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Common Obstetric Complaints — How to Write the HOPI and Obstetric Part of History

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How to Structure an Obstetric History

Mrs. [Name], [Age] years old, [Gravida X, Para A+B], [marital status], [occupation], at [gestational age] weeks by [LMP/ultrasound], with an EDD of [date], presenting with…

• Gravida (G) = total number of pregnancies including this one
• Para (P) = A (births ≥24 weeks) + B (losses <24 weeks, miscarriages, TOPs)
• Example: G4P1+2 = 4 pregnancies, 1 live birth, 2 losses before 24 weeks

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The Universal Obstetric Section (Written After the HOPI for Every Case)

1. History of the Current Pregnancy

• 1st Trimester: LMP, method of confirmation (urine/serum βhCG, USS), EDD (Naegele's rule: LMP + 9 months 7 days), nausea/vomiting, bleeding/pain (? ectopic/threatened miscarriage), vaginal discharge, urinary symptoms, first antenatal bloods (blood group, Rh, FBC, VDRL, rubella immunity, HBsAg, HIV)
• 2nd Trimester (14–28 wks): Fetal movements onset (quickening ~18–20 wks), anomaly scan result, OGTT/GDM screen, amniocentesis if applicable, PET screening
• 3rd Trimester (28 wks–delivery): Frequency and pattern of fetal movements, ANC visits, BP readings, glucose tolerance, symphysio-fundal height, presentation/lie, swelling, headaches, visual disturbances

2. Past Obstetric History (For each previous pregnancy)

• Gestational age at delivery
• Mode of delivery (SVD / instrumental / LSCS — indication)
• Birth weight, sex, outcome (alive/stillbirth/neonatal death)
• Any complications: PPH, shoulder dystocia, GDM, PET, IUGR, preterm labour

3. Gynaecological History

• Age of menarche, cycle regularity, dysmenorrhoea
• Contraceptive method prior to conception
• Cervical smear history
• History of STIs, infertility, pelvic surgery, fibroids, ovarian cysts

4. Past Medical & Surgical History

• Hypertension, diabetes, thyroid disease, anaemia, cardiac disease, renal disease, epilepsy
• Previous surgeries (especially abdominal/pelvic)
• Blood transfusions

5. Drug History & Allergies

• Folic acid, iron, aspirin, antihypertensives, insulin, anticonvulsants
• Teratogenic exposures

6. Family History

• Diabetes, hypertension, multiple pregnancy, congenital malformations, thrombophilia

7. Social History

• Smoking, alcohol, recreational drugs
• Occupation, support at home, partner details
• Housing, domestic violence (ask sensitively)

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COMPLAINT 1 — Antepartum Haemorrhage (APH) / Vaginal Bleeding in Pregnancy

Chief Complaint

Mrs. X, 28 years, G2P1+0, at 32 weeks gestation by sure LMP (EDD [date]), presented to [facility] with painless/painful per vaginal bleeding of [duration].

HOPI of the Complaint

• Onset: When did the bleeding start? Sudden onset (suggestive of placenta previa) vs. progressive
• Amount: How much blood? (Estimate by pads soaked per hour — >1 pad/hour = significant; passage of clots; "flooding")
• Color: Bright red (fresh — previa or local lesion) vs. dark (abruption; concealed)
• Associated pain: Painless bleeding → placenta previa; painful, constant uterine tenderness → placental abruption
• Precipitating factors: Any trauma, coitus, recent cervical examination?
• Passage of tissue/clots: Tissue = possible miscarriage/molar pregnancy
• Associated symptoms: Fetal movements — present, reduced, or absent? (Abruption can cause fetal distress/death)
• Preceding discharge: Mucoid show (early labour) vs. watery loss (PROM)
• Systemic symptoms: Dizziness, fainting, palpitations, syncope (hypovolaemia)

Obstetric Part (Current Pregnancy)

• Booking ultrasound — was low-lying placenta reported?
• Any prior bleeding episodes in this pregnancy?
• Blood group and Rh type (anti-D prophylaxis if Rh-negative)
• Antenatal visits — BP at each visit (hypertension → abruption risk)
• History of smoking, cocaine use (abruption risk factors)
• Fetal movements history — when last felt
• History of trauma or domestic violence

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COMPLAINT 2 — Pre-Eclampsia / Hypertension in Pregnancy

Chief Complaint

Mrs. X, 32 years, G1P0+0, at 36 weeks gestation, presenting with headache, swelling of the face and hands, and blurring of vision of [duration].

HOPI of the Complaint

• Headache: Site (frontal/occipital), severity (grade it 1–10), character (throbbing, pressure), onset, duration, progression, any relieving factors (analgesics), photophobia, phonophobia
• Visual disturbances: Blurring, "flashing lights" (photopsia), scotomata, diplopia — all suggest cerebral vasospasm in severe PET
• Oedema: Distribution — hands, face (facial puffiness), ankles; pitting vs. non-pitting; when it is worst (morning facial oedema = significant; dependent ankle oedema alone = normal pregnancy); sudden rapid onset
• Epigastric/RUQ pain: Burning or tightness under the right ribs → hepatic capsule distension (HELLP syndrome); distinguish from heartburn/reflux (very common in pregnancy)
• Convulsions / loss of consciousness: If present → eclampsia; document sequence, duration, post-ictal state, tongue biting, incontinence
• Nausea and vomiting: Non-specific but can accompany HELLP
• Decreased urine output / dark urine: Suggests renal involvement (oliguria <500 mL/24h = severe PET criterion)
• Fetal movements: Ask carefully — uteroplacental insufficiency reduces fetal movements

• Systolic ≥160 or diastolic ≥110 mmHg = severe
• Symptoms of end-organ damage: vision, neurological, liver, renal
• HELLP: haemolysis (jaundice, haematuria), elevated liver enzymes, low platelets (easy bruising, petechiae)

Obstetric Part (Current Pregnancy)

• BP at booking visit and at each antenatal visit — trend is critical (new rise from baseline)
• Proteinuria on urine dipstick at antenatal visits
• Gestational age — PET occurs ≥20 weeks; before 20 weeks consider molar pregnancy
• Primigravida (highest risk), multiple pregnancy, known chronic hypertension/renal disease
• BMI, pre-pregnancy weight
• Family history of pre-eclampsia (mother, sisters)
• Use of low-dose aspirin from 12 weeks (was it given/taken?)
• Investigations done so far: USS for IUGR / oligohydramnios (uteroplacental insufficiency)

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COMPLAINT 3 — Preterm Labour (PTL)

Chief Complaint

Mrs. X, 26 years, G2P1+0, at 30 weeks gestation, presenting with painful uterine contractions occurring every [X] minutes since [time/duration].

HOPI of the Complaint

• Contractions: Onset (sudden vs. gradual), frequency (e.g., every 5 minutes), duration per contraction (e.g., 45 seconds), regularity, severity (can she speak through them?), progression (are they getting stronger and more frequent?)
• Associated show: Passage of blood-stained mucoid discharge (cervical show = cervix dilating)
• Membrane status: Has she felt a "gush" or constant trickling of fluid? (PROM/PPROM) — fluid — colour, odour, whether it continues to leak
• Bleeding: Any associated PV bleeding?
• Fetal movements: Present and normal?
• Precipitating factors: UTI (dysuria, frequency), uterine anomaly, polyhydramnios (distension), trauma, intercourse, cervical incompetence (previous LLETZ/cone biopsy, previous second-trimester loss)
• Systemic features: Fever, rigors, offensive discharge (chorioamnionitis); urinary symptoms (UTI is a common trigger)
• Previous similar episode in this pregnancy?

Obstetric Part (Current Pregnancy)

• Gestational age confirmation (USS or reliable LMP)
• Number of fetuses (multiple pregnancy = major risk)
• Cervical length measured on USS (short cervix <25 mm = high risk)
• History of cervical cerclage (in situ?)
• Previous preterm births (strongest predictor of recurrence)
• Antenatal steroids (betamethasone 12 mg × 2 doses): have they been given?
• Group B Streptococcus (GBS) swab status
• Urine culture — UTI excluded?

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COMPLAINT 4 — Hyperemesis Gravidarum

Chief Complaint

Mrs. X, 22 years, G1P0+0, at 9 weeks gestation, presenting with persistent nausea and vomiting since [duration], unable to tolerate oral intake.

HOPI of the Complaint

• Onset: When did it start? (Nausea of NVP typically 4–8 weeks; hyperemesis more severe and prolonged)
• Frequency of vomiting: How many times per day? (>3–5 = significant; "vomiting after everything I eat or drink")
• Content of vomit: Food, bile, blood (haematemesis — Mallory-Weiss tear)
• Oral intake: Can she keep any fluids down? How long has she been unable to eat or drink?
• Weight loss: Document weight at booking vs. now — weight loss >5% of pre-pregnancy weight is a diagnostic criterion
• Triggers: Smell, food type, movement
• Relieving factors: Any medications tried? (antiemetics, ginger)
• Associated symptoms:
  • Dysuria/frequency (exclude UTI as a trigger)
  • Diarrhoea
  • Headache, confusion (Wernicke's encephalopathy from thiamine deficiency — a serious complication)
  • Jaundice (rare liver involvement)
• Signs of dehydration: Thirst, dark urine, dizziness on standing, decreased urine output
• Impact on daily functioning: Work, activity, mood (depression/anxiety common)

• Normal NVP (nausea + vomiting, but no weight loss, maintains some oral intake, resolves by 12–14 weeks)
• Molar pregnancy (marked βhCG elevation drives hyperemesis; ask about uterus size larger than dates, no fetal movements, grape-like tissue passed)
• Gastroenteritis, UTI, thyrotoxicosis, hepatitis

Obstetric Part (Current Pregnancy)

• Gestational age (hyperemesis worst at 8–12 weeks, should improve by 20 weeks)
• USS — confirm intrauterine pregnancy, singleton vs. multiple (twins = higher βhCG), exclude molar pregnancy
• βhCG level trend
• TSH (transient gestational hyperthyroidism occurs in ~60% of HEG cases due to βhCG cross-reactivity with TSH receptor)
• Previous pregnancy with same problem (tends to recur)
• Urine dipstick and MSU (exclude UTI, check for ketonuria — indicates starvation)

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COMPLAINT 5 — Reduced / Absent Fetal Movements (RFM)

Chief Complaint

Mrs. X, 30 years, G3P2+0, at 38 weeks gestation, presenting with reduced fetal movements since [time].

HOPI of the Complaint

• Baseline fetal movements: How many movements per hour/day has she been used to? When did she first feel movements (quickening)?
• Change: Since when has she noticed a reduction? Any complete cessation?
• Nature of the change: Reduced in frequency, reduced in strength, or completely absent
• Kick counts: Has she been monitoring? What is the count today vs. usual? (A count of <10 movements in 2 hours = concerning)
• Associated features:
  • Any vaginal bleeding?
  • Any abdominal pain or uterine tightening?
  • Fever (intrauterine infection)?
  • Any fall or trauma?
  • Polyhydramnios (excessive fluid "cushions" movements, making them harder to feel)
  • Anterior placenta (attenuates sensation)
• Last time she was certain baby moved?
• Maternal wellbeing: Any dizziness, decreased activity (sedatives/alcohol can reduce FMs)

Obstetric Part (Current Pregnancy)

• Gestational age and placental location (anterior placenta = reduced sensation — reassure; does not reduce actual movement)
• Known IUGR or SGA on previous scans
• History of pre-eclampsia/gestational hypertension (uteroplacental insufficiency)
• Gestational diabetes (macrosomia, polyhydramnios)
• Maternal medications (opiates, sedatives reduce perceived FMs)
• Results of previous growth scans, Doppler studies
• Prior episodes of RFM in this pregnancy
• Obstetric history of previous stillbirth (highest-risk group)

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COMPLAINT 6 — Prelabour Rupture of Membranes (PROM / PPROM)

Chief Complaint

Mrs. X, 24 years, G1P0+0, at 28 weeks gestation, presenting with a sudden gush of watery fluid per vaginum since [time].

HOPI of the Complaint

• Onset: Sudden gush (classic PROM) vs. slow continuous trickle (high leak)
• Amount: Large gush soaking through clothes vs. mild dampness
• Colour of fluid: Clear/straw-coloured (normal), green/meconium-stained (fetal distress), blood-stained, offensive smell (chorioamnionitis)
• Odour: Offensive odour → infection
• Continued leaking: Is fluid still leaking? Does she still feel wet?
• Distinguish from: Urinary incontinence (common in pregnancy — ask if she can stop the flow voluntarily, whether it smells like urine), increased vaginal discharge, show
• Contractions: Any associated uterine contractions? (If yes, in labour)
• Fetal movements: Present and normal?
• Signs of infection (chorioamnionitis): Fever, rigors, tachycardia, abdominal tenderness, offensive discharge — if present, this is a medical emergency
• Time since rupture: Latency period → risk of infection increases with time

Obstetric Part (Current Pregnancy)

• Gestational age — determines management (conservative vs. delivery)
• Presentation and lie of the fetus (USS) — cord prolapse risk with non-cephalic presentation
• Group B Streptococcus (GBS) status
• Antenatal steroid status (given for lung maturity if <34 weeks?)
• Cervical cerclage in situ? (Must be removed if PROM occurs)
• History of cervical procedure (LLETZ, cone biopsy)
• Recent PV examination or intercourse
• Urine culture (UTI as precipitant)
• Previous PPROM (recurrence risk ~16%)

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COMPLAINT 7 — Gestational Diabetes (GDM) — Antenatal Visit Complaint

Chief Complaint

Mrs. X, 35 years, G2P1+0, at 26 weeks gestation, referred with elevated blood glucose on routine OGTT screening.

HOPI of the Complaint

• Symptoms of hyperglycaemia: Polyuria, polydipsia, polyphagia, unexplained fatigue — though most GDM is asymptomatic and found on screening
• Timing of diagnosis: Routine screen (24–28 weeks) vs. early screen (first trimester if high risk)
• Blood glucose values: Fasting and 2-hour post-load values on OGTT
• Dietary history: Sugar intake, carbohydrate load, junk food, soft drinks
• Home glucose monitoring: Is she doing it? Values?
• Medications taken: Metformin, insulin — response and adherence
• Hypoglycaemic episodes: Shakiness, sweating, dizziness, palpitations after medication
• Symptoms of complications: Excessive thirst despite treatment, recurrent thrush (Candida — common with high glucose), blurred vision
• Known pre-gestational diabetes? (Different diagnosis — document duration, type, complications)

Obstetric Part (Current Pregnancy)

• USS for fetal growth — macrosomia (abdominal circumference > 95th centile), polyhydramnios (AFI)
• Fundal height — uterus larger than dates (polyhydramnios/macrosomia)
• BP and urinalysis (GDM increases risk of PET)
• Family history of DM type 2
• Previous GDM (50–70% recurrence risk)
• Previous macrosomic baby (>4 kg), previous stillbirth, previous shoulder dystocia
• BMI, weight gain in pregnancy
• Ethnicity (South Asian, African, Middle Eastern = high risk)
• Antenatal clinic referrals: dietician, diabetic team, ophthalmology

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Quick Reference Summary Table

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• Rosen's Emergency Medicine: Concepts and Clinical Practice — Complications of Late Pregnancy
• Creasy & Resnik's Maternal-Fetal Medicine: Principles and Practice
• Textbook of Family Medicine, 9e
• University of Queensland / Qatar University — History & Clinical Examination in Obstetrics (academic reference)

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COMPLAINT 1 — Antepartum Haemorrhage (Placenta Previa)

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Chief Complaint (C/O)

• Per vaginal bleeding × 3 hours

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History of Presenting Illness (HOPI)

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Obstetric Part (Current Pregnancy)

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Past Obstetric History

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Gynaecological History

Past Medical / Surgical History

Drug History & Allergies

Family History

Social History

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COMPLAINT 2 — Pre-Eclampsia

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Chief Complaint (C/O)

• Headache × 2 days
• Blurring of vision × 1 day
• Swelling of face and hands × 3 days

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History of Presenting Illness (HOPI)

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Obstetric Part (Current Pregnancy)

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Past Obstetric History

Gynaecological History

Past Medical / Surgical History

Drug History & Allergies

Family History

Social History

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COMPLAINT 3 — Preterm Labour

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Chief Complaint (C/O)

• Painful uterine contractions × 4 hours
• Watery vaginal discharge × 2 hours

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History of Presenting Illness (HOPI)

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Obstetric Part (Current Pregnancy)

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Past Obstetric History

Gynaecological History

Past Medical / Surgical History

Drug History & Allergies

Family History

Social History

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COMPLAINT 4 — Hyperemesis Gravidarum

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Chief Complaint (C/O)

• Persistent nausea and vomiting × 4 weeks
• Inability to tolerate oral intake × 5 days
• Weight loss

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History of Presenting Illness (HOPI)

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Obstetric Part (Current Pregnancy)

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Past Obstetric History

Gynaecological History

Past Medical / Surgical History

Drug History & Allergies

Family History

Social History

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COMPLAINT 5 — Reduced Fetal Movements (RFM)

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Chief Complaint (C/O)

• Reduced fetal movements × 12 hours

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History of Presenting Illness (HOPI)

• She denies any per vaginal bleeding.
• She denies abdominal pain, uterine contractions, or tightening.
• She denies fever, chills, or offensive vaginal discharge.
• She denies any trauma, fall, or road traffic accident.
• She denies taking any medications that could sedate her or the baby (no opiates, no sedatives, no alcohol).
• She reports normal activity levels today — she has not been unusually active or inactive.

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Obstetric Part (Current Pregnancy)

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Past Obstetric History

Gynaecological History

Past Medical / Surgical History

Drug History & Allergies

Family History

Social History

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COMPLAINT 6 — Preterm Prelabour Rupture of Membranes (PPROM)

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Chief Complaint (C/O)

• Sudden gush of watery fluid per vaginum × 3 hours

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History of Presenting Illness (HOPI)

• She denies fever or feeling hot/cold.
• She denies rigors or chills.
• She denies offensive vaginal discharge prior to this episode.
• She denies abdominal tenderness or uterine pain.
• She denies dysuria or urinary symptoms.
• She has not been unwell in the days preceding this presentation.

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Obstetric Part (Current Pregnancy)

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Past Obstetric History

Gynaecological History

Past Medical / Surgical History

Drug History & Allergies

Family History

Social History

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COMPLAINT 7 — Gestational Diabetes Mellitus (GDM)

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Chief Complaint (C/O)

• Referred from ANC clinic with elevated blood glucose on routine OGTT screening
• Increased thirst and frequency of urination × 3 weeks

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History of Presenting Illness (HOPI)

• Fasting glucose: 5.4 mmol/L (normal <5.1 mmol/L — borderline elevated)
• 1-hour glucose: 10.8 mmol/L (normal <10.0 mmol/L — elevated)
• 2-hour glucose: 9.2 mmol/L (normal <8.5 mmol/L — elevated)
• Diagnosis: GDM confirmed (IADPSG criteria — one or more values at or above threshold)

• Polydipsia: She has noticed increased thirst for approximately 3 weeks — drinking significantly more water than usual (approximately 4–5 litres per day versus her usual 1.5 L).
• Polyuria: Urinary frequency has significantly increased — she is waking 3–4 times per night to urinate (nocturia), and urinating every 45–60 minutes during the day. She denies dysuria, haematuria, or offensive urine (excluding UTI as cause).
• Fatigue: She reports feeling unusually tired and "heavy" — significantly beyond what she attributes to the pregnancy itself.
• Recurrent vaginal thrush: She has had two episodes of vulvovaginal candidiasis over the past 6 weeks — treated each time with topical clotrimazole. (Recurrent Candida is a red flag for hyperglycaemia)
• Blurred vision: She noticed intermittent blurring of vision over the past 2 weeks — she attributes this to "tiredness" but has not seen an optician. (Fluctuating glucose causes osmotic lens changes — urgent ophthalmology referral needed)

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Obstetric Part (Current Pregnancy)

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Past Obstetric History

Gynaecological History

Past Medical / Surgical History

Drug History & Allergies

Family History

• Father: Type 2 diabetes mellitus, diagnosed at age 45
• Paternal aunt: Type 2 diabetes mellitus
• No family history of type 1 DM, multiple pregnancy, hypertension, or congenital malformations.

Social History

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Summary of Writing Principles Used Across All Cases

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CLERKING QUESTIONS — OBSTETRICS

From Biodata to the End of History

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📋 SECTION 1 — BIODATA

These are the first questions you ask to introduce yourself and identify the patient.

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📋 SECTION 2 — CURRENT PREGNANCY DETAILS

(Ask Early — Before the Complaint)

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📋 SECTION 3 — CHIEF COMPLAINT

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📋 SECTION 4 — HOPI QUESTIONS BY COMPLAINT

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🔴 COMPLAINT 1 — Vaginal Bleeding (APH)

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🟠 COMPLAINT 2 — Pre-Eclampsia / Headache + Swelling + High BP

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🟡 COMPLAINT 3 — Preterm Labour

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🟢 COMPLAINT 4 — Hyperemesis Gravidarum

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🔵 COMPLAINT 5 — Reduced Fetal Movements

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🟣 COMPLAINT 6 — PROM / PPROM

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⚪ COMPLAINT 7 — Gestational Diabetes (GDM)

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📋 SECTION 5 — OBSTETRIC HISTORY (PAST PREGNANCIES)

Ask for every previous pregnancy — go through them one by one.

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📋 SECTION 6 — GYNAECOLOGICAL HISTORY

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📋 SECTION 7 — PAST MEDICAL & SURGICAL HISTORY

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📋 SECTION 8 — DRUG HISTORY & ALLERGIES

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📋 SECTION 9 — FAMILY HISTORY

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📋 SECTION 10 — SOCIAL HISTORY

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Quick Memory Aid — Order of Sections

B  → Biodata
C  → Current pregnancy (GA, EDD, G/P)
C  → Chief complaint
H  → HOPI (complaint-specific questions above)
O  → Obstetric history (past pregnancies)
G  → Gynaecological history
M  → Medical and surgical history
D  → Drug history and allergies
F  → Family history
S  → Social history

Tip: In obstetrics, always establish gestational age and parity before exploring the complaint — it changes everything about which conditions are possible and how urgently you need to act.

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🌍 TROPICAL MEDICINE 1 — KMTC EXAM MEMORY AID

Kenya Medical Training College | Clinical Medicine Programme

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KMTC Tropical Medicine 1 covers: Malaria · Typhoid Fever · Cholera · Amoebiasis · Schistosomiasis · Trypanosomiasis · Leishmaniasis · Filariasis · Hookworm · Ascariasis · Tapeworm

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🦟 DISEASE 1 — MALARIA

Memory Aid: "FALCIPARUM KILLS FAST"

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The 4 Plasmodium Species — Memory Aid: "FVMO"

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Clinical Features — "FAHSC"

• F — Fever (cyclical — cold stage → hot stage → sweating stage)
• A — Anaemia + pallor
• H — Hepatosplenomegaly
• S — Severe features (see below)
• C — Chills and rigors

The Fever Stages — Memory Aid: "C-H-S"

1. Cold/shivering stage (1 hour)
2. Hot stage — very high temp (2–6 hours)
3. Sweating/defervescence stage (2–4 hours) — patient feels better, then it repeats

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Severe Malaria Features — Memory Aid: "CRABS POO"

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Diagnosis

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Treatment — Memory Aid: "Uncomplicated = AL; Severe = IV AQ"

Uncomplicated Malaria (P. falciparum)

AL = Artemether-Lumefantrine (Coartem)

• 4 tablets at 0h, 8h, then 4 tablets BD × 2 days
• Give with food/fatty meal (increases absorption)
• First-line in Kenya

Severe/Complicated Malaria

IV Artesunate (preferred) OR IV Quinine

• Artesunate 2.4 mg/kg IV at 0, 12, 24 hours, then daily
• Quinine: 20 mg/kg loading dose IV then 10 mg/kg q8h
• Monitor blood glucose — quinine causes hypoglycaemia
• Treat cerebral malaria: nurse patient, anticonvulsants for seizures

P. vivax / P. ovale (Relapse Prevention)

Chloroquine + Primaquine

• Primaquine clears liver hypnozoites (prevents relapse)
• Check G6PD before giving primaquine (causes haemolysis in G6PD deficiency)

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Prevention — "BICS"

• B — Bednets (insecticide-treated — ITNs)
• I — Indoor Residual Spraying (IRS)
• C — Chemoprophylaxis (travellers: doxycycline / atovaquone-proguanil)
• S — Source reduction (eliminate standing water)

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🌡️ DISEASE 2 — TYPHOID FEVER (Enteric Fever)

Memory Aid: "TYPHOID = STEPS"

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Causative Organism

• Salmonella typhi (typhoid) and S. paratyphi A, B, C (paratyphoid)
• Gram-negative bacillus
• Route: Faeco-oral — contaminated water and food
• Reservoir: Humans (carrier state in gallbladder)

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Clinical Stages — Memory Aid: "4 WEEKS"

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Classic Signs — Memory Aid: "ROBS"

• R — Relative bradycardia (pulse slower than expected for the fever)
• O — Obtunded / toxic look (Typhoid toxaemia)
• B — Bradycardia + bloated abdomen
• S — Splenomegaly + rose Spots

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Complications — Memory Aid: "P-H-E-N"

• P — Perforation of ileum (3rd week — surgical emergency)
• H — Haemorrhage (intestinal)
• E — Encephalopathy / meningitis
• N — Nephritis / hepatitis / cholecystitis

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Diagnosis

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Treatment

⚠️ Dexamethasone IV for severe toxaemia/encephalopathy (reduces mortality in severe disease)

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Prevention — "3 C's"

• Clean water and sanitation
• Cooked food only
• Chlorination + vaccine (oral Ty21a or Vi capsular polysaccharide)

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💧 DISEASE 3 — CHOLERA

Memory Aid: "RICE WATER"

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Causative Organism

• Vibrio cholerae O1 (El Tor biotype) and O139
• Gram-negative curved comma-shaped rod
• Route: Faeco-oral — contaminated water
• Produces cholera toxin → ↑ cAMP → massive Cl⁻ and water secretion into gut lumen

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Clinical Features

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WHO Dehydration Assessment — "SOME"

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Treatment — "R-A-Z"

ORS composition: Glucose 75 mmol/L + NaCl 2.6g + KCl 1.5g + NaHCO3 2.9g per litre ORS works because sodium-glucose co-transport in the gut is intact even in cholera

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Prevention — "WASH"

• Water — safe, treated water
• Adequate sanitation — latrines
• Soap — handwashing
• Hygiene — food hygiene, proper cooking

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🦠 DISEASE 4 — AMOEBIASIS

Memory Aid: "AMEBA BITES"

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Two Forms of Disease

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Diagnosis

• Stool microscopy — trophozoites with ingested red blood cells (pathognomonic)
• Ultrasound — liver abscess (single, right lobe)
• Serology (ELISA) — for liver abscess
• Stool: no pus cells (unlike bacillary dysentery)

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Treatment

Always give metronidazole + diloxanide together to prevent recurrence

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Amoebic Dysentery vs Bacillary Dysentery — Know the Difference!

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🐌 DISEASE 5 — SCHISTOSOMIASIS (Bilharzia)

Memory Aid: "SNAIL FEVER"

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Three Main Species

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Life Cycle — Memory Aid: "EGGS → SNAIL → CERCARIAE → HUMAN"

1. Eggs passed in urine/faeces → hatch in fresh water → miracidia
2. Miracidia infect freshwater snail (intermediate host)
3. Snail releases cercariae into water
4. Cercariae penetrate human skin during water contact
5. Travel to liver → mature into adult worms → lay eggs in blood vessels

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Clinical Phases

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Diagnosis

• Stool/urine microscopy — find eggs (haematobium: terminal-spined egg in urine; mansoni: lateral-spined egg in stool)
• Urine dipstick — haematuria
• Serology
• Biopsy (rectal/bladder)
• Eosinophilia on FBC

Treatment

• Praziquantel 40 mg/kg single dose (or two divided doses same day)
• Safe, effective, inexpensive

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😴 DISEASE 6 — TRYPANOSOMIASIS (African Sleeping Sickness)

Memory Aid: "TSETSE FLY SLEEPS"

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Two Forms

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Clinical Features — Two Stages

• Fever, headache, malaise
• Chancre at bite site
• Winterbottom's sign — painless posterior cervical lymphadenopathy
• Hepatosplenomegaly, anaemia

• Progressive sleep disturbance (sleeping during day, awake at night)
• Personality change, confusion, coma
• Involuntary movements, ataxia
• Death if untreated

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Treatment

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🌑 DISEASE 7 — LEISHMANIASIS (Kala-Azar)

Memory Aid: "KALA AZAR = BLACK FEVER"

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Three Forms

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Visceral Leishmaniasis Signs — Memory Aid: "SAFFAW"

• S — Splenomegaly (massive)
• A — Anaemia (pancytopenia)
• F — Fever (irregular, twice-daily spikes)
• F — Fatigue + weight loss
• A — Albumin low (reversed A:G ratio)
• W — Weakness + skin darkening

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Diagnosis

• Splenic aspirate — most sensitive (but risky)
• Bone marrow aspirate / lymph node aspirate — safer
• rK39 rapid test — antigen test (field use, common in Kenya)
• Leishmania skin test (Montenegro test)
• FBC: pancytopenia (anaemia + thrombocytopenia + leukopenia)

Treatment

• Sodium stibogluconate (SSG) 20 mg/kg IM/IV × 30 days — first-line in Kenya/Africa
• Liposomal Amphotericin B — for resistant/immunocompromised
• Miltefosine (oral) — emerging alternative

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🪱 DISEASE 8 — FILARIASIS

Memory Aid: "WORM IN LYMPH BLOCKS FLOW"

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Clinical Features — "ELEPHANTS HAVE BIG LEGS"

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Diagnosis

• Nocturnal blood film — microfilariae (take blood at night — peak microfilariae 10 PM–2 AM with W. bancrofti)
• Antigen test (ICT card test)
• Eosinophilia on FBC

Treatment

• DEC (Diethylcarbamazine) 6 mg/kg/day × 12 days — kills microfilariae and adult worms
• Ivermectin + Albendazole — mass drug administration programmes
• Hydrocele: surgical correction
• Lymphoedema: limb elevation, compression, hygiene

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🪱 DISEASE 9 — INTESTINAL WORMS (Helminths)

Quick Comparison Memory Aid: "HOOK-ROUND-TAPE-PIN"

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Hookworm — Key Points

• Larvae penetrate bare skin (ground itch = entry)
• Attach to intestinal wall → suck blood → chronic iron deficiency anaemia
• Eosinophilia — hallmark of all helminth infections
• Treat: Albendazole 400 mg single dose + iron supplementation

Roundworm (Ascaris lumbricoides)

• Largest intestinal nematode (up to 35 cm)
• Loeffler's syndrome — larvae in lungs → cough, wheeze, eosinophilia
• Complications: intestinal obstruction, biliary obstruction, volvulus
• Treat: Albendazole 400 mg single dose

Tapeworm (Taenia)

• T. solium (pork tapeworm) → cysticercosis (larvae invade brain, eye, muscle) → neurocysticercosis → seizures
• T. saginata (beef tapeworm) — fewer complications
• Treat: Praziquantel 5–10 mg/kg single dose OR Niclosamide

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🧠 MASTER MEMORY TABLES

VECTORS — "Every Vector Has a Disease"

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DIAGNOSIS GOLD STANDARD — "Know Your Best Test"

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TREATMENTS AT A GLANCE — "One Drug Per Disease"

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COMMON EXAM TRAPS — "Don't Fall For These"

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EOSINOPHILIA DISEASES — "WHATS"

Eosinophilia = Helminths (worms) + allergic conditions

• Wuchereria (filariasis)
• Hookworm
• Ascaris
• Toxocara
• Schistosomiasis

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FAECO-ORAL ROUTE DISEASES — "CHAT"

• C — Cholera
• H — Hepatitis A/E
• A — Amoebiasis / Ascaris
• T — Typhoid

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TROPICAL MEDICINE 1 — SAQs, LAQs & EXAM ANSWER TRICKS

KMTC Clinical Medicine | Exam-Oriented Guide

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PART A — HOW TO ANSWER MEDICAL EXAM QUESTIONS (THE RULES)

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The Golden Rules of Medical Exam Answers

Rule 1 — READ THE COMMAND WORD FIRST

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Rule 2 — THE MARK ALLOCATION TELLS YOU HOW MANY POINTS

1 mark = 1 correct point

• If a question is worth 5 marks → write at least 5 clear, separate points
• If a question is worth 10 marks → write 10–12 points (give 2 extra as buffer)
• Never write a paragraph when a list is faster and clearer
• Never write one long sentence that contains 3 points — split them up

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Rule 3 — THE FORMAT THAT EARNS MARKS

HEADING (bold or underlined)
  ↓
Short definition (1–2 lines)
  ↓
Numbered / bulleted points
  ↓
Each point = one idea = one mark
  ↓
End with complications or management if the question allows

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Rule 4 — STRUCTURE EVERY CLINICAL ANSWER WITH "DOCS-MC"

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Rule 5 — CLINICAL FEATURES: ALWAYS SEPARATE SYMPTOMS FROM SIGNS

Symptoms:
1. Fever
2. Headache
3. Chills and rigors

Signs:
1. Pallor
2. Splenomegaly
3. Jaundice

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Rule 6 — MANAGEMENT: USE "ABCDE" FORMAT

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Rule 7 — NEVER LEAVE ANY QUESTION BLANK

• Write the definition
• Write one or two features you know
• Write one treatment
• Partial marks are still marks

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PART B — SHORT ANSWER QUESTIONS (SAQs) WITH MODEL ANSWERS

SAQs = typically 5–10 marks each. Write structured, concise, numbered answers.

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SAQ 1 — MALARIA

Q: Define malaria and list four clinical features of severe malaria. (5 marks)

1. Impaired consciousness / coma (cerebral malaria)
2. Severe anaemia (Hb <5 g/dL)
3. Haemoglobinuria (blackwater fever) — dark/cola-coloured urine
4. Convulsions / repeated seizures
5. (Bonus) Pulmonary oedema / respiratory distress
6. (Bonus) Hypoglycaemia

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Q: State four differences between uncomplicated and severe malaria. (4 marks)

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Q: Outline the treatment of uncomplicated malaria in an adult. (5 marks)

• 0 hours, 8 hours (Day 1)
• Morning and evening (Day 2)
• Morning and evening (Day 3)
• Total = 6 doses over 3 days

1. Give with food or milk (fatty meal increases absorption)
2. Treat fever with paracetamol 1 g TDS
3. Encourage oral fluids and rest
4. Follow up in 48–72 hours; repeat blood film if not improving

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Q: List five complications of malaria. (5 marks)

1. Cerebral malaria (seizures, coma, death)
2. Severe anaemia (haemolysis)
3. Acute renal failure (haemoglobinuria — blackwater fever)
4. Pulmonary oedema / ARDS
5. Hypoglycaemia (especially with IV quinine treatment)
6. (Bonus) Disseminated intravascular coagulation (DIC)
7. (Bonus) Splenic rupture
8. (Bonus) Nephrotic syndrome (P. malariae in children)

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Q: State two methods of malaria prevention. (2 marks)

1. Use of insecticide-treated bed nets (ITNs/LLINs)
2. Indoor residual spraying (IRS) with insecticides
3. (Bonus) Chemoprophylaxis for travellers (doxycycline / atovaquone-proguanil)
4. (Bonus) Elimination of mosquito breeding sites (standing water)

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SAQ 2 — TYPHOID FEVER

Q: Define typhoid fever and state its causative organism and mode of transmission. (4 marks)

1. Faeco-oral route
2. Through ingestion of contaminated food and water
3. (Bonus) Carriers (people who carry bacteria in gallbladder without symptoms) are a source

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Q: Describe the clinical features of typhoid fever in each week of illness. (8 marks)

• Gradually rising "stepladder" fever (temperature rises each day)
• Headache, malaise, general body aches
• Constipation (early)
• Relative bradycardia (pulse slower than expected for fever height)

• Sustained high fever
• Rose spots — salmon-coloured, blanching macules on trunk (rare but pathognomonic)
• Splenomegaly
• Toxic, ill-looking patient

• Pea-soup diarrhoea — profuse, offensive green diarrhoea
• Abdominal distension
• Risk of intestinal perforation and haemorrhage (most dangerous complication)

• Gradual defervescence (temperature settling) in uncomplicated cases
• OR death from perforation/haemorrhage/septicaemia in complicated cases

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Q: List three investigations used to diagnose typhoid fever and state the finding expected in each. (6 marks)

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Q: State four complications of typhoid fever. (4 marks)

1. Intestinal perforation — commonest dangerous complication (week 3)
2. Intestinal haemorrhage
3. Typhoid encephalopathy / meningitis
4. Hepatitis / jaundice
5. (Bonus) Cholecystitis (gallbladder — causes chronic carrier state)
6. (Bonus) Myocarditis

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SAQ 3 — CHOLERA

Q: State the causative organism of cholera and describe the characteristic stool in cholera. (3 marks)

• Described as "rice-water stool"
• Profuse, watery, pale/grey in colour
• Contains flecks of mucus
• Has no blood and no faecal odour
• Passed in very large volumes (up to 10–20 litres/day)

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Q: Outline the management of a patient with severe cholera. (10 marks)

• Assess level of dehydration (skin turgor, sunken eyes, mental state, urine output)
• Weigh patient to guide fluid replacement

• Stool microscopy and culture
• U&E (electrolytes — hyponatraemia, hypokalaemia, metabolic acidosis)
• FBC

• Severe dehydration: IV Ringer's Lactate (NOT normal saline — RL replaces bicarbonate)
• Adult: 100 mL/kg over 3–4 hours, then reassess
• Children: 100 mL/kg over 3–6 hours
• Switch to ORS when patient can drink
• ORS for mild-moderate dehydration: 75 mL/kg over 4 hours

• Antibiotics reduce stool volume and duration by ~50%
• Doxycycline 300 mg single dose (adults, non-pregnant)
• Azithromycin 1 g single dose (children, pregnant women)
• Ciprofloxacin 1 g single dose — alternative

• Strict hand hygiene after toilet use
• Safe water — boil or treat
• Proper disposal of faeces
• Zinc supplementation in children (20 mg OD × 10 days)
• Notification to public health authorities (cholera is a notifiable disease)

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SAQ 4 — AMOEBIASIS

Q: Define amoebiasis and state its causative organism. (2 marks)

• Amoebiasis is an infection of the intestine (and sometimes other organs) caused by the protozoan Entamoeba histolytica, transmitted by the faeco-oral route through ingestion of cysts in contaminated food or water. (1 mark)
• Causative organism: Entamoeba histolytica (1 mark)

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Q: Differentiate between amoebic dysentery and bacillary (shigella) dysentery. (6 marks)

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Q: State the treatment of amoebic liver abscess. (4 marks)

1. Metronidazole 800 mg TDS orally for 10 days — kills tissue trophozoites (2 marks)
2. Diloxanide furoate 500 mg TDS × 10 days — clears luminal cysts and prevents recurrence (1 mark)
3. Aspiration of abscess — if large (>10 cm), risk of rupture, or no response to drugs within 72 hours (1 mark)

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SAQ 5 — SCHISTOSOMIASIS

Q: Name two species of Schistosoma that cause disease in East Africa and state the organ affected by each. (4 marks)

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Q: State three clinical features of urinary schistosomiasis. (3 marks)

1. Terminal haematuria — blood at end of urination (pathognomonic)
2. Dysuria and frequency (bladder irritation)
3. Obstructive uropathy → hydronephrosis (chronic)
4. (Bonus) Bladder cancer (squamous cell carcinoma — long-term complication)
5. (Bonus) Swimmer's itch at entry (cercarial dermatitis)

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PART C — LONG ANSWER QUESTIONS (LAQs) WITH MODEL ANSWERS

LAQs = typically 15–20 marks. Must be structured with headings, well-organised, and comprehensive.

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LAQ 1 — MALARIA (20 marks)

Q: Discuss malaria under the following headings: definition, causative organisms, mode of transmission, clinical features, diagnosis, treatment, and prevention.

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1. Primary route: Bite of infected female Anopheles mosquito (vector)
2. Mosquito bites at night (dusk to dawn)
3. Other routes (rare): Blood transfusion, needle sharing, transplacental (congenital malaria)

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1. Cyclical fever with three stages: cold (shivering) → hot (high temperature) → sweating (defervescence)
2. Headache
3. Chills and rigors
4. Nausea, vomiting, loss of appetite
5. General body weakness and myalgia
6. Joint pains (arthralgia)

1. Pallor (from haemolytic anaemia)
2. Splenomegaly (in chronic/repeated infection)
3. Hepatomegaly
4. Jaundice (haemolysis)
5. Temperature >38.5°C

1. Altered consciousness / coma
2. Repeated seizures (>2 in 24 hours)
3. Severe anaemia (Hb <5 g/dL)
4. Haemoglobinuria (dark/black urine — blackwater fever)
5. Pulmonary oedema / respiratory distress
6. Hypoglycaemia (blood glucose <2.2 mmol/L)
7. Circulatory shock (algid malaria)

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1. Thick and thin blood film microscopy — gold standard; identifies species and parasite density
2. Rapid Diagnostic Test (RDT) — detects P. falciparum HRP2 antigen; fast and field-usable
3. Full Blood Count (FBC): anaemia, thrombocytopenia, leukopenia
4. Blood glucose: hypoglycaemia in severe malaria
5. Renal function tests/LFTs: assess organ damage in severe disease

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• Artemether-Lumefantrine (AL) — 4 tablets at 0h, 8h, then twice daily × 2 days
• Give with food/milk
• Treat fever: Paracetamol 1g TDS

• IV Artesunate 2.4 mg/kg at 0h, 12h, 24h then daily
• OR IV Quinine 20 mg/kg loading dose then 10 mg/kg q8h
• Monitor blood glucose (IV quinine causes hypoglycaemia)
• IV fluids, oxygen, treat seizures (diazepam)

• Chloroquine + Primaquine (check G6PD status first)

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1. Insecticide-treated bed nets (ITNs/LLINs) — sleep under net every night
2. Indoor Residual Spraying (IRS) with insecticides
3. Chemoprophylaxis for travellers and pregnant women (IPTp in pregnancy — SP monthly)
4. Environmental control — drain stagnant water, clear bushes near homes
5. Prompt diagnosis and treatment of all cases (reduces transmission)

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LAQ 2 — TYPHOID FEVER (20 marks)

Q: A 20-year-old student presents with 2 weeks of gradually rising fever, headache, and constipation. Discuss this case under: definition, causative organism, pathology, clinical features, complications, investigations, and management.

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• Salmonella typhi (typhoid)
• Salmonella paratyphi A, B, C (paratyphoid — milder disease)
• Gram-negative rod, motile, bile-soluble
• Humans are the only reservoir

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1. Organism ingested in contaminated food/water
2. Penetrates intestinal mucosa → enters Peyer's patches (lymphoid tissue in ileum)
3. Carried to mesenteric lymph nodes → bacteraemia (1st week)
4. Seeds liver, spleen, gallbladder, bone marrow
5. Rose spots = emboli of bacteria in dermal capillaries
6. Week 3: Peyer's patches necrose → ulceration and perforation of ileum

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1. Fever — stepladder pattern (rises 1°C each day over first week)
2. Frontal headache — prominent, severe
3. Constipation (first 1–2 weeks)
4. Diarrhoea — "pea-soup" in week 3
5. Abdominal pain and distension
6. Loss of appetite, malaise, myalgia

1. Relative bradycardia — pulse-temperature dissociation
2. Rose spots — 2–4 mm salmon-coloured macules on trunk (week 2)
3. Splenomegaly
4. Coated tongue
5. Abdominal tenderness (iliac fossa)
6. Toxic, ill-looking patient

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1. Intestinal perforation — week 3; presents with sudden severe abdominal pain, peritonitis, shock — SURGICAL EMERGENCY
2. Intestinal haemorrhage — PR bleeding
3. Hepatitis and jaundice
4. Typhoid encephalopathy — confusion, psychosis
5. Myocarditis — bradycardia may worsen
6. Chronic carrier state — bacteria persist in gallbladder for >1 year; source of outbreaks

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1. Bed rest
2. Maintain adequate hydration — oral fluids or IV fluids if vomiting
3. High-calorie, low-fibre soft diet (avoids mechanical stress on Peyer's patches)
4. Paracetamol for fever (avoid NSAIDs — risk of GI bleeding)
5. Tepid sponging for very high temperature

• Perforation: IV antibiotics + surgical repair (emergency laparotomy)
• Haemorrhage: blood transfusion, surgical intervention

1. Safe drinking water (boiling/chlorination)
2. Proper food hygiene and handwashing
3. Typhoid vaccination — oral Ty21a (3 doses) or Vi polysaccharide (injection)
4. Treatment of carriers (ciprofloxacin 6 weeks to clear gallbladder carriage)
5. Notification to public health

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LAQ 3 — CHOLERA (15 marks)

Q: Discuss cholera under: definition, causative organism, pathophysiology, clinical features, diagnosis, and management.

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• Vibrio cholerae serogroup O1 (El Tor biotype) — most common worldwide
• Vibrio cholerae O139 — second most common
• Gram-negative, curved comma-shaped rod
• Transmitted by faeco-oral route — contaminated water and food

1. V. cholerae colonises the small intestine
2. Produces cholera toxin (CT) — binds to enterocyte surface
3. Toxin → activates adenylate cyclase → ↑ intracellular cAMP
4. ↑ cAMP → massive secretion of Cl⁻, Na⁺, and water into intestinal lumen
5. Water and electrolyte absorption is blocked
6. Result: massive watery diarrhoea and dehydration

1. Sudden onset profuse watery diarrhoea
2. Effortless projectile vomiting
3. Painless abdomen (no colicky pain — unlike dysentery)
4. Extreme thirst
5. Muscle cramps (hypokalaemia)

1. Rice-water stools — pale, watery, odourless with flecks of mucus
2. Sunken eyes, sunken fontanelle (children)
3. Loss of skin turgor — "skin tent" sign
4. Dry mucous membranes
5. Tachycardia → hypotension → shock (in severe cases)
6. "Washerwoman hands" — wrinkled skin from dehydration
7. Hoarse voice, decreased urine output → anuria

1. Clinical diagnosis in endemic area with typical rice-water stool
2. Stool microscopy and culture — V. cholerae (confirmation)
3. Dark-field microscopy — darting motility of vibrios
4. RDT (Rapid cholera antigen test) — field use
5. U&E — hyponatraemia, hypokalaemia, metabolic acidosis

• Reassess every 30 minutes in severe cases
• Monitor urine output, pulse, skin turgor

• Doxycycline 300 mg single dose (adults, non-pregnant) — reduces stool output by 50%
• Azithromycin 1g single dose — children and pregnant women
• Ciprofloxacin 1g single dose — alternative

• 20 mg OD × 10–14 days

• Continue breastfeeding in infants
• Resume normal feeding as soon as tolerated

• Isolate patient (barrier precautions)
• Notify public health authorities (notifiable disease)
• Trace contacts, treat water source
• Safe disposal of stools

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PART D — COMMON SAQ QUESTION STEMS + FAST-WRITE CHECKLISTS

These are the most commonly repeated patterns in KMTC exams.

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Fast-Write Checklist: "What are the clinical features of ___?"

SYMPTOMS (what patient complains of):
1.
2.
3.
4.
5.

SIGNS (what you find on examination):
1.
2.
3.
4.
5.

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Fast-Write Checklist: "How would you manage a patient with ___?"

A — Admit / Assess
B — Basic investigations (FBC, RFTs, LFTs, cultures, specific tests)
C — Conservative/supportive (fluids, rest, diet, pain relief)
D — Drug treatment (name, dose, route, duration)
E — Education, prevention, follow-up, when to refer

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Fast-Write Checklist: "State the complications of ___?"

EARLY complications:
1.
2.

LATE complications:
3.
4.

LIFE-THREATENING complications:
5.
6.

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Fast-Write Checklist: "Differentiate between A and B"

| Feature | Disease A | Disease B |
|---------|-----------|-----------|
| Onset   |           |           |
| Fever   |           |           |
| Stool   |           |           |
| Cause   |           |           |
| Rx      |           |           |

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PART E — TRICKS AND EXAMINER SECRETS

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🏆 Top 10 Mark-Earning Tricks

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🔴 Most Commonly Lost Marks in Tropical Medicine

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🟢 Phrases That Earn Bonus Marks in Answers

• "This is a notifiable disease — public health authorities must be informed" (cholera, typhoid)
• "Gold standard investigation is..."
• "First-line treatment as per WHO/Kenya national guidelines is..."
• "Complications should be actively monitored for..."
• "Check G6PD status before prescribing primaquine"
• "Relative bradycardia is a characteristic feature of typhoid"
• "Rice-water stool is pathognomonic of cholera"
• "Terminal haematuria is pathognomonic of Schistosoma haematobium"
• "Severe malaria requires IV treatment and ICU/HDU admission"
• "Administer anti-D if Rh-negative" (obstetrics — but same principle: show extra clinical thinking)

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Answer Length Guide

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Final Advice: In medical exams, structure beats bulk. A short, well-organised answer with numbered points, clear headings, specific drug names and doses, and mention of prevention will always outscore a long rambling paragraph — even if the paragraph contains more total knowledge.