4 Year OSCE Guide: (Hold Key and Click To Go Straight To The Page You Want)

4th Year OSCE guide
Table of contents
(Hold <Ctrl> key and click to go straight to the page you want)
1 POG..................................................................................................................................................................................4
1.1 PAEDIATRICS.............................................................................................................................................................4
1.1.1 Information giving stations.................................................................................................................................4
1.1.1.1 Gastro-oesophageal reflux........................................................................................................................................4
1.1.1.2 Immunization............................................................................................................................................................ 5
1.1.1.3 Febrile Convulsion...................................................................................................................................................6
1.1.1.4 Constipation.............................................................................................................................................................. 7
1.1.1.5 Epilepsy.................................................................................................................................................................... 8
1.1.1.6 Newly diagnosed asthmatic......................................................................................................................................9
1.1.1.7 Bed Wetting............................................................................................................................................................10
1.1.1.8 Weaning.................................................................................................................................................................. 11
1.1.1.9 Neonatal jaundice...................................................................................................................................................12
1.1.2 Paediatric history.............................................................................................................................................13
1.1.3 Paediatric examination.....................................................................................................................................14
1.1.3.1 Developmental exam..............................................................................................................................................14
1.1.3.2 Cardiovascular examination....................................................................................................................................15
1.1.3.3 Respiratory examination.........................................................................................................................................16
1.1.3.4 Abdominal examination..........................................................................................................................................17
1.1.3.5 Squint..................................................................................................................................................................... 18
1.1.3.6 Gait examination.....................................................................................................................................................19
1.1.3.7 Types of Gait..........................................................................................................................................................20
1.1.3.8 Peripheral Neurological function examination........................................................................................................21
1.1.3.9 Central Neurological function examination............................................................................................................24
1.1.3.10 Apgar scoring.........................................................................................................................................................25
1.1.3.11 Assessment of the newborn.....................................................................................................................................26
1.2 OBSTETRICS & GYNAECOLOGY..............................................................................................................................27
1.2.1 Information giving stations...............................................................................................................................27
1.2.1.1 Combination Oral Contraceptive Pill Counselling..................................................................................................27
1.2.1.2 Progestogen Only Pill Counselling.........................................................................................................................28
1.2.1.3 Emergency contraception........................................................................................................................................29
1.2.1.4 Post menopausal bleeding.......................................................................................................................................30
1.2.1.5 Cervical smear explanation.....................................................................................................................................31
1.2.1.6 Infertility counselling..............................................................................................................................................32
1.2.1.7 Pelvic Inflammatory Disease (PID)........................................................................................................................33
1.2.1.8 Hormone replacement therapy................................................................................................................................34
1.2.1.9 Endometriosis......................................................................................................................................................... 35
1.2.1.10 Urodynamics interpretation.....................................................................................................................................36
1.2.1.11 Genuine Stress Incontinence (GSI).........................................................................................................................36
1.2.1.12 Urge Incontinence...................................................................................................................................................37
1.2.1.13 Heavy menstrual bleeding / Menorrhagia...............................................................................................................38
1.2.1.14 Explanation of hysterectomy..................................................................................................................................39
1.2.1.15 Induction of labour/ Management of post dates pregnancy.....................................................................................40
1.2.1.16 CTG interpretation..................................................................................................................................................41
1.2.1.17 Bleeding and pain in early pregnancy.....................................................................................................................43
1.2.1.18 Intra Uterine Growth Restriction............................................................................................................................44
1.2.1.19 Pre-eclampsia.........................................................................................................................................................45
1.2.1.20 Gestational diabetes................................................................................................................................................46
1.2.1.21 Miscarriage counselling..........................................................................................................................................47
1.2.1.22 Analgesia in labour.................................................................................................................................................48
1.2.1.23 Explanation of malposition / malpresentation.........................................................................................................49
1.2.1.24 Explanation of caesarean section............................................................................................................................50
1.2.1.25 Ectopic pregnany....................................................................................................................................................51
1.2.1.26 Management of twin/multiple pregnancy................................................................................................................52
1.2.1.27 Premature delivery..................................................................................................................................................53
1.2.1.28 Pre-term rupture of membranes..............................................................................................................................54
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1.2.1.29 Bleeding in 3rd trimester / Antepartum haemorrhage (APH)...................................................................................55
1.2.1.30 Termination counselling..........................................................................................................................................56
1.2.1.31 Triple test counselling.............................................................................................................................................57
1.2.1.32 Placenta praevia explanation...................................................................................................................................58
1.2.1.33 Explanation of antenatal blood tests........................................................................................................................59
1.2.2 Problem based obs & gynae histories..............................................................................................................60
1.2.2.1 Obstetric history.....................................................................................................................................................60
1.2.2.2 Gynaecological history...........................................................................................................................................61
1.2.2.3 Infertility History....................................................................................................................................................62
1.2.3 Obstetric / Gynae examination.........................................................................................................................63
1.2.3.1 Gynaecological examination...................................................................................................................................63
1.2.3.2 Obstetrics examination...........................................................................................................................................64
1.2.3.3 6 week post natal check..........................................................................................................................................65
2 MSS.................................................................................................................................................................................66
2.1 EMERGENCY MEDICINE..........................................................................................................................................66
2.1.1 Procedures........................................................................................................................................................66
2.1.1.1 Wound suturing....................................................................................................................................................... 66
2.1.1.2 Blood gas interpretation..........................................................................................................................................67
2.2 ANAESTHESIA, RESUSCITATION AND PAIN MANAGEMENT.....................................................................................69
2.2.1 Procedures........................................................................................................................................................69
2.2.1.1 Cannulation and setting up a drip............................................................................................................................69
2.2.1.2 Administer antibiotics intravenously......................................................................................................................70
2.2.1.3 Pre-operative assessment........................................................................................................................................71
2.3 DERMATOLOGY.......................................................................................................................................................72
2.3.1 Counselling.......................................................................................................................................................72
2.3.1.1 Psoriasis.................................................................................................................................................................. 72
2.3.1.2 Atopic Eczema........................................................................................................................................................ 73
2.3.1.3 Acne....................................................................................................................................................................... 74
2.3.2 Genito Urinary Medicine..................................................................................................................................75
2.3.2.1 Sexual history.........................................................................................................................................................75
2.3.2.2 HIV and AIDS counselling.....................................................................................................................................76
2.3.2.3 STI explanation.......................................................................................................................................................77
2.3.3 Infectious Diseases...........................................................................................................................................78
2.3.3.1 ID / Travel history...................................................................................................................................................78
2.3.3.2 Hepatitis A, B & C..................................................................................................................................................79
2.3.4 Rehabilitation Medicine....................................................................................................................................80
2.3.4.1 Communication assessment....................................................................................................................................80
2.3.4.2 Cognitive Assessment.............................................................................................................................................81
2.3.4.3 Choosing walking equipment..................................................................................................................................82
2.3.4.4 Orthotics - General.................................................................................................................................................83
2.3.4.5 Ankle and foot orthoses for children.......................................................................................................................84
2.3.4.6 Swallow test............................................................................................................................................................85
2.3.4.7 GAIT examination..................................................................................................................................................86
2.3.5 Oncology and Palliative Medicine...................................................................................................................86
2.3.5.1 Breaking bad news..................................................................................................................................................86
2.3.5.2 Describing cancer treatment options.......................................................................................................................87
2.3.5.3 Describing Radiotherapy........................................................................................................................................88
2.3.5.4 Chemotherapy......................................................................................................................................................... 89
3 PPP..................................................................................................................................................................................90
3.1 PRIMARY CARE.......................................................................................................................................................90
3.1.1 Counselling.......................................................................................................................................................90
3.1.1.1 High cholesterol......................................................................................................................................................90
3.1.1.2 Type I diabetes........................................................................................................................................................91
3.1.1.3 Type II diabetes......................................................................................................................................................92
3.1.1.4 Hypertension........................................................................................................................................................... 93
3.1.1.5 Smoking cessation..................................................................................................................................................94
3.1.1.6 Obesity................................................................................................................................................................... 95
3.1.1.7 CVD risk.................................................................................................................................................................96
3.1.2 Examinations / skills.........................................................................................................................................97
3.1.2.1 ENT Exam.............................................................................................................................................................. 97
3.1.2.2 Eye Exam...............................................................................................................................................................98
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3.1.2.3 GALS..................................................................................................................................................................... 99
3.1.2.4 Gait examination...................................................................................................................................................100
3.1.2.5 Urine Dipstick.......................................................................................................................................................100
3.1.2.6 Prescribing............................................................................................................................................................ 101
3.1.2.7 Insomnia............................................................................................................................................................... 102
3.2 PSYCHIATRY..........................................................................................................................................................103
3.2.1 Histories..........................................................................................................................................................103
3.2.1.1 Depression............................................................................................................................................................ 103
3.2.1.2 Self harm/ suicide risk assessment........................................................................................................................104
3.2.1.3 Cognitive assessment............................................................................................................................................105
3.2.1.4 AMTS................................................................................................................................................................... 106
3.2.1.5 Mini Mental State Examination (MMSE).............................................................................................................107
3.2.1.6 Mania.................................................................................................................................................................... 108
3.2.1.7 Auditory Hallucinations........................................................................................................................................109
3.2.1.8 Alcohol dependency..............................................................................................................................................110
3.2.1.9 Anxiety................................................................................................................................................................. 111
3.2.1.10 Obsessive / compulsive behaviour........................................................................................................................112
3.2.2 Counselling.....................................................................................................................................................113
3.2.2.1 Antidepressants history/counselling......................................................................................................................113
3.2.2.2 Treatment options for depression..........................................................................................................................114
3.2.2.3 Antipsychotics...................................................................................................................................................... 115
3.2.2.4 Antipsychotic history/counselling.........................................................................................................................116
3.2.2.5 Clozapine.............................................................................................................................................................. 117
3.2.2.6 Lithium................................................................................................................................................................. 118
3.2.2.7 ECT...................................................................................................................................................................... 119
3.2.2.8 Dementia.............................................................................................................................................................. 120
3.2.2.9 Panic attacks......................................................................................................................................................... 121
3.2.3 Mental state examination................................................................................................................................122
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1 POG
1.1 Paediatrics
1.1.1 Information giving stations
1.1.1.1 Gastro-oesophageal reflux
 Intro, purpose of discussion, engage child if poss
 What is it?: Non-forceful regurgitation of milk/other gastric contents. Not vomiting which is active.
GORD is when it’s repeated and severe enough to cause harm.
 Is it common?: Common in first year. Occurs once a day in half of infants 0-3 months, peaks
around 6 months.
 What causes it?

- Oesophagus shorter in infants.
- Immaturity / incompetence of sphincter at the gastro-oesophageal junction or where raised
intragastric or intra-abdominal overcomes this.
- Hiatus hernia, Oesophageal dysmotility
- Prematurity, cerebral palsy or severe neurodevelopmental problems, congenital oesophageal
anomalies
 Are there any serious complications? GORD complications:

- Oesophagitis (with haematemesis, anaemia or stricture formation)
- Respiratory problems (eg cough, apnoea, wheeze, aspiration pneumonia)
- Feeding, behavioural problems and failure to thrive
- Sandifer syndrome: episodes associated with dystonic neck movements
 How can it be treated?: Mild reflux: Reassurance (benign, likely to resolve spontaneously),
Feeding advice (avoid overfeeding, try increasing frequency and decreasing volume), Positioning – 30
degrees head up after feeding appears to help
When simple measures fail: Feed thickener. Breastfed infants can be given paste prior. Older children
life-style changes (foods 2 avoid, weight reduction) antacid may help.
- H2-Receptor antagonists (H2RAs, e.g. rantidine).
- Proton pump inhibitors (PPIs, e.g. omeprazole)
- Motility stimulants e.g. domperidone
- Surgery (e.g. fundoplication) significant risk of morbidity
 Tests? FBC, oesophageal pH study (dips in pH <4), barium meal (exclude anatomical
abnormalities), endoscopy (oesophagitis) CXR (aspiration)
 Ideas Concerns Expectations Summarise

 C - Check understanding, A – Ask questions, L –Leaflet, F – arrange a Follow up
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1.1.1.2 Immunization
 Intro, purpose of discussion, engage child if poss\
The MMR Controversy

 Measles - pneumonia, fits, encephalitis, subacute sclerosisng panencephalitis, death
 Mumps can cause meningitis, encephalitis, deafness and sterility
 Rubella in pregnancy can cause severe damage to the foetus
 MMR is safe and effective
 Side effects include sore injection site, flu like symptoms, rare allergic reaction
 No evidence for MMR link to autism or IBD
 Three separate injections means potential for added distress, missed vaccinations, cost
 Ideas Concerns Expectations

5
1.1.1.3 Febrile Convulsion
 Intro, purpose of discussion, engage child if poss
 What is it?: A type of fit due to a high temperature. Most are not serious. Often with ear infections
or cold. Usually full recovery with no permanent damage.
 Is it common? Up to 4% of children, usually between 6 months and 6 years. Genetic predisposition
 What causes it? Temps over 39°C affect ‘wiring in brain’.
 Does my child have epilepsy? Very unlikely: epilepsy occurs without fever. 95-98% of children do
not go on to develop epilepsy. Similar risk to other children, unless focal (focus on one area), prolonged
or repeated (4-12% risk of epilepsy developing). 30-40% will have further febrile fits though.
 What should I do about it? Move away from danger. Nothing in mouth. Place on side. Note the
time. If never happened before call an ambulance or take to hospital for obs. If > 5 mins or two in a
row call an ambulance. Give calpol/paracetamol. Get treatment for cause of fever. Make sure
vaccinations are up to date. 16-20°C is a good room temp.
 Could it be something more serious? Consider meningitis if stiff neck, extreme lethargy > 4 h after
fit, vomiting or < 12 months old. Check for rash, photophobia.
 Can any tests be done? Rule out other possible causes e.g. inspect ears, tonsils, chest, LP, urine,
blood, stools etc. to check for infections.

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1.1.1.4 Constipation
 What is it?: Difficulty/pain or straining passing stools &/or passing stools less often than usual.
Less often than every other day then constipation likely, but can still be normal. May lead to overflow
(explain).
 Is it common?: 5% of school children suffer constipation.
 What causes it?: Low fibre/fluid intake, lack of exercise, poor motility (55% family history).
Holding stools in is common due to; previous stool painful, anal fissure, dislike of toilets, emotional
problems. Medical conditions: hypothyroidism, hypercalcaemia, neurological problems, sexual abuse,
diabetes insipidus, opiates and anticholinergics, intestinal obstruction, food hypersensitivity,
Hirschsprung’s disease (1/5000).
 What can be done?: Prevention:  Fibre fluids & exercise. Limit squash, fizzy drinks & milk.
Encourage regular toilet habit & don't rush them. Toilet footrests may help. Reward system (e.g.
starcharts) but not too much of a fuss. Be 'matter of fact' and relaxed.
 What treatments are available? Important to treat underlying organic cause. Local anaesthetic
(2% lignocaine). Softeners: such as Lactulose. Laxatives: senna, Macrogels: e.g. Movicol. If no
response in 4 weeks enemas. Hospital admission for evacuation under sedation or GA if necessary.
 Can any tests be done? If we think it’s something more serious (RARE) we might want to do some
tests (TFTs, Ca2+, RAST, AXR, rectal biopsy, anorectal manometry (catheter in anus with balloon),
barium studies, spinal imaging.

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1.1.1.5 Epilepsy
What is epilepsy?: Tendency to have recurring seizures. One seizure not = epilepsy. Due to interrupted
electrical signals in the brain.
Why has my child got it? Often don’t know. Links to meningitis, head injury, birth problems, genetic
How is it diagnosed?: After 2 or more seizures. Eye witness accounts useful: location, often no
warning, confused & tired afterwards with no memory of event. Medical history. Blood tests ( BG),
ECG, EEG (usually need to be having a fit at time), video telemetry, MRI, CT (may not help)
What else could it be? Febrile convulsions, breath holding, reflex anoxic (triggers cause heart to stop
or slow down, reducing blood flow to brain), syncope.
What can I do about it? Safety: furniture, fires, cooking, bathrooms, garden, ID card.
What are the different types?

- Simple partial seizures (only part of brain, conscious & aware, aura, twitching, wave, numbness or
tingling, visual disturbance, feel ‘strange’)
- Complex partial seizures (consciousness affected, repetitive movements, picking up objects or
fiddling with clothing, mumbling or lip-smacking, wandering. Last < couple of minutes. May cry
out, strange postures or movements. May not comprehend instructions, tired afterwards).
- Secondary generalised seizures (spread from 1 hemisphere to 2, unconscious, tonic clonic seizure).
- Generalised seizures (affect whole brain, may be no warning, unconscious, amnesia).
- Absences (may look blank and stare or eyelids flutter. Unresponsive, may even be walking)
What do all the fancy words mean? Tonic seizures (muscles stiffen). Atonic seizures (muscles
suddenly relax), Myoclonic seizures (jerking of a limb or part of). Tonic clonic (unconscious, stiffen,
relax and tighten, jerk and shake, May also be affected: breathing, skin colour, incontinent. Nocturnal
seizures (asleep). Status epilepticus ( >30 minutes or no recovery between - medical emergency).
How is it treated? Drug treatments (70% effective), brain surgery, high fat diets, vagal nerve
simulator. AED side effects - drowsiness, dizziness, weight gain or loss, rash etc. most quite rare
What should I do if my child has a fit? ABC. Don’t restrain. Nothing in mouth. Nothing to drink.
Who should I tell? Teachers, youth club leaders, friends and relatives
What about doing sports? Think about safety, but still encourage. Swimming buddy. Crash helmets.
What might reduce chance of fits? Tiredness, stress, alcohol, x medication. Flashing lights (5%).
Can my child get extra help? May be entitled to benefits. Contact benefits agency
What about the future? (Jobs etc?) May affect it. Army. Fit free >1 year to drive, > 10 yrs for HGVs.

 S – Summarise C - Check understanding, A – Ask questions, L –Leaflet, F – arrange a Follow up
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1.1.1.6 Newly diagnosed asthmatic
1. Introduction:
- Introduce self, status, purpose of interview. Clarify name/age of patient.
- Establish what patient knows of condition already.
2. Explanation / Advice:
What is Asthma:
- Asthma is a reversible disease of the small airways that carry air in and out of the lungs.
- The main symptoms are cough, shortness of breath and wheeze.
- During an attack, the airways narrow and swell, and becoming sticky with mucous, making
breathing more difficult.
- An attack can last for several minutes and can be quite frightening. Normally it resolves by
itself. Attacks most commonly occur in the morning and at night.
Causes and triggers:

- FH.
- More common with atopic disease : eczema, hayfever, milk/egg/wheat allergy.
- Smokers in the house?
- Dust-mites, pollen, pets.
- Cold air, exercise.
What to do during an attack:

- Don’t panic, this may cause the symptoms to worsen.
- Recognise symptoms of respiratory distress: (tachypnoea, subcostal recession, nasal flaring).
- And when to call for ambulance: - if symptoms don’t resolve within 10 minutes, or if
respiratory drive or conscious level reduce.
Treatment:
- Relievers and Preventers.
- Salbutamol inhaler, explain spacer device for kids.
(spacer: 1 puff, then 8 breaths, then another puff and so on. Up to 8-10 puffs)
- Different age groups for different inhalers
o < 3 years - spacer with mask
o school age - accuhaler or turbohaler (click, breathe in, hold breath for ten seconds)
o 8-9 years – clickhaler (shake, breathe in, hold for 10 seconds)
- Rinse out breath after steroid use
- Hydrocortisone inhaler.
3. SCALF: Summarise. Check understanding, any Concerns? Ask questions. Leaflet. Follow-up.
See also: http://www.nhs.uk/video/pages/medialibrary.aspx?Tag=Children+and+babies+&Page=4
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1.1.1.7 Bed Wetting
1. Introduction:
What is Enuresis:
Causes and triggers:

- FH
- Too little ADH secreted by pituitary.
- Haven’t learnt to associate feeling of fullness with need to go to toilet.
- Caffeine? Drinks too late at night?
- Bladder capacity, Infection (UTI), Diabetes, Constipation, Neurogenic bladder?
Management / Treatment:
- Mum can notice straining before child (learn to relate feeling to knowing it’s time to go).
- Caffeine? Drinks immediately before bed?
- Star charts.
- Enuresis alarms ( > 7 years ). (attached to bed clothes or bed – takes 3 months).
- Desmopressin (synthetic ADH), Oxybutynin (Anti-muscarinic – relaxes detrussor if unstable).
3. SCALF
Summarise. Check understanding, any Concerns? Ask questions. Leaflet. Follow-up.
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1.1.1.8 Weaning
When to start? ~ 6 months. When baby can sit, wants to chew, putting objects in mouth, reaches and
grabs accurately. Before 6 mo. digestive system still developing - weaning too soon  risk of
infections & allergies. 3-5 mo olds wake in the night but not necessarily sign of hunger. Solids help
baby sleep. < 6 mo. extra breast or formula milk will be enough. NO Solids before four months.
How do I start?: Small amount of mashed veg., fruit etc mixed with milk after/during feed. Allow to
cool. Be patient, let baby touch food, prepare for mess. Teaspoons of food once a day mixed with usual
milk. Range of foods and textures. Don’t force it, try later. If bottle feeding, don’t add food to the milk.
First foods best to try?: Mashed cooked vegetables, fruit. Later low sugar yoghurts etc., Encourage
chewing, even if no teeth, using finger foods (eg. cooked green beans). Avoid sweet biscuits/rusks etc.
Cups?: Introduce from 6 mo. - off bottle by 1 yr. Open cup helps them learn to sip and better for teeth.
Dilute fruit juice, one part to ten parts water and only at mealtimes.
How much/how often?: Judge by appetite of baby. Once a day to two and then three feeds. Offer
variety. Groups: starchy, fruit and vegetables, protein.
Solid food and milk: Reduce milk as solids . Continue breastfeeding or 500–600ml formula/day
until 12 mo. Cow’s milk not suitable drink until 12 months old.
At 9 months: 3-4 servings of starchy food each day, 3-4 servings of fruit and vegetables. 2 servings of
meat, fish, eggs, dhal or other pulses. Full-fat dairy products.
Vitamins?: Vitamin drops with A, C and D from 1-5yrs. 6 months for breastfed babies.
TIPS: Include baby in family mealtime routine. Eating as family important. Use high chair make them
feel included. CHOKING?: Careful with hard or small round foods, skin or bones. Cut to small pieces.
Fussy eater? Praise baby when eat well don’t get frustrated or angry. Set good example. Try to
organise mealtimes for the same time every day.
Allergies  if family history. Excl. bfding for the first 6 mo. Introduce milk, eggs, wheat, nuts, seeds,
fish one at a time & look for reaction, but not before 6 mo. Avoid peanuts until 3 years. Soya-based
formulas only if GP advises. May have soya allergy. Goat’s milk formula not approved in Europe.
Foods to avoid: < 6 mo avoid wheat, gluten, (e.g. bread, rusks, cereals), eggs, fish, shellfish, nuts,
seeds, unpasteurised cheeses. SALT: Do not use stock cubes or gravy. SUGAR: Mashed banana, breast
or formula milk to sweeten food. HONEY: Don’t give until 1. can cause infant botulism. NUTS:
Avoid in < 5’s in case of choking. LOW-FAT FOODS: Not suitable for < 2s
Safety and hygiene. Keep cooked and raw meats separate & away from other foods. Food should not
be reheated more than once. Cook all food thoroughly and cool it to a lukewarm.
Healthy Start?: May be eligible. Free vouchers every week which you can spend on healthy foods.

 S – Summarise - C - Check understanding, A – Ask questions, L –Leaflet, F – arrange a Follow up
11
1.1.1.9 Neonatal jaundice
What is it?
 Skin will look slightly yellow, may be noticed in the whites of the eyes.
 Very common (>50%) usually not worrying and disappears after ~2 weeks.
 Jaundice is more common in boys and in premature babies.
 Usually caused by the liver not being fully developed and not fully functioning.
What are the symptoms

 Usually appears 2-3 days (5-7 in premature). More common in breastfed.
 Usually starts on the head and face and spreads to the chest and stomach.
 Also may have itchy skin, poor feeding, sleepiness, dark urine or pale stools.
 Get medical advice as soon as possible if you think your baby is ill.
What causes it?

 Liver removes yellow chemical, bilirubin (made from breakdown of red blood cells). Newborn
babies have more red blood cells & broken down more quickly.
 Liver not fully developed so bilirubin builds up and causes jaundice.
 Breastmilk may contain harmless substance that causes jaundice. Don’t stop. It may be a sign that
you are not breastfeeding enough.
 Rarer causes: liver disease, infection, hypothyroid, rhesus incompatibility, inherited deficiencies in
enzymes, blockages of the bowel or bile duct, and hepatitis.
Diagnosis?
 If jaundiced, baby may be kept in hospital for observation.
 Self test: Gently press fingers on the tip of your child's nose: goes yellow.
 Blood test (for serum bilirubin). If > 2 weeks further blood test for underlying disease
 Also: dark urine, pale stools (stools should be greeny-yellow). More serious signs.
Treatments?
 Usually disappears after a few weeks without treatment.
 But if not, or if stools pale or urine dark, may need treatment.
 Phototherapy: UV lamp 1-2 days. SEs rash and diarrhoea.
 Blood transfusion may be needed in severe cases.
 If infection or obstructive cause, may need surgery or drug treatment.
Complications
 Build up of bilirubin in brain can lead to kernicterus, brain damage, death.
 It is important that high levels of bilirubin are treated immediately.
Ideas Concerns Expectations Summarise

S – Summarise - C - Check understanding, A – Ask questions, L –Leaflet, F – arrange a Follow up
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1.1.2 Paediatric history
 Appropriate introduction – full name and role

 Establish who is present – i.e. is it a parent or other relative?
 Name and age of child. Where have they come from (i.e. GP or A&E etc)
 PC: “e.g. so, what’s brought you here then?”
 HPC: If pain, SOCRATES. Previous investigations and treatments. Quickly: eating, drinking,
passing urine, stools, acting normal self, vomiting, temperature
B. I. N. D. S.
 Birth history: Birth weight, length of labour, interventions, PROM, fever etc
 Prenatal history: Length of pregnancy, complications, medications, siblings
 Neonatal Hx: probs (e.g. jaundice, cyanosis, resp distress). Vit K, SCBU
 Immunizations: Any missed and why?
 Nutrition feeding method including weaning
 Developmental Hx: Key milestones, e.g. walking, speaking, toilet skills. Growth? Any concerns
about development (e.g. vision, hearing etc).
 Social history: Parental occupations, both parents at home?, housing, pets, upheaval, parents coping
OK? NAI?
 Past medical Hx: previous illnesses and infections, medications, surgery, investigations, currently
seeing anyone?
 Family Hx: Ages of parents and siblings, Illnesses in family, Deaths in the family
 Allergies: what happens?
 Systems review: Head, eyes, ears, nose, and throat. Chest: breathing, exercise, wheeze, chest pain,
coughing, previous X-rays, passive smoking. Heart, GI: appetite, weight, bowels, rectal bleeding, GU:
infection, frequency, dysuria, bedwetting, menarche, Joints & limbs, pain, swelling, weakness,
difficulty walking, Nervous system: fits, faints, funny turns, Skin: rashes etc.
 Ask if parents have red book and have a look

 Remember to thank the patient & parent(s)
 Attempt diagnosis if required
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1.1.3 Paediatric examination
1.1.3.1 Developmental exam

GM = gross motor; VFM = vision fine motor; H&S = hearing and speech; Soc = social. By the
following ages at least 50% will have achieved the following;
1½ months GM: pushes up on arms, lifts head up
VFM: Follows to midline
H&S: Responds to bell
Soc: Smiles responsively
3 months GM: Raises head 45° to 90°, rolls over, sits with support
VFM: Holds rattle, follows 180°
H&S: Laughs and squeals
Soc: Smiles spontaneously
6 months GM: Pull to sit no head lag, stands holding on
VFM: Reaches and plamar grasps, transfers
H&S: Turns to voice, turns to sound 45° upwards
Soc: Resists toy pull, feeds self cracker
9 months GM: Pulls self to stand, crawls on abdomen
VFM: Thumbs & finger grasp, bangs two cubes together
H&S: ‘Dada’ or ‘mama’ non-specific. Imitates speech sounds
Soc: Waves bye bye, plays pat-a-cake, peek-a-boo
12 months GM: Stands momentarily, cruises
VFM: Pincer grasp, casting
H&S: ‘Dada’ or ‘mama’ specific. Talks nonsense
Soc: Gives a brick, indicates wants
15 months GM: Walks well
VFM: Feeds self (messy)
H&S: says up to 5 words
Soc: Domestic mimicry
18 months GM: Jumps both feet, up and down stairs one at a time
VFM: Turms pages 2-3 at a time
H&S: about 12 words, puts 2 words together, knows 3 body parts
Soc: Points to name objects, wary of strangers
24 months GM: Kicks ball, runs
VFM: 6-7 bricks, single pages
H&S: 3-4 word sentences, 5 parts of body
Soc: helps with dressing, shoes and socks, scribbles, turns door knob
3 years Builds a bridge
Copies
  +   
At age: 2 years 3 years 4 years 5 years 6 years 7 years
Causes of developmental delay: Prenatal (genetic, metabolic e.g. phenylketonuria, teratogenic,

congenital infection, neurocutaneous syndromes e.g. tuberous sclerosis), Perinatal (prematurity, birth
asphyxia, metabolic e.g. hyperbilirubinaemia), postnatal (infection, anoxia, trauma, metabolic e.g.
hypoglycaemia)
14
1.1.3.2 Cardiovascular examination
Intro Wash hands, name, role, confirms patients agreement
Inspection General appearance (colour, pain, oedema, dyspnoea)
Positioning, Level of consciousness
Patient surroundings (GTN, O2, cigarettes, ECG)
hands Colour, temperature
Capillary Refill Time (CRT)
Clubbing, Splinter haemorrhages, Palmar creases
Osler’s nodes, Janeaway lesions, Tendon xanthoma
Tar stains, Rheumatoid signs
arm &neck Radial Pulse (rate and rhythm) & respiratory rate
Radio-radial delay
Radio-femoral delay
Collapsing pulse
Blood Pressure
Jugular Venous Pressure (JVP)
Carotids (character & volume)
face Conjunctivae (anaemia)
Sclera (jaundice)
Arcus senilis & xanthelasma
Malar flush
Mouth (Tongue - cyanosis, dentition)
Syndromes (e.g. Marfan’s,Down’s)
chest Visible pulsation / heaves
Scars (central sternotomy, mitral valvotomy)
Dilated veins
Palpation Feel for apex beat (5th ICS, MCL)
Feel for heaves, Thrills
Auscultation Patient should be positioned supine at 30. Use diaphragm;
Apex (time in with carotid pulses)
Aortic area (2nd ICS, RSE)
Pulmonary area (2nd ICS, LSE)
Mitral area (5th ICS, MCL) & with patient rolled onto left
lateral position (bell) for murmur of mitral stenosis.
Mitral regurgitation in axilla
Carotid bruits, murmur of aortic stenosis.
Tricuspid area (4th ICS, LSE) & with patient leaning forward
with breath held in expiration – for murmur of aortic
regurgitation.
Also Lung bases – auscultate and percuss
Examine for sacral and peripheral oedema
End pieces I would also like to check the peripheral pulses, perform
fundoscopy, dipstick the urine, and check for hepatomegaly
and splenomegaly if clinically relevant.
15
1.1.3.3 Respiratory examination
Examine Performed/Identified
General appearance and position of patient (including
colour)
Using O2, Nebulisers or inhalers
Sputum
↑RR? Pursed lip breathing?
Hands: Temperature
Colour
Capillary refill
Clubbing
Palmar creases
Tar staining
CO2 Tremor & Flap
Arms & Neck: Pulse check
Blood pressure
JVP
Face: central cyanosis
Note any breath odour
Check for anaemia
Chest: Check respiratory rate
Note if chest movement symmetrical
accessory muscles/intercostal indrawing
Deformities, Scars
Palpation: Examine lymph nodes
Feel trachea
Feel for apex beat
Chest expansion
Tactile Fremitus
Percussion: Correct technique
Auscultation: Comment
Vocal resonance
Whispering pectriloquy
Back: hest expansion
Tactile fremitus
Percussion
Auscultation
Vocal resonance
End pieces: perform Peak flow reading
Examine any sputum
16
1.1.3.4 Abdominal examination
General Any signs of GI disease? Stomas, special dietary foods
Patient Is the patient breathing comfortably, level of consciousness,

patient in any pain, colour
Hands “Warm and well perfused”

Leuconychia, Koilonychia, Clubbing, Capillary refill, Palmar
creases (anaemia), Palmar erythema, Spider-naevi, Dupuytren’s
contracture, Dehydration, Liver flap
Forearm Pulse, blood pressure, muscel wasting, scratching
Neck JVP, Lymph nodes
Eyes Jaundice, anaemia, xanthelasama, corneal arcus, exopthalmos,
Face Telangiectasia, spider naevi, angular stomatitis, hydration,

halitosis, dentition, ulcers, central cyanosis, glossitis
Chest Spider naevi, gynaecomastia
Abdomen Asymmetry & shape, lumps or swellings, striae gravidarium,

pulsations, distended veins, Cullen’s sign, Grey Turners sign
Palpation Check if any pain first!

Kneel down and do all 9 areas systematically whilst watching
face
Repeat using deeper palpation
Hepatomegaly, Splenomegaly, ballot kidneys, abdominal aorta
Percussion Liver, spleen, bladder, shifting dullness
Auscultation Bowel sounds – comment on normal

Aortic, renal, femoral bruits
End Pieces S – stool sample

H – hernias
R – rectal exam
U – urinalysis
G – external genetalia
17
1.1.3.5 Squint
 Appropriate introduction and explanation
 Environment
o Look around for glasses, eye patch, eye drops
 Inspection
o Normal appearance, symmetry, facies
 Acuity
o Does child wear glasses?
o Simple eye test
 Movement
o Test H pattern or similar
 Opthalmoscopy
o Red reflex
o Normal discs and retinae?
 Cover test
o Cover ‘good’ eye
o If squinting eye moves from inwards to OK then convergent squint
o If squinting eye moves from outwards to OK then divergent squint
 Points
o Most squints aren’t due to ocular disease (e.g. retinoblastoma)
o Latent squints are too difficult for med students to find so will most likely be a manifest
squint!
18
1.1.3.6 Gait examination
 Introduce self and clarify patients name and date of birth

 Explain the examination to the patient
 Ask patient if they have any problems with standing, walking, or if they have any pain
 Ask patient to dress down to underwear (or T-shirt and shorts) and remove shoes
 Ask patient to stand up and inspect posture from front and side (truncal ataxia may = midline
cerebellar lesion)
Gait
 Ask patient to walk to end of room, turn around and come back (using walking aid if necessary)
 Comment on symmetry, toe off, heel strike, and ease of turning etc.
 Ask the patient to walk heel-to-toe (like tightrope) ataxia = cerebellar or vestibular lesion
 Ask patient to stand on toes and take a few steps (S1 lesion makes this difficult)
 Ask patient to stand on heels and take a few steps (L4 / L5 lesion makes this difficult)
 Ask patient to squat (a proximal muscle weakness will make this difficult)
 If appropriate asking patient to run may accentuate findings
Station or Stance
 Stand close enough to patient to steady him or her if necessary
 Ask patient to put feet together, put hands straight out, palms upwards
 Slight swaying is normal with eyes open, but marked swaying = cerebellar or vestibular disease
 Romberg’s sign +’ve if swaying increases markedly when eyes closed ( = proprioceptive loss)
Examine shoes
 The pattern of wear on the shoes provides information about symmetry and nature of abnormalities
 Excessive lateral wear = genu varum, Excessive medial wear = genu valgum
1. 2. 3. 4. 5. 6. 7.
1 = Normal wear 5= Splay foot

2 = Pes Planus 6. = Hallux valgus
3 = Pes Cavus 7. = Hallux rigidus
4 = Also Pes Cavus
 S – Summarise - C - Check understanding, A – Ask questions, L –Leaflet, F – arrange a Follow up
(See overleaf for abnormal gaits)
19
1.1.3.7 Types of Gait
Antalgic gait: altered to reduce pain
Abnormality Causes & treatments

Trendelenberg gait: Polio, paresis of superior gluteal nerve after hip replacement,
contralateral pelvis structural problems eg congenital dislocation of the hip, pain eg
falls when weight osteoarthritis
bearing
Bow legs (genu Bowing of tibia up to 3 years (seldom needs treatment). Rickets or
varum) Blounts disease. Orthoses or surgical correction may be required.
Knock knees (genu Bilateral common usually physiological cause.
valgum) Unilateral: often pathological (eg fibrous dysplasia)
Usually resolves before the age of 6
Flat feet (pes planus) Toddlers have flat arch and fat pad usually disappears.
May be due to collagen disorder (Ehlers-Danlos synd). Arch
support provides symptomatic relief
In-toeing 1. Metatarsus varus (big toes point in no treatment usually required
unless > 5 years). 2. Medial tibial torsion (usually self corrects in 5
years), 3. Persistent anteversion of femoral neck (usually self
corrects by 8 years, femoral osteotomy may be required) .
Out-toeing Usually between 6-12 months. Lateral rotation of hips. Usually
resolves spontaneously.
Toe-walking Common 1-3 years. Mild cerebral palsy, Achilles tendon tightness,
Duchenne’s muscular dystrophy.
Hemiplegic gait http://library.med.utah.edu/neurologicexam/movies/gait_ab_08.mov
Usually due to spastic cerebral palsy, stroke, demyelination
Diplegic gait http://library.med.utah.edu/neurologicexam/movies/gait_ab_09.mov
Usually due to spastic cerebral palsy
Neuropathic gait http://library.med.utah.edu/neurologicexam/movies/gait_ab_10.mov
Diabetes, Alcoholism, HIV, Toxin exposure, Metabolic
abnormalities, Vitamin deficiency, Adverse effects of certain drugs
Myopathic gait http://library.med.utah.edu/neurologicexam/movies/gait_ab_11.mov
pelvic girdle weakness, e.g. muscular dystrophy
Choreiform gait http://library.med.utah.edu/neurologicexam/movies/gait_ab_13.mov
Huntingtons disease, antipsychotics, infections
Ataxic gait http://library.med.utah.edu/neurologicexam/movies/gait_ab_14.mov
Trauma, stroke, TIA, Cerebral palsy, MS, chickenpox,
Paraneoplastic syndromes, Tumor, Toxic reaction
Parkinsonian Gait http://library.med.utah.edu/neurologicexam/movies/gait_ab_12.mov
20
1.1.3.8 Peripheral Neurological function examination
1.1.3.8.1 Upper Limbs
General Inspection Performed/Identified

Postural abnormalities and deformities
Muscle wasting
Fasciculation
Abnormal movements
Tone Performed/Identified
Check that the patient does not have any pain before starting
Flex and extend hand at wrist
Flex and extend arms at elbow
Rotate arm at shoulder
Power Performed/Identified
Pronator drift (arms up, palms up) (UMN disease)
Shoulders – abduction
Shoulders – adduction
Elbows – flexion
Elbows –extension
Wrist – flexion
Wrist – extension
Fingers - flexion
Fingers - extension
Abduction and adduction of fingers
Abduction of thumb
Coordination Performed/Identified
Finger to nose test
Rapid alternating movements at wrist
Tendon reflexes Performed/Identified

Biceps (C5,6)
Triceps (C7)
Brachioradialis (C5,6)
Sensation Performed/Identified
Light touch posterior aspect of the shoulders (C4)
lateral aspect of the upper arms (C5)
Pain tip of the thumb (C6)
tip of the middle finger (C7)
Temperature tip of the little finger (C8)
medial aspect of the lower arms (T1)
medial aspect of upper arms (T2)
Joint position sense
Vibration (using a tuning fork of 128Hz)
See dermatomes picture 2 pages ahead
21
1.1.3.8.2 Lower Limbs
General Inspection Performed/Identified

Postural abnormalities and deformities
Muscle wasting
Fasciculation
Abnormal movements
Tone Performed/Identified
Check that the patient does not have any pain before starting
Rotate leg at hip
Flex and extend knee
Rotate ankle through full range of movement
Test for clonus (hold leg and dorsiflex foot quickly)
Power Performed/Identified
Hips – extension (L5, S1, S2)
Hips – abduction (L5, S1)
Hips – adduction (L2, L3, L4)
Hips – flexion (L1, L2, L3)
Knee – flexion (L5, S1, S2)
Knee – extension (L2, L3, L4)
Ankle – dorsiflexion (L4, L5, S1)
Ankle – plantarflexion (L5, S1, S2)
Big toe – extension (L5, S1)
Can they go up on to toes and rock back on to heels? (ask)
Can they hop? (ask)
Coordination Performed/Identified
Run the heel of one leg up the shin of the other and viceversa
Tap each foot on ground
Reflexes Performed/Identified
Knee (L3,4)
Ankle (S1)
Plantar reflex (S1,S2)
Sensation Performed/Identified
Light touch upper part of the upper leg (L2)
lower-medial part of the upper leg (L3)
Pain medial lower leg (L4)
lateral lower leg (L5)
Temperature sole of foot (S1)
Back of upper leg (S2)
Proprioception -
joint position sense
-
Rombergs (stand feet together eyes
closed - proprioception)
Vibration (using a tuning fork of 128Hz)
Observe gait
If they have a particular complaint, e.g. difficulty in writing, watch them performing this task.
22
1.1.3.8.3 Dermatomes
23
1.1.3.9 Central Neurological function examination

Inspect Face for rashes, scars, Horners, wasting, involuntary movements
I Olfactory: Any change in sense of smell?
II Optic: (very very big fat people are squidgey)
V – visual acuity
V – visual fields
B – blind spot
F – Fundoscopy
P – papillary light reflex
A – accommodation
S – sensory inattention
III, IV Occulomotor, Trochlear & Abducens: ask pt to follow “H”
& VI Start in mideline, finish in midline, check for nystagmus and
diplopia
V Trigeminal: sensory – pin prick and cotton wool

Motor – muscles of mastication
Open mouth against resistance
Corneal response (state but do not test)
Jaw jerk
VII Facial: Any change in sense of taste?
Note any abnormal face movements
Raise eyebrows
Screw up eyes
Blow out cheeks
Show teeth
Smile
VIII Vestibulocochlear: Air conduction

Rinne’s & Webers
IX Glossopharyngeal (sensory): Palatal sensation – understand but
do not elicit (also taste)
IX & X Sensoimotor: Gag reflex – understand but do not try to elicit

X Vagus (Motor): ask patient to say ‘ah’ and check uvula
movement
XI Accessory: shrug shoulders against resistance
Turn head to the right / left
XII Hypoglossal: Open mouth – tongue at rest
Protude tongue
Wobble tongue from left to right
24
1.1.3.10Apgar scoring
Appearance, Pulse, Grimace, Activity, Respiration
score
0 1 2
Colour (Appearance) All blue or white Blue limbs Pink
Pulse (P) 0 <100 >100
Reflex (Grimace) No response feeble cry when sneeze/cough/pulls
stimulated away when
stimulated
Muscle tone (Activity) absent Limb flexion Active
Respirations (R) nil Slow, irregular Strong, cry
 Do test at one and five minutes after birth

 Repeated later if the score is low.
 Scores 3 and below are generally regarded as critically low (mortality 244/1000)
 4 to 6 fairly low
 7 to 10 generally normal (mortality 0.2/1000)
 If Apgar score remains below 3 at later times such as 10, 15, or 30 minutes, risk of longer-term
neurological damage.
 Not designed to make long-term predictions on a child's health.
 Not used to decide if neonate requires resuscitation.
25
1.1.3.11 Assessment of the newborn
 Appropriate introduction and explanation

 Ask mum: pregnancy complications? Type of delivery? Gestational age at birth? Birth weight?
Feeding, urination and defecation? Any concerns?
 General inspection
o Colour, position, tone, movements, skin, breathing (resp rate < 60 pm)
 Head: palpate anterior and posterior fontanelles, measure head circumference
 Face:
o dysmorphology, patency of ears and nostrils
o red reflex and pupillary reflex
o eye movements
o rooting reflex
o cleft palate
 Chest :
o Radial and femoral pulses (100-160 bpm; radio-femoral delay = coarctation of aorta)
o Auscultate heart (bell) and lungs (diaphragm)
 Back
o Spine and sacral pit
o Position and patency of anus
 Abdomen
o Inspect abdomen and umbilical cord
o Palpate abdomen, spleen, liver kidneys
o Genitals – check for undescended testes
 Hips
o Ortolani's test - hips and knees flexed to 90 degrees, thumbs on inner side of knees, index
finger over greater trochanter, abducted hips through 90 degrees smoothly and gently,
feel/listen for a clunk (detects relocation of dislocated hip).
o Barlow test - Stabilize pelvis with one hand gripping between the sacrum and pubic
symphisis, flex knee and bring thigh in line with body, apply downward pressure. A
palpable clunk detects a dislocated hip.
 Arms, hands, feet
o Inspection (palmar crease, fingers, toes, range of movement)
 Posture and reflexes
o Head lag
o Hold baby prone and check head lies above midline
o Check for moro reflex (lift head and shoulders and drop back suddently – but supported!)
o Grasp reflex
 End pieces
o Measure and weight baby
o Reassure mum if appropriate

26
27
1.2 Obstetrics & Gynaecology
1.2.1 Information giving stations
1.2.1.1 Combination Oral Contraceptive Pill Counselling
1. Introduction:
What is COCP? How is it taken?

- It is a pill that is very effective at preventing pregnancy. 99% effective.
- Works by stopping egg release and thickening cervical mucus (↑ hostility to sperm)
- It is taken every for three weeks and then one week off. During week off withdrawal bleed
occurs. Packets may be taken back-to-back to reduce bleeding.
- Start taking on first day of next period – effective from then on.
- If you start on any other day, use condoms for the first seven days.
Side Effects and complications?
- SE: Nausea, headache, ↑ mucus, ↑ fluid / weight, ↑ bp, bleeding, breast tenderness
- Comps: Venous thrombosis, MI
- Mortality 2-5 per million for women <35yrs
- May reduce flow of milk if breastfeeding
What to do if you forget?
- If standard strength (30-35ug) – 1 or 2 missed = No problem.
- If low strength (20ug) only 1 pill can be missed.
- Take missed pill as soon as poss and continue packet as normal.
- If more missed : Use condoms for 7 days.
Caution if:
- Illness: Vomiting (within 3 hours), diarrhoea.
- Drugs: Broad spectrum antibiotics, Anti-epileptics (Phenytoin, Phenobarbitone,
Carbamezipine), some Antifungals (Giseofulvin), some Antivirals used in HIV (nelfinavir),
some OTC drugs (St. John’s Wort)
Contraindications?
- Absolute: BMI >40, >35yr smoking 15/day or more, migraine with aura, hx CVA, IHD,
severe BP, venous thrombosis, active breast/endometrial cancer.
- Relative: BMI 35-40, Smokers, >40yrs, chronic inflammatory disease, renal impairment,
diabetes, breast feeding up to 6 months postpartum.
3. SCALF
28
1.2.1.2 Progestogen Only Pill Counselling
Introduction:
Explanation / Advice:
What is COCP? How is it taken?

- It is a pill that is very effective at preventing pregnancy. 99% effective
- Works by thickening cervical mucus (↑ hostility to sperm), and inhibits ovulation in 50%
- It is taken every day. 28 per pack. No breaks unlike COCP. May still have periods.
- Must be taken at same time +/- 3 hours
- Start on the first day of your next period. Immediately effective. If you start on any other day,
use additional contraceptive methods (such as condoms) for the first two days.
Advantages over combined pill?

- Can take when breastfeeding.
- Less risks associated than COCP (e.g. blood clots).
- Can be used by over 35s, smokers, migraines, high blood pressure.
Side Effects?
- Depression, ↑ weight, acne, PMS like symptoms, breast discomfort, spotting.
- mood swings, reduced sex drive, increase in acne
What to do if you forget?

- If pill missed, take another ASAP then continue pack as normal.
- Use condoms for 2 days afterwards.
Caution if:
- Illness: Vomiting (within 3 hours), diarrhoea.
Contraindications?
- Pregnancy, Unexplained vaginal bleeding, Malignancy
SCALF
29
1.2.1.3 Emergency contraception
When should I use it?

• Following unprotected sex (or contraceptive mistake/accident) if pregnancy not desired
• Emergency contraceptive pill good chance of success within 72 hours
• IUD (coil) can be inserted up to 5 days after unprotected sex
What is it?
• Contains a progestogen hormone. (brand name is Levonelle).
When do I take it and how does it work?

• Take it as soon as possible after unprotected sex (preferably < 72 hours)
• Only use in emergencies – not as effective as regular contraception
• It either prevents or delays ovulation, or prevents fertilised egg from implanting.
• Not thought to cause an already implanted embryo to 'abort'.
How effective is it?

• Within 24 hours 95-100%, 25-48 hours 85-100%, 49-72 hours 58-100%
Side-effects?
• SEs Uncommon. Nausea & Vomiting (ake another pill as soon as possible or consider IUD).
• Abdominal pain, headache, tiredness, dizziness and breast tenderness..
Contraindications?
• Acute porphyria or current severe liver disease
Other things to note

• If your next period is more than seven days late may need pregnancy test
• Next menstrual cycle may be shorter or longer than usual.
• Small risk of pregnancy even with correct use of emergency contraceptive pill.
Follow up
• Consider regular contraceptive needs.
Safety net
• See doctor urgently if lower abdominal pain or abnormal vaginal bleeding over next 2-6 weeks.
SCALF
30
1.2.1.4 Post menopausal bleeding
 What is it?
o Vaginal bleeding after 12 months of amenorrhoea, in a woman of the age where the
menopause can be expected.
 What causes it?

o Trauma or a bleeding disorder.
o HRT
o Vaginal atrophy
o Endometrial hyperplasia; simple, complex, and atypical
o Endometrial, cervical, ovarian carcinoma
o Endometrial polyps or cervical polyps
o Carcinoma of cervix; remember to check if the cervical smear is up to date
o Uterine sarcoma (rare)
 How is it treated?
o Treat as malignant, until proved otherwise.
o Refer to a gynaecologist with an appointment within 2 weeks.
 Investigations
o Transvaginal Ultrasound Scan (TVUS), Endometrial Biopsy: definitive diagnosis
o Hysteroscopy and biopsy: detects polyps and other benign lesions.
 Is it related to drugs I am taking?

o Tamoxifen increases risk of endometrial cancer, so need to be especially careful
SCALF
Summarise. Check understanding, any Concerns? chance to Ask questions. Leaflet. Follow-up.
31
1.2.1.5 Cervical smear explanation
Explanation before a smear test
 Appropriate introduction (full name and role)
 Screening important because can stop cervical cancer from developing
 Small sample of cells from cervix, examined and abnormalities reported
 Every 3 years if 25-49, 5 yearly if 50-64. Don’t need if still a virgin.
 You can test at GP, Family Planning Clinic, GUM clinic, antenatal clinic
 You can ask for female nurse or doctor but may need to do this in advance
 Make appointment for middle of menstrual cycle
 You will need to undress from waist, lie on back with knees drawn up and apart
 Might be uncomfortable. Shouldn't hurt. Try to relax.
 May need a vag. exam where doc. or nurse puts gloved finger(s) inside vagina.
 Doc or nurse puts speculum in vagina. Has two arms that spread apart to see cervix
 Surface of cervix scraped with spatula or brush to collect sample of cells
 Your surgery may not contact you if smear is normal. But will if anything wrong.
Explaining test results
 Establishes reason for attendance
 Explains purpose of interview
 Explains results of smear test:
o 9/10 results normal. 1/20 mild changes, 1/100 moderate, 1/200 severe
o may need a repeat smear
o 'borderline' means cell changes seen but near normal probably go back to normal on their own.
Repeat smear 6 months
o Cervical erosion (ectropion). Cells normally inside cervical canal seen on cervix surface.
Common in teenagers, in pregnancy and if on pill. Can cause bleeding, esp after sex. Usually
resolves by self.
o Abnormal smear results: mild (CIN1), moderate (CIN2) and severe dyskaryosis (CIN3)
Cervical intraepithelial neoplasia = cell change. Not the same as staging1
o CIN 1 = one third of the thickness of the skin covering the cervix has abnormal cells. CIN2
2/3rds, CIN 3 = full thickness. If left untreated, cervical ca could develop
 Management
o Mild: colposcopy or repeat smear in 6 months then need 3 normal 6 monthly smears, one after
the other. Moderate or Severe: treatment necessary. CIN 3 sometimes called 'carcinoma in situ'
but NOT cancer. If smoker try to quit.
o Colposcopy similar to smear but use magnifying glass, may take biopsy
o Treatments attempt to remove abnormal cells. Laser ablation, cold coagulation, cryotherapy,
LLETZ, cone biopsy. May use local anaesthetic.
o Treatments may cause period type pains: paracetamol or ibuprofen will help.
o Piece of cervical tissue may be sent for examination under microscope.
o Bring sanitary towel as may have some bleeding or discharge for about 4 weeks
o Don’t use tampons or have sex for 4 weeks as  risk of infection.
1
Cervical cancer can only be staged from biopsy: Stage 1 - just in the neck of the womb, Stage 2 -
spread around neck of womb, Stage 3 - spread into the pelvis, Stage 4 - spread into other organs
32
 Summarise, Check understanding, Ask questions?, offer Leaflet, arrange Follow up (and explain
need for annual smears)
33
1.2.1.6 Infertility counselling

 Definition: When a couple fail to conceive after two years of trying
1/7 has difficulty, number actually infertile is relatively low.
85% conceive within 1 year, 95% within 2 years, trying > 3 years, 25% in next year
 Causes: 30% no cause identified. Women: Ovulation disorders (Premature ovarian failure, PCOS,
Thyroid problems, Chronic conditions), Womb and fallopian tubes (surgery, fibroids, Endometriosis,
sterilisation (rarely reversible)), drugs (NSAIDs, Chemotherapy, illegal drugs), Age. Men: Semen
(Decreased number, mobility, abnormal shape) may be due to testicular infection, cancer, surgery.
Ejaculation disorders, drugs (e.g. Sulfasalazine, Anabolic steroids, Chemotherapy). Both men and
women: overweight, underweight STIs (e.g. chlamydia), Smoking, certain pesticides, metals and
solvents, Stress.
 Diagnosis: See GP after one year of trying. Both partners. History: Children, Length of time trying,
sex life, contraception, Medication, Lifestyle. Female exam: BMI, pelvic exam, Further tests and
procedures: Pelvic ultrasound, Progesterone (7 days before period), Chlamydia, TFTs,
Hysterosalpingogram, Laparoscopy. Male exam: lumps, deformities, semen analysis, chlamydia.
 Treatment: Varies across the UK. Waiting lists can be long. Right to be referred for the first
investigation. NHS aims to provide 1 IVF cycle. Private treatment £4,000-£8,000 per cycle & no
guarantees.
Options:
1) Medication (eg Clomifene, Metformin, Gonadotrophins),
2) Surgery (fallopian tubes, epididymis), and
3) assisted conception (intrauterine insemination IUI – washed sperm placed in womb, success rate
15% per cycle; IVF - eggs removed and fertilised put back in.  multiple births. Eligibility for IVF:
woman between 23-39 yrs, cause for fertility problems identified, or infertility probs => 3 years. GIFT
(gamete intrafallopian transfer) egg and sperm collected, mixed then the mixture replaced in womans
fallopian tube, ICSI (intracytoplasmic sperm injection) – sperm injected into egg
4) Egg/sperm donation: Note: donors can no longer remain anonymous - child legally entitled to find
out the identity of the donor when 18.
 Complications: Ovarian hyperstimulation syndrome (OHSS), symptoms include: nausea, vomiting,

abdominal pain, bloating, constipation, diarrhoea, dark urine, severe cases can lead to thrombosis, liver
and kidney dysfunction, and respiratory distress. Potentially life-threatening condition. Ectopic
pregnancy, Multiple pregnancy, Stress
 Prevention: Diet, Folic acid, Lifestyle, health checks (eg. STIs, rubella, if history of genetic
conditions you may wish to consider genetic testing).
 Summarise, Check understanding, Ask questions?, offer Leaflet, arrange Follow up
34
1.2.1.7 Pelvic Inflammatory Disease (PID)
What is it?
 An infection of the uterus and/or fallopian tubes causing inflammation
 ~1 in 50 sexually active women in UK develop PID each year.
What causes it?

 Bacterial infection of uterus, fallopian tubes, sometimes the ovaries.
 Common (not always) cause is STI (Chlamydia most common, or Gonorrhoea)
 Non-STI causes include giving birth or insertion of IUD.
 PID may develop weeks or months after having sex with an infected person.
What are the symptoms?

 May develop slowly, quickly, or not at all. Most common pain in lower abdomen.
 Vaginal bleeding (1 in 4) e.g. heavy periods, between periods, or after sex.
 Pain during sex, abnormal discharge, fever, low back pain
Risk factors?
 Aged between 15 and 24.
 Recent change of partner. Number of partners. Previous PID (1 in 5 in 2 years).
 Recent termination, operation to uterus (e.g. D & C), IUD inserted recently.
Diagnosis?
 Cervical swab and/or urethral swab, blood tests. Laparoscopy (under anaesthetic).
Possible complications?
 Complications usually do not develop if diagnosed and treated early.
 Subfertility, scarring or damage to fallopian tubes.
 Increased risk of ectopic pregnancy (1 in 10 chance)
 Chronic pain, including pain during sex.
 Increased risk of miscarriage, premature birth, and stillbirth
 Increased risk of Reiter's syndrome (arthritis & eye inflammation - uncommon)
Treatment?
 Antibiotics: oral ofloxacin 400mg bd + oral metronidazole 400mg bd for 14 days
 If pregnant - erythromycin 500mg qd 14 days + metronidazole 400mg bd 7 days
 Finish course and do not have sex until both you and partner finished treatment.
Contact tracing?
 Any sexual partners within the past six months, men often have no symptoms
Prevention?
 Using condoms and having less sexual partners.
Further information: www.rcog.org.uk
SCALF
Summarise Check understanding, Ask questions, Leaflet, arrange a Follow up
35
1.2.1.8 Hormone replacement therapy
What is the menopause? The last menstrual period. Time around it known as the climacteric. As you
get older ovaries make less oestrogen. Average age 51 years. If hysterectomy may be earlier. If ovaries
removed likely to develop menopausal symptoms straight away.
Symptoms? Possibly none but,

Short term symptoms
- Hot flushes (3 in 4) start just before the menopause, and persist for 2-3 years. Night sweats
- Headaches, tiredness, palpitations, irritable, difficulty sleeping, depression, anxiety, aches and
pains, loss of libido
Long term
- skin drier, thinner, and more likely to itch, vaginal/vulval atrophy & dryness
- risk of osteoporosis increases, especially if menopause before the age of 45, previous fractures,
+FH, BMI < 19, steroids, smoking, vit D deficiency, sedentary, hyperthyroid, Cushings
What is HRT?
- Replaces oestrogen ovaries no longer make after menopause.
- Available as tablets, skin-patches, gels, nasal spray, or implants
- Increases risk of endometrial cancer so combined with progestogen (not if hysterectomy)
Still having periods?

- Take oestrogen every day, add in the progestogen for 12-14 days of each cycle.
- Regular bleed every 28 days, similar to light period.
- Later switch to 'continuous combined HRT' which usually causes no bleeding
Year or more after periods stopped?

- Continuous combined HRT'. - oestrogen and a progestogen every day.
- Usually do not cause a monthly bleed. May get spotting or mild irregular bleeds.
Benefits of HRT?
- Menopausal symptoms usually ease but can take up to a year
- If HRT over several years, protect against osteoporosis and bowel cancer. Effect is small.
Risks in taking HRT?

- DVT (over five years is 7/1000 vs 3/1000)
- Breast cancer - for every 1000 women on HRT for 10 years, there are 19 extra cases. When you
stop, risk falls back to the normal within a few years
- Stroke (>5 yrs 4 vs. 3 in 1000). Heart disease. Extra 8 heart events in every 10,000
- Uterine cancer. Reduced by progestogen . Cancer of the ovary if oestrogen-only for > 5 years.
Side-effects?
- Nausea, breast discomfort, leg cramps, headaches or migraines, dry eyes
Other points
- Still use contraception. Contraindicated if severe liver disease, or cancer of the uterus or breast.
Summarise, Check understanding, any Concerns?, Ask questions, Leaflet, Follow-up.
36
1.2.1.9 Endometriosis
What is it? Endometrial tissue (normally lines womb) is found outside the uterus –e.g. pelvic area
(near ovaries), lower abdomen (bowel), and rarely in other areas in the body (eg lungs).
What causes it? Exact cause unknown. Endometrial cells may get into pelvic area during a period.
These cells then respond to oestrogen each month, multiply and swell, and break down but cannot
escape. Endometriosis may form adhesions, e.g. bladder or bowel may 'stick' to the uterus. Patches of
endometriosis may form cysts which bleed and can form 'chocolate cysts' (filled with dark blood).
• Runs in families • Rare past menopause • Oral contraceptive pill reduces risk.
How common is it? May be asymptomatic so estimates vary: 1 in 10 to 5 in 10
What are the symptoms? Many asymptomatic. Generally, bigger patches = worse symptoms.
• Painful periods. • Painful sex. • Pain in lower abdomen and pelvic area. • Bleeding in between
periods. • Reduced fertility. • Uncommon symptoms: pain passing faeces or urine, blood in the urine
or faeces. • Very rarely, endometriosis in other sites causes pains at the same time as period.
How is it diagnosed? Usually confirmed by a laparoscopy.
Prognosis? If untreated, becomes worse in 4/10 cases, better in 3/10 cases. Not cancerous.
Complications include obstruction of the bowel or of the ureter. If treated may reoccur.
Treatments? • Not treating is option if mild. • Painkillers.

• Hormone treatments reduce oestrogen and may gradually shrink or clear endometriosis. But do not
help fertility. May last several months.
• Combined pill not licensed but may improve symptoms by reducing oestrogen
• Intrauterine system (IUS) (Mirena®) contains progestogen that makes endometrium thinner.
• GnRH analogues are drugs that block the pituitary from releasing gonadotrophins. May be
taken as a nasal spray or injection. Six month course. Side-effects include hot flushes, dry
vagina, reduced sex drive, headaches, difficulties with sleeping, periods stop. HRT may stop
side-effects.
• Progestogen hormone tablets reduce effect of oestrogen causing cells to 'shrink'. Side-effects
include: irregular menstrual bleeding, weight gain, mood changes, and bloating.
Note: Use condoms whilst taking hormone treatments (apart from 'the pill' and IUS which are
contraceptives) as risk that hormone treatments may affect a developing baby..
• Surgery: usually laparoscopic using direct heat, laser, or gas to destroy patches of
endometrium or remove cysts. May help fertility. Other option is hysterectomy/removal of
ovaries - high success rate.
Pregnancy? Chance of reduced fertility increase with time. Symptoms may improve during pregnancy.
Further information? www.endometriosis-uk.org
37
1.2.1.10Urodynamics interpretation
P = Pressure, GSI = Genuine Stress Incontinence, BO = Bladder Overactivity
1.2.1.11 Genuine Stress Incontinence (GSI)
 What is incontinence?
o About 2 in 100 adults, more common in older women, 1 in 5 women > 40 to some degree
o Bladder is muscle that stores urine. Expands as fills with urine.
o Outlet (urethra) normally closed, helped by pelvic floor muscles
o Normally messages between brain, bladder, and pelvic floor muscles tell you how full
bladder is, and which muscles to contract or relax.
 Stress incontinence = leak when extra pressure on the bladder
o Tends to happen when cough, laugh, or exercise
 Causes
o Weak pelvic floor muscles due to childbirth, increasing age (esp after menopause), obesity.
 Treatment options
o Pelvic floor exercises (PFEs) - squeeze muscle above entrance to anus. Imagine trying to
stop from urinating. Do at least 3x every day. Improves 6/10. Other things that may help =
electrical stimulation, biofeedback, vaginal cones.
o Surgery: Tension free vaginal tape-day case surgery 2 small abdo cuts and 1 vaginal cut. 80-
90% cure at 5yrs
o Medication: Duloxetine works by helping the muscles around the urethra to contract + PFEs
 Lifestyle measures
o Incontinence pads, environment (access to toilet), losing weight, stop smoking
(See overleaf for Urge Incontinence)
Further information? www.bladderandbowelfoundation.org
38
1.2.1.12 Urge Incontinence
 What is incontinence?
o About 2 in 100 adults, more common in older women, 1 in 5 women > 40 to some degree
o Bladder is muscle that stores urine. Expands as fills with urine.
o Outlet (urethra) normally closed, helped by pelvic floor muscles
o Normally messages between brain, bladder, and pelvic floor muscles tell you how full
bladder is, and which muscles to contract or relax.
 Urge incontinence = sudden urgent desire to pass urine not able to put off
o aka 'unstable' or 'overactive' bladder, or 'detrusor instability'.
o pass urine more often than normal, during sex, on orgasm
o 2nd commonest cause. Women > men
Causes? Not fully understood. Bladder muscle becomes overactive & sends wrong messages to brain
o Exacerbated by: Stress, caffeine, alcohol
o May be caused by nerve/brain damage
o UTI or bladder stones
Treatments?
o Lifestyle measures:
o Make toilet access easier
o Avoid/limit caffeine & alcohol
o Drink normal quantities of fluids (~2 litres/ day)
o Go to toilet only when you need to
o Lose weight if overweight
o Bladder training: keep a diary with amounts; after 2-3 days try to gold on for as long as
poss by distracting self; keep up with diary – aim for passing urine only 5-6 times in 24
hours
o Pelvic floor exercises
o Medication
o antimuscarinics (oxybutynin, tolterodine, trospium chloride, propiverine etc) work by
blocking nerve impulses to bladder thus relaxing it and increasing capacity.
o Rarely completely successful on its own.
o Side effects: dry mouth, dry eyes, constipation and blurred vision.
o Surgery rarely used
o Sacral nerve stimulation (bladder implant)
o Augmentation cystoplasty: tissue from intestine to increase size of the bladder. May need
catheter.
o Urinary diversion. ureters routed outside body. If all other options failed
o Botulinum toxin A injected into sides of bladder. damps down contractions. May need
catheter
 Further info: www.bladderandbowelfoundation.org
39
 Summarise, Check understanding, any Concerns?, Ask questions, Leaflet, Follow-up.
40
1.2.1.13 Heavy menstrual bleeding / Menorrhagia
What is a normal/heavy period?

 1 in 3 women describe periods as 'heavy'. Difficult to compare.
 Normal period between 20 and 60 ml (4-12 teaspoonfuls). Lasts up to eight days, average five
 Heavy period > 60ml or more. Half a teacupful. Difficult to measure;
 Flooding through to clothes or bedding.
 Need frequent changes of sanitary towels or tampons.
 Need double sanitary protection (tampons and towels).
 Passing large blood clots
 Teenagers - more common in the first few years
What is Menorrhagia? - heavy periods that recur each month & interferes with quality of life.
What causes it? - unknown in most cases:

 'dysfunctional uterine bleeding'.
o Normal uterus and ovaries. Not hormone related. Ovulation usually normal, periods regular.
o High prostaglandin levels may may reduce clotting in uterus, bleeding continues for longer
 Fibroids - benign growths in uterine muscle.
 Endometriosis, infections, polyps, sterilization, endometrial cancer (uncommon, usually > 40 yrs)
 Hormone problems. Eg polycystic ovary syndrome, hypothyroid gland
 IUD, Warfarin, chemotherapy , blood clotting disorders (rare), stopping contraceptive pill
Investigations? - Internal examination, blood test (anaemia), keep a menstrual diary - record the
number of towels/tampons & days bleeding.
Is it cancer?
 Risk factors: > 40 years, never had children, family history, tamoxifen, bleeding between periods,
during or after sex, pain apart from period pains,
 May need: ultrasound scan to detect fibroids, polyps, etc
 Swabs if infection suspected, Endometrial sampling. (by gentle suctioning), Hysteroscopy
(telescope passed into the uterus)
Treatment options?
 Not treating, but giving iron supplements
 Levonorgestrel intrauterine system (LNG-IUS) progestogen thins lining of uterus. Lasts 5 years
 Tranexamic acid tablets: almost halves blood volume, but not pain or duration. Take during period.
Side-effect include upset stomach.
 Anti-inflammatories: eg ibuprofen reduce blood loss by third but not duration. GI disturbance
 The contraceptive pill reduces bleeding by 1/3rd often helps pain
 Progestogen, e.g. injection, implant: up to half have no periods after 1 year.
 Norethisterone: progestogen taken on days 5-26 of the cycle. Side-effects bloating, fluid retention,
breast tenderness, nausea, headache and dizziness. Also used as emergency treatment
 Surgery: Endometrial ablation or resection, Hysterectomy
Further info: www.womens-health-concern.org
41
42
1.2.1.14 Explanation of hysterectomy
What is it?
 Removal of the uterus by an operation. May wish to draw diagram
Why do I need one? – Variety of possible reasons

 Heavy or very painful periods when other options have failed
 Fibroids (abnormal muscle growths), Prolapse, Endometriosis, Cancer
 Usually last resort
Types of hysterectomy
 Total hysterectomy: uterus and cervix removed. Ovaries usually left. If removed this a bilateral
salpingo-oophorectomy (BSO).
 Subtotal hysterectomy uterus removed but cervix left.
 Radical hysterectomy: womb, cervix, fallopian tubes and ovaries, part of the vagina and lymph
glands are removed. This is done for cancer.
How is it done?
 Through a cut in the abdomen (scar) or through vagina (no visible scar). Keyhole (small scars).
Will my ovaries be removed?

 Removal of healthy ovaries not recommended - reduces risk of ovarian cancer but increases risk of
heart conditions
 If removed may require HRT as premature menopause
 If ovaries not removed, still 1 in 3 chance of menopause within 2 years
Will it affect my sex life?

 Usually not, may make it better! Should not affect sex drive unless ovaries removed
 But some report changed orgasm/difficulty reaching orgasm.
 Usually begin to have sex again in 6 weeks. No longer need contraception
What happens after the operation?

 Given painkillers, able to eat and drink within a few hours. May need catheter
 Light bleeding can last up to six weeks. Stitches usually removed after a week
 Likely to need rest; build up exercise gradually.
 Recovery usually takes 6-8 weeks but some report 3 months
 Don’t drive until can do emergency stop usually 6 weeks
Cervical screening tests? – Yes, if subtotal hysterectomy or a hysterectomy because of cancer
Further information: www.hysterectomy-association.org.uk
43
1.2.1.15 Induction of labour/ Management of post dates pregnancy
What is induction of labour? – labour started artificially
Why might I need it?

 Avoid prolonged pregnancy (>42 weeks) (70%) or waters break but no labour after 24 hours.
 Offered after 41 weeks
 Risk of stillbirth increases after from 3/3000 at 42 weeks to 6/3000 at 43 weeks.
 Offered if pregnancy is complicated by diabetes before term.
 Offered to women with premature rupture of membranes after 37 weeks
 Also: fetal growth retardation, hypertension and pre-eclampsia, cardiac abnormalities requiring
immediate surgery
Contraindications?
 Absolute: Severe placenta praevia, transverse lie, severe cephalopelvic disproportion, Cervix <4 on
bishop's score
 Relative: Active primary genital herpes infection, risk of cord prolapse
Before induction?
 Membrane sweep (~40 wks): finger placed into the cervix and circular, sweeping movement to
separate the membranes that surround the baby. May cause discomfort, pain or bleeding
What happens during induction?

 Baby’s heartbeat checked using sensors on abdomen. Cervix examined (bishops score >6 preferred)
 Prostaglandins inserted into the vagina as a gel, tablet or pessary
 Cervix re-examined after 6 hours. More prostaglandin may be used
 Baby’s heartbeat checked again when contractions begin.
 Oxytocin with/ or without artificial rupture of membranes may be offered
 Induced labour may be more painful than spontaneous labour.
Possible Complications?
 Failure – needs C-section
 Uterine hyperstimulation; fetal distress and hypoxic damage to the baby
 Uterine rupture, especially in multiparous women
 Intrauterine infection with prolonged membrane rupture without delivery
 Prolapsed cord can occur with first rush of amniotic fluid, if presenting part not well engaged
 Amniotic fluid embolism
 1.5x increased risk of operative vaginal delivery and 1.8x increased risk of caesarean section
Further information: www.nct.org.uk
44
1.2.1.16 CTG interpretation
Discuss each of the following CTGs (see more details overleaf)
1
2
4
3
DR C BRAVaDO (Normal heartrate 110-160)

Define Risk, Contractions, Baseline Rate, Accelerations, Variability, Decelerations, Overall picture
1 2 3 4
C- every 3-4 minutes C- every 2-3 mins C- every 3-4 minutes C- every 3-4 mins
BR – 120bpm BR – 145-150bpm BR – 120 ish BR – >160 (tachycard)
A – hard to say A – none A – with contractions A – none
Va – abnormal (> 25) Va – normal (5-25) Va – normal (5-25) Va – abnormal
D – late & early D – early deceleration D – none D – late (worrying)
O – foetal distress – O – normal, decal. O – normal O – foetal distress
foetus is dying synch. with contraction
45
46
1.2.1.17 Bleeding and pain in early pregnancy
What does vaginal bleeding and pain mean?

 Common and not always a problem, but can be warning sign of miscarriage.
 Ectopic or molar pregnancy (abnormal placenta) may be cause but uncommon
What tests can I expect?

 Asked about your symptoms, the date of your last period and your medical history.
 A sterile speculum examination - will not cause miscarriage
 Urine sample to confirm a positive pregnancy test.
 Chlamydia
 Blood test(s): blood group and/or pregnancy hormone levels.
 If Rh (rhesus) negative may be given anti-D immunoglobulin injection.
 Ultrasound scan: transvaginal or transabdominal
What are the possible outcomes?

 Threatened miscarriage – bleeding or cramping in a continuing pregnancy.
 Incomplete miscarriage –some pregnancy tissue left inside the womb.
 Complete miscarriage – womb is empty.
 Delayed miscarriage/missed miscarriage/silent miscarriage – pregnancy stopped developing but
still inside the womb.
What is an early miscarriage?

 Loss of pregnancy in the first three months
 One in five (20%) risk of having a miscarriage in the first three months.
 Still good chance of having a successful pregnancy in the future.
Further information: www.earlypregnancy.org.uk
47
1.2.1.18 Intra Uterine Growth Restriction
 Appropriate introduction – full name and role. Explain purpose of interview
 Find out what the patients already knows/understands
 Explain IUGR: Baby's growth slows or ceases when in it is in the uterus. May be small for
gestational age (failed to achieve their growth potential) or constitutionally small (Mother small,
foetus small)
 Explain possible causes:

- Maternal:  maternal age, hypertension, heart disease, diabetes, alcohol (eg FAS), other drugs
(inc cannabis), smoking (30 to 40%) renal disease, thrombophilia, medicines (eg warfarin,
steroids).
- Placental: small placenta insufficient nutrition, placental apoptosis, pre-eclampsia (BP,
proteinuria).
- Fetal causes: multiple pregnancy (twins IUGR in 15 to 20% of cases), chromosomal
abnormalities (inc Down's, Edwards', Patau's, Turner's), congenital defects, intrauterine
infection (eg. cytomegalovirus, toxoplasmosis, rubella, syphilis). Sometimes no cause is found
 Explain how it is diagnosed - Palpation only detects ~30%. Ultrasound - IUGR criteria include:
elevated femoral length:abdominal circumference(AC) ratio, elevated head circumference(HC): AC
ratio, unexplained oligohydramnios (amniotic fluid < 5 cm).
 Explain management: enquire about foetal movement

 Keep a kick chart
 Foetal monitoring required
- Regular CTGs (daily),
- Dopplers (1-2 weekly),
- Repeat growth scan in 2 weeks (inpatient or outpatient)
 Need for BP and urine checks
 May require early delivery if foetal concern
- steroids < 36 weeks for lung maturity
- prognosis good after 34 weeks
 Possible complications
- RDS
- Feeding difficulties
- Hypothermia
- Major complications rare (intrapartum asphyxia, hypoglycaemia, impaired neurodevelopment,
meconium aspiration, intrauterine death)
- If birth weight low, may be at increased risk of later developing coronary artery disease,
hypertension, type 2 diabetes, and autoimmune thyroid disease.
48
1.2.1.19 Pre-eclampsia
What is pre-eclampsia? - Usually occurs after 20th week of pregnancy.

 Causes high blood pressure, protein leaks from kidneys into the urine
 Severity varies. May affect the mother, the baby, or both.
 Any pregnant woman can get pre-eclampsia. Occurs in ~1 in 14 pregnancies.
What is eclampsia? - A type of seizure - a life-threatening complication of pregnancy. ~1 in 100

women with pre-eclampsia develop eclampsia.
Risk factors?
 Pregnant for the first time, or first time by a new partner.
 Have had pre-eclampsia before, Family history, Particularly mother or sister
 High blood pressure before pregnancy
 Diabetes, systemic lupus erythematosis (SLE), or chronic kidney disease.
 Aged below 20 or above 35, Multiple pregnancy, Obesity
What causes pre-eclampsia? - Not known. Possibly partly genetic. Thought that placental blood
vessels do not develop properly, affecting transfer of oxygen and nutrients to baby.
How is pre-eclampsia detected?

 If blood pressure high (> 140/90), and abnormal amount of protein in urine (>300mg in 24hr).
 BUT many pregnant women have mild high blood pressure. Most do not have pre-eclampsia.
 ~1 in 5 pregnant women with high blood pressure progress to pre-eclampsia.
Symptoms of pre-eclampsia?
 May have no symptoms
 Headaches, Blurring of vision, or other visual problems, Abdominal pain (mainly upper), Vomiting,
General Malaise. Swelling of feet, face, or hands but also common in normal pregnancy.
Possible complications of pre-eclampsia? - Most do not develop serious complications.

 For the mother : Eclampsia, Liver, kidney, and lung problems, A blood clotting disorder, Stroke,
Severe bleeding from the placenta, HELLP syndrome (1 in 5 severe pre-eclampsia). HELLP stands
for 'haemolysis, elevated liver enzymes and low platelets'
 For the baby: IUGR, stillbirth
What is the treatment for pre-eclampsia?

 Only complete cure is delivery. After the birth, symptoms usually settle.
 Induced labour if late in the pregnancy. C- section if necessary. Need to balance risks
 Magnesium sulphate halves risk of pre-eclampsia -> eclampsia. Given around delivery.
 Antihypertensives. Rest, although poor evidence. Hospital admission for observation
 Will pre-eclampsia develop in my next pregnancy? - 1 in 10 chance of recurring
 Further info: Action on Pre-EClampsia www.apec.org.uk
49
1.2.1.20 Gestational diabetes
What is it?
 Blood sugar is high because of insulin resistance or insufficiency
 During pregnancy, hormones block some insulin action to ensure baby gets enough glucose
 Body needs more insulin to cope with changes, GD develops when body can't meet extra demand
 Usually begins in second half of pregnancy, and goes away after birth.
 If it doesn't go away you may already have had diabetes
What are the symptoms? - May be none

 Increased thirst, increased urination, tiredness - But also common symptoms in normal pregnancy.
Is it dangerous?
 Higher risk of pre-eclampsia, premature labour, polyhydramnios, future GD and type 2 diabetes
 Large baby, delivery difficult, caesarean delivery
 Baby may get hypoglycaemia (overcompensating with insulin) – needs regular checks
 Baby may get jaundice but usually fades without treatment.
 Increased risk of congenital problems, such as a heart defect, RDS may need ventilated
 Slightly higher chance of stillbirth or death (rare)
 Increased risk of childhood obesity
Causes of gestational diabetes - Increased risk if:

 Family history of gestational diabetes (ie mother, grandmother or sister)
 Previous large baby (weighing over 4.5kg/9lb 14)
 Previous stillbirth, Overweight or obese, PCOS
Diagnosis of gestational diabetes - Glucose tolerance test, in morning, after fasting
Treatment of gestational diabetes

 More frequent antenatal appointments
 Regular testing of your blood sugar, carefully planned diet and keeping active.
 May need daily injections of insulin – watch out for hypos (paleness, shaking, hunger, sweating).
 Let family and friends to know what to do if you have hypo.
After baby is born

 Monitor the blood sugar levels of you and baby
 Best to breastfeed your baby within one hour of delivery.
Prevention of diabetes
 Eat a balanced diet, take regular exercise and maintain the correct weight for your height.
Further information: www.diabetes.org.uk
50
1.2.1.21 Miscarriage counselling
What is a miscarriage?
 The loss of a pregnancy at any stage up to the 24th week. After this time is stillbirth.
 Most occur before 13 weeks
 ~ 1 in 7 confirmed pregnancies. May be as many as 1 in 4 pregnancies (unaware of pregnancy)
 Vast majority have a successful pregnancy next time.
 Recurrent miscarriages occur in ~1 in 100 women.
What causes miscarriage?

 Most early miscarriages may be due to 'one-off' chromosome fault.
 Less common: hormonal imbalance, uterus abnormalities, cervix weakness and infections
e.g.listeria and rubella.
 Alcohol abuse, cigarette smoking, illicit drug use, obesity, caffeine (>200mg)
Misconceptions
 Not caused by lifting, straining, working, constipation, straining toilet, stress, worry, sex, eating
spicy foods, or normal exercise.
What is a 'threatened miscarriage'?

 Light vaginal bleeding sometime in the first 12 weeks of pregnancy.
 Often the bleeding settles and the growing baby is healthy.
 If the pregnancy continues, there is no harm done
What are the symptoms of miscarriage?

 Vaginal bleeding and lower abdominal cramps. 'Tissue' passed from the vagina.
 In some cases there are no symptoms. Baby dies but remains in uterus - 'missed miscarriage'.
 Severe, sharp, or one-sided abdominal pain, may suggest ectopic pregnancy – Emergency!
Treatment?
 Little evidence that an operation is needed in most cases.
 Operation/medicine to clear the uterus option if the bleeding does not stop or if possible infection.
Feelings
 Feelings of shock, grief, depression, guilt, loss, and anger are common.
 Best not to 'bottle up' feelings but to discuss them as fully as possible
 As time goes on, the sense of loss usually becomes less.
Further info: The Miscarriage Association www.miscarriageassociation.org.uk
51
1.2.1.22 Analgesia in labour
 Pain increases with advancing labour, do not feel failure if required

 Presence of trusted member of family or friend helps with pain
Options:
 Epidural analgesia
o Injection of a local anaesthetic close to the nerves that transmit pain.
o Most effective way of relieving pain in labour - complete relief in 95% of cases.
o No need for more analgesia/general anaesthetic if instrumental or caesarean required.
o No increase in perineal trauma and pelvic floor muscle weakness.
Disadvantages:
o Dizziness or shivering may occur
o It increases length of 2nd stage, and rates of operative vaginal delivery.
o Transient hypotension occurs in 20% women
o Greater levels of monitoring of mother and child required
o Dural tap in 1% women causing severe headache in 50%.
o Not available in the community
 Combined spinal-epidural
o Faster onset of pain relief, however CSE women experience more itch.
o No difference in incidence: forceps delivery, caesarean section or neonatal admission
 Nitrous oxide and oxygen (Entonox)

o 50:50 mixture inhaled during painful contractions during 1st and 2nd stages of labour
o Under patient's control, works within seconds and wears off quickly with no side-effects.
o Half of women obtain satisfactory relief.
o Generally considered safe, but case of severe hypoxaemic episode
 Intramuscular opiate
o Intramuscular opiate - Pethidine IM - effective in 15 mins lasts 2-3 hours.
o May work by reducing anxiety and discomfort.
 Local analgesia
o Used if no epidural but require forceps or vacuum extraction delivery.
o Also for repair of episiotomy or perineal tear.
 Transcutaneous electrical nerve stimulation (TENS)

o Applies controlled mild electrical stimulation to the skin by means of electrodes.
o May block pain impulses, stimulate the body to produce natural endorphins.
o Poor evidence, but high patient satisfaction
 Complementary therapies
o Acupuncture & self-hypnosis may be useful
o Water birthing may help
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53
1.2.1.23 Explanation of malposition / malpresentation
 Three types a) Frank b) Flexed c) Footling

o Extended legs (frank) - 85% cases
o Fully flexed legs (flexed)
o Footling 1 or both thighs extended
 Higher perinatal mortality and morbidity
due both to pre-existing congenital
malformation and increased risk of
intrapartum trauma or asphyxia.
 Caesarian now normal mode of delivery
for term breech presentations as reduces
the risk of birth-related complications.
Epidemiology
 15% at 30 weeks, 6% at 35 weeks and 3-4% at term. Majority turn by 36 weeks.
 Lax uterus, Uterine anomalies or tumour, placenta praevia, abnormal pelvic brim
 Maternal smoking, diabetes, fetal malformation (eg hydrocephalus)
 Multiple pregnancy, polyhydramnios or oligohydramnios
 Low birth weight, previous breech delivery
Presentation
 Prior to 32-35 weeks, the diagnosis is of no clinical significance.
 Subcostal tenderness, ballottable head in the fundal area, softer irregular mass in the pelvis
 Fetal heartbeat loudest above the umbilicus, sacrum, anus or foot palpated through the fornix.
Investigations
 Confirmed by ultrasound may reveal fetal or uterine abnormalities predisposing to breech.
Management
 RCOG currently recommend External Cephalic Version @ 37-42 weeks
 Success rates of ECV vary between 46 to over 80%. Adverse outcomes rare
 ECV requires continuous fetal monitoring, ultrasound and emergency caesarean available
 If fetal heart rate falls below 90 bmp, attempt should be abandoned.
Mode of delivery
 C-section recommended. 6% of breech have a vaginal breech delivery as present too late
Complications of vaginal delivery

 Premature rupture of membranes and premature labour
 Cord prolapse, Asphyxia due to cord compression and placental separation
 Intracranial haemorrhage, Traumatic injuries including fractures, brachial plexus injury
Follow-up
 Increased risk of congenital dysplasia of the hip – CDH. Pay extra attention on examination
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1.2.1.24 Explanation of caesarean section
What is a caesarean section?

 Baby delivered by cutting through front wall of the abdomen to open womb.
 ~20% of babies born in UK because of potential/urgent risk to mother or baby.
 Can be: planned (medical need), emergency, or elective procedure (personal choice)
Why might I need one?

 Failure to progress with the labour, breech presentation, previous caesarean
 Emergency lifesaving procedure
 Severe pre-eclampsia (pregnancy-related high blood pressure),
 Baby not receiving enough oxygen, and quick vaginal delivery not possible
 Multiple births, Cephalopelvic disproportion, Placenta praevia
 Genital herpes, HIV - Caesarean reduces chances of baby becoming infected
 Premature labour - may prevent possible trauma to delicate head
 Medical condition – e.g. heart problem, diabetes, which would put the mother at risk
 Women over 35 more at risk of BP, gestational diabetes, placenta praevia
How it is performed?
 Usually takes 30-45 minutes to perform
 Horizontal incision along bikini line & wall of your womb. May be vertical in emergency
 Operation may be performed in subsequent pregnancies, if necessary.
 General, spinal or epidural anaesthetic. Placenta also removed.
 Wall of your womb is swabbed and closed with dissolving stitches.
Recovery
 Longer than vaginal delivery. Should be able to get out of bed fairly soon.
 In the first few weeks try to get as much rest as possible.
 Avoid walking up and down stairs but take gentle walks daily to reduce risk of blood clots
 Takes about six weeks for all tissues to heal completely.
 May need help, especially in the days immediately after birth, e.g. do not drive for a few weeks
Future deliveries
 Subsequent deliveries won’t necessarily require the operation.
 Future labours will not be allowed to go on for too long, as risk of scar opening
 Emergency Caesarean section may be necessary.
Risks
 Still major abdominal surgery, and carries a certain amount of risk
 Infection, endometritis, decreased bowel function, thrombosis, bleeding, bladder problems
 Baby may have temporary breathing difficulties (transient tachypnea) usual complete recovery
within 2-3 days.
 Very small risk of death (you and your baby). Three times greater than vaginal.
End pieces
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1.2.1.25 Ectopic pregnany
What is Ectopic Pregnancy?

 A pregnancy outside the uterus. Ectopic means 'misplaced'.
 Normally sperm combines with ovum in fallopian tube and is 'wafted' along to the uterus.
 Normally attaches to inside uterus, most ectopic pregnancies attaches to fallopian tube
 Rarely in other places such as ovary abdomen.
What are the problems with an ectopic pregnancy?

 Tubal ectopic pregnancy never survives. About half die after a few days.
 If pregnancy grows it will rupture the fallopian tube causing internal bleeding and pain.
What are the symptoms of an ectopic pregnancy?

 Typically develop around 6th week ~ (2 weeks after missed period) but poss 4-10 weeks
 Pain on one side of lower abdomen. vaginal bleeding, diarrhoea, feeling faint, or pain on passing
faeces, shoulder-tip pain (due to blood in abdomen irritating diaphragm).
 If the fallopian tube ruptures severe pain or collapse – Emergency! Sometimes no warning.
Risk factors?
 Previous ectopic - 1 in 10 chance that a future pregnancy will be ectopic.
 Damaged fallopian tube: PID (chlamydia or gonorrhoea), previous sterilisation operation.
 Surgery, endometriosis, intrauterine device (rare), assisted conception, > 40 years, smokers
Diagnosis
 +’ve Pregnancy test, transvaginal ultrasound – may need repeating
 Certain changes in hCG levels
Treatment options?
 Emergency surgery needed if fallopian tube ruptures
 Removal of the tube (either whole or part) laparoscopically - even if one removed, still have 7 in 10
chance of having a future normal pregnancy.
 Medical treatment more common - methotrexate injection kills cells
o Only advised if the pregnancy is very early.
o Need close observation for several weeks, repeated blood tests and scans
o hCG checked every 2-3 days until the levels are low.
o Side-effects include nausea and vomiting, abdominal pains
 Wait and see if not life threatening – may resolve by self (similar to miscarriage).
 If Rhesus negative, need anti-D immunoglobulin prevents production of antibodies
 Common to feel anxious or depressed for a while after treatment. Talk about concerns
Further advice: The Ectopic Pregnancy Trust www.ectopic.org.uk
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1.2.1.26 Management of twin/multiple pregnancy
What is a Multiple Pregnancy?

 Two or more ova = dizygotic (non-identical); single fertilised egg = monozygotic (identical)
 Dizygotic – have own placenta, amnion and chorion, Monozygotic: different possibilities
Epidemiology
 Twins: 1 in 90 pregnancies (approximately 1/3 monozygotic), triplets 1 in 8100. IVF has 
Predisposing factors
 Previous, FH (maternal side),  maternal age,  West African,  Japanese, assisted conception
Presentation
 First trimester ultrasound. Some twins die and are absorbed in the first half of pregnancy.
 Hyperemesis and exaggerated pregnancy-related symptoms. Uterus may be palpated early.
 2nd half pregnancy: large-for-dates,  weight gain, > 2 fetal poles and/or heart rates.
Management
 Nuchal translucency assessment @10-14 weeks identifies high risk of trisomy.
 Amniocentesis and chorionic villi sampling (CVS) problematic but same risk
 Selective termination in monochorionic pregnancies risks other twin
Antenatal care
 Referred to obstetricians & booked to deliver in hospital with SCBU.
 Regular scanning to monitor growth and well-being. Mother monitored more closely too
 Twin-twin transfusion or IUGR: Management: laser surgery of placental anastomoses before 26
weeks; intrauterine blood transfusions, serial amnioreduction or elective delivery.
 Early delivery induced in growth cessation and/or poor Doppler blood flow.
Intrapartum care
 Presentation: both cephalic (45%), 1st cephalic (25%), 1st breech (10%)
 Vaginal delivery: OK if 1st is cephalic, but caesarian or instrumental more likely
Complications
 Foetal: Smaller babies, esp monozygotic; Prematurity - twins average 37 weeks, triplets 31 weeks.
 Congenital abnormalities (x2-4), Cerebral palsy: twins (1-1.5%) and triplets (7-8%).
 Perinatal mortality: twins (x5), triplets (x6).
 Maternal: hyperemesis, polyhydramnios, pre-eclampsia, anaemia, antepartum haemorrhage.
 Malpresentation, vasa praevia, cord prolapse, premature separation of placenta, cord entanglement,
postpartum haemorrhage.
 Developmental: developmental delay, behavioural problems and parent-child interaction probs
 Non-medical financial, social and emotional consequences
Prevention? (only if asked about?) - Limit embryos in IVF, Multifetal pregnancy reduction
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1.2.1.27 Premature delivery
What is prematurity?
 Baby born before 37 weeks from the first day of the last menstrual period ~10% in UK
Risk factors:
 Induction or caesarean due to: pre-eclampsia or abruptio placentae.
 Multiple pregnancy
 polyhydramnios.
 cervical incompetence
 Low socio-economic status, inadequate or absent antenatal care and poor maternal nutrition
 Low body mass index and periodontal disease
 African-American and Afro-Caribbean x2-3
 Smoking, alcohol, heroin withdrawal / reduction of methadone, cocaine
 Maternal age under 17 or over 35 years old.
 Bacterial vaginosis
Complications
 Hypothermia, hypoglycaemia, convulsions (brain damage)
 Respiratory distress syndrome (Steroids before delivery)
 Too high oxygen: retrolental fibroplasia and blindness.
 Neonatal jaundice and kernicterus (brain damage)
 Infection and to necrotising enteritis
 Brain haemorrhage with serious long term effects.
Getting support
 Having baby in SCBU may be emotional and traumatic - visit and stay as much as possible.
 Breastfeeding difficult but best food especially premature babies. May need fortification.
 Need to be fully informed of risks and potentially difficult decisions
Immunisations
 Prematurity not a contraindication - timing based on chronological age from birth
Long term problems

 Severe problems (up to 10 to 15%): e.g. cerebral palsy, blindness and deafness
 Hearing impairment in 1 in 4 with birth weight below 1.5 kg
 Increased risk of retinopathy of prematurity
 Developmental probs at 5 years increase with decreasing gestational age.
 Behavioural and psychomotor problems, e.g. ADHD
Prevention
 Improve nutrition, stop substance abuse, smoking, avoid alcohol
Further info: http://www.bliss.org.uk/
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1.2.1.28 Pre-term rupture of membranes
What is it?
 Rupture of the membranes prior to the onset of labour at less than 37 weeks gestation.
 Occurs in 2% of all pregnancies.
Risk factors
 Smoking, Previous preterm delivery, Vaginal bleeding during pregnancy, UTI, STI
Presentation
 'popping sensation', or a 'gush' with watery discharge, damp, underwear
Investigations / Diagnosis
 Do NOT do a vaginal inspection (increase infection risk)
 Sterile speculum examination: check for liquor and umbilical cord.
 Nitrazine test (vaginal fluid placed on paper strips)
 Ultrasound to check for gestation and liqour volume.
Management
 Temperature monitoring at least 12-hrly for ascending infection:
 Vaginal swab and blood tests
 Fetal monitoring
 Antibiotics (AVOID: Co-amoxiclav - erythromycin may be best)
Delaying premature birth

 Tocolytics, (e.g. atosiban, nifedipine or ritodrine), may delay delivery by 48 hours and enable time
for corticosteroids (only if uterine activity)
 Antenatal steroids if gestation between 24 and 36 weeks.
Delivery or expectant management?

 Consider delivery if: ascending infection, fetal distress or gestation over 34 weeks
 PROM over 37 weeks – give choice of immediate induction or expectant management.
 Term pregnancy can be managed at home with outpatient monitoring
 But recommended that PROM at term should not exceed 96 hours
Complications
 Operative delivery, pre-term delivery
 Ascending infection
 Umbilical cord prolapse
 Placental abruption
 Oligohydramnios, causing underdevelopment of lungs
 Retained placenta, postpartum haemorrhage
 Rupture of vasa praevia with likely resultant fetal exsanguination (fetal mortality 33-100%)
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1.2.1.29 Bleeding in 3rd trimester / Antepartum haemorrhage (APH)
What is it?
 Bleeding from the birth canal after the 24th week
 Affects 3-5% of all pregnancies.
 Should always be admitted to hospital for assessment and management.
Causes - No definite cause is diagnosed in about 40%

 x3 in multiparous than primiparous women.
 Placenta praevia (insertion of the placenta in the lower segment of the uterus).
 Placental abruption (30% of all cases): Risk factors:  maternal age and parity,  BP, trauma,
cocaine use, smoking, infection
 Infection, trauma or tumours.
 Vasa praevia (bleeding from fetal vessels in the fetal membranes)
 Uterine rupture (rare) risk factors: previous caesarean section), > 4 pregnancies, trauma, shoulder
dystocia, forceps deliveries
 Inherited bleeding problems (very rare)
Presentation - Most common after 36th week, may be painless or painful
Investigations
 Transvaginal ultrasound (placenta is praevia)
 Colour flow doppler ultrasound (placenta accreta – deep attachment of placenta)
Management
 Always admit to hospital for assessment and management.
 FBC and clotting.
 Cross match - may require transfusion
 Fetal monitoring.
 Urgent ultrasound.
 Rhesus negative woman given prophylactic anti-D immunoglobulin.
 If severe bleeding or fetal distress: urgent delivery of baby
Delivery
 May be able to deliver vaginally but grades III and IV Placenta praevia: will require caesarean
 Vaginal delivery is the treatment of choice in the presence of a dead fetus.
Complications
 Premature labour
 Disseminated intravascular coagulopathy
 Renal tubular necrosis, postpartum haemorrhage
Prognosis
 Perinatal mortality less than 5%
 Maternal mortality low if managed by experienced obstetrician
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1.2.1.30 Termination counselling
● Appropriate introduction
● Confirm pregnancy and determine how the patient feels it. What options they have considered?
● Establish that they have decided to have a TOP and check what they already know.
● Establish if male partner will be informed (n.b. can not consent or refuse) & other social support
● Be empathic and non judgemental
Q. Can I have an abortion?

● Abortion Act allows it before 24 weeks if it reduces risk to life, physical or mental health of self or
existing children or baby is at substantial risk of being seriously mentally or physically handicapped
● There is no upper limit if: Risk to mother's life, risk of grave, permanent injury to physical/mental
health or substantial risk that child would be seriously handicapped.
● Women should get abortion within 2 weeks of decision (ideally 7 days)
Q. What if I’m under 16?

● Need form signed by 2 doctors. Girls <16 years may be able to reach an informed decision
● Rarely, parent may go against wishes & authorise termination if best interests, but not in Scotland
Q. What tests do I need before hand?

● Chlamydia (25% post-op salpingitis if untreated)
● Check Rhesus status, if negative needs anti-D afterwards
● Haemoglobin, Blood type, Haemoglobinopathies, Hepatitis B virus, HIV
● Cervical screening, possibly ultrasound scanning (if ectopic suspected)
Q. How is it actually done? Two types: surgical & medical
SURGICAL
● < 7 avoid conventional suction. 7-15 weeks conventional suction (cervix stretched and tube inserted)
● > 15 weeks dilatation and evacuation (cervix dilated using drugs (misoprostol 3 hrs, gemeprost 3
hrs, mifepristone 36-48 hrs) prior to surgery and body parts removed using foreceps)
MEDICAL
● < 9 weeks: Mifepristone 600 mg orally followed 36-48 hours by Gemeprost 1 mg vaginally
● < 24 weeks = safe alternative to surgery but…not all women suitable for medical termination
● Contraindications include > 35 & smoker, ectopic preg, heart disease, high blood pressure, liver or
kidney disease, adrenal failure, anti-coagulants, hemorrhagic disease, poorly controlled IBD
Q. What could go wrong?

● Generally safe: 1st trimester, day procedure, low risk to health and fertility
● Complications include: Infection (~10%: so prophylactic antibiotics), trauma (1%) Uncommon:
Haemorrhage, perforation of uterus, failed termination ~ 2/1000
● No evidence for link with breast cancer, infertility, pre-term delivery.
● Psychological effects
End pieces
● Discuss contraception
● Summarise, Check understanding, any Concerns?, Ask questions, Leaflet, Follow-up.
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1.2.1.31 Triple test counselling
What is it?
 Optional blood test at 14-20 weeks of pregnancy- helps detect Down’s syndrome and spina bifida.
What is Downs?
 Caused by the presence of all or part of an extra 21st chromosome (Trisomy 21)
 Causes mild to severe learning difficulties
 Characteristic facial appearance
 Prone to heart defects (typically VSD), GORD, Thyroid dysfunction etc.
 Reduced life expectancy (but may live into 60’s)
What is Spina Bifida?
 Incomplete closure of spinal cord. May lead to disability, hydrocephalus (increased pressure in the
fluid in the brain which can gradually damage brain function especially if untreated). Other
problems include incontinence and urinary tract infections.
How does it work?

 Measures three substances: AFP (alpha fete protein), hCG (human chorionic gonadatrophin) and
uE3 (unconjugated oestriol) in mother’s blood.
 If Down’s risk raised, AFP & uE3 reduced and hCG is raised
What do results mean?

 If risk is low, no further action required.
 If the risk high ( > 1 in 250) you will be offered amniocentesis. You do not have to accept.
 In majority of cases amniocentesis will give negative result.
What is amniocentesis?
 Involves taking a sample of the fluid which surrounds the baby in the womb.
 Risk of miscarriage estimated to be 1/100. But not much greater than natural level of risk
 Test takes about three weeks to give a result.
 A normal result does not guarantee there are no abnormalities
What if abnormality found?

 You will be told about the extent and possible impact of the abnormality
 What you decide to do next is up to you
How long does the triple test take?

 Usually 3-7 days after having the test done. May be quicker.
End pieces
 Discuss contraception
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1.2.1.32 Placenta praevia explanation
What is it?
 Placenta is inserted wholly or in part into the lower segment of the uterus.
 May be associated with sudden onset of painless bleeding in second or third trimester.
 14 times more likely to bleed in the antenatal period
 Over the cervical os = major praevia, if not, then minor praevia.
 1/200 births, and 1/1000 are total with placenta over entire cervix.
Diagnosis - ultrasound imaging graded as:

 I - Encroaches the lower segment but does not reach cervical os
 II - Reaches the internal cervical os but does not cover it
 III - Covers part of the cervical os
 IV - Completely covers the os, even when the cervix is dilated.
Will it fix itself?

 May migrate during 2nd & 3rd trimester, but less likely if posterior or previous caesarean section.
Risk factors
 Prior history of placenta praevia,  maternal age,  parity
 Smoking, cocaine use, previous caesarean section, prior spontaneous or induced abortion
Presentation
 Incidental finding on ultrasound or painless bleeding after 28th week
 In 25% cases, spontaneous labour appears in next few days.
Investigations
 Ultrasound: Transvaginal ultrasound safe in placenta praevia and more accurate
 May include full blood count, group and cross match, fetal monitoring.
Management
 Inpatient management recommended for symptomatic women
 Major placenta praevia previously bled admitted from 34 weeks
 If managed at home attend hospital immediately if any bleeding, contractions or pain
 Have antenatal discussions regarding delivery, haemorrhage, transfusion and surgery
 Cervical cerlage reduces bleeding and prolongs pregnancy.
 May need delivery by caesarean
 Labour can be induced at an optimal time decided upon by tests of fetal lung maturity
 Acute bleeding - admit to hospital, cross-match, delivery if bleeding severe
Complications
 Potentially fatal hypovolaemic shock, infection and embolism,
 Fetal haemorrhage, prematurity, intrauterine asphyxia or birth injury.
Prognosis
  complications, abruption placenta, antepartum haemorrhage, IUGR, perinatal mortality 2-3%.

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1.2.1.33 Explanation of antenatal blood tests
< 10 weeks: Blood test for sickle cell and thalassaemia
8-12 weeks: Blood test for haemoglobin, group, rhesus and antibodies.
8-12 weeks: Blood test for syphilis, Hep B, HIV, Rubella
[8-14 weeks: Dating scan]
10-14 weeks: Blood for early Down’s syndrome test
[11-13½ weeks: nucal translucency scan]
15-20 weeks: Blood for later Down’s syndrome test
[18-20 weeks: Detailed ultrasound anomaly scan]
28 weeks: Repeat blood for haemoglobin and antibodies
Sickle cell and thalassaemia
 Inherited blood disorders affect haemoglobin require specialist care throughout life
 Sickle cell disease: can have: attacks of very severe pain, serious, life-threatening infections,
usually anaemic, need lifelong medication to prevent infections.
 Thalassaemia major: need blood transfusions every 4-6 weeks, lifelong medication
 Need two genes one from their mother, other father. Just one = carrier.
 if Mediterranean, Africa, Caribbean, Middle East, S. America or SE Asia.
 Also diagnostic test during pregnancy. Heel-prick test at 5-8 days tests for sickle cell.
Haemoglobin, group, rhesus and antibodies
 Need to know blood group in case need transfusion.
 If mum Rh– may need Anti-D injection to safeguard Rh+ baby as Rh+ blood cells may enter mum’s
bloodstream, mum may develop antibodies to baby's blood, cross the placenta and destroy baby's
red blood cells - risk of anaemia, brain damage, death
 Anti-D stops mums immune system making antibodies baby's Rh+ cells.
 If  haemoglobin: tired, short of breath, hard to concentrate, irritable and  infections. More
difficult for mums body to cope with losing blood
Syphilis, Hep B, HIV, Rubella
 Can get most from own mother, unprotected sex, sharing needles, tattoo, piercing
 If +’ve your partner and other children should be tested
 Can all be done in one sample. Help protect you and baby. Can refuse.
 Just having the tests does not affect insurance, but results might
 Hep B: infection of the liver caused by a virus. Can have it but feel well.
 If mum +’ve baby at risk of infection. ¼ develop serious liver disease in later life.
 Baby vaccine  risk of becoming carrier. 9/10 adults with Hep B recover fully
 HIV: can pass to baby while during pregnancy, birth, breastfeeding
 If +’ve care and medicines to  chances of baby becoming infected and to treat mum
 Can take up to three months for antibodies to develop so if recent exposure repeat
 Rubella: If not immune you will be offered MMR after baby born
 Airborne virus. First 12 weeks of pregnancy, may damage brain, heart, eyes, hearing.
 1/20 not fully protected by vaccine, so still important to have test
 Syphilis: causes serious damage to mum and baby (brain damage, miscarriage)
 Treatment mum with antibiotics and baby after birth
 See separate stations for Downs syndrome and Ultrasound tests
 Summarise, Check Understanding, Ask Questions, offer Leaflet, arrange Follow Up
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1.2.2 Problem based obs & gynae histories
1.2.2.1 Obstetric history
 Introduction: Name, age, occupation, relationship status
Current pregnancy
 Presenting problem (if any)
 Last Menstrual period (EDD = +9 months +7 days). Regular periods prior to this?
 Contraception prior to pregnancy
 If > 20 weeks: foetal movements: frequency and any recent changes
First trimester
 Planned/unplanned/desired?
 Tiredness, sickness, indigestion, headaches, dizziness, bleeding?
 Ultrasound scan &/or Chorionic Villus Sampling @ 10-13 weeks
 Type of antenatal care (midwife or consultant led?)
Second trimester
 Amniocentesis (16-18 weeks) or anomaly scan (18-20 weeks)
Third trimester
 Blood pressure, proteinuria, vaginal bleeding, hospital admissions
Previous pregnancies
 Gravidity (number of pregnancies including this one)
 Parity (number of births > 24 weeks)
 For previous pregnancies ask: duration + problems, mode of delivery, problems, outcomes
 For previous live births ask: age, sex, birth weight, problems after birth, current health
 Ask about miscarriages, stillbirths, & terminations
Gynaecological history
 Previous gynaecological procedures, last cervical smear test
Past Medical History

 Current, past & childhood illnesses; e.g. hypertension, epilepsy, diabetes
 Any previous surgery
 Recent visits to doctor
Drug and allergy history

 Current prescribed or over the counter medications. Folic acid?
 Any medications taken during pregnancy
 ALLERGIES
Family history
 FH of hypertension, diabetes, heart disease, epilepsy, multiple pregnancies
Social history
 Social support, employment, housing, smoking, alcohol, drug use
 Summarise, Check Understanding, Ask Questions, offer Leaflet, arrange Follow Up
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1.2.2.2 Gynaecological history
 Introduction, explanation of purpose, consent

 Name, age, occupation
Presenting complaint
 Let patient tell their story
History of presenting complaint

 Age at menarche
 Regularity of periods
 Dysmenorrhoea
 Date of LMP – was it normal?
 Vaginal discharge: amount, colour, smell
 Vaginal itching, pain, swelling
 Date and result of last cervical smear
 Vaginal prolapse
 Urinary incontinence
 Sexually active? – pain/bleeding during or after sex, one or more partners?
 Contraception
Past medical history

 Past gynae history
 Past reproductive history: pregnancies, terminations, miscarriages
 Current, past and childhood illnesses
 Previous surgery
 Recent visits to the doctor
Drug History
 Prescribed & OTC medication
 Allergies
Family history
 Parents, siblings children
 If STD suspected, ask about partner
Social history
 Employment
 Housing and home help
 Travel
 Smoking, alcohol, recreational drugs
66
1.2.2.3 Infertility History
 Appropriate introduction
 Establishes purpose of interview
 Establishes duration of trying to conceive
 Establishes history of previous pregnancies
 Establishes if any children from previous relationships
 Establishes LNMP and menstrual history
 Establishes/eliminates known gynae history (STIs, fibroids, endometriosis, etc)
 Establishes any previous surgery (e.g. oopherectomy)
 Establishes past/present health of partner
 Establishes frequency of sexual intercourse
 Ask about occupations of couple and home circumstances
 Establishes smoking and alcohol use
 Appropriate questioning without jargon, organized, emphatic approach.
67
1.2.3 Obstetric / Gynae examination
1.2.3.1 Gynaecological examination

 Wash hands, intro and consent. n.b. if never sexually active do not cervical smear
 Explain need for, and get chaperone
 Allow patient to undress in privacy and if necessary empty her bladder first
 Fetch chaperone and ensure privacy
 General examination
 State that you would like to do an abdominal examination first
 Cover abdomen. Ask pt to lie on back, both knees bent, allow knees to fall apart.
Speculum examination and smear

 Put on gloves, explain what you are about to do
 Separate labia with forefinger and thumb
 Inspect vulva – look for discharge, tumours, ulcerations, rashes, prolapse, excess hair
 Ask woman to cough and look for any prolapse or leakage or urine
 Warm and lubricate speculum, insert half way with blades parallel to labia
 Continue inserting and rotate 90° so locking device anterior
 Open blades slowly and examine cervix for any abnormalities
 Take smear or appropriate swabs
- conventional c smear: insert longer blade of spatula into os, rotate 360°, spread once across
slide, place immediately into fixative for 3-4 mins, leave to dry in air
- liquid based cytology: rotate plastic brush five times through 360°. Remove brush and place in
specimen jar (Surepath) or rinse thoroughly in jar (ThinPrep)
- high vaginal swab if vaginal discharge, endocervical swab to exclude chlamydia
 Withdraw speculum carefully, do not close blades completely. Observe vaginal walls
Bimanual examination following on from speculum exam

 Explain what you are about to do
 Insert right index finger into vagina and turn palm upwards
 Feel for cervix. Note any tenderness as can be a sign of infection
 Place left hand flat on lower abdomen above pubic symphysis
 Push cervix upwards and feel uterus for size, shape, position, surface characteristics and tenderness
 Move fingers to each lateral fornix bringing other hand down to feel for enlargement or tenderness
of ovaries or fallopian tubes
 Thank patient and allow to dress in privacy.
 Debriefs patient regarding when & how results will be made known. Possibility of spotting
 May also wish to do
o FBC, TFT if menorrhagia (menstrual blood loss > 80ml.)
o Pregnancy test if amenorrhoea
o Hormonal analyses if premature menopause, hirsuitism
o Serum tumour markers ca125 if ovarian mass
o Pelvic ultrasound scan if pelvic mass, abnormal bleeding
o Hysteroscopy, Endometrial biopsy if abnormal bleeding
o Laparoscopy if chronic pelvic pain
68
1.2.3.2 Obstetrics examination
 Wash hands, intro and consent

 Appropriately positions patient at slight inclination
 Takes patients blood pressure
 Express need for chaperone
 Exposes patients abdomen from rib cage to pubis
 Inspects abdomen for symmetrical abdominal distension consistent with pregnancy
 Examines for linea nigra (may be due to oestrogen appears around the 2nd trimester)
 Examines for striae gravidarum
 Inspects for abdominal scars
 Examines for visible foetal movements
 Checks if any abdominal pain
 Measures Symphysis-fundal height correctly (blank side facing up)
 Correlates SFH with gestational age (16-26, SFH=g.a.; 26-36, SFH +/-2 = g.a., 36 weeks to term,
SFH +/-3 = g.a.)
 Determines if singleton/multiple pregnancy
 Palpates abdomen correctly to determine foetal lie and back (longit, oblique, trans)
 Palpates abdomen correctly to determine foetal presentation (cephalic or breech)
 Palpates abdomen to determine engagement of presenting part (fifths palpable)
 Palpates abdomen correctly to determine amount of amniotic fluid
 Auscultates foetal heartbeat using pinnards stethoscope / doppler
 Looks for peripheral oedema
 Ensures patient comfortable throughout and covers abdomen when finished
 Presents findings throughout
 Communicates with patient appropriately, explaining what is being done
 Examines in a professional manner
 Thanks patient when complete
 Washes hands when finished
69
1.2.3.3 6 week post natal check
History
Physical
 How was the baby delivered?
 Any particular worries about her own health?
 Is her perineum / Caesarian section scar healing well?
 Periods resumed?
 Bowel and bladder functioning normally?
 Is she breast feeding? If so, encourage to continue & ask if any problems
Psychological
 How was the birth? Are there any issues that need to be talked through?
 Mood? Consider postnatal depression.
 Any worries about the baby? - content? healthy? growing? responsive? Vision? hearing?
Social
 Support at home? Sleeping?
 Household smokers increase risk of SIDS and childhood asthma.
Examination
 Palpate abdomen - retained products of conception or endometritis, if tender.
 Blood pressure
 Vaginal examination if tears, episiotomy, bleeding, dyspareunia
 Cervical smear if indicated
 Haemoglobin if previously anaemic
 Rubella status
Sex and contraception

 If sexual intercourse has not resumed reassure now safe to try.
 Contraception required? - full time breast feeding if amenorrhoeic
 Options: Condoms, IUCD, IUS, progestogen-only pills and implants
Pelvic floor exercises

 Incontinence problems in antenatal period (30% 6 weeks after birth)
 Pull up pelvic floor muscles as though trying to stop self urinating and hold for 10 seconds.
 Contract pelvic muscles, and relax them rapidly in succession 4 times.
 Do this preferably for life
Close
70
2 MSS
2.1 Emergency Medicine
2.1.1 Procedures
2.1.1.1 Wound suturing
 Introduction
 Explain procedure and get consent
 Examine wound for debris, dirt and tendon damage.
 Suggest X-Ray to exclude foreign body
 Assess distal motor, sensory, and vascular function
 Position patient and ensure s/he is comfortable
 Obtain: gloves, suture pack, suture, 5ml syringe, 21G and 25G needles, vial of 1% lignocaine,
antiseptic solution, sharps bin
 Wash hands
 Open suture pack to create sterile field
 Pour antiseptic solution into receptacle
 Open suture, syringe & needles on to sterile field
 Wash hands again using sterile technique
 Don gloves
 Attach 21G needle to syringe
 Ask assistant to open vial of anaesthetic and draw up 5ml. (Average 70kg adult max is 20ml 1%
lignocaine). Max safe dose with epinephrine is 7mg/kg and without is 3mg/kg. Do not use
epinephrine in extremities due to risk of ischaemic tissue necrosis. A 1% solution means it has
10mg/ml so for 70 kg man 3 x 70 = 210mg or 21ml without epinephrine.
 Discard needle into sharps bin and attach 25G needle
 Clean wound with antiseptic soaked cotton wool. Dirty wounds may benefit from iodine, use saline
for clean wound
 Inject local anaesthetic into apices and edges of wound (pull back on plunger before injecting)
 Discard needle into sharps bin
 Indicate you would wait 5-10 mins for anaesthetic to take effect
 Suture 3mm from wound edge and 5-10mm apart
 Use a 2-2-1 see - http://www.youtube.com/watch?v=V1bRq-PW5bw
 Clean the wound and indicate that you would apply a dressing
 Assess the need for a tetanus injection (a full course or booster in last 10 years?)
 Give wound care instructions – advise to get appt. to remove stitches face 3-4 days, scalp 5 days,
trunk 7 days, arm or leg 7-10 days, foot 10-14 days
 Summarise, Check understanding, check if they have any questions to Ask questions, Leaflet,
Follow Up
71
2.1.1.2 Blood gas interpretation
Reference ranges:
Pa02: 9.3 – 13.3 kPa
pH acidosis < 7.35 – 7.45 > alkalosis
PaC02: > 6.0 kPa = respiratory acidosis or respiratory compensation for metabolic alkalosis
< 4.7 kPa = respiratory alkalosis or respiratory compensation for metabolic acidosis
HC03: < 22 metabolic acidosis or metabolic compensation for respiratory alkalosis
> 28 metabolic alkalosis or renal compensation for respiratory acidosis
pH PaC02 HC03
Respiratory acidosis    or 
Respiratory alkalosis    or 
Metabolic acidosis   or  
Metabolic alkalosis   or  
Mixed acidosis   
Mixed alkalosis   
Examples from studentBMJ 2004;12:89-132 March ISSN 0966-6494 (answers overleaf)
1.A 60 year old man was admitted with an exacerbation of chronic obstructive pulmonary disease. His
arterial blood gases on air showed pH 7.29, PaCO2 8.5 kPa (65.3 mm Hg), PaO2 8.0 kPa (62 mm Hg),
and standard bicarbonate 30.5 mmol/l. What is the acid-base disturbance and what is the management?
2.A 30 year old man was admitted with status epilepticus. He is given intravenous diazepam. Arterial
blood gases on 15 l/min via reservoir bag mask showed pH 7.05, PaCO2 8 kPa (61.5 mm Hg), PaO2 15
kPa (115 mm Hg), and standard bicarbonate 16 mmol/l. His other results were sodium 140 mmol/l,
potassium 4 mmol/l, and chloride 98 mmol/l. What is the acid-base disturbance and why?
3.A 45 year old lady with previous peptic ulcer disease was admitted with persistent vomiting. She
looked dehydrated. Her blood results were sodium 140 mmol/l, potassium 2.5 mmol/l, chloride 86
mmol/l, pH 7.5, PaCO2 6.0 kPa (50 mm Hg), PaO2 14 kPa (107 mm Hg), standard bicarbonate 40
mmol/l. What is the acid-base disturbance and why? How would you treat this patient?
4.A 40 year old man with pleurisy for five days was assessed. A moderately sized pneumothorax was
seen in a chest radiograph. His arterial blood gases on air showed pH 7.44, PaCO2 3.0 kPa (23 mm
Hg), PaO2 30.5 kPa (234.5 mm Hg), standard bicarbonate 16 mmol/l. How can you explain the clinical
picture?
5.A 50 year old man with type 1 diabetes and diabetic nephropathy was recovering on a surgical ward
after a total colectomy and ileostomy. He had persistent metabolic acidosis and the surgeons were
concerned about his high potassium concentration and that there may have been some ischaemia in the
abdomen causing the acidosis. However, the patient appeared well perfused and had normal vital signs.
He had normal fluid balance and his results showed sodium 130 mmol/l, potassium 6.5 mmol/l,
creatinine 180 µmol/l (2.16 mg/dl), chloride 109 µmol/l, 8 am cortisol 500 nmol/l (18 µg/dl), pH 7.29,
PaCO2 3.5 kPa (27 mm Hg), PaO2 14 kPa (107 mm Hg), standard bicarbonate 12 mmol/l. What is the
acid-base disturbance and why?
72
Answers:
1. This patient had an acidosis with a high PaCO2 and normal standard bicarbonate--respiratory
acidosis. This is a common finding in acute exacerbations of chronic obstructive pulmonary
disease. Doctors gave medical treatment (nebulisers, steroids, and antibiotics) and non-invasive
ventilation.
2. This patient had acidosis with both a high PaCO2 and a low standard bicarbonate--a mixed
acidosis. The anion gap was 26 mmol/l (increased). The PaO2 is lower than expected because the
patient was breathing around 70% oxygen. Does this fit with the clinical picture? Yes, he had a
lactic acidosis from prolonged fitting and a respiratory acidosis from intravenous diazepam. This
disturbance will return to normal with attention to A--airway manoeuvres and oxygen, B--assisted
ventilation if needed, C--treatment with fluids.
3. This patient had alkalosis due to a high standard bicarbonate-metabolic alkalosis. The PaCO2 was
appropriately low in compensation. This was hypokalaemic hypochloraemic metabolic alkalosis
because of potassium and chloride loss from vomiting. Treatment was of the underlying cause
(pyloric stenosis) and intravenous sodium chloride with potassium.
4. This patient had a normal pH but had both a low PaCO2 and a low standard bicarbonate. How do
we know if this was a compensated respiratory alkalosis or a compensated metabolic acidosis?
Easy. The history indicates five days of hyperventilation, so this is a compensated respiratory
alkalosis. What if this were a diabetic patient who was unwell with fever, vomiting, and high
glucose? Then it would have been a compensated diabetic ketoacidosis.
5. This patient had acidosis due to low bicarbonate. The PaCO2 was appropriately low in
compensation. The anion gap was normal (13.5 mmol/l). This makes intra-abdominal ischaemia
(which causes lactic acidosis) unlikely. Was this a gastrointestinal problem or a kidney problem? If
this were a gastrointestinal problem, you would expect low potassium. This man had diabetic
nephropathy which predisposes to renal tubular acidosis. Type 4 (hyporeninaemic
hypoaldosteronism) is typically associated with high potassium and is found in diabetic and
hypertensive renal disease.
73
2.2 Anaesthesia, Resuscitation and Pain management
2.2.1 Procedures
2.2.1.1 Cannulation and setting up a drip
● Appropriate introduction. Establish patients identity

● Explain procedure to the patient in a clear manner
● Check the fluid prescription chart and check the fluid bag – ask a colleague to confirm
● Gather together the following; gloves, tourniquet, alcohol swabs, adhesive plaster, sharps box, fluid
bag, giving set.
● Remove fluid bag from packaging and hang on drip stand, remove giving set from packaging
● Remove covering from exit port of bag and large pointed end of giving set
● Drive pointed end of giving set into exit port
● Remove protective cap from other end of giving set
● Close roller in middle of giving sets tubing
● Squeeze and release collecting chamber until about half full
● Open roller and run fluid through giving set to expel any bubbles, the close roller
● Make sure the end of the giving set is close by!
● Find a suitable vein, apply tourniquet, put on gloves
● Clean skin and let it dry
● Remove cannula form packaging and remove cap
● Tell patient to expect a sharp scratch, anchor vein and insert cannula at about 30 degrees
● Once flashback is seen, advance cannula and needle by about 2mm
● Hold the needle in place and slide the cannula into the vein
● Keep the needle just inside the cannula and remove the tourniquet
● Occlude the vein and remove the needle. Do not re-cap the cannula.
● Immediately put the needle into the sharps box
● Attach the giving set. Apply the adhesive plaster to fix the cannula
● Adjust the drip rate (1 drop per second = 1 litre per 6 hours) 1L/8h = 40 drips/min 10h = 32dpm
● Thank the patient and document what you have done!
Questions you may be asked

Q1. When giving maintenance fluids what losses are you trying to replace?
Obligatory fluid loss through urination, and defecation and insensible fluid loss through sweating and
breathing. Average fluid requirement = 2500mL/24h
Q2. In what situations do patients need more than just replacement fluids?
Additional fluid loss through bleeding, or third space losses (sequestration into tissues, GI tract and
peritoneal space). Vomiting and diarrhoea.
Q3. What additives might need to be given on this fluid prescription (if only 1L of saline written
up)? 1L of 0.9% saline. Add 2L of 5% dextrose to this over 30 hours, along with 20mmol of KCl /L.
Q4. How do you work out fluids for a child? First 10kg 100ml/kg/24hr, next 10-20kg, 50ml/kg/hr,
above 20kg = 20ml/kg/hr (use 500ml bags of 0.45% saline, 5% dextrose +/- 10mmol KCl)
Q5 Cannula sizes? Biggest-Smallest: Orange (14G), Grey (16G), Green (18G), Pink (20G), Blue
(22G)
Q6 Drip rates? Drop factor is usually 20. Standard giving set = 1L of fluid in 6hrs at a drip rate of 60
per minute, 1L/8 hours = 42 dpm, 1L/10 hours = 33 dpm.
OR Work it out: #ml to infuse (e.g. 1000) x drop rate (e.g.) 20 / time in mins (e.g. 480 mins) = 42dpm
74
2.2.1.2 Administer antibiotics intravenously
Last year the station was to Prescribe, Mix, and administer stat 500mg IV Flucloxacillin
● Wash hands
● Appropriate introduction
● Establishes patient identity
● Explains procedure to patient in a clear manner – e.g. “I would like to give you some antibiotics,
these will help avoid/clear up any infections. I’d like to give you these antibiotics directly into your
vein. As you already have a cannula in, this would be the easiest way for me to give you the
antibiotic, as it would go straight into your vein and then get carried it around you body. Would that
be OK?”
● Check equipment required: Cannula in patient, gloves, saline flush, needles, syringes, antibiotic,
mixing fluid. Check expiry dates!
● Check the patient has no known drug allergies
● Write the prescription – patient name, date of birth, date, time, medication, dose, route (check BNF
if given)
● Wash hands again (if shook patients hand)
● Put on gloves
● Remove seal on antibiotic vial & clean with alcohol wipe
● Attach a green (21G) needle to a syringe
● Draw up mixing fluid (hospital guidelines: 5-10ml for 250mg or 500mg vial, 15 20ml for 1g)
● Inject mixing fluid into antibiotic vial
● Mix antibiotic and fluid appropriately (ensure completely dissolved)
● Draw back antibiotic mixture
● Clean cannula portal with antibiotic wipe
● Remove needle (new 21G needle if injecting into drip bag; if injecting into a vein, put on tourniquet
first, then new 21G needle on syringe)
● Inject antibiotic slowly (should be slow IV injection according to BNF. i.e. > 3 mins)
(If injecting straight into a vein, look for flashback, then remove tourniquet.)
● Flush cannula with 5ml 0.9% saline
● Close cannula portal
● Dispose of sharps appropriately
● Does this in a fluent professional manner.
● Thank patient
● Sign, date and print prescription
N.B. Another option would be to give as an IV infusion 100mL over 30-60 minutes. As a standard
giving set will give 1L of fluid in 6hrs at a drip rate of 60 per minute, 100ml would take 360mins/10 =
36 minutes to run through.
End pieces
● Advise patient to let someone know if there is any local or systemic reaction
● Check if patient has any concerns.
75
2.2.1.3 Pre-operative assessment
● Appropriate introduction and explain purpose of examination

HISTORY:
● Medical History
● Previous surgery and anaesthesia – anaesthetic complications (suxamethonium apnoea, malignant
hyperpyrexia)
● Previous hospital admissions
● Cardio: hypertension, palpitations, angina, MI, cardiac failure, orthopnoea, stroke or TIA
● Respir: dyspnoea, apnoea, cough, tuberculosis
● GI and renal: dysphagia, heartburn, liver disease, renal failure
● Other: diabetes, sickle cell anaemia, epilepsy, neuromuscular problems.
● Drug History
● Prescribed medication – insulin, anticoagulants, any changes in medication
● Over-the counter & alternative medications
● Recreational drug use (esp. ecstasy, cocaine, narcotics)
● Allergies – e.g. antiseptic, plaster, latex
● Smoking & Alcohol
● Family history - of allergic reactions, anaesthetic complications, medical and surgical conditions
● Social history – e.g. level of support in post operative period
EXAMINATION
● Record height and weight and calculate BMI (weight (kg)/ height (m2) – normal = 20-25)
● State that you would wish to examine the CV, Resp, GI and neurological systems
● Assess neck mobility by asking patient to flex and extend neck
● Assess jaw mobility by asking patient to open and close mouth
● Assess dentition state
● Carry out a Mallampati pharyngeal assessment (III and IV are relative contraindications)
INVESTIGATIONS
● Express need for: FBC, LFTs (including clotting screen),U&Es, blood glucose, ECG, CXR, group
save & cross match (In what situations would you need each these?)
● Assess ASA physical status rating 1= healthy, 2=mild/moderate systemic disease, 3 = severe
systemic disturbance, some activity limitation, 4 = life threatening systemic disease, severe activity
limitation, 5 = moribund with limited chance of survival, 6 = brain dead for organ removal
EXPLANATION
● Fasting – solids 6 hours, milk 4 hours, fluids/gum 2 hours
● Pre-medication eg benzodiazepines
● The anaesthetic procedure, post operative pain relief, post operative nausea and vomiting
● Going home / driving
● Summarise, Check Understanding, Ask Questions, offer Leaflet, arrange Follow Up
76
2.3 Dermatology
2.3.1 Counselling
2.3.1.1 Psoriasis
● What is psoriasis?
- Skin cells reproduce too quickly (every 2-6 days rather than every 21-28 days)
- Affects 2% of people in UK. Commonly develops between 11-45 years.
- Skin cells build up causing red, flaky, crusty patches with silvery scales
- Commonly found on elbows, knees, lower back and scalp. Can cause itching/burning.
- Not contagious. Severity varies, but it is chronic.
● What are the different types?
- Plaque psoriasis most common (80%). Dry, red skin lesions covered in silver scales. - Nail psoriasis:
pitting, discolouration, abnormal growth, can become lose and crumble.
- Guttate psoriasis - following throat infection. Small sores on chest, arms, legs and scalp. Good chance
will disappear completely, but may develop plaque psoriasis.
- Scalp psoriasis - back of head, also other parts of scalp. Hair loss but not permanent.
- Inverse psoriasis – folds/creases. Large smooth red patches. Friction, sweat,overweight.
- Pustular psoriasis (rare).
- Erythrodermic psoriasis (rare). Red itchy rash covers body. Can lead to serious illness.
● What causes psoriasis?
- Exact cause unknown. Immune system attacks skin cells-> increased skin production.
- Runs in families – 1 in 3 have a close relative with psoriasis.
- Streptococcal throat infections involved in guttate psoriasis
- Immune system diseases (eg HIV) can cause/worsen psoriasis
● What triggers flare ups? Alcohol, smoking, injury, stress, lithium, antimalarials, anti-
inflammatories, ACE inhibitors, beta blockers.
● How is it treated? Most treatments slow skin cell production
- No cure. Control condition using 1) topical, 2) phototherapy, 3) oral & injected
- Topical: Corticosteroids (mild – moderate) Over-use > tolerance & skin damage.
- Vitamin D cream (e.g. Calcipotriol) - suppresses immune system. No side effects.
- Dithranol - No side effects. But very staining. Washed off after five minutes
- Tazarotene cream like Vitamin A. Skin irritation. Teratogenic. Not children/teens.
- Coal tar - reduces scales, inflammation and itchiness. Staining and strong smell.
Phototherapy - Sunlight but not too much, - UVB phototherapy - Need 10-30 sessions.
- Psoralean plus ultraviolet A (PUVA) - tablet then UVA. Side effects: nausea, headaches, burning and
itchiness. Long-term use not encouraged - skin cancer.
- Combination light therapy - combining phototherapy with other treatments
Oral and injected medication - If severe & resistant. Potentially seriously side effects.
- Methotrexate - suppresses inflammation. Can cause liver damage. Teratogenic.
- Aciterin - Side effects: cracked lips, hair loss, hepatitis. Teratogenic for two years after.
- Ciclosporin – immunosuppressant. Incr. risk infection, kidney disease, blood pressure.
● What are the complications of psoriasis?
Psoriatic arthritis - 10% and 20%. Commonly affects digits. May affect lower back, neck and knees.
Can be treated with anti-inflammatory or anti-rheumatic medicines.
Psychological - low self-esteem and anxiety. Can trigger depression.
● What else can I do? Support group may help. Remember SCALF
77
2.3.1.2 Atopic Eczema
What is it? A.k.a. dermatitis (inflammation of the skin). Most common type is ‘atopic’ eczema -
describes people with certain 'allergic' tendencies, but it is not just a simple allergy.
What are the symptoms? Itchy, dry, red, inflamed. Commonly affects skin creases; elbows and wrists,
backs of knees, and neck, face (esp. in babies). Sometimes skin become blistered, weepy, infected.
Tend to get flare ups.
Who gets it? Mostly children under 5 yrs. About 1 in 6 schoolchildren have it. 2/3rds disappear or
lessen by teens. 1/20 adults have it.a
What causes it? Usually idiopathic. Lipid barrier of skin reduced -> dry skin. Also, some immune
response. Genetic factors play a part. 8/10 chance if both parents, 6/10 if one. May be related to:
pollution, house dust mite or pollens, diet, infections. Dietary causes rare.
How is it treated?
1. Avoid Exacerbating factors: soaps, bubble baths, scratching, wool (wear cotton instead),
temperature extremes, some detergents, house dust mites, stress, pollen, mould, pets, pregnancy,
hormonal changes. Food sensitivities (rare) include: cow's milk, eggs, soya, wheat, fish, and nuts.
Don’t change diet – keep a food diary 4-6 weeks. Only change diet under the supervision of dietician.
2. Emollients: Prevent skin from becoming dry, help to prevent itching and reduce # of flare-ups. You
cannot overdose or overuse emollients. Some people become sensitised to an ingredient – be aware.
3. Topical steroids - work by reducing inflammation e.g. hydrocortisone cream 1% (mild). Use until
the flare-up has completely gone, and then stop. The alternative is weekend therapy (apply steroid
cream on the usual sites of flare-ups for two days every week). One fingertip unit is enough to treat a
hand. Remember to wash your hands (unless you’re treating them). Side-effects: thinning of skin,
striae, bruising, discolouration, telangiectasia. May trigger or worsen acne, rosacea and perioral
dermatitis, may affect growth in children. Apply emollient first, wait 10-15 minutes then apply steroid.
What if it gets infected? May be weeping, have crusts, etc. may develop fever and malaise. Requires
oral or topical antibiotics. Get new supplies of creams.
Other treatments? “Topical immunomodulators” e.g. tacrolimus long-term safety being evaluated.
Hospital treatments include light therapy, immunosuppressives medication. Tar shampoos,
antihistamine help getting to sleep.
See also www.eczema.org
78
2.3.1.3 Acne
What is it? Aka 'spots'. Mostly between 12 and 25 years. Usually affects face, back, neck, chest. 9/10
teenagers. 3/10 bad enough to need treatment to prevent scarring. Lasts about 4-5 years before settling.
What causes it? Sebaceous glands, make oil that comes out through pores sometimes along with a
hair. Teenagers make more sebum due to hormone changes of puberty (Androgen sensitivity). Pores
become blocked with skin & dead skin.
Rare cause: Polycystic ovary syndrome, occupational exposure to halogenated hydrocarbons
Mild: Note blackheads due to pigment, NOT dirt. Whiteheads = trapped sebum.
Moderate to severe: P.acnes bacteria grows in trapped sebum - immune system causes inflammation.
Spots may fill with pus, may form 'nodules' and cysts.
Will it leave scars? Area may remain discoloured for several months afterwards. May leave scars.
What makes it worse? The progestogen-only pill, monthly periods, make-up, picking and squeezing,
hot humid conditions, tight clothes, phenytoin (epilepsy), steroids (eczema, bodybuilding). Do not stop
prescribed drug, consult doctor.
Myths - poor hygiene (excessive washing may exacerbate), diet (but healthy diet should be
encouraged), stress, not contagious, no evidence sunbathing improves it
How is it treated?
Skincare: Wash only twice a day using soap and lukewarm water. Do not scrub, or use exfoliators.
Topical:
1. Benzoyl peroxide - kills bacteria, reduces inflammation, and helps unplug pores. Wash skin 20-30
minutes before using, may bleach things or cause mild irritation. Use lowest strength first (2.5% goes
up to 10%. Apply once daily at first, and wash off after several hours. Azelaic acid – alternative
2. Retinoids.- (e.g. adapalene, tretinoin, and isotretinoin) Unplug pores. Need prescription. May
develop redness and peeling. May get worse before gets better. Sensitive to sunlight - apply at night
and wash off in morning. Use sun protection. Side-effects: burning, irritation, and dryness. Do NOT use
if pregnant or planning to become pregnant.
3. Topical antibiotics or combinations
4. Antibiotic tablets - e.g. Tetracyclines , but NOT under 12 years, pregnant, breastfeeding. Take on an
'empty stomach. If on 'the pill' use additional precautions (e.g. condoms) during first three weeks.
5. The pill - e.g. combined oral pill or Dianette
6. Isotretinoin tablets reduce the amount of sebum you make but risk of serious side-effects
Persevere with treatment for at least six weeks. Refer to dermatologist if treatment-resistant
79
2.3.2 Genito Urinary Medicine
2.3.2.1 Sexual history
 Introduction, explanation, consent. Reassurance about confidentiality
History
 Would you describe yourself as heterosexual, homosexual or bisexual?
 When was the last time you had sex and who with?
 Have you had sex with anyone else in the last three months?
 Regular or casual partners? Gender of partners?
 Was it vaginal/oral/anal sex
 If oral or anal did you give or receive?
 Did you use protection? Any problems (e.g. split condom?)
 Have you ever had sex whilst abroad?
 Where are your sexual partners from?
 Is it possible they’ve has sex whilst abroad?
STDs
 Sores, discharge, itching, dysuria, abdominal pain?
 History of STDs in self or partner?
 Date and result of last cervical smear
Sexula function
 Problems or concerns about sex?
 Erectile dysfunction, ejulatory dysfunction, low libido, anorgasmia, vaginismus, dyspareunia
 Onset, course and duration of problem
 Frequency and timing of problem: partner specific? Situational? Impact on life?
Past medical history

 Current, past and childhood illnesses
 Previous surgery, recent visits to the doctor
Drug History
 Prescribed & OTC medication
 Allergies
Family history
 Parents, siblings children
 If STD suspected, ask about partner
Social history
 Employment
 Housing and home help
 Travel
 Smoking, alcohol, recreational drugs

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2.3.2.2 HIV and AIDS counselling
What is HIV?
 Human Immunodeficiency virus - commonly passed on by sexual contact.
 Attacks immune system, destroys CD4 T-cells (white blood cells), & weakens it ↓ defence
What is AIDS?
 AIDS stands for Acquired Immunodeficiency Syndrome. HIV is not AIDS
 AIDS not single disease. Describes point when immune system no longer copes
 CD4+ T cell count below 200 per ml3 of blood or 14% of all lymphocytes
How do you get HIV?

 Sexual: vaginal, anal or oral sex. Semen, vaginal secretions, blood (needles, transfusions)
 Mother to child (1 in 7 if mum HIV+): pregnancy, childbirth, breastfeeding
 Anti-HIV drugs during pregnancy, caesarean, bottle feeding reduces risk
 You can not get HIV from hugging, shaking hands, sharing food, towels, etc.
How common is HIV? - HIV in UK is steadily rising. Every day worldwide, over 6,800 get infected
How does it cause problems?

 Gets inside CD4 T-cells, replicates & kills these cells. Over time, virus usually 'wins'
 Immune system weakened and develop opportunistic infections

 May have similar to flu or glandular fever 6-8 weeks after infection. HIV test may be negative
 May remain asymptomatic for years (average 10)
 May develop persistent swollen lymph glands or night sweats.
 Later: ulcers, herpes, shingles, dermatitis, TB, diarrhoea, skin rashes, tiredness, weight loss
 AIDS: pneumonia, thrush, fungal infections, TB, toxoplasmosis, cytomegalovirus, etc.
 Increased risk: Kaposi's sarcoma, cancer of the cervix and lymphoma, AIDS dementia, wasting
Tests – can be –ve for (or up to 3 months) several weeks. Re-do. If +’ve: viral load, CD4 count
Treatment?
 Still no cure but treatment now very effective - Antiretrovirals slow HIV virus replicating
 HAART: Take 3 or more at the same time (different points of replication cycle). May be in one pill
 Started with opportunistic infections or CD4 < 350 cells per mm3. High compliance vital
 Side-effects: nausea, vomiting and headaches. Check for drug interactions
 Need regular blood tests to monitor for side effects whilst taking treatment.
Prevention of further infections

 Protected sexual intercourse, vaccinate against Hepatitis A and B, influenza and the pneumococcus
 Low CD4 may need antibiotics
Prognosis - Person now diagnosed at 20 years old could expect to live for another 49 years
Further information: National Aids Trust www.nat.org.uk

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2.3.2.3 STI explanation
What is an STI?
 Infection passed from person to person when having vaginal, anal, or oral sex.
Main STIs?
 Anogenital warts: small lumps on/around genitals or anus. Caused by human papillomavirus
(HPV). Can be a 'carrier' of the virus without realising it. Treatment: chemicals or freezing
 Chlamydia: Chlamydia trachomatis bacteria. Most common STI in UK. Symptoms: vaginal/penile
discharge or asymptomatic carrier. Complications: pelvic infection, infertility. Treat with antibiotics
 Genital herpes: herpes simplex virus. Have it for life but usually dormant. Symptoms: mild
soreness, painful blisters. Can last 2-3 weeks, but may be shorter. Treatment: Antiviral (acyclovir).
 Gonorrhoea: Neisseria gonorrhoeae bacteria. Symptoms vaginal/penile discharge. May be
symptomless carrier. Complications: pelvic infection and infertility in women. Treatment:
Antibiotics
 HIV: human immunodeficiency virus. Weakens immune system. Treatment with antiretroviral drugs
for life. See separate station for more info
 Hepatitis B: virus attacks liver. Sexual contact, sharing needles, mother to her baby. May be
asymptomatic carrier or develop serious liver problems. Antivirals may prevent or reduce liver
damage.
 Hepatitis C: virus attacks liver. Mainly needle sharing, small risk sexual transmission. May clear
spontaneously. May be asympromtic carrier or develop cirrhosis or liver cancer. Treatment works in
50% (interferon and ribavirin)
 Pubic lice ('crabs'): tiny insects. close bodily contact. Main symptom is itch, May be asymptomatic
carrier. Treatment : lotion or cream.
 Syphilis is caused by a bacterium called Treponema pallidum. If it is not treated, it can spread in the
bloodstream from the genital region to cause various symptoms and problems in different parts of
the body over many years. A short course of antibiotics usually clears syphilis infection.
 Trichomonas: tiny germ similar to bacteria. Symptoms: vaginal/penile dischargeMay be
asymptomatic carrier. Treatment: Antibiotics
Common symptoms - swelling, discharge, bleeding, sore, ulcer, rash, lump, pain (sex or urination)
Where should I go? - GP or GUM clinic (may be able to just turn up – call first)
What will happen? - Confidential. Can give false name. History. Examination. Urine, swab, bloods
Results: May be immediate or a few days. Partner tracing.

Treatment: See above: Don’t have sex until advised to do so
Further info: British Association for Sexual Health www.bashh.org
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2.3.3 Infectious Diseases
2.3.3.1 ID / Travel history
Intro and consent – name, age, occupation
Presenting complaint & history of Presenting Complaint

 Site, Onset, Characteristics, Radiation, Associated Symptoms, Timing, Severity
 E.g. Diarrhoea – severity, duration, frequency, consistency, colour (blood), assoc sytmptoms?
 E.g. Fever – duration, frequency, temp recording, night sweats, rigors, associated features
Risk factors
 Contacts – family, friends, work colleagues all well?
 Occupation – do they handle food? Animal exposure?, sewage worker?, healthcare worker?
 Travel – dates, sex, food, drink, air conditioning, swimming, vaccinations, malaria tablets, bites?
 Leisure activities (e.g. hiking tick bites; canoeing & fishing leptosporosis)
 Food – cooking, storage, meals out, shell fish, poultry, raw/undercooked eggs
 Animals – pets, farm visits
 Blood borne risks – drug use, transfusions, tattoos, piercings
 Sexual history – unprotected, new partners, high risk behaviours
Past Medical History

 Previous infections (may be immunosuppressed)
 Other illnesses / surgery / visits to doctor
Systems Enquiry
 General: weight/appetite change, fever, lethargy, malaise
 Respiratory: Cough, sputum, haemoptysis, SOB, wheeze, chest pain
 Cardiovascular: chest pain, palpitations, ankle swelling, orthopnoea, Claudication
 Gastrointestinal: Indigestion, abdo pain, nausea, vomiting, constipation, diarrhoea, blood loss,
dysphagia
 Genito-urinary symptoms: Urinary frequency, polyuria, dysuria, haematuria
 Neurological symptoms: headaches, dizziness, tingling, weakness, tremor, fits, faints, funny turns
 Locomotor system: Aches, pains, stiffness, swelling
 Skin: Lumps, bumps, ulcers, rashes, itch
Drug History
 OTC and prescription
 Allergies
 Vaccinations
Family history
 Relatives with history of infection?
Social History
 Smoking, drinking, coping at home etc
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2.3.3.2 Hepatitis A, B & C
What is Hepatitis?
 Inflammation of liver. Many causes, some more serious. E.g. Alcohol, & Hep A,B&C
Who gets it and how common is it?

 Hep A: Anyone, any age. Faecal-oral route. Water, shellfish. Africa, Asia, E. Europe, middle East.
 Hep B: 1 in 500 in UK. 1 in 10 parts of Asia and Africa. Mother to baby, sexually, needles,
transfusion, toothbrushes, razors, dentists, tattooing, piercing
 Hep C: ~1 in 500. Mainly due to IVDU. Less chance of other routes as Hep B.

 Hep A: incubation 2-6 weeks. Flu-like. Lethargy, nausea, vomiting, diarrhoea, jaundice, pale stools,
itching, aching liver. May last a few weeks. Most fully recover. Complications rare.
 Hep B: Acute – same as Hep A. 9/10 adults completely clear virus in 3-6 months.
 Hep C: May be asymptomatic, incub. 7-8 weeks symptoms as A & B. 1 in 5 clear in 2-6 months.
Long term impact?

 Hep A: not chronic. Rarely, severe liver inflammation & failure. Transplant needed.
 Hep B: 1/10 adults chronic, 9/10 babies chronic. 2/3 carriers. Others: liver inflammation, muscle
aches, tiredness, nausea, ↓appetite, intolerance of alcohol, liver pain, jaundice, depression. Some
get cirrhosis, liver failure, liver cancer.
 Hep C: 4/5 chronic. Mostly carriers, 1/5 cirrhosis over 20-30 years, some get cancer.
How is it diagnosed?
 Hep A: Blood test (anti-HAVIgM = acute) Anti-HAVIgM 2-3 months = immune.
 Hep B: Blood test (HbsAg = infection). May also have LFTs, Liver USS, biopsy.
 Hep C: Blood test (HCV antibody) but +’ve even if cleared, can take up to 6 months to show, so
repeat may be necessary. RNA = ongoing infection. Liver biopsy to find extent of infection.
Can it be avoided?
 Hep A: Immunisation 4-6 weeks before travel. Wash hands after going to toilet.
 Hep B: Immunisation if increased risk (eg travel, HCPs, sex workers, prisoners, regular
transfusions, IVDU, contact sports). Need at least 3 doses of the vaccine.
 Hep C: Don’t share needles. No vaccine available.
What if I’ve got it?

 Hep A: hygiene. Hep B & C: condoms, test partners, don’t share needles, don’t donate blood etc.
What is the treatment?

 Hep A: No specific treatment. Rest, avoid fatty foods, alcohol, good hygiene.
 Hep B: Post exposure: immunoglobulin & immunization. Same for babies. May prevent. No
treatment will halt acute Hep B → chronic. If chronic may need regular liver checks, antivirals (e.g.
interferon alpha) may prevent/reduce liver damage. Transplant may be an option. Avoid alcohol.
 Hep C: Interferon and ribavirin 6-12 months will clear 50% 6-12 months. SEs tiredness, feeling
sick, headaches, depression and other problems. Avoid alcohol.
Further info: www.britishlivertrust.org.uk - www.hepb.org.uk - www.hepcuk.info

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2.3.4 Rehabilitation Medicine
2.3.4.1 Communication assessment
 Introduce self to patient

 Explanation and assessment
 History of presenting complaint
 Brief: time, place and orientation
H.U.R.R.E.W.S.
Hearing
 Do you have any problems with your hearing? Do you wear a hearing aid? Is it turned on?
 Is English your first language?
Understanding (Receptive & Nominal Dysphasia)

 Ask patient if they ever have any problems understanding what people are saying
 Check ability to understand commands: “shut your eyes”, “touch your nose”, “point to the door”
 Ask patient to name some objects (e.g. watch) and components (e.g. strap)
Reading (Dyslexia)
 Check if patient wears glasses for reading
 Ask patient to read a few words form a book etc.
 Can they obey a written command?
Repitition (Dysarthria)
 Repeat “British constitution”, “West Register Street”, “Baby hippopotamus”
 “me me me”, “la la la”, “Khu, gut”, “Ah”
Expressive Dysphasia
 Ask the patient if they ever have trouble finding the right words to describe things
 Assess if this has happened during the consultation
Writing (Dysgraphia)
 Dictate a sentence for the patient to write
Speech (Dysphonia)
 Note the volume of speech. Does the speech appear weak?
End pieces
 Brief social history – how you coping at home, social support etc?
Summarise, Check Understanding, Ask Questions, offer Leaflet, arrange Follow Up
Possible examiner’s questions

 Common causes: Could be congenital or acquired
- Congenital: Cerebral Palsy, Cleft palate, Klinefelter syndrome, Encephalopathy
- Acquired: Stroke, Dementia, Depressive disorder, Parkinson’s disease
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2.3.4.2 Cognitive Assessment
So Lets Carry Vera Pissed Around Manchester
*Alternatively, carry out the MMSE – 3.2.1.5. (but NOT required to memorise this for 4th year)*
Speech, Language & Communication
 Do a communication assessment as in station above

 Ask patient to repeat 3 unrelated objects “apple, table, penny”. Let them know you will ask them if
they can remember these objects later
Vision
 Ask to draw a clock face – look for spatial neglect
Praxis
 Ask patient to do alternating palmar/dorsal clapping

 Nose to finger test
 Heel to shin test
Attention
 Ask to spell world backwards, or serial sevens backwards from 100 for 5 subtractions
Memory
 Ask if they can remember the three objects you asked them to repeat at the beginning
End pieces
 Brief social history – how you coping at home, social support etc?
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2.3.4.3 Choosing walking equipment
 Walking aids may be provided by physiotherapist at local hospital or health centre.

 Range includes: frames; rollators; crutches; walking sticks; tripods/quadrupods.
 Consult GP or physiotherapist before buying – may be alternative treatments
 Before buying, see and try out @ Disabled Living Centre
Purpose Of Walking Equipment

 As part of rehabilitation programme or as a long- term mobility aid
 May provide greater stability/balance by providing a wider support base;
 Facilitate walking speed and stride. Help maintain body posture; increase confidence in walking
ability; reduce pain in the joints, muscles and ligaments
 Walking frames often not long-term as difficult to manoeuvre
 Crutches/sticks give better mobility
Safe Use Of Walking Equipment

 Home environment: watch out for loose rugs, trailing flex, cluttered/wet floors
 Footwear appropriate and supportive.
 Regular maintenance of the walking equipment, esp. ferrules (rubber feet on end)
Different types of equipment and things to consider
 Frames: Correct height important, too high not take enough body weight, too low, poor posture (but
may prevent backward falls). Handgrips level of the wrist bone when elbows very slightly bent.
Wheeled and non wheeled available. Wheels facilitate travel but 4 wheels may be too mobile if
need support – need brakes
 Crutches: Designed to use in pairs. Affected leg stays with the crutch. Steps or stairs - step up with
the good leg first, down stairs, the bad leg and crutches lead
 Axilla crutches: underarm pad under the armpit with two finger widths of space. Handgrips level
with the protruding bone at the side of the wrist. Used by people who must not weight bear on bad
leg. Don’t lean on the underarm pad as this may interrupt the blood flow and put pressure on
important nerves. Instead squeeze pad between the upper arm and the chest wall.
 Elbow crutches: Line up the handgrips with wrist bone. Elbow cuff should cradle the forearm just
below the elbow. Used by people who can partially weight bear.
 Walking sticks, tripods and quadrupods: correct height = distance between the wrist bone and
ground. Use opposite hand to affected leg to maintain natural walking pattern and upright posture.
Move stick and the affected leg forwards together. Tripods and quadropods more stable than
standard walking sticks. Usually used singly rather than in pairs. White walking sticks available to
blind or visually impaired. Red tape indicates both deaf and blind.
 Different shapes, materials, handles, may have seats attached.
 Handgrip Styles: Anatomically shaped handgrips spread the weight more effectively
 Ferrules must be replaced as soon as they show signs of excessive wear
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2.3.4.4 Orthotics - General
What are orthotics?

 Devices used to alter or modify foot function.
 Designed to treat, adjust, and support various biomechanical foot disorders.
 May be simple, commercially-made devices, such as cushioned heel cups or insoles
 May be crafted to meet specific needs of particular individual.
Types of Orthotics
 Functional orthotics: Support abnormal foot biomechanics e.g. prevent abnormal flattening of the
arch and act as shock absorbers while walking or running. Support the joints, stabilize foot and help
prevent injuries. Used to correct many foot deformities.
 Accommodative orthotics: Usually soft supportive device that is designed to relieve mild foot pain
and correct minor foot problems. Often used to correct walking problems in young children.
Include include splints, gait plates, and night bars that correct toe-in or toe-out walking. Braces may
be used in infants to correct foot, leg, or hip abnormalities.
Who Should Use an Orthotic?

 Almost anyone can benefit - can alleviate many common foot problems. Think of glasses!
Symptoms?
 Abnormal shoe wear (e.g., one side of the sole of the shoe wears out faster than the other)
 Bunions
 Chronic heel (e.g., plantar fasciitis), knee, or low back pain
 Flatfeet
 Frequent ankle sprains
 Gait abnormalities (e.g., feet point inward or excessively outward during walking)
 Shin pain (e.g., shin splints)
How Does an Orthotic Work?

 During each step, weight shifts from laterally to medially and back to laterally.
 Orthotics control how the foot strikes the ground, absorbs shock, and reduces stress in foot.
 In high arch (cavus foot) arch does not flatten, foot absorbs shock poorly.
o Over time, this can cause pain in the knees, hips, and lower back.
o Orthotic adjusts and evens out the contact between the foot and the ground.
 In flatfoot (planus) weight distribution too far on the medial side. Does not maintain proper arch.
o Over time, can lead to the development bunions, hammertoes, knee and low back pain.
o Orthotic with increased arch can re-distribute weight.
How Is an Orthotic Made?

 Usually make a plaster cast of foot. T
 Technicians custom-mold an orthotic made of a supportive material.
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Close - Summarise, Check Understanding, Ask Questions, offer Leaflet, arrange Follow Up
90
2.3.4.5 Ankle and foot orthoses for children
What are they?

 Usually plastic external devices
 Prevent unwanted movements due to muscle imbalance/increased tone in leg, foot or ankle
Problems they can help with in children

 Tip-toe walking (Equinus or Plantarflexed Gait)
 Ankle becoming twisted outwards (Varus ankle) or inwards (Valgus ankle)
 Secondary problems of knee (Hyperextension), hip position and balance.
How ankle and foot orthoses (AFOs) help

 Control movement of foot and ankle and correct alignment. Can also help hip and knee position.
 Can dramatically improve gait, balance and posture.
 Fixed AFOs effective at preventing toe-walking, valgus & varus movements stop dorsiflexion
 Hinged AFOs prevent plantarflexion past 90° but allow dorsiflexion to occur
 Hinged AFOs allow for more natural, fluent gait, & allow squatting & climbing stairs.
Different types of orthoses

 Range from simple supportive footwear to complex biomechanical/functional orthoses.
 Medial and lateral wedges can help increase control over unstable ankles.
 Un-affected foot will probably also need orthosis too (if only to level off).
 Some finish just above ankle - useful in improving medial and lateral stability around ankle
Some things orthoses can do:

 Provide hind foot stability (close moulding around heel)
 Provide mid-forefoot stability (medial & lateral extensions. good arch supported)
 Control unwanted exaggerated and abnormal movements
 Reduce the effects of increased tone (spasticity)
 Promote a stable base
 Encourage proximal stability
 Built in rear foot/forefoot wedging or posting (valgus or varus)
 Toe and Metatarsal support (tone management)
 Contoured sole plates to assist in foot stabilisation (reduce tone)
 Manufactured from: semi flexible or rigid materials (polypropylene, polythene etc)
 Orthoses not an answer in themselves but help along with physiotherapy etc.
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2.3.4.6 Swallow test
 Introduction, explanation and consent.
Swallowing problems?
 Swallowing problems affect over a third of people after a stroke.
 Risk that food and drink may get into the windpipe and so into the lungs (called aspiration) - can
lead to chest infections and pneumonia.
The swallow test

 Start with one teaspoon of water
 Gradually build up to 2 and then 3 teaspoons
 If they can swallow without choking / coughing ask to swallow 500ml
Problems with swallowing?

 Refer to the speech and language therapist
 Will carry out more detailed clinical swallowing assessment.
 videoflouroscopy - a type of video x-ray - can help find out exactly what is causing problems.
 Will not be allowed to eat and drink without help and if swallowing problems continue
 Dietician will work out diet to ensure proper nutrition from puréed food or thickened drinks.
 Patient will also be shown how to eat safely and in the correct position.
 Recovery and quality of life after stroke better if patient can take food and drink by mouth
 Artificial feeding methods may be necessary.
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2.3.4.7 GAIT examination
See 1.1.3.6
2.3.5 Oncology and Palliative Medicine
2.3.5.1 Breaking bad news
1. Preparation
 Prepare the Ground
 Know all the facts before the meeting. Find out who the patient wants present, and ensure privacy
and chairs to sit on.
2. What does the patient know?

 Ask for a narrative of events from the patient (eg “How did it all start?”)
3. Is more information wanted?

 Test the waters, but be aware that it can be very frightening to ask for more information
 (eg “Would you like me to explain a bit more?”)
4. Give a warning shot

 eg “I’m afraid it looks rather serious” – then allow a pause for the patient to respond.
5. Allow denial
 Denial is a defence mechanism and a way of coping. Allow the patient to control the amount of
information they receive.
6. Explain (if requested)

 Increase the patient’s information to match the professional’s to the appropriate level. Details of this
information may not be remembered, the way you offer the information will.
7. Listen to concerns
 Ask “What are your main concerns at the moment?” and then allow space for expression of
feelings.
8. Encourage ventilation of feelings

 KEY phase in terms of patient satisfaction with the interview, because it conveys empathy.
9. Summary and plan

 Summarise concerns, plan treatment, foster appropriate hope.
10. Offer availability

 Most patients need further explanation (the details will not have been remembered) and support
(adjustment takes weeks or months) and may benefit greatly from a family meeting.
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2.3.5.2 Describing cancer treatment options
 Introduction, purpose and consent

 Cancer treatments aim to remove the cancerous cells and prevent cancer reoccurring
 One remaining cancerous cell potential to cause a new tumour. Often used in combination
Surgery
 May be possible to remove affected tissue. May have to remove entire organ, e.g. breast
 May be used in combination with chemotherapy and radiotherapy to increase chance of success.
Chemotherapy
 Powerful medicines damage DNA of cancerous cells, interrupting their ability to reproduce.
 Chemotherapy damage healthy tissue, and unfortunately side effects are common.
 Side effects: nausea, vomiting, hair loss, and fatigue. Should stop when treatment finished.
 Can weaken your immune system. May be combined with radiotherapy/surgery.
Radiotherapy
 Uses radiation to damage cancerous cells (also healthy cells but they repair more quickly)
 Side effects: tiredness, nausea, loss of appetite, hair loss, sore skin, and reduced libido
 Side effects may persist after treatment finished.
Hormonal therapy
 Some cancers (e.g. breast, prostate) can be slowed by blocking certain hormones.
 Side effts: hot flushes, sweats, reduced libido, nausea, vomiting, tiredness, aches, headaches, rashes
Monoclonal antibody therapy

 Delivers radioactive materials or chemo directly into cancerous cells, e.g. Herceptin (breast cancer)
 Side effects: nausea, skin rashes, flu-like symptoms, itchy skin, diarrhoea.
 May cause heart problems in some people (may not be used if +’ve history)
 Can cause severe allergic reactions in some people.
Immunotherapy
 Tags cancerous cells so immune system regards them as a foreign object.
 Side effects same as monoclonal antibody therapy (see above).
Angiogenesis inhibitor therapy

 Blocks creation of new blood vessels, slowing the growth of the tumour (not killing it though).
Complementary therapies
 Help coping with the symptoms and psychological effects of cancer.
 Include: yoga, relaxation techniques, such as mediation, hypnotherapy, and acupuncture.
On-going research
 More effective monoclonal antibodies are likely to be developed.
 MRI imaging is likely to become more accurate - allowing tumours to be detected earlier.
 More effective screening programmes may become available
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2.3.5.3 Describing Radiotherapy
What is radiotherapy? (sometimes called radiation therapy)

 High energy beams of radiation focussed on cancerous tissue.
 Kills cancer cells or stops cancer cells from multiplying.
Aims of radiotherapy?
 May aim to ‘cure’ the cancer, but best to say ‘remission’ rather than ‘cured’
 Given after surgery: adjuvant radiotherapy, Given before surgery: neoadjuvant radiotherapy.
 Radiotherapy and chemotherapy may be used in combination.
 May aim to control the cancer: limit growth or spread. Prolong symptomless period
 May be used to ease symptoms: 'palliative' radiotherapy.
How is radiotherapy given?

 Two main types: External radiotherapy (machine outside body), Internal (implants or liquids)
 External most common type. Usually x-rays
 Course of treatment carefully planned by specialist based on the type, size and location of cancer.
 May be short session on most days each week, for several weeks (reduces side-effects).
 CT scans, X-rays etc will find exact site of the cancer in body.
 Location may be marked with small tattoo or using a cast
What exactly will happen?

External:
 Usually lie on a couch with radiation machine positioned above you.
 Lead shields may be placed over certain areas to protect from radiation.
 Therapist goes into a separate control room to protect from repeated exposure
 Each session lasts a few minutes: machine may need adjusting a few times during session.
 Not painful. But side effects may occur later
Internal (brachytherapy)
 May involve inserting small radioactive implant into or next to tumour. Or dinking radioactive
liquid
 May stay for days or minutes, or longer
 An anaesthetic may be needed
 Whilst implant in place you will emit radioactivity. Movements may be restricted.
Side-effects
 Some normal cells will be damaged but recover better than cancer cells
 Often temporary although some are permanent
 Most common is tiredness. Others: skin reaction, pain. Depends on area being treated.
Further information: www.cancerhelp.org.uk
Close
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2.3.5.4 Chemotherapy
What is chemotherapy?
 Literally means 'drug treatment'. Cancer treatment using cytotoxic drugs.
What are cytotoxic drugs and how do they work?

 Poisonous to cancer cells. Kill cancer cells or stops them multiplying.
 Two or more cytotoxic drugs with different actions usually used in combination
 Work best when the cancer cells are rapidly dividing and multiplying.
 Most normal cells not affected much except: hair, bone marrow, and lining of the mouth and gut.
 Normal cells renew better and usually recover quite well following treatment.
What are the aims of chemotherapy?

 May aim to ‘cure’ the cancer, but best to say ‘remission’ rather than ‘cured’
 May be used in addition to another main treatment, e.g. surgery
 After a main treatment = adjuvant. Before main treatment = neoadjuvant chemotherapy
 May aim to control the cancer: limit the growth or spread: Prolong symptomless period
 May be used to ease symptoms: 'palliative' chemotherapy.
How is chemotherapy given?

 Usually intravenously: injected into a vein or via a drip (usually several hours)
 Sometimes longer thin plastic tube placed into deeper vein (PICC2 line).
 Some can be taken orally, some injected into spinal cord or muscle, cream or injected elsewhere
 Usually given in 'cycles' (spell of treatment followed by rest) commonly every 3-4 weeks
 Full course often about six months. May be shorter or longer than six months
 Treatment usually as out-patient. Few hours at hospital or a day or so. Some treated @ home.
Tests
 May need scans, x-rays, ECG, blood tests at baseline and later to check effects of treatment
Side-effects
 Common: tiredness, nausea and vomiting (anti-sickness medication usually helps)
 Anaemia, infection, (see doc straight away if fever or sore throat),
 Bleeding problems ('blood count' regularily checked). See doc straight away.
 Mouth problems (rinse with saline or salt water), frequent sips of water or sugar-free gum
 Hair loss (usually regrows within 4-12 months): wig, scarf. May lose eyeleshes and eyebrows.
 Constipation, Diarrhoea (keep hydrated, may need anti-diarrhoea medicine, or a drip)
 Nerve problems - pins and needles, weakness. Tell your doc.
 Fertility (may be able to store sperm or eggs) May develop early menopause
 Do not become pregnant – may be teratogenic - use reliable contraception.
 May cause another form of cancer much later in life.
 May react with other medicines, alcohol, driving.
Further information: www.cancerhelp.org.uk
2
Peripherally Inserted Central Catheter
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3 PPP
3.1 Primary Care
3.1.1 Counselling
3.1.1.1 High cholesterol
What is cholesterol?
 A fat that made in the liver from fatty foods that we eat. You need some to keep healthy.
 Carried in the blood as Low density lipoproteins (LDL) and HDL
 LDL: 'bad cholesterol' involved in forming atheroma. Usually about 70% of cholesterol in blood
 HDL: ‘good cholesterol’ may actually prevent atheroma formation.
What are atheroma and cardiovascular diseases?

 Small fatty lumps inside lining of arteries. Aka 'hardening of the arteries'
 Patches can become larger, thicker and narrow artery, reduce blood flow – e.g. angina.
 If blood clot forms over atheroma can blocks blood flow causing heart attack, a stroke etc.
 CVDs: heart diseases usually due to atheroma: angina, MI, stroke, TIA, peripheral vascular disease.
 CVDs major cause of poor health, and the biggest cause of death.
What affects blood cholesterol levels?

 In general, if you eat less fat your cholesterol level is likely to go down.
 Also hypothyroid, obesity, alcohol, rare kidney/liver disorders, familial hypercholesterolaemia.
Risk factors for atherosclerosis

 Lifestyle factors: Smoking, sedentary, Obesity, unhealthy diet (incl >6g salt daily), alcohol.
 Hypertension, high blood cholesterol/triglicerides, diabetes, some kidney diseases
 Strong family history, (CHD or stroke in male relative before 55, female before 65)
 Being male, early menopause in women,  age, Indian, Pakistani, Bangladeshi, or Sri Lankan
What is an acceptable cholesterol level?

 Total cholesterol <= 5.0 mmol/l, LDL <= 3.0, HDL >= 1.2, TC/HDL ratio: 4.5 or less.
What is my cardiovascular risk & how is it assessed?

 Risk factor calculator takes account of age, sex, smoking, blood pressure, cholesterol level, etc.
 Blood test (cholesterol and glucose), BP, weight etc.
 % chance of CVD in next 10 years. High risk >= 20%. Moderate risk 10-20%. Low risk < 10%.
Treatments?
 Usually offered if high risk, existing CVD, possibly if diabetes or certain kidney disorders.
 Tackle lifestyle issues, statins (blocks enzyme needed to make cholesterol in liver), aspirin
 Specialists: dieticians, 'stop smoking clinic', supervised exercise programmes.
Further information: www.bhf.org.uk
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3.1.1.2 Type I diabetes
What is diabetes?
 Two types: Occurs when the level of glucose in blood becomes higher than normal.
 Normally after we eat, foods broken down in gut into sugars, mainly glucose. Absorbed into blood.
 Glucose used by the cells in body for energy. Should not go too high or too low.
 Usually when blood glucose rises hormone called insulin also rises.
 Insulin normally made by pancreas and released into blood stream
 Insulin lets cells take in glucose for fuel. Some converted into glycogen or fat (energy store)
 Blood glucose also maintained by breaking down glycogen or fat back into glucose.
What is Type 1 diabetes?

 A.k.a. juvenile, early onset, or insulin dependent diabetes. In UK about 1 in 250 people.
 Usually develops quickly, over days or weeks, as pancreas stops making insulin.
 Thought to be 'auto-immune': trigger may be viral, severe inflammation, or surgical removal.
 Genetic predisposition: First degree relative has 6 in 100 chance
What are the symptoms of Type 1 diabetes?

 Very thirsty, pass a lot of urine, tiredness, weight loss, malaise
 Without treatment, acids form in the bloodstream ('ketosis'), dehydration, coma, death
How is diabetes diagnosed?

 If 'dipstick' shows glucose in urine, likely but not diagnostic: need confirmatory blood test
Possible complications?
 Long-term: damage blood vessels, atheroma, angina, heart attacks, stroke, poor circulation, eye
problems, kidney damage, nerve damage, foot problems, impotence
Treatment & complications

 Need insulin injections for rest of life. ~2-4 injections each day.
 But too much can cause hypos: sweaty, confused, unwell, coma.
 Emergency treatment of hypoglycaemia: sugar or a glucagon injection then starchy snack
 Aim to keep blood glucose near normal, reduce 'risk factors' (e.g. BP), detect complications asap
 Healthy diet: not ‘special’ foods: low fat, high fibre diet, starch, fruit and vegetables. See dietician
 Monitor glucose & adjust insulin: between 4 and 7 mmol/l before meals, < 10 mmol/l 2 hrs after.
 Stop smoking, do regular physical activity, lose weight if overweight
Regular checks
 HBA1c checks control over the last 2-3 months. Aim for 7%
 Blood pressure: may need antihypertensive; Cholesterol - may need statins / low dose aspirin
 Eye checks - detect problems with the retina or glaucoma
 Kidney function, Foot checks - prevent foot ulcers; Coeliac and thyroid disorders more common
 Immunisation against 'flu (each autumn) and pneumococcus (once).
Further info: www.diabetes.org.uk
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3.1.1.3 Type II diabetes
What is diabetes?
 Two types: Occurs when the level of glucose in blood becomes higher than normal.
 Normally after we eat, foods broken down in gut into sugars, mainly glucose. Absorbed into blood.
 Glucose used by the cells in body for energy. Usually when glucose rises insulin also rises.
 Insulin normally made by pancreas and released into blood
 Insulin lets cells take in glucose for fuel. Some converted into glycogen or fat (energy store)
 Blood glucose also maintained by breaking down glycogen or fat back into glucose.
What is Type 2 diabetes?

 a.k.a. Maturity onset, or non-Insulin Dependent. Mainly in over 40’s. 3% over 40, 10% over 65
 You don’t make enough insulin OR cells don’t use it properly (resistance), or combination
 More common in overweight/obese. Tends to run in families. South Asians, African-Caribbeans

 Common: thirst, passing large amounts of urine, tiredness, weight loss.
 Symptoms may develop so gradually (weeks/months) you may not recognise that you are ill
 Also: blurred vision, frequent infections (candiadisis)
Diagnosis - if 'dipstick' shows glucose in urine, likely but not diagnostic: need confirmatory blood test
Possible complications
 Very high blood glucose level: dehydration, drowsiness, can be life-threatening.
 Long-term: damage blood vessels, atheroma, angina, heart attacks, stroke, poor circulation, eye
problems, kidney damage, nerve damage, foot problems, impotence
Treatments & complications

 Address lifestyle factors – stop smoking diet, weight control and physical activity. May be enough.
 Medications: some helping insulin to work (biguanides e.g. Metformin), others boost amount made
(Sulphonylureas e.g. gliclazide), or slow glucose absorption (Acarbose – not used often)
 Insulin injections may be needed if above do not work well enough.
 Hypo (< 4 mmol/l): too much meds, missed meal, unplanned exercise. Symptoms: trembling,
sweating, anxiety, blurred vision, tingling lips, paleness, mood change. Take sugar then starch.
 Aim to keep blood glucose near normal, reduce 'risk factors' (e.g. BP), detect complications asap
 Healthy diet: not ‘special’ foods: low fat, high fibre diet, starch, fruit and vegetables. See dietician
 Monitor glucose & adjust insulin: between 4 and 7 mmol/l before meals, < 10 mmol/l 2 hrs after.
Regular checks
 HBA1c checks control over the last 2-3 months. Aim for 7%
 Blood pressure: may need antihypertensive; Cholesterol - may need statins / low dose aspirin
 Eye checks - detect problems with the retina or glaucoma
 Kidney function, Foot checks - prevent foot ulcers; Coeliac and thyroid disorders more common
 Immunisation against 'flu (each autumn) and pneumococcus (once).
Further info: www.diabetes.org.uk

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3.1.1.4 Hypertension
What is blood pressure?

 The pressure of blood in arteries, measured in mm of mercury (mmHg).
 Two figures: top is systolic (when heart contracts), bottom is diastolic (when heart rests)
What is high blood pressure?

 Sustained 140/90 mmHg or above. Can be just systolic (eg. 170/70) just diastolic (e.g.120/104)
 Over or above 160/100 mmHg usually offered medication to lower it
 140/90 - 160/100 may not need treatment unless: CVD or risk of, diabetes, heart/kidney damage
 130/80 - 140/90 may need treatment if diabetes complication, MI, TIA, stroke, kidney disease
 One-off may be high if stressed or just exercised. Need several readings on diff occasions
 May need an observation period with readings every few weeks or ambulatory BP
What causes high blood pressure?

 Usually unknown (essential hypertension) or slight narrowing of the arteries
 Secondary hypertension – e.g. due to certain kidney or hormone problems
How common is high blood pressure?

 Half of >65s in UK, 25% middle aged
 Linked to: diabetes, Afro-Caribbean, Indian, family history, overweight, salt, poor diet & exercise
Why is high blood pressure a problem?

 Increased risk of CVD (e.g. heart attack or stroke), and kidney damage
  diastolic by 6 mmHg reduces relative risk of stroke by about 35-40%, and CVD by 20-25%.
Am I at risk?
 Risk factor calculator: calculated from age, sex, smoking status, blood pressure, cholesterol etc
 If 20% risk of CVD within next 10 years, then treatment advised
Do I need any further tests?

 May also need urine test (protein or blood), blood test (kidneys, cholesterol, sugar), ECG
 Check secondary causes, heart, other risk factors eg high cholesterol level or diabetes.
How can blood pressure be lowered?

 Tackle lifestyle: weight, exercise, diet, salt, caffeine and alcohol. May be enough
 Antihypertensives if >=160/100 mmHg (or 140/90 and other risks), also statins, low dose aspirin
 Aiming for < 140/90 unless diabetes, CVD, CKD in which case even lower
 Drugs include:
o ACE inhibitors cause blood vessels to relax (e.g. ramipril). SEs include dry cough
o Calcium blockers relax blood vessels (e.g. amlodipine) SEs include dizziness, constipation
o Diuretics (e.g. bendroflumethiazide)  salt and fluid passed in urine. SEs include gout
o Beta-blockers (e.g. atenolol) slow heart rate. SEs include tiredness
Further information: www.bpassoc.org.uk
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3.1.1.5 Smoking cessation
Smoking Facts
 Greatest cause of illness and premature death in UK. Mainly cancer, COPD, and heart disease.
 Half of all smokers die from smoking-related diseases. Life expectancy 10 years less.
 Nicotine: Next cig to avoid withdrawal; Tar: deposits lungs, blood vessels, other parts of the body.
 Over 4000 chemicals, including 50 known carcinogens; Carbon monoxide:  O2 to self or baby.
Which diseases are caused or made worse by smoking?

 Causes 29% of all cancer deaths. 80% lung cancer & COPD. 1/7 heart disease deaths.
 Other cancers: mouth, nose, throat, larynx, oesophagus, pancreas, bladder, cervix, blood, kidney
 Strokes, vascular disease, aneurysms, sexual problems, wrinkles, reduced fertility.. etc…
 Worsens: asthma, colds, infections, rhinitis, diabetic retinopathy, hyperthyroidism, MS… etc…
 Pregnancy - increased risk: miscarriage, premature birth, illness, stillbirth, long-term development.
How does smoking affect other people?

 Children: asthma, infections, SIDS, academic achievement, asthma, becoming smoker
 Adults: lung cancer, heart disease, worsens asthma.
Benefits of stopping smoking?

 Benefits straight away. Sooner you stop, the greater the reduction. Never too late!
 Chest infections and colds less frequent. Smell, taste, financial.
 If smoked since teens and stop before 35: life expectancy only slightly less. Before 50: risk  50%.
How can I stop smoking?

 2 in 3 smokers want to stop. Willpower and determination are most important aspects
 NRT – up to 25% quit. Available in many forms. Can help control weight. SEs: nausea, dizziness,
flu-like, palpitations, dyspepsia, hiccups, insomnia, vivid dreams
 Bupropion (Zyban) up to 40% quit. NOT in pregnancy, breastfeeding, bipolar, seizures, eating
disorders. Risk of seizures and drug interactions. SEs include: seizures 1/1000, insomnia, dry
mouth, hypersensitivity reactions
 Varenicline (Champix) reduces craving. NOT in pregnancy or < 18. SEs: nausea, insomnia, dreams,
headaches, flatulence. Irritability, depression and/or insomnia on stopping the drug.
Tips To Help
 Write a list of the reasons why you want to stop, and keep them with you.
 Set a date for stopping, and stop completely. Get rid of ashtrays, lighters, and all cigarettes.
 Tell everyone that you are giving up smoking. Get a stop buddy.
 Be prepared for withdrawal: worse at 12-24 hours, gradually eases over 2-4 weeks.
 Avoid risky situations: e.g. avoid pub for a while.
 Take one day at a time. Mark off each successful day on a calendar.
 Put away the money you would have spent on cigarettes for a treat or holiday
 Anticipate an increase in appetite: try sugar-free gum and fruit
 Don't despair if you fail. Learn from your mistakes. May take 3 or 4 attempts
Further information: www.smokefree.nhs.uk

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3.1.1.6 Obesity
Am I obese or overweight?
 Body mass index (BMI) estimates how much of body is made of fat. weight (kg)/height (m)2
o <18.5 Underweight - Some health risk
o 18.5 to 24.9 Ideal - Normal
o 25 to 29.9 Overweight - Moderate health risk
o 30 to 39.9 Obese - High health risk
o 40 + > Very obese - Very high health risk
Waist size
 Health risk greater when fat mainly round waist > 102 cm men, > 88 cm women (-10 if Asian)
Benefits of losing weight?

 May feel better, have more energy, improve self-esteem.
If you are obese and reduce weight by 10%:
 Reduced risk of diabetes, high blood pressure, stroke, heart problems, cancer, arthritis gallstones,
menstrual problems, incontinence, breathing probs, pregnancy complications, depression.
 Chance of dying in near future reduced by about 20%.
What is the cause of obesity?

 If energy in doesn’t = energy out then it’s converted to fat
 Most obese or overweight people have a normal, or even high, metabolic rate!
 Caveman theory – we eat more than we need but food no longer scarce.
 Alcohol contains a lot of calories
 Todays lifestyle more sedentary (average UK person watches 26 hours TV per week)
 Inheritance: learn bad eating habits from parents. May be partly genetic.
 < 1 in 100 obese people have 'medical' cause (e.g. Cushing's, hypothyroid, some medicines)
How can I lose weight?

 Motivation is crucial
 Monitor current food intake: keep a food diary (dietician can calculate calories)
 Eat a healthy balanced diet: 5 a day, mostly starch-based, little fat, eat fish, avoid processed food
 Cut back on alcohol
 Do at least 60-90 minutes of moderate physical activity at least five days a week
 Be realistic: losing 5 kg is good, 10 kg is excellent
 Lose weight gradually: ½-1 kg per week. Gets harder as time goes on.
 Address depression or other mental health problems. Counselling may help
 Special diets usually unhelpful. Need to change eating habits for good.
 Medical treatments, e.g. Olrlistat (3 months), but you still need to change your lifestyle
 Surgery is an option if you are very obese. Results are usually good. But risks involved.
 Local support group – e.g. Weightwatchers, Fat Fighters etc.
 Important to maintain healthy lifestyle to keep the weight from coming back
Further information: http://www.nhs.uk/Livewell/loseweight
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3.1.1.7 CVD risk
What is cardiovascular disease?

 Diseases of the heart or blood vessels
caused by atheroma (small fatty
lumps within arteries)
 Aka 'hardening of the arteries'.
Narrows arteries, can reduce blood
flow, clots may form.
 Can cause heart attack, angina,
stroke, peripheral vascular disease
Who is at risk?
 Adults aged > 40.
 Strong family history (dad or
brothger with CVD before 55, mum
or sister CVD before 65.
 First degree relative with serious
hereditary lipid disorder, e.g. familial
hypercholesterolaemia
What does screening involve?

 Lifestyle risk: smoking, obesity, poor
diet, exercise,  alcohol.
 Blood test: cholesterol, glucose &
blood pressure
 % score using above, age, sex, family
history, ethnicity = chance CVD in
next 10 years.
 High risk - 20% or more, moderate If no HDL is available, assume it is “1”
risk - 10-20%, low risk < 10%
Do I need treatment?
 Yes if high risk, existing CVD, diabetes, certain kidney disorders.
How is it treated?
 Tackle any lifestyle issues: smoking, diet, weight, exercise,  alcohol. May be enough.
 Drug treatment (usually statin) aims to reduce cholesterol by 4 mmol/l
 Statin side effects: Muscle pain, nausea, diarrhea, constipation, rash or flushing, liver damage,
dizziness, possible link to memory loss (controversial)
 Also antihypertensives, daily low dose of aspirin (helps prevent clots)
Further information: www.bhf.org.uk
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3.1.2 Examinations / skills
3.1.2.1 ENT Exam
1. Introduction, explanation, consent
2. Inspection (alert, comfortable, no resp distress)
3. Check temp
4. Throat:
- Look at mouth (mucous membranes, teeth, swelling, exudates, redness, white patches, halitosis)
- Tongue depressor, Aghh – soft palate rising on phonation (comment on appearance of tonsils)
5. Feel sinuses. Does it hurt when you lean forward?
6. Nose – tilt head back. (mucous, redness or swelling)
7. Ear – inspection
External ear - Redness/swelling? press on pre-auricular/post-auricular and mastoid bone
Internal ear - Tympanic membrane visible/intact/light reflex/shiny? Redness/swelling/discharge?
8. Lymph nodes
In kids, could do distraction test at the end: Distract from front, sound from side
In kids: do throat last (most distressing bit) and remember to position baby/child correctly on
mum’s knee
Treatments
Otitis media: if no better in 3 days or if perforated- amoxicillin
Otitis externa: gentamicin 0.3 and Gentasone HC
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3.1.2.2 Eye Exam
 Introduction, consent etc.

 Explanation: Bright light in eye, don’t look at light unless asked, will need to get very close
 Check opthalmoscope working
 Focus on distant object, breathe and blink normally
 Right eye, right side, right hand, arms length
 Demonstrate red reflex and move in towards it: optic disc should come into view: focus image
 Be systematic.
 Optic disc: Size, shape, colour, clarity, vessels at disc margin, papilloedema
 Blood vessels: arterio-venous nipping, silver or copper wiring, tortuosity, narrowing, pulsations
 Fundus in quadrants: dot and blot haemorrhages, microaneurysms, hard/soft exudates
 Macula: ask patient to look directly at light. should be creamy yellow.
 Attempt diagnoisis
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3.1.2.3 GALS
Screening Questions:
Do you have pain or stifness in joints/muscles/back?
Can you dress yourself completely without any difficulty?
Do you have any problem getting up and down stairs unaided?
GAIT:
Assess for symmetry, smoothness, ability to turn quickly
From behind look for:

- Muscle bulk and symmetry (Gluteal, Calf muscles)
- Straight spine, Level iliac crests
- Prominent or winged scapula
- Scaring, ulceration, effusions, swelling
From side look for :
- Normal cervical and lumbar lordosis, thoracic kyphosis
- Abnormal knee flexion or hyperextension
SPINE:
- Feel: Spinous processes
- Move: Trunc flexion (two fingers on lumbar spinous processes), Head lateral rotation,
flexion/extension, ear to shoulder, TMJ assessment
ARMS:
- Look: Front observations
- Move: Hands behind head (shoulder abduction and external rotation), Elbows into side with
palms facing downwards.
- Inspect palms of hands, power grip, squeeze fingers, precision pinch, squeeze MCP joints
With patient on couch assess:
LEGS:
- Full knee flexion and internal rotation of hip
- Patellar tap to exclude knee effusion
- Inspect doles of feet
- Squeeze MTP joints
How to record:
Appearance Movement
Gait Tick?
Spine
Arms
Legs
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3.1.2.4 Gait examination
See 1.1.3.6
3.1.2.5 Urine Dipstick
 Introduction, consent etc.

 Explain how to take a mid-stream urine sample (MSU)
 Avoid touching inside of pot to maintain sterility
 Don’t want start or end of stream
 Don Gloves
 Inspect + smell
o Dark: dehydration, jaundice, faeces
o Cloudy/smelly: infection (usually smell of ammonia)
o Pink/red: blood
o Frothy: protein
o Also looks for stones, debris, crystals
o Bubbly/smelly/faecal: colo-vesicular fistula
 Check dipstick label expiry date

 Dip
 Remove excess
 Wait given time (usually 60s)
 Read (making sure to have stick up the right way)
o Leu = Leucocytes - Infection, Cancer
o Nit = Nitrites - Infection
o Pro = Protein - Nephrotic syndrome, glom-nephritis, infection,
o Blood - haemolytic anaemias (sickle cell), Renal – Stones, infection, nephritis, cancer,
Ureteric – cancer (transitional cell carcinoma), Cystic – UTI, Urethral - STD
o SG = Specific gravity - Changes with dehydration and ARF
o Glu = Glucose - diabetes (glucose above threshold for tub trans)
o Ket = Ketones - DKA, Starvation
 Document findings
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3.1.2.6 Prescribing
 Introduction etc
 Check identity of patient and compare against notes
 Any drug allergies? Check, ask, & document
 Any other drugs (including OTC & herbal)? – consider interactions. Check the BNF
 Could the patient be pregnant?
 Explain reason for prescribing, likely effects, possible side effects, warning signs
 Write legibly in black ink

 Avoid all abbreviations apart from those in common use (e.g. “TDS” is OK)
 Todays date
 Name, address and date of birth of patient
 Age if under 12 years
 Generic name of drug
 Method of administration (orally, intravenously etc)
 Dose and frequency (avoid decimals and superfluous zeros – if micrograms spell in full
 Minimum dose interval if PRN
 Quantity to be supplied
 Signature
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3.1.2.7 Insomnia
Normal sleep
 Normal nights sleep has three main parts
1. Deep sleep. 2. REM (Rapid Eye Movement) sleep. Brain and eyes active. Most dreaming in this
stage, 3. Short periods of waking for 1-2 minutes (normally, don’t remember these)
What is insomnia?
 "A persistent difficulty falling or staying asleep, leading to impairment of daytime functioning".
 About 1 in 5 adults don’t get as much as they would like.
 Includes: not being able to get to sleep, waking up early, waking during night, not feeling refreshed
May be tired in the daytime, reduced concentration, be irritable etc
What is a normal amount of sleep? Varies. 6-8 hours average. Older people need less. 70s < 6 hours
Causes?
 May be no apparent reason. May just be concern about (normal) wakefulness
 Temporary problems: stress, a work/family problem, jet-lag, routine change, strange bed etc.
 Anxiety or depression: Other symptoms; low mood, lethargy, poor concentration, tearfulness, etc
 Sleep apnoea: obese people who snore, sleep apnoea: airways narrow or collapse
 Other illnesses: pain, cramps, cough, itch, hot flushes, dementia, mental health problems, etc.
 Stimulants: Nicotene, caffeine in tea, coffee, soft drinks, chocolate, some painkillers, illegal drugs
 Alcohol - causes broken sleep and early morning wakefulness.
 Prescribed drugs: diuretics, antidepressants, steroids, beta-blockers, slimming tablets, painkillers
 Unrealistic expectations, Daytime naps, Can be a vicious cycle
Things that might help?

 Short periods of waking are normal. Hide alarm clock under bed. Is bed comfortable?
 Reduce caffeine - do not have six hours before bed
 Do not: smoke six hours before bed, drink alcohol just before, have a heavy meal just before,
exercise just before BUT exercise in day is helpful, don’t study just before bed
 Try to get into a routine: don’t sleep during day, switch light straight off, get up at same time daily
 Bedroom: too hot, cold, or noisy? Earplugs / eye shades / dark curtains. Don’t work/eat/TV in bed
 'Wind down' before going to bed: stroll, bath, reading, warm drink, bed
 If not sleeping in 20-30 mins - get up, do something else, go back to bed when sleepy.
More possible solutions

 Relaxation techniques: progressive muscular relaxation – hypnosis tapes
 Sleep restriction: under supervision of doctor - sleep diary, restrict time in bed & increase gradually
 Psychologist: CBT: understand & alter unhelpful thought patterns
What about sleeping tablets?

 Not usually advised. Day drowsiness. Driving and machinery, falls in night, tolerance, withdrawal
 If prescribed, usually short course (a week or so) for bad patch.
Further advice: www.sleepcouncil.org.uk
Summarise C - Check understanding, A – Ask questions, L –Leaflet, F – arrange a Follow up

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3.2 Psychiatry
3.2.1 Histories
3.2.1.1 Depression
You are on placement at a GP surgery and have been asked to see Mrs. Hill. This 82-year-old lady has
been brought in by her daughter who is worried about how tearful her mother has been lately. Please
take a full history from Mrs. Hill.
- Can you tell me why you’ve come here today?

- Have you been feeling low in mood recently? How long for?
- Does your mood change at all? Low everyday? All day? Worse at any time of day e.g. first thing in
the morning?
- Can you think of anything in particular that’s causing you to feel down/ upset?
- Biological symptoms:
- Sleep (early morning waking?)
- Appetite, weight loss
- Anergia (low energy levels), loss of libido
- Concentration (if working age - work? Time off?)

- Anhedonia (able to gain pleasure from anything? e.g. can you laugh at a funny programme on TV?)
- Negative cognitions:
- Sometimes when people feel really low they can have feelings of
- Helplessness, hopelessness, worthlessness, guilt
- Have you ever had any thoughts like these?
- Have you ever felt like harming yourself or like ending your life?
- How do you feel about the future?

- Can you foresee a possibility of feeling a bit happier?
- Any similar episodes in the past?
- Are there ever any times when you’ve felt quite the opposite, excessively or inexplicably cheerful?
(screen for BPAD)
- PΨH, PMH, DH, FH of mental illness
- Social/ personal history including relationships, friends, work, premorbid personality, alcohol,
smoking, drugs
- Ideas Concerns Expectations Summarise
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3.2.1.2 Self harm/ suicide risk assessment
You are a junior doctor in A&E and have been asked to see this 26-year-old female who has taken an
overdose. Please take a focused history including a self harm/ suicide risk assessment.
Establish rapport
Can I check why you’re here? / e.g. I understand you’ve taken some tablets – is that right?
Screen for depressive symptoms: mood, anhedonia, sleep, appetite, libido etc. duration.
- Establish precipitating factors
What tablets? How many? When? All at once/ staggered? With alcohol?
What did you expect would happen?
Events leading up to it:

How long had you been thinking of it/ planning beforehand?
Did you go out to buy the tablets or have them in your house already?
Did you take all that were available to you?
Where were you? On your own?
What had happened in the day? i.e. why then? Triggers e.g. arguments?
Did you leave a note/ call anyone/ tell anyone what you were going to do?
What happened? i.e. how did they come to hospital?

Did you expect to be found? Want to be? Wish you hadn’t been?
How do you feel about having taken the tablets now?
What are the chances of you doing it again?
If now unlikely, why? Has anything changed? Original triggers been resolved?
Is there anything that might stop you? (protective factors)
Are there tablets still at home?
Is there anyone at home / any friends or family you could ask to be with you?
Have you ever tried to harm yourself in the past?

Past psychiatric history:
have you ever seen a dr. re: mental health?
Have you ever been to see a psychiatrist/ been treated for a mental health problem?
PMH, DH, alcohol, recreational drugs.
C - Check understanding, A – Ask questions, L –Leaflet, F – arrange a Follow up
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3.2.1.3 Cognitive assessment.
You are a junior doctor on a night shift covering the Medical Assessment Unit. Next on your list of
patients to clerk is Mr. James, an elderly gentleman who was brought into A&E by the police. They
had found him wandering the streets during the night. He had lost his keys and was unable to tell them
where he lived or where he was going.
They have since managed to verify Mr. James’s personal details as follows:
Roland James
Age 78
DOB: 24th May 1930
Address: 17, Norborough Avenue, Leeds LS7 3DJ
Please take a focused history including a cognitive assessment.
Suggestion of how to tackle a cognitive assessment
- Can you tell me/ do you know why you’re here?

- Have you been feeling a bit confused/ muddled at all lately?
- Have you found your memory’s not been quite as good as it used to be?
(or has anyone else commented on this?)
- Have your memory problems ever caused you to do things that could be risky/ dangerous? e.g.
leaving the gas on/ forgetting to lock the door/ getting lost/ wandering at night…(or are other people
concerned about these things?)
- Is it more difficult to remember things that happened a long time ago?
(e.g. Name of first school, where you grew up)
- Is it sometimes difficult to remember things that happened very recently?
(e.g. how did you come here?)
Time course
- gradual: think of progressive degenerative types of dementia
- suddenly/ fluctuating: think of delirium
- stepwise deterioration: think of vascular dementia
- Have you been feeling unwell at all recently? Fever, dysuria, cough?
- Depression screen: mood, sleep, appetite, concentration etc.
- PΨH, PMH, DH
- SH including level of independence in ADL, support at home, alcohol
- AMTS – see overleaf for details

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3.2.1.4 AMTS
You are on placement at a GP surgery and have been asked to see Mrs. Hill. This 82-year-old lady has
been brought in by her daughter who is worried about how forgetful her mother has been lately. Please
take a full history from Mrs. Hill.
- “I’m going to ask you some questions now that you might find bizarre or patronising but it’s just a
standard set of questions we ask lots of patients so I hope you won’t mind”
- Orientation in time
1. Year
2. Time
- Orientation in place
3. Where are we?
- Orientation in person
4. Age
5. DOB
6. Identify 2 people
e.g. you and examiner in OSCE
- Registration
** Ask patient to remember an address:
e.g. 42 West Street
Ask them to repeat it first **
- Long term memory

7. Dates of WW2
8. Monarch
- Attention and concentration

9. Spell WORLD backwards
(Ask them to spell it forwards first)
- Recall
10. Recall address
S - Summarise, C - Check understanding, A – Ask questions, L –Leaflet, F – arrange a Follow up
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3.2.1.5 Mini Mental State Examination (MMSE)
Old Tired Psychiatrists Persevere At Mnemonic Learning Codswallop

Orientation Time Place Person Attention Memory Language Construction
 Used for screening cognitive function. Not suitable for diagnosis.

 Affected by culture, intelligence and education
 Measures orientation, registration (immediate memory), short-term memory (but not long-term
memory) and language.
 25-30 out of 30 normal, 18-24 mild-mod. impairment, 17 or less severe impairment.
 Ensure patient is comfortable and establish rapport
 Use denominator of 30 unless patient unable (e.g. blindness) then ignore these Qs
Orientation (10)
 What is the year, season, date, day and month (max 5 points).
 Where are we: town, county, country, building, floor (max 5 points).
Registration (3)
 Ask the patient if you may test their memory.
 Name three unrelated objects (e.g., apple, table, penny) take one second each.
 Ask the patient to repeat them. (Registration) (max 3 points)
 Repeat for up to six trials (for later recall)
Attention and calculation (5)

 Ask patient to count backwards from 100 subtracting 7 each time. Stop after 5 subtractions
(93,86,79,72,65) (max 5 points).
 OR ask to spell “world” backwards. Max score 5 e.g. dlrow = 5; dlorw =3.
Recall (3)
 Ask to recall 3 objects above (e.g., apple, table, penny). (max 3 points).
Language (9)
 Naming: Show patient a watch and ask what it is. Repeat for pencil. (2 points).
 Repetition: Ask patient to repeat "No ifs, ands or buts" (max score 1)
 3-stage command: "Take a paper in your right hand, fold it in half and put it on the floor" (max 3
points).
 Reading: Ask pt to obey written command "CLOSE YOUR EYES" (max 1 point)
 Writing: Ask to write a sentence of their choice (do not dictate a sentence); must contain a subject
and verb and must make sense. Spelling, punctuation and grammar are not important (1 point).
 Copying: Ask them to copy the design exactly as it is. (All 10 angles must be present and two
shapes must intersect to score 1 point). Tremor and rotation are ignored.
S - Summarise, C - Check understanding, A – Ask questions, L –Leaflet, F – arrange a Follow up
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3.2.1.6 Mania
As a 4th year medical student, you are on placement on a psychiatric ward and have been asked to see
Mr. Thompson, a 70-year-old gentleman who was admitted yesterday with a manic episode. Please take
a full history.
- Can you tell me why you’re here?

- How has your mood been recently?
- Have you been feeling excessively cheerful / inappropriately so?
- Has this been making you behave differently?
- What do you do? Can you take me through a typical day?
- Do you find you need less sleep than usual?
- Are you more active but getting less tired? Why more active?
- Do you have enough time in the day to do all the things you want/ need to do?
- Have you been spending more money than usual? Earning more? Taking more risks?
- Do you feel your mind is more active/ like your thoughts are racing?
- How do you compare yourself to other people?
- Do you feel like there’s something more special about you?
- Things that harm others cannot harm you?
- More efficient? Special abilities?
- Have you had any unusual experiences? e.g. heard voices and turned to find noone there/ seen things
that you think cannot be real?
- Have other people commented that you’ve been behaving differently or having unusual ideas?
- How long has this been going on? Any previous similar episodes? Have there been times when
you’ve felt really low? If so, have you noticed an alternating pattern? How low? i.e. thoughts of self
harm/ suicide?
- Social/ personal history: alcohol, recreational drugs, social support, relationships, forensic history
(have you ever been in trouble with the police?)
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3.2.1.7 Auditory Hallucinations
You are attending a psychiatry outpatient clinic as a 4th year medical student. The next patient to arrive
is a 34-year-old gentleman called Harry Matthews, who has been known to psychiatric services for the
past 12 years and has a diagnosis of schizophrenia. His symptoms have long been well controlled until
recently. He is now complaining of “hearing voices”. Please take a focused history

- Have you had any unusual experiences recently? e.g. heard a voice but turned round to find there was
no-one there?
- Did it have the quality of a real voice like yours and mine?
- How many voices? Who? (voices you recognised?)
- Were they talking directly to you? / about you? / your own thoughts echoed?
- What were they saying?
- running commentary? Arguing about/ discussing you?
- Telling you to do things? Saying unpleasant things to/ about you?
- Can you give any specific examples?
- Where do the voices seem to be coming from?
- How long has this been going on? How often?
- What are you doing at the time? e.g. Falling asleep (hypnogogic)/ waking up (hypnopompic)
- What do you do when you hear them?
- How do they make you feel? Frightening/ distressing?
- Why is this happening, do you think?
Similar questions for visual hallucinations
- Have you seen any unusual things e.g. things you think cannot be really there?
Ask about other 1st rank symptoms:
-Delusions
Have you had any other unusual experiences?
e.g. getting messages from TV/radio
Have you been feeling paranoid/ threatened by anyone?
Has anyone else commented that you’ve been behaving differently or that you’ve been expressing
unusual ideas?
-Passivity
Have you ever felt your thoughts are being interfered with in any way?
- someone putting thoughts in your mind? (thought insertion)
- or taking them away? (thought withdrawal)
- or that others can hear your thoughts? (thought broadcast)
Do you feel completely in control of your feelings, actions and impulses?
Have you ever felt that someone else is controlling these things?
-Mood, sleep, appetite, concentration
-PΨH, PMH, DH, FH, SH including alcohol and recreational drugs.
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3.2.1.8 Alcohol dependency
You are on placement at a GP surgery and have been asked to speak to Mr. Roberts. This 54-year-old
gentleman has been encouraged to attend by his wife who is concerned about his excessive alcohol
consumption. Please take a focused history.
- Can I check why you’re here?

- Are you concerned that you’re drinking too much? CAGE
- How much in one week? Or in one day if everyday? How long for?
- Can you take me through a typical day? What do you do? Work?
- What are you like when you’ve had a lot to drink?
e.g. aggressive towards others? Ever hurt yourself / others?
- Had any treatment for alcohol misuse in the past?
TWiRP CHER
1. Tolerance: Do you feel like you need more and more to get the same effect?
2. Withdrawal symptoms: Shaking, sweating, nausea… Fits? Hallucinations (ever had any unusual
experiences such as hearing voices when no-one’s around/ seeing things which aren’t really there?)
3. Repertoire: Screen for fixed repertoire: Where? At home/ in pub? Alone/ with friends? Always the
same? When? All at one time of day / throughout the day? Early morning? What? Same drink every
time?
4. Primacy: Would you say that drinking is a major part of your life?
5. Control / Compulsion: Reduced control over consumption. How do you feel if you don’t have a
drink for a while? Do you ever feel like you need a drink?
6. Harm: continued drinking despite harm? How has your drinking been affecting your work/
relationships/ health?
7. Eye opener: drinking to avoid withdrawal
8. Rapid reinstatement/Relapse: Have you tried to cut down before – if so what happened? Did you
quickly return to old ways?
- Depression screen:
Mood, sleep, appetite, concentration, thoughts of self harm/suicide
- PΨH, PMH, DH including recreational drugs
- Do you feel like you might be able to cut down/ stop with some help?
Summarise C - Check understanding, A – Ask questions, L –Leaflet, F – arrange a Follow up
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3.2.1.9 Anxiety
You are on placement at a GP surgery and have been asked to see the next patient on your own. Angela
Scott, a 42-year-old lady has come to ask for some tablets “to calm my nerves”. Please take a full
history.

- Are you feeling anxious/ worried about something in particular?
- How long for? What about?
- Screen for depression:

- Has this been affecting your sleep/ appetite/ concentration?
- Feeling low in mood? Anhedonia/ Anergia?
- Negative cognitions: helplessness, hopelessness, worthlessness, guilt, self harm/ -suicidal ideation?
- Physical symptoms of anxiety:

- Panic attacks?
- If so, describe e.g. shortness of breath, palpitations (racing heartbeat), chest pain, pain elsewhere,
dizziness, tingling in fingers, overwhelming feeling that something bad’s going to happen…
- Headaches?
- How long do these symptoms last? How often? What do you do to make them stop? e.g. deep
breathing exercises…
- When do these symptoms come on? What are you doing at the time? When you’re feeling particularly
worried/ stressed? Out of the blue?
- How do you see the future? Can you foresee a possibility of things getting better?

- Personal/ social history including potential stressors e.g. finances, housing, work, relationships,
family; social support, relaxation, alcohol, smoking, recreational drugs.
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3.2.1.10 Obsessive / compulsive behaviour
You are on placement as a 4th year medical student at a GP surgery, and have been asked to see the next
patient, a 21-year-old student called Ben Parker. Ben has reluctantly been persuaded to see the GP by
his housemates who are becoming increasingly worried about his behaviour. For example, they have
observed him scrubbing his hands until they become sore and bleed, and report that he is spending so
much time cleaning that he is failing to meet essay deadlines. Please take a focused history from Ben.
- Obsessive thoughts
- Can you tell me about your thoughts? For instance…
- What kind of thoughts do you have? Do you ever have any unwanted / distressing thoughts?
- Are they intrusive/ disruptive? How much do they disrupt day to day life?
- Are these repetitive thoughts? How often?
- Do you try to resist them? How?
- Can you give specific examples?
- Do you ever worry about being unclean/ contaminated even after you’ve just washed?
- Do you worry excessively about things like whether or not you’ve locked the door/ turned taps/ oven/
lights off even when you’ve just checked?
- Do you ever have unpleasant thoughts about hurting yourself/ others/ doing bad things despite not
really wanting to? Ever acted on them?
- What do you do when you have these thoughts?
-Compulsive actions
- Do you ever find yourself having to check / touch / count things repetitively or perform any other
kind of ritual? What happens if you don’t?
- Biological symptoms of depression:

- Mood, sleep, appetite, concentration, anhedonia, anergia
- Cognitive symptoms of depression:
- helplessness, hopelessness, worthlessness, guilt, thoughts of SH/ suicide
- physical symptoms of anxiety:
- sweating, hyperventilating, palpitations, pain…

- SH including alcohol, recreational drugs, relationships, friends, work
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3.2.2 Counselling
3.2.2.1 Antidepressants history/counselling

You are a junior doctor working at a GP surgery. Your next patient is Julia McKay, a 33-year-old lady
who has been feeling inexplicably low in mood for the past 7-8 months. This has resulted in prolonged
periods of time off work. She has attended today to request “some pills to pick me up”. Please counsel
Mrs. McKay on commencing antidepressant therapy.

- Brief history to check antidepressant therapy is appropriate:
- How long have you been feeling low?
- Sleep, appetite, weight change, concentration, anhedonia
- Thoughts of SH/ suicide? Have you ever acted on such thoughts? What are the chances of you doing
this again?
- Have you ever felt completely opposite? i.e. excessively/ inappropriately cheerful? (screen for BPAD)
- PMH especially cardiac, DH including allergies.
- What do you know already about the treatment of depression?
- Have you had any thoughts about what you’d like to try?
- How do you feel about taking tablets? Shall I tell you a bit about them?
- Of the medicines available, the first one we’d try is one called fluoxetine.
- It’s a tablet that you’d take every day
- Most people (about 60%) improve
- Usually takes about 2-3 weeks to start working – can take a bit longer.
- It’s obviously not going to fix circumstances but should give you a bit of a boost, help you feel a bit
more positive, and improve your ability to cope with the circumstances.
- It’s important that you take it every day because if you miss a dose, it can make you feel rubbish –
sweating, shaking, nausea, very depressed.
- It’s important that you tell someone if you start to feel like harming yourself because motivation
levels can pick up before your mood starts to improve.
- Side effects:
- Nausea, vomiting, diarrhoea, tummy ache, agitation and anxiety
- common but should settle after a week or so persevere
- Other possible side effects may include decreased appetite, weight change, sleep disturbance,
sweating, sexual dysfunction.
- most people don’t notice such side effects but if you have any problems after the first couple of
weeks, come and tell us because there are other options
- Take for around 6 months after you’re better to help prevent a relapse.
- There are other things that can help
- talking therapies e.g. counselling, CBT
- regular exercise, eating well, trying to resolve personal problems
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3.2.2.2 Treatment options for depression
What are the treatment options?

 Important to rule out other possible causes, e.g. hypothyroidism, drugs
Mild depression: (e.g. may still be able to work, but with difficulty)
 Talking, counselling (may be aimed at specific problem), exercise, self-help resources
 Antidepressants not usually recommended for mild depression.
Moderate or severe depression: (e.g. great difficulty coping with normal activities).
 Antidepressants: don’t alter circumstances but ease symptoms, help functioning. More below
 Cognitive behavioural therapy: identify unhelpful ways of thinking and behaving
 Also interpersonal therapy, psychodynamic psychotherapy, exercise, counselling
Alternative treatments?
 St John's Wort: limited evidence. Interferes with a wide range of other drugs, teratogenic
 Electro Convulsive Therapy: severe depression not otherwise improved. SE – memory loss
 Light therapy if depression if seasonal
Other tips
 Talk to people who are close to you about how you feel. Try to keep busy. Eat regularly.
 Don't drink too much alcohol, avoid making major decisions whilst depressed (e.g. moving house)
Types of antidepressants
 SSRIs are recommended as first line for moderate to severe depression.
 Tricyclic antidepressants (TCAs) more side effects, e.g. sedation, cardiotoxicity
 Monoamine oxide inhibitors (MAOIs) used less often - drug interactions and tyramine in food or
drink can cause severe hypertensive reaction.
SSRIs – what are they and how do they work?

 Selective serotonin reuptake inhibitor: alter the balance of chemicals in the brain
 About 5-7 in 10 people improve within a few weeks of starting treatment. But not everybody.
 Do not necessarily make sad people happy.
 Takes 2-4 weeks to start working. Normal course lasts up to six months.
SSRIs – what if I miss a dose?

 If < 2 hours late take as normal. If > 2 hours check the information leaflet
 Missing a dose may make you feel rubbish sweating, shaking, nausea (reference?)
SSRIs - side-effects?
 Common: diarrhoea, feeling sick, vomiting, and headaches. Restlessness or anxiety, sexual
problems. Do not stop taking abruptly without consulting a doctor.
 Many side effects settle after a week or so.
 Some reports link SSRIs and feeling suicidal. Controversial. Make friends and relatives aware.
 Not addictive, but may get 'withdrawal' symptoms: dizziness, anxiety and agitation, sleep
disturbance, 'flu-like symptoms, diarrhoea, abdominal cramps, pins and needles, mood swings.
Further help: www.depressionalliance.org

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3.2.2.3 Antipsychotics
What are they and how do they work?

 Mainly to treat schizophrenia & bipolar disorder. Not cure but help make life as normal as possible
 Work by blocking dopamine's effects on the brain. Typical (1950’s), Aypical less side effects.
 May reduce anxiety within hours, but they may take weeks to reduce symptoms such as
hallucinations, or delusional thoughts. May be used in conjunction with talking treatments -CBT
Before starting on antipsychotics

 History of stroke, TIA, MI, ↑BP, diabetes, AF? (avoid Risperidone or olanzapine)?
 If depots: pulse, ECG, BP, BMI, FBC, renal function and liver function tests.
How are they taken?

 Will start with a low dose that may be increased every couple of weeks
 Can be taken orally (as a pill) or given as an injection (n.b. IM disadvantages).
 Slow release antipsychotics only need to have one injection every 2-6 weeks.
 May only need until your psychosis subsides, but usually 1-2 years
What if I miss a dose? Take as soon possible unless almost time for next dose. Don’t double dose.
What are the side effects?

 Typical antipsychotics: drowsiness, shaking, trembling, muscle twitches, spasms.
 Both types: weight gain, blurred vision, constipation, lack of sex drive, dry mouth.
 May be able to different drug to switch if side effects are particularly troublesome
 LT: Tardive dyskinesia: abnormal and uncontrollable movements face → body.
 Neuroleptic malignant syndrome (rare) ↑temp, rigidity, confusion, ↓consciousness
What about changing antipsychotics?

 Only stop under supervision. Cross tapering recommended when changing to another antipsychotic
Will I need regular tests?

 Regular reviews with community psychiatric nurse (CPN) to check for SEs etc
 Some atypicals (olanzapine and clozapine), have regular weight and blood glucose
Further help: http://www.mind.org.uk/
Ideas, Concerns, Expectations

Some common antipsychotics and side effects

Typ: Chrlorpromazine: One of most sedating. Photosensitivity. Avoid in glaucoma.
Typ: Flupenthixol: more neuromuscular effects. Also antidepressant effect.
Typ: Haloperidol: more neuromuscular effects. Liver toxicity. ↑ risk with Lithium.
Atyp: Amisulpiride: Caution in elderly and those with kidney problems.
Atyp: Clozapine: Need regular blood tests (Agranulocytosis), cardiac toxicity
Atyp: Olanzapine: Weight gain, dizziness or drowsiness
Atyp: Quetiapine: QT prolongation, elevated triglycerides
Atyp: Risperidone: Hyperglycaemia, stroke in >65 yr olds
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3.2.2.4 Antipsychotic history/counselling
You are on placement as a 4th year medical student at a psychiatry outpatient clinic. You have been
asked to see the next patient, 35-year-old Steven Parkes. Steven is attending for a follow up
appointment, having recently been commenced on risperidone. He has been experiencing some erectile
dysfunction and is upset by the amount of weight he has gained since starting this medication. He
wonders if the risperidone could be to blame and is therefore not keen to continue taking this as
prescribed. Please conduct a review of medications and discuss a suitable management plan with
Steven.
Can I check why you’re here?

What are you currently taking?
- Route? (tablets/ injections/ dispersible) Dose?
- How long for?
- What symptoms were you getting? Has it helped your symptoms at all?
- Check compliance (have you been taking it exactly as prescribed?)
- Any problems with this medication?
Have you tried any other medication for the same problem in the past?
- Which medication? Dose? How long for?
- Helped symptoms? Any problems? Why stopped?
PMH, other DH including allergies.
- Potential side effects.

- Do you know much about antipsychotics and their side effects already?
Two broad types, ‘typical’ and ‘atypical’ have some of the following potential side effects in
common… (That’s not to say you would get any of these)
- Symptoms similar to those of people with Parkinson’s disease e.g. muscle rigidity, slowness of
movement, involuntary movements, shakiness
- Weight gain, dry mouth, blurred vision, constipation, difficulty passing water
- Sexual dysfunction
Prefer to try the atypical antipsychotics first as they are much less likely to cause the Parkinson’s type
side effects in particular. However…
- Risperidone is known to cause sexual dysfunction and weight gain.
- Other atypical antipsychotics include…
- Olanzapine: doesn’t tend to cause sexual dysfunction but does cause weight gain.
- Amisulpiride: doesn’t tend to cause weight gain but can cause sexual dysfunction
- Have you tried quetiapine?
- Reducing the dose may be an option but there would be a risk of your symptoms coming back.
Therefore it may be better to try the quetiapine, on which you’re much less likely to get the problems
you’ve been having.
- How do you feel about this plan? Any other questions?
- Offer written information and draw patient’s attention to the leaflet inside the medication packet
which will include a list of potential side effects.
- Encourage patient to come back if any further problems to discuss other options.
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3.2.2.5 Clozapine
What is Clozapine?
 Aka Clozaril®, Denzapine® and Zaponex®. Available as tablets.
 Used to treat: symptoms such as hearing voices, seeing, feeling or sensing things that are not there,
unpleasant thoughts, feeling paranoid, feeling that other people can read your thoughts, etc.
 Often effective when other antipsychotics have failed.
How should I take it?

 Under medical supervision. First need to check if you have any of the following;
 Allergy, heart, blood, liver or kidney problems, fits, glaucoma, prostate problems
 Other medicines may interfere with it e.g. other antipsychotics, epilepsy drugs, anaesthetics
 Not if pregnant, planning pregnancy, or breast-feeding
 DO NOT STOP if feeling better - tends to be needed long term.
 If you want to stop discuss with your doctor
 If you forget a dose, take the missed dose as soon as possible, but do not double dose
 If you miss more than two days, see your doctor, nurse or pharmacist quickly.
How long does it take to work?

 Can take up to six to eight weeks
Do I need blood tests?

 Yes. Very important.
 Blood test before you starting, then every week for the first eighteen weeks
 Then every two weeks for first year, then monthly
 Due to very rare, but serious side effect (Agranulocytosis: sudden fever, rigors, sore throat)
 Can lower white blood cells count and weaken immune system
Side effects?
 Tiredness or sleepiness, lots of saliva and drooling, excessive sweating, headache, shakiness and
tremor, sickness, indigestion, hunger, dizziness, dry mouth, constipation, weight gain
 More serious: allergic rash, flu-like symptoms (fever, sore throat), fits, odd movements, stiffness or
twitches, blurred vision, slow, fast or odd heart beats, breathing problems, heart problems, blood
problems, diabetes, bladder problems
 Always ask doctor or pharmacist before taking any other medicines.
What Can I can I not do?

 Do not drive or work with machinery if it makes you drowsy
 Avoid drinking alcohol
 Avoid getting pregnant
Summarise, C - Check understanding, A – Ask questions, L –Leaflet, F – arrange a Follow up
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3.2.2.6 Lithium
What is lithium and what is it used for?

 Mood stabiliser used for manic episodes, bipolar illness, recurrent depression.
 Alters the way chemicals work in the brain. Known to be very effective.
 Causes little interference with normal emotional reactions.
Before starting to take Lithium

 Need some tests: Weight, BP, pulse, blood tests (kidneys, thyroid), ECG.
 Poss Contriaindicat.: psoriasis, heart, kidney, or thyroid problems.
 Avoid in first trimester pregnancy (teratogenic). Only later if essential.
 Avoid if breast-feeding - risk of toxicity.
 May take weeks before you feel the full benefits. It’s a long term treatment
How should I take it?

 Usually start on one tablet a day at same time each night.
 Do not crush or chew tablets as you might absorb too much
 Get the same brand of lithium each time you receive a new prescription.
 Do not stop taking it without discussing with your doctor first.
What if I miss a dose?

 If < 3 hours take normal dose. Otherwise do not double up on your dose.
What are the common side effects?

 Abdominal pain, nausea, metallic taste, fine tremor, thirst, polyuria, weight gain and oedema. Can
worsen acne, psoriasis, eczema
 Longer term: Underactive thyroid, mild memory problems (usually reversible)
Warning signs to look out for

 Blurred vision, loss of appetite, vomiting, diarrhoea, muscle weakness, drowsiness, lethargy,
shakiness and lack of co-ordination, fainting, inability to urinate, slurred speech or convulsions -
seek urgent medical attention.
 Carry a Lithium card (available from pharmacists).
The need for regular monitoring

 Blood tests (12 hours post dose) check levels after 5 days and 5 days after changes
 Further blood tests to check lithium level/U&Es at least every 3 months, TFTs every 6-12 months
and calcium and creatinine every 12 months.
What do I need to be careful about?

 Some medicines can cause problems: ibuprofen, ACE inhibitors, diuretics, SSRIs
 Drink plenty of fluids while you are being treated with lithium.
 Maintain usual salt intake and avoid changes from regular diet
 Consult doctor if you have heavy sweating, vomiting or diarrhoea
 No more than 1-2 units alcohol per day
Ideas Concerns Expectations

Summarise Check understanding, Ask questions, Leaflet, arrange a Follow up
126
3.2.2.7 ECT
You are a junior doctor on a psychiatry ward. One of your patients, a 68-year-old lady called Helen
Crawford, is suffering from a severe depressive disorder, which has caused her to stop eating and
drinking altogether. She is due to have ECT tomorrow morning. Helen’s husband, Michael Crawford,
is very concerned and upset and would like to speak to you. He has seen patients undergo ECT in the
film, One Flew Over the Cuckoo’s Nest and is not happy about his wife having “such a cruel, barbaric
treatment”. Please counsel Mr. Crawford on his wife having ECT.
- Can I check who you are/ why you’re here? What do you know about ECT already?
- It’s nothing like the film – made a long time ago
- ECT stands for Electroconvulsive Therapy – can be very effective in the treatment of severe
depression.
- As you may know, everyone has electrical activity in the brain and all we do in ECT is introduce a
very small bit more to just alter this natural electrical activity slightly.
- She will be put to sleep under general anaesthetic so she won’t be aware of what’s happening at the
time, and she’ll be well-looked after by specialist doctors, nurses and an anaesthetist who do this
procedure all the time.
- Two ‘electrodes’ (just like stickers) will be placed on her head and we just introduce a small amount
of electrical current for only a few seconds.
- The idea is to cause a fit (like an epileptic fit) but she will be given a medicine that relaxes the
muscles beforehand so she won’t hurt herself. She may have a slight twitching in her arms and legs for
the few seconds that the procedure lasts for but she certainly won’t be throwing her arms about or
anything like that.
- She will then wake up in the recovery room where she will again be well-looked after and reassured
by specialist nurses.
- Potential side effects such as headache, nausea, confusion and muscle pain, but these tend to be quite
mild and short-lived. There is also a risk of some memory loss, particularly for events surrounding the
ECT.
- However, severe depression can often benefit greatly from it.
“Aren’t there other options?”

Talking therapies and antidepressant medication can be very effective in mild-moderate depression and
these may well be things we think about if we can first improve her condition considerably with ECT.
This is the best option for her at the moment.
“How much will she need?”

Difficult to say – we will continually reassess her to see what she needs but patients usually have 2-3
sessions a week and most patients will need somewhere between 4-12 sessions in total.

S – Summarise, C - Check understanding, A – Ask questions, L –Leaflet, F – arrange a Follow up
127
3.2.2.8 Dementia
What is Dementia?
 A condition of the brain which causes a gradual loss of mental ability.
 May also develop personality changes, decline in social function, decline in ability to self care
 1 in 20 people > 65 years develop dementia. ~1 in 5 people > 80 years
 Most cases: Alzheimer's disease, vascular dementia or dementia with Lewy bodies.
 Differentials: depression, anxiety, underactive thyroid, 'Age Associated Memory Impairment'
What are the different types of dementia?

 Alzheimer's: ~6 in 10 cases. Brain shrinks and number of nerve fibres reduce. Some brain
chemicals involved in signalling reduce, especially acetylcholine. Tiny deposits or 'plaques' also
form throughout brain. Exact cause unknown. Not hereditary.
 Dementia with Lewy bodies: ~2 in 10 cases. Exact cause unknown. Tiny abnormal protein deposits.
 Vascular dementia: ~1 in 10 cases. Mental ability gradually declines. Like having many tiny
strokes. Increased risk: high blood pressure, smoking, high cholesterol level, lack of exercise, etc.
 Other causes: Alcohol abuse or infections which may be treated.
What are the symptoms of dementia?

 Memory loss. Most recent events forgotten first e.g. misplace objects.
 Later may appear to be 'living in the past'. May not realise age. Disorientation, new surroundings
confuse. Lose track of time, poor concentration, failing intellect, cannot grasp new ideas.
 Personality changes: irritable, moody, disinhibited, poor self care. May remain cheerful.
 Weight loss, falls, Severe dementia = lose speech, immobility, incontinence.
How fast does it happen?

 Tends to develop over several years (8-10 years from first signs to severe). But varies a lot.
How is dementia diagnosed?

 Standard 'memory test' to confirm. Rule out other causes (kidney, liver & thyroid, brain scan etc.)
Treatments? - None will reverse dementia.

 Cholinesterase inhibitors: (donepezil, rivastigmine, galantamine) work by increasing acetylcholine.
May slow progression of some symptoms in 50% of Alzheimers. Currently not available if mild
(controversial). Side-effects such as feeling sick, cramps and diarrhoea may occur.
 Memantine: Reduces calcium in certain brain cells. Seems to slow progression in some cases.
 Tranquillisers: if easily agitated. Antidepressants if depressed. Aspirin: reduce vascular risk.
 Other possible treatments: Reality orientation – e.g. board with details of the day, date, season etc.
Cognitive stimulation – e.g. recreational activities, problem-solving activities, and talking. Regular
physical activity, reminiscence therapy.
Who will care for me/my relative?

 Main carer often family member. Social Services advise on local facilities such as daycare centres,
benefits, help with care in the home, sitting services, respite care, etc. Voluntary organisations.
Residential or nursing home if appropriate. If carer, think of own health - ask a GP to assess.
 Further information: www.alzheimers.org.uk
128
3.2.2.9 Panic attacks
Counsel a patient who is experiencing panic attacks. Explain what they are, what causes them, and
what the treatment options are.
● What is a panic attack?
A severe sudden attack of anxiety and fear, often for no apparent reason. Stressful life events may
trigger them. Usually lasts 5-10 minutes
Symptoms: Palpitations or a thumping heart, sweating and trembling, Hot flushes or chills, shortness of
breath, chest pains, nausea, dizzy, faint, fear of dying or going crazy, numbness, pins and needles,
feeling of unreality.
Does not mean there is a physical problem with the heart, chest, etc. The symptoms may start as part of
the fight or flight response and get worse due to awareness of these changes.
Hyperventilating means you 'blow out' too much carbon dioxide which changes the acidity in the
blood. -> more symptoms; confusion, cramps, palpitations, dizziness, pins and needles. Vicious cycle.
At least 1 in 10 people affected. Women > men. Tend to run in some families.
● Dealing with a panic attack
Breathe slowly and deeply, into a cupped hand or paper bag..
● Treatment
If occasional No regular treatment necessary. Increase your understanding and get reassurance re:
physical symptoms.
If frequent: Avoid caffeine. Non-pharmacological: Relaxation techniques, Education, Cognitive and

behavioural therapy (> 60% of patients no relapse at 6 months), psychotherapy. Pharmacological:
SSRIs or TADs if no response with SSRIs after 12 weeks. 3-4 weeks for onset & usually need six
months. Side effects common. Benzodiazpines may cause tolerance and dependence so not currently
recommended.

129
3.2.3 Mental state examination
Appearance and behaviour

Mr. Shaw presented as a well-kempt, smartly dressed gentleman or an unkempt, unshaven gentleman,
dressed in heavily stained clothing, who appeared malnourished and older than his years.
He exhibited marked psychomotor retardation, entering the room very slowly and staring at the floor
throughout most of the interview, only making eye contact once or twice.
Or… He was restless and agitated, pacing the floor, but took a seat when invited to do so and remained
seated throughout a 30 minute consultation.
Or... He was pleasant and cooperative, reactive and appropriate, maintained good eye contact and good
rapport was easily established. He smiled on a number of occasions.
Mood
Subjectively his mood was “terrible” / “on top of the world” / “fine”
Objectively his affect was depressed / euthymic / elated / blunted or flat
Speech
His speech was spontaneous and coherent, with appropriate responses to questions, and was normal in
rate, tone and volume.
Or… He was dysarthric and difficult to understand. There was poverty of speech and he gave
monosyllabic responses to most questions.
Or… His speech was pressurised and high in rate, tone and volume. His speech was, at times,
disinhibited, as he would frequently swear and occasionally make inappropriate comments with
overfamiliarity.
Thought
Content
He was preoccupied with anxieties regarding his financial situation.
Or… He expressed fixed ideas of delusional intensity regarding his wife having an affair with a
pedestrian he saw crossing the street.
Or… He expressed a number of grandiose delusions. For example, he reported being next in line to the
throne, and that he has achieved 12 1st class degrees within 6 months.
He expressed negative cognitions of helplessness, hopelessness, worthlessness and guilt. He admitted
to having had thoughts of self harm but denies any current suicidal ideation, identifying concern for his
wife and children as a protective factor.
Form
There was no evidence of any formal thought disorder.
Or… He exhibited disorganised thinking. For example…
Loosening of association
- Lack of an obvious connection between one thought and the next. At its most extreme, this is
sometimes known as ‘word salad’ with no connections at all.
Flight of ideas
- A nearly continuous flow of rapid ideas that jump from topic to topic, which may be connected
only by rhyme or pun.
130
Tangential thinking
- ‘Going off on a tangent’ and never returning to the original point.
Circumstantial / circumferential thinking
- As above but eventually returning to the original point (over-inclusive).
- Not always pathological!
Thought blocking
- When a patient forgets what he/she is talking about, stops, and starts a new topic
- Again, not always pathological!
Neologisms
- Creating new words
Idiosyncratic word use
- Attaching new meanings to recognised words.
Perseveration
- Frequent repetition of words or phrases.
Palilalia
- Repetition of the final word of a sentence
Logoclonia
- Repetition of the final syllable of a sentence.
Echolalia
- Senseless repetition of words or phrases spoken by someone else.
Perception
He denied any false perceptions. However, he appeared to be responding to internal stimuli during the
interview.
Or… He described 3rd person auditory hallucinations in the form of a running commentary,
occasionally critical and unpleasant in nature.
Cognition
He was well-orientated in time, place and person, but appeared to have reduced attention and
concentration at times, and whilst his long term memory was grossly intact, his short term memory was
impaired. He scored 26/30 on the MMSE, with points lost mainly on the aspects of the test which
assess registration and recall, and attention and concentration.
Insight
He had poor insight as he did not believe himself to be unwell or that that he required any help or
medication.
Or... He had some insight, recognising that he has some problems regarding his mental health.
However, he does not appear to understand the full nature or severity of his condition. Nevertheless, he
is currently agreeable to stay on the ward for the time being and is compliant with medication.
131
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4 Year OSCE Guide: (Hold Key and Click To Go Straight To The Page You Want)

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4th Year OSCE guide

1.1.1.1 Gastro-oesophageal reflux

 Intro, purpose of discussion, engage child if poss

 What causes it?

 Are there any serious complications? GORD complications:

 Ideas Concerns Expectations Summarise

 Intro, purpose of discussion, engage child if poss\

The MMR Controversy

 Ideas Concerns Expectations

 Intro, purpose of discussion, engage child if poss

 Is it common? Up to 4% of children, usually between 6 months and 6 years. Genetic predisposition

 What causes it? Temps over 39°C affect ‘wiring in brain’.

 Ideas Concerns Expectations

 Is it common?: 5% of school children suffer constipation.

 Ideas Concerns Expectations

What are the different types?

 Ideas Concerns Expectations

Causes and triggers:

What to do during an attack:

See also: http://www.nhs.uk/video/pages/medialibrary.aspx?Tag=Children+and+babies+&Page=4

Causes and triggers:

Summarise. Check understanding, any Concerns? Ask questions. Leaflet. Follow-up.

 Ideas Concerns Expectations Summarise

What are the symptoms

What causes it?

Ideas Concerns Expectations Summarise

 Appropriate introduction – full name and role

 Ask if parents have red book and have a look

 S – Summarise - C - Check understanding, A – Ask questions, L –Leaflet, F – arrange a Follow up

1.1.3.1 Developmental exam

Causes of developmental delay: Prenatal (genetic, metabolic e.g. phenylketonuria, teratogenic,

General Any signs of GI disease? Stomas, special dietary foods

Patient Is the patient breathing comfortably, level of consciousness,

Hands “Warm and well perfused”

Forearm Pulse, blood pressure, muscel wasting, scratching

Neck JVP, Lymph nodes

Eyes Jaundice, anaemia, xanthelasama, corneal arcus, exopthalmos,

Face Telangiectasia, spider naevi, angular stomatitis, hydration,

Chest Spider naevi, gynaecomastia

Abdomen Asymmetry & shape, lumps or swellings, striae gravidarium,

Palpation Check if any pain first!

Percussion Liver, spleen, bladder, shifting dullness

Auscultation Bowel sounds – comment on normal

End Pieces S – stool sample

 Appropriate introduction and explanation

 Ideas Concerns Expectations Summarise

 Remember to thank the patient & parent(s)

 Attempt diagnosis if required

 S – Summarise - C - Check understanding, A – Ask questions, L –Leaflet, F – arrange a Follow up

 Introduce self and clarify patients name and date of birth

1 = Normal wear 5= Splay foot

 S – Summarise - C - Check understanding, A – Ask questions, L –Leaflet, F – arrange a Follow up

(See overleaf for abnormal gaits)

Antalgic gait: altered to reduce pain

Abnormality Causes & treatments

1.1.3.8.1 Upper Limbs

General Inspection Performed/Identified

Tendon reflexes Performed/Identified

General Inspection Performed/Identified

Intro Wash hands, name, role, confirms patients agreement

V Trigeminal: sensory – pin prick and cotton wool

VIII Vestibulocochlear: Air conduction

IX & X Sensoimotor: Gag reflex – understand but do not try to elicit