ASPIRE ASPIRE: THE QUEST FOR EXCELLANCE a Facebook Pa; a! plab a Facebook Grou spire2plab & Tube: u AnkurGargAspire S Cy ram: aspire2education @ “a ‘\ E-mail: info@aspire2plab.com C Q Website: www.aspire2plab.com Y / “The best preparation for tomorrow is doing your best today”. H. Jackson Brown, Jr. 167 Union Street, Oldham, Greater Manchester, OL11TDDisclaimer! ASPIRE2PLAB Ltd does not guarantee or declare that the information on this is accurate and correct. They are not responsible, nor can they be held liable for any errors or interruptions in the content of the webinar. ASPIRE2PLAB is neither responsible nor liable for any damage caused by viruses to your computer or other property due to your accessing using or surfing the site or through the downloading of material, information, text, images, videos, webinars or audio from the site. The views expressed by speakers or other third parties in these webinars, are those of the speaker or third party and not necessarily of ASPIRE2PLAB. 167 Union Street, Oldham, Greater Manchester, OL11TDFollow Us & Stay Connected with us through our SOCIAL MEDIA Platforms. ‘OUR JOURNEY Aspire was founded in DECEMBER 2017. Started with small batches of Doctors coming to. the UK to attend our training courses for PLAB. Since then, Aspire has grown to be the leading training facility for Foreign Doctors. Aspire kept moving forward and leading the charge in conducting courses all over the world including INDIA, EGYPT, BURMA, UAE, TURKEY, NIGERIA and BANGLADESH. Aspire has conducted over 50 courses with outstanding results till date,. Aspire is literally everywhere! Aspire has digitally taken the PLAB Courses directly to your ‘homes with ONLINE Courses. We are proud to say that we have conducted webinars for ALL on a regular basis. The testimonies speak for themselves. Aspire could not have achieved it without the support of the fantastic team of tutors and'mock examiners. Ps. We have continued running courses ONLINE during the Pandemic and will continue to doso. We are the ONLY training facility to have OPEN ACCESS for all DOCTORS to view our ‘examination videos. Follow usion YOUTUBE! YouTube: https://www.youtubéleom/e/ankurGargAspire/ PLAB 2: Introduction https: 1 (PSO Hip Examination https: i be/hmzvtej Elbow Examination https://youtu.be/LVFVEFF4Ick Knee Examination https://youtu.be/ZESSDPKc-ka Upper Limb Examination 167 Union Street, Oldham, Greater Manchester, OL11TD_https: 1. /DB_s2Rk Blood Sampling Basic Life Support hittps://voutu.be/FHPX2gNUEVE Meningitis https://youtu.be/A4iPHEGEOTs \ Ai bef Hw\ Otoscopy Antenatal 167 Union Street, Oldham, Greater Manchester, OL11TD167 Union Street, Oldham, Greater Manchester, OLL1TDTable of Contents Epi Pen Teaching. Mannequin Patient (Urosepsis) Cystic Fibrosis .. PMS. ‘Mood Swings (Depo-Provera) .. Negativism. PMR Refusing Steroids...... Post-Partum Psychosis (Telephonic) ‘STI (Male) UTI in Pregnant Woman. Pregnancy (16-Year-Old Vomiting) . Prescription Writing (Terminally ill patient) .. Infective Exacerbation of COPD (Prescription Alcoholic Hepatitis. Antenatal Check-up (Rubella/RH Neg: Boaen 12 Low Mood (Lesbian Miscarriage) Depression (CBT Failed) Hypothyroidism... PeEE ERE REESE Otoscopy Child... PSA Rectal Examination Seborrhoea Keratosis.Epi Pen Teaching You are an FY2 in A & E. Mother of 3 year old child was brought in to the hospital because of anaphylaxis happening second time. Talk to the mother and address her concern. D: How can | help you? M: My child has got peanut allergy and he got this anaphylaxis attack second time. | was given Epi-Pen and | was explained how to use it previously. However, | didn’t listen properly to the doctors that time. This time | was very worried when he developed the attack. D: Do you know how to use it? No 1, Pull off blue safety Cup. Grasp EpiPen in dominant hand, wi cap and form fist around EpiPen and pull of the blue safety c the sky, orange to the thigh’. 2. Position Orange Tip. Hold the EpiPen at a distance o 10cm away from nes ie to 3. Jab Orange Tip. Jab the EpiPen firmly into t! Hold firmly against thigh for 3 seconds piper discarded. The orange needle cover 16 4. Dial 999. Dial 999 and ask for ambylanee andstate ‘angle (90° angle). be removed and safely r the needle. yylaxis’. Severe Symptoms: ifficulty/noisy breathing ‘Swelling of throat and@iputh Difficulty swallhtly elevated to keep your blood flowing or sit up if breathing is Id lie down on left side. Place the patient in the recovery position if unconscious. Remember: 1. Note down the time the Epi-pen was used, if there is no response within 5 mins use a second Epi-pen if available. 2. Always carry 2 pens with you. 3. Discard the pen to pharmacy, ambulance or hospital staff.Mannequin Patient (Urosepsis) You are an FY2 in Accident and Emergency. David, 80-year-old, has been brought in by daughter due to confusion. Talk to the daughter and address her concerns. D: How can | help you? : My father has been confused since morning. He has been mumbling and I can’t understand anything. ny other symptoms? P: He is going to the loo more often cloudy urine. (Ask about other UTI, BPH & Cancer symptoms) PMH: No positive finding PMH: No positive finding YU Examination/Investigations: Vitals: BP - 150/90, Temp — 38° All others normal Abdominal Examination: Bulge pubieArea P: Why is he behaving like D: He is in confusior 1e E@implication of Urinary Tract Infection. st ? tion of UTI. In fact, any infection at this age can cause changes as we get older, it responds differently to the yymptoms, sometimes old age people with such kind of infection -d signs of confusion, agitation or withdrawal. to admit him, and we will do necessary investigations like Bloods (FBC/UR&E’s/IFT/Glucose/ABG/Clotting Screen/Blood Culture), Urine test, ECG, Imaging (Abdominal USG). We will also measure his urine output. We will give him oxygen. we will give him fluids through his blood vessel as a drip. We will give him antibiotics through his blood vessel (Vein) to treat the infection. Ifin Sepsis > SEPSIS SIX: within one hour. Give high flow of 02, IV Antibiotics, IV Fluids to the patient. ‘Take Blood culture, serum lactate, and hourly urine output.We will give him pain killers if he has any pain. Once the infection is controlled, his symptoms should come back to normal. P: How long are you going to keep him in the hospital? D: We will keep him in the hospital till he gets better and his infection is treated. We will confirm this by doing blood tests. D: May I know if you have any concern for him to stay in the hospital? P: No doctor P: Isit stroke? D: gyCystic Fibrosis You are an FY2 in GP. Alisha, 30-year-old, has come to you for pre-natal counselling. Talk to her and address her concerns. D: How can | help you? P: 1am thinking of becoming pregnant and | am concerned about CF D: May | know why? P: My half-brother is suffering from Cystic Fibrosis. D: What kind of symptoms is he experiencing? P: I'm not sure because we don’t live together D: How is your general health? P:I'm fine D: Any symptoms? P:No D: How is your partner? P: My partner is fine Cystic fibrosis is an inherited conditi es 1ucus to build up in the lungs and digestive system. This cau: ns blems with digesting food. Symptoms of cystic fibr * recurring chest infectior * wheezing, coughi and damage to the airways (bronchiectasis) * difficulty puttin i * jaundice * diarrhoea, This, along with recurrent infections, can result in a build-up of thick, sticky mucus in the body's tubes and passageways ~ particularly the lungs and digestive system. A person with cystic fibrosis is born with the condition. It's not possible to “catch” cystic fibrosis from someone else who has it.How cystic fibrosis is inherited To be born with cystic fibrosis, a child has to inherit a copy of the faulty gene from both of their parents. This can happen if the parents are "carriers" of the faulty gene, which means they don't have cystic fibrosis themselves. Diagnosing cystic fibrosis In the UK, all newborn babies are screened for cystic fibrosis as part of the newborn blood spot test (heel prick test) carried out shortly after they're born. If the screening test suggests a child may have cystic fibrosis, they'll nee tional tests to confirm they have the condition: + a sweat test- to measure the amount of salt in sweat, whic! ortmally high d for in someone with cystic fibrosis ‘+ agenetic test - where a sample of blood or sali faulty gene that causes cystic fibrosis These tests can also be used to diagnose “ children and adults who didn’t have the newborn test. Antenatal: Amniocentesis/cho <) ) Treatments for cystic fibrasis: Medicines for lung os Medicines fordang pt includ@Antibiotics, Steroids, bronchodilators, medicine to reduce the | \d to make the mucus in the lungs thinner. Any kind activity, like running, swimming or football, can help clear mucus from jprOVe physical strength and overall health. A physiotherapist can advise on the right exercises and activities for each individual. Dietary and nutritional advice Eat high-calorie diet, vitamin and mineral supplements, and taking digestive enzyme capsules with food to help with digestion. Lung transplants.Complications of cystic fibrosis: People with cystic fibrosis also have a higher risk of developing other conditions. These include: Osteoporosis, DM, Nasal polyps, sinus infections, Liver problems, fertility problems. Prognosis: Cystic fibrosis tends to get worse over time and can be fatal if it leads to a serious infection or the lungs stop working properly. Choices for having children: ions available to couples who are both CF carriers whi wolves prenatal testing to check if CF has been passed on in members of a couple are CF carriers and planning children) local genetics service. An appointment will then be arr: options.PMs. You are an FY2 in GP. Angela Di Caprio, aged 17, has come to you with complaint of headache. Talk to her and address her concerns. D: How can | help you? P: 1am having headaches on the right side of my head for the last one year. Scoring - 7/8, paracetamol didn’t help. D: Is the headache there all the time? P: only during my periods. D: How long does your period last? P:S days. D: Any other symptoms? P: No (Rule out headache differentials) PMH: Negative Personal: Not sexually active and not taking Patience concerns: What could this be Ipame with this? The most common symptoms ‘* mood swings * feeling upset, anxious opierit '* tiredness or trouble slee| * bloating or tummy + breast tenderne ‘+ headaches + spotty skin(@F greasy * changes in’ rive Treati I syndrome) ‘As well ur lifestyle, a GP can recommend treatments including: + hormo —such as the combined contraceptive pill + cognitive B@bavioural therapy —a talking therapy + antidepressants If you still get symptoms after trying these treatments, you may be referred to a specialist. This could be a gynaecologist, psychiatrist or counsellor. Do regular exercise eat a healthy, balanced diet get plenty of sleep ~7 to 8 hours is recommendedtry reducing your stress by doing yoga or meditation ‘take painkillers such as ibuprofen or paracetamol to ease the pain keep a diary of your symptoms for at least 2 to 3 menstrual cycles — you can take this to a GP appointment Don't do not smoke do not drink too much alcoho! gy 10Mood Swings (Depo-Provera) You are an FY2 in GP. Katie, aged 29, has come to you with some concerns. One week ago investigations was done in the GP and came back normal. Talk to her and address her concerns. D: How can I help you? : My husband thinks | am moody on a monthly basis at the time of my periods from last 8 months. (Elaborate) Mood: Fine (According to her) Personal: 2 children, stopped Depo-Provera one year ago. Now using;natural ing method for contraception. The most common symptoms of PMS include: * mood swings * feeling upset, anxious or irritable * tiredness or trouble sleeping * bloating or tummy pain * breast tenderness + headaches * spotty skin or greasy hair * changes in appetite and sex drive Treating PMS (premenstrual As well as changes to you! + hormonal medi * cognitive behavioy + antidepressants reéommend treatments including: ontraceptive pill g therapy ine ~ su If you still ge€symptomseffter trying these treatments, you may be referred to a specialist. This could be’ gistpsychiatrist or counsellor. Do regular eat a healthy balanced diet get plenty of Sleep - 7 to 8 hours is recommended try reducing Your stress by doing yoga or meditation take painkillers such as ibuprofen or paracetamol to ease the pain keep a diary of your symptoms for at least 2 to 3 menstrual cycles — you can take this to a GP appointment Don't do not smoke do not drink too much alcohol uNegativism You are an FY2 in GP. Lisa James, aged 30, is concerned about her 4-year-old daughter. Talk to her and address her concerns. jow can | help you? P: My child doesn’t listen to me. She is always playing with her food. She is taking roughly 30 mins to go to bed. She sleeps alone. This has been going on for 3 months. She started her nursery 2 weeks ago. Social: | am the only carer. My friends take care of her when | have to go Autism — Negative ADHD ~ Negative D: Can you bring your child in to the hospital for assessmei P:Yes Patient Concerns: 1. Can you prescribe any medications? 2. Will this stay forever? Conduct disorders are the most com children and young people. They are antisocial, aggressive or defiant, a child of that age. Types of b people or animals. behavioural problem in ited and persistent patterns of fhan would normally be expected in , fighting, vandalism, and harming Conduct disorder is asional tantrum or “naughtiness” in a child. Younger chil disorder”. I se chil arguing (“op) type BPtonduct disorder called “oppositional defiant the antisocial behaviour is less severe and often involves ying (“defying”) the adults who look after them. Intee jth condde® disorders, the pattern of behaviour can become more extreme and ind aggression towards people or animals oW destruction of property © persistent lying and theft © serious violation of rules What causes conduct disorders? Possible environmental factors include: © a “harsh” parenting style 12© parental mental health problems such as depression and substance misuse parental history, such as the breakup of a marriage poverty individual factors, such as low achievement the presence of other mental health problems How can conduct disorder be treated? Several approaches have been developed for children at risk of, or diagnosed with, conduct disorders. In particular, parenting programmes are run by health and soci professionals to help parents improve their children’s behaviour. Treatmi jJdren themselves includes psychological therapies and sometimes, medication. Warning signs and symptoms: Younger children (aged under 11) may repeatedly argue with, disobey se looking after them. Selective prevention One of the key messages contained in the NI Slit of selective prevention. Selective preventi above average risk of develo} and prevent that from occurring. The disease than to cure one. in 1e importance and usefulness ntifyini individual children with an 1d then Providing treatment to try is usually easier to prevent a NICE recommend that younger! d selective prevention if ‘to seven years should be considered for ip TW poor household \derat i at schoo! story of child abuse or parental conflict, are separated or divorced otf of the parents has a history of mental health problems and tance abuse problems both parents have come into contact with the criminal justice Initial assessi@ent should involve checking for the following complicating factors: © a coexisting mental health problem (for example, depression or post- traumatic stress disorder) a neurodevelopmental condition (in particular ADHD and autism) a learning disability or difficulty substance misuse (in older children)In younger children aged between three and 11 years, a type of treatment programme known as group parent training programme is recommended. In some cases, drug treatments may also be recommended. Parent/foster parent/guardian training programmes NICE recommend that this treatment should be offered to children who: © have been identified as being at high risk of developing oppositional defiant disorder or conduct disorder have oppositional defiant disorder or conduct disorder are in contact with the criminal justice system becaus behaviour Parent/foster parent/guardian training programmes are based on t ig parents make the most of their parenting skills so they can, s behaviour. The programmes are run by specially trained he! fe professionals. They cover communication skills, problem-solving t Je ncourage positive behaviour in children. It is best if both parents, foster carers or gua te programme if this is possible and in the best interests of the child or yaungipersi The programmes are usually run on a’ isi fo to 12 parents, over the course of 10-16 meetings, with each m round Wto 2 hours. Medication Ina minority of case; ung person is finding it especially difficult to control their anger ioM@aljed WBperidone, which helps reduce aggressive tendencies, maybe nde The most cof of risperidone include: Parkinson's like symptoms such as muscle jerks and problems with body vents idaches insomnia Autism Symptoms: 1. Not responding to their name, 2. Avoiding eye contact, 3. Not smiling when you are smiling at them, 4, Repeating same phrase and movements like flapping of hands, 5. Not talking as much as other child, 6, Developmental delay, 7. Not socializing with others. 4ADHD Symptoms: The main signs of inattentiveness are: having a short attention span and being easily distracted making careless mistakes ~ for example, in schoolwork appearing forgetful or losing things being unable to stick to tasks that are tedious or time-consuming appearing to be unable to listen to or carry out instructions constantly changing activity or task having difficulty organising tasks Hyperactivity and impulsiveness ‘The main signs of hyperactivity and impulsiveness are: being unable to sit still, especially in calm or quiet sUefeundings constantly fidgeting being unable to concentrate on tasks excessive physical movement excessive talking being unable to wait their turn acting without thinking terrupting conversations little or no sense of dan, 15PMR Refusing Steroids You are an FY2 in GP. Janet, aged 50, has been diagnosed with Polymyalgia Rheumatica. She is on steroids, aspirin, lansoprazole and bisphosphantes. ESR and CRP are normal. Talk to her and address her concerns. D: How can | help you? P: | don’t want to take the steroids. (Elaborate the symptoms of PMR) Ask for GCA/Eye Problems. PMH: High Blood Pressure and Diabetes (Elaborate) Patient Concerns: Weight Gain - 13 Stones, Height - 170cmpDiabetes Pressure. 16Post-Partum Psychosis (Telephonic) You are an FY2 in GP. Amanda, aged 31, came to you with complaint of insomnia. Talk to. her and address her concerns. D: How can | help you? P:1 can’t sleep for the last S months since | gave birth. | am feeling tired also. Elaborate insomnia and tiredness. Mood ~ 2/3 No Suicidal thoughts/Hallucination/False belief. No thoughts of harming herself and baby. Lives with her husband and kid Told her situation to her mom, but her mom thinks that it’s normal Patient has to be admitted in the hospital for the further trgatment. Most women need to be treated in hospital. Ideal! be ir baby ina specialist psychiatric unit called a mother and baby ut . Medication * You may be prescribed one or mogg@f the follo + antidepressants © antipsychotics mood stabilisers (for exat ) ical therapy CBT Causes 1. postpartu a previous pregnancy or have a family history of mental health illnes: stpartum psychosis (even if you have no history of mental illness 2. al of bipolar disorder or schizophrenia 3. you rth or pregnancy 7sthMare) You are an FY2 in GP. Mark, aged 23, has come to you with some concerns. Talk to him and address his concerns. D: How can | help you? P: am having burning sensation when | pee. (Elaborate) D: Anything else? P: I noticed some discharge from my private area. (Green and foul smelling) Ask about UTI and STI symptoms. Sexual History: has a wife and another partner. Gives history of unj se} other partner. PMH: Insignificant Lifestyle: Insignificant Diagnosis: STI Treatment & 18UTI in Pregnant Woman You are an FY2 in GP, Samantha, aged 30, has come to you with some concerns. She is 29 weeks pregnant. Talk to her and address her concerns. D: How | help you? P: 1am having burning sensation. {UTI symptoms — present) Antenatal history — fine PMH: Not significant Personal: Not ignificant | would like to check your vitals, urine and bloods. y Ex: Nitrates and leukocytes positive. Treatment: Antibiotics and General Advices. 19Pregnancy (16-Year-Old Vomiting) You are an FY2 in GP. Leanne, aged 16, has booked an emergency appointment. Talk to her, assess and manage her concerns. D: How can | help you? P: I'm feeling sick from last couple days and I have vomited few times. D: Anything else? Also ask signs of dehydration. P:No D: Tummy pain, Fever, Loose stools, Trauma, Headache. P: LMP: late by one week. D: How was your periods previously? P: Regular Sexual History: Active and partner is 17-year- er. Weuse withdrawal method (Coitus Interuptus) P: Is this conversation confidential? D: PMH: Not significant Personal: Not significant Social History: ha¥Bgood relationship with her. | would like toi@fieck Is and Ufine pregnancy test. and UI Ex: Vitals not ositive Treatment: | Concel ell qaiom | am pregnant. She was n't know there is lot to take in. 20Prescription Writing (Terminally ill patient) You are an FY2 in Medicine. Leanne, aged 95, is suffering from pancreatic cancer and is. terminally ill. She is not eating and drinking, and we have decided to put her on palliative care with these medications. Please write this medicine in the prescription paper. As required: Morphine Cyclizine Midazolam (Agitation) Hyoscine bromide (Secretion) Paracetamol. Regular: Atorvastatin $ & anInfective Exacerbation of COPD (Prescription Writing) You are in Acute Medical Unit, Jonathan, aged 50, is a diagnosed case of COPD presented with pneumonia. He was admitted to the A&E last night and the consultant have decided to treatment community acquired pneumonia. Clarithromycin: 500 mg BD for 7 days (CAP) Titropium Bromide: 2 putts Serene: 1 puff Atorvastation: OD Levothyroxin: OD gy 22rus mesecrion 3 _TE5|| Write patient details or affix Sa Identification label | [aaa ; Resp Word [™ | Hospital Number: = Ds. Buon inveg || Bre. ay weer co it] 29 [eee be lo ces! ala Date of Birth: eae waren NHS Number: jows_|__a ___\ Pn aie a keen Raeemiae [ALLERGY STATUS should be confirmed and documented prior to medication being prescribed. Please indicate if there are 'no known allergies ie. NKA ‘Allergy oF Sensitivity to eran P a Name: Do DOLLAR DiS TRiCT signature: Ceeema ee kukelcciats emu ii Mic MEN | ONCE-ONLY and PRE-MEDICATION on fae | toe Type of Reaction (eg. rash) Date: Continual review as per POTTS Chart OXYGEN (see conPGUIDS12 for guidance) we DATEMONTA ToT eS aC 7 OR TRF Device Code: Venturi Mask (VM) Simple Face Mask (SFM); Huridified (HS): Non-rebreathing Maik (NAB); Natal Cannulae (NC) Hinmiitied via Trarhe Rk TMS)Eeusce) TELM MASTS UC Ste CSN MLA MLL SA) eI LL ANTIBIOTICS ONLY SEAT TES REGED [CLP RITHROMYCIN ee Bi 50 mM I En La TOP DAE logo | ess isle aa 7 2 Sewn evston |xnvree | 1 wocaTon Sexstames: | coro. — vm [vw [ose fone | Sato | Stora ‘PRESCRIEES SGNATURE (ALSO PRCT NAME CLEARLY) = cr — ‘- ‘scan ‘saammanes: | macho areRoveo: | —> mm ™ ‘ACOMONAL BORATION T resnmaacr Prescriptions for intravenous antibiotics must be reviewed after 24-48 hours, Switch to Meleneetnennersi ee Guinier Oke Rae EstoyFILEIN SECTION 3 5] {write it details or affix =e Identification label wo Toa Hospital Number: cor Nome: Address: aE OFAEMESON ional cg ae wnTON a TEN Date of Birth: oan ot NHS Number: PEE e sedan a heed REGULAR Yaa (aaa ‘DALTEPARIN, [am a TS TOE} S00 urths| SIC defer \<—De DAN Pour “ ANTI-EMBOLISM STOCKINGS [ar EY a} ET A HT ar Ta TREE a ToTRo Pury BRomo € = a ra 2 pute | payor aes ST CV 2-Toun EvsTon a CE Fy SéeeTI0E 250 Evowace Re pa — nH Be <— MARIA CLAPHAM A RETR ee TORU ST ATI aa 20 Po |not/ipe a 1 LUTON HEATER I i wil TevoTwieoxine 100. heron) Po peak aa a a 2 sagen greranner|REGULAR no» Tons Tusa J SSS TFET} {Pocme Bonne |se omen|B/e [ae l BareceTamel 1000 0ANTICOAGULANT TREATMENT (see CORP/GUID/310) EXISTING / NEW PATIENT Anticoagulant book issued (Counselling provided By... Giannini 1 First Name Diagnosisindication cee nonn wav Date Started. Desired Range of INR. Donage | Presibers Signature Dorage | Prescibers signature Dore | wm | mgidey | horimtmameceady) | Meer | Oxte | MR | movday | tabopriat name cent | SSP NON-ADMINISTRATION OF MEDICINES (see CORP/PROC/307) \WHEN THE PATIENT DOES NOT RECEIVE THE PRESCRIBED DOSE, THE NURSE MUST ENTER A NON-ADMINISTRATION CODE, INFORM DOCTOR iF DRUG OMITTED. 1. Patient refused 4. Nil by mouth 2. Patient away from ward 5. Mediine unavailable (attempt to obtain failed) 3. Patient unable to receive mediinevlor no access 6. Self-administered rmedicinesfor no access 7. Other reason - see notes INSTRUCTIONS FOR USE ‘Sign and print your name clearly against each prescription Use APPROVED DRUG NAME and print each entry LEGIBLY IN CAPITAL LETTERS in Black indelible ink. Do not we abbreviation of drug names. Always write units and micrograms in full NEVER alter existing instructions write a new entry. When drugs are dacontinued draw a diagonal line through the drug name and administration sections. Date and sign cancellation. All antibiotic prescriptions MUST have an indication and stopireview date Additional advice availabe in Prescribing Medicines CORPIPROC/30 Pharmacists ote any sgnifcant Trsert7 to Indicate checks or assessments completed SigyDate Ireervenion/gnatnaretieal care problem 0 inaiate ti SS ‘Drag history checkednedicines] Details of admission medication= reconciled ene (lease note problemslomissions) ‘Alergy status checked SigDate ‘Drug rewrite checked Sigdate PODs checked SigDate TT completed SigDete ‘Compliance aid in use NOYES Tao i Rt Cn EDAlcoholic Hepatitis You are an FY2 in Medicine. Janet, aged 40, came for the blood reports. Bilirubin - Normal ALT ~ Normal AST ~ 63 (Raised) Explain to her the blood results and address her concerns. D: How can |help you? P: am here for my blood results. D: Why did you have the blood test done? P: | turned 40 and that’s why | wanted my routine blood check doi ‘Ask symptoms for hepatitis Rule out Hep A, B, C PMH — Not significant Personal — Alcohol — daily half bottle of wine andweel ttle of Wine Social - Lives with husband, who is supporti westigations: ‘Symptomatic treatment Advice: Decrease al i Concerns: Alcotiol wi 23Antenatal Check-up (Rubella/RH Negative) You are an FY2 in Antenatal Clinic. Chelsea, aged 30, is 14 weeks pregnant and has come to the hospital for the reports. She came to antenatal clinic when she was 12 weeks pregnant for routine antenatal clinic. Report: Rubella; nonimmune Rh: -ve or O Rhesus antibodies were negative Blood: Normal. Urine: Normal D: How can | help you? P: I'm here for my results ‘Ask question for the ANC (for her and her child's well-bein Itis not a planned pregnancy and she is single parent. Personal: She is a smoker, alcoholic and cannabis abuser, Rubella Ababy born damaged by rubella is sai ‘ony {ubella Syndrome (CRS). Many will have hearing loss, cataracts, eyetorditions, end heart problems that require significant hospital cosmenndfetts th ughout their life. A baby’s brain can also be affected It can cause: loss of the baby (miscarriage) Sen that patient is not immune to rubella. misS@xh out on their MMR vaccinations could spread rubella so isk. If@RY of your friends or their children have a rash, it’s .m until the rash has gone. After you've had your baby, you 1S So you're protected next time you get pregnant. If patient is pregna This means that cl you need to better to st should have ie vaccine causes harm to unborn babies, but if you need the eit after your baby is born. MMR immuni- sation during pregnancy is Some young Women missed out on their immunisations when they were children. They be particularly at risk. We can give two MMR immunisations three months apart and with the second one at least a month before pregnancy will offer excellent protection against the disease. Rh Incompatibility If the mother is RhD negative, she'll be offered injections of anti-D immunoglobulin at certain points in her pregnancy when she may be exposed to the baby's red blood cells. This 24anti-D immunoglobulin helps to remove the RhD foetal blood cells before they can cause sensitisation. Rhesus disease can only occur in cases where all of the following happer + the mother has a rhesus negative (RhD negative) blood type the baby has a rhesus positive (RhD positive) blood type + the mother has previously been exposed to RhD positive blood and has developed an immune response to it (known as sensitisation) Rhesus disease can largely be prevented by having an injection of a medical immunoglobulin. This can help to avoid a process known as sensitisation, whi negative blood is exposed to RhD positive blood and devel Anti-D immunoglobulin The anti-D immunoglobulin neutralises any ive ens that may have entered the mother's blood during pregnancy. If the aptigens have beenMfeutralised, the mother's blood won't produce antibodies. gy 25Low Mood (Lesbian Miscarriage) You are an FY2 in GP. Joanna, aged 30, has come to you with low mood. Talk to her and address her concerns. D: How can | help you? P: I'm not feeling myself lately. D: Tell more about it. P: | had miscarriage 2 weeks ago. (sometimes says partner had miscarriage) D: Can you score your mood? P:30r4 ‘Supportive family and partner. Concern: 1. Will | ever feel better again. 2. Isit depression? Depression Core symptoms r without, a tendency to cry. ven for activities that you normally 1. Persistent sadness or low moot 2. Marked loss of interest enjoy. Other common symptoms Disturbed jovements. Nogeenyp symptom and? 1. Symptoms cause you distress or impair your normal functioning, 2. Symptoms occur most of the time on most days and have lasted at least two weeks; 3. The symptoms are not due to a medication side-effect, or to drug or alcohol misuse, or to a physical condition such as an underactive thyroid or pituitary gland. Doctors describe depression by how serious itis: ‘+ mild depression — has some impact on your daily life 26‘+ moderate depression — has a significant impact on your daily life + severe depression — makes it almost impossible to get through daily life; a few people with severe depression may have psychotic symptoms Risk assessment and psychosocial history: gprru-z &. Most people with depression will get better without treatment. However, this may take several months or even longer. Relationships, employment, etc, may be seriously affected. There is also a danger that some people turn to alcohol or illegal drugs. Some people think of suicide. Therefore, many people with depression opt for treatment. » Cognitive behavioural therapy (CBT): Cognitive therapy is based on the idea tt js of thifiking can trigger, or fuel, certain mental health problems such Antidepressant medicines: Antidepressant medicines ar it moderate or severe depression. Antidepressant medicatic nded for the initial treatment of mild depression. However, an ai .d With mild depression that persists after other treatm ‘ociated with a physical illness and patient had an episode of moder: ifgtead of CBT. IPT is based on the idea that your personal rge role in affecting your mood and mental state... For example, : may sometimes be recommended if the person has severe depression and other treatments, including antidepressants, have not worked. + For people starting an antidepressant: © Consider suicide risk and toxicity in overdose. © Explain that symptoms of anxiety may initially worsen. 27© Explain that antidepressants take time to work. © Explain that antidepressants should be continued for at least 6 months following, ion of symptoms, as this greatly reduces the risk of relapse. ‘SSRis and SNRIs side effects: Agitation, sickness, indigestion loss of appetite dizziness a sedating effect. headaches low sex drive (difficulties achieving orgasm during sex or masturb: (erectile dysfunction) These side effects should improve within a few weeks, alt! some sionally persist. Tricyclic antidepressants (TCAs) side effects: dry mouth slight blurring of vision constipation problems passing urine drowsiness dizziness weight gain excessive sweating ( heart rhythm pro! palpitations or a fast heartbeat (tachycardia) The side ef ‘ould @86e after a couple of weeks as your body begins to get used to the medicine. Don't ings up and 'go it alone’. Try to tell people who are close to you how |. It is not weak to cry or admit that you are struggling. sspair - most people with depression recover. It is important to remember 3. Don't drink too much alcohol. Drinking alcohol is tempting to some people with depression, as the immediate effect may seem to relieve the symptoms. However, ing heavily is likely to make your situation worse in the long run. Also, itis very difficult either to assess or to treat depression if you are drinking a lot of alcohol. 4. Don't make any major decisions whilst you are depressed. It may be tempting to up a job or move away to solve the problem. if at all possible, you should delay any major decisions about relationships, jobs, or money until you are well again. 28Do's 1. Dotry to distract yourself by doing other things. Try doing things that do not need much concentration but can be distracting, such as watching TV. Radio or TV is useful late at night if sleeping is a problem. 2. Do eat regularly, even if you do not feel like eating. Try to eat a healthy diet. 3. Dotell your doctor if you feel that you are getting worse, particularly if suicidal thoughts are troubling you. See the separate leaflet called Dealing with Suicidal Thoughts. ‘Sometimes a spell off work is needed. However, too long off work might dwelling on problems and brooding at home may make things worse. Ge reluctant to mention it. One example is sexual abuse as a ch psychological difficulties as an adult. Tell your doctor, gy 29Depression (CBT Failed) You are an FY 2 in GP. Steven Douglas, aged 35 has been divorced from his wife and is in depression. He saw the psychiatrist and he was given CBT treatment. Speak to the patient, take focussed history and address the patient concern. You are an FY 2 in GP. Maria Douglas, aged 35, has been on CBT treatment for her depression for 8 weeks. She has come in at 6 weeks and does not want to continue with it. Speak to the patient, take focussed history and address the patient concern. Low mood Because of the divorce. ru-z F A: Drinking heavily M Admission Medication??? Refer to Depression Scenal Pt. concern: 1. Side effect: ni ants: 2. Will it caug@tfoss of Ii 30Hypothyroidism You are an FY2 in GP, Katie, aged 35, came to the hospital for the blood results. T4 decreased TSH Increase. Please explain about the blood results and address her concerns. D: How can | help you? P: 1am here for my results. D: Why did you do this blood test? P:1 am having weight gain (Half stone and 3 months) D: Anything else? P: Feeling cold. P: Patient is feeling low. P: Patient is feeling tired. D: Anything else? P:No D: Any bowel problems? Any problem with menstru: PMH: Nothing significant. Personal: Nothing significant. Social: Works as an receptionist. Pt. Concern: 1. Why | am having this problem? 2. What we are going to do? QS 31Dementia Mother You are an FY2 in GP.Elenna Petrovich, 80 years old, was diagnosed with dementia 3 years ago. Patient is a diagnosed case of Hypothyroidism taking Thyroxine. Patient is taking Amloidipine for the high blood pressure. Daughter is concerned about the deteriorating health of the Mother. Alll the blood tests are done and are normal. Talk to the daughter and address her concern. was expecting your call dr. D: May | know what exactly happened? : When I come home, and | see the faeces in the room, and she keeps o: her childhood. (Mother has incontinence) Sometimes she thinks | am her Mom. Assess the mother: PMH Personal: Social: Mother is active, and she is able to do i She needs support from the doctors. Offer her support: Arrange video conferencing with the Dementia Nurses Social services. Carer at home Day care Care homes. 32Abdominal Examination You are an FY2 in Medicine. Andy is a 2™ year medical student, he has missed his class for abdominal examination. Teach him abdominal examination. Do not let him do the examination. Students Concerns: Peritoniti nm Abdominal i a of your stomach muscles that worsens when you touch, or someone else touches, your fdomen. This is an involuntary response to prevent pain caused by pressure on your abdomen. Abdor It is the tensing of the abdominal wall muscles to guard inflamed organs within the abdomen from the pain of pressure upon them. The tensing is detected when the aBpminal wall is pressed. General Inspection: Inspect of the hands Inspect the palms for Pallor, Palmar erythema and Dupuytren's contracture Inspect the nails for the Koilonychia and Leukonychia. To assess for finger clubbing check for Schamroth’s window. To assess for asterixis or flapping tremor. 33‘Assess the patient’s radial pulse for Rhythm and volume. Face Eyes * Conjunctival pallor: Ask the patient to gently pull down their lower eyelid. ‘Jaundice: ask the patient to look downwards as you lift their upper eyelid. Mouth: Tell the patient to open his mouth and check for Angular stomatitis, Glossitis, Oral candidiasis and Aphthous ulceration. Neck + Palpate the supraclavicular fossa on each side, paying particular to node on the left for evidence of lymphadenopathy. Chest * Spider naevis + Gynaecomastia: ‘Hair loss: ‘Abdominal inspection Position the patient lying flat on the for abdominal inspection and subseq their sides and legs uncrossed Inspect the patient’s abdomer Scars: * Abdominal distension: * Caput medusae: * Striae (stretch + Hert ‘gastrointestinal pathology Murphy's sign Palpate the spleen Ballot the kidneys ‘Abdominal percussion Percuss the liverPercuss the spleen Assess shifting dullness Abdominal auscultation Assess bowel sounds Legs Assess the patient's lower legs for evidence of pitting oedema. Further assessments and investigations * Check hernial orifices * Perform a digital rectal examination (PR) ‘= Perform an examination of the external genitalia 35Simman Hypoglycemia You are an FY2 in A & E. Samuel, aged 40, is in the hospital drowsy. Assess and manage him. Please follow ABCDE protocol. Inside the cubicle: Blood Sugar - 1.8 ‘Treating someone who's unconscious or very drowsy Follow these steps: i 2 Put the person in the recovery posi mouth ~ so they do not choke. n and do not put an\ Give them an injection of glucagon medicine — if it's available how to do it. Call 999 for an ambulance if an injection is nof@Vailable or Yap do not know how to do it. n to step 4 if the ince if they do not Wait about 10 minutes if you have given th person wakes up and starts to feel bet improve within 10 minutes. Give them a sugary drink or snacl the drinks and snacks used to irate-containing snack ~ urself should work. 36Psychosis You are an FY2 in GP.Mother is concerned for her 40 year old son behaviour as he is behaving strange since 3 weeks. The other day she made an appointment for face to face consultation for her son. Talk to him and address his concerns. P: I don’t have any clue why | am here. | am absolutely fine. Patient keeps tapping feet on the ground, shaking the knees and moving his head. Complete MSE: M: Fine, average. C: Fine S:NO ‘ ~ H: Yes, hear voices. They are talking to him regarding kil gone. I: No T= Yes, Radio is stealing my thoughts F : Lives alone, GF left 4 weeks ago and tt erm starte ks ago. On benefits left the job 6 months ago. A:No. M:No ‘Admission Investigation Psychiatrist 7Heparin Sub Cutaneous Injection You are an FY2 in Medicine.Lorrie 3" year medical student. Please teach him how to put subcutaneous heparin injection. Don’t ask him to do the procedure. ‘Subcutaneous (SC) injections pierce the epidermis and dermis of the skin to deliver medication to the subcutaneous layer. It is a common route of delivery for medications such as insulin and low molecular weight heparin (LMWH). Things you may find inside: Yellow Bin. (Labelled Needle Only) Apen and paper Akkidney tray for other waste. A kidney tray with the needle/alcohol swab/cotton/ labelled pi 1. Draw-up the appropriate medication into the syringe using a drawi may get prefilled syringe) (You 2. Remove the drawing-up needle and immediately it ps bin, then attach the needle to be used for performing the inje 3. Choose an appropriate site for the inject + Abdomen: avoid injecting within a @inch radius a fe umbilicus ‘© Upper outer aspect of the arm * Outer aspect of the upper t © Upper buttock + DoNOTuse a site that «If multiple injectior injection. If fre irritated or bruised. istered, use different sites for each subsequent inistered, rotate injection sites. 4. Cleaning * Ro lly required prior to subcutaneous injection. - In ‘who are immunocompromised, skin preparation using an alco fab (70% isopropyl alcohol) may be recommended. 5. Pinch 2 Gem fold of skin between the thumb and index finger, using your non-dominant the skin increases the depth of the subcutaneous tissue available). 6. Warn the patient of a sharp scratch. 7, Pierce the skin at a 45-90” angle, aiming to remain in the subcutaneous tissue layer. Insert the needle quickly and firmly, with the bevel facing upwards. 8. Inject the contents of the syringe whilst holding the barrel firmly. Aspiration is not recommended for subcutaneous injections, as there are no major blood vessels in the 38subcutaneous tissue and the risk of inadvertent intravenous administration is mit should, however, always follow your local guidelines. imal You 9. Remove the needle and immediately dispose of it into a sharps container. 10, Apply gentle pressure over the injection site with a cotton swab or gauze and avoid rubbing the site. 11. Replace the gauze with a plaster. 12. Dispose of your gloves and equipment into an appropriate cli Post-injection care: ‘+ itis normal for the injection site to be sore for one or two days. experience worsening pain after 48 hours they should seek medic: ‘+ Reiterate the potential complications of subcutaneous inj formation, persistent nodules, local irritation and rarely al Please document the details of the procedure and gy 39Domestic Violence Burn You are an FY2 in GP. Ella Jackson, 18-year-old came, in because of scalded injury on her tummy. Nurse has seen the patient and have done the dressing. Talk to her and manage her condition and address her concern. Jam burnt, Where: | don’t know. insignificant ive with other girls. I don’t want to go with him. with this man who is taking care of us. How about other girls. 2 Is he doing it with other girls too. Deal as domestic violence stat ‘Acknowledge non-verbal cu Confidentiality HARK Offer support MARACHIV You are an FY2 in GP. Harry Josh, 21 year old, presented with lumps in groin area. talk to him and address his concern. (Patient may find it difficult to open up) Elaborate lymphadenopathy. Fever one month ago. No Pain in inguinal area. Travelled abroad Not having stable partner. Male/female partner ‘Anal without condom. HIV possibly. HIV management: HIV antibody and p24 antigen test are don Regular blood test: You'll have regular blood tests t. treatment. Two important bl 1. HIV viral load test: Blood te: 2. €D4 lymphocyte cell coUttalt rogress@F the HIV infection before starting imount of HIV virus in your blood the HIV has affected your immune system Antiretroviral dr HIV is treated wi ral medications, which work by stopping the virus replicating in the body. fs alloy immune system to repair itself and prevent further damage. A s TslUsed because HIV can quickly adapt and become resistant. nts have been combined into a single pill, known as a fixed dose 'us in your blood (viral load) is measured to see how well treatment is it can no longer be measured it's known as undetectable. Most people taking ent reach an undetectable viral load within 6 months of starting treatment 4lCombined Pill Prescription You are an FY2 in OBG. Avery smith, aged 22 has come to you asking for 6 months prescription of OCP. She was not using condom for 5 months. Starting the combined pill: Itis important to remember that you cannot put in repeat prescription requests for the Pill or for HRT as you would for other medications. Once the doctor is satisfied that, the contraceptive pill or HRT you are on is the most suitable one for you they Wilfusually, issue a prescription for a six-month supply. You should not take the pill if you: + are pregnant * smoke and are 35 or older ‘+ stopped smoking less than a year agol@nd arelgs or * are very overweight + take certain medicines (askyyour healthiprofessional at a contraception clinic about this) You should also not 3. Pilhif YOUhave (Or have had): . lot) in @Wein, for example in your leg or lungs + strok@6r any oth@tdisease that narrows the arteries, . ne e Family having a blood clot under the age of 45 . i or heart disease, including high blood pressure s especially with aura (warning symptoms) + bredshcancer + disease of the gallbladder or liver, ‘+ diabetes with complications or diabetes for the past 20 years You may need to use additional contraception during your first days on the pill - this depends on when in your menstrual cycle you start taking it. 2Starting on the first day of your period If you start the combined pill on the first day of your period (day one of your menstrual cycle) you will be protected from pregnancy straight away. You will not need additional contraception. Starting on the fifth day of your cycle or before If you start the pill on the fifth day of your period or before, you will still be protected from pregnancy straight away, unless you have a short menstrual cycle (your perig@li@every 23 days or less). If you have a short menstrual cycle, you will need additional i such as condoms, until you have taken the pill for seven days. Starting after the fifth day of your cycle You will not be protected from pregnancy straight away and Willneed additional contraception until you have taken the pill for sever If you start the pill after the fifth day of your risk of pregnancy since your last period. If y the pill, take a pregnancy test three we /ou have not put yourself at re pregnant when you start had unprotected sex. You can get contraception fre , if yore under 16, from: * contraception cli + sexual heal 01 medicine) clinics services Ifyou ar pill then, for your safety, you will need check-ups every 6-12 months wi , before your repeat prescriptions can be continued. The GP or nurse will tell you how oft@fyou need a check. Please book your check-up well before you will run out of your If you do need a repeat prescription at the same time as your check-up we can arrange this for you, but you will need to call back to collect your prescription once the GP has signed it. This may be after ‘5.30pm the same day or another day. Alternatively, some pharmacies can collect a prescription for you, if you arrange this with them. Taking 2 packets of the combined pill back-to-back If you take a combined contraceptive pill, you can delay your period by taking 2 packets back-to-back. 43How you do this will depend on which pill you take. Examples are: ‘+ monophasic 21-day pills, such as Microgynon and Cilest — you take a combined pill for 21 days, followed by 7 days without pills, when you have a bleed (period). To delay your period, start a new packet of pills straight after you finish the last pill and miss out the 7-day break ‘+ everyday (ED) pills, such as Microgynon ED and Lorynon ED — you take a combined pill every day. The first 21 pills are active pills and the next 7 pills ar dummy pills, when you have your period. To delay your period, away the dummy pills, and start the active pills in a new packet strai + phasic 21-day pills, such as Binovium, Qlaira and Logynon — each pill is different, depending on which phase you're in. Yo pills in the correct order to have effective contracepfign. Ask yi ‘community contraception clinic or GP for more informétion. Patient Concerns: (On the holiday how can | avoid having perio« yePremature Ovarian Insufficiency You are an FY2 in OBG. Sana, aged 26, presented with history of amenorrhoea. She had blood test done. Results were as follows: Oestrogen is low FSH and LH high Diagnosis of Premature Ovarian Insufficiency was made. Talk to her, explain the results and address her concerns. D: How can | help you? P: Amenorrhoea. For 2 years. (Elaborate) D: How were your pe P: Regular D: Any Contraception P:NO D: Who do you live with? P: Partner D: Are you sexually active? P: Yes PMH: NO No family history Lifestyle: she drinks alcohol ré oki Concerns: She wants to beco! dn Causes of eat The ovaries ly menopause can happen naturally if a woman's ovaries stop making norm: hormones, particularly the hormone oestrogen. This is som re ovarian failure, or primary ovarian insufficiency. The cau: re ovarian failure: 1. often u 2. chromosome abnormalities ~ such as in women with Turner syndrome 3. an autoimmune disease ~ where the immune system starts attacking body tissues 4. certain infections, such as tuberculosis, malaria and mumps. 5. Family history. 6. Certain Cancer treatments 7. Surgical removal of the ovaries. ‘Symptoms of early menopause: 1. periods becoming infrequent or stopping altogether. 4s2. hot flushes, night sweats 3. vaginal dryness and discomfort during sex 4. difficulty sleeping 5. low mood or anxiety 6. reduced sex drive (libido) 7. problems with memory and concentration Women who go through early menopause also have an increased risk of osteoporosis and cardiovascular disease because of their lowered oestrogen hormone levels. Diagnosing early menopause: based on your symptoms your family history, blood tests to check your hormone levels. Treatments for early menopause: combined contraceptive pill or HRT unless contrain in incer) Life style changes. specialist menopause centre. P:1 want to have children? D: Permanent early menopause vi abilit#@ have children naturally. This can be very distressing to women of u MapstilfBE able to have children by using IVF and donated eggs from anot! jwn eggs if you had some stored. Surrogacy and adoption m: tions #8r you. 46Otoscopy Child You are an FY2 in GP. Mary mother of 3 Year of David has come in with some concerns. Talk to her and address her concerns. D: How can I help? P: My child is not feeling well. D: May | know why? P: He has not been feeding well. D: Any symptoms? P: He had fever and URTI 3 weeks ago. Rule out Meningitis, Otitis Media, UTI and Tummy Infection. Nanny reported discharge from one of the ears. Otoscopy: Perforation??? A perforated or burst eardrum is a hole in the eardi ithin a few weeks all and might not need any treatment. But it's a goodide GP if You think your eardrum has burst, as it can cause problems, ar tions. ‘Symptoms of a perforated eardrum: hearing loss earache and itching discharge from your ear Fever Tinnitis The symptomsapill u! 3s onceour eardrum has healed or any infection has been treated. Youfeardrum ually heal without treatment, but a GP can check for an infectign (whi ment) and talk to you about how you can look after your ear. Things y u have a perforated eardrum Perforated'@ardrums do not always need to be treated because they often get better by themselves within a few weeks. While it heals, the following tips can help you relieve your symptoms and reduce the chances of your ear becoming infected: do not put anything in your ear, such as cotton buds or eardrops (unless a doctor recommends them) do not get water in your ear ~ do not go swimming and be extra careful when showering or washing your hair 47try not to blow your nose too hard, as this can damage your eardrum as it heals, hold a warm flannel against your ear to help reduce any pain take painkillers such as paracetamol or ibuprofen to relieve pain if you need to (do not give aspirin to children under 16) Treatments for a perforated eardrum: Ifyou have an ear infection caused by a perforated eardrum, a GP may prescribe antibiotics. If the hole in your eardrum is big, or does not heal in a few weeks, the GP may refer you to. an ear specialist to talk about having surgery to repair a perforated eardr Causes of a perforated eardrum: 2. an injury to the eardrum, such as a blow to your ear or poking an n bud deep into your ear 3. changes in pressure, such as while flying or scuba 4. a sudden loud noise, such as an explosion The following tips may help you avoid dama; see a GP for treatment if you have sympt do not push anything deep into your wear suitable ear protection if you're of noises when flying, try swallowing, y sucking on a boiled sweet during take-off and landing N for more than 2 or 3 days 48PSA Rectal Examination You are an FY2 in GP. Tony Montana, aged 56, has come to you for his results. Talk to him and explain the blood results and address his concerns. Patient had PSA test. PSA is normal. Uand E normal Assess and disclose the news. D: How can I help you? am here for my results. D: Why did you get the PSA test done? P: My friend died of Prostate Cancer Rule Out: BPH, UTI & Cancer History. For frequency, nocturia, urgency - Present Rectal Examination: Explain the examinatior Today | need to perform a rectal exa into your back passage to feel for any. little uncomfortable. Could you, lie towards your chest. This is th You can ask me to stop at ‘me inserting a gloved finger Idn’t be painful, but it will feel a left side, with your knees lifted up imine your rectum. Chaperone Consent ny Pi before doing the clinical examination. redness, swelling, bleeding, Skin excoriation, Skin tags, External or fistula Warn the patient you are about to insert your finger. In males, palpate the prostate gland anteriorly and assess the size, symmetry and texture of the gland (A normal prostate is approximately walnut-sized with a palpable midline sulcus) Rotate your finger 360 degrees to assess the entirety of the rectum Note the size, location and texture (e.g. smooth, irregular) of any rectal lumps 49Assess anal tone by asking the patient to squeeze your finger. Withdraw your finger and inspect for blood or mucous: Clean the patient using paper towels. BPH: Both the lobes or one lobe might be enlarged, and you may be able to feel the deep sulcus. Cancer: you might not be able Median sulcus and one of the lobes might be enlarged. ye 50Seborrhoea Keratosis You are an FY2 in GP. Nancy James, aged 70 emailed you a picture of skin lesion. She has called you to discuss about her skin lesion. Talk to her and address her concerns. She noticed it 2 months back and has increased in size. There is no change in shape or colour No history of weight loss, lumps and bumps and appetite. Loss. Positive family history of cancer. Concerns: Isit cancer: gy SL