated with vulval itching and soreness.
4. There is no history of fever with chills, loin pain, nausea, vomiting, haematuria, or passage of stone.
5. There is no history of foul-smelling or yellowish-green discharge, dyspareunia, postcoital bleeding, or lower abdominal tenderness.
6. The patient gives a separate history of recurrent lower abdominal pain for the last 1 year, related to menstruation.
7. The pain starts before menstruation and persists for a few days after menstruation, associated with dysmenorrhoea and low backache.
8. There is no history of menorrhagia, intermenstrual bleeding, fever, weight loss, or chronic cough.

Why this order is correct

• Lines 1-5 describe the current acute illness: UTI with vulvovaginal candidiasis.
• Lines 6-8 describe the past chronic symptom, which may need separate gynecological evaluation and should not be presented as part of the acute UTI unless the clinician confirms a link.
• A 1-year history of cyclical lower abdominal pain is not typical uncomplicated UTI, so keep it separate.

HOPI

1. Patient was reasonably well 5 days back, with a history of recurrent cyclical lower abdominal pain for the last 1 year.
2. Five days back, she developed burning sensation during micturition, gradual in onset and progressively increasing in severity.
3. It was associated with increased frequency and urgency of micturition, along with suprapubic discomfort.
4. She also developed curdy white, non-foul-smelling per-vaginal discharge associated with vulval itching and soreness.
5. There is no history of fever with chills, loin pain, nausea, vomiting, haematuria, or passage of urinary stone.
6. There is no history of foul-smelling or yellowish-green discharge, dyspareunia, postcoital bleeding, or fever.
7. The lower abdominal pain is dull aching, occurs before menstruation and persists for a few days after menstruation, and is associated with dysmenorrhoea and low backache.
8. There is no history of menorrhagia, irregular menstrual bleeding, intermenstrual bleeding, significant weight loss, or chronic fever.

Why this is acceptable

• Lines 1 and 7 acknowledge the chronic menstrual-related pain without wrongly making it part of the acute UTI.
• Lines 2-5 support lower UTI and exclude pyelonephritis/renal stone.
• Line 4 supports vulvovaginal candidiasis.
• Line 6 helps exclude PID, cervicitis, trichomoniasis, and bacterial vaginosis.
• Line 8 addresses important gynecological differential diagnoses of chronic cyclical lower abdominal pain.

1. Lower UTI/cystitis
2. Acute pyelonephritis
3. Urinary stone disease
4. Vulvovaginal candidiasis
5. Bacterial vaginosis/trichomoniasis
6. PID or cervicitis
7. For the separate 1-year cyclical pain: endometriosis, adenomyosis, or fibroid uterus

Patient was reasonably well ___ days back, when she developed burning sensation during micturition.

Patient was reasonably well 5 days back, when she developed burning sensation during micturition, gradual in onset and progressive in nature.

She had, however, a history of recurrent cyclical lower abdominal pain for the last 1 year.

History of Presenting Illness

1. Patient was reasonably well 5 days back, when she developed burning sensation during micturition, gradual in onset and progressive in nature.
2. It was associated with increased frequency and urgency of micturition, with mild suprapubic discomfort.
3. She also developed curdy white, non-foul-smelling per-vaginal discharge with vulval itching and soreness.
4. There is no history of fever with chills, loin pain, nausea, vomiting, or haematuria.
5. There is no history of colicky loin-to-groin pain or passage of stone in urine.
6. There is no history of foul-smelling yellowish/greenish discharge, dyspareunia, postcoital bleeding, or fever.
7. She gives a history of recurrent lower abdominal pain for the last 1 year, occurring before menstruation and persisting for a few days after menstruation, associated with dysmenorrhoea and low backache.
8. There is no history of menorrhagia, irregular menstruation, intermenstrual bleeding, significant weight loss, or chronic fever.

• Lines 4-5: acute pyelonephritis and urinary calculus
• Line 6: bacterial vaginosis, trichomoniasis, cervicitis/PID
• Line 8: fibroid uterus, adenomyosis, genital tuberculosis or malignancy

Acute Gastroenteritis: HOPI

1. Patient was reasonably well 2 days back, when he developed sudden onset loose motion, initially ___ times per day, watery in consistency and large in amount.
2. The stool was non-bloody, without mucus, and was not associated with tenesmus.
3. It was followed by multiple episodes of vomiting containing recently taken food, non-bilious and non-blood-stained.
4. He also had colicky, diffuse abdominal pain, which was relieved temporarily after defecation.
5. There was history of intake of outside/unhygienic food or contaminated water before the onset of illness.
6. He complained of thirst, generalized weakness, decreased urine output and dizziness on standing, suggesting dehydration.
7. There was low-grade fever, but no high-grade fever with chills, severe abdominal pain, or abdominal distension.
8. There was no history of blood or mucus in stool, persistent localized right iliac fossa pain, jaundice, recent antibiotic intake, or similar illness in the past.

Relevant negative points and differentials

• No blood/mucus in stool and no tenesmus: against bacillary dysentery/invasive diarrhoea.
• No persistent right iliac fossa pain, guarding, or rebound tenderness: against acute appendicitis.
• No jaundice, dark urine, pale stool, or right hypochondrial pain: against acute viral hepatitis/hepatobiliary disease.
• No recent antibiotic use or hospital admission: against antibiotic-associated diarrhoea, including Clostridioides difficile infection.

Investigations for Acute Gastroenteritis

For a typical ward case, write these as the main investigations

CBC with DC, serum electrolytes, serum urea and creatinine, RBS, urine R/E, stool R/E with microscopy, stool culture and sensitivity, and blood culture if febrile/septic.

Expected findings in uncomplicated acute watery gastroenteritis

Haemoconcentration, mild electrolyte imbalance, raised urea/creatinine if dehydrated, and stool microscopy negative for RBC and pus cells.

Expected Examination Findings in Acute Gastroenteritis

General examination

• Patient may look ill, weak, thirsty and dehydrated.
• Pulse may be rapid and low volume.
• Blood pressure may be low, with postural hypotension in moderate to severe dehydration.
• Temperature may be normal or mildly raised.
• Dry tongue and dry oral mucosa.
• Sunken eyes and reduced skin turgor.
• Capillary refill may be delayed.
• Urine output may be reduced.

Signs of dehydration

• Restlessness, thirst
• Dry mouth
• Sunken eyes
• Tachycardia
• Reduced skin turgor
• Decreased urine output

• Lethargy or altered consciousness
• Cold clammy extremities
• Feeble rapid pulse
• Marked hypotension
• Delayed capillary refill
• Very low or absent urine output

Abdominal examination

• Abdomen usually soft and non-distended.
• Mild diffuse tenderness may be present.
• Bowel sounds may be increased.
• No guarding, rigidity, rebound tenderness, organomegaly or palpable mass in uncomplicated gastroenteritis.

Other systems

• Respiratory and cardiovascular examinations are usually normal apart from tachycardia and hypotension due to dehydration.
• CNS examination is normal unless severe dehydration, hypoglycaemia, electrolyte imbalance, or sepsis causes altered sensorium.

Proper short ward-case statement

On general examination, the patient is ill-looking, dehydrated, tachycardic and mildly hypotensive, with dry tongue, dry mucosa, sunken eyes, reduced skin turgor and decreased urine output. Per abdominal examination reveals a soft, non-distended abdomen with mild diffuse tenderness and increased bowel sounds, without guarding, rigidity or rebound tenderness.

Pulmonary Tuberculosis: Ward Case Format

HOPI, 8 lines

1. Patient was reasonably well ___ weeks/months back, when he developed cough, gradual in onset and progressive in nature.
2. Cough is productive, with mucoid/mucopurulent sputum, more marked in the morning, without foul smell.
3. There is history of low-grade fever with evening rise of temperature, associated with night sweats.
4. The patient complains of progressive loss of weight, loss of appetite, generalized weakness and fatigability.
5. There is occasional streaky haemoptysis, but no massive haemoptysis.
6. He also complains of gradually progressive breathlessness and dull chest pain, without orthopnoea or PND.
7. There is history of contact with a known TB patient / previous anti-TB treatment / diabetes mellitus / smoking, if present.
8. There is no history of high-grade fever with chills and rigor, acute pleuritic chest pain, wheeze, or sudden onset severe breathlessness.

Expected examination findings

• Ill-looking, undernourished, low BMI
• Pallor, low-grade fever
• Cervical or supraclavicular lymphadenopathy may be present
• Clubbing may occur in chronic disease
• No pedal oedema unless there is another associated illness

• Reduced chest expansion over the affected upper chest
• Reduced tactile vocal fremitus if fibrosis/pleural involvement
• Impaired percussion note over consolidation
• Bronchial breath sound or amphoric breath sound over a superficial cavity
• Increased vocal resonance
• Post-tussive crepitations, especially over upper zones
• Tracheal shift toward the affected side if fibrosis and volume loss
• Signs of pleural effusion if TB pleurisy is present: stony dullness, decreased breath sounds and decreased vocal fremitus

Expected investigations

Relevant negatives and differential diagnoses

• No acute high-grade fever with chills, purulent sputum, or sudden onset symptoms: against acute bacterial pneumonia.
• No long smoking history, chronic daily productive cough, or diffuse wheeze: against COPD.
• No episodic wheeze, atopy, seasonal variation, or childhood-onset symptoms: against bronchial asthma.
• No orthopnoea, PND, bilateral pedal oedema, raised JVP, or basal fine crepitations: against left ventricular failure.
• No recurrent oral ulcers, joint pain, skin rash, or other systemic features: consider but make less likely systemic inflammatory disease if radiology is atypical.

Acute Exacerbation of COPD: HOPI

1. Patient was reasonably well 7 days back, when his usual breathlessness suddenly increased in severity and became limiting on minimal exertion.
2. It was associated with increased cough and wheezing, more marked at night and early morning.
3. He had increased expectoration, which changed from scanty mucoid to copious yellowish sputum.
4. There is a history of long-term smoking/bidi smoking and/or exposure to biomass fuel smoke.
5. He gives a history of similar episodes of cough, expectoration and exertional breathlessness in the past, relieved partially by inhalers/nebulisation.
6. There is no history of high-grade fever with chills, pleuritic chest pain, or focal chest pain.
7. There is no history of haemoptysis, evening rise of temperature, night sweats, loss of weight, or contact with a TB patient.
8. There is no history of orthopnoea, paroxysmal nocturnal dyspnoea, pedal oedema, chest pain, or palpitation.

What the negative points exclude

• Line 6: Pneumonia
• Line 7: Pulmonary tuberculosis
• Line 8: Left ventricular failure/cardiac failure

Acute Exacerbation of COPD

Positive examination findings

• Tachypnoea, tachycardia, low SpO₂
• Use of accessory muscles of respiration
• Pursed-lip breathing and tripod posture
• Central cyanosis in severe exacerbation
• Barrel-shaped chest
• Low BMI and muscle wasting in long-standing disease

• Bilaterally reduced chest movement
• Bilaterally decreased tactile vocal fremitus
• Hyper-resonant percussion note
• Bilaterally decreased vocal resonance
• Diminished vesicular breath sounds
• Prolonged expiratory phase
• Diffuse bilateral polyphonic rhonchi

• Raised JVP
• Bilateral pitting pedal oedema
• Tender hepatomegaly
• Loud P2 may be present

Expected investigation findings

The patient is tachypnoeic and tachycardic with use of accessory muscles of respiration and reduced oxygen saturation. Chest is barrel shaped with bilateral reduced chest movement, hyper-resonant percussion note, diminished vesicular breath sounds, prolonged expiration, and diffuse bilateral polyphonic rhonchi.

Enteric Fever (Typhoid): HOPI

1. Patient was reasonably well 7 days back, when he developed gradual-onset fever, initially low grade but progressively becoming high grade and continuous in nature.
2. Fever is associated with headache, generalized body ache, malaise, anorexia and marked weakness.
3. There is history of diffuse, dull abdominal discomfort with constipation initially, followed by loose motion.
4. The patient also complains of nausea and occasional non-bilious, non-blood-stained vomiting.
5. There is history of intake of unsafe water/outside food or similar illness among family members, if present.
6. There is no history of cough with sputum, pleuritic chest pain, or breathlessness, making pneumonia less likely.
7. There is no history of dysuria, frequency of micturition, loin pain, or chills with rigor, making UTI/pyelonephritis less likely.
8. There is no history of altered consciousness, convulsion, abdominal distension, severe localized abdominal pain, melaena, or fresh per-rectal bleeding, which would suggest complications.

Positive examination findings

General examination

• Ill-looking, febrile, toxic appearance
• Temperature raised, often with relative bradycardia
• Coated tongue
• Mild dehydration
• Pallor may be present
• Rose spots over the trunk may occur, but are often absent
• Mild hepatomegaly and splenomegaly may be present

Abdominal examination

• Abdomen usually soft
• Mild diffuse abdominal tenderness, especially in the right iliac fossa
• Mild hepatosplenomegaly
• Bowel sounds may be sluggish
• No guarding, rigidity, rebound tenderness, or marked distension in uncomplicated enteric fever

Expected investigations

Short examination summary

The patient is febrile, ill-looking and mildly dehydrated, with coated tongue and relative bradycardia. Per abdominal examination reveals mild diffuse tenderness with mild hepatosplenomegaly, without guarding, rigidity or rebound tenderness.

Acute Viral Hepatitis: HOPI

1. Patient was reasonably well 7 days back, when he developed low-grade fever, malaise, generalized weakness, anorexia, nausea and occasional vomiting.
2. After ___ days, he noticed yellow discoloration of sclera and skin, which was gradual in onset and progressively increased.
3. It was associated with high-coloured urine, pale/clay-coloured stool and generalized itching.
4. He also complains of dull aching pain and heaviness in the right hypochondrium.
5. There is history of intake of contaminated food/water, contact with a jaundiced patient, recent blood transfusion, injection/drug abuse, unsafe sexual exposure, or hepatotoxic drug intake, if present.
6. There is no history of high-grade fever with chills and rigor, dysuria, cough or breathlessness.
7. There is no history of severe colicky right hypochondrial pain radiating to the right shoulder, which makes biliary obstruction less likely.
8. There is no history of altered behaviour, excessive drowsiness, hematemesis, melaena, abdominal distension, or pedal oedema.

Positive Examination Findings

General examination

• Icterus
• Mild fever
• Scratch marks due to pruritus may be present
• Mild dehydration
• No features of chronic liver disease in uncomplicated acute hepatitis

Abdominal examination

• Mild tenderness in right hypochondrium
• Smooth, soft, mildly enlarged and tender liver
• Spleen may be mildly enlarged
• Usually no ascites, dilated abdominal veins, or pedal oedema in uncomplicated acute hepatitis

Short examination presentation

On examination, the patient is mildly ill-looking with icterus. Per abdominal examination reveals mild right hypochondrial tenderness with a smooth, soft, mildly enlarged and tender liver. There is no ascites or other stigmata of chronic liver disease.

Expected Investigations

Relevant Negative Points and D/D

• No severe colicky right hypochondrial pain, fever with rigor, or dilated biliary tree on USG: against choledocholithiasis/acute cholangitis.
• No history of paracetamol overdose, herbal medication, anti-tubercular drugs, or other hepatotoxic drugs: against drug-induced hepatitis.
• No chronic jaundice, ascites, pedal oedema, hematemesis, splenomegaly, or caput medusae: against decompensated chronic liver disease/cirrhosis.
• No altered sensorium, asterixis, recurrent vomiting, hypoglycaemia, or rapidly prolonged INR: against acute liver failure.

Proper relevant negative points

1. No cough, sputum, pleuritic chest pain or breathlessness
   • Against pneumonia/lower respiratory tract infection.
2. No dysuria, increased frequency of micturition, loin pain or fever with chills and rigor
   • Against UTI/acute pyelonephritis.
3. No periodic fever with chills and rigor, profuse sweating, or recent travel to a malaria-endemic area
   • Against malaria.
4. No severe myalgia, retro-orbital pain, skin rash, bleeding manifestation, or shock
   • Against dengue fever.
5. No jaundice, high-coloured urine, pale stool, or right hypochondrial pain
   • Against acute viral hepatitis.
6. No blood/mucus in stool, tenesmus, or severe colicky abdominal pain
   • Against bacillary dysentery/invasive gastroenteritis.

Best 3 to write in a short HOPI

There is no history of cough, sputum, pleuritic chest pain or breathlessness. There is no history of dysuria, frequency of micturition or loin pain. There is no history of periodic fever with chills and rigor, severe myalgia, retro-orbital pain, rash, bleeding manifestation, or jaundice.

Proper negative points with differentials

1. No severe colicky right hypochondrial pain radiating to the right shoulder, no high-grade fever with rigor, and no history of pale stool with intense pruritus from the beginning.
   • Against extrahepatic biliary obstruction, such as choledocholithiasis and acute cholangitis.
2. No history of paracetamol overdose, anti-tubercular drug intake, herbal or indigenous medication, or other hepatotoxic drugs.
   • Against drug-induced liver injury/hepatitis.
3. No history of recurrent jaundice since childhood, anaemia, passage of dark urine without bile pigment, or family history of haemolytic disease.
   • Against haemolytic jaundice.
4. No abdominal distension, pedal oedema, haematemesis, melaena, altered sleep pattern, altered behaviour, or previous episode of jaundice.
   • Against decompensated chronic liver disease/cirrhosis and hepatic encephalopathy.
5. No altered consciousness, excessive drowsiness, flapping tremor, spontaneous bleeding, or decreased urine output.
   • Against acute liver failure.

Best short version for HOPI

There is no history of severe colicky right hypochondrial pain radiating to the right shoulder, high-grade fever with rigor, or previous similar episode of jaundice. There is no history of paracetamol overdose, anti-tubercular drugs, herbal medication, or alcohol intake. There is no history of abdominal distension, pedal oedema, haematemesis, melaena, altered behaviour, excessive drowsiness, or bleeding manifestation.

Acute Viral Hepatitis: HOPI

1. Patient was reasonably well 7 days back, when he developed low-grade fever, malaise, generalized weakness, anorexia, nausea and occasional vomiting.
2. After 2-3 days, he noticed yellow discoloration of the sclera, followed by yellowish discoloration of the skin, gradual in onset and progressive in nature.
3. It was associated with high-coloured urine, pale stool, generalized itching, and dull aching pain/heaviness in the right hypochondrium.
4. There is history of decreased appetite and inability to take normal meals, but no significant abdominal distension.
5. There is history of intake of outside food/unsafe water or contact with a jaundiced person; history of blood transfusion, needle exposure, unsafe sexual contact and hepatotoxic drug intake should be specifically asked.
6. There is no history of severe colicky right hypochondrial pain radiating to the right shoulder, high-grade fever with chills and rigor, or persistent vomiting.
7. There is no history of paracetamol overdose, anti-tubercular drugs, herbal/indigenous medicine, alcohol intake, or any other prolonged medication use.
8. There is no history of previous jaundice, abdominal distension, pedal oedema, haematemesis, melaena, altered behaviour, excessive drowsiness, flapping tremor, or bleeding manifestation.

• No severe colicky right hypochondrial pain radiating to shoulder, no high fever with rigor
  → excludes obstructive jaundice due to gallstone and acute cholangitis.
• No paracetamol overdose, anti-TB drugs, herbal/indigenous medicine, alcohol or other long-term drugs
  → excludes drug-induced hepatitis and alcoholic hepatitis.
• No previous jaundice, abdominal distension, pedal oedema, haematemesis or melaena
  → excludes chronic liver disease with portal hypertension/decompensated cirrhosis.
• No altered behaviour, excessive sleepiness, flapping tremor or bleeding manifestation
  → excludes acute liver failure with hepatic encephalopathy and coagulopathy.
• No persistent vomiting
  → makes severe acute hepatitis/impending acute liver failure less likely, though it is not a strong differential point by itself.

Acute Viral Hepatitis

Positive examination findings

• Ill-looking, febrile or afebrile
• Icterus of sclera and skin
• Scratch marks due to pruritus may be present
• Mild dehydration may be present
• No chronic liver disease stigmata in uncomplicated acute hepatitis

• Mild right hypochondrial tenderness
• Liver may be mildly enlarged, smooth, soft and tender
• Mild splenomegaly may occur
• Abdomen is usually soft, without ascites or dilated abdominal veins

The patient is mildly ill-looking with icterus and mild dehydration. Per abdomen, there is mild right hypochondrial tenderness and a smooth, soft, mildly enlarged tender liver. There is no ascites or stigmata of chronic liver disease.

Expected investigation findings