PLAB 2 Notes Part 2

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2453 Video not available
Cyclical Mastalgia : 12 April 2019

You are a FY2 in GP clinic. A 28 years old lady come for lumpiness and pain in her
breasts. Take history, do relevant examination and address her concern.
GRIPS plus rapport with the patient
Take history:
Pt: I feel lumpiness in my both breasts
Dr: I am sorry to hear that! For how long?Pt: 18 months
Dr: Do you have pain now? Pt: No
Dr: Anything more can you tell me about it?Pt: like what doctor?
Dr: Is it painful at all? Pt: Yes, I felt pain but I don’t have pain now.
Dr: Do you have your menstrual period now? Pt: I had my LMP 2 weeks ago.
Dr: When did you feel lumpiness and pain more? Pt: During my periods
Dr:Do you drink too much tea/coffee? Alcohol? Pt: No
Dr: Do you take oral contraceptive pills? Pt: No
Dr: Have you noticed any swelling/lumps? Pt: No
Dr: Do you have fever (mastitis)? Pt: No
Dr: Did you notice any discharge (intra ductal papilloma), or blood discharge (cancer)
from the nipple? Pt: No
Dr: Have you noticed any lumps on your arm pits? Pt: No
Dr: Have you injured your breast? Pt: No
Dr: Are you currently breastfeeding, or have done in the past? Pt: Yes/ No
Dr: Did you have any swellings/lumps in the breast before? Pt: No
Dr: Any of your family members had breast lumps/cancer? Pt: No
Mrs…. I need to examine your breasts now.
Pt : Ok doctor.
Examine the breast.
Explain the procedure “while examining, I will be asking you to do some manoeuvres
and will be looking at you and touching your breast and arm pits to feel for any lumps. If
you feel uncomfortable on any point please let me know I will stop the examination.
Exposure: Can you please undress above your waist.
I will ensure privacy and have a chaperone with me. Is that OK?
[Position: 3 different position will be used during examination. Sitting, Lying down at
45
degrees and Standing. Do the Inspection plus Palpation]
Dr: From the history and examination findings I could not find any lump/swelling. We are
suspecting you are having this lumpiness and pain because of a condition what we called
Cyclical Mastalgia. This is not a serious condition. Symptoms get worse while you are
having periods/menstruation.
However, I will talk to my seniors they will do further assessment.
Dr: We will give you painkillers: Oral paracetamol and/or ibuprofen, or a topical
nonsteroidal anti-inflammatory preparation, as required. We will refer you to a Breast
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specialist (As she is having this for 18 months)
Pt: What I will do in the future?

Dr: Please weara better-fitting bra during the day and a soft support bra at night. Ask the
woman to keep a pain diary (if she has not already done so) to evaluate the severity and
timing of the pain, and its response to treatment.
Plus give warning signs of any lumps or discharge.
NICE GUIDELINE:
Reassure the woman that there is no serious underlying pathology.
 Consider the following treatment options:

o A better-fitting bra during the day.
o A soft support bra at night.
o Oral paracetamol and/or ibuprofen, or a topical nonsteroidal anti-
inflammatory preparation, as required.
 Ask the woman to keep a pain diary (if she has not already done so) to evaluate the
severity and timing of the pain, and its response to treatment.
 Consider referring to a breast specialist if the pain is severe enough to affect
quality of life or sleep and does not respond to first-line treatment after 3 months.
 Specialist treatment options include danazol and tamoxifen.
Prostate Specific Antigen

OR
Patient Worried About Prostate Cancer
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Question - You are a FY2 at the G.P clinic. A 65 years

old man Mr.Samuel Lowe came to the G.P clinic. Talk
to him and address his concerns.
Dr - Hello Mr.Samuel… I am Dr……. How are you doing?

Or How can I help you today?
Pt - Dr. I am worried about having prostate cancer. I

think I have prostate cancer OR i may have prostate
cancer.(He can say either one)
*You can check his knowledge about the prostate

gland. Usually he will say he knows what is prostate
but If he does not know then explain him
What is the prostate?
The prostate is a small gland in the pelvis, found only in men.
About the size of a satsuma, it's located between the penis

and the bladder, and surrounds the urethra.
The main function of the prostate is to produce a thick white

fluid that creates semen when mixed with the sperm
produced by the testicles.*
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Dr - Well Mr.Samuel please tell me why do you think

like this. Do you have any symptoms?
Pt - Dr. my best friend, he is also the same age as me

and he is diagnosed with prostate cancer recently and I
think that I can also have it. I heard that it is common
in men above 60 years of age. That’s what I am worried
about.
Dr - Mr.Samuel, I am sorry to hear about your friend,

let me reassure you that not all men who are above 60
years of age get prostate cancer. However before we
go further can I ask you few questions regarding your
general health. Would that be alright with you?
Pt - Yes doctor.
*Patient here is very worried about having cancer. So

make sure you reassure him and consider his level of
emotions here.*
Dr - Mr.Samuel have you been checked for prostate

symptoms earlier? Pt - No doctor.
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Dr - Do you have any symptoms recently?
Pt - Like what doctor?
Dr - Do you havefever recently? Pt - No Dr.
Dr - Did you notice any change in colour of urine recently? Pt

- No doctor.
Dr - Did you notice blood in theurine? Pt - No
Dr - Any pain intummy? Pt - No
Dr - Do you have pain in the loinarea (Peylonephritis)? Pt - No
Dr - Do you pass urine more times thanusual? Pt - No doctor.
Dr - Do you have to get up in the nightto go toloo? Pt - No

doctor.
Dr - Any dribbling of urine? Pt - No doctor.
Dr - Do you have any back pain (secondaries in the vertebra).

Pt - No
Dr - Have you noticed any weight loss(cancer)?Pt - No
Dr - Any problem openingbowel ? Pt - No
Dr - Do you have anymedical conditions? Pt - No

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Dr - Did you have any kidney stonesbefore? Pt - No
Then do MAFTOSA
He will have no medical conditions and he will be a non

smoker and non alcoholic. (History can change in future
station so please make sure you ask about more probable
risk factors and causes of prostate cancer and BPH)
Ask questions related sexual health also.
There will be no strong history or no risk factors in history

which will indicate towards BPH or Prostate cancer
symptoms.
Explain to him that from history it does not look like he is

having any symptoms of prostate cancer.
But as his age is one of the factor you can talk to your seniors
and after discussion with seniors you can arrange for few
investigations only if seniors advice so.
As NHS is not private funded so no tests are done
unnecessarily.
To some he said doctor just in case if I had symptoms then

what can you do, then explain to him you would have done
Digital Rectal examination to look for prostate enlargement.
Tell him that we can go for PSA but its not very reliable as it
can be raised in many cases. A PSA level can be seen in
multiple conditions including B.P.H, old age, acute prostatitis
and prostate cancer.
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Just for exam consider prostatic cancer if PSA is
More then or equal to 2ng/ml at age 40-49 years.

More then or equal to 3ng/ml at age 50-69 years.
More then or equal to 5ng/ml at age 70 years or older.
If PSA is raised first MRI is done now before going for any
kind of biopsy.
There's currently no screening programme for prostate

cancer in the UK. This is because it has not been proved that
the benefits would outweigh the risks.
So basically in this station you have to take history, reassure

him and tell him the plan if you find positive symptoms of
prostate cancer or if just in case he ask you what can be done
if he had symptoms then talk about first Digital exam then
PSA then MRI then Biopsy then further treatment as per
findings.
He kept on saying that he want to have investigations done

such as PSA . Tell him you would do all if necessary. Try to
reassure him and be considerable as he is worried that his
friend got cancer so he can also have the same.
In order to answer any of his other questions information is

given below. Please make sure to give this a read also.
Info about PSA

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◦ How accurate is the PSA test?
About 3 in 4 men with a raised PSA level will not have cancer.
The PSA test can also miss about 15% of cancers.
Pros and cons of the PSA test
Pros:
 it may reassure you if the test result is normal

 it can find early signs of cancer, meaning you can get
treated early
 PSA testing may reduce your risk of dying if you do have
cancer
Cons:
 it can miss cancer and provide false reassurance

 it may lead to unnecessary worry and medical tests
when there's no cancer
 it cannot tell the difference between slow-growing and
fast-growing cancers
*Information About Prostate Cancer*
Prostate cancer does not usually cause any symptoms until

the cancer has grown large enough to put pressure on the
tube that carries urine from the bladder out of the penis
(urethra).
Symptoms of prostate cancer can include:
 needing to pee more frequently, often during the night

 needing to rush to the toilet
 difficulty in starting to pee (hesitancy)
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 straining or taking a long time while peeing

 weak flow
 feeling that your bladder has not emptied fully
 blood in urine or blood in semen
These symptoms do not always mean you have prostate

cancer. Many men's prostates get larger as they get older
because of a non-cancerous condition called prostate
enlargement.
Signs that the cancer may have spread include bone and back
pain, a loss of appetite, pain in the testicles and unexplained
weight loss.
Causes
It's not known exactly what causes prostate cancer, although

a number of things can increase your risk of developing the
condition.
These include:
 age – the risk rises as you get older, and most cases are
diagnosed in men over 50 years of age
 ethnic group – prostate cancer is more common among
men of African-Caribbean and African descent than in
Asian men
 family history – having a brother or father who
developed prostate cancer before age 60 seems to
increase your risk of developing it; research also shows
that having a close female relative who developed
breast cancer may also increase your risk of developing
prostate cancer
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 obesity – recent research suggests there may be a link

between obesity and prostate cancer, and a balanced
diet and regular exercise may lower your risk of
developing prostate cancer
 diet – research is ongoing into the links between diet
and prostate cancer, and there is some evidence that a
diet high in calcium is linked to an increased risk of
developing prostate cancer
If you have symptoms that could be caused by prostate

cancer, you should visit your GP.
There's no single, definitive test for prostate cancer. Your GP

will discuss the pros and cons of the various tests with you to
try to avoid unnecessary anxiety.
Your doctor is likely to:
 ask for a urine sample to check for infection

 take a blood sample to test your level of prostate-
specific antigen (PSA) – called PSA testing
 examine your prostate by inserting a gloved finger into
your bottom – called digital rectal examination
Your GP will assess your risk of having prostate cancer based

on a number of factors, including your PSA levels and the
results of your prostate examination, as well as your age,
family history and ethnic group.
If you're at risk, you should be referred to hospital to discuss

the options of further tests.
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◦ MRI scan
If you have a raised PSA level, your doctor may refer you to
hospital for an MRI scan of your prostate. If the scan shows a
problem, it can be targeted later with a biopsy.
◦ Having a biopsy to diagnose prostate cancer
There are a few types of biopsy that may be used in hospital,

including the below.
A transperineal biopsy
This is where a needle is inserted into the prostate through

the skin behind the scrotum. It's usually done under a general
anaesthetic (while you're asleep). It has the advantage of a
reduced risk of infection.
A transrectal biopsy
This is where a needle is inserted into the prostate through

your rectum (back passage).
During this biopsy, an ultrasound probe (a machine that uses
sound waves to build a picture of the inside of your body) is
inserted into your rectum. This allows the doctor or specialist
nurse to see where to pass the needle to take small samples
of tissue from your prostate.
This procedure can be uncomfortable and sometimes painful,

so you may be given a local anaesthetic to numb the area
and minimise any discomfort. As with any procedure, there
may be complications, including bleeding and infection.
A biopsy may also be taken during a cystoscopy examination.

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There's currently no screening programme for prostate

cancer in the UK. This is because it has not been proved that
the benefits would outweigh the risks.
PSA screening
Routinely screening all men to check their prostate-specific

antigen (PSA) levels is a controversial subject in the
international medical community. There are several reasons
for this.
PSA tests are unreliable and can suggest prostate cancer

when no cancer exists (a false-positive result). Most men are
now offered an MRI scan before a biopsy to help avoid
unnecessary tests, but some men may have invasive, and
sometimes painful, biopsies for no reason.
Furthermore, up to 15% of men with prostate cancer have

normal PSA levels (a false-negative result), so many cases
may be missed.
The PSA test can find aggressive prostate cancer that needs
treatment, but it can also find slow-growing cancer that may
never cause symptoms or shorten life. Some men may face
difficult decisions about treatment, although this is less likely
now that most men are offered an MRI scan before further
tests and treatment
Treating prostate cancer in its early stages can be beneficial

in some cases, but the side effects of the various treatments
are potentially so serious that men may choose to delay
treatment until it's absolutely necessary.
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Although screening has been shown to reduce a man's

chance of dying from prostate cancer, it would mean many
men receive treatment unnecessarily.
More research is needed to determine whether the possible

benefits of a screening programme would outweigh the
harms of:
 overdiagnosis – people being diagnosed with a cancer

that would never cause symptoms or shorten life
expectancy
 overtreatment – people being treated unnecessarily for
tumours that would unlikely be harmful
Should you know your PSA level?
Instead of a national screening programme, there is an

informed choice programme, called prostate cancer risk
management, for healthy men aged 50 or over who ask their
GP about PSA testing. It aims to give men good information
on the pros and cons of a PSA test.
If you're a man aged 50 or over and decide to have your PSA
levels tested after talking to your GP, they can arrange for it
to be carried out free on the NHS.
If results show you have a raised level of PSA, your GP may

suggest further tests.
Treatment for prostate cancer will depend on your

individual circumstances. For many men with prostate
cancer, no treatment will be necessary.
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When treatment is necessary, the aim is to cure or control

the disease so it affects everyday life as little as possible and
does not shorten life expectancy.
Sometimes, if the cancer has already spread, the aim is not to

cure it but to prolong life and delay symptoms.
◦ Staging of prostate cancer
◦ Watchful waiting or active surveillance
◦ Surgically removing the prostate gland (radical prostatectomy)
A radical prostatectomy is the surgical removal of your

prostate gland. This treatment is an option for curing
prostate cancer that has not spread beyond the prostate or
has not spread very far.
◦ Radiotherapy
Radiotherapy involves using radiation to kill cancerous cells.
This treatment is an option for curing prostate cancer that

has not spread beyond the prostate or has not spread very
far.
◦ Brachytherapy
◦ Brachytherapy is a form of radiotherapy where the radiation dose is delivered
inside the prostate gland. It's also known as internal or interstitial radiotherapy.
The radiation can be delivered using a number of tiny

radioactive seeds surgically implanted into the tumour. This
is called low dose rate brachytherapy.
◦ Hormone therapy
Hormone therapy is often used in combination with

radiotherapy. For example, you may receive hormone
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therapy before undergoing radiotherapy to increase the

chance of successful treatment.
It may also be recommended after radiotherapy to reduce

the chances of cancerous cells returning.
◦ Trans-urethral resection of the prostate (TURP)
TURP is a procedure that can help relieve pressure from the

tube that carries urine from your bladder out of your penis
(urethra) to treat any problematic symptoms you may have
with urination.
It does not cure the cancer.
During TURP, a thin metal wire with a loop at the end is

inserted into your urethra and pieces of the prostate are
removed.
This is carried out under general anaesthetic or a spinal

anaesthetic (epidural).
◦ High-intensity focused ultrasound (HIFU)
HIFU is sometimes used to treat men with localised prostate

cancer that has not spread beyond their prostate.
An ultrasound probe inserted into the bottom (rectum)

releases high-frequency sound waves through the wall of the
rectum.
These sound waves kill cancer cells in the prostate gland by

heating them to a high temperature.
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◦ Cryotherapy
Cryotherapy is a method of killing cancer cells by freezing

them. It's sometimes used to treat men with localised
prostate cancer that has not spread beyond their prostate
gland.
Tiny probes called cryoneedles are inserted into the prostate

gland through the wall of the rectum. They freeze the
prostate gland and kill the cancer cells, but some normal cells
also die.
The aim is to kill cancer cells while causing as little damage as

possible to healthy cells.
◦ Treating advanced prostate cancerIf the cancer has reached an advanced stage,
it's no longer possible to cure it. But it may be possible to slow its progression,
prolong your life and relieve symptoms.
Treatment options include:
 radiotherapy
 hormone treatment
 chemotherapy
If the cancer has spread to your bones, medicines called

bisphosphonates may be used. Bisphosphonates help reduce
bone pain and bone loss.
Chemotherapy
Chemotherapy is often used to treat prostate cancer that's

spread to other parts of the body (metastatic prostate
cancer).
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Chemotherapy destroys cancer cells by interfering with the

way they multiply. It does not cure prostate cancer, but can
keep it under control to help you live longer.
It also aims to reduce symptoms, such as pain, so everyday

life is less affected.
The main side effects of chemotherapy come from how it

affects healthy cells, such as immune cells.
They include:
 infections
 tiredness
 hair loss
 a sore mouth
 loss of appetite
 feeling sick (nausea)
 being sick (vomiting)
Many of these side effects can be prevented or controlled

with other medicines that your doctor can prescribe.
Steroids
Steroid tablets are used when hormone therapy no longer

works because the cancer is resistant to it. This is called
castration-resistant prostate cancer (CRPC).
Steroids can be used to try to shrink the tumour and stop it

growing. The most effective steroid treatment is
dexamethasone.
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Other medical treatments
There are a number of new medications that could be used if

hormones and chemotherapy fail. Your medical team can tell
you if these are suitable and available for you.
NICE has issued guidance on medications called abiraterone,

enzalutamide and radium-223 dichloride.
All of these may be used to treat men with metastatic

prostate cancer that no longer responds to standard
hormone therapy.
For more info visit

https://www.nhs.uk/conditions/prostate-cancer/
2455 Video available
Fundoscop
y
Explain Procedure : I need to examine the back of your eye with a special instrument called
opthalmoscope . For that I will be shining a bright light on your eyes . During the
examination I will be coming very close to you and will be touching your cheek and face. I
will be using some dilating drops which might dim or blur your vision; therefore you are
advised not to drive home alone or to sign any important legal documents during theday.
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Exposure / Position : You can blink normally during the procedure but don't move your head
and sit comfortably . I will be dimming the lights of the room and you should fix your vision
at a distant object .
Check Instruments Check power

of lens. Check light – BIG FULL
MOON
Inspection – coming at eye level Both Eyes are at same level No Ptosis No signs of
inflammation Orbit and appendages are normal
Do a Red Reflex – same level as the eye. Look through the fundoscope for Red
Reflex ( seen in normal eye and it means media is clear) Media is clear therefore I
proceed to Fundoscopy.
In real patient I would have examined with Fundoscope light on but in exam since there is a
bright light shining from back I may have reflection or glare so I would like to examine now
with Fundoscope light switched off .
Right eyeofpatient Left eye ofpatient Right eyeof examiner Left eye
ofexaminer Right handofexaminer Left hand ofexaminer
Do the procedure, approach at an angle of 30-45 , and follow the red reflex .
0.
Ask to follow into the instrument visualize macula . Explain findings to the
examiner.
Description of
Slide
Comment on
Optic disc :(1) Colour (2) Margins (3) Contour (4) Cup disc ration {CD Ratio}

Origin ofBlood Vessels: shape of vessel and caliber ofvessels.
Periphery and Rest of

Retina
Macul
a
Normal
Fundus
A. Optic disc –
Alwaysnasal
• Colour – Pinkish pale or pinkishyellow
• Margins – Welldefined
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• Circular or Rounded inContour

• Cup disc Ratio – 0.3 –0.5
B. Blood Vessels -Originating from Optic disc, straight not tortuous normal caliber
of
vessels-A :V2:3 C. Periphery and rest of retina – Healthy and Normal – no
exudates, nohaemorrhage D. Macula – Healthy andNormal
SLIDE OF NORMAL FUNDUS: SLIDE 9 I can see the OD, pinkish pale or pink
yellow in colour, well defined margins, circular in contour CD ratio is normal. Vessels
are originating from the OD, Straight not tortuous, normal in calibre. Periphery and rest
of retina and macula appears healthy and normal. Therefore my diagnosis is NORMAL
FUNDUS.
SLIDE OF OPTIC ATROPHY I can see the OD, pale or chalky white in colour, margin
well define, and circular in contour .Cup cannot be appreciated. Origin of vessels not clear,
they are straight and normal in calibre. Macula and periphery and rest of retina appear
healthy and normal. Therefore my diagnosis is Optic Atrophy.
SLIDE OF DISC CUPPING: SLIDE 10 I can see the OD, pinkish pale in colour, circular
in contour, margins ill defined. CD ratio is increased in size indicating cupping of the optic
disc. Origins of vessels not clear, they are straight not tortuous, normal in calibre . Macula
and periphery and rest of retina appear healthy and normal. Therefore my diagnosis is Disc
Cupping most probably due to glaucoma. Treatment: Urgent reduction of intra ocular
pressure e.g. mannitol oracetazolamide.
SLIDE OF PAPILLOEDEMA: SLIDE 11 I can see the OD which is swollen, oedematous,

hyperaemic and bulging, margins are blurred or ill defined and cup cannot be appreciated.
Origin of vessels are not clear but vessels are engorged, tortuous and congested. Periphery
and rest of retina appears hyperaemic. Therefore my diagnosis is Papiloedema. Urgent MRI
to rule out intracranial mass.
SLIDE OF CENTRAL RETINAL VEIN OCCLUSION: SLIDE 15 I cannot appreciate

the OD. Origin of vessels is not clear, but veins are engorged, tortuous andcongested. I can
appreciate flame shape, dot and blot haemorrhages in all quadrants, hard exudates and
cotton wool spots. Periphery and rest of retina appears hyperaemic and seems to be a
stormy sunset or tomato splash appearance. Therefore most probable diagnosis is CRVO.
SLIDE OF SENILE MACULAR

DEGENARATION
I can see the OD which is pale towards temporal side, margins well defined, circular
in contour cup cannot be appreciated.
Origin of vessels not clear but they are straight and not tortuous, normal in caliber.
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I can appreciate macula, there are few unusual pigmentations around it and also
scattered around periphery of retina.
Therefore my most probable diagnosis is senile macular or age related macular
degeneration.
SLIDE OF BACKGROUND DIABETIC RETINOPATH:

SLIDE 1
Optic disc is not so
clear.
Origin of vessels not so clear but they are straight and not tortuous.
Can appreciate hard exudates along the inferior temporal arcade, discrete, having
irregular surface, margins are ill defined.
Can also appreciate dot and blot haemorrhages in the nasal macular area and
superior temporal arcade, micro aneurysms in the macular area.
Therefore my most probable diagnosis is background diabetic retinopathy.
SLIDE OF PRE-PROLIFERATIVE DIABETIC RETINOPATHY: SLIDE

3
Pre-proliferative diabetic retinopathy is characterised by retinal ischaemia. Cotton wool spots

represents area of focal retinal ischaemia. Initial description of background + Can also
appreciate hard exudates, dot and blot haemorrhages, micro aneurysms and cotton wool
spots. Therefore my most probably diagnosis is Pre Proliferative Diabetic Retinopathy.
SLIDE OF PROLIFERATIVE DIABETIC RETINOPATHY: SLIDE

4
Can appreciate neo vascularization around OD and elsewhere along the vascular
arcade.
Can also appreciate hard exudates, micro aneurysms and dot and blot haemorrhages,
pre retinal fibrosis. The new vessels grow into the vitreous and are fragile leading to
haemorrhage. As the haemorrhage organises, fibrous tissue reaction occurs.
Therefore my most probably diagnosis is Proliferative Diabetic

Retinopathy.
Management
:
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The most important part of treatment is to keep diabetes under

control.
In the early stages of diabetic retinopathy, controlling diabetes can help prevent
vision problems developing.
In the more advanced stages, when vision is affected or at risk, keeping diabetes
under control can help stop the condition getting worse.
. Treatment for advance diabetic

retinopathies:
1. Laser treatment: To treat the growth of new blood vessels at the retina in case
of proliferative diabeticretinopathy.
2. Eye injections:
AntiVEGF
3. Eye surgery: To remove blood or scar tissue from the eye if laser treatment is
not possible.
SLIDE OF SUB HYALOID

HAEMORRHAGE:SLIDE22
Can appreciate massive boat shaped haemorrhage in , which is most probably a sub
hyaloids haemorrhage .
Can also appreciate a few, micro aneurysms, dot and blot

haemorrhages.
Therefore my most probably diagnosis is Pre Proliferative Diabetic Retinopathy with

pre retinal haemorrhage.
SLIDE OF LASER COAGULATION

:SLIDE7
Can appreciate a few scar marks at the periphery of the retina, which are
homogeneously distributed throughout periphery and are most probable due to laser
burns .
Therefore most probably diagnosis is diabetic retinopathy treated with laser

photo coagulation
SLIDE OF HYPERTENSIVE RETINOPATHY: SLIDE

14
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Can see diffusive narrowing and tortuosity of arterioles. Can also appreciate changes at
arterio venous crossings along infero temporal arcade (A-V nipping) Absence of
haemorrhages (flame shaped) and disc swelling suggest early changes or chronic
hypertension. Grade 1: Arteriolar narrowing Grade 2: A-V nipping Grade 3: Exudates,
haemorrhages, cotton wool spots Grade 4: Papilloedema
Hypertensive retinopathy is managed primarily by controlling hypertension. If vision

loss occurs, treatment of the retinal edema with laser or with intravitreal injection of
corticosteroids or anti VEGF drugs may be useful.
Arterial blood gas (ABG)
Consent: Verbal Level: F1 Difficulty:3/5
Indications Assessment of hypoxia, CO2 retention, acid-base status, acutely ill patients.
Consider if venous sample would give sufficient information.
Contraindications Absolute Competent patient refusal; Radial AV fistula, poor/ absent
collateral circulation, bony fracture; Femoral Femoral artery graft or aneurysm; Relative
Overlying infection, abnormal clotting.
Site Radial artery (usual), femoral artery, ulnar artery, brachial artery (last resort).
Equipment Non-sterile gloves, antiseptic swab, anticoagulant-filled syringe and cap, needle
(blue for radial, green for femoral), gauze/ cotton ball, tape, sharps bin.
Checks Notes the concentration of O2 the patient is breathing and their temperature. Locate
the nearest ABG analysis machine. Radial ABG Check Ulnar circulation adequacy by
squeezing the hand into a first, occluding the radial and ulnar arteries in the wrist, holding for
10s then opening the hand and releasing the pressure on the ulnar artery only; looking for
reperfusion of the whole hand (modified Allen’s test).
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Patient position Upper limb Sit the patient upright, arm and wrist extended, put a pillow
under the wrist to hold the position; Femoral ABG Lie patient flat on their back with their
groin exposed.
Procedure Wash hands and wear non-sterile glove. Attach needle to syringe and expel the
excess heparin (if present). Palpate radial pulse. Local anesthetic can be given intradermally
or topically prior to this procedure. Roll your finger back and forth over the artery to assess
its width and course. Do not use a tourniquet. Clean the skin using ed 2% chlorhexidine.
Place a finger on the radial pulse, hold the syringe like a pen with the bevel facing upward
and proximally. Warn the patient and insert the syringe at 300 to the skin, aiming for the
centre of the artery against the direction of blood flow. Once you hit the artery the blood
should pulse into the syringe (best method of assessing whether arteral or venous) if not re-
assess the positions of the pulse and needle by feeling for the needle tip as you gently press
the syringe upwards. Once you have about 1mL of blood apply gentle pressure to the
puncture sit with cotton wool and withdraw the needle. Ensure firm pressure applied to the
site for 3 minutes use an assistant is necessary but not the patient. Remove the needle using a
sharps bin and put the cap on the syringe. Label the syringe at the beside with the patient
details, O2 concentration, and temp and take it to the ABG machine.
Confirmation during procedure Pulsatile, bright-red blood fills the syringe

automatically; Post-procedure Blood O₂ saturation (SaO₂ ) is the same as that measured
with a sats probe
(Sp O₂ )
Complications Bleeding, haematoma, arterial damage and peripheral ischaemia, pain,

infection, local tendon/nerve damage.
Safety Steady the patient’s arm on a pillow to reduce movement and risk of needle-stick
injury, dispose of needles into a sharps container immediately, do not resheath them.
Alternatives
 Femoral blood gas Similar to femoral stab but aim for the femoral pulse (usually 2
fingers width below the inguinal ligament), with the patient lying flat on their back.
Insert the green (21G) needle at 900 to the skin
 Brachial artery gas (If unable to get radial or femoral.) Extend the patient’s arm and
insert needle at 450 into the brachial artery (medical to the biceps tendon, on the inner
aspect of the upper forearm)
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 Arterial cannula Used for repeated arterial samples or direct BP measurement (seek
senior/ specialist advice)
 Venous sample Collecting a venous blood sample using an arterial syringe or a
dedicated venous syringe compatible with your gas analyzers is often less painful than
an ABG and may provide sufficient information- eg although the sample may have a
slightly lower pH than arterial blood (higher venous CO2 concentration) you will still
know the lower limit of the pH in an acidotic patient as well as the venous lactate.
Hints and tips

 Consider applying topical or infiltrated local anaesthetic (bled of 1% lidocaine over
the artery using orange needle)
 If no blood is seen reposition the needle without withdrawing it completely from the
skin ; ask the patient to dorsiflex the wrist fully
 You may miss the artery which lies superficially and hit the bone (painful): if this
happens gently withdraw the needle to just under the skin , reposition the needle in
line with the pulse and try again , taking your time
 The ED, ICU, HDU, neonatal , and labour wards often have ABG machines; if you
cannot process the ABG within a few minutes put it on ice (remove and dispose of the
needle first)
 Expel air bubbles from the syringe before presenting the sample to the analysis
machine.

ABG Disorders/ ABG interpretation part 1
Causes of respiratory acidosis

Airway obstruction CNS depression
-Upper
-Lower Sleep disordered breathing (OSA or OHS)
 COPD
 Asthma Neuromuscular impairment
Other obstructive lung disease Ventilatory restriction
Increased CO2 production: shivering, rigors, seizures,

malignant hyperthermia, hypermetabolism, increased
intake of carbohydrates
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Incorrect mechanical ventilation settings
Causes of respiratory alkalosis
 CNS stimulation: fever, pain, fear, anxiety, CVA, cerebral edema, brain trauma, brain tumor,
CNS infection
 Hypoxemia or hypoxia: lung disease, profound anemia, low FiO2
 Stimulation of chest receptors: pulmonary edema, pleural effusion, pneumonia,
pneumothorax, pulmonary embolus
 Drugs, hormones: salicylates, catecholamines, medroxyprogesterone, progestins
 Pregnancy, liver disease, sepsis, hyperthyroidism
 Incorrect mechanical ventilation settings
Causes of metabolic alkalosis
 Hypovolemia with CL- depletion

o GI loss of H+
 Vomiting, gastric suction, villous adenoma, diarrhoea with chloride-rich fluid
o Renal loss H+
 Loop and thiazide diuretics, post-hypercapnia (especially after institution of
mechanical ventilation)
 Hypervolemia, Cl- expansion
o Renal loss of H+: edematous states (heart failure, cirrhosis, nephrotic syndrome),
hyperaldosteronism, hypercortisolism, excess ACTH, exogenous steroids,
hyperreninemia, severe hypokalemia, renal artery stenosis, bicarbonate administration
Causes of metabolic acidosis

 Elevated anion gap:
o Methanol intoxication
o Uremia
o Diabetic ketoacidosisa, alcoholic ketoacidosis, starvation ketoacidosis
o Paraldehyde toxicity
o Isoniazid
o Lactic acidosisa
 Type A: tissue ischemia
 Type B: Altered cellular metabolism
o Ethanolb or ethylene glycolb intoxication
o Salicylate intoxication
a
Most common causes of metabolic acidosis with an elevated anion gap
b
Frequently associated with an osmolal gap
 Normal anion gap: will have increase in [CL-]

o GI loss of HCO3-
 Diarrhoea, ileostomy, proximal colostomy, ureteral diversion
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o Renal loss of HCO3-

 Proximal RTA
 Carbonic anhydrase inhibitor (acetazolamide)
o Renal tubular disease
 ATN
 Chronic renal disease
 Distal RTA
 Aldosterone inhibitors or absence
 NaCl infusion, TPN, NH4+ administration
Selected mixed and complex acid-base disturbances
Disorder Characteristics Selected situation

Respiratory acidosis with ↓in pH  Cardiac arrest
metabolic acidosis ↓in HCO3  Intoxication
↑in PaCo2  Multi-organ failure
Respiratory alkalosis with ↑in pH  Cirrhosis with diuretics
metabolic alkalosis ↑in HCO3-  Pregnancy with vomiting
↓in PaCO2  Over ventilation of COPD
Respiratory acidosis with pH in normal range  COPD with diuretics,
metabolic alkalosis ↑in PaCO2 vomiting, NG suction
↑in HCO3-  Severe hypokalemia
Respiratory alkalosis with pH in normal range  Sepsis
metabolic acidosis ↓in PaCO2  Salicylate toxicity
↓in HCO3  Renal failure with CHF or
pneumonia
 Advanced liver disease
Metabolic acidosis with pH in normal range  Uremia or ketoacidosis with
metabolic alkalosis HCO3- normal vomiting, NG suction,
diuretics, etc.
ABG QUESTIONS
1. A 24 year old woman known to be suffering from panic disorder presents to the hospital with
tingling and numbness in her fingers. The ABG analyisis is as follows:
Ph: 7.52
PCo2: 2.2 KPa
PO2 : 11 kPa
Bicarbonate: Bicarbonate 20
What is the most likely condition?
A. Acute metabolic Alkalosis
B. Acute Respiratory Alkalosis
C. Compensated Respiratory Alkalosis
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D. Compensated Metabolic Acidosis

E. Acute metabolic acidosis
2. A girl with signs of hyperventilation. What is the most likely ABG derangement ?
A. pH increased pCo2 increased
B. pH decreased pCo2 increased
C. pH increased pCo2 decreased
D. pH decreased pCo2 decreased
3. A young child of 3 years old has present with vomiting for 3 days. On examination he is mild to
moderate dehydrated. What is his ABG profile likely to show?
A. PH low, PCo2 low
B. PH low, PCo2 High
C. PH High, PCo2 low
D. PH High, PCo2 High
E. PH Normal, PCo2 Normal
4. A 29 year old male patient presented with complaints of diarrhoea for the last 4 days. Biochemical
investigations were carried out. What is the key metabolic change that will be noticed ?
A. Metabolic alkalosis
B. Hyperkalemia
C. Metabolic acidosis
D. Hypernatremia
E. Hypercalcaemia
5. A patient is admitted with fever, photophobia, and a non blanching rash. His ABG values are as
follows:
pH-7.5
PaCO2 – 2.2 KPa
PaO2 – 9.0 KPa
What is the most likely diagnosis?
A. Metabolic acidosis
B. Metabolic alkalosis
C. Respiratory alkalosis
D. Respiratory acidosis
Acid base balance
Options:
A. Metabolic acidosis- acute, normal oxygenation
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B. Metabolic acidosis- acute with hypoxaemia

C. Metabolic acidosis-compensated, normal oxygenation
D. Metabolic alkalosis- acute, normal oxygenation
E. Metabolic alkalosis- acute with hypoxaemia
F. Metabolic alkalosis-compensated, normal oxygenation
G. Normal blood gases
H. Normal ventilation with hypoxaemia
I. Respiratory failure- acute, normal oxygenation
J. Respiratory failure- acute with hypoxaemia
K. Respiratory failure-compensated, normal oxygenation
L. Respiratory failure-compensated with hypoxaemia
M. Respiratory Alkalosis- acute with hypoxaemia

ABG interpretation part 2
Instruction:
For each of the following blood gas results, select the most appropriate designation from the
list of options. The line labelled Oxygen concentration represents the concentration of oxygen
that each individual is inhaling; Normal values are:
PaO2- 12.0-14.7 KPa PaO2 - 90-110 mmHg

pH- 7.35-7.45
PaCO2-4.5-6.0 KPa PaCO2 - 34 -45 mmHg
Bicarbonate – 24 – 28 mmol/l H + molarity - 35-45 nmol
1. pO2 – 10.0 kPa (80 mm Hg); pC02 -5.8 kPA (44 mmHg); pH – 7.24; H+ molarity-57
nmol/l
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Bicarbonate – 18 mmol/l; Base excess – 7 mmol/l; Oxygen concentration – 40%
2. pO2 – 6.7 kPa (50 mm Hg); pC02 -10.1kPA (76 mmHg); pH – 7.38; H+ molarity-42
nmol/l
Bicarbonate – 42.4 mmol/l; Base excess +14mmol/l; Oxygen concentration – 21%
3. pO2 – 14.3 kPa (108 mm Hg); pC02 - 6.0 kPA (48 mmHg); pH – 7.52; H+ molarity-30
nmol/l
Bicarbonate – 39 mmol/l; Base excess +14 mmol/l; Oxygen concentration –30%
4. pO2 – 4.7 kPa (35 mm Hg); pC0 2 -12.7 kPA (95 mmHg); pH – 7.12;
H+ molarity-76 nmol/l; Bicarbonate – 29.5 mmol/l; Base excess – 4 mmol/l; Oxygen
concentration – 21%
5. pO2 – 16.3 kPa (122 mm Hg); pC02 -7.5 kPA (56 mmHg); pH – 7.26; H+ molarity-55
nmol/l
Bicarbonate – 24.1 mmol/l; Base excess – 2 mmol/l; Oxygen concentration – 75%
6. pO2 – 10.3 kPa: pCO2 -4.1 kPA : pH – 7.53; Bicarbonate – 24.8 mmol/l
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ABG Answer Sheet
Question Question Question3 Question Question Question Question Question

1 2 4 5 6 7 8
O2 10.0 6.7 14.3 4.7 16.3 10.3
(kPa –
12.0 –
14.7)
( 90-110
mm
Hg )
PH 7.24 7.38 7.52 7.12 7.26 7.53
(7.35-
7.45)
Co2 5.8 kPa 10.1 6.3 12.7 7.5 4.1
(4.5-6
KPa)
(34-45
mmHg)
HCO3 18 42.2 39 29.5 24.1 24.8
(24-28
mmol)
Answer
ABG Interpretation
Below 7.35 Normal range of PH Abo

7.35 is 7.45 7.45
acidosis alkalo
Uncompensated(Acute) PH between 7.35 Normal PH between 7.4 to

to 7.4 PH - 7.4 7.45
Fully Fully compensated
PH - 7.27(eg) PH - 7.31(eg) compensated PH
Uncompensated Partially
Compensated co
Respiratory Metabolic Respiratory
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Acidosis Acidosis Alkalosis

(Respiratory failure)
Un- Partially Fully Un- Partially Fully Un- Partially Full
Compen Compen Compens Compe Compen Compe Compen Compen Comp
sated sated ated nsated sated nsated sated sated sate
PH
(7.35-7.45)
Co2
(4.5-6
KPa)
HCO3
(24-28
mmol)

DNACPR Simman--- Talk to nurse. (11th July )
You are FY2 in department for elderly medicine
80 years old Mr. Albert Corrigon has been admitted for some time with lung cancer. He
has been receiving treatment.
Nurse wants to talk to you about Mr. Albert Corrigon.
Speak to the nurse, assess the patient and write medical notes.
Hello my name is doctor------------. I am one of the Junior doctors in the department.

Are you nurse------------? Yes
Dr: I understand that you wanted to talk to me, how can I help you today?
Nurse: Doctor, Mr. Corrigon is admitted with us for past few weeks. For last 10 days he is
not well and today he suddenly became like this.
Dr: Ok, let me just have a look at Mr Corrigon.
Dr: Hello Mr. Corrigan………….no response.
Mr. Corrigon, tapped the patient, no response.
Assess airway, check carotid pulse and look for breathing.( patient had no Pulse and was not
breathing.)
Dr: It seems that Mr Corrigon is in cardiac arrest. Please help me connect monitor to confirm.
Nurse: Sorry doctor, there are no monitors here.
Dr: Ok then we must start CPR. Please call crash team but before that I would like to know if
Mr Corrigon had any end of Life Care wishes.
Nurse: Yes doctor, Mr. Corrigon had signed DNACPR form. Here I have the form if you
want to have a look at it. (it is completely filled form with lot of information.)
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Dr: Yes, you are right, It appears that Mr. corrigon had wished for no resuscitation and we
must respect that.
(There is a stethoscope and a pen torch inside the cubicle).
Confirm patient death and write in notes
Death Confirmation Assessment:

 Identity confirmed as Mr./Mrs._____ from wrist band.
 Patient lying in bed, eyes closed, no signs of life.
 No respiratory effort noted.
 No response to verbal or painful stimuli.
 No carotid pulse palpable.
 Pupils fixed and dilated bilaterally.
 No heart sounds noted during 3 minutes of auscultation.
 No Breathing sounds noted during 3 minutes of auscultation.

Death Confirmed at (time), on (date).
No concerns from staff members.

( If discussed with family then you have to write “ No concerns from family members”).
Signature
Name
GMC Reg No:
Dr: I would like to contact Mr Corrigon’s family so that we can break the news to them.
Nurse: Sorry doctor they are not around.
Dr: Ok, do we have their contact numbers? Nurse: Yes
Dr: We should contact and inform them of Mr Corrigon’s death.
Nurse: I will contact them and you can speak to them.
Dr: That would be great, Thank you.
Dr: I will inform this to my seniors.
Thankyou.

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SIMMAN-Anaphylaxis due to Blood transfusion/Antibiotic

Scenario-
Middle aged patient had undergone surgery on the abdomen and was given blood
transfusion. While receiving 2nd unit of blood he experienced shortness of breath.
(Inside the cubicle, there is a Simman. There is a wrist band that stated penicillin allergy.
There is a bag of blood that is connected – showing transfusion is taking place at the moment.
There is also a bag of IV fluid, Adrenaline, colloid on the table nearby.)
Monitor findings - ECG-normal Oxygen- 80-85% BP- 90/60 )
D- How can I help you? S – Dr I am not feeling well.

Dr - What exactly happening to you? S- Dr, I have shortness of breath
D- “I am really sorry to hear about that. Since when ? S - In the last few minutes.
D - Any other problem ?
S - Dr, I can’t speak properly. My lips and tongue have swollen, hands are itchy
ABCDE approach.
Check the monitor for vitals and tell the findings to the examiner.
Mention to the patient – I will stop the blood transfusion immediately.
Check whether the patient id on wrist band with the id on blood bag are matching or
not.
D – Mr.. Please don’t worry I am going to give you some Oxygen now. You should feel
better.
Mention high flow Oxygen( with reservoir bag) to the examiner. Oxygen saturation may
increase. If saturation did not improve – auscultate chest – there may be rhonchi – give
salbutamol nebuliser – 5 mg – change to nebuliser mask.
Tell the examiner : I would like to give
- 0.5ml (500 micrograms) 1:1000 adrenaline IM (repeat after 5 min if no better)
- IV fluid ( Normal saline - fluid challenge): Adult - 500 ml
- Chlorphenamine (IM or slow IV) - 10 mg
- Hydrocortisone (IM or slow IV) - 200mg
Examiner may say - Assume Doctor.
The blood pressure may return to normal. Patient begins to speak properly
If the blood pressure did not improve – repeat the Adrenaline 0.5ml IM – call seniors.
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If still not improved – Tell the examiner – we may need to consider giving Adrenaline as
infusion. ( IV adrenaline can be given only by experts)
D - can you please tell me more about what is happening to you ?
P- Dr, I had a surgery done on my tummy. Since then, I am having the shortness of breath”
D- When was the surgery done ? For what ?
D- Any other symptoms ?
D - Any pain anywhere ? Any pain in tummy or chest ?
D - Are you allergic to any medicine ? P -Yes to Penicillin.
D- What reaction you had when you were given Penicillin previously?
D- “Do you know if any antibiotics was given after the surgery?”
P – I don’t know / No
D- “Do you know your blood group?” P- “I am sorry Doctor, I do not know”
D- Did you had any other surgery previously ? If so, were you given blood transfusion ? Did
you have any problem after receiving blood transfusion ?
Examination:
Recheck the vital signs.
Check the wrist band – Band may show allergy to Penicillin
D- “Is it alright if I can examine you? I will ensure privacy and chaperone with me.”
Simman asks you to expose him on your own.
Examination findings- red spots all over the chest and dressing on the abdomen.
Examine the chest and abdomen – everything else may be normal.
Cover the Simman
Diagnosis and management
D - From what you have told me and from what I have examined, it seems that you had a
serious allergic reaction what we call anaphylactic reaction. It happens when you are
allergic to something. In your case, it could be due to reaction to the blood transfusion or
Pencillin if it was given.
I will check your notes as to see what kind of antibiotics were given to you after the surgery.
If it belongs to the penicillin group, then that could explain the symptoms. However, I need to
check if there has been any mismatch of blood as well.
I sincerely apologize for all you have been going through. I will talk to my seniors about this.
Examiner asks about further management
- Blood bag to be sent to the lab for further investigation.
- Patient’s blood sample for Blood group incompatibility.
- Further investigations – Blood – FBC, U&Es, Creatinine, ABG, Clotting screen, LFT,
first sample urine ( for Hb), Repeat group and save, IgA level, serial mast cell
tryptase.
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- Check for blood in the urine.

- Inform seniors and blood bank immediately. Contact allergy specialist Heamatolgist
immediately.
Upper GI bleeding - SimMan

Question
You are the FY 2 doctor in the A& E department.
Mr Alex ..60 year man brought in by his wife to A& E department because he is feeling dizzy
and feeling faint. Assess and discuss further management with him.
SimMan and Nurse is present inside the cubicle. Wife is not present inside the cubicle.
Talk to the nurse first.

Dr: Hello, I am Dr.. May I know your name please? Can you please tell me about the patient?
Nurse : Hello Doctor, I am Hawkins we have a patient here Mr Alex brought in by his wife, I
have attached the monitors, please look at the patient.
Dr: Do you know why he was brought in ?
Nurse : He has some problems. You can talk to him doctor.
Look at the monitor – vitals may be stable/ fluctuating ( keep looking at the monitor)
Then talk to the patient.

Dr: Hello Mr. Alex .. I am Dr.... How can I help you ?
Pt: Doctor I am having dizziness, feeling faint.
Dr: Since when ? Pt: since last 3 days.
Dr: When do you feel dizzy Pt: Since the last few hours.
Dr: How is it now ? Pt: It is getting worse.
Do you have diabetes ? No ask the nurse to check the blood sugar.
Dr: Anything else other than dizziness ? Pt: Like what ?

Dr: Did you lose consciousness ? Pt: No but I feel like I am going to faint.
Dr: Do you chest pain ? Pt: No I feel some discomfort in my chest.
Dr: What do you mean by discomfort ? can you please describe ? I can’t describe – I feel it
all over my chest.
Dr: Any Shortness of breath ? Yes/ no
Dr: Do you feel your heart beating fast or slow ( palpitation) ? yes/no
Dr: Do you have any headache ? No Dr: Any weakness in your arms or legs ( TIA) ? No
Dr: Do you have pain in your tummy ? No

Dr: Any change in your bowel habits ? Dr: Any loose stools? Yes/no
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Dr - Any bleeding from anywhere ? No

Dr: Any bleeding from your back passage ? Yes/ No
Dr: What is the colour of your stool ? Pt: Normal/ Dark colour / I didn’t look my stool
recently.
Past history
Dr: Did you have this problem before ? No
Dr: Did you have any medical conditions or did you have any medical conditions previously?
I have Osteoarthritis - knee joint pain.
Dr: Do you take any medications for that ? Yes/No painkillers
Dr: Which one ? Diclofenac. Who gave that ( prescribed doctor or over the counter) ?
Dr: How long have been taking this medication ? For many months.
Any other medications ( PPIs, Steroids, Blood thinners) ? No
Dr: Do you have bleeding from anywhere like – urine, nose, gums ? No
Dr: Do you have any bleeding disorders ? No
Dr: Any heart problems ? No HTN ? No DM ? No

Dr: Do you have any allergies ? No
Patient says – I soiled myself now doctor/ I am dying doctor.
Dr: I see. Don’t worry. You are in safe place. I need to examine you.
Check the monitor again – Blood drops to 90/60, Pulse – very high. Low oxygen saturation.
Ask nurse to give IV fluid immediately
Hartman’s – one litre bolus within 10 min. Use 2 large bore cannulae
( Grey colour – 16G) in 2 arms;
Give Oxygen ( mask may be present put on the manikin)
Nurse will put cannula on the arm. Examiner says assume she has given fluid.
Check the monitor again.
Blood pressure picks up and Oxygen saturation improves.
Ask patient are you feeling better ? Yes doctor.
Dr: need to examine your chest and tummy. Can you please undress?
Doctor you do it. Remove his hospital gown.
Examine chest
Inspection - chest appears normal on inspection. Movements symmetrical. Auscultation –
normal.
Examine abdomen – Inspection, palpation percussion auscultation normal.
Remove inners – Maleana – dark stool visible.
If the blood pressure did not improve talk about blood transfusion – Examiner may
increase blood pressure.
Cover him
Diagnosis:
I can see you have passed dark loose stool now. Looks like you have bleeding in your
tummy. It could be due to the Diclofenac medication what you are taking which causes
damage to stomach wall or ulcers in the stomach and causes bleeding in the stomach.
Further investigation and treatment.
Dr: We need to do some more blood tests – check for anaemia, blood group and cross match,
clotting tests. We need to give blood transfusion immediately. Is that Okay ? Yes doctor.
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We will call the specialist doctor called Gastro-enterologist. They will do some test called
Endoscopy which is a camera test where they pass a tube with a camera at its tips through
your mouth to the food pipe and stomach. This will help to check where is the bleeding and
also it will help to stop the bleeding. We will also give some medication called PPIs.
We may even need to give you blood transfusion. Is that Okay ? Pt – OK
You should stop taking Diclofenac. We will give you some other medication for your pain.
Pt: Can I go home? Dr: No unfortunately this is very serious condition. We need to keep you
in the hospital and treat you.
Tell the nurse. Could please send the blood for the tests and keep monitoring the patient and
arrange for blood transfusion. I will inform my seniors and call the Gastro-enterologists to
come immediately. Nurse – Okay doc
Thank the patient, nurse and the examiner.
Postpartum haemorrhage
Information -
Postpartum haemorrhage is the second leading direct cause of maternal deaths in the UK.
It is defined as blood loss of more than 500 ml from the female genital tract after
delivery of the foetus (or >1000 mL after a caesarean section).
Primary postpartum haemorrhage occurs within the first 24 hours of delivery, whereas
secondary postpartum haemorrhage occurs between 24 hours and 12 weeks after delivery
and is less common.
A PPH may be accompanied by one or more clinical signs and/or symptoms depending on
the amount of blood loss. Clinical signs of a PPH include palpitations, dizziness, tachycardia,
weakness, sweating, restlessness and pallor, and ultimately collapse.
If the blood loss is 500ml to 1000ml with no clinical signs of shock, then it is regarded as a
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minor PPH. When there is a loss of over 1000ml, or the woman has signs or symptoms of
shock, then it is a major PPH .
Once a PPH is identified, four components of management should be instigated

simultaneously: communication and resuscitation, monitoring and investigation, as well as
measurements to control the bleeding.
Communication
The midwife should communicate to the woman and her birth partner the need to summon
help quickly and press the emergency buzzer.
If it is a minor PPH, the midwife in charge and first-line obstetric and anaesthetic staff should
be contacted in the first instance. For a major PPH, summon the obstetric, anaesthetic and
haematology consultants, as well as the blood transfusion laboratory and porters.
Resuscitation – the woman should be laid flat, her breathing assessed and she should be kept
warm. If required, she should be given a high flow oxygen mask at 10L to 15L per minute.
In the event of a minor PPH, with no clinical signs of shock, insert one large bore cannula
and start rapid fluid resuscitation with two litres of crystalloid.
For a major PPH, or if the woman is displaying signs and symptoms of clinical shock, insert
two large bore cannulae and transfuse blood as soon as possible. Until blood is available, start
a rapid warmed infusion of up to 3.5L of crystalloid (Hartmann’s solution two litres) and/or
one to two litres of colloid.
Monitoring and investigation

In order to monitor the woman’s condition, her respiratory rate, pulse and blood pressure
should be assessed and a modified obstetric early warning system chart should be completed.
For a minor PPH, bloods for group and screen, full blood count and coagulation screen
should be taken and identified. The woman’s pulse, respiration rate, temperature and blood
pressure should also be recorded every 15 minutes. A foley catheter should be inserted and
the woman’s urine output should be monitored.
For a major PPH, in addition to the management above, these measures should be considered:
the woman’s blood being taken for crossmatch (four units minimum), a full blood count and
renal and liver function for baseline.
Also, the pulse oximetry, blood pressure and respiratory rate should be continuously
recorded. It is important to try to identify the possible cause or causes of the PPH . Then
measures should be taken to stop the bleeding.
Stopping a bleed
If the cause is uterine atony, the midwife should massage the uterus to expel any clots, and
administer drugs to promote contractions. The drug treatment used will depend on local
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guidelines.
If management of the third stage was physiological, then either 10mg of oxytocin or one
ampule of syntometrine should be administered intramuscularly (IM), depending on clinical
circumstances and availability. If the woman has already received an oxytocic drug, a second
dose should be given. The RCOG and WHO recommend five units of oxytocin by slow IV
infusion, which may be repeated if required.
The WHO recommends that if IV oxytocin cannot be administered, or if the bleeding does
not respond to it, then IV ergometrine, syntometrine, or a prostaglandin drug should be given.
If the bleeding is unresponsive to oxytocin then a slow IV injection of 0.5mg of ergometrine

be given, unless there is a history of hypertension. However, ergometrine is not advised if the
placenta is still inside the uterus.
If the uterus contracts after these measures, a syntocinon IV infusion should be administered,
unless there is fluid restriction.
If a uterus is still not well contracted after the second dose of an oxytocic drug, carboprost
0.25mg by IM injection repeated at intervals of no less than 15 minutes to a maximum of
eight doses (contraindicated in women with asthma) or misoprostol 1000μg rectally should be
used.
Should these physical and pharmacological methods fail to control excessive blood loss, then
balloon tamponade, haemostatic brace suturing, bilateral ligation of the uterine arteries or the
internal iliac arteries, selective arterial embolisation or a hysterectomy may be needed.
Most causes of PPH will be successfully controlled via a second dose of oxytocic drug,
bladder catheterisation and repair of vaginal tears. However, if not, subsequent management
is most effectively performed in the operating theatre.
Identifying possible causes of PPH

The four T’s to look for:
Tone
Failure of the myometrium to contract adequately (atonic uterus) after the birth is the most
common cause of PPH.
Tissue (retained products of conception)

The placenta and membranes should be checked to ensure they are complete
Trauma
A vaginal examination should be carried out to check for any bleeding from the genital tract.
If this is the cause, the woman should be stabilised and the tear repaired
Thrombin (abnormalities of coagulation)
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The woman’s blood loss should be observed to assess whether it is clotting.
Bimanial compression of uterus

Wearing gloves, place one hand inside the vagina, form a fist and push up in the direction of
the anterior vaginal fornix
Place the other hand on the abdominal wall and push down behind the uterus, pulling it
forwards and towards the symphysis
Press the hands together to compress the uterus
Maintain the pressure until the uterus contracts and remains retracted.
Question
35 year old lady had her 5th delivery just now. She is bleeding. Assess and discuss the
management.
There was nurse inside the cubicle.
Talk to the nurse first. Hello I am Dr.... May I know your name please ...
Nurse – I am ... Doctor this lady had her 5th delivery just now and she is bleeding.
Dr: May I know what time she had the delivery ( bleeding within 24 hour of delivery is
primary portpartum haemeorrhage) ? Nurse - ..
Talk to the patient Dr - How can I help you ?
Patient only says hmm haa hmm (or she may say I can’t breath )
Ask the nurse to check the blood sugar. Check the monitor
Shows very low Oxygen saturation, low BP and high pulse.
Tell the nurse to give high flow oxygen ( 15 Litres/min) with mask with reservoir bag.
Saturation improves.
Tell the patient I need to examine your chest and tummy.
Remove dress from chest and abdomen. Blood visible in the vagina. Ask nurse - do know
how much blood she lost already ? She may show a bucket which has blood in that
( heavy bleeding).
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Reassure patient. You are having some bleeding from your front passage. Please don’t worry.
We can manage that. We need to give some fluid through your veins and also blood
transfusion. I will call my seniors immediately. Is that Oaky?
Pt – yes doctor.
Tell the nurse to insert 2 large bore IV cannulae ( grey colour 16G) in both forearms and
start her on 2 L Hartman’s solution ( rapid infusion). Also we need to transfuse blood
immedaitely. Can you please take some blood for FBC, U& Es, Group and cross match 4
units, clotting profile, LFT, Creatinine,
Nurse pretends to give fluids. Check the monitor. Blood pressure improves.
Ask the patient Do you feel better ? Pt – Yes.
Dr - Do you have any problem now ? Pt – No
Auscultate chest, Examine abdomen. – Normal
Ask patient did you have this type of problem before during your previous deliveries ? No
Do you have any bleeding disorders ? No
Ask the nurse did she have any vaginal tear or episiotomy during this delivery ? Yes/ No
Was the delivery of placenta complete ? Yes/No
Tell the nurse to insert urine catheter and monitor vitals and urine output.
Tell the nurse we may need to give Oxytocin 10mg IM. Let me call the seniors and
Anaesthetist immediately.
Examiner may ask questions ( or may pretend as if he/she is the registrar).
What happened and what have you done so far ?
What are the causes of postpartum haemorrhage ?
Uterine atony, Incomplete delivery of placenta, Bleeding disorders and trauma during
delivery.
What else you think we may need to do to control the bleeding ?
We can give Oxytocin 10 mg IM, can be repeated once again. Or we can give syntomtrine. If
the medical methods do not help then we can do –
Take her back to the theatre to re-explore and stop the bleeding.
Bimanual compression of uterus, balloon tamponade, haemostatic brace suturing,
bilateral ligation of the uterine arteries or the internal iliac arteries,
selective arterial embolisation or a hysterectomy may be needed.

Post hysterectomy (for DUB)? bleeding ?PE 17 January 2019
: Simwoman and has deteriorated now, not much given in the scenario
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 go and see her p/c feeling faint/dizzy and heart is racing, bp was 80/60 (give 2L hartmanns
solution via wide bore cannula but no further improvement means active bleeding
internally?) and O2 sats in 70s (give O2 100% with Hudson mask and sats rise). Talk about
blood transfusion.
 Did examination but no visible bleeding. Chest was clear, equal air entry bilaterally (others
believed it was PE). Vasopressors not present to give for low BP
 Had a hysterectomy for DUB and discuss reasons for dysfunctional uterine bleeding
(polyps, fibroids or cancer?) and deterioration at the 6 minute bell with the examiner ?
hemodynamic shock from internal bleeding or shock?
Treatment as usual to any other bleeding cases

Oxygen, IV fluids, Blood transfusion. If no improvement Call seniors and shift to theatre for
re-exploration to stop the bleeding.

SIMMAN- POST-TURP INFECTION
Causes of acute urinary retention

The most common cause in men is benign prostatic hyperplasia (BPH). Other
common obstructive causes include urethral strictures or prostate cancer.
Urinary tract infections can cause the urethral sphincter to close, especially in

those with already narrowed outflow tracts (e.g. BPH).
Constipation can also cause acute retention, through compression on the urethra.
Severe pain can often cause patients to enter acute retention.
Medications, such as anti-muscarinics or spinal or epidural anaesthesia, can affect

innervation to the bladder, resulting in acute retention.
Neurological causes can include peripheral neuropathy, iatrogenic nerve damage

during pelvic surgery, upper motor neurone disease (such as Multiple Sclerosis
Parkinson’s disease), or Bladder Sphincter Dysinergy*.
*Bladder Sphincter Dysinergy is the lack of co-ordination of detrusor muscle

contraction with urethral sphincter relaxation, leading to contraction against a closed
sphincter, often seen with spinal cord pathology or traumatic injury
If the patient is catheterised – catheter kinking, Obstruction in the catheter due to debri
( infection) or blood clot
Scenario-
80 year old man was brought in by wife, and he is feeling sick. Talk to him and address
his concerns.
(Inside the cubicle, you may find a Simman in a hospital robe and connected to the monitors.
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Monitor reading- ECG-Normal, Pulse- 100/mt(tachycardia), Blood Pressure- 100/70 mm hg,

SPO2-97%, Temperature- 37 degree Celsius)
S = Simman D= Doctor
D- “Hello, I am Dr.------, one of the junior doctors in the department.”

How can I help you?
S- Dr., I am feeling sick

D- Do not worry, I am here to help you. Could you tell me more about it?
I am feeling sick sine today morning.
D - Do you have any other symptoms ?
S- I am feeling very tired. I haven’t peed for a day and it is quite uncomfortable.
D- I am really sorry to hear about that. Is it alright if I can ask a few questions to know more
about your condition? S - Yes
D- Did you have tummy pain? S - Yes lower part of my tummy.
Did you vomit?
Did you have fever ? – I felt feverish
Were you able to pee well before this? No
Did you have to get up in the night many times to go to the loo? Yes
Dribbling? Pain while passing urine? - Yes there was dribbling.
Bowel movement-loose stools/constipation?
D- Any back pain ? weight loss ( for cancer prostate?) - No
D - Any constipation ? No
D – Any kidney stone before ? No
D - Any blood in the urine before ( stone) ? No
D- Any medical conditions ? No
Any weakness in arms and legs ? ( neurological conditions) - No
D- Are you on any medications ? No
D- Are you allergic to anything ? No
D - Have you had any operations done on your tummy ?
S - Yes, Dr. I was operated for TURP 4 days ago”
D- Did you have any problems after the operation ?
Examination :
D- “I would like to examine you and will ensure privacy and chaperone. I would like to
examine your chest and tummy. S- doctor you do it.
(Remove the hospital robe as well as the shorts underneath.
Urine catheter attached to urine bag may show yellowish turbid urine with pus collection. No
blood )
Examiner may say- chest is normal. Abdomen is normal except for suprapubic tenderness.
Cover the patient after examination.
Talk to the examiner:
E- “Dr, what do you think this is?”

D- “I think he has Sepsis due to urinary tract infection- probably after TURP.
E - Alright, what would you like to do now ?
D- I would like to take sample from the catheter - test for culture and sensitivity. I would also
like to test for urea and electrolytes as well as the FBC, blood culture and blood gases.
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Examiner may show ABG
ABG shows metabolic acidosis. Ph - low, Low HCO3, Low or normal CO2.
( This could be sepsis)
E – How do you manage ?
“I would like to involve my seniors. I will change the urine catheter. I will give him IV broad
spectrum antibiotics according to the hospital protocol.
E- “Ok
-------------------------------------------------------------------------------------------------------------
(Different scenario- Simman presents with enlarged prostate and did not pass urine since 2
days. He was catheterised. He is posted for surgery after 3 weeks later)
Similar to above except the operation was planned later.

Septicaemia after UTI ( SIM WOMAN) – 3rd Oct
You are an FY2 in the Medicine Department.
An elderly lady (? Name/ Age) was admitted 3 days ago for UTI
The nurse has called you and says that the patient has been “feeling poorly” and that
you are the only doctor available to see her.
Assess the patient and manage her appropriately.
When you enter the cubicle there is no nurse to ask history. Breathing sounds are heard from
the speaker.
Only SIMWOMAN is inside with the monitors attached –
Temperature- 39 C B.P- Low, for some the B.P was normal Oxygen saturation – 88%
Sw- I cannot breathe Dr – Since when – since last few hours.
Dr- Don’t worry Mrs.____, You are in safe hands, we will do everything we can
to help you. I am going to give you some oxygen to help you breathe.
Attach the oxygen mask and start O2 at 15 litres per min.
The examiner increases the SpO2 to 93 %
Dr- Mrs.____, I hope you are feeling better now. Your blood pressure is low so I will be
giving you some fluids through your vein.
A stand with IV fluid bag is present, connect the IV line to the cannula (no need to open the
cork). The examiner increases the blood pressure to normal.
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Dr – May I know why are admitted here?

Sw – Doctor I had burning sensation while passing urine and fever since the last few days.
Dr – Were you feeling better in the last few days after the treatment in the hospital ? Yes.
Dr - Do you know which medication was given to you? No

Dr - Was it given by mouth ( Oral ) or through your veins ? Mouth/ IV
Dr - Did the nurses insert any catheter for passing urine ? Yes/No
Dr – Any bowel or bladder incontinence ( cause of urine infection) ? No
Dr – Do you wear diaper ( not frequently changed diaper cause UTI) ? Yes/ No
Dr – D you have any medical conditions other than this urine problem? No
Dr - Diabetes ? No HTN ? – No
Dr – Are you on any other medication other than given for urine problem ? No
Dr- Mrs.____, I would like to do a head to toe examination to find out the reason for your
condition. I would like to examine your Chest and Abdomen. For this I would like you to
undress completely. I will ensure your privacy and make sure a chaperone is with me.
You undress the patient and proceed with the examination.
Chest examination- Bilateral crackles ( sepsis) are present all over the lungs.
Abdominal examination- Look for any distension, Guarding or Rigidity or any Suprapubic
tenderness. Observe if any catheter is attached.
The examiner doesn’t confirm/deny the findings.
Dr- Mrs.____, thank you for your cooperation. You can get dressed now ( you cover the
SIMWOMAN)
From the monitor observations and the examination findings, I think you may be having a
condition called septic shock, this means that the infection from your urinary tract has spread
throughout your body.
I would like to arrange for a Chest X-ray. I would like to do a FBC, Urea and Electrolytes,
Blood culture, and ABG and also test your urine for bugs. I would also like to insert a catheter
so that we can monitor your urine output (If it is not already inserted).
We will contact and inform the relatives.
We will review the antibiotics ( check culture report) you are receiving whether. We will be
starting you on some stronger antibiotics through your veins to treat you. We may change
these later when the culture reports come back. I will talk to my seniors.
Tell the examiner if he ask - I would like to inform my seniors about your condition. I will
check for any advance care decisions whether to give active treatment or not. We may
have to shift you to the ICU so that you can receive the appropriate care.

HYPOGLYCEMIA SIMWOMAN STATION- FEB 6TH &
MARCH 9TH
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Lady scheduled for discharge today. She was admitted 6 days back Nurse called you
because the patient stopped responding. Evaluate and manage. Talk to the examiner while
examining.
Its a Simwoman on the couch and her hands are dangling on the side. Only Examiner is there
inside. There is a table nearby with different syringes labelled with Dextrose, a glucometer and
a sheet with a list of her medications. Pt has been treated for pneumonia.
Dr : Hello I’m Dr…. A junior doctor in this dept, can you confirm your name please?
Pt : no response. (for some eye were blinking)
Look at the monitor : Vitals are stable. HR : 72, BP : 145/90, SpO2 : 96%, Temp : 36.5,
Dr : Checking airway, examiner : clear,
Dr :Breathing : on auscultation : b/l crepitations +,
Dr :circulation : I will be checking Capillary refill
Examiner : normal
Dr : I want to check her notes
Examiner takes the files from underneath two other files and gives you
Notes says : she is hypertensive, Diabetic on Tab Gliclazide 20 mg or Insulin
Dr : Disability, I’d like to check my patients blood sugar level and GCS
Examiner : 2.1mmol/l
Dr : thank you examiner, Pt has severe hypoglycaemia. I’d like to put an IV cannula and give
100 ml of 20% dextrose intravenously
Examiner : what is your immediate management?
Dr : I want to check for response now
Examiner : the blinking has increased
Dr : I will talk to her
Examiner : She is well now, assess her
Dr : I will check for her diet today and assess her medications ( May be skipped meal – given
in the question)
Examiner : what else would you like to do?
Dr : Since she is a hypertensive I would assess her plantar response to see if she had a stroke
Examiner : no response.
Dr : I’d check pupillary response and the size of the pupils
Examiner : normal, what else?
I will take detailed history, full examination and investigations.
Dr : I would run investigations : Urea, electrolytes, chest X-ray since she still has crepitations,
review her medications. : I would call my seniors and inform them about the patient. Advise her
about how to avid hypoglycemia. No to skip meals.

Acute Asthma SimMan
Exam question
30 year old man came to the emergency department c/o SOB

Take history, examine and discuss your diagnosis and management with the
examiner.
Differentials for Shortness of breath

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1) Acute Asthma
2) Acute exacerbation of COPD
3) Heart failure
4) PE
5) Pneumonia
6) Pneumothorax
7) Anaphylaxis
8) Arrhythmias ( SVT)
Dr - Hello Mr ... I am doctor ... How can I help you Mr... ?

Pt - Doctor I can’t breath properly
Dr - Since when ? Pt - since last few hours.
Dr - Did you have this problem before? Pt – Yes, I have asthma ( Known Asthma patient)
[ If patient says – no, ask do you have Asthma or smoker’s cough, then patient may say –
I have asthma]
Dr - Did you take your medication ?
Pt - yes, it is not helping me. They are on the table. ( inhalers may be kept on the table –
Look at the medicines).
Look at the monitor for Oxygen saturation, respiratory rate, pulse and BP, temperature,
ECG rhythm and tell the examiner. Usually oxygen saturation is 82 to about 84%. Tell
the examiner - I will give high flow oxygen 100% concentration with flow rate of 15
litres/min.
Tell the patient – I am going to give you some oxygen you will feel better. Put the
Hudson mask with reservoir bag on the mannequin face and tie properly.
Hudson mask with reservoir bag Simple face mask without reservoir bag
Dr - Any chest pain ( MI leading to heart failure) ? Pt-No
Dr: Does SOB gets better or worse while lying down ( heart failure) ? No change doctor.
Dr: Did you have any heart problem before ? Pt - No
Dr: What were you doing when this started ( exercise induced) ? Pt: I was just resting
Dr - Any fever ( Pneumonia) Pt - No
Keep looking at the monitor – Oxygen saturation should improve by this time. If not jump
to treatment ( I will give him Salbutamol 5mg as nebuliser and call my senior immediately)
Make sure the saturation improves. And then continue.
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Dr: Do you smoke ( COPD) ? Pt: yes / No

Dr: Any pain or swelling in calf ( PE) ? Pt: No
Dr: Recent Travel or immobilisation ( Surgery ) (PE) ? Pt: No
Dr : Do you take any other medications other than Inhalers ? Pt – No
Check the monitor for oxygen saturation.
Examine.
Exposure - Dr - I need to examine your chest. Can you please undress above your waist ?
Patient ( mannikin) may say - you do it [and then you expose the mannikin].
Inspection- Appears severely breathless, No cyanosis in hands and lips
No neck vein engorgement, No tracheal shift ( to r/o tension pneumothorax)
Chest – Inspection – Movements symmetrical.
Palpation - Movements symmetrical,
Percussion – No hyper - resonance or dullness
Auscultation – Air entry bilaterally equal, Wheeze heard bilaterally all over the lung fields.
No crepitation.
Cover the patient.
Tell the patient : It looks like your Asthma has come back. We will give you some
medicine and you will feel better soon.
Then talk to the examiner.

Diagnosis – Acute Severe Asthma
Tell the other management to the examiner.
I will admit the patient.
- Salbutamol nebuliser – 5mg,

- Ipratropium bromide 0.5mg Neb
- Hydrocortisone 100 mg IV every 6 hours
- Keep monitoring the oxygen saturation, respiratory rate, ABG
- Do portable chest X Ray and ECG
- If no improvement – repeat salbutamol nebuliser every 15 minutes.
- I will call the seniors immediately.
- If no improvement – IV Magnesium 2gm over 20 minutes
- If no improvement talk to seniors and consider Aminophylline infusion
If still no improvement – needs intubation and ventilation so I will call the anaesthetist
also.
[ If the patient says I am dying – stop taking history or examination check the
monitor reassure the patient that you will give medicine and he will be better soon,
and tell the management to the examiner and then continue.
Keep looking at the monitor at all times – jump to the treatment if the saturation did
not go above 94% or if it drops any time, or if the patient says I am dying or if the
patient shows signs of respiratory distress].
Talk to the patient
Mr ... Your Asthma has come back. Your inhaler medication is not working. So we need to
keep you in the hospital and treat you with nebuliser medications – salbutamol to widen
your airways. This medication will be given like a steam inhalation. We will also be giving
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some steroid medication through your veins. Any questions ?
We need to do some tests like chest X Ray to make sure that you do not have any other
problems. Also we will be doing some blood tests to check blood gases and other things.
Once you have improved then we will discharge you. Is that OK?
Any concerns?
If the patient did not know what is Asthma - then explain.
Dr: In this condition your airways become narrow which is causes breathing difficulty.
Sometimes this condition runs in the family. Most of the time it is due to allergy to dust,
animal fur, pollens or sometimes it may be due to exercise.

SIMMAN - ACUTE LIMB ISCHEMIA
Question:
You are an FY2 doctor in the A&E department
A 55 year old female presented with a history of severe pain on her right leg since today
morning.
Take history, examine the patient and comment on the management.
Differentials:
1. Acute limb ischemia
2. DVT
3. Sciatica
4. Cellulitis
5. Trauma
Dr: Hello ,I’m doctor ………. One of the junior doctors in the A&E department. How can I
help you today?
Pt: I am having pain on my right leg doctor! I was absolutely fine until yesterday. I can’t take
this pain anymore. Please help me!
Dr: I’m sorry to hear that Mrs ……. but don’t worry. I will definitely help you.
Could you please tell me a little bit more about this pain?
Pt: It is just started on its own since today morning. …I don’t know why this happened…
Dr: are you comfortable to talk to me right now ? Pt: okay doctor
Dr: can you please tell me where exactly the pain is ?
Pt: It is all over my right leg doctor.
Dr: can you grade the pain for me from 1 to 10, 1 being the mildest and 10 being the most
severe. PT: 10 out of 10 ( Okay, I will tell the nurse to give you strong painkiller medicine (
Morphine).
Dr : Do you know how did this pain start ? – Suddenly on its own.
Dr: Did you have any injury to your leg ? - No
Dr- Do you have any cast put on your leg for fracture ? No ( compartment syndrome)
Dr - Is it coming from the back of your body, and travelling to your leg? (sciatica) Pt: No
Dr: Is there anything that is making it better or worse?? Pt: no doctor.
Dr: is there any other symptoms, apart from the pain?
Pt: I feel my legs are weak doctor.
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Dr: I’m really sorry about that as well. Do you feel weakness in both of the legs or just the
right leg? (Nerve compression) Pt: my right leg only doctor.
Dr: Any other symptoms?? Pt: No
Dr: Were you having pain in the legs while walking for some distance ? Pt: no ( PVD – Limb
ischemia)
Dr: Was there any pain on your legs at night? (LIMB ISCHEMIA)
Dr: do you have more pain on your calf muscle? Pt: no ( DVT)
Dr: Do you have pain in your chest??(DVT AND PE) Pt: No.
Dr: Do you feel short of breath? Pt: no (PE and AF)
Dr: Did you have feeling of heart racing or irregular heart beat ? Pt: I felt my heart was
thumping ( heart racing ). AF ( one of the cause of acute limb ischemia)
Dr: Alright. Do you have fever ? ( CELLULITIS) Pt: no
Dr: Is this the first time that you are having a pain like this? Pt: Yes doctor
Dr: Do you have any medical condition? HTN? DM/ High cholesterol ? No ( Risk factors for
any vascular conditions)
Dr: Are you on any medications now? Pt: No
Dr: Are you allergic to any medications? Pt: no
Dr: Do you smoke? Pt: Yes ..( most common risk factor for PVD)
( She may be chronic smoker)
Dr: Is there anything else you would like to tell me? Pt: No doctor
Examination: Okay Mrs….. I would like to examine you. Check monitor. I would like to
examine your hands, chest and your legs as well. Would that be okay ? I will ensure your
privacy and will have a chaperone with me. Pt: ok doctor.
Exposure: Could you please undress below the waist ? Pt says you do it.
Remove the dress below the waist.
Legs: Right leg bluish in colour

Temperature : Compare both the legs ( right leg may be cold)
Check femoral, popliteal, dorsalis pedis and posterial pulses in both legs and compare.
Distal pulses ( dorsalis pedis and posterial pulses ) absent on right leg
CHEST :
Inspection - Chest appears normal, Auscultation – No murmur heard. Normal heart sounds.
Thank you, could you please dress up now. Cover the manikin.
Monitor shows Atrial fibrillation.
Stop the examination at the 6th minute and proceed with management
Do you have any idea about what is happening to you? PT: no doctor
Dr: On examination your heart is beating irregularly,also, your leg is bluish in colour and
pulses in your lower part of legs are absent as well. From the information you have given me
and after the examination, I suspect you have a condition called ACUTE LIMB
ISCHEMIA. Do you know anything about it? Pt: no
Let me explain, we have blood vessels in our legs which supplies blood to the legs.
Sometimes this blood supply to the legs gets blocked with blood clots, what we call as an
emboli. Are you following me?? Yes doctor but why do I have this blood clots ?
Dr - As I told you, your heart beating has an abnormal rhythm. Usually emboli( blood clots)
are formed in the heart, when there is an abnormal rhythm in the heart. In your case I suspect
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it is an emboli ( blood clot) in the heart is causing this problem. It can travel from your heart
to the blood vessels in the legs and can block the blood vessels and stopping the blood supply
to the legs. Are you able to follow me?
Pt: Yes doctor, Is it serious?

Dr: Unfortunately, this is a serious condition if left untreated. If it is not treated urgently then
you may even lose your leg. However, we do have good treatment for this.
Pt : What will you do for me?
Dr: We need to admit you right away.! Would that be okay with you.? Pt: yes doctor.!
Dr: I would like to run few tests. I will inform my seniors and the Vascular
surgeonsimmediately.
I would like to do some blood tests, your blood sugar, blood cholesterol, clotting tests
[ INR, APTT, U&E, Creatinine kinase, platelet count – don’t mention these to patient).
I would also like to take an X RAY of chest, an ECG, which is a tracing of your heart and
an arterial doppler scan of your leg to confirm the condition. Specialists may also consider
doing CT angiography or MR angiography
Pt: Ok doctor. How are you going to treat me?

Dr: Sure! I will explain the treatment options.
In order to relieve the symptoms, we will be starting you on painkillers (IV MORPHINE
5mg) and would like to start on Oxygen to improve oxygen circulation in the legs.
The treatment depends on the test results. Vascular surgeons will assess you and they will
tell you the exact treatment. If the condition can be managed with medications, they will give
you a blood thinner medication called heparin through your veins. There are other options
where the surgeons can remove the blood clots from the legs what we call embolectomy
or a vascular bypass where they put an artificial tube to bypass the blockage and restore the
blood flow to the legs. Are you following me? Pt: Yes doctor
Dr – Also we will refer you the Heart specialist to treat the abnormal heart rhythm.
I sincerely advise you to stop smoking because smoking is a most common risk factor for
developing this condition. Also we would also check your cholesterol level and will inform
accordingly
Dr: Any other concerns? Pt: no. doctor. Thank you,
Dr: okay Mrs….. I will inform my seniors right now. Thank you .

Atrial fibrillation SimWoman
Exam question
60 year old lady presented with feeling dizzy. History examination and management
with the examiner. At 6th minute discuss finding’s with the examiner.
( Positive findings – Dizziness and palpitations for about 2 weeks)
Dr: Hello Mrs ... I am Dr ... junior doctor in the medical department. How can I help you ?
Pt: I am feeling dizzy and I get palpitations since the last 2 weeks.
Dr: I am sorry to hear that. Is there anything else you can tell me about it?
Pt: Doctor it just started on its own. I was perfectly fine before that.
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Dr: You said you felt dizzy – is it like light headedness or you feel the room is spinning?
Pt: I feel like light headedness/ not like the room is spinning
Dr: Can you please tell me when do you get dizziness – all the time or it happens only
some times? Pt : It happens only some times
Dr: How many times it happened since it started? Pt: --
Dr: How long does it last ? Pt: ---
Dr: Did you lost consciousness any time at all ? Pt : No
Dr Do you have any balance problem ? Pt: Ye I feel as if I don’t have balance when I feel
dizzy
Dr: Any problem in your ears like – hearing problem, any ringing sound in ears ? Pt : No
Dr: You said palpitations – since how long you had this ?Pt : about 2 weeks.
Dr: Does it also comes once in a while or is it continuous ? Pt: -
Dr: How many times you think you had this problem since it started ? Pt :
Dr: Do you feel dizzy when you get palpitations or they occur at different times ? Pt –
Dr: How do you feel the palpitations – do you feel as if the heart is racing or missing heart
beat ? Pt –
Dr: Do you have any chest pain or did you have any chest pain when all these symptoms
started ? Pt : No
Dr: Do have shortness of breath? Pt : yes Dr: Since when? Pt: Since the same time.
Dr: When do you get SOB – all the time or when you lie down or when doing exercise ?
Dr: Any swelling in your ankle ( Heart failure) ? Pt : Yes / No
Dr: Did you have any recent surgery ( PE) ? Pt: No Dr: Recent travel ( PE) ? Pt: No
Dr: Do you get too tired ( Anaemia) ? Pt : No
Dr: Have noticed any bleeding from gums or back passage ( anaemia) ? Pt: No
Dr: Any changes in the bowel habits ( hyperthyroidism) ? Pt: No

Dr: Any weather preference ( Hyperthyroidism) ? Pt: No
Dr: Have you been diagnosed with any medical conditions ? Pt : No

Dr: Like high blood pressure ?Pt : No Dr: Diabetes ? Pt- No
Dr: Heart conditions ? Pt: No
Dr: Are you taking any kind of medications ? Pt: No

Dr: Are you allergic to any medications ? Pt: No
Dr: Do you live with any one ? Pt: Yes/No
Dr: Is there anything else you think is important that we may need to know? Pt: No
Examination :
Mrs. I need to examine your chest. Could you please undress above the waist ? I will
ensure privacy and have a chaperone with me.
Mannikin may say - Doctor you do it. Then undress the manikin ( do not undress if the
examiner says assume the patient is exposed)
Examine the hands – no clubbing, palmar erythema, no cyanosis.

Ankle – No pedal oedema
Ideally I will check for raised JVP ( can’t check JVP in Manikin)
Check the pulse ( for about 10 seconds) – may show irregular rhythm.
Examine the chest – No scars or deformities in the chest.

I will check for apex beat to see shift in the apex beat ( manikin has no apex beat)
No palpable thrill
No Para sternal heave
Auscultate all the areas – for heart sounds and murmurs
Auscultate for basal crepitations ( on the sides of the chest because can’t make the manikin
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sit up)
Check the monitor for Pulse rate, BP, Respiratory rate, Temperature and tell the examiner
your findings
Check the ECG on the monitor – may show Atrial fibrillation ( irregularly irregular
rhythm, narrow QRS complex, Abscent P wave) (Look at the ECG on the monitor for at
least 15 seconds otherwise you may miss AF because sometimes normal rhythm come in
between irregular rhythm)
Cover the patient. Thank the patient.
Talk to the examiner
Patient has palpitations, dizziness since last 2 weeks. Had no medical problems previously.
On examination, I found the ECG showing Atrial fibrillation with the pulse of ... and BP ...
I think the patient has Atrial fibrillation.

I want to do further investigations like FBC, U&Es, chest X Ray. ECG,
Examiner may not give any results.
I will admit the patient, Inform my seniors–
She may need to be treated with beta blockers and anticoagulation for Atrial fibrillation.
I will refer her to cardiology for further management.
Alcoholic foot Examination

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Causes of burning sensation on feet.

Diabetes and alcohol
Chronic kidney disease (uremia)
 Vitamin deficiency (vitamin B12, folate, and occasionally vitaminB6)
Hypothyroidism
 HIV/AIDS
 Drug side effects, including chemotherapy drugs, vitamin B6 overdose, HIV
medicines, amiodarone, isoniazid, metformin, andothers
 Erythromelalgia
 Vasculitis (inflammation of bloodvessels)
 Guillain-Barre syndrome(GBS)
Infections and inflammation of the feet can also cause a burning sensation. The most
common of these is athlete's foot, an infection of the skin caused by fungus.
Peripheral artery disease (PAD) also commonly causes burning feet.
You are the FY 2 doctor in the medical department.

50 year old lady Mrs Sarah Boyer presented with burning sensation on feet. She is
chronic alcoholic. She was on alcoholic rehabilitation programme 5 years ago. Take
focussed history, do the relevant examination and discuss the management with
her.
Hello Mrs Sarah Boyer I am Dr … one of the junior doctor in the medical department.
How are you doing ? Pt : I am Ok
Dr: How can I help you Mrs Boyer ?
Dr: I am having burning sensation in my feet.
Dr: Since when are you havingthisproblem? Pt: Since the lastfewweeks.
Dr: Do you have burning sensation in hands also? Pt:No
Dr: Are you able to walk properly? Pt: Yes
Dr: Any tingling numbness in hands and feet ? Pt: No
Dr: Do you have any medical conditions ? Pt: No
Dr: Like - Diabetes, High blood pressure ? High cholesterol? Kidney or Thyroid disease
? Pt – No
Dr: Do you smoke ? ( can cause PVD) Pt: No / Yes
Dr: Do you drink alcohol ? Pt: Yes
Dr: What do you drink ? How much ? how long ? Pt – I drink …
Dr: Have tried to cut down drinking alcohol? Pt: I tried 5 years ago. I was in the
rehabilitation program for that.
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Dr: How is tour diet – do you eat healthy diet fruits and vegetables in your diet ? (
vitamin deficiency) ? Pt: Yes
Dr: Are you taking any medications ? Pt : No
Dr: Mrs Boyer I need to examine your kegs now. Can you please undress below your
mid-thigh area.
Pt: Ok doctor.
Examination
Same as diabetic foot examination.
[ Stop examination at 6th Minute bell ].
Management
Mrs Boyer, I think you have a condition what we call as Alcoholic neuropathy – that is
alcohol has affected the nerves in your legs.
We will do some tests to check whether you have any other causes – like diabetes and
blood circulatory problems. Also we will do some nerve conduction tests.
Treatment – unfortunately there is no cure for this condition.

 However we can give you some medications to relive your pain like
amitriptyline,
carbamazepine, gabapentin.
 We will give you some vitamintablets.
 You must cut down drinking alcohol to prevent progression of this condition.
Also eat healthydiet.
Diabetic footexamination
You are the FY 2 doctor in the Medical department.
45 year old Mr Henry Rickman is a known Diabetic patient on diet control diabetes
came to the hospital for routine follow up.
Take a brief history and do the necessary examination and talk to him about the
further management
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Hello MrHenryRickman I am Dr … one of the junior doctor inthemedical

department. How are you doing?
Pt: I am fine doctor.
Dr: I understand you have diabetes ? How is your diabetes now – are you monitoring
your sugar regularly? Is it controlled well?
Pt: I am monitoring the sugar. It is controlled well.
Dr: Are you taking any medicationsfordiabetes? Pt:No
Dr: Do you have any concerns ?

Pt: My friend has diabetes and doctors have amputated his toes. I am worried whether I too
will end up having the same problem.
Dr: Mr Rickman, Don’t’ worry everyone who has diabetes will not end up having their toes
amputated. These things happens only if the sugar is not controlled well for long time. If you
control your sugar well and take care of your foot this problem will not happen.
Dr: Can I ask few questions to see whether the diabetes has affected any organs oryour
legs? Pt: Yesdoctor.
Dr: [Eye] Do you have blurry vision or any other problem with your vision? Pt : No Dr:
[Kidney] Do you pass more urine than normal – do you have to go to loo moretimes than
usual recently ? Pt:No
Dr: [ Heart] Any chest pain or palpitation Shortness of breath? Pt – No Dr:
[ Nerve] – Any tingling or numbness in the hands or legs ? Pt – No Dr: Do
you have any pain in yourlegs? Pt -No
Dr: Any pain in your calf muscles after walking forsometime? Pt –No
Dr : Do you have any other medical conditions like high bloodpressure? Pt–NoDr-
Have you checked your cholesterolrecently? Pt -No
D: Do yousmoke? Pt- No /Yes
Dr: Mr Rickman I need to examine your legs. Could you please undress belowyour mid-
thigharea. . Pt:Ok
Inspection of the legs
There is no Swelling, Redness, Pallor, Muscle wasting.

Check for loss of hair, shiny skin, nail changes, fungal infections between the web spaces
of toes, pressure sores. Check the heels for pressure sores by lifting the legs.
Palpation –.Temperature both legs – normal [ cool (e.g. PVD) / hot (e.g. cellulitis)]
Dorsalis pedis artery – lateral to extensor hallucis longus tendon
Posterior tibial artery – posterior and inferior to medial malleolus

Sensation – Fine touch with cotton wool – distal to proximal. Throw cotton wool into
the clinical waste bin. Use monofilament for sole.
Pain with neuropin – throw into sharp bin.
Vibration – use tuning fork – 128 Hz Joint
positionsense
Check if there is any sensory loss and if there is sensory loss up to what level ?
Motor – Check the knee and ankle reflexes

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Check the gait
Observe the patient walking whilst assessing:
 Symmetry /balance
 Turning – quick / slow /staggered
 Abnormalities – broad based gait / foot drop /antalgia
Examine footwear:
 Note pattern of wear on soles – asymmetrical wearing – gaitabnormality

 Ensure the shoes are the correct size for thepatient
 Note holes and material inside the shoes that could cause footinjury
Findings – usually there will be loss of sensation either below mid shin or below the
knee.
[Stop the examination at 6th minute bell if you have at least finished the
sensory part of fine touch and pain – if not finish sensory]
Management:
Diagnosis : Mr Rickman, you have loss of sensation on your legs. This is because the
diabetes has had affected the nerves supplying the legs. Do you follow me?
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Pt: Yes doctor.
Investigations –
We need to do blood test to check your sugar control (Hg A1c )
We also need to check your cholesterol, kidney function tests and liver function tests.
Treatment
 We may need to start you on medications to control your sugar. I will discuss this
with my seniors and let youknow.
 It is very important to control your sugar properly. Eat healthy balanced diet. Check
your sugarregularly.
 It is very important to take care of yourfeet.
 Avoid going barefoot, test water temperature before stepping into a bath.
 Trim toe nails to shape of the toe; remove sharp edges.
Wash and check feet daily for any injuries or infections.
 Stop smoking because it can worsen the condition if he is asmoker.
5.Do regularexercises.
Unfortunately the sensations what you have lost in your legs may not come back.
However we can stop it from getting worse if you follow all our advise.
Thank you very much.

Visual field examination
You are the FY 2 doctor in the Medical department.
Mr Stephen George 45 year presented to the hospital with bumping into

neighbouring objects while driving and even walking. His wife advised him to go
for check up with the doctor.
Take a brief history and do the relevant examination and discuss your findings and
further management plan with the patient.
Causes of tunnel vision

1 Glaucoma - Halos, Pain, triggered by amitryptilline
2 Retinitis pigmentosa
Symptoms often start in childhood with impaired night vision
(nyctalopia) or dark adaptation.
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Progressive loss of peripheral vision is common (resulting in a

tendency to trip over things), although there may be loss of central
vision which tends to occur later. This eventually leads to impaired
sight at a variable rate.
The symptoms usually become apparent between the ages of 10 and
30, although some changes may become apparent in childhood.
3 Eye strokes or occlusions
4 Detached retina- sudden oncet, like a curtain coming down.
5 Brain damage from stroke ( headache, weakness in any part of body),

disease or head injury
6 Optic neuritis - usually affects one eye, Pain. Vision loss, Loss of
colour vision, Flashing lights.
7 Compressed optic nerve head (papilledema)
8 Concussions (head injuries)
9 Pituitary adenoma – bitemporal hemianopsia, tunnel vision, family

history of vision problem or tumours in the brain, milk discharge from
breast
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Have noticed any milk discharge from your nipple ( pituitary adenoma) ? No
Any vomiting ( brain tumour) ?No
Do you have any medical conditions ? No
Are you taking any medications ? No
Any of your blood relatives have such problems ( pituitary adenoma) ? No
Mr George I need to examine your eyes and check your vision. Is that OK
OK doctor
Examination
Inspection eyes – Normal
Visual acuity – Normal
Red reflex and fundoscopy examiner says normal
Visual field – Finding may be tunnel vision rarely bitemporal hemianopia.
Diagnosis, Investigations and treatment.
Mr George, after assessment I can see that you are not able to see especially outer part of
your vison area. That is the reason you may be bumping onto the things. This could be due
to problem in the brain. I suspect there is tumour ( growth) in a gland in the brain called
Pituitary gland which is located at the base of your brain near your nasal passages. This
gland produces hormones. This gland is pressing on the nerves suppling the eyes.
Most likely this a non-cancerous growth. Do you follow me? Yes doctor.
We need to do some test to confirm it. We will do some blood tests check the hormones
and also MRI scan of the brain to look for this tumour. Is that OK? Ok doctor.
If the tests does show that you have this growth of the Pituitary gland then depending on
what type of growth it is we will treat with either medication or surgery or radiation
therapy. Most likely your vision will come back after the treatment. Any questions ?
Fundoscopy
Explain Procedure : I need to examine the back of your eye with a special instrument called
opthalmoscope . For that I will be shining a bright light on your eyes . During the examination I
will be coming very close to you and will be touching your cheek and face. I will be using some
dilating drops which might dim or blur your vision; therefore you are advised not to drive home
alone or to sign any important legal documents during theday.
Exposure / Position : You can blink normally during the procedure but don't move your head
and sit comfortably . I will be dimming the lights of the room and you should fix your vision at
a distant object .
Check Instruments Check power

of lens. Check light – BIG FULL
MOON
Inspection – coming at eye level Both Eyes are at same level No Ptosis No signs of
inflammation Orbit and appendages are normal
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Do a Red Reflex – same level as the eye. Look through the fundoscope for Red Reflex
( seen in normal eye and it means media is clear) Media is clear therefore I proceed to
Fundoscopy.
In real patient I would have examined with Fundoscope light on but in exam since there is a
bright light shining from back I may have reflection or glare so I would like to examine now
with Fundoscope light switched off .
Right eyeofpatient Left eye ofpatient Right eyeof examiner Left eye
ofexaminer Right handofexaminer Left hand ofexaminer
Do the procedure, approach at an angle of 30-45 , and follow the red reflex .
0.
Ask to follow into the instrument visualize macula . Explain findings to the
examiner.
Description of Slide
Comment on
Optic disc :(1) Colour (2) Margins (3) Contour (4) Cup disc ration {CD Ratio}

Origin ofBlood Vessels: shape of vessel and caliber ofvessels.
Periphery and Rest of Retina
Macula
Normal
Fundus
A. Optic disc – Alwaysnasal

• Colour – Pinkish pale or pinkishyellow
• Margins – Welldefined
• Circular or Rounded inContour
• Cup disc Ratio – 0.3 –0.5
B. Blood Vessels -Originating from Optic disc, straight not tortuous normal caliber of
vessels-A :V2:3 C. Periphery and rest of retina – Healthy and Normal – no
exudates, nohaemorrhage D. Macula – Healthy andNormal
SLIDE OF NORMAL FUNDUS: SLIDE 9 I can see the OD, pinkish pale or pink
yellow in colour, well defined margins, circular in contour CD ratio is normal. Vessels are
originating from the OD, Straight not tortuous, normal in calibre. Periphery and rest of
retina and macula appears healthy and normal. Therefore my diagnosis is NORMAL
FUNDUS.
SLIDE OF OPTIC ATROPHY I can see the OD, pale or chalky white in colour, margin well
define, and circular in contour .Cup cannot be appreciated. Origin of vessels not clear, they are
straight and normal in calibre. Macula and periphery and rest of retina appear healthy and
normal. Therefore my diagnosis is Optic Atrophy.
SLIDE OF DISC CUPPING: SLIDE 10 I can see the OD, pinkish pale in colour, circular in
contour, margins ill defined. CD ratio is increased in size indicating cupping of the optic disc.
Origins of vessels not clear, they are straight not tortuous, normal in calibre . Macula and
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periphery and rest of retina appear healthy and normal. Therefore my diagnosis is Disc
Cupping most probably due to glaucoma. Treatment: Urgent reduction of intra ocular
pressure e.g. mannitol oracetazolamide.
SLIDE OF PAPILLOEDEMA: SLIDE 11 I can see the OD which is swollen, oedematous,

hyperaemic and bulging, margins are blurred or ill defined and cup cannot be appreciated.
Origin of vessels are not clear but vessels are engorged, tortuous and congested. Periphery and
rest of retina appears hyperaemic. Therefore my diagnosis is Papiloedema. Urgent MRI to rule
out intracranial mass.
SLIDE OF CENTRAL RETINAL VEIN OCCLUSION: SLIDE 15 I cannot appreciate

the OD. Origin of vessels is not clear, but veins are engorged, tortuous andcongested. I can
appreciate flame shape, dot and blot haemorrhages in all quadrants, hard exudates and cotton
wool spots. Periphery and rest of retina appears hyperaemic and seems to be a stormy sunset
or tomato splash appearance. Therefore most probable diagnosis is CRVO.
SLIDE OF SENILE MACULAR

DEGENARATION
I can see the OD which is pale towards temporal side, margins well defined, circular
in contour cup cannot be appreciated.
Origin of vessels not clear but they are straight and not tortuous, normal in caliber.
I can appreciate macula, there are few unusual pigmentations around it and also
scattered around periphery of retina.
Therefore my most probable diagnosis is senile macular or age related macular
degeneration.
SLIDE OF BACKGROUND DIABETIC RETINOPATH:

SLIDE 1
Optic disc is not so clear.
Origin of vessels not so clear but they are straight and not tortuous.
Can appreciate hard exudates along the inferior temporal arcade, discrete, having
irregular surface, margins are ill defined.
Can also appreciate dot and blot haemorrhages in the nasal macular area and
superior temporal arcade, micro aneurysms in the macular area.
Therefore my most probable diagnosis is background diabetic retinopathy.
SLIDE OF PRE-PROLIFERATIVE DIABETIC RETINOPATHY: SLIDE 3

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Pre-proliferative diabetic retinopathy is characterised by retinal ischaemia. Cotton wool spots

represents area of focal retinal ischaemia. Initial description of background + Can also
appreciate hard exudates, dot and blot haemorrhages, micro aneurysms and cotton wool spots.
Therefore my most probably diagnosis is Pre Proliferative Diabetic Retinopathy.
SLIDE OF PROLIFERATIVE DIABETIC RETINOPATHY: SLIDE 4
Can appreciate neo vascularization around OD and elsewhere along the vascular arcade.
Can also appreciate hard exudates, micro aneurysms and dot and blot haemorrhages, pre
retinal fibrosis. The new vessels grow into the vitreous and are fragile leading to
haemorrhage. As the haemorrhage organises, fibrous tissue reaction occurs.
Therefore my most probably diagnosis is Proliferative Diabetic Retinopathy.
Management:
The most important part of treatment is to keep diabetes under control.
In the early stages of diabetic retinopathy, controlling diabetes can help prevent vision
problems developing.
In the more advanced stages, when vision is affected or at risk, keeping diabetes under
control can help stop the condition getting worse.
. Treatment for advance diabetic

retinopathies:
1. Laser treatment: To treat the growth of new blood vessels at the retina in case of
proliferative diabeticretinopathy.
2. Eye injections: AntiVEGF
3. Eye surgery: To remove blood or scar tissue from the eye if laser treatment is not
possible.
SLIDE OF SUB HYALOID HAEMORRHAGE:SLIDE22
Can appreciate massive boat shaped haemorrhage in , which is most probably a sub hyaloids
haemorrhage .
Can also appreciate a few, micro aneurysms, dot and blot haemorrhages.
Therefore my most probably diagnosis is Pre Proliferative Diabetic Retinopathy with pre
retinal haemorrhage.
SLIDE OF LASER COAGULATION :SLIDE7
Can appreciate a few scar marks at the periphery of the retina, which are homogeneously
distributed throughout periphery and are most probable due to laser burns .
Therefore most probably diagnosis is diabetic retinopathy treated with laser photo
coagulation
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SLIDE OF HYPERTENSIVE RETINOPATHY: SLIDE 14
Can see diffusive narrowing and tortuosity of arterioles. Can also appreciate changes at arterio
venous crossings along infero temporal arcade (A-V nipping) Absence of haemorrhages
(flame shaped) and disc swelling suggest early changes or chronic hypertension. Grade 1:
Arteriolar narrowing Grade 2: A-V nipping Grade 3: Exudates, haemorrhages, cotton wool
spots Grade 4: Papilloedema
Hypertensive retinopathy is managed primarily by controlling hypertension. If vision loss

occurs, treatment of the retinal edema with laser or with intravitreal injection of
corticosteroids or anti VEGF drugs may be useful.
Knee Examination
Teach the medical student about Knee Examination. Do not tell the
medical student to examine the patient after teaching.
Dr: Hello I am Dr …. How are you doing today David?

Student: I am doing fine. How are you?
Dr: I am good too how are your studies going?
Student: They are going alright. I actually need your help regarding examination of Mr
Smith’s knee.
Dr: Yes sure I will help you. It’s a very good thing that you are keen to learn. Do you have
any prior knowledge about the topic?
Student: No.
Dr: That’s alright David, I will tell you. Now if you don’t understand anything just tell me. I
will try to explain it in a better way. Is that alright?
Student: Okay.
Dr: So first of all whenever you are about to examine any patient you need to first identify
and take consent from the patient. Have you taken consent from the patient?
Student: Yes/ No
Dr: Okay I will show you. Lets start.
Dr: Hello I am Dr … I am one of the junior doctors in the department. He is david he is a
medical student. How may I call you?
Pt: You can call me Mr Smith.
Dr: okay Mr Smith how are you doing today? Pt: I am doing alright. I just have some pain in
my knee.
Dr: oh I am really sorry about that. would that be alright if we examine your knee joint? we
will try to be as gentle as possible. Pt: Yes its fine.
Dr: May I please know which side is it? This examination involves inspecting your knee
joint, touching it and performing few movements. (talk to student : So after the consent
David, we justexplainedour purpose of examination, next we need to ask about the
exposure)
Exposure:
Dr: For the purpose of this examination I would like you to get undressed below your waist
please but you can remain in you briefs.I will ensure your privacy and request for a chaperone.
Mr Smith: okay.
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(talkto David) Sometimes patient is in the bed and knees are already exposed, in that case
don't ask for exposure but say, thank you for adequate exposure.
Check student understanding also by asking him to perform few tests like drawer’s test
Position:
 Standing and lying flat. (Sometimes in exam, examiner might not allow you to make
patient stand. In that case, do everything in lying position only but don’t comment on
level of joints)
Inspection:
 Ask patient to stand up.
 Make patient stand in anatomical position with arms tucked in by sides, feet together
and palms facing towards you.
Front:
 Comment on levels of Ant. Sup. Iliac Supine, Knees and Med. Malleoli.
 Note any deformity. Genu Valgum (knock knee) or Genu Varum (Bow legs)
 Scars
 Sinuses
 Erythema
 Muscle wasting
Back:
 Popliteal swelling indicates baker’s cyst
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Gait:
 Ask patient to take a few steps. Observe the gait and comment on either normal
(smooth & symmetrical) or antalgic (limp to avoid pain) gait.
Ask patient to lie down on couch which must be flat.

Feel
Warm up your hands
Temperature: Assess temp, compare on both sides.
Palpation:
Look at patient’s face for tenderness.
Joint lines: Ask patient to flex knee slightly. Feel both tibial and femoral joint lines and look
for any tenderness.
Palpate above (Quadriceps tendon) & below (Patellar tendon) patella and look for
tenderness.
Move
Flexion: With patient supine, ask to “bend knees up and bring foot as close to hip as
possible”
Extension: Tell patient to extend (straighten) the leg back down to couch. Ask patient to lift
one leg from couch and look at full knee extension. Do it on both sides.
Comment on full and free/ restricted/ painful movements.
Tests of stability:
Collateral ligament
 Extend patient’s knee fully and hold the ankle between your elbow and side.
 Valgus: Apply force laterally on knee with one hand to feel for laxity or pain. It
suggests medical collateral ligament injury.
 Varus: Apply force medially on knee with one hand to feel for laxity or pain. It
suggests lateral collateral ligament injury. (Give your findings)
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McMurray’s Test
Medial Meniscus
 Passively flex the knee fully.
 Externally rotate the foot, heel facing medially, abduct the upper leg at hip.
 Extend the knee smoothly. In medial meniscus tear a click/clunk is heard or pain is
felt.
Lateral Meniscus
 Passively flex the knee fully.
 Internally rotate the foot, heel facing laterally, adduct the leg at hip.
 Extend the knee smoothly. In lateral meniscus tear, a click/clunk is heard or pain is
felt.
 (Give your findings)
Drawer’s Test
 Fix the patient’s knee to 90 degree and maintain this position by sitting with your
thigh trapping the patient’s foot.
Anterior drawer sign

 Place your hands behind the tibia and both thumbs over tibial tuberosity, pull the
tibia anteriorly. Significant movement suggests anterior cruciate ligament rupture.
Posterior drawer sign

 Push backwards on tibia. Significant movement of tibia suggests posterior cruciate
ligament injury. (Give your findings)
Patellar Tap:
With patient knee extended, empty the supra patellar pouch by sliding your left hand down
the thigh until you reach the upper edge of the patella.
Keep your one hand there and with the fingertips of other hand, press down briskly over the
patella. You may feel a fluid impulse in your left hand.
Neurovascular
 Check distal pulse. (Dorsalispedis)
 Ask patient to wriggle the toes.

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Thank the patient and ask to dress up.

Finish your station by saying “I will examine joint above and below”.
General advice:
p: protection: Avoid activity which causes pain to allow the inflammation to heal.
R: Rest
I: Ice packs
C: Compression
E: Elevation
NSAID: we will give you some pain killers to relieve the pain
Physiotherapy: an appointment with physiotherapist
Follow up appointment: we will see you in the follow up appointment to see, how well you
are doing.
Surgical treatment: if the above measures fail then we can refer you to a specialist doctor, who
can consider an operation.

Suspected Cerebellar Ataxia -
Referred by GP
Causes of Acquired cerebellar ataxia
 severe head injury– after a car crash orfall, forexample
 bacterial brain infection, such as meningitisorencephalitis(an infection of the
brainitself)
 viral infection – some viral infections, such as chickenpoxormeasles,can
spread to the brain, although this is veryrare
 conditions that disrupt the supply of blood to the brain, suchas a
stroke,haemorrhageor atransientischaemic attack(TIA)
 cerebral palsy– a condition that can occur if the brain develops abnormallyor is
damaged before, during or shortly afterbirth
 multiple sclerosis– a long-term condition that damages the nerve fibres of the
central nervoussystem
 sustained long-term alcohol misuse
 an underactive thyroidgland
 vitamin B12deficiency
 brain tumoursand other types ofcancer
 certain toxic chemicals, such as mercury and some solvents – these can trigger
ataxia if a person is exposed to enough ofthem
medications such as benzodiazepines can occasionally trigger ataxia as a side effect
Exam question
60 year Lady Mrs Cathleen Nelson presented to the GP with unsteady feet.
GP referred her to you for suspected “Cerebellar ataxia”.
Take focused history from the patient, examine and talk to her about the
management.
Dr: Hello Mrs Cathleen Nelson… I am Dr… Can you please tell me what brings you to the
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hospital?
Pt: Doctor, My hands are very clumsy. I can’t knit sweater. I keep dropping things
from my hands. ( patient may or may not give history of unsteady feet)
Dr: Is it one hand or both hands? Pt: Both hands.
Dr: Since when this problems started? Pt: Since last few weeks. Dr:
Did this happen suddenly or gradually you noticed this problem? Pt:
Suddenly / sometimes she may say gradually.
Dr: Did you have any other symptom when you developed this problem?
Dr: Do you have any pain in your neck ? Pt; Yes/ No
Dr: If there is pain – does the pain go any where ? ( to the arms – radiation?
Pt – Yes/ No
Dr: Any stiffness in the neck ? Pt: Yes/ No
[ Pain and stiffness in the neck are symptoms of cervical spondylosis]
Dr: Any tingling numbness in your hands? Pt: No

Dr: Do you have any tremors in hands ? Pt: Yes/No
Dr: Are you able to eat with the help of spoon? Pt: Yes Dr:
Do you have balance problem while walking ?

Pt: Yes / sometimes she may say no [ If she say no – ask her - did you see your GP before
for any balance problems because GP has mentioned in his notes – she may then admit it ]
Dr: Any vision problem ( MS) ? Pt : No
Dr: Any bowel or urine incontinence ( MS, Cervical spondylosis) ? Pt - No
Dr: Do you have headache ( stroke, brain tumors) ? Pt: No
Dr: Did you have such problems any time before this last few weeks? Pt: No Dr:
When these symptoms started – at that time did you have headache, fever,
vomiting? Any skin rashes? Head injury? ( Stroke, brain infections, chicken pox – all
risk factors for cerebellar ataxia).
Dr: Do you have any medical conditions? Pt : I have diabetes.
Dr: Are you taking medications for that? Pt: Yes I am taking Insulin.
Dr: Do you keep checking the sugar level - Is the sugar controlled well do
you know ? Pt : Yes/No
Dr: Any thyroid problems ( risk factor for cerebellar ataxia) ? Pt: No
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Dr: Do you drink alcohol? ( Risk factor for Cerebellar ataxia) Pt : Not much.
Dr: Thank you very much. I need to examine you now. Is that OK?
Pt: Yes doctor
Examination
Check for Nystagmus
Check the neck :

Inspection -No swelling redness,
Palpate for tenderness over the spine,
Check for movements.
Neurological examination of the upper limbs

Exposure - Above waste
Inspection – No muscle wasting, Tremors, No deformity of joints.
Co ordination – Finger nose test, Disdiadokokinesia, Heel to Shin test.
Check the Gait ( broad based gait in Cerebellar ataxia)

Rhomberg’s test.
Sensations – fine touch, pain, vibration-
Power – shoulder – abduction and adduction, elbow –flexion and
extension, finger extension at wrist. Finger abduction and grip.
Examiner may say – power is normal.
Reflexes – Biceps, triceps and supinator. - Examiner may say normal. -
[Stop examination at 6 minutes].
Management:
Mrs. Nelson on examination I do not see anything abnormal. However, since you are
having these symptoms – we need to evaluate it further to why you are having these
symptoms. We will refer you to Neurologist who is a specialist in this type of problems.
They may do tests like X Rays of your neck, CT and MRI scans of your head and neck,
Also some nerve conduction tests. They may also do some blood tests like liver function
and thyroid function and tests for any vitamin deficiencies.
Is that OK?
Pt: Do you think I have a brain tumor or Stroke?
Dr: Mrs. Nelson, with the examination findings it does look like you have any such condition.
However after the investigations Neurologists may be able to say what exactly may be the
problem.
Pt – Ok Is this a serious condition?
Dr: Mrs. Please do not be worried. Most of the time this type of problems are not
serious at all. However, only after the investigations we will be able to tell you
properly.
Pt: Any treatment?

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Dr: Mrs Nelson treatment depends on the diagnosis. However, specialist may arrange for
physiotherapy and also he may refer you to Occupational therapists if you need any kind
of aids. Also please keep checking your sugar and keep it under control.
If the patient gives the history of neck pain and stiffness – give the diagnosis of cervical spondylosis
Mrs – Nelson, I think you may be having condition called cervical spondylosis. This is due to
degeneration mean wear and tear of the bones and the discs ( soft cushions between the bones) at the
neck. In this condition there will be some extra bony lumps develops in the bones of the neck which
presses on the spinal cord and the nerves and causes these type of muscle weakness in the hands and
sometimes balance problems when walking. Do you follow me ? Pt : Yes.
Dr: We will refer you to the Orthopaedician who are bone specialist who may investigations like X
Ray and CT and MRI scans of your neck and also nerve conduction tests to check whether this is the
problem. Do you follow me?
Pt : Yes. How will treat me doctor.
Dr: Treatment depends on the diagnosis. If it is cervical spondylosis - then the specialist may give
pain killers – if you have pain and arrange physiotherapy, and the investigations that there is pressure
on the spinal cord they may advise surgery to relieve pressure on the spinal cord. Do you follow me ?
Pt : Is that OK? Pt : Yes. Dr Any other questions ? No

TIA with cranial nerve examination
New Station on 7th August 2018
Question
50 years old male presented with the history of TIA symptoms yesterday.
Take history do the cranial nerve examination and discuss the further management with the
patient.
[ Do not do fundoscopic examination]
History
How can I help you ?

I had facial weakness, weakness of arms and legs yesterday which lasted for few hours.
Do you have those symptoms now ? No
Did you see any doctor for this yesterday ? No

Did you have such problems before ? No
Do you have high blood pressure, diabetes, high cholesterol, heart problems ( abnormal heart
rhythms), stroke or mini stroke before ? No
Any medications ?
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Ask about life style ( smoking, alcohol, exercise, diet)
Family history of stroke or mini strokes or heart problems ?
Examination
[ watch the video in you tube - www.youtube.com/watch?v=sJBpai74tlU]
Olfactory nerve
Did you notice any change in the smell at all ? No
Optic nerve
Two important aspects of the optic nerve are visual acuity and visual field.
Visual acuity
Visual acuity can easily be tested with Snellen type. If the patient normally wears spectacles
both tests may be done with them on.
Colour vision can be tested with Ishihara plates. Deterioration may be significant but
remember that 8% of men and 0.5% of women have congenital X-linked colour blindness.
Visual fields
Ophthalmoscopic examination ( do not do it in the exam)
3rd Oculomotor, 4thTrochlear ( SO4) and 6th Abducent ( LR 6)

These three nerves are examined together, as they control the external ocular muscles.
The oculomotor nerve is the third cranial nerve (CN III). It innervates extrinsic eye muscles
that enable most movements of the eye and that raise the eyelid. The nerve also contains
fibers that innervate the intrinsic eye muscles that enable pupillary constriction and
accommodation (ability to focus on near objects as in reading).
Internal ocular muscles : Direct and consensual light reflex and accommodation reflex
External ocular muscles: H test
5th Trigeminal nerve

The trigeminal nerve is largely a sensory nerve but it does have a motor component in the
mandibular division.
Lightly touch each side of the face with a piece of cotton wool and ask if it feels normal and
symmetrical. Test the areas supplied by the ophthalmic, maxillary and mandibular branches.
Ask the patient to clench his/her teeth. Both masseters should feel firm and strong. The
contracting temporalis may also be felt.
Corneal reflex ( do not do in the exam)

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7th Facial nerve

Ask the patient to raise his/her eyebrows. Are the furrows of the forehead symmetrical?
Ask the patient to screw up his/her eyes. Gently try to prise them open. You should fail.
Ask the patient to give a broad toothy grin, demonstrating what you want. Do not say, 'Show
me your teeth', or he/she may remove any dentures and hand them to you. Is the grin full and
symmetrical? - Angle of the mouth deviates to the normal side.
Paralysis of the facial nerve causes face drop. This is more marked with a lower motor
neurone (LMN) lesion than an upper motor neurone (UMN) lesion. The best way to
differentiate between the two is to test the muscles of the forehead. They have bilateral
innervation at the upper motor neurone level and so, in a UMN lesion such as a pseudobulbar
palsy, they are spared. An LMN lesion such as Bell's palsy will involve the forehead.
8th Vestibulocochlear nerve

Testing of the vestibular component is - Hallpike's manoeuvre ( do not do).
Formal testing of the cochlear component requires audiometry. Hearing tests – Rinnes and
Webers tests ( examiner may say no need to do).
Either whispering or use of a high-frequency tuning fork can give a very crude assessment of
hearing. A 516 Hz (upper C) tuning fork is usually employed:
Strike the tuning fork and hold it about 2 cm from the ear, asking the patient to tell you when
it stops. Then listen to it yourself and the intensity of the sound indicates the degree of loss in
that ear.
If it is marked, place the still vibrating fork on the mastoid process and ask if it is heard. If it
is heard by bone but not air conduction, there is a marked conductive loss. With profound
nerve deafness, the patient may be hearing it by bone conduction in the other ear.
If there is significant loss in one ear, Weber's test can be employed. Strike the tuning fork and
place it on the centre of the forehead. Ask the patient in which ear it seems louder. The
vibration is conducted through bone and it will be quieter in the bad ear with nerve deafness
but louder with conductive deafness as the affected ear becomes more sensitive.
9th Glossopharyngeal and 10th Vagus nerves

Assessment of the glossopharyngeal and vagus nerves is difficult.
Glossopharyngeal nerve lesions produce difficulty swallowing; impairment of taste over the
posterior one-third of the tongue and palate; impaired sensation over the posterior one-third
of the tongue, palate, and pharynx; an absent gag reflex; and dysfunction of the parotid gland.
Vagus nerve lesions produce palatal and pharyngeal paralysis; laryngeal paralysis; and
abnormalities of esophageal motility, gastric acid secretion, gallbladder emptying, and heart
rate; and other autonomic dysfunction.
Ask the patient to swallow. Is there any difficulty? Ask the patient to open his/her
mouth wide and to say 'Ahh'. Phonation should be clear and the uvula should not move
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to one side.
The quality of the dysarthria differs for central and peripheral lesions. Central lesions produce
a strained, strangled voice quality, while peripheral lesions produce a hoarse, breathy and
nasal voice.
It is also possible to test the gag reflex by touching the pharynx with a tongue depressor.
Most people omit this unless there is evidence of a local lesion. It is unpleasant and around
20% of normal people have a minimal or absent response.
Isolated lesions of the IX nerve are very rare. Taste to the anterior two thirds of the tongue
travels with the VII nerve until it leaves in the chorda tympani to join the V nerve. The
posterior third of the tongue is supplied from the IX nerve that also provides parasympathetic
fibres to the salivary glands. It is possible to test taste with small bottles and a dropper. The
bottles usually contain sugar or salt solution. Most generalists do not perform this test.
Accessory nerve
The accessory nerve supplies the trapezius and sternomastoid muscles. Is there any wasting?
Ask the patient to shrug his/her shoulders up and try to push them down.
Ask the patient to push his/her head forwards against your hand. Both these movements
should be very difficult to resist.
LMN lesions produce weakness of both muscles on the same side. UMN lesions produce
ipsilateral sternomastoid weakness and contralateral trapezius weakness, because of differing
sources of cerebral innervation.
Hypoglossal nerve
It is often more convenient to assess the XII cranial nerve before the XI as the mouth is
examined for IX and X.
Ask the patient to protrude his/her tongue and note any deviation. A fluttering motion called
fibrillation rather than fasciculation may be seen with an LMN lesion.
If the tongue deviates to one side when protruded, this suggests a hypoglossal nerve lesion. If
it is an LMN lesion, the protruded tongue will deviate towards the side of the lesion. With a
UMN lesion, the tongue will deviate away from the side of the lesion.
Note the wasted left side of the tongue and deviation to the left suggesting a left LMN lesion.
Tell the examiner that you would like to do neurological examination of the upper and lower
limbs – examiner may they are normal

Diagnosis investigations and management
Mr... On examination everything looks normal at the moment.
With what you have told me and after examination I think you had a condition what we call
Transient ischemic attack.
Dr: A TIA is a medical condition where there is a momentary decrease or loss in blood supply to the
brain. This could either be because of some narrowing of the blood vessels in the neck that supply
blood to the brain... or because of some rhythm problems in the heart. Are you following me Mr...?
P: Yes doctor.. Is it serious?
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Dr: Mr... A TIA as such is not serious as it usually resolves by itself within 24 hours. But there is a
risk of having stroke next time which is a very serious condition.
We need to do investigations to find what exactly caused this problem and treat that condition so as to
reduce the chances of you getting a stroke. Is that Okay ? Yes
P: What kind of tests doctor?
Dr: First we will have to do a CT scan of head... to make sure that there is no evidence of a stroke.
We will then do an ECG or a heart tracing to look for any rhythm problems. We will also do some
blood tests to check her sugar and cholesterol levels ( high cholesterol is a risk factor for
stroke).
Additionally, we will have to do a scan called a Doppler... of the blood vessels of your neck to see if
they are narrowed. Are you with me Mr...? P: Yes
Treatment:
Dr: Mr... There is no need to egt admitted to the hospital at the moment. We will also start you on
Aspirin, which can help prevent such attacks in the future. We will refer you to the Neurologist
urgently. Do you have any questions for me Mr...?
Treat other conditions if the patient has like HTN or Diabetes.
Advise life style. ( diet, exercise, smoking, alcohol).
Warning signs :
I would like to inform you about the warning signs of a stroke [FAST – Facial weakness, Arm
weakness, Speech problem – Time to call the ambulance]. If you ever notice any weakness in face
or limbs... or any slurring of her speech, please call an ambulance and come to the hospital
immediately as the next time, it can be even stroke. Do you have any questions for me ?
H: No doctor.. Thank you.
HIP EXAMINATION – OSTEOARTHRITIS
Where you are

You are an FY2 in the Rheumatology department
Who the patient is
Bella Mustapha is a 69 years old lady who has presented with some pain in her hip joint
Other information you have about the patient
She has been referred by her GP who she saw 2 weeks ago
What you must do
Take a focused history, assess the patient, discuss management with the patient and
address her concerns.
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CONSULTATION
GRIPS  Patient [Greet, Rapport, Introduce, Posture, Smile]
Hello. Bella Mustapha? Hi, my name is Dr. Swamy, I am one of the junior doctors here in the
Rheumatology department.
What would you like me to call you?
Bella please
I understand you have recently visited you GP who referred you to us?
That’s correct
Do you have your referral letter with you?
I’m really sorry doctor, I left it at home
Can you just tell me what made you visit your GP in the first place?
Yes, I’ve been having some pains in my hips for some time now
I’m really sorry to hear that.
Are you in pain now? – Just a little bit

Are you ok to continue? – Yes (if no, ask next question)
Have you been offered any painkillers? – No (if no, ask next question)
Would you like me to give you some painkillers? – No (if yes, ask next question)
Are you allergic to any medication at all? – No
PC  SOCRATES PDA  DDx  SR
And how can we help you today?

I’m still having pain in both of my hips. I went to my GP and she told me that you would be in a
better position to help me. They just feel so stiff. I just want this pain to go away. Maybe if you
could tell me why this is happening as well that would be helpful
Ok, well I’ll do my best. I do have to ask you a few questions first, and I would also need to
take a closer look at your hips.
How does that sound? – Sounds good to me doctor
Can you tell me a little bit more about the pain you are having?
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Yes, it started about a year ago. I didn’t think much of it then, and I thought it would go away
by itself. It did go away at times when I took paracetamol, but these past few months it has been
a constant nuisance. Sometimes I can’t get up in the morning! And at night sometimes I can’t
sleep because my body aches so much!
Is this the first time you’re experiencing these symptoms?
No, it’s been a year now
Can you tell me which hip it is? Where exactly? Can you point to me?
It’s both my hips. The right is sorer, but sometimes it’s the left. *hands on ASIS*
And how did it come about? Sudden/Gradual
Well it’s been a gradual thing over many months
And how would you define the nature of this pain? Dull? Burning? Sharp?
It’s a dull, achy pain
Does the pain travel anywhere else in your body?
No
Does it worsen with any activity you do?
Yes, moving. If I have an active day where I do the shopping and the gardening, my body really
aches at the end of the day
Does it improve at any time? Rest? Medication?
When I rest, it feels so much better. I do feel better in the mornings. But I can’t rest for too long
as I love cooking, cleaning, gardening and looking after the grandchildren. I tried 2 tablets of
paracetamol. It did make some difference at first, but I think I must be resistant to it now, it
doesn’t help anymore
And is the pain always there, or is it there at a specific time?
Sometimes it’s there all day. But mostly, the mornings are pain-free. It’s much worse at night-
time before I go to sleep. Sometimes I can’t sleep
On a scale of 1-10, 1 being the least amount of pain and 10 being the most, how would you
describe the pain you are having?
I would say it’s either a 1 or 2 in the mornings and a 6 or 7 in the evenings
Is the pain getting better or is it getting worse?
Worse
For how long have you been experiencing this pain?
A year
Is there anything else you’d like to add that I may have missed?
No
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 Trochanteric Bursitis
 Osteoarthritis
 Dislocation
 Rheumatoid Arthritis
 Fracture Neck of Femur
 Psoriatic Arthritis
 Avascular Necrosis of
 Ankylosing Spondylosis
Femoral Head
 Trauma
 Malignancy/Metastases
 Septic Arthritis
 Muscle Strain
 Osteomyelitis
 Referred Pain
Why are my hips hurting so much?
There are a few possible causes as to why this could be happening. I do have a few more
questions to ask you about your health in general. Maybe after those have been answered, I’ll be
in a better position to tell you.
How does that sound? - Fine
Did you hurt-yourself in any way? Falls? Are any of your other joints involved? Fever? Joint
swelling? Rash? Discharge? Redness? Flu-like illness? Weight loss? Loss of Appetite? Lumps
& bumps?
No
2PMAFTOSA
Hypertensive for 25 years

On Amlodipine 5mg, compliant – no side effects
Swelling of your legs or ankles
tiredness or extreme sleepiness

stomach pain
nausea
dizziness
hot or warm feeling in your face (flushing)
irregular heart rate (arrhythmia)
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very fast heart rate (palpitations)
No Allergy Hx
No Family Hx
No Travel Hx
Has found her day to day activities significantly hindered. Can’t enjoy gardening as much.
Can’t spend much time in the kitchen to cook.
Housewife
Personal –
Non-smoker
Drinks alcohol on weekends only
No history of recreational drug use
Healthy diet
Adequate exercise – shopping, gardening, looking after grandchildren
A little stressed
Good hygiene
Sleep has been affected due to the pain
Husband passed away 2 years ago
Lives with son and his wife and 2 children who look after her
Coping ok
RISK FACTORS
Factors that can increase your risk of osteoarthritis include:

Older age. The risk of osteoarthritis increases with age.
Sex. Women are more likely to develop osteoarthritis, though it isn't clear why.
Obesity. Carrying extra body weight contributes to osteoarthritis in several ways, and the more
you weigh, the greater your risk. Increased weight adds stress to weight-bearing joints, such as
your hips and knees. Also, fat tissue produces proteins that can cause harmful inflammation in
and around your joints.
Joint injuries. Injuries, such as those that occur when playing sports or from an accident, can
increase the risk of osteoarthritis. Even injuries that occurred many years ago and seemingly
healed can increase your risk of osteoarthritis.
Repeated stress on the joint. If your job or a sport you play places repetitive stress on a joint,
that joint might eventually develop osteoarthritis.
Genetics. Some people inherit a tendency to develop osteoarthritis.
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Bone deformities. Some people are born with malformed joints or defective cartilage.
Certain metabolic diseases. These include diabetes and a condition in which your body has too
much iron (hemochromatosis).
EXAMINATION
VITALS - (Pulse 68/min, BP 135/70mmHg, RR 14/min, Temp 37.5 °C, O2 Saturation 98%)
EXAMINER’S PROMPT: GIVE OBSERVATIONS FINDINGS WHEN CANDIDATE

MENTIONS WHAT HE/SHE WOULD LIKE TO OBSERVE
BMI
I would like to take a look at your Body Mass Index, or BMI. Do you know what that is? - NO
Simply put, it is the ratio of your height and your weight.
Normally our BMI is between 18.5 and 25.
Under 18.5 = Underweight

25 – 30 = Overweight
>30 = Obese
5 Protocol
 Consent
 Exposure
 Privacy
 Chaperone
 Confidentiality
EXAMINER’S PROMPT: BMI IS 28
HIP JOINTS
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Ok, I will need to take a closer look at your hip joints. Is that alright? – YES
For this exam we will need adequate exposure of waist downwards,so Bella you may need to
take your shoes off and remove your trousers – you can remain in your under-garments.
I’ll do up the curtains for you so you can have some privacy.
We do have the examiner here with us today who will act as our chaperone.
Any findings that we obtain from examining you will remain between you and the medical
team.
Are you able to bear weight on your hip joints? – YES
Do you have any problems with walking? – NO
Have you noticed a limit in the movements your hips can make?
Yes, I don’t find myself as nimble as I used to be. For example, when I’m gardening, I can’t
cross my legs as easily as I used to
INSPECTION
I’m just going to be taking a closer look at your lower limbs. What I would like you to do is just
stand up for me with your feet together. If you feel any pain or discomfort at any time, please let
me know and we can stop right there.
FRONT; straight line from ASIS to Medial Malleolus
SIDES
BACK; Gluteal muscle wasting
Abnormality
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Discharge
Redness
Swelling
Scar Marks
Skin Changes
GAIT;
Could you please take a few steps for me please?
Antalgic? Shuffling? Waddling? Drunken? Stepping? Etc
TRENEDELENBURG’S TEST
The Trendelenburg test is a quick physical examination that can assist the examiner to assess for
any hip dysfunction. A positive Trendelenburg test usually indicates weakness in the hip
abductor muscles: gluteus medius and gluteus minimus.
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A positive Trendelenburg’s test is one in which the pelvis drops on the contralateral side
during a single leg stand on the affected side.
Wonderful, thank-you for that.
Can you lie down on the couch for me now? – YES

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Can you just wriggle your toes for me please? - YES

PALPATION
Ok, I will be gently touching your hip joint. If you feel any pain or discomfort at any time, do
let me know and we can stop right there.
Temperature – ASIS, Greater Trochanter, PSIS

Tenderness – ASIS, Greater Trochanter, PSIS
Movements
Active (at 45° unless stated otherwise)
Flexion: Can you lift your leg as high as possible for me please?
Abduction: Can you move your foot away from the other as far as possible?
Adduction: And now can you bring your 2 feet together?
M. Rotation: Can you put your toes together and put your heels apart?
L. Rotation: Now can you put your heels together, and send your toes apart?
Extension: (Flat 0°) Can you lay on your side and without bending your knees can you touch
your back with your legs?
Passive
Same as above, gentle manipulation of joints to see extent of motion and any rigidity while
throughout comparing both sides.
Special Tests
Resisted Adduction Test – Can you move your leg outward while I resist it?
Resisted Internal Rotation – Can you raise your leg (45°), I’ll try to rotate your leg inwards, can
you resist it?
Resisted External Rotation – Can you raise your leg (45°), I’ll try to rotate your leg outwards,
can you resist it?
Trochanteric Thump Test – I will gently be bumping your hip joint with my fist to check for any
tenderness, can you let me know if you experience any discomfort?
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Thomas Test – Lay the patient flat. Check the lumbar spine area for any tenderness. Can you
bend your knee and bring it towards your chest? *Look at opposite side for flexion at the hip
joint.
Neurovascular
Bulk
Tone
Power
Reflexes (Knee, Ankle, Plantar)
Dermatomes
Distal Pulses – Dorsalis Pedis bilaterally
Capillary Refill
IF CANDIDATE WANTS TO EXAMINE ANYTHING ELSE, ASK THE CANDIDATE WHY AND COMMENT
NO ABNORMAL FINDINGS
FINDINGS & Dx
What is happening to me?
So from what you have told me, you have been experiencing pain in your hip joints which
usually gets worse as the day progresses and, in the mornings and after rest it gets better. You
had tried some painkillers in the form of paracetamol but they no longer relieve your pain. And
now you also seem to be having problems with your day to day activities like gardening and
cooking.
Is that correct? – YES
Have I missed anything? – NO
When I took your observations, your blood pressure was 135/70mmHg and seems to be well
controlled and you don’t seem to be experiencing any of the side effects of the medication that
you are taking, Amlodipine.
When I observed your BMI – which was the ratio of your height and your weight - it came back
as 28.

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Under 18.5 = Underweight

25 – 30 = Overweight
>30 = Obese
So you are categorized as being overweight.
Are you with me? – YES
When I examined your hip joints, I noticed there was tenderness on both your hip joints and a
decrease in range of motion on both sides, with the right side affected slightly more.
I do believe this is due to the age-related changes in the cartilage that surrounds your joints – a
condition termed Osteoarthritis.
Do you know anything about the condition called Osteoarthritis? – NO
Osteoarthritis is a condition that causes joints to become painful and stiff. It's the most common
type of arthritis in the UK.
It occurs when the protective cartilage that cushions the ends of your bones wears down over
time.
Although osteoarthritis can damage any joint, the disorder most commonly affects joints in your
hands, knees, hips and spine.
Osteoarthritis symptoms can usually be managed, although the damage to joints can't be
reversed. Staying active, maintaining a healthy weight and some treatments might slow
progression of the disease and help improve pain and joint function.
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Osteoarthritis of the Spine
Osteoarthritis of the Hip
Osteoarthritis symptoms often develop slowly and worsen over time. Signs and symptoms of
osteoarthritis include:
Pain. Affected joints might hurt during or after movement.
Stiffness. Joint stiffness might be most noticeable upon awakening or after being inactive.
Tenderness. Your joint might feel tender when you apply light pressure to or near it.
Loss of Flexibility. You might not be able to move your joint through its full range of motion.
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Grating Sensation. You might feel a grating sensation when you use the joint, and you might hear
popping or crackling.
Bone Spurs. These extra bits of bone, which feel like hard lumps, can form around the affected
joint.
Swelling. This might be caused by soft tissue inflammation around the joint.
Osteoarthritis occurs when the cartilage that cushions the ends of bones in your joints gradually
deteriorates. Cartilage is a firm, slippery tissue that enables nearly frictionless joint motion.
Eventually, if the cartilage wears down completely, bone will rub on bone.
Osteoarthritis has often been referred to as a "wear and tear" disease. But besides the breakdown
of cartilage, osteoarthritis affects the entire joint. It causes changes in the bone and deterioration
of the connective tissues that hold the joint together and attach muscle to bone. It also causes
inflammation of the joint lining.
Complications
Osteoarthritis is a degenerative disease that worsens over time. Joint pain and stiffness can
become severe enough to make daily tasks difficult.
Chronic Pain
Depression
Sleep disturbances
INVESTIGATIONS
Imaging tests
To get pictures of the affected joint, your doctor might recommend:
X-rays. An X-ray is a simple scan to get a better look at your bones. Cartilage doesn't show up
on X-ray images, but cartilage loss is revealed by a narrowing of the space between the bones in
your joint. An X-ray can also show bone spurs around a joint.
Magnetic Resonance Imaging (MRI). An MRI is a special scan. It uses radio waves and a strong
magnetic field to produce detailed images of bone and soft tissues, including cartilage.
An MRI isn't commonly needed to diagnose osteoarthritis but can help provide more
information in complex cases.
Lab tests
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Analysing your blood or joint fluid can help confirm the diagnosis.
Blood Tests. Although there's no blood test for osteoarthritis, certain tests can help rule out
other causes of joint pain, such as rheumatoid arthritis by checking for a substance called Rh
Factor.
Joint Fluid Analysis. We may need to use a needle to draw fluid from an affected joint. The
fluid is then tested for inflammation and to determine whether your pain is caused by gout or an
infection rather than osteoarthritis. Markers such as ESR and CRP can be a sign of acute
inflammation.
MANAGEMENT
Osteoarthritis is a long-term condition and cannot be cured, but it doesn't necessarily get any
worse over time and it can sometimes gradually improve.
It's not possible to prevent osteoarthritis altogether. However, you may be able to minimise your
risk of developing the condition by avoiding injury and living a healthy lifestyle.
Mild symptoms can sometimes be managed with simple measures including:
regular exercise
losing weight if you're overweight
wearing suitable footwear
using special devices to reduce the strain on your joints during your everyday activities
ensuring adequate amounts of rest for your joints
As your BMI was slightly high at 28, and classified as overweight, would you like some ideas
as how to reduce your weight? – YES
Diet:
5 fruit and veg / day
8 glasses of water / day
2 portions of fish / week
Reduce the amount of junk food/fatty foods
Reduce the amount of cholesterol in diet
Alcohol
Less than 14 units of alcohol per week
This equates to 2 units per day
Cutting down altogether
Tobacco
Smoking Cessation
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Exercise:
At least 30mins of exercise per day, or
2hours 30mins of exercise per week
Avoid exercise that puts strain on your joints and forces them to bear an excessive load, such as
running and weight training.
Instead, try exercises such as swimming and cycling, where the strain on your joints is more
controlled.
Try to do at least 150 minutes of moderate aerobic activity (such as cycling or fast walking)
every week, plus strength exercises on 2 or more days each week that work the major muscle
groups, to keep yourself generally healthy.
Stress:
Reduce stress
Pain Relief
If your symptoms are more severe, you may need additional treatments such as painkillers.
Paracetamol and Ibuprofen are usually the first choice.
I’ve tried Paracetamol and Ibuprofen. They just don’t relieve the pain anymore. What else is
there?
However, there are other painkillers available such as;
Codeine.
Another way to manage the pain is by using injection of local anaesthesia where the pain
occurs. This is a temporary and ineffective method for pain control,
However, we would have to refer you to a pain clinic, and they would be better suited to advise
you on your medication to control your pain.
Anti-Inflammatory Medication
They may also be recommended for osteoarthritis if your joints are very painful or if you need
extra pain relief for a time. A local injection of steroids can reduce inflammation, which in turn
should reduce pain.
Physiotherapy
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A structured exercise plan with a physiotherapist can be really beneficial. It can improve the
mobility of your joints and can help with management of the pain.
Surgery
In a small number of cases, where these treatments haven't helped or the damage to the joints is
particularly severe, surgery may be done to repair, strengthen or replace a damaged joint.
Assisted Mobility
Currently, you don’t seem to be having any problems with your mobility, so I would not
recommend you any assisted mobility devices such as a walking stick or Z-frame. However if
things do worsen, they are an alternative to reduce stress on the affected joint, relieve pain and
give it some rest.
Posture
It can also help to maintain good posture at all times and avoid staying in the same position for
too long. If you work at a desk, make sure your chair is at the correct height, and take regular
breaks to move around.
Taking your Medicine
It's important to take your medicine as prescribed, even if you start to feel better.
Continuous medicine can sometimes help prevent pain, although if your medicines have been
prescribed "as required", you may not need to take them in between painful episodes.
If you have any questions or concerns about the medicine you're taking or any side effects you
think you may be experiencing, talk to your healthcare team.
It may also be useful to read the information leaflet that comes with the medicine, which will
tell you about possible interactions with other drugs or supplements.
Check with your healthcare team if you plan to take any over-the-counter remedies, such as
painkillers, or any nutritional supplements, as these can sometimes interfere with your
medicine.
Regular Reviews
Because osteoarthritis is a long-term condition, you'll be in regular contact with your healthcare
team.
Having a good relationship with the team means you can easily discuss your symptoms or
concerns.
The more the team know, the more they can help you.
We can arrange a follow-up in 2 weeks’ time.
Vaccinations
People with long-term conditions such as osteoarthritis may be encouraged to get an annual flu
jab each autumn to protect against flu.
You may also be advised to get a pneumococcal vaccination.
This is a one-off injection that protects against a serious chest infection called pneumococcal
pneumonia.
Talking Therapy & Support Groups

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Some people may find it helpful to talk to their GP or others who are living with osteoarthritis,
as there may be questions or worries you want to share.
Many people find it helpful to talk to other people who are in a similar position to them.
You may find support from a group or by talking individually to someone who has
osteoarthritis.
There are also various support groups available that can help you reduce weight.
I can give you more information on that if you’d like? – YES Please
You can find the nearest weight loss support group by putting your post-code on the NHS
website, and they’ll locate the closest group to where you are.
The Versus Arthritis helpline is open Monday to Friday, 9am to 8pm. You can call free on 0800
5200 520. You can also email them at helpline@versusarthritis.org
Versus Arthritis also have an online forum where you can communicate with other people who
have osteoarthritis.
Work and Money
If you have severe osteoarthritis and are still working, your symptoms may interfere with your
working life and may affect your ability to do your job.
If you have to stop work or work part time because of your arthritis, you may find it hard to
cope financially.
You may be entitled to 1 or more of the following types of financial support:
if you have a job but cannot work because of your illness, you're entitled Statutory Sick
Pay from your employer
if you do not have a job and cannot work because of your illness, you may be entitled to
Employment and Support Allowance
if you're aged 64 or under and need help with personal care or have walking difficulties, you
may be eligible for the Personal Independence Payment
if you're aged 65 or over, you may be able to get Attendance Allowance
if you're caring for someone with rheumatoid arthritis, you may be entitled to Carer’s
Allowance
You may be eligible for other benefits if you have children living at home or a low household
income.
If however your symptoms worsen, and your unable to mobilise your joints then do come back
to us. If you experience a fall, find yourself unable to bear weight or walk properly – do come
back to us again. Alternatively, in an emergency situation you can call an ambulance at 999 or
visit the A&E.
I would like to consult my seniors if I missed anything, or was unable to answer any of your
questions so I can get back to you with the appropriate information
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I do have some reading material available about the condition that’s affecting you, called
Osteoarthritis.
Is there anything else I can help you with? – No
Is there anything in particular you were expecting to get out of this consultation? – No
Great, so thank-you for coming in today. We will see you in a fortnight
TIA with Cranial Nerve Examination

New Station on 7 August 2018
th
Question
50 years old male presented with the history of TIA symptoms yesterday.
Take history do the cranial nerve examination and discuss the further management with the
patient.
[ Do not do fundoscopic examination]
History

I had facial weakness, weakness of arms and legs yesterday which lasted for few hours.
Do you have those symptoms now ? No
Did you see any doctor for this yesterday ? No

Did you have such problems before ? No
Do you have high blood pressure, diabetes, high cholesterol, heart problems ( abnormal heart
rhythms), stroke or mini stroke before ? No
Any medications ?
Ask about life style ( smoking, alcohol, exercise, diet)
Family history of stroke or mini strokes or heart problems ?
Examination
[ watch the video in you tube - www.youtube.com/watch?v=sJBpai74tlU]

Olfactory nerve
Did you notice any change in the smell at all ? No
Optic nerve
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Two important aspects of the optic nerve are visual acuity and visual field.
Visual acuity
Visual acuity can easily be tested with Snellen type. If the patient normally wears spectacles
both tests may be done with them on.
Colour vision can be tested with Ishihara plates. Deterioration may be significant but
remember that 8% of men and 0.5% of women have congenital X-linked colour blindness.
Visual fields
Ophthalmoscopic examination ( do not do it in the exam)
3 Oculomotor, 4 Trochlear ( SO4) and 6 Abducent ( LR 6)
rd th th
These three nerves are examined together, as they control the external ocular muscles.
The oculomotor nerve is the third cranial nerve (CN III). It innervates extrinsic eye muscles
that enable most movements of the eye and that raise the eyelid. The nerve also contains
fibers that innervate the intrinsic eye muscles that enable pupillary constriction and
accommodation (ability to focus on near objects as in reading).
Internal ocular muscles : Direct and consensual light reflex and accommodation reflex
External ocular muscles: H test
5 Trigeminal nerve
th
The trigeminal nerve is largely a sensory nerve but it does have a motor component in the
mandibular division.
Lightly touch each side of the face with a piece of cotton wool and ask if it feels normal and
symmetrical. Test the areas supplied by the ophthalmic, maxillary and mandibular branches.
Ask the patient to clench his/her teeth. Both masseters should feel firm and strong. The
contracting temporalis may also be felt.
Corneal reflex (do not do in the exam)
7 Facial nerve
th
Ask the patient to raise his/her eyebrows. Are the furrows of the forehead symmetrical?
Ask the patient to screw up his/her eyes. Gently try to prise them open. You should fail.
Ask the patient to give a broad toothy grin, demonstrating what you want. Do not say, 'Show
me your teeth', or he/she may remove any dentures and hand them to you. Is the grin full and
symmetrical? - Angle of the mouth deviates to the normal side.

Paralysis of the facial nerve causes face drop. This is more marked with a lower motor
neurone (LMN) lesion than an upper motor neurone (UMN) lesion. The best way to
differentiate between the two is to test the muscles of the forehead. They have bilateral
innervation at the upper motor neurone level and so, in a UMN lesion such as a pseudobulbar
palsy, they are spared. An LMN lesion such as Bell's palsy will involve the forehead.
8 Vestibulocochlear nerve
th
Testing of the vestibular component is - Hallpike's manoeuvre ( do not do).

Formal testing of the cochlear component requires audiometry. Hearing tests – Rinnes and
Webers tests ( examiner may say no need to do).

Either whispering or use of a high-frequency tuning fork can give a very crude assessment of
hearing. A 516 Hz (upper C) tuning fork is usually employed:
Strike the tuning fork and hold it about 2 cm from the ear, asking the patient to tell you when
it stops. Then listen to it yourself and the intensity of the sound indicates the degree of loss in
that ear.
If it is marked, place the still vibrating fork on the mastoid process and ask if it is heard. If it
is heard by bone but not air conduction, there is a marked conductive loss. With profound
nerve deafness, the patient may be hearing it by bone conduction in the other ear.
If there is significant loss in one ear, Weber's test can be employed. Strike the tuning fork and
place it on the centre of the forehead. Ask the patient in which ear it seems louder. The
vibration is conducted through bone and it will be quieter in the bad ear with nerve deafness
but louder with conductive deafness as the affected ear becomes more sensitive.

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9 Glossopharyngeal and 10 Vagus nerves

th th
Assessment of the glossopharyngeal and vagus nerves is difficult.

Glossopharyngeal nerve lesions produce difficulty swallowing; impairment of taste over the
posterior one-third of the tongue and palate; impaired sensation over the posterior one-third
of the tongue, palate, and pharynx; an absent gag reflex; and dysfunction of the parotid gland.
Vagus nerve lesions produce palatal and pharyngeal paralysis; laryngeal paralysis; and
abnormalities of esophageal motility, gastric acid secretion, gallbladder emptying, and heart
rate; and other autonomic dysfunction.
Ask the patient to swallow. Is there any difficulty? Ask the patient to open his/her
mouth wide and to say 'Ahh'. Phonation should be clear and the uvula should not move
to one side.
The quality of the dysarthria differs for central and peripheral lesions. Central lesions produce
a strained, strangled voice quality, while peripheral lesions produce a hoarse, breathy and
nasal voice.
It is also possible to test the gag reflex by touching the pharynx with a tongue depressor.
Most people omit this unless there is evidence of a local lesion. It is unpleasant and around
20% of normal people have a minimal or absent response.
Isolated lesions of the IX nerve are very rare. Taste to the anterior two thirds of the tongue
travels with the VII nerve until it leaves in the chorda tympani to join the V nerve. The
posterior third of the tongue is supplied from the IX nerve that also provides parasympathetic
fibres to the salivary glands. It is possible to test taste with small bottles and a dropper. The
bottles usually contain sugar or salt solution. Most generalists do not perform this test.
Accessory nerve
The accessory nerve supplies the trapezius and sternomastoid muscles. Is there any wasting?
Ask the patient to shrug his/her shoulders up and try to push them down.
Ask the patient to push his/her head forwards against your hand. Both these movements
should be very difficult to resist.
LMN lesions produce weakness of both muscles on the same side. UMN lesions produce
ipsilateral sternomastoid weakness and contralateral trapezius weakness, because of differing
sources of cerebral innervation.
Hypoglossal nerve
It is often more convenient to assess the XII cranial nerve before the XI as the mouth is
examined for IX and X.
Ask the patient to protrude his/her tongue and note any deviation. A fluttering motion called
fibrillation rather than fasciculation may be seen with an LMN lesion.
If the tongue deviates to one side when protruded, this suggests a hypoglossal nerve lesion. If
it is an LMN lesion, the protruded tongue will deviate towards the side of the lesion. With a
UMN lesion, the tongue will deviate away from the side of the lesion.
Note the wasted left side of the tongue and deviation to the left suggesting a left LMN lesion.

Tell the examiner that you would like to do neurological examination of the upper and lower
limbs – examiner may they are normal

Diagnosis investigations and management
Mr... On examination everything looks normal at the moment.
With what you have told me and after examination I think you had a condition what we call
Transient ischemic attack.
Dr: A TIA is a medical condition where there is a momentary decrease or loss in blood supply to the
brain. This could either be because of some narrowing of the blood vessels in the neck that supply
blood to the brain... or because of some rhythm problems in the heart. Are you following me Mr...?
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P: Yes doctor.. Is it serious?

Dr: Mr... A TIA as such is not serious as it usually resolves by itself within 24 hours. But there is a
risk of having stroke next time which is a very serious condition.
We need to do investigations to find what exactly caused this problem and treat that condition so as to
reduce the chances of you getting a stroke. Is that Okay ? Yes
P: What kind of tests doctor?
Dr: First we will have to do a CT scan of head... to make sure that there is no evidence of a stroke.
We will then do an ECG or a heart tracing to look for any rhythm problems. We will also do some
blood tests to check her sugar and cholesterol levels ( high cholesterol is a risk factor for
stroke).
Additionally, we will have to do a scan called a Doppler... of the blood vessels of your neck to see if
they are narrowed. Are you with me Mr...? P: Yes
Treatment:
Dr: Mr... There is no need to egt admitted to the hospital at the moment. We will also start you on
Aspirin, which can help prevent such attacks in the future. We will refer you to the Neurologist
urgently. Do you have any questions for me Mr...?
Treat other conditions if the patient has like HTN or Diabetes.
Advise life style. ( diet, exercise, smoking, alcohol).
Warning signs :
I would like to inform you about the warning signs of a stroke [FAST – Facial weakness, Arm
weakness, Speech problem – Time to call the ambulance]. If you ever notice any weakness in face
or limbs... or any slurring of her speech, please call an ambulance and come to the hospital
immediately as the next time, it can be even stroke. Do you have any questions for me ?
H: No doctor.. Thank you.
TEACHING 8TH CN EXAMINATION

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Where you are

You are an FY2 in Acute Medical Unit
Who the patient is
George Hoffman is a 42 years-old male
George been seen by the Registrar and is due to be discharged today
What you must do
Sue is a 4th year medical student who wants to learn more about the examination of the VIIIth Cranial
Nerve. Teach her how to examine the auditory part of the eighth cranial nerve.
SPECIAL NOTE: Do not ask Sue to perform the examination
CONSULTATION
1. GRIPS  Student [Greet, Rapport, Introduce, Posture, Smile]
Hello there Sue, my name is Swamy, one of the FY2’s in the AMU.
 How are you doing today?
 Good thank-you
 How are you finding your studies? Wards?
 Good thank-you.
Ok. So I understand you want to learn about the examination of the 8th CN. What we can do is
go through it together.
 How does that sound?
 That sounds great
 So what do you know about the 8th CN?
 Well, I know it divides into 2 – the auditory and vestibular part
 And are you aware of the relevant anatomy?
 Yes
 Is there anything in particular you want me to go over, or would you like a general
overview?
 A general overview would be good
Ok great. Luckily, today we have a patient being discharged today called Mr. Hoffman.
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What I would like to do is for us to introduce ourselves to him, explain to him what we would
like to do and get his consent for us to examine his 8th CN. Alright? - YES
Hello. George Hoffman? Hi, my name is Dr. Swamy, I am one of the junior doctors here in the
department. I have with me Sue here, she is a medical student who wants to learn a little bit
about the examination of the nerve involved with our hearing and balance. Is that ok? - YES
I understand that you’ve been seen by the Registrar, and that you are to be discharged today. Is
that correct? – YES
 Can you just tell us what made you come to the hospital in the first place?
 Yes, I was painting my ceiling. I was on the ladder, and I slipped and sprained my wrist
when I landed on my outstretched arm
 And how are you feeling now?
 I’ve been given some painkillers, and I feel much better
Great.
5 Protocol
 Consent
 Exposure
 Privacy
 Chaperone
 Confidentiality
1) Consent
 So, is it alright if we look at your nerve responsible for hearing and balance? - YES
Sue will be here as an observer only, and I will be the one examining you. If you feel any
discomfort or pain at any time please let me know and we can stop right there. Ok? – YES.
Great.
2) Exposure
For this exam we need adequate exposure of the head and neck area, so Mr. Hoffman can you
please remove any head-ware.
3) Privacy
This exam is not an intimate exam as such, but it is better to perform it in an isolated cubicle.
NOISE
4) Chaperone
We do have the examiner here with us today, who will act as our chaperone
5) Confidentiality
The results of today’s exam will remain between you, Mr. Hoffman and the medical team.
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Ok so Sue, as you said rightly, there are 2 parts of the vestibulocochlear nerve, the auditory part
and the vestibular part. Today we will be focusing on the Auditory part.
When examining the 8th Cranial Nerve, there are a few important steps.
A. INSPECTION
B. PALPATION
C. OTOSCOPY
D. TUNING FORK TESTS
E. ROMBERG’S TEST
A. INSPECTION – George, we’ll just be taking a closer look at both your ears.
a. With inspection it’s important to take a close look at both the ears (front &
behind), including the ear canal to ensure there isn’t any foreign body or wax
that may be causing conductive hearing loss.
b. Sometimes, we can also identify congenital abnormalities such as Microtia and
Ear Canal Atresia.
c. Discharge, Redness, Swellings, Scar marks etc…
B. PALPATION – George, now we’ll be gently touching your head and ears to look
for any signs of temperature or tenderness. If you experience any pain/discomfort
let us know and we’ll stop right there.
So there are 3 important areas where we want to palpate.
(I) Pre-Auricular
(II) Auricular Temperature
(III) Post-Auricular
Tenderness
*Special Test* - TRAGUS test; Using your index finder, gently press down on the tragus and
observe the facial expressions of the patient. If the patient has pain/discomfort, that is a (+)
Tragus test, and a contraindication to Otoscopy. The provisional diagnosis is Acute Otitis
Externa.
C. OTOSCOPY
Next Sue we will be looking at the ear canal of our patient through a procedure we call
Otoscopy. To do this we need an instrument called an Otoscope.
 Have you ever used an Otoscope before?
 No Doctor
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Ok, so this is an Otoscope. This is how we turn it on and off. *Show Sue*
We use our RIGHT hand for the patient’s RIGHT ear, and we hold the otoscope horizontally so
that the tail of the otoscope is pointing towards the patient’s cheek.
It’s important that we use a new earpiece for each ear, to prevent the spread of infection.
We have to ensure our light source is adequate.
By gently pulling on the ear upwards, backwards and laterally, we can straighten the ear canal
to get a better view of any wax, foreign body and the tympanic membrane.
Mr. Hoffman, I’ll just be looking inside your ear using this gadget called an Otoscope. Is that
alright? – YES. Thank-you.
*Show Sue in 1 ear*
Ideally, we would repeat for the other side using a new earpiece.
D. TUNING FORK TESTS

Well done George. You’re doing really well, and we’re almost finished. I have with me here a
buzzing instrument called a tuning fork. This is what it feels like. *show on chest*
 Sue, do you know how to use a tuning fork? – NO
Well a tuning fork has two parts, the parallel prongs and the handle/base. We strike the prongs
against a hard surface to get them vibrating and creating sound. There are different types of
tuning forks, but the most common ones are the 256 and 512Hz. *show Sue*
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Now there are 2 important tuning fork tests that we must do, and I will go through them
individually. Now let us perform on Mr. Hoffman.
(I) Rinne’s Test

To perform the Rinne’s test we strike the tuning fork and place the bottom end of the handle flat
on the mastoid. Ideally, we do this until the subject no longer hears the sound, but due to time
constraints, we can do it for 5-10 seconds, and then without re-striking the fork, place the
prongs in perpendicular position, 1cm in front of the ear for another 5-10 seconds.
We then ask the patient which sound he heard better, the 1st or the 2nd.
George, I’ll be placing this on your head and then in front of your ear. I’d like you to say which
sound you could hear better, the 1st of the 2nd. Is that ok? – YES
*Perform Rinne’s Test*
George, can you tell me which sound you heard better? The 1st or the 2nd? – 2nd
Great.
When Rinne’s Test is (+) it means that Air Conduction (AC) is > Bone Conduction (BC).
When Rinne’s Test is (-), it means BC > AC, which means there is Conductive Hearing Loss
(CHL)
So if there is RIGHT sided CONDUCTIVE HEARING LOSS eg; impacted wax, foreign body,
ear canal atresia, otosclerosis, the Rinne’s test would be (-) on the RIGHT side, and (+) on the
left side.
(II) Weber’s Test

Next we have the Weber’s test. The purpose of this test is for localization of the affected side.
What we do is, we place the tuning fork on the vertex/middle of forehead, and the patient is
asked to report on which side the sound is head louder.
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In a normal person, both sides will be equal.

Ok Mr. Hoffman. I will be placing the buzzing instrument on your forehead. Could you please
tell me on which side you can hear the sound better? – SAME. Excellent, thank-you.
In Conductive Hearing Loss (CHL), the sound will be localized to the ipsilateral side. This is
due to the lack of outside sound interference. Therefore, BC > AC on the affected side.
In Sensorineural Hearing Loss (SNHL), the sound will be localized to the contralateral side.
This is because of the inability of the affected sound to transmit the nerve impulses forwards.
Normal – Equal Localization

CHL – Ipsilateral Localization
SNHL – Contralateral Localization
P a g e | 592
E) ROMBERG’S TEST
To complete the examination of the 8th CN, we must look at its vestibular component by doing
the Romberg’s Test.
However, today we will keep our focus on the auditory part, and next time we can continue with
the vestibular part.
Brilliant. So that concludes the examination of the 8th CN.
Thank-you very much Mr. Hoffman for your patience. I do understand that you’re being
discharged today, and I’ll go and check if the paper-work is complete. You can relax now.
Do you have any questions for me at all, Sue?
1. Can you please explain the difference between Rinne’s & Weber’s Test?
The Rinne’s test is done to check whether AC > BC or whether BC > AC or if they are equal.
In normal individuals, AC > BC.
In CHL, BC > AC.
The Weber’s test is done to localize the site of hearing loss.
In CHL, localization will be to the ipsilateral side.
In SNHL, localization will be to the contralateral side.
2. And what’s the difference between CHL & SNHL?
In CHL, there is a problem with the outer ear, which contains the external 1/3 and middle 1/3 of
the ear. This part contains the pinna, ear canal, tympanic membrane and the ossicles.
In SNHL, there is a problem with the inner 1/3 which constitutes the fluid containing cochlea,
and nerve fibres that arise from hair cells.
3. What are the usual findings on Otoscopy?

o Pearlish-Grey Tympanic Membrane
o Surrounded by Annulus Fibrosus
o Umbo near the centre – Malleus
o Malleus ossicle
o Cone of Light in anteroinferior quadrant
If you have any more questions you can ask me later. There are lots of videos available online
for you to watch and learn. Make sure you practice a lot. You can have my bleep. If you have
any more questions or concerns regarding your studies in general, just ask. Ok? Great.
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DE QUERVAIN’S TENOSYNOVITIS
Where you are

You are an FY2 in GP Surgery
Who the patient is
Joanna Campbell is a 33 years-old female
She has presented to you with some wrist pain
What you must do
Talk to the patient, perform relevant examinations and address her concerns
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CONSULTATION
Hello. Joanna Campbell? Hi, my name is Dr. Swamy, I am one of the junior doctors here in the
department.
What would you like me to call you?
Hi, Jo is fine
PC  SOCRATES PDA  DDx  SR
How can we help you today Jo?

Doctor, I’ve been having pain in my wrist
Oh, I’m really sorry to hear that.
Are you in pain now? – Just a little doctor
Have you been offered any painkillers? – Yes (if no, ask next question)
Can you tell me a little bit more about the pain you are having?
Yeah, it’s just been bothering me for some time now and I’m finding it hard at work
Is this the first time you’re experiencing these symptoms?
Yes doctor
Can you tell me which wrist it is? Where exactly? Can you point to me?
It’s my right wrist, just here *points at base of the thumb on dorsal surface*
And how did it come about? Sudden/Gradual
Well it’s been a gradual thing over a few days
And how would you define the nature of this pain? Dull? Burning? Sharp?
It’s a dull, achy pain
Does the pain travel anywhere else in your body?
No
Does it worsen with any activity you do?
Yes, it’s really painful when I write and when I type
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Does it improve at any time? Rest? Medication?

I don’t know. Sometimes I feel like the pain is going away when I shake my hand, but then it
just starts again later. Paracetamol didn’t help at all!
And is the pain always there, or is it there at a specific time?
It’s constantly there doctor, I’m really disappointed
describe the pain you are having?
I would say it’s either a 3/7 out of 10. When I work it’s severe, and when I rest its mild
Is the pain getting better or is it getting worse?
Worse
For how long have you been experiencing this pain?
It’s been almost 1 week now
Is there anything else you’d like to add that I may have missed?
No
Why is my thumb hurting so much?
There are a few possible causes as to why this could be happening. I do have a few more
questions to ask you about your health in general. Maybe after those have been answered, I’ll be
in a better position to tell you.
How does that sound? - Fine
 De Quervain’s Tenosynovitis
 Osteoarthritis
 Rheumatoid Arthritis
 Ganglion Cyst
 Trauma
 Scaphoid Fracture
 Septic Arthritis
 Gout
 Pseudogout
 SLE
 CTS
P a g e | 596
Did you hurt-yourself in any way? Fever? Joint swelling? Other joint pains? Discharge?
Redness? Flu-like illness?
No
Have you noticed a limit in the movements your hand can make?
Yes doctor, it really hurts to move my thumb
Are you Right or Left-handed?
Right
2PMAFTOSA
Unremarkable
Secretary
Really difficult coping at work, so really stressed. Huge back log of work that has gone undone
because she hasn’t gone into work since the last 2 days.
RISK FACTORS
Age. If you're between the ages of 30 and 50, you have a higher risk of developing de
Quervain's tenosynovitis than do other age groups.
Sex. The condition is more common in women.
Jobs or hobbies that involve repetitive hand and wrist motions. These may contribute to de
Quervain's tenosynovitis.
Being pregnant. The condition may be associated with pregnancy.
Baby care. Lifting your child repeatedly involves using your thumbs as leverage and may also
be associated with the condition.
EXAMINATION
VITALS - (Pulse 78/min, BP 120/80mmHg, RR 18/min, Temp 37.6°C, O2 Saturation 100%)

EXAMINER’S PROMPT: GIVE OBSERVATIONS FINDINGS WHEN
CANDIDATE MENTIONS WHAT HE/SHE WOULD LIKE TO EXAMINE
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HANDS
INSPECTION
Exposure up to the elbows

Palmar & dorsal surface
Compare both sides
DRSSS – Discharge, Redness, Swelling, Scars, Skin changes etc…
PALPATION
Temperature (using the back of your index and middle finger)
Tenderness (using index finger and thumbs of both hands; DIP, PIP, MCP Joints) [Always start
with the normal unaffected side first, to gain trust, confidence and get a feeling of how the
normal side should feel]
Movements
Active: Get the patient to move his DIP, PIP, MCP & wrist joints
Passive: As the examiner, manipulate the joints carefully to assess joint movement, rigidity and
tenderness.
Thumb: Flexion, Extension, Abduction, Adduction, Circumduction
Special Tests
Median Nerve – Male ‘Ok’ sign with index finger and thumb and then try to break it.
Ulnar Nerve – Make patient squeeze your index and middle fingers together and pull.
Radial Nerve – Prevent the patient from giving the thumbs up sign by pushing down on thumb.
Button-unbutton
Pick up a coin
Hold paper tightly in between fingers
P a g e | 598
Finger counting
Tinel Sign – Lightly tap on the ventral surface of the wrist and note any distal tingling on
percussion. (+) Tinel Sign is suggestive of CTS.
Phalen’s Test (Reverse Prayer Sign) – see below. (+) Phalen’s is suggestive of CTS.
Finkelstein’s Test
Flex Thumb Diagnostic for De Quervain’s Tenosynovitis
Flex MCP Joints

Ulnar Deviation
Phalen’s Test
Neurovascular Status
Bulk
Tone
Power
Reflexes
Dermatomes
Distal Pulses
Capillary Refill
FINDINGS & Dx
From what you have told me - that you have pain at the base of your right thumb - and from
what I’ve examined; you have tenderness at the base of your right thumb, and had pain whilst
performing some of the tests [Finkelstein Test (+)], I do believe that you may be suffering from
a condition called Tendonitis.
Do you know what that is? - NO
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This is the inflammation of one of your tendons in your hand, which attach the muscles to the
bone.
Do you understand? – YES
Symptoms usually include; pain at the wrist, spasms, tenderness, occasional burning sensation
in the hand, and swelling over the thumb side of the wrist, and difficulty gripping with the
affected side of the hand. The onset is often gradual. The pain is usually made worse by
movement of the thumb and wrist, and may travel to the thumb or the forearm.
Are you following me? – YES
But what is the cause of this pain?
You do have some risk factors that are associated with tendonitis. These include being in the
30-50 age group. Furthermore, females are more at risk than males. You also work as a
secretary, so repetitive movements such as writing and typing can result in inflammation of the
tendon.
It isn’t a serious condition and is relatively mild. It’s simply because of the over-working of the
muscles that control your thumb.
INVESTIGATIONS
Routine Blood Tests [FBC, LFT, RFT (Urea & Electrolytes), Coagulation Profile (PT, APTT,
INR), Blood Group & Cross Match, Blood Sugar Levels]
ESR/CRP
Rh Factor
Uric Acid
Do I need an X-ray
I don’t think that an X-ray is necessary, because I don’t think that you’ve fractured any bone in
your hand. The X-ray usually helps us visualize bone. In your case, I suspect that the problem is
arising from your softer tissues, which don’t necessarily show up on an X-ray.
An X-ray would therefore expose you to an unnecessary amount of radiation, be an
inappropriate use of resources and only prolong your stay at the hospital.
MANAGEMENT
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Tendonitis is a self-limiting condition, and a prolonged period of rest for 2-5 weeks can be
enough for the inflammation to settle down
Do you think you can take some time off from your work to rest?
You must be joking doctor. I only just got this job!
Well, we can talk to your employers and provide you with a sicknote to cover your absence. It
will state that you’re too poorly to work
There are some medications that can be given to reduce the level of pain & inflammation which
are; PCM & Ibuprofen
Applying a splint is an effective way to limit movement and pain
Sometimes, steroid injections into the joint may be required to reduce the inflammation
Rarely, surgery is performed
Occupational Therapist
Physiotherapist
We can follow-up in 10 days’ time to see how you’re progressing
Meanwhile, if the pain worsens, or you notice redness, swelling, discharge or skin changes,
don’t hesitate to come back to us or go to the A&E immediately
If it doesn’t settle, we may have to involve a specialist – Rheumatologist
I would like to consult my seniors if I missed anything, or was unable to answer any of your
questions so I can get back to you with the appropriate information
I do have some reading material available about the condition that’s affecting you, called De
Quervain’s Tenosynovitis
Is there anything else I can help you with? - NO
Was there anything in particular you were expecting to get out of this consultation. – I just
wanted to know what the issue was, and if it was serious.
Thank-you very much.

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TENNIS ELBOW – LATERAL EPICONDYLITIS
Question: You are an FY2 in GP Surgery. Sarah Silverman is a 33 years-old woman who
has presented with some concerns. Talk to the patient and address her concerns.
Hello. Sarah Silverman. Hi, my name is Dr. ……… I am one of the junior doctors here in
the GP Surgery.
What would you like me to call you? – Sarah, please

Can you please confirm for me your age? – 33
How can we help you today Sarah? – Doctor, I’m having some pain in my arm
Are you in pain now? – Just a little
Can you tell me a little bit more about the pain you are having? – Like what?
Can you tell me where exactly is the pain located? Which arm? Which side? Can you
locate it with a finger? – It is my left arm on the outer part of my elbow
How long have you been having this pain? – Approximately 1 month
And how did it come about? Sudden/Gradual? – Gradually
And how would you describe the nature of this pain? – It really aches
Does the pain travel to any other part of your body? – No
Is the pain aggravated by anything you do? Activity? – When I move my elbow it hurts.
When I lift heavy objects, and when I exercise and play sports
And does it improve with anything? Resting? Medication? – Yes, when I rest it.
Paracetamol helps a little bit too
Is the pain worse at a particular time of the day? – No
On a scale of 1-10, 1 being the least amount of pain and 10 being the worst. How would
you describe it? – 4
Has the pain gotten worse or better? – Worse
Do you have any other symptoms other than pain? – Like what?
Rule out common Elbow Pain causes;

Tennis Elbow (Lateral Epicondylitis/Tendonitis), Sprain/Strain, Ruptured Tendon,
Osteoarthritis, Rheumatoid Arthritis, Carpel Tunnel Syndrome, Frozen Shoulder, Bursitis,
Cellulitis, Angina/MI, Trauma
Stiffness? Swelling? (TE, S/S, OA, RA) – Yes

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Difficulty Moving Joint? (TE, S/S, OA, RA) – Yes

Pain in forearm? Pain in back of the hand? (TE, RA) – No
Stiffness coming down form the shoulder?(Frozen Shoulder) – No
Fever? (OA, Bursitis) – No
Chest Pain? (MI/Angina) – No
Do you think you could have hurt yourself in any way? (Trauma) – No
Is there anything else that you would like to add, that I may have missed? – No
Risk Factors for Tennis Elbow Age (40-60), Activities:
playing racquet sports – such as tennis, badminton or squash
throwing sports – such as the javelin or discus
using shears while gardening
using a paintbrush or roller while decorating
manual work – such as plumbing or bricklaying
activities that involve fine, repetitive hand and wrist movements – such as using scissors
or typing and playing the violin
Is this the first time you are experiencing these symptoms? – Yes
Have you ever been diagnosed with any medical condition before? – No, like what?
High blood sugar? High blood pressure? Arthritis? – No
Have you ever undergone a surgical procedure before? – No
Are you currently taking any prescribed medication? OTC? – I am taking some vitamin
supplements. Iron Tablets
How have you been coping at home? Hobbies? Family? Sleep? Relationships? – Not well.
At home it is a little difficult. My hobbies include a lot of racket sports such as tennis and
badminton. My family are really supportive. It hasn’t affected my sleep as such. No
problems with my relationships
Job? My job is as a professional athlete. It has been significantly impacted. I can’t play
tennis the way I’d like to and I’m losing a lot of games, and financially too. I’m beginning
to lose interest in the sport
Has it been affecting your day-to-day activities? – Yes
Is there anything in particular that you’re concerned about? – I’m really worried that I
won’t be able to perform at the highest level. I have a tournament coming up in a few days’
time, I’m doubtful whether I’ll be able to participate. I’m really worried my career may be
affected, and that I’ll have to stop playing
Anything else you would to add that I may have missed? – No
EXAMINATION
What I would like to do now is to examine your vitals and check your pulse, blood
pressure, breathing rate, temperature and levels of oxygen in your blood.
I would also like to take a look at both your upper limbs, and take a closer look at your
affected elbow.
CONSENT. EXPOSURE. CHAPERONE. PRIVACY. CONFIDENTIALITY.
Inspection
Discharge
Redness
Swelling
Skin Changes
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Scar Marks
Palpation
Temperature
Tenderness
Passive Movements
Active Movements
Special Tests
Mills Manoeuvre for Lateral Epicondylitis
1. Patient is seated.
2. The clinician palpates the patient’s lateral epicondyle with one hand, while
pronating the patient’s forearm, fully flexing the wrist, the elbow extended.
3. A reproduction of pain in the area of the insertion at the lateral epicondyle indicates
a positive test.
Cozen Manoeuvre for Medial Epicondylitis
Upper Limb Neurological Examination
What is wrong with me?
PROVISIONAL DIAGNOSIS
From what you have told me and from what I have seen, your vitals seem to be normal.
Upon closer look at your left elbow, I could appreciate the temperature was raised and
there was also some tenderness in the outer part of your elbow. Movement was also
restricted, and tenderness was elicited on some special tests.
Sarah, do you have any idea at all why you may be having this problem? – I don’t think it’s
because of my tennis because I’ve been playing for over 15 years, and it’s never happened
to me before. So, no I don’t know
Unfortunately, it is likely that you could be suffering from something quite common.
You’ve done the right thing by coming to the GP Surgery. I suspect that you may be
suffering from a condition called a Lateral Epicondylitis/Tendonitis or more commonly
something we call Tennis Elbow.
Is that something you might have heard of before? – No

Would you like me to tell you more about it? – Yes
Tennis elbow is a condition that causes pain around the outside of the elbow.It's clinically
known as lateral epicondylitis. It often occurs after strenuous overuse of the muscles and
tendons of the forearm, near the elbow joint and you may also find it difficult to fully
extend your arm.
You may notice pain:
on the outside of your upper forearm, just below the bend of your elbow
when lifting or bending your arm
when gripping small objects, such as a pen
when twisting your forearm, such as turning a door handle or opening a jar
Are you following me so far? – Yes
Why did it happen to me?
Unfortunately, you do have some risk factors that increase the likelihood of you having this
condition. Of those, the most striking are your Hobbies&Occupation. You did mention you
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are a professional athlete and that you’ve been playing tennis and other racquet sports.
As the name suggests, tennis elbow is sometimes caused by playing tennis. However, it is
often caused by other activities that place repeated stress on the elbow joint, such as
decorating or playing the violin.
The elbow joint is surrounded by muscles that move your elbow, wrist and fingers. The
tendons in your elbow join the bones and muscles together, and control the muscles of your
forearm.
Tennis elbow is usually caused by overusing the muscles attached to your elbow and used
to straighten your wrist. If the muscles and tendons are strained, tiny tears and
inflammation can develop near the bony lump (the lateral epicondyle) on the outside of
your elbow.
Pain that occurs on the inner side of the elbow is often known as golfer's elbow.
What are you going to do for me?
MANAGEMENT
I would like to reassure you, that tennis elbow is a Self-Limiting Condition, which means it
will eventually get better without treatment. However, there are treatments that can be used
to improve your symptoms and speed up your recovery.
Taking Painkillers, such as Paracetamol may help reduce mild pain caused by tennis
elbow. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), such as ibuprofen, can also be
used to help reduce inflammation. As well as tablets, NSAIDs are also available as creams
and gels (topical NSAIDs). They are applied directly to a specific area of your body, such
as your elbow and forearm. Topical NSAIDs are often recommended for musculoskeletal
conditions, such as tennis elbow, rather than anti-inflammatory tablets. This is because
they can reduce inflammation and pain without causing side effects, such as nausea
and diarrhoea. Some NSAIDs are available over the counter without a prescription,
while others are only available on prescription.
It's important that you Rest your injured arm and stop doing the activity that's causing the
problem. Unfortunately, this does mean that for the next few weeks you should discontinue
any vigorous exercise that may cause additional stress to your elbow.
Holding Ice or cold Compress, such as a bag of frozen peas wrapped in a towel, against
your elbow for 15-30 minutes several times a day can help ease the pain.
Elevating, massaging and manipulating the affected area may help relieve the pain and
stiffness, and improve the range of movement in your arm.
Following these steps known as the PRICE therapy for 2-3 days can help bring down
swelling and support the injury.
Physiotherapy may be recommended in more severe and persistent cases.
We may have to refer you to a Specialist called a Rheumatologist. There, an intra-articular
injection (an injection into your joint) may be performed to reduce the pain and swelling.
Shockwave Therapy is a non-invasive treatment, where high-energy shockwaves are
passed through the skin to help relieve pain and promote movement in the affected area.
How many sessions you will need depends on the severity of your pain. You may
have a local anaesthetic to reduce any pain or discomfort during the procedure. The
National Institute for Health and Care Excellence (NICE) states that shockwave therapy is
safe, although it can cause minor side effects, including bruising and reddening of skin in
the area being treated. Research shows that shockwave therapy can help improve the pain
of tennis elbow in some cases. However, it may not work in all cases, and further research
is needed.
Platelet Rich Plasma (PRP) is a newer treatment that may be offered by a surgeon in
hospital to treat tennis elbow. PRP is blood plasma containing concentrated platelets that
your body uses to repair damaged tissue. Injections of PRP have been shown to speed up
the healing process in some people but their long-term effectiveness is not yet known. The
surgeon will take a blood sample from you and place it in a machine. This separates the
healing platelets so they can be taken from the blood sample and injected into the affected
joints. The procedure usually takes about 15 minutes.
Surgery may be used as a last resort to remove the damaged part of the tendon. Invasive
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treatments - such as surgery - will usually only be considered in severe and persistent cases
of tennis elbow where non-surgical approaches have been ineffective. Usually, a minor
operation would be performed on the place where there is inflammation.
I would like to consult my seniors for a 2nd Opinion and hopefully they can answer any of
your questions that I may not have been able to answer.
I would like to give you a Leaflet about Tennis Elbow.
Is there anything else I can help you with? – Yes
Is there anything else I can do?
It's not always easy to avoid getting tennis elbow, although not putting too much stress on
the muscles and tendons surrounding your elbow will help prevent the condition getting
worse. If your tennis elbow is caused by an activity that involves placing repeated strain on
your elbow joint - such as tennis - changing your technique may alleviate the problem.
Listed below are some measures you can take to help prevent tennis elbow developing or
recurring:
if you have tennis elbow, stop doing the activity that is causing pain, or find an alternative
way of doing it that does not place stress on your tendons
avoid using your wrist and elbow more than the rest of your arm. Spread the load to the
larger muscles of your shoulder and upper arm
if you play a sport that involves repetitive movements, such as tennis or squash, getting
some coaching advice to help improve your technique may help you avoid getting tennis
elbow
before playing a sport that involves repetitive arm movements, warm up properly and
gently stretch your arm muscles to help avoid injury
use lightweight tools or racquets and enlarge their grip size to help you avoid putting
excess strain on your tendons
wear a tennis elbow splint when you are using your arm, and take it off while you are
resting or sleeping to help prevent further damage to your tendons. Ask your GP or
physiotherapist for advice about the best type of brace or splint to use
increasing the strength of your forearm muscles can help prevent tennis elbow. A
physiotherapist can advise you about exercises to build up your forearm muscles
You can expect to make a full recovery from tennis elbow. Most cases of tennis elbow last
between six months and two years. However, in about 9 out of 10 cases, a full recovery is
made within a year.
Was there anything in particular you were expecting to get out of this consultation? – No
.
Do you have any other concerns? – Yes
Will I be able to play the tournament tomorrow? Next week? Next month?
Ideally, you should rest the elbow for a period of at least 4-6 weeks, so any inflammation
can settle and you can become pain free. It is also important to increase your workload by
increments and not to put too much stress on your elbow all of sudden. Therefore, it would
be wise to limit any future tournament appearances over the next 4-6 weeks. Of course, this
too would also aim to prolong your career in the future.
Do come back to us at the GP Surgery if:
your symptoms do not improve within a few weeks
you're in a lot of pain
you think you have ruptured (torn) a tendon
(A ruptured tendon usually causes sudden and severe pain. You might hear a popping or
snapping sound during the injury.)
Not taking any prescribed/OTC medications. Taking vitamin supplements only, like iron.
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No Allergies. Family Hx unremarkable. No significant Travel Hx. Professional tennis

player. Unmarried. Sexually inactive. Healthy diet, lots of water, fruit and veg. Occasional
alcohol drinker. Non-smoker. Plentiful exercise. Mild stress. Does not use recreational
drugs. Lives alone. Has been playing all types of racquet sports (badminton, tennis, squash)
since a child. Became a professional at age 18. Still plays regularly, but has lost her
enjoyment in the sport due to the pain. Otherwise fit and well. Mood – Distressed, unable
to perform at her best in matches. Losing out financially due to her inability to participate
in tournaments.
Vitals – Pulse 66/min, BP 120/75mmHg, RR 13/min, O₂ Saturation 99%, Temp 37.4°C
Joint Examination – Swollen Left Lateral Elbow region, visible colour changes,
temperature raised, tender. Movements limited. Positive Mills Test. Rest of the joint
examinations, unremarkable.

CARPAL TUNNEL SYNDROME
Question: You are an FY2 in GP Surgery. Aleena McVee is a 30 years-old lady who has
presented with some concerns. Take a focused history, perform relevant examination,
discuss management with the patient and address her concerns.
Hello. Aleena McVee? Hi, my name is Dr. ……… I am one of the junior doctors here in
the GP Surgery.
What would you like me to call you? – Hi, Aleena please
How can we help you today Aleena? – I have got this pain in both of my hands
Are you in pain now? – Yes

Can you tell me a little bit more about the pain you are having? – Yes, it just feels like
there’s tingling in both of my hands
Can you tell me where exactly it is you feel pain? Which hand? Can you point to me?
Which fingers? – It’s like in both my palms, and in between my fingers sometimes. Index
and middle finger. Even my thumb hurts now and then
For how long have you been experiencing this pain? – 2 weeks now
Is one hand affected more than the other? – Yes, my right
Are you right-handed or left-handed? – Right
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How much does it affect your life/Are you able to do your work and daily activities? – Yes,
but it’s getting harder to look after my son, Billy
And how did the pain come about? Sudden/Gradual? – It’s happened gradually
And how would you define the nature of this pain? Dull? Burning? Sharp? Tingling? It’s
like pins and needles travel down the side of my fingers and palm
Does the pain travel anywhere else in your body? Wrists? Arms? Shoulders – No
Does it worsen with any activity you do? Work? Movement? Heavy Lifting? – Well I don’t
work at the moment because I’m on maternity leave. But yes, it’s really painful when I
hold my baby, and when I change his diaper
Congratulations on your new-born! So how old is he? How is he doing? Is it your first
child? – 1 month. He’s doing really well, yes – Billy’s our first
So you said you were on maternity leave, what work do you do? – I’m a teacher
Does your pain improve at any time? Rest? Medication? Raising/Hanging arm? Flicking
wrist? Yes. Sometimes I feel like the pain is going away when I flick my wrists. When I
raise my hands or hang them, I also get some relief
And is the tingling always there, or is it there at a specific time? – It comes and goes and is
worse at night time
describe the pain you are having? – It’s not that painful. 2. It’s more of a pins and needles
Is the pain getting better or is it getting worse? – It seems to be getting worse
Is there anything else you’d like to add that I may have missed? – No, not that I can think
of right now
Rule out common hand pain causes;

Carpel Tunnel Syndrome, Arthritis (OA, RA), de Quervain’s Tenosynovitis, Cervical
Radiculopathy, Peripheral Neuropathy (DM, Hypothyroidism), Pronator Syndrome,
Raynaud’s Syndrome, Ulnar Nerve Neuropathy, Cellulitis, Trauma
Numbness? Loss of sensation? Glove/stocking?(CTS, CR, PN)–Thumb

Skin Changes –Dryness? Colour? (CTS, RS, Cellulitis) – No
Muscle Weakness? (CTS, PS, UNN) – No
Joint pains? Stiffness? (Arthritis, dQT) – No
Cold weather pain? Intermittent? (RS) – No
Neck Pain (CR) – No
Fever? (Arthritis, dQT, Cellulitis) – No
Tiredness? Weight Gain? Menstrual irregularity? Hair changes? Cold intolerance?
(Hypothyroidism) – No
Did you hurt yourself at all? (Trauma) – No
Sleep problems? – No
Is this the first time you’re experiencing these symptoms? – Yes

Risk factors for Carpal Tunnel Syndrome– Repetitive Manoeuvres, Family Hx, Pregnancy,
Obesity, Diabetes Mellitus,Hypothyroidism, RheumatoidArthritis, Diabetes Mellitus,
Acromegaly, Trauma, Mass Lesion, Amyloidosis, Sarcoidosis, Multiple Myeloma,
Leukaemia
Have you ever been diagnosed with any medical condition before? – No
Like Diabetes? Hypothyroidism? RA? – No
Have you ever undergone any prior Surgery? – No, but I did deliver 1 month back
How did that pregnancy work out? – It was really difficult, but rewarding. Now we have a
new baby boy in our lives, and I’m really happy
What type of delivery was it? – It was a vaginal birth
Did you experience anything like this pain during your pregnancy at all? - No
Were there any other complications during the pregnancy? At birth? During? After? - No
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Does anyone in your Family have similar symptoms? – No

So you said you worked as a teacher, does theinclude a lot of
computer work? – No, but I do have to mark lots of papers…
work with vibrating tools? – No
work that requires a strong grip? – No
Anything else you would to add? – No
Examination:
Aleena, is ok for me to examine you now? I need to check your observations: pulse, blood
I also need to calculate your body mass index (BMI) – which is a ratio of your weight and
height.
We need to take a closer look at your hands, wrists and arms too, to look for any discharge,
redness, swelling, skin changes or scars. I’ll gently be touching your upper limb to assess
for the temperature and any tenderness. If you feel any pain, let me know and we’ll stop.
INSPECTION
Exposure up to the elbows
Palmar & dorsal surface – weakness/atrophy of hand/thumb muscles
Compare both sides
DRSSS – Discharge, Redness, Swelling, Scars, Skin changes etc…
PALPATION
Temperature (using the back of your index and middle finger)
Tenderness (using index finger and thumbs of both hands; DIP, PIP, MCP Joints) [Always
start with the normal unaffected side first, to gain trust, confidence and get a feeling of how
the normal side should feel]
Movements
Active: Get the patient to move his DIP, PIP, MCP & wrist joints
Passive: As the examiner, manipulate the joints carefully to assess joint movement, rigidity
and tenderness.
Thumb: Flexion, Extension, Abduction, Adduction, Circumduction
Special Tests
Median Nerve – Male ‘Ok’ sign with index finger and thumb and then try to break it.
Ulnar Nerve – Make patient squeeze your index and middle fingers together and pull.
Radial Nerve – Prevent the patient from giving the thumbs up sign by pushing down on
thumb.
Button-unbutton
Pick up a coin
Hold paper tightly in between fingers
Finger counting
Tinel Sign
Phalen’s Test (Reverse Prayer Sign
Neurovascular Status
Bulk
Tone
Power
Reflexes
Dermatomes
Distal Pulses
Capillary Refill
Thank-you for letting me examine you, Aleena.
Provisional diagnosis:
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From what you have told me and from what I have seen from examining you, you seem to
be having tingling sensations in both your hands, which has been happening for 2 weeks, is
on and off and is located at the thumb and first three fingers. Is that correct? - Yes
You also felt some pain on performing some of the special tests.
Aleena, do you have any idea at all why you may be having this problem? – None at all
Well Aleena, it seems to be a quite common condition, would you like to know more about
it? – Yes
It looks like you may have may have a condition called Carpal Tunnel Syndrome (CTS).
Do you know anything about it? – No
CTS is pressure on a nerve in your wrist. It causes tingling, numbness and pain in your hand and
fingers. The symptoms of CTS include: an ache or pain in your fingers, hand or arm; numb
hands, tingling or pins and needles and a weak thumb or difficulty gripping. These
symptoms often start slowly and come and go and they're usually worse at night. CTS
sometimes clears up by itself, particularly if the cause is pregnancy related.
What causes hand pain and numbness in pregnancy?

CTS is common in Pregnancy. It happens when there is a build-up of fluid in the tissues in
your wrist during pregnancy. This swelling squeezes a nerve, called the median nerve, that
runs down to your hand and fingers. This causes tingling, pain and numbness. You may
also find your grip is weaker and it's harder to move your fingers.
It may be worse in the hand you use most often - your dominant hand - and in the first and
middle fingers, though it may affect your whole hand. It may be particularly painful at
night.
Why did it happen 1-month after I gave birth?

CTS usually happens in your second trimester or third trimester. If you have CTS in one
pregnancy, you’re likely to have it in later pregnancies. It usually disappears after
your baby's birth when the swelling goes down. But for some mums including yourself,
symptoms can appear and last for up to a year after their baby is born.
You're more likely to develop CTS if a parent, brother or sister has it, and if you've had any
previous injuries to your wrists. Also if you have any medical conditions like high blood
sugar, arthritis and under functioning of the thyroid gland there’s an increased risk. CTS
can also happen if you’re obese – which is another risk factor, but your BMI was 25 and
within the normal limit.
Do you follow? – Yes

So what are you going to do for me?
MANAGEMENT
Often the symptoms are so typical that no tests are needed to confirm the diagnosis.
If the diagnosis is not clear then a test to measure the speed of the nerve impulse through
the carpal tunnel – a Nerve Conduction Test - can be advised. A slow speed of impulse
down the median nerve will usually confirm the diagnosis.
Some people may also be referred for an Ultrasound scan or a Magnetic Resonance
Imaging (MRI) scan to look at their wrist in more detail.
We may need to do some routine blood tests to check your blood count and check for any
signs of inflammation.
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A Random Blood Glucose and Fasting Blood Glucose may be required to rule out
Diabetes, which is a risk factor for CTS.
We may have to perform a Thyroid Function Test – to look at the activity of your Thyroid
gland.
We may also have to check for the presence of a protein in your blood called Rh Factor, to
rule out Rheumatoid Arthritis
In about 2/3 of cases that develop during pregnancy, the symptoms go after the baby is
born. In your case, you developed the symptoms of CTS in your 1st month after delivery.
Still, not treating is an option, particularly if symptoms are mild. The situation can be
reviewed if symptoms become worse. In up to 1 in 4 cases the Symptoms Go Without
Treatment within a year. Symptoms are most likely to resolve in your age group - people
aged 30 and under.
Being physically active can decrease the risk of developing CTS, however it is important to
Rest your hands when you experience pain. Try not to over-use your wrists by excessive
squeezing, gripping, wringing, etc. It’s especially important when you’re taking care of
your baby, as it can cause extra stress on your thumb joints.
If you are overweight, losing some weight may help. Your BMI was ok.
How can I ease the pain of CTS?
Painkillers may be prescribed to ease the pain, i.e. Aspirin, Ibuprofen, or Naproxen. While
these methods can help, keep in mind that they don't cure carpal tunnel syndrome. At best,
they may give you short-term relief as you try other treatments.
A removable wrist Splint (brace) is often advised as a first active treatment. The aim of the
splint is to keep the wrist at a neutral angle without applying any force over the carpal
tunnel so as to rest the nerve. This may cure the problem if used for a few weeks. However,
it is common to wear a splint just at night, which is often sufficient to ease symptoms.
An injection of Steroid into, or near to, the carpal tunnel is an option.
Surgery is recommended for severe cases but the jury is still out as to whether it is better
than injections for moderate symptoms. A small operation can cut the ligament over the
front of the wrist and ease the pressure in the carpal tunnel to give your nerve more space.
This usually cures the problem. It is usually done under local anaesthetic. There are two
main types of surgery - open and keyhole. Your surgeon will discuss which technique is
appropriate for you. You will not be able to use your hand for work for a few weeks after
the operation. A small scar on the front of the wrist will remain. There is a small risk of
complications from surgery. For example, following surgery there is a very small risk of
infection and damage to the nerve or blood vessels. Sometimes, the nerve can get caught
up in the scar and become stretched when the wrist is moved: this is known as tethering.
Further splinting after the surgery is not needed.
We may have to refer you to a Neurologist – a doctor who specializes in problems
concerning the nervous system.
If the condition is part of a more general medical condition (such as arthritis) then
treatment of that condition may help.
Which complementary therapies can help with CTS?
If you decide to consult a complementary therapist, choose one who's registered, qualified
and experienced in treating pregnant women and women who have recently delivered.
Over the years, a wide range of other treatments has been tried. For example;
Massage; Ask your partner to gently massage your hands and wrists, moving up towards
your armpits, and then your shoulders, neck and upper back. Again, while there’s no
evidence that this helps, it won’t do you any harm to try. At the very least you’ll get a
soothing massage!
Exercise; You may find hand exercises ease the pain. There’s some evidence they help so
they’re worth a try. Begin by clasping one wrist with your other hand and massage it with a
circular movement. This may ease pressure on the nerve. Gently stretch your hands and
arms. Bear in mind that some movements can make CTS worse so stop if any stretches
start to feel uncomfortable.
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Acupuncture; Acupuncture may help to ease the pain of carpal tunnel syndrome. Some
studies suggest it reduces pain more than using splints at night. You could try acupressure
at home. You can try this yourself. If both of your hands are affected you may not be able
to press firmly enough, so ask someone to do it for you. Apply pressure at regular intervals
to the inside of your wrist
Aromatherapy; If you enjoy using essential oils, try making a compress to soothe your
aching wrists. Cypress and lemon essential oils may help to reduce swelling. Add two
drops of each essential oil to warm or cool water and soak a cloth in it. Wrap the soaked
cloth several times around your wrists.
Osteopathy; Osteopathy, and the related practice of chiropractic, aim to re-align your
muscles, bones, joints and ligaments. Osteopathy can help to relieve neck, shoulder, wrist,
hand and finger pain.
Reflexology; Reflexology works on the principle that your foot represents a map of your
body. There's no strong evidence that it's effective but it can be a pleasant and relaxing
treatment. You would have to pay for a session with a reflexologist. Alternatively, you
could try a simple reflexology method yourself
Controlled Cold Therapy
Ice Therapy
Laser therapy
None of these treatments has good research evidence to support its use and so they are not
commonly advised. However, they can work for some people. There is some evidence that
acupuncture may relieve symptoms in some people.
Steroid tablets may ease symptoms in some cases. However, there is a risk of serious side-
effects from taking a long course of steroid tablets. Also, a local injection of a steroid
(described above) probably works better. Therefore, steroid tablets are not usually advised.
I do have some reading material available with me to give you entitled – Carpal Tunnel
Syndrome.
How can I prevent the pain and numbness in a future pregnancy?
You may not be able to prevent carpal tunnel syndrome, but by reducing your swelling
you’ll probably be able to relieve the symptoms.
If you’re overweight or you gain too much weight in pregnancy you're more likely to

develop CTS. So try to eat a balanced diet to keep your weight gain healthy.
Aim to cut down on sugar and fat, as well as salt, which makes you more likely to retain
fluid. Drink plenty of water, and eat at least five portions of fresh fruit and vegetables a day.
Get fitted for a properly supportive maternity bra. This will take the weight off your ribcage
and breastbone, which may help to relieve pressure on the median nerve, which starts at
your shoulder.
If the symptoms of carpal tunnel are disrupting your sleep, preventing you carrying out
everyday activities, adversely affecting your performance at work or don’t resolve within 1
year after the birth of your child, please do come back and visit us at the GP Surgery. We
will be more than happy to address any of your concerns.
If you do experience severe pain, then do pay a visit to the A&E.
No significant past Medical Hx. Surgical Hx - Normal Vaginal Delivery (NVD) 1 month
ago. 1st child. Child is healthy. Uncomplicated pregnancy. No symptoms during pregnancy,
or immediately after. No Allergic Hx. No Family Hx. No Travel Hx. Teacher. Teaches
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Math. Menstrual cycle restarted. Lives at home with boyfriend. 1 sexual partner –
boyfriend for 2 years. Non-Smoker. Drinks alcohol occasionally. Does not use recreational
drugs. Diet healthy. Hygiene good. Exercises regularly.
Vitals – NORMAL, BMI – 25, Inspection is unremarkable. On Palpation; there is neuralgia

on thumb & radial 3.5 fingers – bilaterally. Difficult to make OK sign, and easy to break.
Tinel Test + , Phalen Test +.
TEACHING RESPIRATORY SYSTEM EXAMINATION

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Where you are

You are an FY2 in Acute Medical Unit
Who the patient is
Henry Newbold is a 36 years-old male
None
What you must do
Simon is a third-year medical student who wants to learn more about the examination of
the respiratory system. Teach him how to examine the respiratory system.
SPECIAL NOTE: Do not ask Simon to perform the examination
CONSULTATION
GRIPS  Student [Greet, Rapport, Introduce, Posture, Smile]
Hello there Simon, my name is Swamy, one of the FY2’s in the AMU.
How are you doing today?
Good thank-you
How are you finding your studies? Wards?
Good thank-you.
Ok. So I understand you want to learn about the examination of the respiratory system. What we
can do is go through it together.
How does that sound?
That sounds great
So what do you know about examination of the respiratory system?
Nothing at all
And are you aware of the relevant anatomy?
Yes
Is there anything in particular you want me to go over, or would you like a general overview?
A general overview would be good
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If you have any questions – you can either ask me there and then or wait until the end – it’s
entirely up to you - OK
Ok great. Luckily, today we have a patient with us today called Mr. Newbold.
What I would like to do is for us to introduce ourselves to him, explain to him what we would
like to do and get his consent for us to examine his respiratory system. Alright? – YES
Hello. Henry Newbold? Hi, my name is Dr. Swamy, I am one of the junior doctors here in the
department. I have with me Simon here; he is a medical student who wants to learn a little bit
about the examination of the breathing system. Is that ok? - YES
Can you just tell us what made you come to the hospital in the first place?
Yes, I slipped on my porch and the doctors said I sprained my ankle
And how are you feeling now?
I feel much better
Do you have any pain elsewhere? - NO
And what have you been told regarding your treatment?
The senior doctor looking after me, he explained everything to me. That we have to follow
something called PRICE, Painkillers, Rest and so on…
Great. So I can see that you’re fully aware of the treatment being offered to you.
Is there anything that you’re unsure of about your treatment? - NO
Fantastic. 5 Protocol
 Consent
 Exposure
Consent  Privacy
 Chaperone
 Confidentiality
So, is it alright if examine your breathing system? - YES

Fantastic. Simon will be here as an observer only, and I will be the one examining you. If you
feel any discomfort or pain at any time please let me know and we can stop right there. Ok? –
YES.
Great.
Exposure
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For this exam we need adequate exposure of the hands, face and chest area, so Mr. Newbold can
you please remove your gown so we can take a closer look at your chest? Thank-you
Privacy
We’re already in an isolated cubicle, but what I will do for you is draw up the curtains to ensure
your privacy.
Chaperone
We do have the examiner here with us today, who will act as our chaperone.
Confidentiality
The results of today’s exam will remain between you, Mr. Newbold and the medical team.
Ok, so Simon, when examining the respiratory system, there are a few important steps.
What we want to focus on is the:
HANDS
FACE
CHEST
INSPECTION
PALPATION
PERCUSSION
AUSCULTATION
LEGS
HANDS – Mr. Newbold, we’ll just be taking a closer look at both your hands. Could you
please sit upright on the end of the couch and could you please hold your arms outwards with
your palms facing the sky. And now facing downwards.
When looking at the hands, there are a few important observations to make;
Cyanosis
Clubbing
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Tremors as a sign of carbon dioxide retention

Pulse
At this time, it is good practice to take the observations of the patient – which include the pulse,
blood pressure, breathing rate, oxygen saturation and temperature. However, this can also be
done at the end of the examination – as long as it is not forgotten!
FACE – Mr. Newbold, now we’ll examining your face.
When looking at the face, we are checking for;

pallor in the lower conjunctiva
jaundice in the sclera and under-surface of the tongue
cyanosis in the tip of the nose, the lips, the tongue and the lobules of the ear
nose – deformity, deviated nasal septum, polyps or foreign body that can obstruct the airway
passages
.
CHEST
Now we are going to move on to the examination of the chest which is the most important
aspect of examination of the respiratory system, as this is where the lungs are located. There are
4 important steps:
INSPECTION
PALPATION
PERCUSSION
AUSCULTATION
INSPECTION (Front & Back)
For this, ideally, we would like the patient to lie down on the couch at 45°. It is paramount to
inspect the anterior and posterior surface of the chest.
Mr. Newbold could you please lie down with your back against the couch? - YES
What we are going to do is take a closer look at your chest. We will also be touching various
areas of your chest, and we may ask you to perform some actions. We will also be listening to
your breath sounds using a special tool called a stethoscope.
Is that alright? – YES
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If you do feel uncomfortable or distressed at any time, let me know and we’ll take a pause right
there. - OK
Great.
So, starting off the examination of the chest with inspection, with the patient exposed from the
waist upwards at 45° we have to observe a few things, first from the side of the patient and then
from the foot end. It is important to always approach the patient from the RIGHT side.
What we are looking at is:
Any visible chest deformity (Pectus Excavatum/Pectus Carinatum/Kyphosis)
The respiratory rate
The type of respiration (Thoracoabdominal Vs Abdominothoracic)
Abnormal chest movements
Paradoxical chest movement
Discharge, Redness, Swelling, Scar mark, Skin changes
Hair distribution
Pulsations
Dilated Veins
Nipples (symmetrical, everted/inverted)
Are you following me? – YES

Great
PALPATION (Front & Back)

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After inspection, we now move on to palpation of the chest. It’s important to wash your hands
before examining a patient, and gloves should be worn. It’s also important to warm your hands
in cold temperatures. The steps of palpation include;
Trachea (2 or 3-finger method)
Apex beat
Temperature
Tenderness
Chest Expansion (with a tape measure)
Chest Movements (with your hands – 1 level above nipple, 1 at the level of the nipple and at 1
level below the nipple)
Tactile Fremitus – Ninety Nine
Palpable added sounds
You’re doing really well Mr. Newbold. Well done.
And that concludes palpation.
Is there any confusion so far? – NO
Trachea Palpation
Chest Movements
Chest Expansion
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Vocal Fremitus
PERCUSSION (Front & Back)

Mr. Newbold, now I will be gently tapping on your chest to appreciate the sounds. You may
feel a tad discomfort. Is that alright? - YES
In percussion what we are looking for is the normal resonant sound of the air-filled lung within
the chest cavity.
The plexor finger should strike the pleximeter finger at 90 degrees (see below).
We do have to take into account the viscera present. On the left we have the heart, and on the
right, we have the liver – in these areas there may be a dull sound.
In different pathologies the character of the sound would change – so for instance in pleural
effusion it would be stony dull – like percussing against a stone.
AUSCULTATION (Front & Back)

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Simon have you ever seen one of these before? *shows stethoscope* - NO
This is a stethoscope and is used to hear the breath sounds and the heart sounds. It consists of;
The ear piece – which should be facing forwards to match the direction of your ear canal
The tubing
The diaphragm & bell
This is how we wear it. And now I’ll show you how to use it.
Mr. Newbold, I have with me a stethoscope here which will aid me in hearing your breath
sounds. I will be placing it on different parts of your chest.
It might feel a little cool against your skin, so could you bear with me for a few moments more?
– YES
And that is how we use a stethoscope. It’s important to auscultate all the key areas of the chest
to listen for abnormal chest sounds, like stridor, crepitations and wheeze.
We can also check for Vocal Fremitus by auscultating and asking the patient to say ninety-nine.
It is good practice to auscultate both the front and back of the chest. However, breath sounds
can better be appreciated from the back, where viscera and bone do not interfere as much with
the quality of sound. We can ask the patient to cross his arms and place his hand on his opposite
shoulder to retract the scapulae so we get unrestricted access to the posterior mediastinum to
hear the lung sounds.
LEGS
Looking at the legs may appear odd, but it is important to check for
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Leg swelling
This could indicate many things, but with respect to the respiratory system it may signal a
potentially lethal condition called a Deep Vein Thrombosis which has the capability to cause a
Pulmonary Embolism.
With that concludes our examination of the respiratory system.
Thank-you very much Mr. Newbold. You did really well. Now you can sit up, pop your shirt
back on and get comfortable.
To recap, examination of the respiratory system incudes 4 important steps, which are, looking at
the;
HANDS
FACE
CHEST
INSPECTION
PALPATION
PERCUSSION
AUSCULTATION
LEGS
Do you have any questions for me at all, Simon? – NO

Brilliant.
What I would like you to do is to practice yourself on another patient by going through the steps
we have discussed.
We can review what we’ve done today again at a later date.
You can also take my pager, and bleep me if you have any more queries regarding the
examination of the respiratory system or anything regarding your work or studies.
Meanwhile, there are excellent resources available on the internet to review examination videos,
so do take a look at those too.
Thanks very much.
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Thyroid Examination
( new station came on 25th Jan 2018)
You are an FY2 in the GP clinic. Lucy Talbot was diagnosed with Thyrotoxicosis and
started on carbimazole a year back. She has come now for her annual follow-up.
Discuss and agree a management plan with her.
Inside the cubicle, there may be knee hammer and BNF on the table. The simulator sitting on
a chair and there was no couch or any other equipment inside the cubicle.

I had overactive thyroid. I am on medication. I have come for follow up.
I am glad that you came for the follow up. Is it Ok to ask few questions to see everything is
OK with your condition ?
Do you have any problems with that now ?
May I know what medications are you taking now ?Carbimazole .
How much ? Pt: 5 mg once a day. Check BNF for the correct dose ?
Are you taking it regularly ? Yes
Since how long you had this problem ?since – One year / ? ...
Do you have any other medical conditions at all ? No
Are you taking any other medications ? No
How are the symptoms you had before we started taking the medications ? They are all gone
now.
Ask about hyper and hypo - thyroid symptoms
Hyperthyroid Hypothyroid
 Do you feel any irregular

or unusually fast heart rate (palpitations)  tiredness
 Any problems in vision ( double  weight gain
vision)  Constipation
 Any twitching or trembling in hands being sensitive to the cold
 Loose stools
 Change in Voice ?
 weight loss
 Any problem in the periods ?

 Any sensitivity to heat
 Any swelling in your neck from
an enlarged thyroid gland (goitre)
Are you taking your medications properly ? Yes/ No

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Ask about Side-effects of carbimazole;
Any joint pains, headaches, jaundice, Itching, Rash, taste disturbance.

Rare side effect: agranulocytosis ( ask about recurrent infections)
Patient may say no for all the symptoms.
Are you pregnant at all? No

Any plans for pregnancy ? No my husband had vasectomy.
Is there anything else you want to tell me
That is good that you do not have any symptoms.

I need to examine you now. I need to examine your hands eyes and your neck – is that Okay?
Can you please undress your neck and upper part of chest please.
Thyroid Examination
( you tube - www.youtube.com/watch?v=ziaYBkgEZNU )
Position: Sitting
Inspection:
Hands:
 No Dryness (hypothyroid) or Sweatiness (Hyperthyroid)
 No Clubbing
 No Palmar Erythema (Hyperthyroid)
 No Tremor: Ask patient to outstretch arms and place a paper on back of hands
and observe the tremor. (Hyperthyroid)
 Pulse: Tachycardia (Hyper), Bradycardia (hypo), Irregular- AF (Hyper) check the
NEWS chart if present – if not ask for it.
Eyes:
 Exopthalmos (Inspect from front and side)
 Lid lag: Ask patient to look at your moving finger without moving head. Move it
from upper to lower part of visual field and note for delay in descent of upper
eyelid to that of eyeball.
 Lid retraction: It is present if sclera is visible above the iris.
Thyroid:
Inspect the midline of neck: Ask patient to move chin up a bit. Comment on:
 Swelling
 Skin changes
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 Scar
Swallow Test:
 Ask patient to swallow some water.
 Observe any movement of mass. Most swellings move upwards on swallowing.
Tongue Protrusion:
 Look at neck and ask patient to bring out the tongue.
 Thryoglossal cysts will move upwards.
Palpation:
 Inform patient that you are going to feel neck from behind.
 Stand behind the patient and ask patient to bend neck. (To relax the
sternocleidomastoid muscle)
 Place your hands on either side of neck.
Thyroid:
 Place 3 fingers along the midline of neck below the chin and slide downwards
until the area of thyroid gland, which is just located below the thyroid cartilage.
 With 1 hand fix one side of thyroid and palpate the other side with help of 3
fingers. Do same on the other side.
 Feel for the gland and ask patient to swallow some more water and feel for any
swelling moving with your hands.
 Verbalise that there is no abnormality noted.

Lymph Nodes:
Check all groups of lymph nodes
i) Submental
ii) Submandibular
iii) Anterior cervical chain (Tonsillar and deep cervical lymph nodes)
iv) Posterior cervical chain
v) Pre auricular
vi) Post auricular
vii) Occipital
viii) Supraclavicular
Percussion:
 Percuss down starting from sternal notch to listen for retrosternal dullness.
Auscultation:
 Auscultate both lobes of thyroid. (Thyroid bruit in Grave’s disease)
Pretibial myxoedema:
 Ask patient to roll up trouser.
 Note for the raised, discoloured appearance over legs.
Upper limb reflexes: Biceps, triceps and supinator.
Thank the patient.
Mrs.. With the information you have given me and after the examination everything looks
normal. However we need to do blood tests to check Thyroid function. ( examiner may not
give results).
I will let you know once we get the blood results.
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Do you have any concerns ? No

You are doing fine now. Usually we give medications for about 18 months and stop it if
everything is fine. You may be able to continue the medication with the same dose.
I will discuss with my seniors about you and get back to you.
[ If patient is already on Carbimazole for 18 months - We need to consider stopping the

Carbimazole as you may not need it any more – I will discuss with my seniors and get back
to you about it ].
Hip examination ( teaching)

HIP EXAMINATION - OSTEOARTHRITIS
Where you are
You are an FY2 in the Rheumatology department
Who the patient is
Bella Mustapha is a 69 years old lady who has presented with some pain in her
hip joint
She has been referred by her GP who she saw 2 weeks ago
What you must do
Take a focused history, assess the patient, discuss management with the patient
and address her concerns.
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CONSULTATION
1. GRIPS  Patient [Greet, Rapport, Introduce, Posture, Smile]
Hello. Bella Mustapha? Hi, my name is Dr. Swamy, I am one of the junior doctors here in the
Rheumatology department.
 What would you like me to call you?
 Bella please
 I understand you have recently visited you GP who referred you to us?
 That’s correct
 Do you have your referral letter with you?
 I’m really sorry doctor, I left it at home
 Can you just tell me what made you visit your GP in the first place?
 Yes, I’ve been having some pains in my hips for some time now
 Are you in pain now? – Just a little bit

 Are you ok to continue? – Yes (if no, ask next question)
 Have you been offered any painkillers? – No (if no, ask next question)
 Would you like me to give you some painkillers? – No (if yes, ask next question)
 Are you allergic to any medication at all? – No
2. PC  SOCRATES PDA  DDx  SR
 And how can we help you today?
 I’m still having pain in both of my hips. I went to my GP and she told me that you would be in a
better position to help me. They just feel so stiff. I just want this pain to go away. Maybe if you
could tell me why this is happening as well that would be helpful
Ok, well I’ll do my best. I do have to ask you a few questions first, and I would also need to take a closer
look at your hips.
 How does that sound? – Sounds good to me doctor
 Can you tell me a little bit more about the pain you are having?
 Yes, it started about a year ago. I didn’t think much of it then, and I thought it would go away by
itself. It did go away at times when I took paracetamol, but these past few months it has been a
constant nuisance. Sometimes I can’t get up in the morning! And at night sometimes I can’t sleep
because my body aches so much!
 Is this the first time you’re experiencing these symptoms?
 No, it’s been a year now
 Can you tell me which hip it is? Where exactly? Can you point to me?
 It’s both my hips. The right is sorer, but sometimes it’s the left. *hands on ASIS*
 And how did it come about? Sudden/Gradual
 Well it’s been a gradual thing over many months
 And how would you define the nature of this pain? Dull? Burning? Sharp?
 It’s a dull, achy pain
 Does the pain travel anywhere else in your body?
 No
 Does it worsen with any activity you do?
 Yes, moving. If I have an active day where I do the shopping and the gardening, my body really
aches at the end of the day
 Does it improve at any time? Rest? Medication?
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 When I rest, it feels so much better. I do feel better in the mornings. But I can’t rest for too long as
I love cooking, cleaning, gardening and looking after the grandchildren. I tried 2 tablets of
paracetamol. It did make some difference at first, but I think I must be resistant to it now, it doesn’t
help anymore
 And is the pain always there, or is it there at a specific time?
 Sometimes it’s there all day. But mostly, the mornings are pain-free. It’s much worse at night-time
before I go to sleep. Sometimes I can’t sleep
 On a scale of 1-10, 1 being the least amount of pain and 10 being the most, how would you describe
the pain you are having?
 I would say it’s either a 1 or 2 in the mornings and a 6 or 7 in the evenings
 Is the pain getting better or is it getting worse?
 Worse
 For how long have you been experiencing this pain?
 A year
 Is there anything else you’d like to add that I may have missed?
 No
 Osteoarthritis
 Rheumatoid Arthritis
 Psoriatic Arthritis
 Ankylosing Spondylosis
 Trauma
 Septic Arthritis
 Osteomyelitis
 Trochanteric Bursitis
 Dislocation
 Fracture Neck of Femur
 Avascular Necrosis of Femoral Head
 Malignancy/Metastases
 Muscle Strain
 Referred Pain
2. Why are my hips hurting so much?

There are a few possible causes as to why this could be happening. I do have a few more questions
to ask you about your health in general. Maybe after those have been answered, I’ll be in a better
position to tell you.
 How does that sound? - Fine
 Did you hurt-yourself in any way? Falls? Are any of your other joints involved? Fever? Joint
swelling? Rash? Discharge? Redness? Flu-like illness? Weight loss? Loss of Appetite? Lumps &
bumps?
 No
3. 2PMAFTOSA
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 Hypertensive for 25 years

 On Amlodipine 5mg, compliant – no side effects
o Swelling of your legs or ankles

o tiredness or extreme sleepiness
o stomach pain
o nausea
o dizziness
o hot or warm feeling in your face (flushing)
o irregular heart rate (arrhythmia)
o very fast heart rate (palpitations)
 No Allergy Hx
 No Family Hx
 No Travel Hx
 Has found her day to day activities significantly hindered. Can’t enjoy gardening as much.
Can’t spend much time in the kitchen to cook.
 Housewife
 Personal –
o Non-smoker
o Drinks alcohol on weekends only
o No history of recreational drug use
o Healthy diet
o Adequate exercise – shopping, gardening, looking after grandchildren
o A little stressed
o Good hygiene
o Sleep has been affected due to the pain
o Husband passed away 2 years ago
o Lives with son and his wife and 2 children who look after her
o Coping ok
4. RISK FACTORS
Factors that can increase your risk of osteoarthritis include:
u Older age. The risk of osteoarthritis increases with age.
u Sex. Women are more likely to develop osteoarthritis, though it isn't clear why.
u Obesity. Carrying extra body weight contributes to osteoarthritis in several ways, and the more
you weigh, the greater your risk. Increased weight adds stress to weight-bearing joints, such as
your hips and knees. Also, fat tissue produces proteins that can cause harmful inflammation in and
around your joints.
u Joint injuries. Injuries, such as those that occur when playing sports or from an accident, can
increase the risk of osteoarthritis. Even injuries that occurred many years ago and seemingly
healed can increase your risk of osteoarthritis.
u Repeated stress on the joint. If your job or a sport you play places repetitive stress on a joint, that
joint might eventually develop osteoarthritis.
u Genetics. Some people inherit a tendency to develop osteoarthritis.

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u Bone deformities. Some people are born with malformed joints or defective cartilage.
u Certain metabolic diseases. These include diabetes and a condition in which your body has too
much iron (hemochromatosis).
5. EXAMINATION
I. VITALS - (Pulse 68/min, BP 135/70mmHg, RR 14/min, Temp 37.5 °C, O2 Saturation 98%)
EXAMINER’S PROMPT: GIVE OBSERVATIONS FINDINGS WHEN CANDIDATE MENTIONS

WHAT HE/SHE WOULD LIKE TO OBSERVE
II. BMI
 I would like to take a look at your Body Mass Index, or BMI. Do you know what that is? -
NO
Simply put, it is the ratio of your height and your weight.

o Under 18.5 = Underweight
o 25 – 30 = Overweight
o >30 = Obese 5 Protocol
 Consent
EXAMINER’S PROMPT: BMI IS 28  Exposure
 Privacy
 Chaperone
 Confidentiality
III. HIP JOINTS
1. Ok, I will need to take a closer look at your hip joints. Is that alright? – YES
2. For this exam we will need adequate exposure of waist downwards,so Bella you may
need to take your shoes off and remove your trousers – you can remain in your under-
garments.
3. I’ll do up the curtains for you so you can have some privacy.
4. We do have the examiner here with us today who will act as our chaperone.
5. Any findings that we obtain from examining you will remain between you and the
medical team.
 Are you able to bear weight on your hip joints? – YES
 Do you have any problems with walking? – NO
 Have you noticed a limit in the movements your hips can make?
 Yes, I don’t find myself as nimble as I used to be. For example, when I’m gardening, I can’t cross
my legs as easily as I used to
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A. INSPECTION
I’m just going to be taking a closer look at your lower limbs. What I would like you to do is just stand up
for me with your feet together. If you feel any pain or discomfort at any time, please let me know and we
can stop right there.
- FRONT; straight line from ASIS to Medial Malleolus
- SIDES
- BACK; Gluteal muscle wasting
- Abnormality
- Discharge
- Redness
- Swelling
- Scar Marks
- Skin Changes
- GAIT;
 Could you please take a few steps for me please?

 Antalgic? Shuffling? Waddling? Drunken? Stepping? Etc
- TRENEDELENBURG’S TEST
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The Trendelenburg test is a quick physical examination that can assist the examiner to assess for any hip
dysfunction. A positive Trendelenburg test usually indicates weakness in the hip abductor muscles: gluteus
medius and gluteus minimus.
A positive Trendelenburg’s test is one in which the pelvis drops on the contralateral side during a single
leg stand on the affected side.
Wonderful, thank-you for that.

 Can you lie down on the couch for me now? – YES
 Can you just wriggle your toes for me please? –YES

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B. PALPATION
Ok, I will be gently touching your hip joint. If you feel any pain or discomfort at any time, do let me know and
we can stop right there.
 Temperature – ASIS, Greater Trochanter, PSIS

 Tenderness – ASIS, Greater Trochanter, PSIS
 Movements
(i) Active (at 45° unless stated otherwise)
o Flexion: Can you lift your leg as high as possible for me please?
o Abduction: Can you move your foot away from the other as far as possible?
o Adduction: And now can you bring your 2 feet together?
o M. Rotation: Can you put your toes together and put your heels apart?
o L. Rotation: Now can you put your heels together, and send your toes apart?
o Extension: (Flat 0°) Can you lay on your side and without bending your knees can you touch your back
with your legs?
(ii) Passive
Same as above, gentle manipulation of joints to see extent of motion and any rigidity while throughout
comparing both sides.
 Special Tests
(a) Resisted Adduction Test – Can you move your leg outward while I resist it?
(b) Resisted Internal Rotation – Can you raise your leg (45°), I’ll try to rotate your leg inwards, can you
resist it?
(c) Resisted External Rotation – Can you raise your leg (45°), I’ll try to rotate your leg outwards, can you
resist it?
(d) Trochanteric Thump Test – I will gently be bumping your hip joint with my fist to check for any
tenderness, can you let me know if you experience any discomfort?
(e) Thomas Test – Lay the patient flat. Check the lumbar spine area for any tenderness. Can you bend your
knee and bring it towards your chest? *Look at opposite side for flexion at the hip joint.
 Neurovascular
o Bulk
o Tone
o Power
o Reflexes (Knee, Ankle, Plantar)
o Dermatomes
o Distal Pulses – Dorsalis Pedis bilaterally
o Capillary Refill
IF CANDIDATE WANTS TO EXAMINE ANYTHING ELSE, ASK THE CANDIDATE WHY AND COMMENT
6. FINDINGS & Dx
NO ABNORMAL FINDINGS
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3. What is happening to me?

4.
5. So from what you have told me, you have been experiencing pain in your hip joints which usually gets
worse as the day progresses and, in the mornings and after rest it gets better. You had tried some painkillers in
the form of paracetamol but they no longer relieve your pain. And now you also seem to be having problems
with your day to day activities like gardening and cooking.
 Is that correct? – YES
 Have I missed anything? – NO
When I took your observations, your blood pressure was 135/70mmHg and seems to be well controlled and you
don’t seem to be experiencing any of the side effects of the medication that you are taking, Amlodipine.
When I observed your BMI – which was the ratio of your height and your weight - it came back as 28.
o Under 18.5 = Underweight
o 25 – 30 = Overweight
o >30 = Obese
So you are categorized as being overweight.
 Are you with me? – YES
When I examined your hip joints, I noticed there was tenderness on both your hip joints and a decrease in range
of motion on both sides, with the right side affected slightly more.
I do believe this is due to the age-related changes in the cartilage that surrounds your joints – a condition
termed Osteoarthritis.
 Do you know anything about the condition called Osteoarthritis? – NO
 Osteoarthritis is a condition that causes joints to become painful and stiff. It's the most common type of
arthritis in the UK.
 It occurs when the protective cartilage that cushions the ends of your bones wears down over time.
 Although osteoarthritis can damage any joint, the disorder most commonly affects joints in your hands,
knees, hips and spine.
 Osteoarthritis symptoms can usually be managed, although the damage to joints can't be reversed. Staying
active, maintaining a healthy weight and some treatments might slow progression of the disease and help
improve pain and joint function.
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Osteoarthritis of the Spine
Osteoarthritis of the Hip

Osteoarthritis symptoms often develop slowly and worsen over time. Signs and symptoms of
osteoarthritis include:
 Pain. Affected joints might hurt during or after movement.
 Stiffness. Joint stiffness might be most noticeable upon awakening or after being inactive.
 Tenderness. Your joint might feel tender when you apply light pressure to or near it.
 Loss of Flexibility. You might not be able to move your joint through its full range of motion.
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 Grating Sensation. You might feel a grating sensation when you use the joint, and you might hear
popping or crackling.
 Bone Spurs. These extra bits of bone, which feel like hard lumps, can form around the affected joint.
 Swelling. This might be caused by soft tissue inflammation around the joint.
Osteoarthritis occurs when the cartilage that cushions the ends of bones in your joints gradually
deteriorates. Cartilage is a firm, slippery tissue that enables nearly frictionless joint motion.
Eventually, if the cartilage wears down completely, bone will rub on bone.
Osteoarthritis has often been referred to as a "wear and tear" disease. But besides the breakdown of
cartilage, osteoarthritis affects the entire joint. It causes changes in the bone and deterioration of the
connective tissues that hold the joint together and attach muscle to bone. It also causes inflammation
of the joint lining.
u Complications
Osteoarthritis is a degenerative disease that worsens over time. Joint pain and stiffness can become
severe enough to make daily tasks difficult.
 Chronic Pain
 Depression
 Sleep disturbances
7. INVESTIGATIONS
A. Imaging tests
To get pictures of the affected joint, your doctor might recommend:
I. X-rays. An X-ray is a simple scan to get a better look at your bones. Cartilage doesn't show up on X-ray
images, but cartilage loss is revealed by a narrowing of the space between the bones in your joint. An X-
ray can also show bone spurs around a joint.
II. Magnetic Resonance Imaging (MRI). An MRI is a special scan. It uses radio waves and a strong
magnetic field to produce detailed images of bone and soft tissues, including cartilage. An MRI isn't
commonly needed to diagnose osteoarthritis but can help provide more information in complex cases.
B. Lab tests
Analysing your blood or joint fluid can help confirm the diagnosis.
I. Blood Tests. Although there's no blood test for osteoarthritis, certain tests can help rule out other causes
of joint pain, such as rheumatoid arthritis by checking for a substance called Rh Factor.
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II. Joint Fluid Analysis. We may need to use a needle to draw fluid from an affected joint. The fluid is then
tested for inflammation and to determine whether your pain is caused by gout or an infection rather than
osteoarthritis. Markers such as ESR and CRP can be a sign of acute inflammation.
8. MANAGEMENT
Osteoarthritis is a long-term condition and cannot be cured, but it doesn't necessarily get any worse
over time and it can sometimes gradually improve.
It's not possible to prevent osteoarthritis altogether. However, you may be able to minimise your risk
of developing the condition by avoiding injury and living a healthy lifestyle.
 Mild symptoms can sometimes be managed with simple measures including:
 regular exercise
 losing weight if you're overweight
 wearing suitable footwear
 using special devices to reduce the strain on your joints during your everyday activities
 ensuring adequate amounts of rest for your joints
 As your BMI was slightly high at 28, and classified as overweight, would you like some ideas as how
to reduce your weight? – YES
 Diet:
o 5 fruit and veg / day
o 8 glasses of water / day
o 2 portions of fish / week
o Reduce the amount of junk food/fatty foods
o Reduce the amount of cholesterol in diet
 Alcohol
o Less than 14 units of alcohol per week
o This equates to 2 units per day
o Cutting down altogether
 Tobacco
o Smoking Cessation
 Exercise:
o At least 30mins of exercise per day, or
o 2hours 30mins of exercise per week
o Avoid exercise that puts strain on your joints and forces them to bear an excessive
load, such as running and weight training.
o Instead, try exercises such as swimming and cycling, where the strain on your joints is
more controlled.
o Try to do at least 150 minutes of moderate aerobic activity (such as cycling or fast
walking) every week, plus strength exercises on 2 or more days each week that work
the major muscle groups, to keep yourself generally healthy.
 Stress:
o Reduce stress
1) Pain Relief
 If your symptoms are more severe, you may need additional treatments such as painkillers.
Paracetamol and Ibuprofen are usually the first choice.
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6. I’ve tried Paracetamol and Ibuprofen. They just don’t relieve the
pain anymore. What else is there?
7.
8. However, there are other painkillers available such as;

 Codeine.
 Another way to manage the pain is by using injection of local anaesthesia where the pain occurs. This
is a temporary and ineffective method for pain control,
 However, we would have to refer you to a pain clinic, and they would be better suited to advise you on
your medication to control your pain.
2) Anti-Inflammatory Medication
◦ They may also be recommended for osteoarthritis if your joints are very painful or if you need
extra pain relief for a time. A local injection of steroids can reduce inflammation, which in turn
should reduce pain.
◦
3) Physiotherapy
 A structured exercise plan with a physiotherapist can be really beneficial. It can improve the
mobility of your joints and can help with management of the pain.
4) Surgery
 In a small number of cases, where these treatments haven't helped or the damage to the joints is
particularly severe, surgery may be done to repair, strengthen or replace a damaged joint.
5) Assisted Mobility
 Currently, you don’t seem to be having any problems with your mobility, so I would not
recommend you any assisted mobility devices such as a walking stick or Z-frame. However if
things do worsen, they are an alternative to reduce stress on the affected joint, relieve pain and
give it some rest.
6) Posture
 It can also help to maintain good posture at all times and avoid staying in the same position for too
long. If you work at a desk, make sure your chair is at the correct height, and take regular breaks
to move around.
7) Taking your Medicine

 It's important to take your medicine as prescribed, even if you start to feel better.
 Continuous medicine can sometimes help prevent pain, although if your medicines have been
prescribed "as required", you may not need to take them in between painful episodes.
 If you have any questions or concerns about the medicine you're taking or any side effects you
think you may be experiencing, talk to your healthcare team.
 It may also be useful to read the information leaflet that comes with the medicine, which will tell
you about possible interactions with other drugs or supplements.
 Check with your healthcare team if you plan to take any over-the-counter remedies, such as
painkillers, or any nutritional supplements, as these can sometimes interfere with your medicine.
8) Regular Reviews
 Because osteoarthritis is a long-term condition, you'll be in regular contact with your healthcare
team.
 Having a good relationship with the team means you can easily discuss your symptoms or
concerns.
 The more the team know, the more they can help you.
 We can arrange a follow-up in 2 weeks’ time.
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9) Vaccinations
 People with long-term conditions such as osteoarthritis may be encouraged to get an annual flu jab
each autumn to protect against flu.
 You may also be advised to get a pneumococcal vaccination.
 This is a one-off injection that protects against a serious chest infection called pneumococcal
pneumonia.
10) Talking Therapy & Support Groups

 Some people may find it helpful to talk to their GP or others who are living with osteoarthritis,
as there may be questions or worries you want to share.
 Many people find it helpful to talk to other people who are in a similar position to them.
 You may find support from a group or by talking individually to someone who has osteoarthritis.
 There are also various support groups available that can help you reduce weight.
 I can give you more information on that if you’d like? – YES Please
 You can find the nearest weight loss support group by putting your post-code on the NHS website,
and they’ll locate the closest group to where you are.
 The Versus Arthritis helpline is open Monday to Friday, 9am to 8pm. You can call free on 0800
5200 520. You can also email them at helpline@versusarthritis.org
 Versus Arthritis also have an online forum where you can communicate with other people who
have osteoarthritis.
11) Work and Money

 If you have severe osteoarthritis and are still working, your symptoms may interfere with your
working life and may affect your ability to do your job.
 If you have to stop work or work part time because of your arthritis, you may find it hard to cope
financially.
 You may be entitled to 1 or more of the following types of financial support:
o if you have a job but cannot work because of your illness, you're entitled Statutory Sick Pay from your
employer
o if you do not have a job and cannot work because of your illness, you may be entitled to Employment
and Support Allowance
o if you're aged 64 or under and need help with personal care or have walking difficulties, you may be
eligible for the Personal Independence Payment
o if you're aged 65 or over, you may be able to get Attendance Allowance
o if you're caring for someone with rheumatoid arthritis, you may be entitled to Carer’s Allowance
 You may be eligible for other benefits if you have children living at home or a low household income.
 If however your symptoms worsen, and your unable to mobilise your joints then do come back to us. If you
experience a fall, find yourself unable to bear weight or walk properly – do come back to us again.
Alternatively, in an emergency situation you can call an ambulance at 999 or visit the A&E.
 I would like to consult my seniors if I missed anything, or was unable to answer any of your questions so I
can get back to you with the appropriate information
 I do have some reading material available about the condition that’s affecting you, called Osteoarthritis.
 Is there anything else I can help you with? – No
 Is there anything in particular you were expecting to get out of this consultation? – No
Great, so thank-you for coming in today. We will see you in a fortnight

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CONCERNED ABOUT MENINGITIS
CONSULTATION
1. GRIPS [Greet, Rapport, Introduce, Posture, Smile] – How can we help you?
2. PC + SR – concerned about meningitis  EXPLORE;
 Doctor, I’m really worried I might get meningitis.

 Is there any particular reason why you’re worried about meningitis?
 My nephew Alex is only 3 months old, and he’s been diagnosed with meningitis.
 My sister was given pro prophyc something like that antibiotics and I’m worried I might get
meningitis because Alex has it. I also work in a nursery, and I’m scared I might get one of the
children ill.
4. Can you please prescribe me antibiotics?

Oh, I’m really sorry to hear about your nephew and I’m sure we can help you with that.
 how is he doing?
 He’s still a bit poorly
 Whereis Alex now?
 He has been admitted to the children’s ward.
 When was he diagnosed?
 Yesterday
 What symptoms did he have?
 He had a fever and a rash all over his body, and he kept crying.
 And what about your sister, is she alright?
 Yes, she’s just worried sick
 Did she have any symptoms?
 She was beginning to run a temperature
 Do you live together?
 No
 Who else is at home/who else has been affected?
 No-one else, Alex’s dad is on a business trip abroad.
 When did you last have contact with Alex and his mum?
 I haven’t seen them in 2 months
 Is there anything else you would like to add?
5. My sister got ‘prophylactic’ antibiotics. Do I need them too?

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Well, I’d like to ask you a few more questions and then I’d be in a better position to help you, is
that alright?
 How are you feeling? Fever? Headache? Photophobia? Neck stiffness? Nausea?
Vomiting? Muscle aches? Rash? Seizures? Drowziness/Confusion?
 No symptoms – NO fever/headache/rash/neck pain/photophobia/vomiting/seizures. Feeling
healthy.
3. Risk Factors
 Did you come into contact with him?
 No, I haven’t seen him since he was a month old
 Any coughing/sneezing/kissing?
 No Doctor
 Are you up to date with your vaccinations?
 Yes, doctor, I’m fully up to date, I’ve had the MenB/MenC/MenACWY/PCV/Hib done
 Any sharing of utensils, cutlery and toothbrushes?
 No doctor, we don’t live together
4. 3PMAFTOSA
Vitals
5. Ex
CNS (Upper + Lower)
Head& Neck (Neck Rigidity/Kernig/Brudzinski)
Skin - Rash
EXAMINER’S PROMPT: ALL

EXAMINATION FINDINGS ARE NORMAL
6. FINDINGS & Dx– From what you’ve told me and from what I’ve examined, you don’t seem
to be showing any signs or symptoms of meningitis, such as; Fever/Headache/Photophobia/
Neck stiffness/Nausea/Vomiting/Muscle aches/Rash/ Seizures/ Drowzy/Confusion.
 So can you tell me, do you know anything about meningitis?

 I don’t know what meningitis is
 Meningitis is the inflammation of the layers surrounding the brain and spinal cord.
6. Is meningitis serious?
 It can be a potentially serious condition that affects the brain and nerves if not treated quickly.
 It can affect anyone, but more commonly it is babies, children and young adults who are
affected the most.
CHUNK + CHECK … Do you follow me?

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 It is an airborne disease, so transmission mainly occurs through close contact via

sneezing/coughing/kissing.
 It can be caused by bacteria but more often it is a virus that is the causative organism.
 A number of vaccinations are available that prevent meningitis and sometimes we give
‘prophylaxis’.
7. What do you mean by ‘prophylaxis’?

9. Prophylaxis just means giving treatment in order to prevent an illness.
8. So why was my sister given antibiotics and not I? Why don’t I need
antibiotics?
10. Well, from what you’ve told me, your sister has been in direct contact with Alex – and you
have not. She has a greater risk of getting the infection. She’s also begun experiencing some
symptoms like fever. Meningitis is a contagious infection and it can spread due to close contact. The
period between exposure to an infection and the appearance of the first symptoms is called the
incubation period. The illness can spread during this time, and sometimes up to 14 days to a month
after the onset of symptoms.
9. Will I get meningitis?Am I at risk of getting meningitis?

11. From what you’ve told me, you haven’t had contact with Alex, you have been vaccinated and
you are not experiencing any symptoms. It is therefore highly unlikely that you will get meningitis.
However, the risk is not completely eliminated, as there are lots of other harmful bugs that can cause
meningitis, like Fungi, Tuberculosis and Herpes Virus.
10. How will I know if I have it?

12. The most common symptoms and red flags to look out for are Fever/Headache/Photophobia/
Neck stiffness/Nausea/Vomiting/Muscle aches/Non-blanching Rash/ Seizures/ Drowziness
&Confusion. If you do experience any of these, we can arrange a follow-up, and if your health really
deteriorates then do call 999 for an ambulance and visit the emergency department immediately.
11. Will the vaccines be helpful?

13. Of course, the vaccines will give a certain degree of protection. However, meningitis can be
caused by other bugs.
12. What will happen if I get prophylactic antibiotics?

14. Unfortunately, antibiotics do have minor and major side effects.
15. Minor side effects include nausea, vomiting and diarrhoea and abdominal pain and cramps.
16. Major side effects can include a severe drug allergy and resistance to the antibiotic drug. A
condition called pseudomembranous colitis has also been associated with inappropriate use of
antibiotics, where the normal flora of your gut is accidentally destroyed and replaced with non-
friendly bugs.
17.
 I would like to reassure you that it’s highly unlikely for you to get meningitis from what
you’ve told me.
 I would like to review your vaccination records in greater detail.

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 I would also like to point you towards the Occupational Health Department, who would better
advise if you need to make an modifications in your working environment or lifestyle as a
Nursery Manager.
 The most common symptoms and red flags to look out for are: Fever/Headache/Photophobia/
Neck stiffness/Nausea/Vomiting/Muscle aches/Non-blanching Rash/ Seizures/ Drowziness &
Confusion. If you do experience any of these, we can arrange a follow-up, and if your health
really deteriorates then do call 999 for an ambulance and visit the emergency department
immediately.
 If there is anything I’ve missed or unable to answer I will consult with my seniors and get back
to you.
 I have some reading material available here for you to review, about Meningitis and
Vaccinations.
Do you have any other concerns?
Is there anything in particular you were expecting to get out of this consultation? Thanks.
Prophylaxis
The risk of someone with meningitis spreading the infection to others is generally low.
But if someone is thought to be at high risk of infection, they may be given a dose of antibiotics as a
precautionary measure.
This may include anyone who's been in prolonged close contact with someone who developed
meningitis, such as:
 people living in the same house
 pupils sharing a dormitory
 university students sharing a hall of residence
 a boyfriend or girlfriend

People who have only had brief contact with someone who developed meningitis will not usually need
to take antibiotics.
Deterrence and prevention of meningococcal meningitis can be achieved by either
immunoprophylaxis or chemoprophylaxis.
Person-to-person transmission can be interrupted by chemoprophylaxis, which eradicates the
asymptomatic nasopharyngeal carrier state.Rifampin, quinolones, and ceftriaxone are the
antimicrobials that are used to eradicate meningococci from the nasopharynx.
Vaccination is used for immunoprophylaxis for close contacts of patients with meningococcal disease
due to A, C, Y, or W135 serogroups, to prevent secondary cases.Current meningococcal vaccines are
indicated for active immunization to prevent invasive meningococcal disease caused by Neisseria
meningitidis.
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1. PRIMARY SURVEY:
Look for immediately life threatening and limb threatening injuries in the order of priority,
manage them and stabilize the patient.
PRIMARY SURVEY:
A Airway with Cervical Stabilization
B Breathing With Ventilation
C Circulation with Control of haemorrhage
D Disability
E Exposure
AIRWAY:
If the patient is able to speak in a normal speech there can’t be any obstruction in their airway.
Cervical Stabilization:
Assume all the major trauma victims to be having neck injury and stabilize their neck to prevent any
cord injury happening, if it is not already injured.
Two ways to stabilize 1 ) Manual inline immobilization, 2) Triple immobilization
Give High flow oxygen
BREATHING:
1. Tension Pneumothorax:
Signs & Symptoms: Breathless, Engorged Neck Veins, Trachea Shifted To Opposite
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Slide, Decreased Chest, Wall Movement,

Hyper-Resonance, Absent Breath Sound,
Tachycardia, Hypotension, Hypoxia.
Management:
Emergency Needle Thoracocentest to decompress the chest
Insert wide bore needle in the 2nd intercostal space, mid clavicular line on the affected side and leave
the cannula in situ. Listen for hissing sound of gush of air coming out. Then reassess.
Definitive Management:
Intercostal chest drain in the 5th intercostal space which is connected to the underwater sealed bottle.
2) Open Pneumothorax
Signs & Symptoms: Breathlessness, no engorged neck veins or tracheal shift, decreased chest
wall movement, open wound over the chest, hyper-resonance, diminished breath sounds.
Management
Cover the wound with a bandage which is stuck on three sides only which allows the air to escape out,
but prevents air getting sucked in.
Definitive Management:
Intercostal Chest Drain
3) Massive Heamothorax
Has double problem: Blood Loss and Lung Compression
Signs & Symptoms

Decreased level of consciousness, pallor, cold periphery,
Breathlessness, tracheal shift, collapsed neck veins,
Decreased chest wall movement, bruises, dullness on percussion, absent or diminished breath sounds.
Management
Resuscitate; Oxygen, IV Access, Blood Testing, IV Fluids, Chest Drain, Thoracotomy and repairing
of all the damages.
4) Cardiac Tamponade
Can die of reduced cardiac output
Signs & Symptoms
Decreased level of consciousness, cold peripheries,
Becks’ triad- engorged neck veins, hypotension, muffled heart sounds.
Management: Oxygen, IV Access, Maintenance fluid, Attach Cardiac Monitor, Defibrillator should
be available
Pericardiocentesis by seniors
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3). Flail Chest

Fracture of two or more ribs at two or more sites.
Causes pulmonary contusion causing hypoxia.
Pain – shallow breathing –hypoxia.
May have associated injuries like pneumothorax or heamothorax.
Management
Oxygen, analgesics, fluid resuscitation, strapping the segment, IPPV
CIRCULATION:
External Bleeding:
Direct Pressure Bandage, IV fluids if required and wound repair.
Internal Bleeding
Chest, Abdomen, Pelvis and Thigh
Intra Abdominal Bleeding-

Signs and Symptoms
Distension, bruises, wounds, tenderness, rigidity, guarding, flank dullness, absent or sluggish bowel
sounds.
Management
Resuscitate
Call for surgeons and make arrangements to shift the patient to theatre for urgent laparatomy.
Pelvic Fracture
Signs and symptoms
Bruises, pelvic deformity, blood at the external urethral meatus, scrotal or perineal heamatoma
Spring test
Spring test can dislodge clot or rupture more pelvic vessels causing more bleeding - so do it only if
necessary to do it.
Management
Resuscitate
Apply pelvic strapping, call for Orthopeadicians for external pelvic fixators and for further
management.
THIGH; fracture of shaft of femur can cause internal bleeding up to about 2 liters on one side itself.
Signs and Symptoms

LOOK – swelling, bruises, deformity.
FEEL – distal pulses
MOVE- Do not try to move if there is a swelling seen over the thigh also do not try to move his legs
if he had pain on his pelvis( ie –if spring test was positive).
Management
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Resuscitate, Thomas splint, call for Orthopeadicians for further management.

Look for swelling or deformity in any other part of the limbs, and if any check distal pulse
DISABILITY :
Check level of consciousness ( GCS )
Also check the pupils
Look for head injury signs – swelling, lacerations or bruise on head and forehead.
Check the sugar
EXPOSURE: expose the patient completely but keep him covered with warm blankets to prevent
hypothermia.
ADJUNCTS IN PRIMARY SURVEY:
1) MONITORS:Cardiac Monitor
2) PRIMARY SERIES OF X RAYS
A) Chest X Ray
B) Pelvic X Ray
3) TUBES
A) Nasogastric tube
B) Urinary catheter
(Urethral catheter if no urethral injury and Supra Public Cystostomy if
Urethral injury)
3 things to assume in a patient met with high velocity trauma
1) Neck injury
2) Hypoxia
3) Hypovolemia
PRIMARY SURVEY ( Initial assessment after trauma)
You are the FY 2 doctor in the A& E department.

Mr Robinsonis a 30 year old man fell from 2 meter height onto concrete floor from a
building while painting the building about half an hour ago. He was brought into the
hospital A&E Department.
His pulse is 100/min and BP is 90/40.

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Do the systematic assessment for trauma. Stop the assessment at 6th min bell and discuss
the further management with the examiner.
Greet the examiner.

Tell the examiner – I assume I have taken all Universal precautions (gloves, gown and
goggles) and I will call the Trauma team.
Airway
Patient lying down with collar.
Check response. Hello Mr Robinson, I am Dr… one of the junior doctor in the A&E
department. I am here to examine you. Is that OK ?
Patient - OK.
Tell the examiner –Since he is speaking - he is conscious and airway is patent.
His neck is already stabilized with collar. I will give him high flow oxygen.
Mr Robinson – can please tell me what happened?

Pt: I fell from a building while painting.
Dr – Do you have any pain anywhere at all?
Pt: Yes/ No .
Tell the patient about the exposure - Mr Robinson, I need to examine now, for that we
need to undress you by cutting all the clothes. I will ensure privacy and have chaperone
with me. Is that OK ? Pt – OK doctor.
Ask the examiner – what shall I do ? Examiner says – assume he is exposed.
Breathing
Inspection – I will check for Breathlessness,

Neck – I will check for engorged neck veins, tracheal shift.
Chest – Bruises, open wound, flail chest, asymmetry of movement.
Palpation – Expansion is equal
Percussion – I will check for hyper resonance or dullness.
Auscultation- I will check for absent or diminished breath sounds and muffled heart
sounds.
If nothing, I assume the chest is fine.
Circulation
There are no signs of external bleeding

I will check for pallor and cold peripheries.
Pulse and BP (check the monitor, or NEWS chart – mention the reading to the
examiner. If there is no monitor or NEWS chart then ask the examiner for the vital
signs)
Check for internal Bleeding--

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Abdomen-: Inspection - bruises, distension, wounds,

Palpation – Tenderness, rigidity, Guarding
Percussion- Flank dullness
Auscultation – Sluggish or absent bowel sounds
If no signs – I assume the abdomen is fine.
Pelvis: Inspection – I will check for bruises, deformity, scrotal or perineal hematoma or
blood at the external urethral meatus.
Then do the spring test - First warn the patient - I will be pressing your hips and if it
hurts please let me know. Gently press on his pelvis either trying to open it or to close it.
If no signs – Pelvis is fine.
In the exam if they keep Pelvic fracture as the diagnosis patient will scream with pain.
Tell the patient - I am sorry to hurt you.
Thigh - Inspection – There are no bruises, swelling and deformity

Palpation – I will check distal pulses.
Movement – Do not check.
If there is no swelling of the thigh – I assume there is no fracture femur both sides.
Disability
Do the GCS. Use the GCS chart on the wall. GCS may be 15.
I will check for head injury signs like swelling laceration and any bruises on head and
forehead. Any bleeding from nose and ears.
Check the pupils – pupils are equal in size and reacting to light.
I will check the sugar
Exposure
I will cover him with warm blankets to prevent hypothermia
I will tell the nurses to arrange for Chest and Pelvic X Rays.
Tubes
I will insert urinary catheter and Nasogastric tube.
Once he is stable I will do secondary survey.
Thank the patient and the Examiner.
At 6th min – stop the assessment if you have completed and discuss further management
with the examiner
Tell you diagnosis and management – Fracture pelvis, or fracture pelvis and intra
abdominal bleeding.
I will send the blood testing (FBC, U/E, Group and X-match 4 units, sugar,ABG,
clotting screen)
I will give him IV Fluids - 2 litres of warm Hartman’s solution. ( One litre fast ( within
10 min) next one litre in the next one hour). – arrange blood transfusion immediately –
may be O negative then cross matched blood.
I will stabilize the pelvis with pelvic strapping and inform the Orthopaedicians for
external pelvic fixator and for further management.
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If signs of intra - abdominal bleeding – I think he has intra - abdominal bleeding, I will
resuscitate, inform the surgeons and shift him to the theatre for urgent laparotomy.
If there is swelling of thigh – I can see swelling of thigh, I will check distal pulse, I think
he has fracture femur, I will resuscitate, apply Thomas splint, and inform
Orthopaedicians for further management.
ATLS [Primary and secondary survey]

Question :-
A man was found lying on the pavement. He has been brought into the hospital by the
ambulance.
You are the FY2 doctor in the A& E department. Your Consultant and registrars are busy.
A&E nurse has taken the hand over from the Ambulance who brought him in. Nurse is
with the patient in the resuscitation room. She has checked his vitals and inserted IV
cannula. She has checked his blood sugar which is 5.7 mmols.
Assess the patient and discuss your findings and the management with the examiner.
Greet the examiner and tell him “ I assume I have taken all the universal precautions
Talk to the nurse – Hello I am Dr ..What is your name?
Nurse: I am Sarah Doctor.
Dr: Hello Sarah can you please tell me what happened ?
Nurse : We have a 30 year man Mr….met with trauma was found on the pavement by the
ambulance and they brought him in just now.
Dr: Do you know his vitals.
Nurse: Yes his BP is 130/80 and his pulse is 85.
Dr: OK, I can see on the monitor his O2 is 96 %. (Give O2 - if saturation is low). Resp
Rate – 18/min. Patient is already on collar. Sarah – Can you please call the trauma team.
Talk to the patient
“Hello Mr … , Are you OK” – ( He may make some incomprehensible sounds).
Tell the examiner – since he is making sound his airway is patent.
He is breathing and respiratory rate is 18/min
Dr: Sarah we need to cut all his clothes – do we have scissor ( examiner may say – assume
he is exposed)
Examine for breathing :
He is not breathless, No neck vein engorgement or tracheal shift.
Chest examination :
Inspection –I will check for bruises, open wounds any flail segments on the chest.
Palpation : Expansion is equal.
Percussion : No hyper resonance or dullness.
Auscultation: No absent or diminished breath sounds or muffled heart sounds.
I assume the chest is fine.
Check for external and internal bleeding
No signs of any external bleeding.
Examine the abdomen:
Inspection : No distension, bruises or open wounds.
Palpation – No tenderness and rigidity or guarding.
Percussion – No flank dullness
Auscultation – No absent or sluggish bowel sounds.
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I assume the abdomen is fine.

Examine the pelvis:
I will check the pelvis for bruises, deformity and for any blood in the external urethral
meatus.
Do Spring test – if patient did not show signs of tenderness – I assume the pelvis is fine.
Examine the thighs:
There are no swellings or deformities on both the thighs. I assume there is no femur
fracture.
Disability
Dr: Sarah, what is his blood sugar?
Nurse : It is 5.7 mmols doc.
Check conscious level with GCS – patient is responsive to the verbal stimulus. Tell the
score to the examiner.
Check the pupils with torch – both pupils are equal in size and reacting to light.
I will check the head for injuries – There are no swellings or lacerations on the head but I
can see bruise on the left side forehead.
There are no bleeding or CSF leakage in the ears and nose.
Do quick neurological examination.
I can’t do sensory and motor because he is not conscious.
Reflexes are normal in all 4 limbs including plantar reflex.
I will log roll the patient with the help of 3 other people and examine the back for any
injuries, any spinal injuries, I will do per rectal examination.
Dr: Thank you. Can you please send his blood for group and cross match, FBC and U&E.
Can you also ask the radiographer to do chest and pelvic X Rays.
I will insert NG tube and urinary catheter.
Talk to the examiner - I think he has head injury because he has low conscious level and
has bruise on the forehead.
I will inform the seniors immediately and start with IV fluids and arrange CT scan of his
head. Will consider giving Mannitol after consulting seniors.
Patient may need surgery if he has intracranial bleeding. I will inform the Neurosurgeon.
I will do the secondary survey one he is stable.

Since he is not conscious I cannot take history.
( If patient is responding take brief history
What happened, when happened, Any pain anywhere? Any medical conditions, Any
medications, Any allergies? When did you eat or drink last?)
Head to toe examination.
No swelling lacerations on head. Bruise is present on the left side fore head.
Eyes appears fine.
There are no swelling bruises on cheeks or jaws.
I will examine thoroughly for any injuries over neck, chest, abdomen and pelvis again.
There are no swellings or deformities in the upper limbs. Radial pulse is present both sides.
There are no swellings or deformities in the lower limbs. Dorsalis pedis pulse is present
both the sides.
I will remove the collar if there are no signs of neck injury.I will cover the patient.
I will keep monitoring the patient until the trauma team arrives.
Thank you Sarah. Thank the examiner.
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Thyroid Examination
( you tube - www.youtube.com/watch?v=ziaYBkgEZNU )
Position: Sitting
Inspection:
Hands:
 No Dryness (hypothyroid) or Sweatiness (Hyperthyroid)

 No Clubbing
 No Palmar Erythema (Hyperthyroid)
 No Tremor: Ask patient to outstretch arms and place a paper on back of hands and
observe the tremor. (Hyperthyroid)
 Pulse: Tachycardia (Hyper), Bradycardia (hypo), Irregular- AF (Hyper) check the
NEWS chart if present – if not ask for it.
Eyes:
 Exopthalmos (Inspect from front and side)

 Lid lag: Ask patient to look at your moving finger without moving head. Move it
from upper to lower part of visual field and note for delay in descent of upper
eyelid to that of eyeball.
 Lid retraction: It is present if sclera is visible above the iris.
Thyroid:
Inspect the midline of neck: Ask patient to move chin up a bit. Comment on:
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 Swelling
 Skin changes
 Scar
Swallow Test:
 Ask patient to swallow some water.

 Observe any movement of mass. Most swellings move upwards on swallowing.
Tongue Protrusion:
 Look at neck and ask patient to bring out the tongue.

 Thryoglossal cysts will move upwards.
Palpation:
 Inform patient that you are going to feel neck from behind.
 Stand behind the patient and ask patient to bend neck. (To relax the
sternocleidomastoid muscle)
 Place your hands on either side of neck.
Thyroid:
 Place 3 fingers along the midline of neck below the chin and slide downwards until
the area of thyroid gland, which is just located below the thyroid cartilage.
 With 1 hand fix one side of thyroid and palpate the other side with help of 3 fingers.
Do same on the other side.
 Feel for the gland and ask patient to swallow some more water and feel for any
swelling moving with your hands.
 Verbalise that there is no abnormality noted.

Lymph Nodes:
Check all groups of lymph nodes
i. Submental
ii. Submandibular
iii. Anterior cervical chain (Tonsillar and deep cervical lymph nodes)
iv. Posterior cervical chain
v. Pre auricular
vi. Post auricular
vii. Occipital
viii. Supraclavicular
Percussion:
 Percuss down starting from sternal notch to listen for retrosternal dullness.
Auscultation:
 Auscultate both lobes of thyroid. (Thyroid bruit in Grave’s disease)
Pretibial myxoedema:
 Ask patient to roll up trouser.

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 Note for the raised, discoloured appearance over legs.
Upper limb reflexes: Biceps, triceps and supinator.
Thank the patient.

Mrs.. With the information you have given me and after the examination everything looks
normal. However we need to do blood tests to check Thyroid function. ( examiner may not
give results).
I will let you know once we get the blood results.
Do you have any concerns ? No
You are doing fine now. Usually we give medications for about 18 months and stop it if
everything is fine. You may be able to continue the medication with the same dose.
I will discuss with my seniors about you and get back to you.

[ If patient is already on Carbimazole for 18 months - We need to consider stopping the
Carbimazole as you may not need it any more – I will discuss with my seniors and get back to
you about it ].
Whiplash injury
Information.
This is a soft tissue injury in the back of the neck due excessive movement of
the neck (eg - in Road traffic accidents) which causes stretching of muscles
and ligaments in the back of the neck. There is no bony injury or spinal cord
injury.
Symptoms usually appear after few hours or may the next day. Symptoms are
pain in the back of the neck and stiffness of the neck which usually lasts about
2 to 3 weeks and subsides on their own.
Other symptoms: Headache, Pain in shoulders and arms, dizziness, Blurred
vision, pins and needles in arms, memory loss, irritability.
Treatment – Analgesics, neck exercise and ice compressions. If they do not
subside in 2 to 3 weeks time then - Physiotherapy.
Advise them not to drive until pain and stiffness subsides.
In some people symptoms can lasts for few months.
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Neck Injury
Differentials – Whiplash injury, Stable fracture of the cervical vertebra, Radiculopathy
( root compression – causes tingling numbness in hands).
Question
30 year old Mr Morrison met with a road traffic accident 2 hours ago. He came to the
hospital now complaining of pain and stiffness in his neck. Take a brief history and do the
necessary examination and discuss the further management with the patient.
Patient may be sitting on the chair or couch.
History :
Dr: How can I help you ?
Pt : I met with the road accident about 2 hours ago. Now I have pain in my neck.
Dr. I a sorry to hear about the accident. Can you please tell me more about the accident ?
Pt: I was driving my car. Another car hit the back of my car.
Dr: What happened after that ?
Pt: I was fine initially. I went to the office then I started to have pain in my neck.
Dr: Where in the neck you have this pain? –Pt: Back of the neck.
Dr: Since when? Pt: There was no pain immediately after the accident but then I went to
the office I started to have pain - almost one hour now.
Dr: Does the pain go anywhere from the neck ? Pt: No
Dr: Anything else? – My neck is stiff. Since when?- Pt: Since the last one hour.
Dr: Anything else? – Like what doctor?
Dr : Do you have headache? Pt : No Dr Any dizziness ? Pt : No
Dr: Any problem in your vision? Pt : No
Dr: Any tingling or numbness in your hands? – Pt: No
Dr: Any problem in the neck before this accident? – Pt: No
Dr: where there anyone else in the car ? Anyone else had serious injuries?
Pt : No ( sometimes he may say driver was driving the car but he is fine).
Examination :
I need to examine you now. [ patient may be adequately exposed. If not mention about the
exposure. Can you please undress above the waist ? Pt - Ok. Patient may then remove the
shirt]
Inspection of the neck :
Look all around the neck ( front sides and back)
No swelling, no bruise or wounds around the neck. No neck deformity.
Palpation : I’m going to feel the back of your neck over the spine with my thumb. Please
tell me if it hurts. Just say yes or no but do not move your head too much. – Pt: Ok Doctor.
Then check for tenderness over the cervical spine up to about 2nd thoracic vertebra : (there
may or may not be any tenderness over the spine)
Then check for tenderness over both the para-spinal areas : ( Usually there is tenderness
there).
Then do neurological examination. –
Sensory – fine touch (with wisp of cotton) on both the upper limbs.
Then check for pain sensation with neuropin : [No sensory loss].
C4 – top of shoulder, C5 – Outer aspect of upper arm, C6 – outer aspect of hand ( thumb
area), C7 – middle finger, C8 – Little finger, T1 – Medial aspect of elbow.
Check the vibration sensation and Joint position.
Motor – C5- Shoulder abduction and Elbow flexion, C6 - Elbow flexion and wrist
extension, C7 – Elbow extension and wrist flexion and finger extension, C8 – finger
flexion, T1 – Finger abduction ----- No motor deficits.
Check reflexes in upper limbs : Biceps reflex ( C5), Brachioradialis reflex ( C6), Triceps
reflex (C7). --- Normal
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No need to do neck X Rays if there is no bony tenderness.

If there is bony tenderness - Tell the examiner I will make him lie down and stabilize his
neck and send him for X rays of his neck. Can I know the X-ray result please ?
( Examiner may say – X Ray – normal )
I will remove his collar and check for neck movements.
Ask the patient - Please turn your head to right, left, up and down and both sides- flexion
movements. Movements are restricted ( whichever direction). Thank you.
Management with the patient : You have a condition what we call us whiplash injury. It
is due to sudden stretching of muscles and ligaments at the back of your neck which
happens due to excessive movements of the neck during the accident. Usually there is
tearing of muscles and ligaments at the back of the neck. But you do not have any serious
problems like fracture or spinal cord injuries.
The symptoms of whiplash injuries – that is pain and stiffness will subside on their own in
about 2 to 3 weeks.
Please take pain killers like Paracetamol and keep doing some neck exercises until then.
Sometimes it can last for months. If it does not subside in 2 to 3 weeks we will arrange
physiotherapy. Is it Ok? Any questions.
Pt: Can you please give me a collar to the neck
Dr: We used to give collar previously but we found out that the collar will only worsen the
stiffness of your neck. So nowadays we do not give collar. It is better that you keep moving
your neck.
Pt; Can I drive doctor?
Dr: It is better not to drive until your pain and stiffness in your neck subsides.
Pt; Why did I get pain in my neck after few hours not immediately?
Dr: This is what usually happens in whiplash injury because it takes some time for the
inflammation ( soreness) to start and then it becomes painful.
Brachial plexus injury

38 year old Mrs Sharon ... had Road Traffic Accident one year ago. She had brachial
plexus injury. She wants to go back to her work. Assess her condition to check whether
she is fit to go back to work. At 6th min bell examiner will ask you questions.
Dr: Hello Mrs Sharon .. I am Dr.... one of the Junior doctor in the ... department. How can I
help you ?
Pt: Doctor I met with a road traffic accident one year ago. Had injury to Brachial plexus on
my right side. I was undergoing physiotherapy for that. I was not working all this time since
the accident. I want to know whether I can go back to work now ?
Dr: First of all I am very sorry to hear about the accident and the injury you had. You said
you had brachial plexus injury – do you know what type of injury was that – were the nerves
cut or was the nerves just got stretched ? Pt: I do not know.
Dr: Were you told that you had any fracture in the neck bones or any disc prolapsed in the
neck? Pt: No /Yes
Dr: Ok. Did you have any wounds over the neck ? Pt: No
Dr: Ok, May I know what is your job ?
Pt: I work as engineer at Royal Air Forse ( RAF). My work involves tightening screws
P a g e | 656
( rotational movements at wrist)

Dr: Did you have any problem working on computer or any other type of work before you
had this accident ?
Pt: No doctor. I was perfectly fine. I could do all the jobs properly.
Dr: May I know what functions in the hand you could not do after the accident ?
Pt: Doctor I could not do ......
Dr: Have you tried doing those jobs now ?
Pt: Yes, I can do all those now. Can I go back to work ?
Dr: Let me assess you completely and then I will tell you if that is OK with you ? Pt: Ok
Dr: Are you able to write with a pen on paper ? Pt: Yes I can now.
Dr: Are you able to eat food with a spoon? Pt: Yes
Dr: Do you feel hot and cold sensations in your hands ? Pt: Yes
Dr: Do you have any other medical conditions ? Pt: No
Dr: Are you on any medications ? Pt: No
Dr: Mrs Sharon .. I need to examine your neck and hands now Is that OK? Could you please
undress those area. Pt: Yes doctor
Examination
Inspection of neck.
No scars over the neck, No deformity or swellings.
Do the upper limb neurological examination.

Sensory - fine touch and pain.
Check Joint position and vibration
Check power – C 5 – shoulder abduction, C6 – elbow flexion, C7 – elbow extension. C8 –
finger extension, T1 – finger abduction.
Check the grip – ask the patient to hold your 2 fingers tight and you try to pull that out.
Ask the patient to touch his thumb to tips of other fingers in the same hand.
Check the typing action movement of fingers.
Check reflexes
Everything will be normal or there may be weakness.
Dr: Thank you Mrs Sharon ...
Talk to the examiner

I would to talk to the physiotherapist and the Occupational therapist and seniors and take
their opinion about this. We may need to do nerve conduction studies. However, so far with
the information what Mrs Sharon gave me and with the examination findings which were are
normal, I think she is fit to go back to work / she still has weakness – so she is not fit to go
back to work. She may need to continue Physiotherapy.
2548 Videoavailable
MMR
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Information:
The MMR vaccine is an injection that prevents you from catching measles, mumps and
rubella.
It’s usually given during childhood as part of the routine vaccination schedule. However,
you can have the MMR vaccine at any age.
MEASLES is a very contagious infection and may cause complications such as diarrahea,
ear infections, pneumonia.
MUMPS is also a contagious infection. It may cause complications such as meningitis and
deafness. In boys, it may damage the testicles and in girls, it may cause swelling of the
ovaries.
RUBELLA (German measles) is usually a mid-infection; however, it can be harmful to
pregnant women. It may cause deafness, brain and heart damage, and eye defect in unborn
babies.
OTHER FACTS
 The MMR vaccine consists of a combination of three individual vaccine against
measles, mumps and rubella in a single shot. The three vaccine combined inMMR
are not available as single vaccine on theNHS.
 This is because the NHS does not recommend single measles, mumps orrubella
vaccines as there is no evidence to support their use or to suggest that they are
“safer” thanMMR.
 World Health organization support the use of MMR, and none support the use of
singlevaccines.
 Be aware, though, that MMR is a ‘live’ single vaccine, they will have to waitat
least four weeks until they can have the MMRvaccines.
 Child may develops a mild symptoms of measles [post-vaccination symptoms]
after receiving their MMR vaccine, post-vaccination symptoms are not infectious,
so your child will not pass anything on to non-vaccinatedchildren.
 To get the best protection children should be vaccinated with the MMR vaccineat
the scheduled times-between 12 and 13 months of age and again at 3 years 4
months.
WHY MMR GIVEN AFTER 1 YEAR OLD?

Newborn babies are already protected against several diseases such as measles, mumps
and rubella, because antibodies have passed into them from their mothers via the placenta.
This is called “passive immunity”. Passive immunity only lasts for a few weeks ormonths,
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which is why the MMR jab is given to children’s just after their first birthday.
MMR – exam question
You are the FY 2 doctor in the Paediatric department.

Rachel 13 month old child is scheduled for the MMR Vaccine next week.
Her mother Mrs Jennifer Anderson has some concerns about the MMR vaccine.
Talk to her and address her concerns.
Hello I am Dr.... one of the junior doctor in the Paediatric department.

Dr: Are you Mrs jennifer Anderson ? Mother :Yes.
Dr: Are you the mother of Rachel Anderson ? Mother :Yes
Dr: How areyoudoing? Mother: I am finedoctor.
Dr: How can I help you Mrs Anderson ?
Mother: I was told that my daughter has to have a MMR vaccine next week. I am
concerned about it.
Dr: May I know what are you concerned about?
Mother: I heard MMR vaccine causes Autism.
Dr: First of all I am very glad that you came to us with your concerns.
 Yes it was true that such an article was written by one of the PaediatricConsultant
long time ago. He was found to havemisconducts.
 But then the article published was proven to be wrong and publisherswithdrawn.
 There are many study done after that and all shows it issafe.
 The million peoples taking this vaccine around the world and they do not have any
problem.
 MMR is given around 15 months of age and this is the same age around which
autism is diagnosed so there was a fake impression that autism is caused byMMR.
Mother: But why do you want to give the MMR vaccination because those diseases are not
in UK anymore!
Dr: The reason these illnesses are not seen in the UK is because we give this vaccination to almost every one
here in UK. If we stopped giving this vaccination these illnesses would reappear in the UK.
 Also Your child may come into contact with a foreigner who has entered the UK
and is infected with Measles, Mumps or Rubella and your child may get the
infections fromthem.
 These infections are dangerous if at all your child gets this infections-
MEASLES is a very contagious infection and may cause complications such as diarrhoea,
P a g e | 659
ear infections, pneumonia.

MUMPS is also a contagious infection. It may cause complications such as meningitis and
deafness. In girls, it may cause swelling of the ovaries. In boys, it may damage the
testicles.
RUBELLA (German measles) is usually a mid-infection; however, it can be harmful to
pregnant women. It may cause deafness, brain and heart damage, and eye defect in unborn
babies.
By giving your child a vaccination it helps to lower the chances of them contracting a
serious illness. It also helps to prevent other children from contracting the disease as
less people will have the disease to pass on.
Mother: I also heard that MMR vaccine can cause bowel problems ( Colitis) !
Dr: I would like to reassure you there is no link between bowel problems (Colitis) and the MMR vaccination.
Mother: Is there any alternative to MMR vaccine?

Dr: Unfortunately there is no alternative to MMR vaccine. The only alternative available is that - these
vaccine can be given as single doses rather than all three combined. But the single doses are available only
privately but not available in the NHS because the
 Studies have not shown any advantage of giving MMR as separatevaccinations.

 If given separately, we have to wait 4 weeks in between eachvaccination.
 We don't want to put the child through unnecessary pain by injectingthe
vaccination on three separateoccasions.
Mother: How will you give the vaccine?
Dr: I need to ask you few questions about your child to see whether it is suitable to give
vaccine now.
Take a short history for contraindication:
 Is your child currently unwell?No
 Does your child has any long term illnesses?No
 Have they ever had any immunizations before? Yes - usualjabs
 Were there any problems afterwards?No
 Are they on any regular medications?No
 Any allergies?No
Dr: Your child is safe to receive this vaccination. We give 2 doses of MMR vaccine – first doseis given after
the child’s first birthday, and the second the dose before pre-school (3 and half years)
 The vaccination will be given as an injection into the muscles of thigh or upper
arm.
 EMLA cream is a local anesthetic cream that can be applied to the skin tosuppress
the pain ofinjections.
 After, may be your child may develop Redness and Swelling around the site ofthe
injection or fever. But this is very common and not dangerous – you can give
Calpol ( Paracetamolsyrup)
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 You should contact your GP if: very high temperature, fits, high pitched cry,huge
swelling anywhere on the body but especially around the site of injection or lips
and mouth.
MMR vaccine can cause mild reaction like indurations ( thickness in the skin) and pain at
the site of injection
Mother : My child has egg allergy, is it safe to give vaccine?
Dr: Egg allergy is not a contraindication for giving the MMR vaccine. This vaccine is not made from yolk
cell.
Dr: Do you have anyotherconcerns? Mother :No
Dr: Are you happy to have MMR vaccine to your child now?
Mother : Yes / I will think over it.
Dr: Once again Mrs Anderson I am very glad that you came to us with your concerns
about the vaccine. I hope I was able to clear all your doubts. Hope everything goes well.
Thank you very much

Flu ( Influenza) Jab to child ( 30th May 2018 - new station)
Question : 3 year old child Like is due for Flu vaccination in one week. Mother wants to
talk to a doctor. Address her concerns.
D: How can I help you ?
M: My son is due for Flu vaccination in one week. Does he really need it ?
D: I will explain that. Before that Can I ask you what do you know about flu ?
M: I know he can have fever and cough.
D: Yes it is a very common infection in babies and children. One can catch flu all year round, but it's
especially common in winter, which is why it's also known as seasonal flu.
Children with flu have can have symptoms like fever, chills, aching muscles, headache, stuffy nose,
dry cough and a sore throat.
Flu (influenza) is a common infectious viral illness spread by coughs and sneezes. Symptoms usually
subside within about a week on its own. However sometimes it can cause serious complications such
as bronchitis, pneumonia ( infection of lungs) and a painful middle ear infection.
They may need hospital treatment, and very occasionally a child may die from flu.
In fact, healthy children under the age of 5 are more likely to have to be admitted to hospital with flu
than any other age group.
Also if children with long-term health conditions such as diabetes, asthma, heart disease or lung
disease, getting flu can be very serious as they are more at risk of developing serious complications.
So prevent such serious complications it is very important prevent children getting Flu. That is why
we recommend Flu vaccine to children to prevent them from getting Flu.
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D: Can I ask does your child has any medical conditions like Diabetes, asthma, any allergies?M: No
D: Has he got any runny nose ? M : No
D: Has he had Flu jab before ? M : No
D: Has he got Fu symptoms now ? M: No
(M: Is the Flu same as common cold ?

D: Flu is not the same as the common cold. Flu is caused by a different group of viruses and the
symptoms tend to start more suddenly, be more severe and last longer).
D: Any other concerns ?
M: How do you give the Flu vaccine ?

D: There are two ways we can Flu vaccine - one type if nasal spray and the other type is injection.
However nowadays we give nasal spray rather than injections because nasal sprays are more effective
than injections. We usually give this vaccination before the start of winter.
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M: Are there any side effects of this vaccine( what are the symptoms to watch out for?
The nasal spray flu vaccine has few side effects – most commonly getting a runny nose after
vaccination for a few days.
D: The flu vaccine for children is usually safe but like all vaccines, some children may experience
side effects. The side effects linked with the flu nasal spray vaccine are almost always mild and short-
lived.
Common side effects of the flu nasal spray vaccine
a runny or blocked nose
 headache
 general tiredness
 loss of appetite
Rare side effects of the flu nasal spray vaccine
As with all vaccines, there's a very small chance of a severe allergic reaction (known medically as
anaphylaxis). The overall rate of anaphylaxis after vaccination is around 1 in 900,000 (so slightly
more common than 1 in a million).
( Anaphylaxis is very serious but it can be treated with adrenaline. When it happens, it does so within
a few minutes of the vaccination. Staff who give vaccinations have all been trained to spot and deal
with anaphylactic reactions and children recover completely with treatment).
M: What should I do if my child has a side effect from the flu nasal spray vaccine ?
D: If your child has a runny nose after their flu vaccination, simply wipe their nose with a tissue and
then discard it.
M: What if my child has to have the injected flu vaccine what are the side effects ?
D: Some children can't have the nasal spray flu vaccine and are offered the injected flu
vaccine instead.
Children having the injected vaccine may get a sore arm at the injection site, a mild fever and
aching muscles for a day or two after the vaccination.
M: How is the nasal spray flu vaccine given?
D: The vaccine is given as a single spray squirted up each nostril. Not only is it needle-free – a big
advantage for children – the nasal spray is quick, painless, and works even better than the injected flu
vaccine.
The vaccine is absorbed very quickly. It will still work even if, after the vaccination, your
child develops a runny nose, sneezes or blows their nose.
Are there any children who should delay having the nasal spray flu vaccine?
Children should have their nasal spray flu vaccination delayed if they:
 have a runny or blocked nose or if they are wheezy
If a child has a heavily blocked or runny nose, it might stop the vaccine getting into their system. In
this case, their flu vaccination should be postponed until their nasal symptoms have cleared up.
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If a child is wheezy or has been wheezy in the past week, their vaccination should be
postponed until they have been wheeze-free for at least 3 days.
M: Can children with egg allergy have this vaccine ?

(Are there any children who should not have the nasal spray flu vaccine)?
D: There are a few children who should avoid the nasal spray flu vaccine.
The vaccine is not recommended for children who have:
 1) a severely weakened immune system

 2) severe egg allergy
 3) severe asthma – that is, those being treated with steroid tablets or high-dose inhaled
steroids
 4) an allergy to any of the vaccine ingredients, such as neomycin
Children unable to have the nasal spray vaccine may be able to have the injectable flu vaccine instead.
M: How safe is the flu vaccine for children?
D: The flu vaccine for children has a good safety record. In the UK, millions of children have been
vaccinated safely and successfully.
M : How does the children's flu vaccine work?
D :The vaccine contains live but weakened flu viruses that do not cause flu in children. It will help
your child build up immunity to flu in a similar way as natural infection, but without the symptoms.
Because the main flu viruses change each year, a new nasal spray vaccine has to be given each year,
in the same way as the injectable flu vaccine.
M: Whatare the advantages of having Flu vaccine ?

D: The nasal spray flu vaccine will not only help protect your child against flu, the infection will
also be less able to spread from them to their family, carers and the wider population.
Children spread flu because they generally don't use tissues properly or wash their hands.
Vaccinating children also protects others that are vulnerable to flu, such as babies, older people,
pregnant women and people with serious long-term illnesses.
M: How many doses of the flu vaccine do children need?
D: Most children only need a single dose of the nasal spray.
Children aged 2 to 9 years at risk of flu because of an underlying medical condition, who have not
received flu vaccine before, should have 2 doses of the nasal spray given at least 4 weeks apart.
Does my child have to have the nasal spray flu vaccine?
No. As with all immunisations, flu vaccinations for children are optional. Remember, though, that
this vaccine will help protect them from what can be an unpleasant illness, as well as stopping them
spreading flu to vulnerable friends and relatives.
Why can't under-2s have a nasal spray flu vaccine?
The nasal spray vaccine isn't licensed for children younger than 2 because it can be linked
to wheezing in children this age.
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Why is it just younger children who are routinely being given the nasal spray flu vaccine?
The children's flu vaccination programme is being rolled out in stages.
This year (2017/18) it is routinely being offered to all children aged 2 and 3, plus children in reception
class and school years 1, 2, 3 and 4.
In some areas all primary school children will be offered the vaccine.
Over the next few years, the programme will gradually be extended to include children in other age
groups.
All children aged between 6 months and 2 years who are at risk of flu because of an underlying health
condition are already eligible for the injected flu vaccine.
Why aren't children being given the injected flu vaccine instead of a nasal spray?
The nasal spray flu vaccine is more effective than the injected flu vaccine, so it's the preferred option.
Will the flu vaccine give my child flu?
No. The vaccine contains viruses that have been weakened to prevent them causing flu.
Does the nasal vaccine contain pork?
Yes, the nasal spray contains a highly processed form of gelatine (porcine gelatine), which is used in
a range of essential medicines.
The gelatine helps to keep the vaccine viruses stable so that the vaccine provides the best protection
against flu.
Can my child have the injected vaccine that doesn't contain gelatine instead?
The nasal vaccine provides good protection against flu, particularly in young children. It also reduces
the risk to, for example, a baby brother or sister who is too young to be vaccinated, as well as other
family members (for example, grandparents) who may be more vulnerable to the complications of flu.
The injected vaccine is not being offered to healthy children as part of the children's flu vaccination
programme.
However, if your child is at high risk from flu due to one or more medical conditions or treatments
and can't have the nasal flu vaccine for the reasons of faith ( vegetarians or those who does not have
pork) they should have the flu vaccine by injection.
Some faith groups accept the use of porcine gelatine in medical products – the decision is, of course,
up to you.
M: My friends child had fits after receiving Flu jab ? Does the Flu jab cause fits ?
D : Flu vaccination by itself does not cause fits. However, children with Flu have high
temperature and that high temperature can cause fits. Flu vaccination prevents children getting
Flu.
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Ear infection in child
Earache in 9 month old child. Child had fever + pulling on his ear + can’t tolerate oral
feeding.
On examination right eardrum pink, left ear drum is red. cappliary refil less than 2
sec.
Child was kept in the A& E for few hours. Given paracetamol. Temperature come
down after the paracetamol.
[ Vitals before and after pcm administration: Temp- 38.8/37celsius, RR-
40cpm/25cpm, PR- 130bpm/100bpm ]
All the blood tests - normal
Talk to the father.
Take history
Fever – since when ?

Ear pulling, discharge from ear ? - No
Child has nasal discharge, not eating drinking properly. No fits.
Has he shown the child to GP before coming to hospital ( father said GP did not give
antibiotic)
Any medication given
R/o meningitis ( shying away from light, rashes on body)
UTI ( crying on passing wee)
Past history – any medical conditions? Medications ? Allergy ? previous such

incidents.
Tell the father
We have examined – child had high fever – now after Paracetamol - it has come
down.
His left ear drum is red. He has not other problem. All the blood tests are also normal.
Diagnosis.
Looks like child has viral infection affecting the left ear.
They usually subside on its own in the new few days.
Antibiotic medications not required.
Admission not required.
Once he starts eating and drinking now - you can take him home.
Keep giving him regular paracetamol. Give him plenty of fluids to drink.
Hopefully he will completely improve in the next few days.
Warning signs
Is he become very unwell, very lethargic and has discharge from his ear – these shows
that he is may have developed Bacterial infection which sometimes can happen –
please bring him back to the hospital.
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FEBRILE CONVULSION
Information
A febrile seizure is a convulsion that occurs in some children (aged 6 month to 5 years) with
a high temperature (fever). The vast majority of febrile seizures are not serious. Most occur
with common illnesses such as ear infections and colds. Full recovery with no permanent
damage is usual. The main treatment is aimed at the illness that caused the fever.
Symptoms of febrile seizures
The main symptom of a febrile seizure is a fit that occurs while a child has a fever.
 Febrile seizures often occurs during the first day of fever, which is defined as ahigh
temperature of 38C (100.4F) orabove.
 However, there appears to be no connection between the extent of your child’s fever
and the start of a seizure. Seizures can occur even if your child has mildfever.
Seeking medical advice
You should take your child to hospital or dial 999 for an ambulance if:
 Your child is having a fit for the firsttime.
 The seizure lasts longer than five minutes and shows no signs ofstopping.
 You suspect the seizure is being caused by another serious illness, for example
meningitis.
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 Your child is having breathingdifficulties.

If your child has previously had febrile seizures, it’s recommended that you telephone your
GP or call NHS 111 for advice.
You should also contact your GP or NHS 111 if your child shows signs and symptoms
ofdehydration (a lack of fluid in the body). This includes:
 A drymouth
 Sunkeneyes
 A lack of tears whencrying
 A sunken fontanelle – the soft spot usually found at the top of a young child’shead.
MANAGING A FEVER
 The reason to do this is not to treat the infection but to make the childmore
comfortable. [to reduce thetemperature]
 It is important for your child to drink, small amounts of fluid little and oftento
prevent them from gettingdehydrated.
 Give paracetamol and ibuprofen if your child is distressed or in pain, following the
instructions on the packet. Do not give paracetamol and ibuprofen at the sametime.
 Do not tepid sponge your child if they have a fever. This causes them to shiverwhich
can make the temperaturerise.
 Do not use a fan directly on the child, use to cool the room and to circulate theair
around theroom.
COMPLICATIONS
 There is a slightly increased risk ofepilepsy.
DIFFERENTIAL DIAGNOSIS
 Meningitis
 Epilepsy
 Hypoglycemia
 Febrile convulsionlesion
 Headinjury
 Poisoning of anytype
ABOUT DIAZEPAM
 Prophylaxis of febrile seizures may be considered for situations such as prolonged
recurrent seizures or for children who have a low threshold for seizures, especiallyif
the family lives far from medical help. [2 hours away fromhospital]
 Rectal diazepam repeated once after 5 minutes if the seizure has not stopped, orone
dose of buccalmidazolam.
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FEBRILECONVULSION - examquestion
You are the FY 2 doctor in the Paediatric department
Mrs Julia Robert has brought her 18 months old son Ben to the hospital with complaint
of an episode of fit which lasted for few minutes today. She is worried about her son.
On examination – his ear drum was red and had high temperature.
Take history from the mother and talk to her about the further management.
Hello I am Dr… one of the junior doctor in the Paediatric department. Are Mrs Julia Robert?
Mother:Yes
Dr: Are you the mother ofBen? Mother:Yes
Dr: How can I help you MrsRobert?
Mother: Dr, My child had fits
Dr: Could you please tell me in detail, what happened before that?
Mother: He was sweating before fits and he was pale as well.
Dr: Can you please confirm the duration of fits?
Mother: 2 min
Dr: Is it the first time?
Mother:Yes
Dr: How is your child after this fit?
Mother : He seems to be fine now.
Dr: Did he have fever before this incident ?
Mother: Yes, He had flu and his nose was running. I gave him Paracetamol. But still he was
hot before fits.
Dr: Did Ben have any rash? High grade fever? Was he crying while moving his neck?
(meningitis)
Mother: No
Dr: Did he have his food today as usual ? (hypoglycaemia)? Mother :Yes
Dr: Ben diagnosed with any medical condition likeDiabetes,Epilepsy? Mother: No
Dr: Does Ben feel sick in morning? Does he have any weaknessinlimbs? Mother:No
Dr: Did he have any headinjuryrecently? Mother :No
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Dr: Is he on any medication? Mother – No

Dr: How was his birth – was there any problemsduringbirth? Mother :No
Dr: Any problems with the development? Mother -No
Dr: Any one in the family hasfits ? Mother:No.
Dr: Mrs Roberts we have examined the child and found that one of the ear drum of your
child’s is red and also his temperature is high.
Mother: Ok
Diagnosis: I think your child has a condition what we call as febrile convulsions. Do you
know anything about this?
Mother : No doctor
Dr: This is condition where the children get fits when they have fever.
Mother : Is it a dangerous condition?
Dr: The vast of majority of febrile seizures are not serious. Children usually have full
recovery with no permanent damage. Most illness which cause fever and febrile convulsions
are the common coughs, colds and viral infections which are not usually serious. However,
the illness that causes the fever sometimes can be serious- for example, pneumonia or
meningitis.
Mother: Why my child is having fever?
Dr: I think your child is fever because he has ear infection – we need to treat the ear infection
with some medications.
Mother: Will this fit happen again doctor ?
Dr: Febrile Convulsion is common in children aged between 6 months and 5 years,
Generally, most of the children grow out of this condition. So usually after the age of 5
years they will not get this condition. However until they reach 5 years old they may getthis
fits again if they havefever.
Mother: What can I do if it happens again?
Dr: First of all you should make sure that your child will not get high fever to prevent him
from getting the fits. If he has fever- keep giving him regular Calpol ( paracetamol) to keep
the temperature under control. Keep your child very lightly dressed. You can also give him
plenty of fluids to prevent dehydration.
When he has a fit
 Lay them on his side with his face turned to on the side. (This will stop them
swallowing any vomit, and prevent chocking)
 Don’t put anything , including medication, in your child’s mouth while theyare
having a fit. Do not put any hard objects into the mouth to prevent tongue bite
because it can break teeth and the broken teeth can go into the wind pipe and
cause choking. It is better to have tongue bite rather than broken teeth because
tongue bite will heal on its own in fewdays.
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 Stay with your child and Note thetime.

1. Usually the fit will stop in about 5 minutes. There is no need tobring
oyur child to the hospital. You can tell to your GP aboutit.
2. If it lasts longer than five minutes, (or if it’s your child’s firstseizure)
call the ambulance.
Mother: Is febrile convulsion a type of epilepsy?

Dr: No, the cause of a febrile convulsion is related to the feverish illness and
epilepsy is because of abnormal electrical activity in brain.
Mother: Will it lead into epilepsy.
Dr: It is very rare that this will lead into epilepsy.
Mother: Will it cause learning disability? Or brain damage ?
Dr: There is no research that suggests simple febrile convulsions cause long-term
problems, for example brain damage or learning difficulties
Mother: Will you give me some medication?
Dr: There are no medications required to treat this condition. [ parents have been to
taught to give per rectal diazepam if the fits lasts longer than 5 minutes – but this is
taught to only those people who live far away from the hospital – more than 2 hours
journey] (no need to tell this to the mother in exam)
Mother: What will you do now?
Dr: I will examine and admit your child, we will do some tests (Blood tests and
urine tests). We will keep him for observation for some time. If all investigations
are normal, then it is Febrile convulsion. Then you can take your child home.
Dr: Any other concerns Mother : No Thank you very much.
Child with night terrors January 15

Question
Mother has come to speak with the GP as she is concerned about her daughter. (Daughter is not
with her)
5 year old girl named Jasmine has episodes of screaming 1-3 times a night almost every night
for around 2-3 months. She screams and shouts and is panicked during the episode. No other
abnormal movements/seizure like activity/pain. No recollection the next day.
Family dynamic is good, she is the only child and parents married and all live together.
No indication of NAI.
Father had similar episodes as a child and went away with time. Development has been
fine, all milestones achieved within the correct time frame and was delivered normally without
any complications. No fever, infections or recent illnesses.
She has started a new school and is not having any trouble/bullying.
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Further history to ask: diet changes? Any t.v. / scary story/ ipad or computer usage before bed?
Any significant recent events? Loss in the family member/pet ? Room/bedding comfortable?
New home? Any medications? Any bed wetting ? any sleep walk ?
What are night terrors: Condition is called night terror. common in children aged between 3 -
8 years old. A child who experiences night terrors may scream, shout and thrash around in
extreme panic. They could even jump out of bed. Their eyes may be open, but they're not fully
awake or alert as to what just occurred. The episodes usually occur in the early part of the night,
continue for several minutes (up to 15 minutes) and may happen several times in one night.
(different from nightmares in which child has recollection the next day)
Why do they happen: family history of night terrors or sleepwalking, excessive tiredness,
fever or certain medications, anxiety and any sudden noises or a full bladder.
Management:Notice a time frame when the episodes occur and possibly wake the child 15
mins prior to expected time for 7 days to stop the night terrors from happening and help break
the cycle (will wake the child up but will not disturb the sleep quality). Stay calm while the
child is having an episode of night terror and wait until they calm down as well. Best not to
intervene or wake the child during the episode as they may not recognise you and become more
anxious. Communication as to discuss any stressors for the child is valuable however do not
discuss the details of the episodes as it may in turn cause more anxiety.
It will also help if they have a relaxing bedtime routine; sleep hygiene, comfortable bed, a
nightlight to avoid being in the dark, emptying bladder before going to bed along with any other
appropriate comfort measures.

Constipation in a child16 April 2019
You are a FY2 in GP clinic. Mother of 2 years old boy Daniel has visited GP 1 week ago
because Daniel has constipation. Daniel was examined, and examination was normal.
Dietary advice was given and asked her to come back after 2 weeks, but she came after
1 week. Talk to her and address her concerns.
GRIPS plus rapport first
Dr: I understand that you visited our GP practice 1 week ago as Daniel had constipation. Can
you please tell me how is he doing now?
Mo: He is still having constipation!
Dr: I am sorry to hear that. Can I ask few questions to help Daniel with the condition? Mo:
Ok
Dr: May I know what advice and treatment were given last time?
Mo: They gave me dietary advice and asked me to give Daniel lots of fruits and
vegetables (high fibre diet) and plenty of water.
Dr: Were you giving those? Mo: Yes
Ask details about diet plus fluids?Is he eating well? Mo:Yes
Is he physically active? Playing well?
When was the last time he passed stool? Mo: 10 days ago
Ask about potty training? Does he cry while sitting on the potty? Mo: Yes
Any overflow diarrhea? Any vomiting?
Rule out Intestinal obstruction: any tummy pain? No
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Able to pass wind? Mo: Yes

Does he go to school? Yes
Anything significant happened recently?
Ask BIRD questions?
Ask MAFTOSA
Ask NAI Questions
Ideally, I need to examine the child
Management:Dietary advice plus potty training. After talking to seniors, laxatives may be
given
Constipation in young children
Constipation is common in childhood, particularly when children are being potty trained at
around two to three years old.
Symptoms of constipation in children
Your child may be constipated if:
 they don't poo at least three times a week
 their poo is often large, hard and difficult to push out
 their poo looks like "rabbit droppings" or little pellets
If your child is already potty trained, soiled pants can be another sign of constipation,
as runny poo (diarrhoea) may leak out around the hard, constipated poo. This is
called overflow soiling.
If your child is constipated, they may find it painful to poo. This can create a vicious circle:
the more it hurts, the more they hold back. The more constipated they get, the more it hurts,
and so on.
Even if pooing isn't painful, once your child is really constipated, they may stop wanting to
go to the toilet altogether.
Why children get constipated
Your child may be constipated because they:

 aren't eating enough high-fibre foods like fruit and veg
 aren't drinking enough
 are having problems with potty (or toilet) training
 are worried or anxious about something, such as moving house, starting nursery or the
arrival of a new babY
How to treat your child's constipation
The treatment for constipation depends on your child’s age.
The longer your child is constipated, the more difficult it can be for them to get back to
normal, so make sure you get help early.
Laxatives are often recommended for children who are eating solid foods, alongside diet
and lifestyle changes.
It may take several months for the treatments to work,but keep trying until they do.
Remember that laxative treatment may make your child's overflow soiling worse before it
gets better.
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Once your child's constipation has been dealt with, it's important to stop it coming back. Your
GP may advise that your child keeps taking laxatives for a while to make sure their poo stays
soft enough to push out regularly.
Try to stay calm
Getting constipated and soiling their clothes isn't something your child is doing on purpose,
so there's no reason to get cross with them.You may both find the situation stressful, but
staying calm and relaxed is the best attitude to help your child deal with the problem.
How to prevent constipation
 Make sure your child has plenty to drink – offer breastfed babies who aren’t eating solids
yet plenty of breastfeeds. Formula-fed babies can have extra drinks of water between their
formula feeds.
 Give your child a variety of foods, including plenty of fruit and vegetables, which are a
good source of fibre. Encourage your child to be physically active.
 Get your child into a routine of regularly sitting on the potty or toilet , after meals or before
bed, and praise them whether or not they poo. This is particularly important for potty-
trained boys, who may forget about pooing once they are weeing standing up.
 Make sure your child can rest their feet flat on the floor or a step when they're using the
potty or toilet, to get them in a good position for pooing. ERIC, The Children's Bowel &
Bladder Charity's leaflet, Children’s Bowel Problems.
 Ask if they feel worried about using the potty or toilet – some children don't want to poo in
certain situations, such as at nursery or school.
 Stay calm and reassuring, so that your child doesn't see going to the toilet as a stressful
situation – you want your child to see pooing as a normal part of life, not something to be
ashamed of.If you'd like advice about taking the stress out of going to the toilet for your child,
speak to your health visitor.

Chest infection in child with asthma
Exam question:
7 year old Child with SOB. History and management

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Differentials
Asthma, Pneumonia, FB, heart failure ( any heart conditions previously)
Why he is still getting asthma attack ?

Is he already
diagnosed asthma May be still has risk factors:
Dust ( carpet floor)
Pollen ( Plants inside or near home)
Unusual too much exercise ( too much playing)
Passive smoking
Cold weather
Infection
Why the medication is not working :-
Using expired medication
Wrong technique of using inhalers.
Wrong washing technique
If not diagnosed Check weather it is asthma

with asthma
Family history of asthma any skin lesions
Symptoms – wheeze, cough
Check triggers.
Child had Fever, cough and SOB for – 2 days.
Has eczema. Father has Asthma.
Child had 2 attacks of similar episodes previously once when the child was 2 years old and he
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again when the child was 3 year old.
Known asthma child. Ask whether mother gave any medicines now. Mother gives blue
inhalers.
Has pets at home and also has collection of flowers at home.
No dust. No carpet floor.
Check is she giving medications whenever required.
Any other past medical conditions
Past admissions
Any other medications?
Allergy
Examination
NEWS chart
Chest examination – examiner may or may not give findings
Provisional diagnosis
I think your child has infection in the chest – means there are bugs in the chest which makes
the asthma worst.
We need to do some test like blood tests and chest X Ray
We need to admit the child for treatment
We will give him antibiotics and also Paracetamol.
We may need to give him the salbutamol medicine as nebuliser ( like a steam inhalation
through a machine) until he improves.
We will also give some steroid medications.

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I will talk to my seniors.
Once he improves then we will discharge our child.
Advise : Avoid all trigger factors. It is better to avoid close contact with the pets and flowers
because it can exacerbate asthma. Better to have wooden floor at home rather than carpet
floor. Keep the home clean avoid dust.
Do you know how to use the inhalers properly – check the technique if time permits.
Changed question – child had only Asthma without chest infection.
2555 Video Not available
Sick child with chest infection (Traige care call) Tel Conv : (16th Oct 2018)
Question:
You are an FY2 in a Paediatric Ward.
A young baby 10 months old has been sick for two days and is on a triage care call. His
mother, Mrs Sharon Stone, is concerned.
Task – Talk to the mother and discuss the initial management plan with her.
(Mom sounds very worried and is panicking)
Phone is present in the station.

Dr- Hello, I am Dr ..., F2 at the Paediatric department. Are you Mrs.... (Confirm the child’s
name & age)
Mother- Doctor, can you please come and see my baby, he is very ill.
Dr- Mrs...., Please don’t worry. We will do our best to help you. Can I ask few questions to
know about your baby’s condition to see how we can help you?
Dr- Can you tell me what happened?
Mom - My baby has fever since 2 days. I recorded it with my home thermometer and it
showed 39 C. I have been giving him Paracetamol but the fever is not improving.
Dr: Has he got any other problems ? Mom : Like what ?
Dr: Has he got any rashes on the body ? No
Dr- Did you notice if he had any difficulty moving his neck?Mom – No
Dr: Does he shy away from light ? No
Dr: Is he got any breathing problem ? Yes he is very breathless
Dr: Since when ? Since the last 12 hours but it is worse he is gasping for breath now.
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Dr: I can imagine this must be very distressing for you. Has he got cough ? Yes since
yesterday.
Dr: Does he cough up any phlegm ? No
Dr- Did he have any nasal discharge? P- No
Dr- Mrs___,. Is your baby feeding well ? M– No doctor. He hasn’t been feeding at all
since yesterday.
Dr- Is your baby active ?M - No doctor. He has been listless and is lethargic.
Dr- Did he passing urine normally ?M- No. I haven’t changed his diaper since yesterday.
Dr: Did you see any discharge from his ear ( Ear infection) ? Mom: No
Dr: Was he crying while passing urine ( UTI)? Mom: No
Dr: Is he having loose stools (GE)? Mom: No
Dr- Do you feel his development is normal? P- Yes
Dr- Did your baby have any similar problems in the past? M– No
Dr- Is your baby on any medications ? M- No
Dr- Is your baby allergic to anything? M- No
Dr: Do you have any other children at home ?
Dr: Any one at home has any kind of infection or who is not well ?
No
Dr Did he come into contact with anyone who is not well recently?
Dr: Can you think of anything else which might be important for us to know?
Mom: No Dr, I am just worried about my son. He is also a bit drowsy so I am very concerned.
Dr– Thank you for the information you have given me. Your baby needs immediate
admission and treatment in the hospital. ? I will send an ambulance to your place immediately.
Is that Okay ?
[ Do not advise the mother to bring the child to the hospital on her own]
Mom: But Doctor, what is wrong with him ?
Dr: I am suspecting that he might be having some kind of chest infection but to be sure we
need to examine him. We may need to do some blood tests and chest X ray and urine test. If
we find out that is infection we need to give him antibiotics. Is that Okay ?
Mom: Okay. When will the ambulance arrive here ?
Dr: I will send the ambulance immediately. Hopefully they should reach within the next 10 to
15 minutes. Any other concerns? No
Thank you.

Chest infection ?Bronchioloitis : 4 months old baby.
Question:
Mother Zara brought in her child Zain( 4 months old) with fever, inconsolable cry and poor
feeding.
In exam electrolytes are given…. May be all normal.
Vitals : O2 saturation: 92%, R.R: 57Pulse: 157 Temp: 38

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-GRIPS
- How can I help you?
M- Doctor my little Zain he is crying a lot since past 3 days. He is not even feeding properly.
D- I am Sorry to hear that. We are here to take care of your child. He is safe hands now.
D- Can you please tell me anything more about it?
M- He is having Dry cough since past 3 days.
D – does he cough up any phlegm at all ? Yes/no
D- Is it there at specific time or all the times? M- It is there all the time.
D- Did you notice the cough sounds like barking ? … No
D – any discharge from nose ?
D- Did you notice any shortness of breath?... yes /No
D- have you noticed any rashes on his body and any neck stiffness ?.... no
D- Is he crying while passing urine/ if the urine is more smelly ? passing less urine
( dehydration) …. No
D – Have you noticed that his mouth is dry ( dehydration) ?
D- How is the poo ?any loose stool… No
D – How is the feeding ? Breast feeding or Bottle feeding ?
D - Is he active or drowsy ?
D- Any similar problems inthe past?.... Yes/no
D- Any history of similar problems in the family members? … Yes his father has Asthma
D- Is he your only child? …. Yes/no
D- How was the delivery? ….normal
D _ Has he born premature, low birth weight ? ( risk factor for Bronchiolitis)
D- Has he got the jabs so far ? … Yes
D-Any problem with the redbook so far? …. No
D- Any problem with the development? …. No

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D- Who takes care of your child …. I take care
D - any other children at home ? Any other children has similar problems ?
Anyone else at home not well ?
D- any previous heart or lung conditions ?
Thankyouvery much for giving me all the information.
Examination:
For now I need to examine your child. I will do the general physical examination, check
pulse, blood pressure and temperature and examine chest.
( Examiner may give a long sheet with all the information on it)
Chest: Crackles and wheeze
Temperature: Increased
SpO2: 92% (check for any other information that might be written on the paper)
Management:
Investigations:
For now we need to do some investigations to confirm the reason what may be causing this
problem in him.
 Chest X- Ray
 Blood tests including infection markers and electrolytes
 We need to do some type of blood test what we call Blood gases.
 Blood Tests to check for bugs.
 We do some tests on nose discharge (Nasopharyngeal aspirate for:RSV rapid testing)

for virus kind of bugs
Diagnosis
I think your child has a condition what we call as Bronchiolitis. It is an infection of the lungs
by virus kind of bugs. It could be early oncet of Asthma also since his father has Asthma.
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However we need to test for that.
Treatment:
Admit
We will start your child on
 Oxygen
 Nebulisation with salbutamol
 Antibiotics – after confirming if it is viral or bacterial
 I.V fluids.
Breast-feeding is considered protective in Bronchiolitis and should be encouraged for this and
other reasons.
M - Doctor please give me antibiotics I will go. I don’t want my child to get admitted as I
have some work. Try to convince her and she will agree to stay back at hospital.
Thank you.
Additional information on cough in Baby of 4 months:
Causes of cough
Coughs are usually a symptom of an infection, typically the common cold virus.
 Croup, a viral infection of the voice box and airways.
 Whooping cough, a bacterial infection of the windpipe and airways. You will be
offered a vaccination against whooping cough for your baby.
 Bronchiolitis, a viral infection of the lungs.
Coughs can also have non-infectious causes, such as asthma.

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Bronchiolitis is an acute infectious disease of the lower respiratory tract that occurs primarily
in the very young, most commonly infants between 2 and 6 months old. It is a clinical
diagnosis based upon:
 Breathing difficulties
 Cough
 Decreased feeding
 Irritability
 Apnoeas in the very young
 Wheeze or crepitations on auscultation
It is usually due to a viral infection of the bronchioles. Respiratory syncytial virus (RSV) is the most
common pathogen, causing 50-90% of cases. A combination of increased production of mucus, cell
debris and oedema produces narrowing and obstruction of small airways.
Common Causes
 Respiratory syncytial virus (RSV)[3]
 Human metapneumovirus (hMPV) - causes a similar spectrum of illness to RSV and is

thought to be the second most common cause[4]
 Adenovirus - occasionally causes a similar syndrome with a more virulent course
 Parainfluenza virus
Epidemiology
 Peak incidence of RSV infections is in the winter months (November to March), although the
size of the peak varies from winter to winter.
 By their first birthday over 60% of children have been infected and, by 2 years of age, over
80%. The antibodies that develop following early childhood infection do not prevent further RSV
infections throughout life.
Risk factors[2]
Environmental and social risk factors:
 Older siblings
 Nursery attendance
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 Passive smoke, particularly maternal
 Overcrowding
Risk factors for severe disease and or complications:
 Prematurity (<37 weeks)
 Low birth weight
 Age less than 12 weeks
 Chronic lung disease (eg, cystic fibrosis, bronchopulmonary dysplasia)
 Congenital heart disease
 Neurological disease with hypotonia and pharyngeal dis-co-ordination
 Epilepsy
 Insulin-dependent diabetes
 Immunocompromise
 Congenital defects of the airways
 Down's syndrome
Presentation
Symptoms
 Early symptoms are those of a viral URTI, including mild rhinorrhoea, cough and fever.
Fever >39°C is unusual and should prompt a thorough examination and further investigations to
exclude other possible causes.
 For the 40% of infants and young children who progress to lower respiratory tract
involvement, paroxysmal cough and dyspnoea develop within 1-2 days.
 Other common symptoms include the following: wheeze, cyanosis, vomiting, irritability and
poor feeding.
 Apnoeas may occur, especially in young infants.
Signs
 Look for tachypnoea, tachycardia, fever, cyanosis and signs of dehydration. It is unusual for a
child to appear 'toxic' (suggested by drowsiness, lethargy, pallor, mottled skin) and this should
prompt urgent action in terms of the need for immediate treatment and exclusion of other potential
causes.
 Mild conjunctivitis, pharyngitis.
 Evidence of increased respiratory work: intercostal, subcostal and supraclavicular recession,

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nasal flaring.
 Widespread fine inspiratory crackles are considered a key finding in the UK, whilst high-
pitched expiratory wheezing is commonly present but not essential to a diagnosis.
 Liver and spleen may be palpable due to hyperinflation of the lungs.
Investigations
 Pulse oximetry.
 Nasopharyngeal aspirate for:
 RSV rapid testing - to enable isolation or cohort arrangements and to prevent further,
unnecessary testing.
 Viral cultures for RSV, influenza A and B, parainfluenza and adenovirus can also be
undertaken.
Other investigations that are not recommended for typical acute bronchiolitis include:
 CXR: bronchiolitis produces:
 Nonspecific hyperinflation and patchy infiltrates
 Focal atelectasis
 Air trapping
 Flattened diaphragm
 Increased anteroposterior diameter
 Peribronchial cuffing
CXR should only be performed if there is diagnostic uncertainty or an atypical course.
 FBC.
 Electrolytes and renal function: only perform if the child is dehydrated or on IV fluids.
 Blood and urine culture: consider if pyrexia >38.5°C or the child has a 'toxic' appearance.
 Arterial blood gases: may be required in the severely ill patients, especially in those who may
need mechanical ventilation.
Management
Primary care
 Most infants with acute bronchiolitis will have mild, self-limiting illness and can be managed
at home. Supportive measures are the mainstay of treatment, with attention to fluid input, nutrition
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and temperature control.
 Within general practice, a doctor's role is to assess current severity of illness and, for those
with mild-to-moderate disease, to support and monitor. Consider whether the presentation is in the
early stages of disease, when a child is more likely to get worse before improving. Careful safety
netting is important, teaching parents to spot deterioration and to seek medical review should this
occur.
 For the majority, bronchiolitis lasts 7-10 days, with 50% asymptomatic by two weeks and
only a small subgroup still symptomatic at four weeks.
Referral
Hospital referral is suggested where there is:
 Poor feeding (<50% usual intake over the previous 24 hours) which is inadequate to maintain
hydration
 Lethargy
 History of apnoea
 Respiratory rate >70 breaths/minute
 Nasal flaring or grunting
 Severe chest wall recession
 Cyanosis
 Saturations ≤94%
 Uncertainty regarding diagnosis
 Where home care or rapid review cannot be assured
The threshold for admission should be lower in those with significant comorbidities, premature
infants and those under 3 months old.
PICU admission is necessary if the child has increasing severe respiratory distress with desaturation
or apnoea whilst receiving 50% oxygen. Continuous positive airway pressure (CPAP) or intubation
may be required in these cases, although one study found that the majority of children could be
managed with non-invasive ventilation outside the PICU setting.
Secondary care
 Even amongst hospitalised children, supportive care is the mainstay of treatment, including
oxygen and nasogastric feeding where necessary.
 Other treatments have shown inconsistent or little evidence of benefit:
 Bronchodilators: modest short-term improvement in clinical scores but no reduction

in the rate or duration of hospitalisation.
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 Corticosteroids: trials have consistently failed to provide evidence of benefit. A large

multicentre randomised controlled trial (RCT), comparing the use of a single dose of oral
dexamethasone with placebo in children diagnosed with bronchiolitis in Emergency
Departments, failed to show any significant differences in the rates of hospital admission,
respiratory status after four hours or longer-term outcomes.
 Racemic adrenaline (epinephrine) - racemic = 1:1 mixture of the dextrorotatory and

levorotatory isomers: one study reported that inhaled racemic adrenaline (epinephrine) was no
better than inhaled saline.
 Hypertonic (3%) saline: thought to act by unblocking mucous plugs and reducing
airways obstruction. A Cochrane Review concluded that there was evidence its use did reduce
length of hospital stay and clinical severity scores.A later study found no difference in clinical
outcome between 3% and 0.9% saline.
 Antibiotics: there is minimal evidence to support their use, except in a small subset of
patients with respiratory failure.
 Ribavirin: may reduce the need for mechanical ventilatory support and the number of
days in hospital but there is no clear evidence of clinically relevant benefits (eg, preventing
respiratory deterioration or mortality).
 Chest physiotherapy does not improve the severity of the disease, respiratory parameters, or
reduce length of hospital stay or oxygen requirements in hospitalised infants with acute
bronchiolitis not on mechanical ventilation.
Prognosis
 Most children with bronchiolitis make a full recovery.
 Mechanical ventilation is required for some patients but one study found that the majority can
be managed without.
 Most deaths occur in infants younger than 6 months or in those with underlying cardiac or
pulmonary disease..
Prevention
Vaccine
A vaccine is available for babies most at risk of developing severe, and occasionally fatal, RSV
infection. These will be very young infants born prematurely who have predisposing conditions such
as chronic lung disease, congenital heart disease or children who are immunodeficient. It is usually
given in secondary care.

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Extradural Heamatoma in child

10 year old boy Joshua Pilmore was brought into the hospital by the ambulance
because he met with the Road traffic accident.
CT scan of the head showed he had extradural heamatoma.
Seniors are getting ready to take him to the theatre. He is in a critical condition.
You have not seen the child.
Talk to his parents and address their concern.
Dr: Hello Mr and Mrs Pilmore ? ….. I am Dr ….. one of the junior doctor in the
Paediatric department. Are you the parents of Joshua ? Parents: Yes doc
Dr: I am one of the team of doctors looking after your son.
Parent: Oh, How is he doctor ?
Dr: Joshua is in the resuscitation room now. Our team is taking care of him.
I have come here to talk to you about him. Before that – Mr Pilmore, I was told that he met
with an accident. Can you please tell me more about ii?
Parent: Doctor we were about to go to a restaurant and Joshua suddenly ran to cross the
road and the next thing I heard he was calling me Papa Papa. When we saw him he was
under the car. We called the ambulance immediately. They brought him here.
Dr: I am very sorry to hear that. When did this happen ?
Parent: About half an hour ago.

Dr: Mr and Mrs Pilmore, I have not seen him as yet. I will be seeing him soon after I
talk to you. I do have some news about him. I wish I could give you some good news
but unfortunately Joshua is in a very critical condition now ?
Parent: What happened why do you say that?
Dr: Mr and Mrs Pilmore, we examined him and did a CT scan of his head which showed
he had head injury and has bleeding inside the head.
Parent: Is it serious ?
Dr: This is a very serious condition. I am very sorry to say this.
Parent: Don’t you have any treatment for this?
Dr: We can do surgery and try to remove the blood clot from the brain. That is what our
team is trying to do. We do have the best surgical team to deal with such problems. We are
doing our best to save him. Most of the time surgery is very successful and they recover
from the condition. However sometimes it can be very serious. In fact sometimes it can be
even life threatening.
Parent: Is he going to die doctor ?
Dr: As I mentioned our team will try to do the best for Joshua. As I told you before, most of
the time children do recover from the problem once we do the operation and remove the
blood clot from inside his head. However, there is slight chance that he may not make it. I
am sorry to say this.
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Mother may cry – console her and dad. ( tissues – glass of water to drink).
Parent: Doctor I can’t believe this !
Dr: I can’t even imagine how you are feeling now. We will do everything possible from
our side.
Parent: Thank you doctor
Parent: Can we see him?
Dr: I can understand you want to see him. As you know at the moment we are
resuscitating him. You may not be able to see him for long time because we need to
operate on him as soon as possible. May be you can have a quick look at him now
and you can see him properly after the operation, is that OK Mr and Mrs Pilmore.
Parent: Ok doctor. Will there be any damage to the brain after the operation ?
Dr: Hopefully he will not have any brain damages. However, we can’t say much about it
now. We may know that only after the surgery.
Dr: Any other concerns Mr and Mrs Pilmore? Parents : No doctor.
Dr: Are you Ok for us to go ahead with the operation?

Parents: Sure doctor, if you think that it is necessary. Please do whatever is best for
him.
Dr: Thank you. I need to ask you few questions about his health ? Is that OK?
Parents : OK
Dr: Can I ask you how was Joshua’s health before this happened ?
Parent: He was completely fine.
Dr: Did he have any medical conditions at all ? Parents: No
Dr: Is he on any medications? Parent: No
Dr: Is he allergic to anything you know? Parent: Strawberries
doctor.
Dr: I see. It is good that you told me about it. I will make a note of
this in his notes and let everyone know about this so that no one
gives him strawberries here. Can I ask is he allergic to any
medications at all? Parents - No
Dr: Any medical conditions in the family members ? Parent: No
Dr: When did he last eat or drink? Parent: Just before this happened / in the morning.
Dr: How many hours ago is that? Parents … hours ago.
Dr: Thank you very much for the information. Is there any other questions? Parents: No
P a g e | 688
Dr: Thank you very much Mr and Mrs Pilmore, once again I am very sorry to give this news.
We will keep you informed about everything.

I will be around if you need any other help. I hope to come back with good news.

Fracture pelvis in child
10 year old boy Joshua Martin was brought into the hospital by the ambulance
because he met with the Road traffic accident.
Investigations revealed that he has fracture pelvis.
Pulse – high. BP – very low. He is not stable.
Talk to his parents and address their concern.
Dr: Hello Mr and Mrs Martin ? ….. I am Dr ….. one of the junior doctor in the
Paediatric department. Are you the parents of Joshua ? Parents: Yes doc
Dr: I am one of the team of doctors looking after your son.
Parent: Oh, How is he doctor ?
Dr: Joshua is in the resuscitation room now. Our team is taking care of him.
I have come here to talk to you about him. Before that – Mr Martin, I was told that he met
with an accident. Can you please tell me more about ii?
Parent: Doctor we were about to go to a restaurant and Joshua suddenly ran to cross the
road and the next thing I heard he was calling me Papa Papa. When we saw him he was
under the car. We called the ambulance immediately. They brought him here.
Dr: I am very sorry to hear that. When did this happen ?
Parent: About half an hour ago.

Dr: Mr and Mrs Martin, I do have some news about him. I wish I could give you some
good news but unfortunately Joshua is in a very critical condition now.
Parent: What happened why do you say that?
Dr: Mr and Mrs Martin, we examined him and did some investigations. They show that he
has broken his hip bones. Because of that he is bleeding heavily inside in his hip area.
Parent: Is it serious ?
Dr: This is a very serious condition. I am very sorry to say this.
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Parent: Don’t you have any treatment for this?

Dr: We can do surgery and try to fix the fracture. That is what our team is trying to do. We
do have the best surgical team to deal with such problems. We are doing our best to save
him. Most of the time surgery is very successful and they recover from the condition.
Usually that controls the bleeding. Also we may need to give him blood transfusion
because he would have lost lot of blood. Is that OK for us the give the blood
transfusion ?
Parents: Yes doctor you can give blood transfusion.

Dr: Mr and Mrs Martin, As I told you before most of the time the operation is very
successful and we will be able to control the bleeding. However sometimes it is be very
difficult to control the bleeding in that case it can still be very serious and it can be even
life threatening.
Parent: Is he going to die doctor ?
Dr: As I mentioned our team will try to do the best for Joshua. As I told you before, most of
the time children do recover from the problem once we do the operation and fix the
broken bones.
However, there is a very slight chance that he may not make it.
Mother may cry – console her and dad. ( tissues – glass of water to drink).
Parent: Doctor I can’t believe this !
Dr: I can’t even imagine how you are feeling now. We will do everything possible from
our side.
Parent: Thank you doctor
Can we see him?
Dr: I can understand you want to see him. As you know at the moment we are
resuscitating him. You may not be able to see him for long time because we need to
operate on him as soon as possible. May be you can have a quick look at him now
and you can see him properly after the operation, is that OK Mr and Mrs Martin.
Dr: Any other concerns Mr and Mrs Martin ? Parents : No doctor.
Dr: Are you Ok for us to go ahead with the operation?

Parents: Sure doctor, if you think that it is necessary. Please do whatever is best for
him.
Dr: Thank you. I need to ask you few questions about his health ? Is that OK?
Parents : OK
Dr: Can I ask you how was Joshua’s health before this happened ?
Parent: He was completely fine.
Dr: Did he have any medical conditions at all ? Parents: No
Dr: Is he on any medications? Parent: No
Dr: Is he allergic to anything you know? Parent: Strawberries
doctor.
Dr: I see. It is good that you told me about it. I will make a note of
this in his notes and let everyone know about this so that no one
gives him strawberries here. Can I ask is he allergic to any
medications at all? Parents - No
Dr: Any medical conditions in the family members ? Parent: No
Dr: When did he last eat or drink? Parent: Just before this happened / in the morning.
Dr: How many hours ago is that? Parents … hours ago.
Dr: Thank you very much for the information. Is there any other questions? Parents: No
Dr: Thank you very much Mr and Mrs Pilmore, once again I am very sorry to give this news.
P a g e | 690
We will keep you informed about everything.

I will be around if you need any other help. I hope to come back with good news.

NEONATAL JAUNDICE
INFORMATION
Jaundice is a common and usually harmless condition in newborn babies that causes yellowing of the skin
and the whites of the eyes.The medical term for jaundice in babies is neonatal jaundice.
The symptoms of newborn jaundice usually develop two to three days after the birth and tend to get better
without treatment by the time the baby is about two weeks old.
PATHOPHYSIOLOGY
Jaundice is caused by the build-up of bilirubin in the blood. Bilirubin is a yellow substance produced when red
blood cells are broken down.
Jaundice is common in newborn babies because babies have a high level of red blood cells in their blood, which
are broken down and replaced frequently. The liver in newborn babies is also not fully developed, so it's less
effective at removing the bilirubin from the blood.
By the time a baby is about two weeks old, their liver is more effective at processing bilirubin, so jaundice often
corrects itself by this age without causing any harm.
It is normal to have some bilirubin in the blood. A normal level is: Direct (also called conjugated) bilirubin: less than 0.3
mg/dL (less than 5.1 µmol/L) Totalbilirubin: 0.1 to 1.2 mg/dL (1.71 to 20.5 µmol/L)
Jaundice is considered pathologic if it presents within the first 24 hours after birth, the total serum bilirubin level rises by
more than 5 mg per dL (86 mol per L) per day or is higher than 17 mg per dL (290 mol per L), or an infant has signs and
symptoms suggestive of serious illness.
SYMPTOMS
In premature babies, who are more prone to jaundice, it can take five to seven days to appear and usually lasts
about three weeks. It also tends to last longer in babies who are breastfed, affecting some babies for a few
months.
If your baby has jaundice, their skin will look slightly yellow. The yellowing of the skin usually starts on the
head and face, before spreading to the chest and stomach. In some babies, the yellowing reaches their legs and
arms. The yellowing may also increase if you press an area of skin down with your finger.
A newborn baby with jaundice may also:
be poor at sucking or feeding

be sleepy
have a high-pitched cry
be limp and floppy
have dark, yellow urine – it should be colourless
have pale poo – it should be yellow or orange
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CAUSES
Some causes of pathological jaundice include:
Anunderactive thyroid gland (hypothyroidism) – where the thyroid gland doesn't produce enough
hormones
Blood group incompatibility – when the mother and baby have different blood types, and these are
mixed during the pregnancy or the birth
rhesus factor disease – a condition that can occur if the mother has rhesus-negative blood and the baby
has rhesus-positive blood
a urinary tract infection
Crigler-Najjar syndrome – an inherited condition that affects the enzyme responsible for processing
bilirubin
a blockage or problem in the bile ducts and gallbladder – these create and transport bile, a fluid used
to help digest fatty foods
An inherited enzyme deficiency known as glucose 6 phosphate dehydrogenase (G6PD) could also lead to
jaundice or kernicterus.
TREATMENT
Most babies with jaundice don't need treatment because the level of bilirubin in their blood is found to be low. In
these cases, the condition usually gets better within 10 to 14 days and won't cause any harm to your baby.
If treatment is felt to be unnecessary, you should continue to breastfeed or bottle feed your baby regularly,
waking them up for feeds if necessary. If your baby's condition gets worse or doesn't disappear after two weeks,
contact your midwife, health visitor or GP.
Prolonged newborn jaundice (lasting longer than two weeks) can occur if your baby was born prematurely or if
he or she is solely breastfed. It usually improves without treatment. However, further tests may be recommended
if the condition lasts this long to check for any underlying health problems.
If your baby's jaundice doesn't improve over time or tests show high levels of bilirubin in their blood, they may
be admitted to hospital and treated with phototherapy or an exchange transfusion.
These treatments are recommended to reduce the risk of a rare but serious complication of jaundice
called kernicterus, which can cause brain damage.
PHOTOTHERAPY Phototherapy is treatment with light. It is used in some cases of newborn jaundice to lower
the bilirubin levels in your baby's blood through a process called photo-oxidation.
A commonly used rule of thumb in the NICU is to start phototherapy when the total serum bilirubin level is greater than 5
times the birth weight. Thus, in a 1-kg infant, phototherapy is started at a bilirubin level of 5 mg/dL; in a 2-kg infant,
phototherapy is started at a bilirubin level of 10mg/dL and so on
Photo-oxidation adds oxygen to the bilirubin so it dissolves easily in water. This makes it easier for your baby's
liver to break down and remove the bilirubin from their blood.
There are two main types of phototherapy.
conventional phototherapy – where your baby is laid under a halogen or fluorescent lamp with their
eyes covered
fibreoptic phototherapy – where your baby lies on a blanket that incorporates fibreoptic cables; light
travels through the fibreoptic cables and shines on to your baby's back
 Treatment won't be stopped during continuous multiple phototherapy. Instead, milk that has been
squeezed out of your breasts in advance may be given through a tube into your baby's stomach, or
P a g e | 692
fluids may be given into one of their veins (intravenously).
 During phototherapy, you baby's temperature will be monitored to ensure they're not getting too hot and
they'll be checked for signs of dehydration. Your baby may need intravenous fluids if they're becoming
dehydrated and aren't able to drink a sufficient amount.
 The bilirubin levels will be tested every four to six hours after phototherapy has started. Once levels
start to fall, they'll be checked every six to 12 hours.
 Phototherapy will be stopped when the bilirubin level falls to a safe level, which usually takes a day or
two.
Differential diagnosis
1. Physiological Jaundice
2. Haemolysis (ask about father’s and other’s blood group)
3. Biliary Atresia (Pale stool dark urine)
4. Sepsis ( Fever)
5. Breast milk Jaundice.
What does kernicterus cause?

When severe jaundice goes untreated for too long, it can cause a condition called kernicterus. Kernicterus
is a type of brain damage that can result from high levels of bilirubin in a baby's blood. It can cause
athetoid cerebral palsy and hearing loss.
Symptoms of kernicterus can vary, but may include:

Drowsiness or lack of energy.
Uncontrollable or very high-pitched/shrill crying.
Fever.
Trouble feeding.
Limpness or stiffness of the whole body.
Unusual eye movements.
Muscle spasms or reduced muscle tone.
Kernicterus treatment. The goal of treatment is to reduce the amount of unconjugated bilirubin in a baby's
body before it gets to levels that cause brain damage by kernicterus. Babies with high bilirubin levels are
often treated with phototherapy, or light therapy.
Exam question:
15 day old baby was noticed to have jaundice by the midwife.

Talk to the mother and discuss management with her.
History- 1. I was told by the midwife that your child has yellowish colour of the skin. Did
you notice his skin turning yellow? –No
2. Is he active? Playful? Yes
3. Did he have fever? Vomit? No
4. Did you notice any rash? No
5. Bowel movements- how is his poo? Any colour change? Blood in the poo? Any
change in consistency? (Everything may be normal)
Any problems with the wee? Is he passing urine well? Any discolouration?
Presence of blood in the urine
6.Do you breast feed your child? Yes

7. Is he feeding well ? Yes
8. Was there any recent change in your diet? Changes in his diet? No
9. Did you notice any lump in the tummy? No
10. Is he gaining weight normally ? Yes
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11. Were you told whether your baby had underactive thyroid or urine infection after he was
born ? ( pathologic cause)
12. Were you told that there was some mismatch of the blood group between yours and your
baby’s blood ? ( pathologic cause)
13. Do you have any other children – if so - did they have jaundice like this when they were
born ? ( Crigler nazzar syndrome)
MAFTOSA-
1. Does the baby have any medical conditions?
2. Does the mother have any medical conditions? ( diabetes has an increased risk of
causing neonatal jaundice)
3. Is the baby/mother on any medications?
4. Does the baby have any allergies?
5. Any medical conditions in the family?
DELIVERY HISTORY-
1. Was it normal delivery or caesarean section?
2. Was there any complications with the pregnancy or delivery?
3. Were any instruments used during the delivery? (cephalohaematoma can cause
jaundice )
4. Is he your first child? (if not, ask for if there was any similar history of physiological
jaundice in the previous pregnancy)
Examination : I need to examine your child. I need to check for jaundice in eyes and skin,
also I need to examine his tummy.
Ask for NEWS chart.
I shall be doing a couple of tests- FBC, LFT
Examiner may give findings- vitals normal

Icterus present
Abdomen examination-normal
Tests- FBC -normal, total bilirubin-150 (below treatment level), direct-10
Diagnosis:From what you have told me and from what I have examined, it seems your baby
has a condition calledbreast milk jaundice a type of harmless jaundice.
Mother : What is that, Doctor ?
Dr: Jaundice is a common and usually harmless condition in newborn babies that causes
yellowing of the skin and the whites of the eyes.The medical term for jaundice in babies is
neonatal jaundice.
Blood has red blood cells which are broken down and replaced frequently. When it breaks
down it produces a yellow substance called Bilirubin. Jaundice is caused by the build-up of
bilirubin in the blood. This bilirubin is usually removed from the blood by Liver. The liver in
newborn babies is also not fully developed, so it is less effective at removing the bilirubin
from the blood.
By the time a baby is about two weeks old, their liver is more effective at processing
bilirubin, so jaundice often corrects itself by this age( 2 weeks) without causing any harm.
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This type of Jaundice usually happens after 2nd day of birth and usually resolves by 2 weeks,
however sometimes it can last longer time what we call as prolonged physiological
Jaundice. This prolonged jaundice could be due to the breast milk.
◦
◦ Mother: What Is Breast Milk Jaundice?
Dr: Breast milk jaundice is a type of jaundice associated with breast-feeding. Breast Milk
Jaundice is jaundice that persists after physiologic jaundice subsides. It is seen in otherwise
healthy, full-term, breastfed babies. ... Most babies who present with true breast milk
jaundice (only 0.5% to 2.4% of all newborns) may see another rise in bilirubin levels at
about 14 days.
It typically occurs one week after birth. The condition can sometimes last up to 12 weeks,
but it rarely causes complications in healthy, breast-fed infants.
The exact cause of breast milk jaundice isn’t known. However, it may be linked to a
substance in the breast milk that prevents certain proteins in the infant’s liver from breaking
down bilirubin. The condition may also run in families.
Breast milk jaundice is rare, affecting less than 3 percent of infants. When it does occur, it
usually doesn’t cause any problems and eventually goes away on its own. It’s safe to continue
breast-feeding your baby.
◦ What Are the Symptoms of Breast Milk Jaundice?

The symptoms of breast milk jaundice often develop after the first week of life. These may
include:
 yellow discoloration of the skin and the whites of the eyes

 fatigue
 listlessness
 poor weight gain
 high-pitched crying
◦ Mother: How Is Breast Milk Jaundice Treated?

◦ Dr: If the level of bilirubin is below the treatment level ( tell the mother - We have done a
blood test to check the level of bilirubin. (Show the blood test to the mother) and explain
bilirubin is below treatment level).
- It’s safe to continue breast-feeding your baby. Jaundice is a temporary condition that
shouldn’t interfere with the benefits of breast milk. Mild or moderate jaundice can usually be
monitored at home. It is better to breast-feed your baby more frequently or to give your baby
formula in addition to breast milk. This can help your infant pass the bilirubin in their stool or
urine.
( If the examiner says level is above the treatment level - Severe jaundice is often treated with
phototherapy, During phototherapy, your baby is kept under a special light for one to two
days.
◦ How Can Breast Milk Jaundice be prevented?

Most cases of breast milk jaundice can’t be prevented.
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What level of bilirubin requires phototherapy?
A commonly used rule of thumb in the NICU is to start phototherapy when the total serum
bilirubin level is greater than 5 times the birth weight. Thus, in a 1-kg infant, phototherapy is
started at a bilirubin level of 5 mg/dL; in a 2-kg infant, phototherapy is started at a bilirubin
level of 10mg/dL and so on
If the bilirubin is above the treatment level –
If the level of bilirubin is high then it can cause a condition called Kernicterus a type
of brain damage. It can cause cerebral palsy and hearing loss.
We need to start your baby on phototherapy treatment either in the hospital or at home. This
involves placing the baby in a cot under UV lamp( special light) for one or two days. The
baby will be naked and eyes will be covered. However, you can take the baby out for feeds
and nappy changes. Your baby will wear protective glasses throughout phototherapy to
prevent eye damage.
The light changes the structure of bilirubin molecules in a way that allows them to be
removed from the body more quickly.
We will test his bilirubin levels every 4 to 6 hours and also check his temperature once the
treatment starts and once the bilirubin levels falls, we can stop the treatment. (S.E of
phototherapy- rash, diarrhoea). The child must continue feeding even during this treatment.
If the bilirubin levels hasn’t come down after the phototherapy treatment, exchange blood
transfusion can be done-where we have to replace the baby’s blood with new blood.
If the examiner did not say whether the bilirubin is above or below the treatment level – then
tell the mother that if the level below – what we do and if the level is high what we do.
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PRIMARY NOCTURNAL ENURESIS

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Where you are
You are an FY2 in GP Surgery
Who the patient is
Sarah Coulter is a 35 years-old who has presented to you with some

concerns about her son Thomas
CONSULTATION
1. GRIPS  Mother [Greet, Rapport, Introduce, Posture, Smile]

18.
19. Hello. Sarah Coulter? Hi, my name is Dr. Swamy, I am one of the junior doctors here in the GP Surgery.
20.
 What would you like me to call you?

 Sarah is fine
 I understand you have some concerns about your son Thomas, is that correct?
 Yes
 Is Thomas here with us today?
 No, I’ve dropped him off with his grandparents today
2. PC  FODPARA  DDx  SR
 How can we help you today Sarah?

 Well doctor, it’s a little embarrassing, but Thomas keeps on wetting the bed at night, and it’s really gone
out of control
Oh, I’m really sorry to hear that.

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 Can you tell me a little bit more about Thomas?

 Yes, he’s 3 and a half years old. He has an older brother David who is 7. He’s completely healthy and he
loves playing with his brother. It’s just the bedwetting I’m concerned about
 Can you tell me a little bit more about the bedwetting?
 Yeah, I mean the sheets get absolutely soaked. It used to be once or twice a week but now it’s daily, we
kind of anticipate it’s going to happen every night!
 Is this the first time Thomas is experiencing these symptoms?
 No doctor, he’s been wetting the bed for a few months now
 And how did it come about? Sudden/Gradual?
 It happened suddenly when we got him off diapers
 And for how long has Thomas been having this problem?
 It’s been about 6 months now
 Has it been getting better or worse?
 Worse
 Do you think the bedwetting is aggravated by anything he does? Eating? Drinking? Activity?
 I don’t know
 And has the bedwetting improved with anything? Resting? Medication?
 No
 Is there anything else you’d like to add?
 No doctor, I’m just really annoyed that each morning I have to change his bedsheets, wash them and dry
them. I mean how long can I keep doing that?
Yes, you’re absolutely right, it must be quite stressful.
 Has he been experiencing any day-time symptoms?

 No, during the day he knows where the bathroom is and he does it all by himself. He’s dry during the
day, it’s only at night that it happens
 Primary Nocturnal Enuresis

 Secondary Nocturnal Enuresis
 Nightmares/Night Terrors
 Eating or Drinking before bedtime
 Neurological Problem
 Stress
 Urinary Habit
 Interventions/Drugs (Diuretics)
 Relative with similar issue
 Snoring
 Punishment & Reward
 UTI
 Domestic Abuse
 Parasomnias
 PTSD
 Polyuria
 T1DM
 Diabetes Insipidus
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21. Why is it happening?

22.
23. There are a few possible explanations as to why Thomas is wetting his bed at night. What I would like
to do is ask you a few more questions about the bedwetting, so I can paint a better picture as to why this is
happening.
24.
 How does that sound? – OK
 Can you recall for me the first time Thomas wet the bed? How long ago was it?
 He first wet the bed about 1 year ago just after his second birthday, when we forgot to put his nappy on
after we changed it
 Does he wet the bed every night?
 Yes, this last few weeks he has
 Has he ever awoken at night and paid a visit to the toilet?
 Sometimes he goes once or twice at night, sometimes he just sleeps through it
 And has he ever had a sustained 6-month period where he didn’t wear a nappy and he didn’t wet the
bed?
 No
 Is he aware he wets the bed, or does he sleep through it?
 Usually, he sleeps through it, and we find out together in the morning when we do the bed
 Has he ever awoken at night complaining of any bad dreams?
 No
 Can you just talk me through his routine before going to bed? Videogames? Movies?
 Well we have dinner around 5 or 6pm, and after that I get him into a bath. I give him some warm milk
and cookies around 7. We brush his teeth, I read him a book, and by 8pm he’s usually fast asleep. We
don’t watch any television
 Is he toilet-trained?
 Yes
 Does he have bathroom facilities nearby where he sleeps?
 Yes, he has an attached bathroom
 Does he drink a lot of fluids before going to bed?
 Well, just a glass of milk an hour before bed
 And does he use the toilet before going to bed?
 Sometimes, if he needs to
 How has Thomas been dealing with the bedwetting?
 He seems oblivious to it, like it isn’t a problem. Like it’s normal
 How have you been coping with his bedwetting?
 I’ve been really patient. I thought he would get better on his own
 Have you ever punished him because of his bedwetting?
 No
 Does Thomas have any problems with his brother or his dad?
 As I said, Thomas loves playing with David. His dad loves him so much
 I’m really sorry to have to ask you this, but is there any possibility that Thomas may have been
involved with any abuse at home?
 No doctor, why would you ask that?
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I’m really sorry, it is a routine question that we have to ask
 Fever? Headache? Photophobia? Neck stiffness? Nausea? Vomiting? Diarrhoea? Constipation? Muscle
aches? Seizures? Drowziness/Confusion? SOB? Chest Pain? Cough? Tummy pain? Pain on passing
wee? Blood in wee? Polyuria? Polydipsia? Polyphagia? Problems on passing poo? Dribbling? Urgency?
Hesitation? Incontinence? Tenesmus? Excessive crying?
 No
 Is there anything else that I may have missed which you would like to add?
 No
3. RISK FACTORS
Bedwetting is not your child's fault, and there's often no obvious reason why it
happens. But sometimes there may be more than one underlying cause.
u Having Drinks Before Bed
Drinking lots of fluids in the evening could cause your child to wet the bed during the night,
particularly if they have a small bladder.
Drinks containing caffeine, such as cola, tea and coffee, can also increase the urge to wee.
u Not Waking During the Night
Once the amount of urine in the bladder reaches a certain point, most people wake up as
they feel the need to go to the toilet.
But some younger children are particularly deep sleepers and their brain doesn't respond to
signals sent from their bladder, so they don't wake up.
In some children, the nerves attached to the bladder may not be fully developed yet, so they
don't send a strong enough signal to the brain.
Sometimes a child may wake up during the night with a full bladder but not go to the toilet.
This may be because of childhood fears, such as being scared of the dark.
u Underlying Health Condition
Bedwetting can also be caused by an underlying health condition, such as:
 Constipation – if a child's bowels become blocked with hard poo, it can put pressure on the
bladder and lead to bedwetting
 A UTI – your child may also have other symptoms, such as a fever and pain when they wee
 Type 1 Diabetes Mellitus – other symptoms of this include tiredness and feeling thirsty all
the time
u Emotional Problems
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In some cases, bedwetting can be a sign your child is upset or worried. Starting a new
school, being bullied, or the arrival of a new baby in the family can be very stressful for a
young child.
If your child has started wetting the bed after being dry at night for a while, there may be
an emotional issue behind it.
u Familial. In many cases, bedwetting runs in families.
4. 2PMAFTOSA + PBINDD
 No past Medical Hx
 No Medication Hx
 No Allergy Hx
 No Family Hx of bedwetting in David or the boys’ dad.
 No Travel Hx
 Will start nursery next month
 No Social Hx
 Personal –
o No smoking at home
o Father is a baker
o Diet healthy – drinks 8 glasses of water per day. Has dinner at 5pm, and after that has a warm
glass of milk before bed
o Sleeps 10 hours at night, no interruptions usually but sometimes awakes because of enuresis, no
naps.
o Good hygiene
o Active – football with his brother
 Pregnancy – Unremarkable
 Birth – NVD
 Immunizations – Up to date
 Nutrition – Healthy, balanced diet
 Development – Satisfactory
 Dehydration – No signs of dehydration
5. EXAMINATION
Ideally, I would like to have examined Thomas, and take a look at a few things, such as;

u VITALS
u GIT – Tummy
u GUT – External Genitalia
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Next time, I think it would be good to have Thomas with us so I could have a general look at him as an
overview.
6. FINDINGS & Dx
So from what you have told me, Thomas who is 3 & a half years old, has been wetting his bed for the past 6
months, and in recent weeks it’s become more of a daily issue. He has never had a dry spell of 6-months,
where he didn’t have to use a nappy or didn’t wet the bed.
 Is that correct? – YES
It seems like to me, that Thomas may be suffering from a condition called Primary Nocturnal Enuresis, which
is the medical term for bedwetting.
 Have you heard of that before? – NO
Primary nocturnal enuresis is the involuntary discharge of urine at night by children old enough to be
expected to have bladder control.
Enuresis – or involuntary urination - is considered primary when bladder control has never been attained and
secondary when incontinence reoccurs after at least six months of continence.
Since Thomas has never attained control of his bladder, his condition is categorized as Primary. Because he
wets his bed at night, it is termed as Nocturnal. And enuresis simply means involuntary urination. Hence
Primary Nocturnal Enuresis.
 Do you follow? - YES
Bedwetting is common in young children, but gets less common as children get older. The
majority of children learn to control their bladders as they grow older without any medical
intervention.
When treatment is warranted, most children respond exceptionally well to treatment, although they
may still wet the bed from time to time.
25. What can you do?

26.
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7. MANAGEMENT
It is normal for children to wet the bed while sleeping during the learning process. Bedwetting is typically not
even considered to be a problem until after age 7. I would like to reassure you that many children Thomas’
age wet the bed, and this usually resolves without treatment — reassurance maybe is all that is required.
Bedwetting Treatments at Home
It's best to try a few measures yourself first, such as:
 Reassure your child. It's important for them to know they haven't done anything wrong, and it
will get better
 Don't tell them off or punish them for wetting the bed as this won't help and could make the
problem worse
 Establishing a regular bedtime routine that includes going to the bathroom
 Avoid waking your child in the night or carrying them to the toilet, as it's not likely to help them in the
long term.
 Not giving your child anything to drink in the hour before bedtime
 Making sure they have a wee before going to sleep
 You could also consider buying a bedwetting alarm
 Drink plenty of fluids during the day
 Encourage regular toilet breaks during the day
 Waterproof bedsheets
 A reward scheme for acts such as; using the bathroom before bedtime and drinking fluids
throughout the day
 Ensuring easy access to toilet facilities
 Talking to your child about the advantages of toilet-training, such as not having to wear diapers and
becoming a "big kid"
 Writing and maintaining a diary to record the date and time of events and monitor progress
 Using nappies is a short-term fix
u Medical Treatments
 If a bedwetting alarm doesn't help or isn't suitable, treatment with medicines is usually
recommended
 You may be suggested a medicine called desmopressin. This helps reduce the amount of wee
produced by the kidneys. It's taken just before your child goes to bed
 If desmopressin or a bedwetting alarm (or a combination of both) doesn't help, your child may
be referred to a specialist, who may recommend other medicines
 Usually, desmopressin is not recommended for children under the age of 5
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 ERIC, The Children’s Bowel and Bladder Charity, is a UK charity for families affected by bedwetting,
daytime wetting, constipation and soiling. Their website has useful advice for both children and
parents
 We can follow-up in 10 days’ time to see how Thomas is progressing
 If there doesn’t seem to be an improvement, and the bedwetting persists beyond the age of 6/7 we
may need to consult a specialist called a Paediatrician
 Meanwhile, if the bedwetting worsens, causes a lot of distress, disrupts daily activities or occurs
alongside other symptoms, do come back to us or go to A&E
 I would like to consult my seniors if I missed anything, or was unable to answer any of your questions
so I can get back to you with the appropriate information
 I do have some reading material available about the condition that’s affecting Thomas, called Primary
Nocturnal Enuresis.
 Is there anything else I can help you with? – No, thank-you, you have been really helpful
 Is there anything in particular you were expecting to get out of this consultation today? – Yes, I
just wanted to know what the problem was and if it was serious. You seemed to have done
really well in addressing that
 For children older than 5 years of age:

o If bedwetting is infrequent (less than twice a week), reassure the parents or carers that
bedwetting may resolve without treatment and offer the option of a wait-and-see approach.
o If long-term treatment is required, offer treatment with an enuresis alarm (first-line
treatment) in combination with positive reward systems (for example star charts).
 Desmopressin is less preferred but may be considered if the child, parents, or carers do
not want to use an alarm or are unable to use an alarm.
o If rapid or short-term control of bedwetting is required (for example for sleepovers or
school trips), offer treatment with desmopressin.
 If bedwetting recurs after being treated successfully, consider:

o Restarting treatments which have been previously successful.
o Offering combination treatment with desmopressin and an enuresis alarm.\
 Seek specialist advice before initiating tricyclic antidepressants (such as imipramine) or

antimuscarinics (such as oxybutynin).
o Tricyclic antidepressants and antimuscarinics may be initiated in secondary or primary care
following an assessment by a healthcare professional with expertise in managing bedwetting.
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 Referral — if bedwetting has not responded to at least two complete courses of treatment with either
an alarm or desmopressin (this may be one course of each treatment, or two of the same), refer to secondary
care, an enuresis clinic, or a community paediatrician, depending on local protocols and availability.
o Further assessment is required for factors that may be associated with a poor response, such as
an overactive bladder, an underlying disease, or social and emotional factors.

Pyloric stenosis
Vomiting in New Born Child – Pyloric stenosis

Causes of vomiting in babies
1 Meningitis Does your child shy away from light, Rashes
2 UTI Fever, smelly urine, does he cry more while

passing wee
Gastroenteritis
3 Vomiting, Fever, Diarrhoea, Other similar
problem ( contact)
Food or milk intolerance
4 Any change in food, New food introduced
Gastro-oesophageal reflux –
5 Food dribbling, Reflux is just your baby
effortlessly spitting up whatever they've
swallowed. Muscles do not contract.
Too big a hole in the bottle teat
6 which causes your baby to swallow too much
milk
Over feeding
7 Do you think you are feeding more than usual
Accidentally swallowing
8 Any chance baby would have swallowed
something poisonous anything poisonous
Congenital pyloric stenosis

9 Presentation – 2 week old to 2 month old babies,
First child, Boy, Projectile vomiting (vomiting
quite a distance like a fountain), The baby
remains hungry and will usually feed well - only
to vomit the milk back soon after feeding. The
vomiting tends to become worse and worse over
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several days. The milk in the stomach often

curdles before the baby is sick.
Strangulated hernia –
1 Baby cries a lot, Swelling in the groin
0
Intussusception– Cries a lot, Mass felt in the tummy, red colour
1
stool,
1
1 Head injury Any injury to head

2
1 Pneumonia Fever
3
1 Middle ear infection Ear discharge

4
Dehydration question
dry mouth, crying without producing Lethargy, floppy, Drowsy, not active
tears, urinating less or not wetting
many nappies,
Exam question
You are FY2 doctor in Paediatric Department.

6 weeks old boy, Rhys was brought in by his mother with history of persistent
vomiting for last 2 days.
Take history from the mother Mrs Nicola Hampshire and talk to her about further
management.
Vital signs are given in question.
Hello I am Dr... one of the junior doctor in the Paediatric department. Are you the
mother of Rhys? Mother: Yes. I am
Dr: How may I call you? Mother: ? You can call me Nicola
Dr: How can I help you Miss/Mrs. . .?
Mother: My son has been vomiting a lot since last 2 days.

Dr: I am really sorry to hear about that. Can you tell me more about that?
Mother: Doctor he is throwing everything out.
Dr: How did it start? Mother: Doctor it started almost suddenly.
Dr: What do you feed him? Mother: I breastfeed him.
Dr: Does the vomiting occur in immediately after ( pyloric stenosis, GER) you
breastfeed him or later ?
Mother: Yes, doctor he vomits when I feed him.
Dr: Is it like throwing up or just dribbling of the food from the mouth (Regurgitation) ?
Mother: He is throwing up.
Dr: Does the vomit go far away like a fountain (Pyloric Stenosis)? Mother : yes
Dr: How many times does he vomit in the day?
Mother: Every time I feed him, (almost instantly) he throws up.
Dr: What is the content of the vomiting?
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Mother: It is just the milk.

Dr: Is it ever green coloured (bilious – duodenal atresia) or blood stained? Mother: No.
Dr: Do you think you are feeding him more than usual (Overfeeding) ? Mother : He is
very hungry all the time ( may be because of pyloric stenosis also)
Dr: Does your child shy away from light, Any Rashes ( meningitis) ? Mother : No
Dr: Has he got fever ( Meningitis, UTI, Pneumonia, Ear infection) ? Mother : No
Dr: Doe she cry a lot ( meningitis, Obstructed hernia, Intussusception) ? Mother : No
Dr: Have felt any lump in his tummy ( Pyloric stenosis, Intussusception) ? Mother
Yes/No
Dr: How is his poop? Is it normal or has he got diarrhoea( loose stool) (Gastroenteritis)
? Mother – Normal. ( may be less in quantity in Pyloric stenosis) .
D: Is the poop red coloured( Intussusception) ? Mother: No
Dr: Does his urine smell bad? (UTI) Mother: No.
Dr: Is there any recent change in his feed ( Milk allergy) ? Mother: No doctor.
Dr: Did he have any injury to the head? Mother : No
Dr: Is his mouth dry ( dehydration) ? Mother: Yes/No
Dr: How is he – is he active or drowsy (severe dehydration) ?Mother :He is not active
bit drowsy.
Dr: How has been your child before? Has been diagnosed with any medical conditions?
Has he ever been admitted to hospital before? Mother: No.
Dr: Any medications that your child is on? Mother: No doctor.
Dr: Does your child have any allergies? Mother: No.
Dr: Does any child in your family now or in the past had similar problems as Rhys?
[Family History risk factor for Pyloric Stenosis, gastroenteritis (contagious) ]
Mother: Yes/No
Dr: Is he your fist child or do you have any other children?
Mother : He is my first child. ( First child – risk factor for Pyloric stenosis)
Dr: When you delivered Rhys – was it normal birth or did you have any problems ?
Mother: It was normal.
Dr: Any problems during development? Mother: No doctor.
Dr: Is there anything else you think that may be important that we may need to know ?
Mother : No
Examination:
Well, I need to examine your baby’s tummy.

(Examiner may say there is no abnormal finding)
Diagnosis:
Dr: From the information that I have gathered I think Rhys might be having a condition
what we call as Pyloric Stenosis. Do you know anything about it?
Mother: No doctor.
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Dr: It is a condition in the tummy that can sometime affect the new born children. Let
me explain it to you. Our stomach opens into the gut ( bowel). The outlet of the stomach
into the gut is called the Pylorus. Stenosis means a narrowing. Pyloric Stenosis means a
narrowed outlet of the stomach. Because of the narrowing of the outlet of the stomach
food is not going to the gut. So the babies vomit the food out.
Mother: Is it serious doctor?
Dr: It is not a serious problem because we have a good treatment for this. This is not a
worrying condition.
Mother: Why did this happen?
Dr: It is not known why this occurs. This condition is seen more in boys than in girls.
And sometimes, it can run in families.
Mother: What are you going to do?
Dr: We need to admit Rhys. First of all, we need to confirm whether this is the problem
with Rhys.
I think Rhys is very drowsy because of severe dehydration which can happen when they
vomit a lot. We need to do some blood tests to check whether he has severe dehydration.
We will do some blood tests on him to check the blood gases.
[ Examiner may give the test result. Picture is as follows:
pH = High ( Normal 7.35 to 7.45 )

PaCO2= normal or high
HCO3- = high
Tell the mother - Blood test shows he has some problem called metabolic alkalosis this
is due to vomiting. (If asked then mention vomiting of acid from the tummy).
We also need to perform Ultrasound of his tummy to confirm whether this is the
condition. Mother: Ok doctor.
Treatment
Dr: We need to admit him and give some fluids through his veins for the hydration and
nutrition. So, please do not feed him until we tell you to do so. Is that Okay?
Mother: Okay. How will you treat him doctor ?
Dr: We can do a small operation to correct the narrowing of the stomach outlet and it
normally cures the problem. This operation is usually done by keyhole surgery. A small
cut is made in the skin over tummy. The operation allows the obstruction site to widen
into a normal size. This means that milk and food can pass easily out of the stomach into
the bowel.
Mother: Will there be any complication?
Dr: Some complications from surgery include bleeding and infection. However,
complications aren't common, and the results of surgery are generally excellent.
Mother: Will he be normal after this?
Dr: Yes, he will be normal and he will grow normally without having any problems.
Dr: Any other concerns ? Mother: No Thank you.
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Intussusception
Symptoms – Inconsolable cry, Diarrhoea – red currant jelly type of stool, vomiting
So the differential should include causes of inconsolable cry of diarrheoa.
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History should also include risk factors for Intussusception

Differential diagnosis for inconsolable cry in child
If symptoms started suddenly and recently, consider:

 Meningitis
 Intussusception, volvulus, strangulatedhernia.
 Torsion of thetestis.
 Corneal abrasion (such as from a scratch from the baby'snails).
 Non-accidentalinjury.
For more persistent crying, consider:

1. Transient cow's milkintolerance.
2. Transient lactoseintolerance.
3. Nappyrash.
4. Wind (inadequate burping: try sitting a bottle-fed baby upright when feeding to
reduce airintake).
5. Woman's diet if breastfeeding (for example too much coffee, tea, or soft drinksthat
contain caffeine, or too much alcohol or spicyfood).
Differentials for acute diarrhea:

1.Viral gastro enteritis = watery diarrhea, contact ( others having samesymptom),
food fromoutside
2.Bacterial – blood in stool,fever
3.Antibiotics
4.Meckel’s diverticulum – red colour stool but child is not ill, not crying.
Risk factors for Intussusception
Causes and associated conditions
Non-pathological lead point (>90%)
 Viral 50% - rotavirus, adenovirus and humanherpesvirus

 Amoebomata, shigella,yersinia.
 Peyer's patchhypertrophy.
Pathological lead point (<10%)
 Meckel's diverticulum(75%).
 Polyps and Peutz-Jeghers syndrome(16%).
 Henoch-Schönlein purpura(3%).
 Lymphoma and other tumours(3%).
 Foreignbody.
 Postoperative - rarely, postoperative intussusception following operative treatment ofan
P a g e | 711
intussusception has been reported.
Intussusception- exam question

GP referred a 20 month old child Andrew Collins because he was crying, lethargic, cold
and pale, but making enough urine.
Take history from child’s mother Mrs Samantha Collins and talk to her about the
further management.
Dr: Hello Mrs Sarah Collins. I am Dr … junior doctor in the Paediatric department. How can
I help you? Mom: My son has been crying a lot since almost 10 hours.
Dr: I am very sorry to hear that.
Dr: Do you know why he cryingatall? Mom: No doctor
Dr: Did he fall or have anyinjuries? Mom: No doctor
Dr: Has he got anysymptoms?
Mom: He has been passing loose stools since yesterday.
Dr: How manytimes ? Mom: May be 3 to 4times
Dr: What is the colour of the stool?
Mom: It looks red doctor ( looks like red currant jelly )
Dr: Has beenvomiting? Mom : Yes 3 to 4times
Dr: What is in thevomit? Mom: It is green colour liquid ( Bile)
Dr: Did you notice any lump or swelling in his tummy?
Mom: Yes his tummy looks bloated
Dr: Has he got high temperature?(meningitis) Mom:No
Dr: Has he got anyrashanywhere? Mom:No
Dr: Is the first time these things are happeningtohim? Mom:Yes
Dr: Does his urine smell bad ?(UTI) Mom:No
Dr: Has he got any swelling in the groin ( obstructed hernia) ? Mom: No Dr:
Any swelling or redness in the scrotum? ( torsion testes) ? Mom: No Dr: Do
you give him breast milk or bottle milk ?
Mom: Bottle milk / breast milk
Dr: Any change in his diet ? (milkallergy) Mom:No
Dr: Any change in your diet ( if she is breast feeding – intolerance to dairy products if mother
is drinking too much coffee tea, dairy products)
Dr: Does he have any othermedicalcondition? Mom:No
Dr: Did he have any problem in thetummybefore? Mom: No
Dr: Did he have any operations inthetummy? Mom:No
Dr: Is he on anymedications? Mom:No
Dr: Was there any problem during his birth ordevelopment? Mom:No
Dr: Do you have anyotherchildren? Mom:No
Dr: Any medical conditions in the familymembers? Mom:No
Examination
Dr: Mrs Collins I need to examine your child’s tummy. ( examiner may say there is massin
theabdomen)
Diagnosis:
With what you are telling me, I think your son has a condition what we call as
P a g e | 712
Intussusception. Do you anythingaboutthis? Mom:No
Dr: It is a condition in the tummy. As you know bowel looks like a tube. In this
condition a part of the bowel goes inside another part of the bowel like a telescopewhich
causes bowel obstruction. This quite a serious condition if we do not treat immediately.
This condition is usually seen in children between the age of 3 months to 24months.
Mom: Why did this happen?
Dr: Sometimes this can happen for no known reason. Sometime if he had any other
medical condition affecting the bowel can cause this. ( Meckel's diverticulum (75%),
Polyps, Henoch-Schönlein purpura (3%), Lymphoma and other tumours (3%), Cystic
fibrosis, An inflamed appendix, Foreign body, Postoperative ).
Mom: What are you going to do doctor?
Investigation
Dr: First of all we need to do some tests to confirm whether this is the problem.
We will do X ray of his tummy ( for perforation) and ultrasound scan of his tummy ( USG
- may show doughnut or target sign, pseudo kidney/sandwich appearance).
Also we will do some blood tests to check whether he is dehydrated because sometimes the
children can be very dehydrated withthis condition. Is that OK?
Mom: OK
Dr: Please do not give him anything to eat or drink now until we tell you to do so. To treat
him initially we will give some fluids through his veins to hydrate him.
There are 2 different ways to treat the condition. One is by doing an operation other one
without doing any operation with a simple procedure.
First we will try with a simple procedure - Our Radiology specialist doctors may try to push
the bowel back to the original position by giving some type of air enema ( air and water
double contrast enema) with high pressure through the back passage of your child.
If it is not possible to correct with the enema or if there are any other problems in his tummy
we may need to do the operation and correct the condition. ( indications for laparotomy:
Peritonitis, Perforation, Prolonged history (>24 hours), High likelihood of pathological lead
point, Failed enema.
Mom: Can you leave it like that doctor ? Won’t it become normal on its own ?
Dr: It is very rare that it will correct itself. Since he already has severe symptoms it is very
P a g e | 713
unlikely it will correct itself now. If we leave it like that for long time it can cause damage to
the bowel wall and we may have to do the operation.
Mom: When can I take him back home ?
Dr: If it corrected by enema, you can take him back home in a day or two. If we have to do
the surgery to correct the problem then we need to keep him in the hospital for about 3 to 4
days.
Mom: Will there be any problem after the treatment?
Dr: Usually there is no problem after the treatment.
Mom: Will it happen again?
Dr: Very rarely it can happen again ( recurrence rate :5-15%)
Dr: Any otherconcerns ? Mom:No
Dr: Thank you very much. I will try to arrange the tests now and keep you informed.

Head injury in children
P a g e | 714
Indications for referral to hospital A&E department after head injury for children
➢ A high-energy head injury - eg, diving accident, high-speed motor vehiclecollision.
➢ GCS <15 at any time sinceinjury.
➢ Any loss of consciousness as a result of theinjury.
➢ Any focal neurological deficit since theinjury.
➢ Amnesia for events before or after theinjury.
➢ Persistent headache since theinjury.
➢ Any vomiting episodes since the injury (clinical judgement should be used in those aged≤12
years).
➢ Any seizure since theinjury.
➢ Irritability or altered behaviour, particularly in infants and youngchildren.
➢ Any suspicion of a skull fracture or penetrating head injury since the injury (eg, clear fluidfrom
the ears or nose, black eye with no associated damage around the eyes, bleeding from one or more
ears, new deafness in one or more ears, bruisingbehind
one or more ears).
Visible trauma to the head not covered above but still of concern to the professional
The following children meet the criteria for admission to hospital following a head injury
➢ History of loss ofconsciousness.
➢ Neurological abnormality, persisting headache orvomiting.
➢ Clinical or radiological evidence of skull fracture or penetratinginjury.
➢ Difficulty in making a fullassessment.
➢ Suspicion of non-accidentalinjury.
➢ Other significant medicalproblems.
➢ Not accompanied by a responsible adult or social circumstances consideredunsatisfactory.
Selection of children (under 16 years) for CT scan [ NICE guideline]

Children
For children who have sustained a head injury and have any of the
following risk factors, perform a CT head scan within 1 hour of the risk
factor beingidentified:
 Suspicion of non-accidentalinjury
 Post-traumatic seizure but no history ofepilepsy.
 On initial emergency department assessment, GCS less than 14, or for childrenunder
1 year GCS (paediatric) less than15.
P a g e | 715
 At 2 hours after the injury, GCS less than15.

 Suspected open or depressed skull fracture or tensefontanelle.
 Any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluidleakage
from the ear or nose, Battle'ssign).
 Focal neurologicaldeficit.
 For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on
the head.
A provisional written radiology report should be made available within 1 hour of the scan
being performed. [new 2014]
For children who have sustained a head injury and have more than 1 of the following risk
factors (and none of those in recommendation 1.4.9), perform a CT head scan within 1 hour ofthe
risk factors beingidentified:
 Loss of consciousness lasting more than 5 minutes(witnessed).
 Abnormal drowsiness.
 Three or more discrete episodes ofvomiting.
 Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian,
cyclist or vehicle occupant, fall from a height of greater than 3 metres, high-speed injury
from a projectile or otherobject).
 Amnesia (antegrade or retrograde) lasting more than 5minutes [4].
being performed. [new 2014]
Children who have sustained a head injury and have only 1 of the risk factors in recommendation
(and none of those in recommendation 1.4.9) should be observed for a minimum of 4hours
after the head injury. If during observation any of the risk factors below are identified, perform a
CT head scan within 1hour:
 GCS less than15.
 Furthervomiting.
 A further episode of abnormaldrowsiness.
being performed. If none of these risk factors occur during observation, use clinical
judgement to determine whether a longer period of observation is needed. [new 2014]
Head injury in child exam question

9 Month old child Jane was brought in by her mother with a history of fall from sofa.
Take history from the mother and talk to her about further management.
P a g e | 716
History should include pre –incident – incident and post incident – also questions for Non
accidental injuries)
Check for indications for CT scan of head and admission.
P a g e | 717
Hello I am Dr … one of the junior in the Paediatric department. Are you the mother of Jane
Anderson ? Mother : Yes:
Dr: How can I call you please ?
Mother : You can call me Mrs Anderson. Dr: How can I help you Mrs Anderson?
Mother: My daughter Jane fell from the sofa today.
Dr: I am sorry to hear that. When did this happen? Mother : About an hour ago.
Dr: Can you please tell me what happened immediately after that?
Mother : She was quite for some time then she started crying.
Dr: Why did you worry about Jane to bring her to the hospital?
Moher: She has some bruise on her head.
Dr: What did you do immediately after that? Mother : I brought her here to the hospital.
Dr: It is really good that you brought her I immediately.
Can you please tell me what was Jane doing before she fell from the sofa?
Mother: She was lying on the sofa and playing.
Dr: Was she well before this happened?
Mother: She was completely fine before this happened.
Dr: How did she fall from the sofa?
Mother: She rolled over and fell down. I was changing the nappy of my other child
Dr: Ok. What type of floor was it? Carpeted or tiled floor?
Mother: Carpet floor.
Dr: Did she lose consciousness after she fell down?
Mother : She was limp for few seconds but she did not lose consciousness. She started crying
immediately.
Dr: Has been fully conscious after that until you brought her in here? Mother – Yes
Dr: was she drowsy at all after the fall? Mother : No
Dr: Can you please show me in your finger how big is the bruise?
Mother: This long doctor ( she may show in her finger ( may be lesser than or more than 5 cm).
Dr: Did you notice any other injury on her head apart from bruise like wound or swelling ?
Mother : No
Dr: Did she have any bleeding or fluid discharge from her ear or nose ? Mother : No
Dr: Did you notice any injury anywhere else in the body?
Mother : No Dr: Did she vomit after the fall? Mother: Yes twice/once.
Dr Did she have any fits? Mother : No
Dr: Did you notice any abnormal behaviour of your child after this incident? Mother: No
Dr: Was she completely fine and playful after this incident apart from vomiting? Mother : Yes
Dr: Did Jane have any injuries in the past for which she was brought into the hospital or even not
brought into the hospital? Mother: No
P a g e | 718
Dr: May I ask who looks after Jane?

Mother: I look after Jane – sometimes my sister looks after Jane. Dr: Do you mean your sister lives
with you.
Mother: Yes/ No. Sometimes when I have work I drop Jane in my sister’s house.
Dr: Does your sister like your child ? Mother : Yes, she likes her a lot.
Dr: What aboutJanes’Father? Mother: We aredivorced.
Dr: Does he look after Jane anytime? Mother – Sometimes yes.
Dr: Does he take her with him to look after her ? Mother : No
Dr: Did you have any problem when you were pregnant with Jane? [ to check whether she is the
biological mother] Mother : No
Dr: How was the delivery? Did you have normal delivery or caesarean section ?
Mother: Normal delivery
Dr: Was this a planned pregnancy? Mother : Yes
Dr: Has Jane been diagnosed with any medical conditions at all? Mother: No
Dr: Do you have any other children ?
Mother: Yes I have another 3 year old daughter.
Dr: Did she have any injuries any time? Mother: No
Dr: Whom do you live with? Mother: I live on my own with my 2 children
Dr: How does the father and the children get along with each other? Mother: They are Ok.
Dr: Sorry to ask you this Does the father or any one hurt your children at all? Mother : No
Dr: Is there anything else you think that we may need to know?
Mother: I just feel guilty doctor!
Dr: Please don’t feel guilty. Sometimes it does happen.
Mrs Anderson. I need to examine your child for any signs of head injuries
[ Examiner did not give any findings – if the examiner asks - what you want to examine – I will
check for head injuries any other new or old injuries. Check the GCS and vital signs – examiner
may say child is fine apart from bruise]
Management:
I think your child has no serious head injury with the information what you have given me.
Normally we do tests like CT scan of the head to look for any bleeding inside the head if the child
vomits more than 3 times or if the bruise is more than 5 cm or if they lose consciousness and other
things. You said she vomited only twice and her bruise is very small and she is completely fine
now - the chances she is having any bleeding inside the head very very low. So we do not need to
do CT scan of the head of your child. There is no need for any treatment. There is no need to keep
her in the hospital.
You can take your child back home. It is very unlikely that she will have any further problems.
You can give her some paracetamol if she keeps crying. Is that OKMrsAnderson? Mother :
Okdoctor.
Dr: You need to observe her at least for 24 hours at home. If she has any symptoms like
P a g e | 719
1. If she losesconsciousness,
2. She is abnormally drowsy (feeling sleepy) that goes on for longer than 1 hour when theywould
normally be wideawake,
3. you find difficulty in waking her up,
4.weakness in one or more arms or legs
5.vomiting (beingsick)
6.seizures (also known as convulsions or fits)
7.clear fluid coming out of their ear or nose
8.bleeding from one or both ears
I suggest you call the ambulance and bring her back to the hospital emergency department as soon
as possible because these symptoms show there is bleeding inside the head. But I as I told you
before these are very rare to happen.
Do make sure that there is a nearby telephone and you should stay within easy reach of the hospital
Any other question ? Mother: No
Dr: Thank you.

Mother doesn’t want IV cannula.
Question:
Child
Dr:with cerebral
Anyone elsepalsy………
lives at your home? Mother - No
You are FY2 in Pediatrics department. 4 years old child, Teddie is admitted with severe
pneumonia.
Dr: What work do you do? Mother : I work as …
This is the 4th time he is admitted with pneumonia. He has been prescribed course of I/V
antibiotics for 5 days. This is the second day of treatment.
Patient has Fever and Tachypnea. On x-ray there is consolidation.
Talk to mother and address her concerns.
Dr: Hello I am Dr……………., One of the junior doctors in the department. Are you the
mother of Teddie? Mother: Yes.
Dr: How may I call you? Mother: Call me Stacey.
Dr: Alright Stacey, How may I help you today?
Pt: Doctor, I don’t want Teddie to have an I/V Cannula.
Dr: Stacey, is there any reason for you to say that?
Pt: Yes Doctor, He is already in lot of discomfort. He has very thin and small veins. Doctors
and nurses keep pricking him again and again. He cries a lot, it is really hard for me to see
that.
Dr: Stacey your concern is valid, I do understand this process can be painful. You are very
caring mother and I know it is your love for your son which is making you say this… but do
you know why are we trying to pass cannula?
Pt: Yes doctor I know that Teddie has chest infection and you want to give him medicine
through his veins. But it is very painful for him and I cannot allow that. Give him some other
medicine, give him syrup or tablets.
P a g e | 720
Dr: Yes Stacey you are right, Teddie has pneumonia and I really wish if we could give him
medicine in form of syrups or tablets. But these are not as effective as medicines through
veins. As you know this is the fourth time that he is being admitted with pneumonia and this
time it is severe. So, I am afraid, syrups and tablets won’t help Teddie much with this
condition.
These medicines are antibiotics and they are necessary for Teddie. It is really important that
we complete their course for five days.
Pt: Yes doctor I want Teddie to get better but this is too difficult for me to watch. Doctors and
nurses prick him like he is a pin cushion. He doesn’t speak much but pain shows on his face.
Dr: I am really sorry that you have to see all this. We are only doing all this because we want
Teddie to get better as soon as possible. As you are aware that Teddie unfortunately has
cerebral palsy. In this condition muscles of chest wall are weak and if any chest infection is
left untreated or if the treatment is not adequate, it can be very dangerous. So we have to act
very fast. This can only be done if we give him medicines through his veins.
If you would like I would request most senior person to put in the I/V cannula. We would
also apply local anesthetic cream on him arm before the procedure so that he doesn’t feel any
pain. What do you think?
Pt: Okay, doctor you may pass the cannula. I just don’t want to see him in pain.
Dr: Stacey, We will be very careful and once the cannula is in place we will make every
effort that it is maintained and we don’t have to repeat the procedure.
Is there anything else we can do for you?
Pt: No doctor, Thank you.
Dr: Thank you very much Stacey for understanding the need and allowing us to pass I/V line.
If there is anything else, We will be glad to help you.

Cerebral palsy patient. Father thinks unfairly
treated.
20 year old man with cerebral palsy was brought into the A&E 5 days ago because he
fell from a wheel chair. He had footinjury. He was treated with just pain killers
without doing any X Ray to rule out fracture. X Ray was not needed at that time
because there was no bony tenderness. He was treated with Paracetamol.
Father brought him again today requesting for X Ray.
Talk to the father and address his concerns.
Points to cover
1. Ask what happened
2. History during first presentation and what was done and told to him
P a g e | 721
3. How is the progress

4. Why is he worried
5. Tell the reason why X Ray was not done last time
6. Reassure that you will do X Ray this time if needed
7. With his information – X Ray not needed now.
8. Reassure that it is just soft tissue injury and it takes time to heal.
9. Explain that the discrimination is unlikely. We treat everyone equally
10. If he still feels that the discrimination has been done – apologize and say that he can
complain.
Dr: Hello I am one of the junior doctors in the department. How may I call you?
Father: You can call me Mr Fredrick.
Dr: How can I help you Mr Fredrick?
Father: My son was brought into the hospital few days ago. I am very disappointed with
the treatment given to him.
Dr: I am really sorry that you feel that way. Can you please tell me what happened to your
son?
Father: He has Cerebral palsy. He fell down when I was shifting him from the wheel chair
to his bed 5 days ago. He injured his foot. I brought him in here 5 days ago. Doctors did
not even do any X ray and said he has just muscle pain and gave just paracetamol. Instead
of providing special care my son was treated very unfairly. I am very upset about it. This is
not how it should be.
Dr: Why do you think that he was treated unfairly Mr Fredrick?

Father: He injured his foot and none of the doctors did X ray of his foot. They just gave
him few medicines and sent us away. That shouldn’t be the way in hospital.
Dr: Certainly you are right Mr Fredrick no patient should be ignored or neglected in any
setting. We try our level best to give the good l care to all our patients. Can you please tell
me what were the symptoms he was experiencing when you brought him to the hospital
last time ?
Pt: He was having pain in the ankle and he was crying. Initially he could put weight on the
foot. But later on he couldn’t even put weight on the foot. He had swelling and bruise also
on the ankle. I have been so worried. They should have done an X ray to check if there
was bone damage.
Dr: Mr Fredrick I can understand why you are worried. We normally do the X Ray if there
is suspicion of fracture when we examine the patients. But if there is no suspicion of
fracture then we do not do X Ray. Sometimes it’s apparent from the history and assessment
that there is no bone damage. It might have been the case. Was he able to move his toes
after the injury? Father....
Dr:. How is the swelling around the ankle now ?
Father: Swelling has subsided now but there is still a bruise.
Dr: That is a good sign that the swelling has decreased. It means that the injury is healing.
The bruise will take slightly longer to go away.
Dr: Has the pain been the same since injury or has it changed in intensity? Father:...
Dr: what did the doctor advise him in the last visit?
Father: Doctors said there is no fracture. May be he has a fracture. Isn't it still better to do
an X Ray. Don’t people have X Ray done for smallest of reasons my son actually had a
fall. I feel as if he was treated as a second grade citizen and deemed not worthy of equal
care as others. He can't put weight on his feet though in the beginning he could. It worries
me I want to have an X Ray done for him now.
Dr: I can understand how you feel Mr Fredrick. It is very difficult to see your child in pain.
I want to assure you that all our patients are equally dear to us. We try our best to provide
all of them with best care possible. Also we try to keep our patients safe and try not to give
them unnecessary treatments. If at all the Xray was needed we would have done it.
P a g e | 722
Father: What if he is having a fracture?

Dr: I can see that you are a very concerned father. I will definitely examine him again and
see whether he needs X Ray now and if he needs it we will definitely do that now.
( Talk about examination – examiner may say there is no bony tenderness and the
swellinghas subsided just a bruise seen – tell the father I examined him now and there is no
pain over the bone and has gone down ). With the information what you are giving me that
his swelling has reduced since the injury and after examining him , I still do not think he
has a fracture and I do not think we need to do X Ray.
Let me explain in detail about when we do the X Ray and when we avoid doing the X ray
- For ankle or foot injury we do preliminary assessment of the patient and see if he was
able to put weight initially. If one can put weight on his foot, it is very unlikely that the
bone is broken. On examining the patient if there is pain when we press on the bony points
which suggests there could be fracture then we do the X Ray. But if there is no pain when
we press on the bony points which suggest the fracture is very unlikely then we avoid
doing the X Ray because doing unnecessary X ray can cause radiation which itself can
cause cancers. So we try to avoid doing unnecessary X Rays for patient’s own benefit.
I see that you are worried about him because of the bruise. It may take few more days for
the bruise to go down. Are you following me Mr Fredrick?
Father: Yes.
Dr: Mr Fredrick I want to reassure you again. There is a standard procedure we normally
follow whether is patient is a normal person or differently abled person. It is very unlikely
that he was treated unfairly because of his condition. However if you still want to escalate
the matter you can make a formal complaint. We have a separate department for this
purpose called Patient Advisory Liaison Service (PALS). They will help you make the
complaint. Any complaint will be taken seriously and respective authorities will assess the
matter and I assure that if there is any sort of discrimination there will be action taken on
the concerned person.
Father: Thank You Doctor I will see about that.I feel relieved after talking to you.
Dr: I am glad I could help Mr Fredrick. I hope your son recovers soon. If you have any
problems please do not hesitate to come to us. We are here for you.
Father: Thank You Doctor.
Sometimes the question may say that only father is here in the hospital. In that case ask the
father to bring his son – We will examine him and see whether he requires X Ray.

Epipen use Teaching
Question: You are an FY2 in the GP Surgery.
Jason Winslow 8-year-old boy was admitted to the hospital with anaphylaxis after
ingesting peanuts one week back. His mother Becca Winslow has questions about
how to use the EpiPen.
(On the table there is a dummy EpiPen)

Hello. My nameisDr.................I am one of the junior doctors here in the GPSurgery.
Is it Becca Winslow? Yes, I am Becca. Jason’s mother.
P a g e | 723
It’s nice to meet you, Becca. Could you confirm Jason’s age for me please? He’s eight.
How can we help you today?
Doctor, my son Jason has a peanut allergy and I was given an EpiPen to use but I am not
at all confident on how to use it.
I see. That’s all right, Becca. We can explain when and how to use the Epipen. Before we
start is it all right if I ask you a few questions regarding Jason’s health? Sure.
When was he prescribed the EpiPen? When he was four.
What happened at that time?

He had difficulty breathing and was taken to hospital after I gave him some peanut butter.
Have you had to use the EpiPen in the last four years?
No, Doctor, I have been really careful not give him peanuts but last week we were at
a birthday party and I don’t know whatheate. there must have been peanuts in
thecake.
That’s really good that you have been careful about not giving him peanuts. As you
know, when it comes to allergies, the best thing to do is to avoid the cause. It is good to
read the labels on food and ingredients and letting staff at a restaurant know that Jason is
allergic to peanuts so it's not included in his meal. Also, try to let the parents of Jason’s
friends
know about his allergy as well. Most importantly, Jason himself should be taught about his
allergy and to avoid peanuts.
What happened after that at the Party?
Jason came up to me and said he had trouble breathing. I knew it was an allergic
reaction but I was too nervous to give him the EpiPen. So, I called the ambulance
instead. They came and gave him medicines and took him to the hospital.
How is Jason doing now? He is fine. He is at school.
That’s good to hear. It’s really good that you recognized that it might be an allergic
reaction called the ambulance quickly and Jason got the treatment he needed.
Does Jason have any other allergies? No
Has he been diagnosed with any medical conditions? Asthma, for instance? No
Does he take any medications? No

What was his birth like? It was fine
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Is he up-to-date with his jabs? Yes
Who takes care of him usually? Just me.
Thank you, Becca for answering my questions.

Becca, you mentioned that you were carrying the EpiPen…that is a very good practice.
Always carry two EpiPens when you are with Jason. If someone else is with Jason make
sure they have his EpiPens and know how to use them. You should store your Epipens in
the hard carry case at room temperature and they should not be left in the car or put into the
refrigerator. Extreme temperatures can ruin the medication. Do you follow me?
Let’s have a look at the EpiPen we have here. This is called an EpiPen Autoinjector. It
contains one fixed dose of a medication called epinephrine. There are two types of
EpiPens, one is the EpiPen and one is the EpiPen Jr. Each is colour coded and these
are prescribed based on weight. The colour green is for smaller kids and yellow for
biggerkids andadults.
(0.15 mg epinephrine in children less than 25 kg and 0.3 mg in adults and

childrenmore than25kg)
In a severe allergy also called an anaphylaxis, the body produces chemicals that
makes the blood pressure drop and the airways to become narrow which can be life
threatening.
Epinephrine works by reversing these effects. It is a life-saving medicine when
someone has anaphylaxis. Am I going too fast? No, It’s fine.
On the EpiPen there is a small clear, viewing window where you can see the medicine
inside. Check your pens every month. The medication should be a clear liquid. If it’s
dark, cloudy, brown, pink or looks like it has particles, this pen may have been
damaged. Also check the expiry date to make sure, it’s not expired. You can sign up
for a reminder service with the manufacturer where they call you and remind you to
check your pens every month. Would you likethat? No, I can remember.
Becca, you mentioned that you knew that Jason was having an allergic reaction
because he said he was having difficulty in breathing. You are right, that is one of the
signs of anaphylaxis. Other signs could include: swelling/tingling of the lips, tongue,
shortness of breath and an itchy or tight throat, an itchy raised rash, confusion,
dizziness, noisy breathing, a racing heart, collapsing or losing consciousness
So, if Jason has these symptoms or if you know he has ingested peanuts- use the
EpiPen on him immediately, okay? Okay
So, if you notice Jason having these symptoms, the first thing to do is not to panic. I
can imagine that it might be difficult in such a scary situation but the best thing you
can do for Jason is to remaincalm.
Lay him down flat on the floor, with his legs raised up. Lay him down on his side if
he is unconscious or drowsy.
Take the EpiPen out of the hard carry cover.
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Hold it in your dominant hand with your fingers and thumb wrapped around the
body of the pen making a fist. Make sure your fingers don’t cover either end of the
pen.
Each Epipen has a blue safety cap on the top and an orange tip at the bottom.
Remember, blue to the sky, orange to the thigh.Could you repeat that for me?
Blue to the sky. Orange to the thigh.
Excellent.Nowtakethebluesafetycapoffandholdit withtheorangetipabout10cm
away from his upper, outer thigh. This part of the thigh has a big muscle and
medicine needs to be injected into it. The thigh should be held still
whileinjecting.
The needle is designed to be able to go through clothes, even jeans. There is no

need to remove his clothing. But make sure you avoid seams or zippers.
Withoneswiftjab,bringthependownata90-degreeangleon his thighuntilyouheara

click.Holditinplaceandcounttothree-nottoofast-count-Oneelephant,twoelephant,
threeelephant.
Then,removethepenandcall999immediatelyandsay-ANAPHYLAXISorSEVERE
ALLERGY. They will bring Jason to the hospital for furthertreatment.
Could you repeat for me what you will say when you call 999? Anaphylaxis.
Perfect. At this point, make a note of the time, stay with Jason and observe him closely.
If Jason’s symptoms are not better in 5 minutes and the ambulance has not yet come
then use another EpiPen on his other thigh.
Even if he is feeling better, it is important he keeps lying down and is assessed
at the hospital. Okay? Yes.
Once an EpiPen has been used the orange guard comes down over the needle and
the viewing window is obscured. It cannot be used again. You can give your used
EpiPen to pharmacy, ambulance or hospital staff. Make sure you replace your
EpiPen from the pharmacy as soon as possible.Do you have any questions?
Do I need the massage the site of injection?

P a g e | 726
There is no need to massage the area. As long as you hear the click it means the
medicine has been injected.
Does he need to go to the hospital if he is feeing better?

Yes. It’s important, as sometimes there can be a second reaction after the first.
He will be observed at the hospital– usually for 6-12 hours – as the
symptoms can occasionally return during this period.
While in hospital he might be given oxygen, fluid through his veins and medicines
such as anti-histamines and steroids to relieve his symptoms. EpiPen auto-injectors
may be provided for emergency use between leaving hospital and attending the
follow-up appointment. Do you have any more questions?
Reference information:
Identify triggers
Finding out if you're allergic to anything that could trigger anaphylaxis
can help you avoid these triggers in the future.
If you've had anaphylaxis and have not already been diagnosed with an
allergy, you should be referred to an allergy clinic for tests to identify
any triggers.
The most commonly used tests are:
 a skin prick test – your skin is pricked with a tiny amount of a
suspected allergen to see if itreacts
 a blood test – a sample of your blood is taken to test its reaction to

a suspectedallergen.
Avoid triggers
If a trigger has been identified, you'll need to take steps to avoid it in
the future whenever possible. Read our advice about avoiding some
specifictriggers.
Food
You can reduce the chances of being exposed to a food allergen by:
 checking food labels andingredients
 letting staff at a restaurant know what you're allergic to so it's
not included in yourmeal
 remembering some types of food may contain small traces of
potential allergens – for example, some sauces contain wheat
andpeanut.
Insect stings
You can reduce your risk of being stung by an insect by taking basic
precautions, such as:
 moving away from wasps, hornets or bees slowly without panicking –
do not wave your arms around or swat atthem
 using an insect repellent if you spend time outdoors,
P a g e | 727
particularly in thesummer
 being careful drinking out of cans when there are insects around –
insects may fly or crawl inside the can and sting you in the mouth
when you take a drink.
Medicines
If you're allergic to certain types of medicines, there are normally
alternatives that can be safely used.
For example, if you're allergic to:
 penicillin – you can normally safely take a different group of
antibioticsknown asmacrolides
 non-steroidal anti-inflammatory drugs (NSAIDs), such as
ibuprofenand aspirin – you can normally safely take paracetamol;
read the ingredients of things like colds medicines carefully to make
sure they do not containNSAIDs
 one type of general anaesthetic– others are available, or it may be
possible to perform surgery using alocal anaestheticor
anepiduralinjection.

Newly diagnosed Epilepsy in child
Exam question
You are the FY 2 doctor in Paediatric department.
12 year girl Anna had a fit for the second time and was diagnosed with
Epilepsy. She was treated with medications by the Paediatric Neurologist.
She is about to be discharged.
Talk to her mother and address her concerns.
Dr: Hello I am Dr… one of the junior doctor in the department. Are you Anna’s mother?
Mother: Yes
Dr: How are you doing? Mother I am Ok.
D: I am one of the junior doctor looking after your daughter Anna. I am here to talk to you
about her. Is that Ok? Mother: Yes.
Dr: I understand that Anna had a fit and was brought into the hospital. Can you please tell
me bit more about the fit?
Mother: She had a fit. Her whole body was jerking.
Dr: Did she have fit like this before ?
Mother : Yes she had a fit few months ago.
Dr: Is this the second time she had a fit? Mother : That is right.
Dr; Was she diagnosed with any medical condition at all before this? Mother: No
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DR: Does she has Diabetes ? No

Dr: Did she have any headache or rashes on her body when she had fits ? No
Dr: Did she have fever when she had Fits ? No
Dr: Any of her family members had fits like this at all? Mother : No
Dr: Do you have any idea why Anna had that fit Mrs.. ?
Mother : No / Yes
Dr: If she say no - Unfortunately it is not a good news. Do you want to know about it?
Mother: Yes
Dr: Mrs… Our Paediatric Neurologist has seen her. We have done some tests on her and
unfortunately she has a condition called Epilepsy. Do you know anything about it ?
Mother: No doctor.
Diagnosis:
Dr: I will explain everything to you. Epilepsy is a condition that affects the brain and
causes repeated fits. It is due to abnormal electrical activity in the brain. Sometimes there is
no reason why this condition happens although sometimes it could be an inherited
condition.
Mother: Is it a serious condition ?
Dr: Unfortunately it is a serious condition because even if we treat she can have fits like
this again for a long time may be even for years.
Mother: What are you going to do now ?
Dr: Our specialist doctor has decided the treat her with some medications. She has to take
this mediations which are tablets regularly every day without forgetting. It is important that
she takes this medicines even when she does not have fits because there should be certain
amount of medicine in her blood all the time to prevent hr having fit. [ check whether the
medication on the table. If there is medicine check the BNF for the dose and side effects]
Mother: Ok
Dr: If she is going to take any medications she should tell her GP about it because other
medications can interact with the epilepsy medications.
Mother : Ok
Dr: We will keep monitoring her. As she grows older we may need to increase the dose of
her medication. If she has diarrhoea and vomiting then the medications may not be
absorbing into her system, in that case you need to inform the GP.
Dr: There are several factors which can trigger these fits like exposure to too much light in
cinema, watching TV for long time.
Does she happen go to cinema or watch TV for long time? Mother: Yes
Dr: It is better for her to avoid watching cinema or watching TV for long time.
Dr: Does she work on the computers for long time or does she play computer games?
Mother: Yes she does.
Dr: Again I advise you to tell her to avoid looking at the computer continuously for long
time.
Dr: It’s better for her to avoid places with bright flashing lights like clubs because flashing
lights can trigger fits. Mother: OK
Dr: Also sometimes lack of sleep or starving for long time also trigger fits. Please tell her to
sleep well and have food at regular intervals – she should not starve for long time.
Dr: She should be careful when taking shower. It is better for her not take bath in bath tub
instead she should take a shower because if at all she has fit while taking bath in bath tub it
can be dangerous to her.
Mother: OK
Dr: Does she swim ? Mother: Yes she loves to swim.
Dr: If she is swimming in the swimming pool or sea or river she should tell the lifeguards
that she has this condition. Swimming in the river or sea is more risky than swimming in
the pool.
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Mother: Can she dance doctor? She loves to dance.

Dr: She can certainly dance. But she should avoid dancing in the clubs where there are
flashing lights. Also someone should be there while she dances who knows her condition
and what to do is she has the fits when she dances. Mother : OK
Dr: She should not go near to the fire. If there is gas cooker at home it may be better to
change to electric cooker and it is better for her to avoid cooking.
Dr: In the future she may not be able to drive if she still has fits. You can take advise from
the DVLA at that time. Mother : OK
Dr: Please inform her school and friends about her condition and let them know how to
help her. Please make sure she wears her epilepsy bracelet all the time. Any other
concerns ?
Mother : What to do if she has a fit ?
Dr: When she has a fit
 Lay her on her side with her face turned to on the side. (This will stop them
swallowing any vomit, and prevent choking )
 Don’t put anything, including medication, in your her mouth while she is having a
fit. Do not put any hard objects into the mouth to prevent tongue bite because it can
break teeth and the broken teeth can go into the wind pipe and cause choking. It is
better to have tongue bite rather than broken teeth because tongue bite will heal on
its own in few days.
 Stay with her. If it lasts longer than five minutes call the ambulance.

Mother: Ok
Dr : Any other concerns ? Mother : No. Thank you.
Information
Relevant recommendations Children, young people and adults with epilepsy and their
families and/or carers should be given, and have access to sources of, information about
(where appropriate):
 epilepsy in general
 diagnosis and treatment options
 medication and side effects seizure type(s),
 triggers and seizure control
 management and self-care
 risk management first aid, safety and injury prevention at home and at school or
work
 psychological issues
 social security benefits and social services
 insurance issues
 education and healthcare at school
 employment and independent living for adults
 importance of disclosing epilepsy at work, if relevant (if further information or
clarification is needed, voluntary organisations should be contacted) road safety and
driving prognosis sudden death in epilepsy (SUDEP) status epilepticus lifestyle,
leisure and social issues (including recreational drugs, alcohol,
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Mother with premature child – upset with nursing care

Exam question
Child born at 24 weeks ( premature birth) was in the hospital for 10 months.
Mother is very upset with the nursing care. Talk to her.
Dr: Hello Mrs.. I am Dr... How can I help you?
Mother: My child is prematurely born and he is in this hospital for the last 10 months. I am
very upset with the nurses.
Dr: I am very sorry you felt that way. May I know why your child is in the hospital ?
Mother : He has ... condition.
Dr: I am sorry that your child is in the hospital for such a long time. May I know exactly why
you are upset with the nurses ?
Mother: Whenever I come to see my child I see the poo and vomit is on my child’s body.
These nurses don’t even clean my child.
Dr: I am very sorry to hear that. I can imagine why you are so upset. This should not have
happened. I will talk to my seniors about this issue. They will talk to the nursing supervisors
and find out why this is happening. We will make sure that this will never happen again. Is
that Okay?
Mother: I did mention this to the nursing staff before. But they don’t care for my child. These
nurses are temporary nurses. They don’t even know what is happening to my child. That is
why they don’t care!
Dr: Once again I feel deeply sorry about the incident. You are right that if it was permanent
nurses then they know the patients well and they get attached to the patients especially if they
are children. We always prefer to have permanent nurses. Unfortunately, because of shortage
of nurses sometimes it is very difficult for us to appoint permanent nurses. However this
should not be the reason for not to show good care for our patients. As I mentioned earlier, I
will talk to my seniors and I am sure we can come up with some solutions to this problem.
How do you feel about this Mrs.. ? Mother: Thank you doctor.
Dr: Do you have any other concerns ? Mother : My child was in the intensive therapy unit
and there my child was looked after well but he was shifted to the ward these problems are
happening. Why is that doctor ?
Dr: Mrs... I am glad to your child was looked after well in the ITU. It may be because in the
ITU we have one to one care means one nurse will be taking care of only one patient whereas
in the ward one nurse has to look after many patients. However this cannot be an excuse not
to look after the patients well. As I mentioned earlier we will make sure that your child will
be looked after well in the ward also. Is that Okay ? Mother: Okay.
Dr: How is the medical care by doctors ? Are you happy or not ? - I am happy with the
doctors. Dr: I am glad to know that. However if you feel anything is not right, please do let
us know.
Mother: Do you think I should take my child to the private hospital?

Dr: I am really sorry if you are not happy with the way we have treated you and your child
here. If you even have to think of taking your child to the private hospital, that shows that we
P a g e | 731
shoed very poor care for your child. I will reassure once again that we will definitely try our
best to improve the care. Your child really deserves it.
However, you know what is best for your child. If you still feel that you need to take your
child to the private hospital, it is up to you. But if you decide to stay with us we will
definitely look after your child really well. We also want the best for your child. What you to
think Mrs.. ? Mother: You made me relieved. I will keep my child here doctor.
Dr: Is there any other expectations from us or any suggestions to improve our patient care
Mrs ... ? Mother: No doctor. Thank you very much.
Offer PALS
( Exam question)
Mother concerned about her minor daughter taking
OCPs
Mrs. Jordan has scheduled an urgent appointment with a doctor to discuss her
daughter, 15 year old Katy Jordan.
Mr and Mrs. Jordan and their daughter are regular registered patients at the clinic
and visits are logged into medical records, but you have not seen them. Talk
to the mother and address her concerns.
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Dr: Hello Mrs Jordan.. My name is Dr... I am one of the junior doctors here in the clinic. How
can I help you ?
M: I want to know if my daughter Katy has come to the clinic for a visit. Dr: May
I ask why, Mrs. Jordan?
M: I was cleaning her room and I found some oral contraceptive pills under her bed. I want to know
if you have prescribed them.
Dr: Did you ask her about the pills, Mrs. Jordan?
M: I did. She said they were her friend Sara's and slammed the door shut. She wouldn't tell me
anything more. Can you please tell me if she has been here?
Dr: I can see that you are concerned Mrs. Jordan, but I'm sorry. We are not at liberty to divulge
that information.
M: Why not?! I'm her mother. I deserve to know!
Dr: I can see that you are a very concerned mother, Mrs. Jordan.. But as I said... I'm sorry. I'm
legally bound to keep any patient visits confidential.I can’t specifically discuss your daughter’s
records with you without her consent.
M: Doctor she is only 15! She is a minor. She is a child. I have the right to know about my child. I
have parental responsibility.
Dr: Mrs Jordan, I can completely understand that you are upset and you feel you need an
explanation. I recognise that she is 15 and that she is a minor, but to maintain the trust with our
patients we need to preserve that level of confidentiality regardless of their age. This is exactly in
the same way I would never discuss your record with anyone else without your consent.
As doctors we do have guidelines on dealing with patients who are under 16. I can’t say that we
have or have not seen your daughter but I can explain the process we go through as doctors if a girl
of your daughter’s age request contraception.
Mother: What is that process ?
D. If a 15 years old girl came to ask for the pill, we are trained to assess their level of maturity. We
talk at great lengths about risks and benefit and we also encourage them to talk to their parents.
However, if we do feel that they are mature enough to take the pill and they will continue to be
sexually active with pill or without the pill and would therefore put themselves at risk of becoming
pregnant, we do prescribe it to them. In other words, we act in their best interest. Does that make
sense?
M: Doctor she won't talk to me. Can't you just give me some peace of mind and just tell me?
Dr: I'm sorry Mrs Jordan... I have not seen your daughter. Medical records might have details if
she has visited the clinic, but even if that were the case, I am legally obligated to keep that
information.
Mother: She may be having sex. No one should have sex with a child. It is illegal.
Dr: I understand what you are saying. Mrs. Jordan... As per the law, sex is not illegal above the age
of 13 if it is with consent and with a partner of the same age.
Mother: She may be having sex with a 20 year old man.
Dr: Mrs Jordan, first of all we cannot tell you whether your daughter has come here or not.
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However, I can reassure you that if any minor girl comes here asking for contraceptive
pills, we do advise that no adult should be having sex with them and if we come to know
about it we do take appropriate action on that.
Mother: I'm worried she could be even pregnant. What if she is your daughter how would
you feel?
Dr: Mrs Jordan, I can’t even imagine how you may be feeling. Unfortunately we cannot
reveal any information about her.
Mother: We are Catholics. It is against our culture. She should not be having sex.
Dr: I completely understand you. I sincerely advise you to talk to your daughter directly. It
often does help when parents discuss the matter with their daughter, in a safe environment
where she does not feel threatened. You should create the environment for her where she
feel safe and discuss openly withyou.
Mother: But she would not tell me anything.
Dr: May be her father can talk to her!
Mother: I have not told this to her father. He will be very furious if he comes to know
about it.
Dr: If you like we can have a meeting with you and your daughter together if she agrees
and we can discuss thesethings.
Mother: OK, so if we have a meeting will you tell me whether you gave the pills to her ?
Dr: Mrs Jordan, we can discuss about it if she agrees for that. But as of now we cannot
even say whether she even camehere.
Mother: Ok then, I will try to talk to her.
Dr: Thank you very much. I am sorry that I was not much helpful. If we can be any help in
the future please do let us know.

Autism
You are a FY2 doctor in GP,mother of a 3 yrs old child Jason is concerned
about her son. Talk to her and address her concern.
Hello I am Dr … one of the junior in the GP clinic toady. Are you the mother of Jason?
Mother: Yes.
Dr: How can I call you please?
Mother: You can call me mrs.….Dr: How can I help you Mrs….?
Mother: I am worrying about my son!
Dr. May I know why?
Mother: Health assessor of Jason is concerned about him.
Dr: May I know why?
Mother: Jason is not interacting with other children at the nursery!
Dr: I am sorry about that! Can I ask few questions to help Jason with the condition?(explore
details about what does she mean by not interacting with others like playing/talking etc)
Mother: Sure
Dr: Can you confirm the age of Jason?
Mother: 3 years
Dr: At what age did you first notice this behavior?
Mother: ….
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Dr: Is Jason your first child? Mo: Yes

Associated other Developmental Questions:
Dr: Does he respond to you when you call his name? Mo: Yes
Dr: Are there any other delays in walking or speaking? Mo: No
Dr: Is he playful? Mo: Yes, he plays with blocks
Dr: Any repetitive behavior (Autism)?
Dr: Do you notice any abnormal movements in the child?
Dr: Does he climbs stairs?
Dr: Does he copy circles?
Dr: Does he say 2-3 words sentences?
Dr: Any spasms or increased/decreased tone of muscles?
Dr: Fixation on specific objects?
Dr: Does he seem withdrawn?
Dr: Anything significant happen recently?
Dr: Anything else? Mo: he doesn’t like cuddling!
Dr: Does his face look flattened?Short neck?Small head?Protruding tongue? (Down syndrome)
Dr: Any vision/hearing problem? Heart problem? (Congenital Rubella Syndrome)
BIRDS Questions
Dr : How was Jason’s birth? Did any of you need immediate medical attention after his birth?
Mother : …
Dr: Was he born as pre-term or term baby?
Dr : how about his Jabs?
Mother: Yes, he has been up to date with all jabs.
Dr : Are you satisfied with the red book?
Dr : How is his development? Similar toother kids of his age?
Medical History
Dr : does he have any medical conditions (Cerebral Palsy, Epilepsy)? Mo: no
Dr :Any medications, Mo: no
Dr : Family history of similar conditions Mo: no
NAI questions
Dr: How is the financial situation at home? Mo : good
Dr: Is your husband Jason’s Biological father? Mo : yes
Dr: Does anybody else take care of him, Mo : no
Dr : Thank you Mrs… for answering my questions.
Ideally, I would like to examine Jason first.
Dr: It could be Autism; need to talk to seniors for further assessment
To confirm diagnosis: (need at least 6 months assessment to confirm)
Referral to a specialist autism team ora healthcare professional who specialises in diagnosing
autism.
Autism is sometimes called autism spectrum disorder or ASD or Asperger

syndrome.Unfortunately, Autism is a lifelong condition that affects how people understand
and interact with the world around them, including how they communicate with other people.
Autism affects people in different ways. But most autistic people see, hear and experience the
world differently from people without autism. It's estimated about 1 in every 100 people in
the UK is autistic. More boys and men are diagnosed with autism than girls and women.But
it's now thought older girls and women may manage the condition differently and are
therefore underdiagnosed.
Although there's no "cure" for autism, with the right support many autistic people live
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fulfilled and active lives.
The specialist or specialist team will make a more in-depth assessment, which should be
started within 3 months of the referral, though this can take longer in some areas.
Mother: Is he having this because of MMR Vaccine?
DR: In the past, some people believed the MMR vaccine caused autism. But this has been
investigated extensively in a number of major studies around the world, involving millions of
children, and researchers have found no evidence of a link between MMR and autism.
Mother: Why he is having this?
Dr: The exact cause of autism is currently unknown.Autism is a complex

neurodevelopmental condition. The causes are still being investigated.Current evidence
suggests that autism may be caused by many factors that affect the way the brain
develops.These include:
 genetics
 environmental triggers
Genes
Most researchers believe that certain genes a child inherits from their parents could make
them more likely to have autism. This is called a genetic predisposition.
Autism is known to run in families. For example, younger siblings of autistic children can
also be autistic. It's also common for identical twins to both be autistic.
Although scientists are still trying to identify the genes involved, signs of autism may be a
feature of some rare genetic syndromes.These include:
 Fragile X syndrome
 Williams syndrome
 Angelman syndrome
Environmental triggers
Very few conditions are caused only by genes. Most are caused by a combination of genes
and environmental factors or triggers.Environmental triggers include lifestyle factors, such as
diet and exercise.Researchers believe that there are some possible triggers that may increase
the likelihood of being autistic.These include:
 being born prematurely (before 35 weeks of pregnancy)

 being exposed to alcohol in the womb
 being exposed to certain medicines, such as sodium valproate (sometimes used to treat
epilepsy), in the womb
What does not cause autism
In the past, a number of things were linked to autism, but extensive research has found no
evidence to suggest that any of these contribute to the condition.These things include:
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 the MMR vaccine
 thiomersal – a mercury compound used as a preservative in some vaccines
 the way a person has been brought up
 diet, such as eating gluten or dairy products
 pollution
 maternal infections in pregnancy
18 April 2019 (Twisted case of Autism)

Same case came but already been diagnosed with Autism.
You are FY2 in GP. A 3 years old child Graham already been diagnosed with Autism.
Take history and address concern of the mother.
Mother was worried about how to cope up with the condition.
Unfortunately, There's no 'cure' for autism, but there are ways to support autistic
people, their families, carers and friends.
Although there's no "cure" for autism, with the right support many autistic people live
fulfilled and active lives. Support for autistic people and their families is designed to help
understand their differences, improve communication, and provide help with their
educational and social development.
It can be difficult to know what type of support will work best for you or your child because
each autistic person is different.
Help and support: National Autistic Societyand National Autistic Society's Community
Support for autistic children
The detailed assessment, management, and care and support for your child should involve
local specialist community-based multidisciplinary teams (sometimes called "local autism
teams") working together.
The team may include:
 a paediatrician
 mental health specialists, such as a psychologist and psychiatrist
 a learning disability specialist (if appropriate)
 a speech and language therapist
 an occupational therapist
 education and social services representatives from your local council
Every child or young person diagnosed with autism should have a case manager or key
worker to manage and co-ordinate their care and support, as well as their transition into adult
care.
The parents of an autistic child play a crucial role in supporting them and improving their
skills.
Helpful interventions:Some interventions can help your child's development.These include:
 communication skills – such as using pictures, sign language or both to help communicate
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as speech and language skills can be significantly delayed

 social interaction skills – play-based strategies, comic strips and some computer-based
interventions can help
 imaginative play skills – such as encouraging pretend play
 learning skills – such as pre-learning skills to help concentration, reading, writing and
maths
How to communicate with your autistic child

Communication can be particularly difficult for autistic children and young people.
Helping them communicate can reduce anxiety and the risk of behaviour that may be difficult
or challenging.
Try these tips when interacting with your child:
 use your child's name so they know you're addressing them

 keep background noise to a minimum
 for some autistic children, it can help if you keep language simple and literal
 speak slowly and clearly
 some parents find it useful to accompany what they say with simple gestures or
pictures
 allow extra time for your child to process what you have said
Help for behaviour that may be seen as challenging
It's important to remember that behaviour is a way of communicating.
If an autistic child or young person is behaving in a challenging way and this is affecting
family life, ask for help and support from a GP or another healthcare professional.
A GP or another healthcare professional will check for things that may be causing your child
to behave in a challenging way.
They'll check:
 teeth
 ears or hearing
 digestion
 pain in an area a child or young person cannot point to
If the GP thinks the person may have anxiety problems, they may recommend mental health
support, such as talking therapies.
Medicines
Medicines may sometimes be prescribed to treat some of the symptoms or conditions

associated with autism.
For example:
 sleeping problems – this may be treated with a medicine, such as melatonin
 depression – this may be treated with a type of medicine known as a selective serotonin
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reuptake inhibitor (SSRI), though these do not always work for autistic people
 serious aggressive or self-harming behaviour – this may be treated with a type of medicine
called an antipsychotic if other support has not helped
 epilepsy – this may be treated with a type of medicine called an anticonvulsant
 attention deficit hyperactivity disorder (ADHD) – this may be treated with a medicine, such
as methylphenidate
These medicines can have significant side effects and should only be prescribed by a doctor
who specialises in the condition being treated.
If medicine is offered, the autistic person will have regular check-ups to assess whether it's
working.
Treatments' that are not recommended
A number of alternative treatments for autism have been suggested. But there's no evidence
to support them. And some are dangerous.
Potentially harmful "treatments" for autism include:
 neurofeedback – where brain activity is monitored (usually by placing electrodes on

the head) and the person being treated can see their brain activity on a screen and is
taught how to change it
 auditory integration training – a therapy that involves listening to music that varies in
tone, pitch and volume
 chelation therapy – this uses medication or other agents to remove metal (in
particular, mercury) from the body
 bleaching – sometimes called CD (chlorine dioxide) or MMS (Mineral Miracle
Solution)
 hyperbaric oxygen therapy – treatment with oxygen in a pressurised chamber
 facilitated communication – where a therapist or another person supports and guides a
person's hand or arm while using a device such as a computer keyboard or mouse.

Chlamydia eye infection in a neonate (10days old) : 12 April 2019
You are a FY2 in medical ward. A 10 days old boy (PAT Murphey) had red and sticky
eyes for last 3 days. Swab been taken from the eyes and Chloramphenicol eye drop is
being given to the boy. Talk to the mother and address her concern.
Take history:
Ask which eye one or both?
Any other symptoms:
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any chest pain/breathing difficulties?

Is the boy crying constantly? Any fever? Any cough? Any vomiting or diarrohea?
Is he eating well?
Mother: Why he is having this?
Dr: There could be many reasons of this eye infection.We have taken swab from PAT’s eye
unfortunately, it has come positive for bacterial type of bugs (Chlamydia). Our seniors have
already given antibiotics eye drop (Chloramphenicol). We called this condition Ophthalmia
neonatorum. This type of infection can happen in the first 28 days of life.
As Chlamydia is positive, after confirming with my seniors we may need to give him
Azithromycin Eye drop to kill the bugs (NICE Guidelines).
Mother: Did I give this infection to him?
Dr: I am afraid if you have sexually transmitted infection this could be the reason as well.
Can I ask few questions?
Dr: Do you practice safe sex?Mo: No
Dr: Do have a stable sexual partner?
Mo:Yes, I am in relationship with my boyfriend for last 2/3 years.
Dr: Did you have any sexually transmitted infection recently or before? Any discharge from
front passage? Any pain in your lower tummy? (Ask question about STI)
Dr: We need to take swab from your front passage to find out if you have the infection or
not?
Mo: But I don’t have any symptoms!
Dr: I am afraid we still have to do those tests (swab tests) to be in the safe side.
Mo: I have only one sexual partner! Does it mean my boyfriend cheating on me?
Dr: I am sorry if I hurt your feeling! We can’t say at the moment as we are not sure!
By any chance did your boyfriend have any Sexually transmitted infection recently?
Mo: I don’t know.
Dr: Did he have any discharge from his penis?Mo: No
Dr: We request you to bring your partner as well to find out whether he also has infection or
not!
Dr: if it is confirmed that either you or your partner have sexually transmitted infection, then
we
Need to treat you both! (If doesn’t agree about partner then talk about partner
notification programme).
Referral to Local GUM (Genito Urinary Medicine) Clinic

Delayed walking in child.16January 2019:
What is considered delayed walking?
Most children are able to walk alone by 11 to 15 months but the rate of development is very
variable. Some children will fall outside the expected range and yet still walknormally in the
end. Walking is considered to be delayed if it has not been achieved by 18 months.
Causes of delayed walking: -
Delayed motor maturation,

Severe learning disabilities (more associated with fine motor skills and language and social
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skills),
Hypertonia (cerebral palsy),
muscular dystrophy (DMD: Baby boys are often normal at birth and delayed walking may only
be identified retrospectively, with symptoms really appearing between 4 and 6 years of age),
Hypotonia (Down’s Syndrome, Tay Sachs),
Maternal antenatal infections, infections (meningitis, encephalitis),
Head injury,
Malnutrition
Overly protective environment when parents tend to keep children in confined area in order to
keep them safe.
Question
14 month old boy (first child/only child) has not started walking.
Gross motor development about 7months

fine motor: holds spoon, draws with crayon, crawling normal,
Says Mama and Papa, plays with blocks. No family history or development issues so far.
No injuries.No family hx and child gets along well with other children and adults. Positive
family dynamic at home. No indication of NAI. Mother and father both biological parents. Has
not been encouraged by parents to walk.
Mothers main concerns are: is it normal if hasn’t walked by now?
Ask in history: issues with pregnancy? Full term normal delivery? Preterm birth? Red book and
development? Child fed well? (malnourished) Past illnesses? Family history- parents walked?
Any medical conditions in family? (muscular dystrophy or neurological disorder) Care at home?
Overprotected or neglect or emotionally deprived? Child encouraged to walk?
Head injury, infections
Check milestones ( given below)
Examination: neurological examination of the lower limbs, strength, symmetrical movements,

reflexes, muscle tone and bulk
Investigations: CPK to r/o muscular dystrophy in child with no other developmental delays
Diagnosis – With your information and examination evry thing looks normal except he has not
started walking. Sometimes this is normal to some children. They are bit slow to start walking.
Management: depends on examination findings. No issues review in one month, encourage

walking by holding hands ( avoid child walker) use and parents to motivate child to walk.
Paediatrician refer and physiotherapy refer may offer appropriate management.
Milestones
Gross motor developmental milestones
6 weeks: sits with curved back, needs support. Head control developing. In ventral suspension
(when held above couch with examiner's hand supporting the abdomen) can hold head at level of
body briefly.
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3 months: can hold head at 90° in ventral suspension.

6 months: no head lag when pulled to sit. Can sit with support. When lying face down, can lift
up on forearms.
9 months: gets into sitting position alone. Sits unsupported and can pivot. Crawls. (Age of
crawling varies widely, and some infants never crawl.)
10 months: pulls to standing and stands holding on.
12 months: stands and walks with one hand held. May stand alone briefly. May walk alone.
18 months: walks well. Climbs stairs holding rail. Runs. Seats self in chair.
2 years: goes up and down stairs alone. Two feet per step. Kicks a ball.
3 years: climbs stairs one foot per step. Able to stand on one foot for a few seconds.
Most children are able to walk alone by 11 to 15 months but the rate of development is very
variable. Some children will fall outside the expected range and yet still walk normally in the
end. Walking is considered to be delayed if it has not been achieved by 18 months.
Red flags
Poor head control or floppiness at 6 months.
Unable to sit unsupported at 9 months.
Not weight bearing through legs at 12 months.
Not walking at 18 months.
Not running at 2 years.
Not climbing stairs at 3 years.
Persistent toe walking.
Increased muscle tone
Mother requesting Tonsillectomy

Question - Mrs. Claire Johnson came to the GP clinic with her 6 years old son Andrew.
You are a FY2 in GP clinic.
Child was referred to the ENT specialist for tonsillectomy by GP because the mother was
forcing the GP, but the ENT specialist has refused to do Tonsillectomy.
SIGN (Scottish Intercollegiate Guidelines Network ) criteria for tonsillectomy :

1) 7 or more significant sore throats (with impact to patient and family) in the preceding 12
months or
2) 5 or more episodes in each of the preceding two years, or
3) 3 or more in each of the preceding three years)
4) The impact of recurrent tonsillitis on a patient’s quality of life and ability to work or
attend education should be taken into consideration.
A fixed number of episodes, as described above, may not be appropriate for children and adults
with severe or uncontrolled symptoms, or if complications (e.g. quinsy) have developed.
What are the complications of tonsillectomy?

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Tonsillectomy is one of the most common childhood operations. Possible

postoperative complications of tonsillectomy include pain, postoperative nausea and
vomiting (PONV), delay to oral intake, airway obstruction with respiratory compromise,
and primary or secondary postoperative bleeding.
Doctor- Hello, I am Dr….. , I am one of the FY2 in this GP clinic. Are you the mother of
Andrew. Mother : Yes.
Doctor - How can I call you please ? Mother : You can call me Mrs Johnson.
Doctor - How can I help you today?
Mother - I want you to remove my child Andrew’s tonsils.
Doctor- Mrs. Johnson I can understand that you are worried about this situation but can
you please tell me why you want his tonsils to be removed.
Mother – Doctor, He keep having this tonsillitis, he suffers a lot with that. Once his tonsils
are removed he will not have these bouts of tonsillitis. He will not have fever because most
of the time he has fever and pain in throat because of tonsillitis.
Doctor – Mrs. Johnson, I can understand that being a mother you cannot see your child
going through this pain again and again. Can I ask does have sore throat now ?
Mother : No
If the child has sore throat now - take full history ( rule out quinsy)
 a sore throat
 difficulty swallowing
 hoarse or no voice
 a high temperature of 38C or above ( if she has measured)
 swollen, painful glands in your neck (feels like a lump on the side of your neck)
 white pus-filled spots on your tonsils at the back of your throat – if she has seen
his throat ( quinsy)
 bad breath
Ask is it affecting him in any way – missed school
If he has symptoms now – say you want to examine him. Examiner may or may not
give findings.
Doctor : How many times he had tonsillitis ? ( ask each episode in the previous 2 years
too). Has she seen doctor for every episode or not ?
Mother : 5 times in the last year [ her answer may be different for different candidates. She
might ask that why you want to know about the episodes. She might say that there has been
enough to disturb his daily activities and he misses school because of this]
Doctor –Mrs. Johnson, May I ask what do you know about tonsillitis.
Mother : I know - it is infection of the tonsils.
Doctor: That is right, it is the infection of the tonsils either by bacteria or virus type of
bugs. Most of the time it is virus type of bugs causes this infection. Most of the time they
resolve by itself without any treatment in about a week time. However sometimes if it is
caused by bacteria and if the symptoms are severe then we give antibiotics to treat that.
However, antibiotics does not prevent it from coming again. Sometimes the children keep
having this infection recurrently and has to go through lot of problems.
As you rightly mentioned, if the tonsillitis keeps coming back again and again we do
consider removing the tonsils so that it will not come back again.
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However, there are advantages and disadvantages of removing the tonsils.
Let me explain what are tonsils what is the normal function of them so that you can
understand better.
The tonsils are a pair of soft tissue masses located at the rear of the throat.
Tonsils helps to fight infections. The main function of tonsils is to trap germs (bacteria and
viruses) which we may breathe in. Proteins called antibodies produced by the immune cells
in the tonsils help to kill germs and help to prevent throat and lung infections.
1) Advantage of course if that the child will not suffer from tonsillitis again.
2) Disadvantages of removing the tonsils are that it reduces the body’s capacity to
fight infection and lot of complications of the operation itself like pain, nausea and
vomiting, delay to oral intake, airway obstruction with respiratory compromise, and
postoperative bleeding.
However, in certain situation we do consider removing tonsils like

1) 7 or more significant sore throats (with impact to patient and family) in the
preceding 12 months or
2) 5 or more episodes in each of the preceding two years, or
3) 3 or more in each of the preceding three years)
4) The impact of recurrent tonsillitis on a patient’s quality of life and ability to work
or attend education should be taken into consideration.
[ If the story fits into the criteria ( including child missing the school many times) – tell
her – I will speak to my senior ( GP) about your concern and see whether we can consider
again about removing the tonsils.
If the story does not fit to the criteria try to convince her that it is not required at the
moment giving the reasons of disadvantages. Reassure that -as the children grow olderthey
will not have this recurrent infections. If she still insists - tell her that you will talk to the
GP about it].
Mother – Doctor. I know why you don’t want to do surgery because its expensive. If you
cannot do it, I will take my son to private hospital.
Doctor – I can understand that you are worried about him. And let me reassure you if we
find that he needs surgery we will do it as tonsillectomy is funded by NHS. If you still feel
you need to take him to private practice that’s totally your decision as he is your son and a
mother always thinks in the best interest of their children.
If the child has symptoms of tonsillitis currently – treat accordingly

Take a swab for culture ( antibiotics if bacterial infection)
To help ease the symptoms:
 get plenty of rest
 drink cool drinks to soothe the throat
 take paracetamol or ibuprofen (do not give aspirin to children under 16)
 gargle with warm salty water (children should not try this)
Then she will say its ok doctor I will wait for the results to come back.
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Then as a doctor you tell her that you will discuss the whole case with the seniors and will
tell them about tonsillectomy also. And wait for the results to come back. Thanks the
mother.

Fluid infusion to child with Appendicitis.
Child diagnosed with Appendicitis. Planned for Appendicectomy.
Child kept nil by mouth. Consultant advised IV fluids.
Calculate and prescribe IV fluids.
Explain the father about the necessity of giving IV fluids to his child.
Do not explain about the operation.
Child is 6 years,
Weight – 25 kg
Formula
Daily maintenance fluid requirement in paediatrics.
Formula: 100mls/kg for the first 1 to 10kg;

then 50mls/kg for the next 1 to 10kg;
then 20mls/kg for the next 1 to 10kg.
( Max – 2 litres in females and 2.5 litres in males)
Fluid bag contains 500ml.
Assess knowledge.
Explain condition if he is not aware – Child has appendicitis. We all have any organ in our
tummy called appendix which looks is like a finger attached to the beginning of the larger
bowel ( gut). Normal it has no important function in the body. In your child this organ in
inflamed or become sore. Only treatment is operation and remove that organ. He will lead a
normal life afterwards.
Take history
How was your child before this ?

Any medical conditions ? Any surgeries in the past ? Any medications ?
Any allergy ?
P a g e | 745
Need to give him IV fluids
We cannot allow him to eat or drink at the moment until and after about one or two days of
the surgery. If his tummy has food when we Anaesthesia for the operation sometimes the food
comes back from the stomach to the food pipe and then it can enter the wind pipe and can
cause severe infections in the lungs. To prevent this happening his stomach should be empty
when we do the operation.
Also since we cannot feed him by mouth for his energy requirement and to prevent
dehydration we need to give him fluids through his veins.
What type of fluids
We will be giving him fluids which contains glucose for his energy and also salts to prevent
dehydration.
Is that OK ? Any questions ?
I need to write up the fluid prescription for him is that OK ?

Then write prescription on the fluid chart provided. (The paper includes maintenance fluid
replacement formula).
Ask about Full name, DOB,
past history of any medical conditions? Any medications? Allergy
Do not forget to date and sign.
Calculator is kept in the cubicle.
Use the Formula
25kg child = 10kg + 10kg + 5kg

First 10kg = 100mls × 10kg = 1000mls
Next 10kg = 50mls × 10kg = 500mls
Next 5kg = 20mls × 5kg = 100mls
Total fluid = 1000mls + 500mls + 100mls = 1600mls/day.
1600 divided by 24 hours = 67ml/hour.

Fill up the prescription chart
Nam DOB Allergy - NKDA

e
Date Fluid quantity Rate Additive Sign
Dextros 1600ml/24 67ml/hou Nil &&&
e saline hours r

Cystic fibrosis-prenatal counseling
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You are FY2 in General practice. A 28 year old lady is coming with some
concerns.Talk to her and address concerns.
Dr:Hello my name is dr XYZ.I am one of the juniors doctors in general practice.

How can I help you?
Pt:I am planning to get pregnant and I am afraid that my baby will get cystic fibrosis.
Dr:Why do you think like this? Pt:My brother has cystic fibrosis. Dr:I am sorry to hear about him.
Dr:Are you planning for your first pregnancy? Pt:Yes
Dr:Do you have any symptoms of CF? Pt:No
Dr:Any recurrent chest infections?(Ask CF symptoms in her)
Pt:No
Dr: Any shortness of breath?
Pt:No
Dr:Any bowel problems? Pt:No
Dr:What about your partner? (Ask same symptoms of CF in partner and partner’s family)
Pt:He is healthy Dr:That’s good
Dr:What are you expecting from us today?
Pt:I want to know that what are my chances to have normal baby?
Dr:Sure,I will draw a diagram to show you.Is that ok? Pt:Ok
Dr:This diagram implies to the scenario, in which you and your partner both are carriers of CF i.e.
you are absolutely healthy but you are carrying one affected gene.Am I clear?
Pt:Yes doc
Rr x Rr
RR Rr Rr rr
Where:
R=Normal gene
R=Affected gene
RR=Normal
Rr=Carrier
rr=Affected(Cystic fibrosis) So,
I. 25%(1 in 4) chances of Normal child.
II. 25%(1 in 4) chances of affected CF child. III. 50%(1 in 2) chances of carriers Dr:Is
everything clear?
Pt:Yes doc
Dr:We will refer you and your husband to genetic clinic for genetic assessment.Is that ok?
Pt:Sure
P a g e | 747
Dr:Any other concerns? Pt:What is CF?

Dr:It is an inherited condition that causes sticky mucus build up in lungs and digestive tract. This
causes lung infections and problems with digesting food.
Pt:Is there any treatment for it?

Dr:There is no definite cure for this condition unfortunately but a range of treatments can help
control symptoms and complications.
Pt:Like what doc? Dr:Alright,I will explain you:
• Lung problems:
o Antibiotics to treat chest infections
o Medicines to make the mucus in lungs thin eg hypertonic saline.
o Bronchodilators to widen the airways
o Routine jabs
• Exercise also helps in clearing up the mucus.
• Specific breathing techniques like postural drainage also helps.
• Good high caloric diet including vitamin and mineral supplements is important for CF
patients as mucus makes it difficult to digest food.
• Last resort is lung transplant. Pt:Ok doc any complications of CF? Dr:Complications are:
o Weak and brittle bones (Osteoporosis)
o Diabetes
o Sinus infections/Nasal polyps
o Liver problems
o Fertility problems
But don’t worry all these complications can be managed.
Pt: During pregnancy, can we know how baby is?
Dr:Yes,we have some procedures like amniocentesis or chorionic villous sampling in which they
take some fluid from the baby to check the genetic makeup.
Pt:Ok doc and after the delivery, can we check that whether my baby is having CF?
Dr:Yes,we do heel prick test at birth to check this. If CF is confirmed then we can do further
confirmatory tests as well like sweat test.
Pt:Ok doc
Dr:Any other concerns? Pt:No doc ,thank you
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Child with tantrums
27.
You are FY2 in General practice. A 30 year old mother wants to talk to you
regarding her 3 year old child. Talk to her and address her concerns.
History
Dr:Hello,my name is dr XYZ,I am one of the junior doctors in GP clinic. How can I help
you?
Pt:My child is showing a bit strange behavior now a days.
Dr:Please explain it
Pt:He gets out of the bed when I put him to sleep and then he comes out and plays with
toys.
Dr:I see,is there anything else that you would like to tell about his behavior?
Pt:He also throws the plates when he is given food Dr:From how long he is showing such
behaviour ?
Pt:2 to 3 months
Dr:How many times he shows such behaviour in a day? Pt:3 to 4 times
Dr:Any fits in a day?
Pt:No Dr:Alright,anything else? Pt:Like what?

Dr:Is he able to walk,speak,laugh and cry? Pt:Yes
Dr:Does he have any repetitive behaviour ?(Autism) Pt:No
Dr:Does he have friends? Pt:Yes
Dr:Does he play with different toys? Pt:Yes
Dr:Does he cuddle you back? Pt:Yes
Dr:Any fever? Pt:No
Dr:Does he have any health problems? Pt:No
Dr:Is he on any medication? Pt:No
Dr:Who takes care of the child mostly?
Pt:Grandmother
Dr:How is he with grandmother? Pt:They get along very well Dr:Do you spend time with
him? Pt:Not much
Dr:May I know why?
Pt:I am searching jobs now a days Dr:How is everything financially? Pt:It is fine
Dr:Does he go to Nursery? Pt:Yes,he enjoys there
Examination
Ideally, I would like to examine him.(Patient is not with mother)
Diagnosis
Dr:From what we have discussed, we think that your son is absolutely fine. This a normal
behaviour usually shown by the children in this age to gain more attention and care from
their loved ones.
Pt:Ok doc so what are you going to do ?
Dr:We can give you some suggestions for how to cope with your son.
• Spend more time with child, show him that you love him.
• Involve him in every activity which you are doing.
• Decorate the kitchen plates which he likes and all family should eat together at a
time.
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• At night time, read him stories, kiss him, If he is coming out, again put him to
sleep.
• Don’t get angry on him.
Dr:We will arrange a follow up in a month time. If in the meantime, he develops any fever,
fits or if his behaviour is getting worse ,please let us know.
There are lots of possible reasons for difficult behaviour in toddlers and young children.
Often it's just because they're tired, hungry, overexcited, frustrated or bored.
How to handle difficult behaviour
If problem behaviour is causing you or your child distress, or upsetting the rest of the
family, it's important to deal with it.
Do what feels right
What you do has to be right for your child, yourself and the family. If you do something
you do not believe in or that you do not feel is right, it probably will not work.
Children notice when you do not mean what you're saying.
Do not give up
Once you've decided to do something, continue to do it. Solutions take time to work. Get
support from your partner, a friend, another parent or your health visitor. It's good to have
someone to talk to about what you're doing.
Be consistent
Children need consistency. If you react to your child's behaviour in one way one day and a
different way the next, it's confusing for them. It's also important that everyone close to
your child deals with their behaviour in the same way.
Try not to overreact
This can be difficult. When your child does something annoying time after time, your
anger and frustration can build up.
It's impossible not to show your irritation sometimes, but try to stay calm. Move on
to other things you can both enjoy or feel good about as soon as possible.
Find other ways to cope with your frustration, like talking to other parents.
Talk to your child
Children do not have to be able to talk to understand. It can help if they understand
why you want them to do something. For example, explain why you want them to
hold your hand while crossing the road.
Once your child can talk, encourage them to explain why they're angry or upset. This
will help them feel less frustrated.
Be positive about the good things :When a child's behaviour is difficult, the things they
do well can be overlooked. Tell your child when you're pleased about something they've
done. You can let your child know when you're pleased by giving them attention, a hug
or a smile.
Offer rewards : You can help your child by rewarding them for good behaviour. For
example, praise them or give them their favourite food for tea.
If your child behaves well, tell them how pleased you are. Be specific. Say something
like, "Well done for putting your toys back in the box when I asked you to."
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Do not give your child a reward before they've done what they were asked to do.
That's a bribe, not a reward.
Avoid smacking : Smacking may stop a child doing what they're doing at that moment,
but it does not have a lasting positive effect.
Children learn by example so, if you hit your child, you're telling them that hitting is
OK. Children who are treated aggressively by their parents are more likely to be
aggressive themselves. It's better to set a good example instead.
Things that can affect your child's behaviour
 Life changes – any change in a child's life can be difficult for them. This could
be the birth of a new baby, moving house, a change of childminder, starting
playgroup or something muchsmaller.
 You're having a difficult time – children are quick to notice if you're feeling
upset or there are problems in the family. They may behave badly when you feel
least able to cope. If you're having problems do not blame yourself, but do not
blame your child either if they react with difficult behaviour.
 How you've handled difficult behaviour before – sometimes your child may
react in a particular way because of how you've handled a problem in the past.
For example, if you've given your child sweets to keep them quiet at the shops,
they may expect sweets every time you gothere.
 Needing attention – your child might see a tantrum as a way of getting
attention, even if it's bad attention. They may wake up at night because they
want a cuddle or some company. Try to give them more attention when they're
behaving well and less when they're beingdifficult.
Extra help with difficult behaviour
Do not feel you have to cope alone. If you're struggling with your child's behaviour:
 talk to your health visitor – they will be happy to support you and suggest
some new strategies to try
 visit the Family Lives website for parenting advice and support.

AGITATION AND SEIZURES- MENINIGITIS- TALK TO
FATHER
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Question: You are an FY2 in the A&E.

Mr William Carson has brought his 20 year old son, Max Carson to the A&E.
Take history from Mr William Carson and discuss management with him.
Hello. My name is Dr. ……… I am one of the junior doctors here in the A&E. Is it Mr William
Carson? Yes.
How are doing today, Mr Carson? I am fine.
Could you please confirm your relationship with Mr Max Carson? He is my son.
Could you confirm Max’s age for me please? He is 20 years old.
Could you tell me what made you bring Max to the hospital today?
Well, we were just watching football together on the sofa when suddenly he seems to be really out
of it. He seemed really confused. He was mumbling something that I didn’t understand. Then he
had a sort of a fit- his entire body started shaking. He wouldn’t respond to me. I got really scared
and called ambulance.
D- That must have been quite scary for you to see. It’s good that you called the ambulance and
brought him in. Could you tell me a bit more about the fit?
F- What would you like to know?
D- When was did the fit happen? About an hour ago now.
How long did it last? Around 2 minutes.
Has he ever had a fit before? No
Did he have jerky movements of his arms and legs? He was shaking all over.
Did he lose consciousness? No
Did he happen to wet himself? No
Did he bite his tongue? No
What was he like after the fit? He seemed confused as if he didn’t know where he was.
Was he drowsy? Yes.
Before he had the fit, you mentioned he was behaving strangely- has he ever been that way before?
No.
Did he mention feeling unwell before the incident? Not really. But he did have a bit of the flu for
the last couple of days.
Did he have a fever? He was a bit feverish.
Did he have any other symptoms along with the fever? Like what?
Like a headache? He did have a mild headache.
Did he mention anything about a pain in the neck or difficulty moving the neck? No.
Did he have a rash anywhere on his body? I didn’t notice.
Was he feeling sick or did he throw up? No
Did he any ear pain? No
Did he have runny nose? No
Did he have sore throat? No
Any cough? No
Any pain while passing wee? I don’t know.
Any discharge from the penis? I wouldn’t know.
Was he more tired than usual? I think so, yeah.
Was he losing weight? No

Did he have any lumps or bumps in his body? Perhaps in the neck? No.
By any chance had he hurt his head recently? No.
Has Max been in contact with someone with similar symptoms? Anyone with TB?
I don’t know.
Has he been diagnosed with any medical conditions before? No
Diabetes, for instance? Any mental health conditions? No.
Any past hospital admissions or surgery? No

P a g e | 752
Does he take any medications? Including over the counter medicines and supplements? No
Are there any medical conditions that run in the family? No
Has any body in the family been diagnosed with epilepsy? No
Do you know if he is allergic to any food or medication? No
Has he travelled outside of the UK recently? No
Is he working or is he a student? He is a student at University
Did he take a vaccine for meningitis any time in the past? I am not sure.
Other than Max and yourself, who else is at home? Just him and me.
Does Max drink alcohol? Yes, occasionally with his friends.
Are you aware if he as ever used any recreational drugs? I don’t think so.
Is he sexually active? I think so, yeah.
Is there anything else you think is important that we may need to know? No
Thank you for answering my questions.
Examination:
I need to examine Max now. I want to check his pulse, his blood pressure, his body temperature,
breathing rate and the oxygen levels in his blood.
I need to check his consciousness level, a neurological examination and look at his pupils and at the
back of his eyes.
I will do a head to toe examination, check his body for rashes and check for stiffness in the neck
and swelling in the neck. Is that okay? Yes
Following that I would need to do some tests: a full blood count to check for signs of infection, a
blood sugar level, salt levels in the blood and the function of the kidney and liver, blood gases,
markers of inflammation blood culture to check for bugs. Check his urine for signs of infections,
toxins and drugs.
We may also decide to do a scan of his head called a CT scan.
We also need to do perform a spinal tap where we take some fluids from around his spine and test it
for signs of infection.
Findings:
Following were written on a piece of paper: ( Look at this)
Pulse- 100 BP-110/70 Temperature- 38 Sp02- 96%
GCS- 11/15 Patient drowsy, confused

Red, non-blanching rash all over the body.
Kernig’s sign and Brudzinki sign positive
CT scan- Normal
CSF- glucose low, cells increased, mostly PMN’s
Diagnosis:
P a g e | 753
When we examined Max found that his consciousness level was low. He had a rash and he had pain
and stiffness in his neck.
The scan of his brain was normal.
When we tested the fluid from around his spine, we were some findings which indicates he has an
infection.
Do you have any questions so far? What does he have Doctor?
I suspect that Max has a condition called meningitis. Have you heard of it?
I have but I don’t know exactly what it is.
D- Our brain and spine has a protective membrane covering them. Meningitis is the infection of
this covering. I suspect this is being caused by an infection from a bacterial type of bugs.
Management:
What is going to happen now?

D- Meningitis can be a very serious condition so it’s important to admit Max and treat him
immediately.
How are you going to treat him?

D- I am going to inform my seniors about Max’s condition immediately
We need to admit him into the Intensive Treatment Unit.
We are going to give him fluids through his veins and oxygen through a mask. We will start him on
some antibiotics through his veins immediately to kill the bugs (IV Ceftriaxone). He might also
need medicines to prevent seizures and steroids to prevent swelling around his spine and brain. Are
you following me? Yes.
After all the test result come back the specialists will be able to tell you more about which bug
might be causing this. But generally the bacterial type of meningitis can be contagious so we would
need to give you a single dose of antibiotic tablet call Ciprofloxacin to all those who came into
close contact with him in the last few days including you to prevent from getting meningitis. Is that
okay with you? Yes.
Do you have any questions for me?
Will Max be okay doctor?
Most people make a full recovery from meningitis, but it can sometimes cause serious long-term
problems and can be life threatening. But since you brought Max in early we can start treating him
quickly and hopefully he will recover completely.
What type of complications can he have, Doctor?
Most people with bacterial meningitis who are treated quickly make a full recovery, although
sometimes there are long-term problems.
They may have repeated fits.
There might be partial or total, hearing or vision loss.
Problems with memory, concentration, co-ordination, movement and balance
In rare cases amputation of affected limbs is sometimes necessary.
But we do have support available to help with any long-term complications.
How long does he have to stay in the hospital?

It depends on how he responds to the treatment but it is generally 7-14 days.
Any other questions? No.
I hope Max makes a quick and full recovery.

P a g e | 754
2579 Not available
NEUROBLASTOMA – Mother giving green liquid to child

SCENARIO-
Nurses notice Mrs. Devoine (mother) giving green liquids to 19 month old
child diagnosed to have Neuroblastoma and is currently being treated for
sepsis. Talk to the mother and address concerns
Dr: Hello Mrs Devoine: I am Dr... how are you doing ? I am fine doctor.Dr: I understand
your child is in the hospital. May I ask why your child is in the hospital Mrs Devoine?
Mother: My child was prematurely born and he has Neuroblastoma.
Dr: That is right. Do you know what problem he is having currently ? I was told that he has
sepsis.
Dr: That is right Mrs. Devoine. Do you know what is sepsis ? I do not know exactly.
Dr: Sepsis means he has infection in the blood means there are bugs in his blood which is a
very serious condition. We are treating with strong antibiotic medications.
Are you happy with the care what we are providing ? Yes
Dr: Are you happy with the treatment what we are giving? Yes doctor.
Dr: Mrs Devoine do you have any concerns regarding your child ? No doctor.
Dr: Mrs Devoine, can I ask are you giving your child anything other than food ?
- Like what doctor ?
Dr: Any kind of medicine ? - No
Dr: Actually one of our nurse noticed that you are giving some kind of green liquid to your
child and she is concerned about it. She has told us about it. We are also bit concerned about
it? May I ask are you giving any green coloured liquid to your child ? - No doctor
Dr: Mrs Devoine, as I mentioned we are concerned about your child’s well being because if
it all you are giving any other kind of medicine other than what we prescribed to your child
it may cause harm to your child. I am sure you don’t want that to happen to your child isn’t
it Mrs Devoine ? - Yes doctor.
Dr: May I ask again are you giving any such liquid to your child ? - Yes.
Dr: May I know what is that ? - It is some herbal medicine doctor.
Dr: May I know what kind of herbal medicine ? - It contains minerals and vitamins.
Dr: May I know the name of the medicine ? - I don’t know that doctor.
Dr: How long have you been giving that Mrs Devoine? For few months now.
Dr: Mrs Devoine, I can see that you are a very caring mother. This herbal medicine can
cause harm to the baby. Can you please stop giving that your child?
- Doctor it contains only minerals and vitamins. It is good for the health. They are plant
products. It does not cause any harm to my child.
Dr: Mrs Devoine you may be right that some of the herbal medicine may not cause harm to
the health. However, some types of herbal medicine can cause harm to the health and also it
can interact with the medicine what we are giving and can reduce the effect of the medicine
what we are giving to your child. As I mentioned your child has a very serious infection. If
at all this herbal medicine interact with the antibiotic medicine what we giving and the effect
of the antibiotic reduces it will be a serious problem to your child. As you may know some
of the mushrooms are poisonous though they are plants. What do you think Mrs Devoine ? -
No doctor it does not cause any harm. I am giving this medicine for a long time now ( for
months). Has it caused any harm?
Dr : Well so far no harm is visible to us. However, sometimes there could be long term
P a g e | 755
problem which we may know only after long time. – I see.

Dr: May I ask who advised you to give that medicine to your child ? My friend told me. She
has a breast cancer. She used it and she found it good.
Dr: As I mentioned before some types of herbal medicine may not cause harm but some of
does cause harm. Beside that we are not sure what exactly does it contain thigh you have
been told that it contains vitamins and minerals. We do not have any scientific proof of what
does it contain. Mrs Devoine the type of medicine what we give are tested and researched
properly before we start giving it the patients. Besides that our medicine are regulated by the
proper authorities who checks the safety of the medicines. Where as the herbal medicine
what you are giving may not be researched properly and is not checked by the Medicines
and Healthcare products Regulatory Agency (MHRA) of the United Kingdom (UK).
So Mrs Devoine do you think you can stop giving that medicine ? - Doctor I am sure it
contains minerals and vitamins ?
Dr: How are you sure of that ? - The person who gave me told me about that.
Dr: Mrs Devoine, can we test in the lab to check properly what does it contain and then we
tell you about it ? Okay.
Dr: Can we get some sample of that please ? - Okay I will give you that.
Dr: Mrs Devoine can you please stop giving that medicine for the time being at least until
we get the result from the lab and we know what exactly it contains and whether it is safe to
give to the child? - Okay doctor.
Dr: Thank you very much Mrs Devoine. I can see that your very caring mother and you
want the best for your child. We also want to do the best for your child. Is there anything
else you want to ask me ?
Mother – Doctor can you please give me some examples where the herbal medicine interacts
with your kind of medicines.
Dr: Yes sure
Aspirin can interact with Garlic extract
Pseudoephedrine (nasal decongestant) can interact with Green tea supplement.
Digoxin, warfarin can interact with St. Johns wort ( herbal medicine).
Dr: Is there any other question ? – Doctor will my child die because I gave this medicine ?
Dr: Don’t worry Mrs Devoine. As I mentioned before so far we do not see any serious harm
happened because of this. However we will keep checking for that. Also when we get the
lab test result of this medicine we will know more about it.
Any other concerns Mrs Devine ? - No doctor. You have been very kind.
Dr: Mrs We are always here to help you. If you wish to give any other kind of medicine to
your child, please ask us before you give that, Is that Okay Mrs Devoine ? - Yes doctor
surely.
Thank you once again Mrs Devoine.
Pelvic Inflammatory Disease (PID)
Background
P a g e | 756
us) and Fallopiantubes.

tion usually travels from vagina or neck of womb (cervix) into the uterus andovaries.
m a sexually transmitted infection. Chlamydia and gonorrhoea are the most commonly found causes of PID. Inmanyothercasesitiscause
months after having sex with an infectedperson.
xually transmitted infection. This is more of a risk after having a baby, or after a procedure such as inserting a contraceptivecoil.
Notes
Pelvic inflammatory disease (PID) is an infection of the female upper genital tract, including
the womb, tubes and ovaries.
Symptoms
PID often doesn't cause any obvious symptoms. Most women have mild symptoms that may
include one or more of the following:
• pain around the pelvis or lower abdomen(tummy)
• discomfort or pain during sex that's felt deep inside thepelvis
• pain duringurination
• bleeding between periods and aftersex
• heavyperiods
• painfulperiods
• unusual vaginal discharge, especially if it's yellow orgreen A
few women become very illwith:
• severe lower abdominalpain
• a high temperature(fever)
• nausea andvomiting
Examination
• Abdominal
• Gynaecological,speculum
INVESTIGATIONS
Urinalysis: protein, blood; leucocytes; nitrites
Endocervicalswab
Chlamydial swab
High vaginal swab
Trans vaginal ultrasound report
P a g e | 757
Diagnosis
Diagnosis is based on symptoms and examination (the finding of tenderness on a vaginal
(internal) examination).
Swabs are taken from vagina and cervix (neck of the womb), but negative swabs don't rule
out PID.
In some cases, laproscopy (keyhole surgery) may be used to diagnose PID. (This is usually
only done in more severe cases where there may be other possible causes of the symptoms,
such as appendicitis).
Risk
factors
• havemorethanonesexualpartner
haveanewsexualpartner
haveahistoryofsexuallytransmittedinfections
there's been damage to the cervix following childbirth or amiscarriage
have had a procedure that involves opening the cervix – such as an abortion,
inspection of the womb, or insertion of ancoil.
havehadPIDinthepast
areunder25
startedhavingsexatayoungage
Complications of Pelvic Inflammatory Disease

Abscesses
Long Term Pelvic Pain ( dyperunia)
Miscarriage
Ectopic Pregnancy
Infertility
StillBirth
PREVENTION
Use of barrier contraception significantly reduces the risk of PID.
Limited evidence suggests that screening for Chlamydia and treating identified
infection pr ior to IUCD insertion reduce the risk of PID.
The English National Chlamydia Screening Programme (NCSP) recommends that
all se xually active men and women under the age of 25 be tested for Chlamydia
annually or on change of sexual partn er.
Visit local genitourinary medicine (GUM) or sexual health clinic for advice.
P a g e | 758
In case of invasive gynaecological procedure, such as insertion of a coil or an

abortion, have a check-up beforehand.
P a g e | 759
Treatment
Antibiotics
Needs to be started quickly, before the results of the swabs are
available. Antibiotics commonly prescribed to treat PID include:
 ofloxacin
 metronidazole
 ceftriaxone
 doxycycline
Ceftriaxone 500 mg as a single intramuscular (IM) dose, followed by

Doxycycline 100 mg orally twice daily and Metronidazole 400 mg twice daily for 14 days
Painkillers
If you have pain around your pelvis or tummy (paracetamol,
ibuprofen)
Avoid intercourse
You should avoid having sex until both you and your partner have completed the course
of treatment- till at least 7 days after treatment is finished.
Follow-up
In some cases, you may be advised to have a follow-up appointment three days after
starting treatment so your doctor can check if the antibiotics are working.
If the antibiotics seem to be working, you may have another follow-up appointment at the
end of the course to check if treatment has been successful.
Treating sexual partners
Any sexual partners you've been with in the six months before your symptoms started
should be tested and treated to stop the infection recurring or being spread to others, even
if no specific cause is identified.
Your doctor or sexual health clinic can help you contact your previous partners and this
can usually be done anonymously, if you prefer.
Advise protected sex after the treatment.
Task
25 year old Mrs Sarah boyer was diagnosed with pelvic inflammatory disease as she
presented with discharge from front passage 4 days ago. She is already on antibiotics and
taking OCP as well. US Scan has been done which shows Hydrosalphinx. Talk to Mrs Sarah
Boyer and explain about possible complications of PID.
Assessment- 8 steps
1. Ask herconcerns
P a g e | 760
2. Assess her knowledge of hercondition

3. Explain PID and itscauses
4. Ask if she wants to know about a specific complication orall?
P a g e | 761
 Pelvicpain
 Deepdyspareunia
 Abscess
 Menorrhagia
 Secondarydysmenorrhoea
 Discharge
 Miscarriage
 Ectopicpregnancy
 Infertility
5. Keep checking herunderstanding Anythingelse?
6. Stress oncompliance
7. Partner notificationprogramme
8. Prevention in thefuture
9. Follow Up- 2 weeks &anythingelse
Dr: hello Mrs Sarah Boyer. I am one of doctor in Gynae/Obs department. How can I help
you?Pt: doctor I was diagnosed with PID and I am on antibiotics but I am still worried
about this condition.
Dr: Mrs Sarah I am here for this to address your concerns today regarding your condition. I
will try my best to answer your questions. So do you know what it is?Pt: No/yes
Dr: if No: it is infection (bugs) spreading from vagina or cervix (entrance of the womb) into
the womb and Fallopian tubes and ovaries.
If yes: That is right. May I know why you are worried?Pt: I want to know why did it happen to
me?
Dr: it’s difficult to say right at the moment but risk is always higher in women who are using
coil or had any surgery of womb or any instrumentations. Have you had any of this? Pt: No
Dr: OK. There are other causes, like this could be a sexually transmitted infection some
times.
P a g e | 762
Pt: doc, how it’s possible, do you think my Partner is cheating on me?
Dr: I am sorry if you misunderstood me, I did not mean that as there could be other causes
also as I told you. And also sometimes these types of bugs persist for longer period of time and
symptoms develop later in life if not treated immediately. Usually only one fourth of the time
it is due to sexually transmittedinfection.
Pt: What should I do?
Dr: Do not worry; as long as you complete your treatment everything will be fine. It is very
important for you to complete your treatment.
Pt: is there anything which can happen to me?
Dr: I am afraid if you do not get proper treatment or do not follow proper instructions which
we will give to you, there are chances to get complications like;
1. You may not be able to become pregnant, calledinfertility
2. If you becomepregnant
You can lose your pregnancy called Miscarriage.
It can be on abnormal place called ectopic pregnancy
Your baby can be premature baby.
3. You can get pain duringintercourse
4. Most importantly this infection can spread to other parts of body which isdangerous.
5. Pt: what can you do for me?
Dr: I just want to tell you please don’t worry as you are already on antibiotics so please
continue your treatment as advised to you. Hopefully you will be alright but few things are
very important for you:
1) Please do not stop treatment early even if your symptomsdisappear.
2) You should avoid even safe sex till you finish complete treatment. (National Chlamydia
ScreeningProgramme:Donothaveanysexwithyourpartner(s)untilsevendaysafter
you have both completedyour treatment.)
3) Your partner should also gettreated.

4) Pt: why partner:
Dr: I am afraid if he is not treated then you can get infection back and can get complications
what we discussed and I am sure you don’t want that.
Can you bring your partner in?Pt: Yes. (If patient says No)
Dr: It’s fine. We have something called partner notification program in which we will call
your partner anonymously and treat him without revealing your identity.
Pt: Will it happen again?

P a g e | 763
Dr: 1 in 5 women can have it again but if you and your partner both
get proper treatment and follow advice hopefully you will not get it.
Would you like me to give you some advice?
Pt: yes doc, sure
Dr: 1: Please avoid multiple sexual partners.
2: Practice safe sex in future.
3: If anytime you are suspicious of getting this infection please come to GUM clinic
immediately
{ If the patient has IUD – it needs to

be removed
28.
29.
30.
31.
32. 2611 33. Video available
34. OVARIAN CYSTECTOMY ( 5th Dec 2017)
35.
36. Q. 23 years old lady presented with abdominal pain. USG has been done and it
shows dermoid cyst in the right ovary. You consultant has decided to do open ovarian
cystectomy (pfannensteil incision). Talk to patient and address her concerns.
37. Consultant has planned to keep the patient in the hospital for 2 days after the
operation.
38.
39. Assess knowledge
40. Dr: How much do you know about your condition?
41. Pt:
42. Dr: Certainly, I am here to discuss the result with you. As you know that you
came with severe pain and we did TV scan on your tummy. In which we have found that
there is a fluid filled sac on your right ovary (egg producing gland), known as ovarian
cyst.
43. Pt: What is ovarian cyst?

P a g e | 764
44. Dr: An ovarian cyst is a fluid filled sac which develops in an ovary. They are
very common and do not usually cause any symptoms. In most cases, they are
harmless and usually disappear without the need for treatment. However, if the cyst is
large or causing symptoms, it may need to be surgically removed.
45. Pt: What’s going to happen now?
46. Dr: My consultant has planned for an operation to remove this cyst.
47. Pt: Why do you have to do an operation, what happens if not removed?
48. Dr: The sac is a potentially dangerous, if it is not removed now then it can
continue to grow in that case it might rupture, bleed or twist on itself creating a situation
in which we will have to remove it by an emergency operation. Since you are here now
we can plan ahead to avoid that situation.
49. Pt: What will you do?
50. Dr: My consultant has decided to do an operation called laparotomy in which an

incision will be given on the bikini line (Pfannenstiel incision: also called “bikini line
incision”). This is an open operation means we have to open the tummy through this
bikini line incision and then remove the ovary.
51. Sometimes, in case of larger cyst, my consultant/ the surgeon might decide to
remove the whole ovary.
52. Pt: How long will the surgery be?
53. Dr: 45 minutes to 1 hour.
54. Pt: How big will the scar be? Will it not look bad when I wear bikini?
55. Dr: Incision will be about 8 inches long. However the scar will be very thin and
it will not be visible even if you wear bikini because it will be covered by the bikini.
56. Pt: When Can I go back home?
57. Dr: It depends on your operation and recovery. We are hoping that you will be
able to go home in about 2 days if everything goes well.
58. Pt: Is it cancerous or benign?
59. Dr: Most of the ovarian cysts are non cancerous. However we will be sending the
cyst once removed to the laboratory to confirm that.
60. Pt: Will I be able to conceive after removal of ovary? / Can I become a mother?
P a g e | 765
61. Dr: You have the problem in only one ovary so we will be removing the cyst
from only one side. The other ovary is fine. So you will be able to have babies.
62. Pt: What will happen to my sex life? When can I resume sex?
63. Dr: You can start having sex after 4-6 weeks after the surgery ( laparotomy).
64. (2-3 weeks in laparoscopy)
65. Pt: When can I go back to work?
66. Dr: If only cyst is removed, you may be able to return to work within 2 weeks.
However, if whole ovary is removed then 5-6 weeks rest is essential.
67. Pt: When can I drive?
68. After about 4 to 6 weeks you may be able to drive.
69. Pt: Are there any complications?
70. Dr:
Pain: You might experience some pain after the operation but do not worry we have
very good pain control team who will take care of you.
Bleeding: Do not worry, in case it does happen, we keep matched blood which can be
given to you if needed.
Infection: Again, do not worry. We will give you antibiotics
71. Damage to surrounding organs: Very rare. We have an excellent team. If

anything happens we will manage accordingly.
72. Dr: Do you have any other concern? Pt: No
73. Dr: Can I ask you few questions jut to make sure that you are fit for surgery ?
Pt : Yes
74. Dr: Do you have any medical conditions ? No
75. Dr: Are you taking any medications? No
76. Dr: Have you undergone any surgeries previously? No
77. DR: That is good. We will be doing some blood tests and other tests to make you
that you are fine and then we will do the surgery. Is that Ok ? Pt: Ok
78. Thank you.

P a g e | 766
79.
80.
81. If task says laparoscopic surgery has been planned.
82. Smaller cysts can sometimes be removed using a procedure known as

a laparoscopy. This is a type of keyhole surgery where small cuts are made in your
lower abdomen and gas is blown into the pelvis to lift the wall of your abdomen away
from the organs inside.
83.
84. A laparoscope, which is a small, tube-shaped microscope with a light on the
end, will be passed into your abdomen so the surgeon can see your internal organs.
Using tiny surgical tools, the surgeon will remove the cyst through the small cut in your
skin.
85.
86. After the cyst has been removed, the cuts will be closed using dissolvable
stitches. Depending on the type and size of cyst, the operation usually takes about an
hour. Most women are able to go home later on the same day or the following day.
87.
88. A laparoscopy is the preferred surgical method because it causes less pain and
allows you to resume normal activity sooner
89.
90.
91.
92.
93.
94. 2612 95. Video not available
96. Antenatal assessment - lady had miscarriage
previously.
97.
98. 28 year lady Mrs... (P 0+2) presented to the antenatal care unit. Nurse has checked BP
and tested urine for infection and protein which are normal.
99. She is registered first time for the antenatal care.
100. Do the initial antenatal assessment and address here concerns.
101.
102.
103. Hello Mrs..... I am Dr... How are you doing? Pt: I am fine.
104. Dr: how can I help you Mrs. Pt: Doctor, I am pregnant.
105. Dr: Congratulations. May I know how many weeks pregnant are you ? Pt -6 weeks
106. Dr: Do you know what we do here in the antenatal care unit ? Pt - No
107. Dr: Don’t worry, let me explain. First of all I am very glad that you have come here.
We assess the pregnant ladies to see if they have any health or other issues which can affect
the pregnancy and the baby and manage them so that they that they will not have problems
P a g e | 767
during pregnancy and ultimately have a healthy baby. We also educate the parents about how
to cope with pregnancy and delivery and address any concerns you have. We have Obstetrics
doctors, midwife and the whole team to help you to go through this process. Do you follow
me? Pt - Yes doctor.
108.
109. Dr: I need to ask few questions about your health and other things for that. Before that
do you have any concerns which you like to ask me?
110. Pt: Doctor, I was pregnant twice before and I had miscarriage.
111. Dr: I am very sorry to hear that. Can I know when this happened ?
112. Pt : One miscarriage was about 3 years and the other one year ago.
113. Dr: At what week of pregnancy you had these miscarriages? Pt - Both were at 8
weeks.
114. Pt: Did you come for antenatal visits at that time ?
115. Pt - No / Yes ( If no – May I know why ?)
116. Dr: Do you know why you had these miscarriages ? Pt - No ( ? Intentional abortion)
117. Dr: Is this the third time you are pregnant then ? Pt - Yes
118. Dr: Do you have any concerns now ?
119. Pt - Yes doctor. I worried whether the same thing will happen again.
120. Dr: I can understand your worries. But don’t worry. I will explain about it.Before I
explain about the miscarriage, I need to ask you few questions -
121. Do you have any bleeding from the vagina now at all? ( r/o- miscarriage now)? No
122. Dr : Any pain in tummy ( ectopic pregnancy) ? Pt - No
123.
124. Dr: Do you have a stable partner ? Pt - Yes.
125. Dr: Is this a planned pregnancy ? Pt - Yes
126. Dr: Is your partner also happy with this pregnancy ? Pt - Yes ( r/o abuse)
127. Dr: Was he the father both times previously when you were pregnant? Yes.
128. Dr: Do you smoke ? Pt -I stopped one year ago.
129. Dr: Do you drink alcohol ? Pt - No
130. Dr: Do you use any recreational drugs? Pt - No
131. Dr: Do you drink too much coffee ? Pt - No
132. Dr: Mrs.... Most of the time people do have one two miscarriages before they have
normal deliveries. This is quite common. Sometimes the risk of miscarriage is high in those
mothers who smoke, drink alcohol, use recreational drugs or drink too much coffee.
133.
134. Anyway, just because you had miscarriage twice before it does not mean you will
have the same problem again. There is a good chance that you have normal delivery this time.
135.
136. However, if it happens more than 3 times then we call it recurrent miscarriage and
then we start investigating for the causes of miscarriage. One of the common causes of
miscarriage in early pregnancy is chromosome abnormality in the baby means there is
problem in the gene of the baby. If miscarriage happens more than 3 times then we check for
any gene problems in the parents. Other cause of miscarriage is development of some
antibodies in the mother called antiphospholipid antibody which causes thickening of the
blood.
137. Again we test for this condition if the miscarriage happens more then 3 times and we
give medications like Aspirin and some heparin injections to thin the blood which helps in
normal delivery.
P a g e | 768
138.
139. Also we look for other causes like any problem in the mother womb or any infections
which may cause recurrent infections.
140. So for now please do not worry about the miscarriage. Hopefully you will have
normal delivery. Is that OK? Pt - Yes
141. Dr: Do you have any other concerns ? Pt - No
142.
143.
144. Dr: I need to ask few questions about your health now. How is your general health
now?
145. Pt - I am fine now.
146. Dr: Do you have any other symptoms like fever pains any where? Pt - No
147. Dr: Do you have any medical conditions ? Pt - No
148. Dr: Like high blood pressure, diabetes, any blood disorders like thalassemia, sickle
cell disease, blood clots or bleeding disorders ? Pt - No
149. Dr: Did you have any kind of infections before?Pt - No
150. Dr: Did you have any problems in your womb or ovaries were you told of ? Pt - No
151. Dr: Did you have any surgeries to your tummy or pelvis before ? Pt - No
152. DR: Are you taking any medications ? Pt: No
153. Dr : Are you taking folic acid? Pt: Yes/ No
154. Dr: Are you allergic to any thing ? Pt : No
155. Dr: Does your partner have any medical conditions ? Pt - No
156. Dr: Do you and your partner get along well with each other? Pt - Yes. ( ? Abuse)
157. Dr: Any mental health issues with you, your partner or both of your families ? Pt - No
158. Dr: Any medical conditions running in your family or in your partner’s family ? Pt -
No
159. Dr: Anyone else in your or partners family had miscarriages or abnormalities in the
babies or twins ? Pt - No
160. Dr: Have you planned where you want to deliver – at hospital or home?
161. Dr: Is there anything else you like to tell me ? Pt - No
162.
163. Examination
164.
165. Dr: Mrs.. I will be examining your heart, lungs and tummy to check everything is fine
with you. Our nurse has already checked your blood pressure – that is normal. [if there is
NEWS chart – look at it.] Also she has tested your urine for infections and some substance
called protein. They are all normal. We will check your height and weight also.
166.
167.
168.
169. Investigations
170.
171. We will do some blood tests to check blood group, sugar, infections like rubella
syphilis, hepatitis and HIV ? Is that OK? Pt - Yes.
172. We will do tests to check for abnormality in the baby like Downs syndrome, also we
will do ultrasound scan when you are 8 to 10 week pregnant. Pt: OK
173. Dr: Any questions so far? Pt - No
174.
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175.
176. Advise:
177.
178. Dr: I advise you to eat a healthy diet. Have good life style. It is good that you
stopped smoking. We advise you not to restart the smoking habit. Also do not drink alcohol
use recreational drugs and drink too much coffee.
179. We will prescribe some Folic acid tablets for you.
180. You can join some parentcraft classeswhere they will teach you about coping at home
with pregnancy, labour feeding and caring of baby and other things. I also advise you to join
some exercise classes. Have proper dental check up. Avoid travelling to malaria prone
countries. Is that Ok ? Pt - Ok
181. Any other questions? Pt - No
182.
183. Dr: I will talk to my Consultant and arrange the date for your next visit. However if
you have any problem like bleeding or pain abdomen or any other problem, please come
back.
184. Thank you very much.
185.
186. PARENTCRAFT classes for pregnant women. They cover many topics including:-
Signs of labour Coping at home in early labour Pain relief in labour Normal labour
Infant feeding workshop Caring for your newborn baby Safer sleeping Tour of the
maternity unit
187.
188. [ Flight travel is allowed up to 34 weeks in most of the flights]
189.
190.
191.
192.
Ectopic Pregnancy
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Information
 A tubal ectopic pregnancy never survives. Possible outcomes include the following:
 The pregnancy often dies after a few days. About half of ectopic pregnancies probably
end like this. You may have no symptoms, and you may never have known that you
were pregnant. Sometimes there is slight pain and some vaginal bleeding like a
miscarriage. Nothing further needs to be done if thisoccurs.
 The pregnancy may grow for a while in the narrow Fallopian tube. This can stretch the
tube and cause symptoms. This is when an ectopic pregnancy is commonlydiagnosed.
 The narrow Fallopian tube can only stretch a little. If the pregnancy grows further it
will normally split (rupture) the Fallopian tube. This can cause heavy internal bleeding
and pain. This is a medicalemergency
An ectopic pregnancy is when a fertilised egg implants itself outside of the womb, usually in
one of the fallopian tubes.
The fallopian tubes are the tubes connecting the ovaries to the womb. If an egg gets stuck in
them, it won't develop into a baby and your health may be at risk if the pregnancy continues.
Unfortunately, it's not possible to save the pregnancy. It usually has to be removed using
medicine or an operation.
In the UK, around 1 in every 80-90 pregnancies is ectopic.
Symptoms
Symptoms of an ectopic pregnancy usually develop between the 4th and 12th weeks of
pregnancy.
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Main symptoms
 Missing a period or positive pregnancytest
 Vaginalbleeding
 Tummy pain - typically low down on oneside.
 Shoulder tippain
Symptoms of a rupture.
 a sharp, sudden and intense pain intummy
 feeling very dizzy orfainting
 feelingsick
 looking verypale
What can cause an ectopic pregnancy?

In many cases, it's not clear why a woman has an ectopic pregnancy. Sometimes it happens
when there's a problem with the fallopian tubes, such as them being narrow or blocked.
The following are all associated with an increased risk of ectopic pregnancy:
 pelvic inflammatory disease (PID)– inflammation of the female reproductive
system, usually caused by asexually transmitted infection(STI)
 previous ectopic pregnancy – the risk of having another ectopic pregnancy is
around10%
 previous surgery on your fallopian tubes – such as an
unsuccessfulfemalesterilisationprocedure
 fertility treatment, such as IVF – taking medication to stimulate ovulation (the
release of an egg) can increase the risk of ectopicpregnancy
 becoming pregnant while using anintrauterinedevice
(IUD)or intrauterine system (IUS)for contraception – it's rare to get pregnant
while using these, but if you do you're more likely to have an ectopic pregnancy
 smoking
 increasing age – the risk is highest for pregnant women who are aged 35-40 You
can't always prevent an ectopic pregnancy, but you can reduce your risk byusing
acondomwhen not trying for a baby, to protect yourself from STIs, and bystoppingsmoking.
Diagnosing ectopic pregnancy
 Pregnancy test –positive

 Symptoms of ectopicpregnancy
 USG
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 Blood tests - to measure the pregnancy hormone human chorionic gonadotropin (hCG),
may also be carried out twice, 48 hours apart, to see how the level changes overtime.
 Laproscopy/Keyholesurgery
 If it's still not clear whether it is an ectopic pregnancy, or the location of the pregnancy
is unknown, a laparoscopy may be carriedout.
Treating ectopic pregnancy

Unfortunately, the baby cannot be saved in an ectopic pregnancy. Treatment is usually needed
to remove the pregnancy before it grows too large.
The main treatment options are:

Expectant management –Expectant approach is suitable if the HCG at 48h is decreasing
spontaneously and the woman remainsasymptomatic.
If you have no or mild symptoms and the pregnancy is very small or can't be found, you may
only need to be closely monitored. You'll have regular blood tests to check that the level of
hCG in your blood is going down. You may need medical or surgical treatments if your
hormone level doesn't go down or it increases.
You'll usually have some vaginal bleeding.
You may experience some tummy pain.
The main advantage of monitoring is that you won't experience any side effects of treatment. A
disadvantage is that there's still a small risk of your fallopian tubes splitting open (rupturing)
and you may eventually need treatment. If you develop more severe symptoms come to
hospital immediately.
Medication – a medicine called methotrexate is used to stop the pregnancy growing. This
works by stopping the pregnancy from growing and is given as a single injection into your
buttocks. You won't need to stay in hospital after treatment, but regular blood tests will be
carried out to check if the treatment is working. A second dose is sometimes needed and
surgery may be necessary if it doesn't work.
side effects of methotrexate include:
 tummy pain – this is usually mild and should pass within a day ortwo
 dizziness
 feeling and beingsick
 diarrhoea
Surgery – Keyhole surgery (laparoscopy) will be carried out to remove the pregnancy before it
becomes too large.
The entire fallopian tube containing the pregnancy (salpingectomy) is removed or only the
pregnancy is removed (salpingotomy) without removing the whole tube.
Removing the affected fallopian tube is the most effective treatment and isn't thought to
reduce your chances of becoming pregnantagain.
Most women can leave hospital a few days after surgery, although it can take four to six weeks
to fullyrecover.
If your fallopian tube ruptures, you'll need emergency surgery. The surgeon will make
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a larger incision in your tummy (laparotomy) to stop the bleeding and repair your fallopian tube,
if that is possible.
Counselling after ectopic pregnancy

• Explanation of diagnosis andoperation
• Appropriate counselling that the woman may grieve (this is the loss of a pregnancy) with
advice about furthersupport
• Avoid the progesterone only contraceptive pill (POP) andintrauterine contraceptive
device (IUCD) (both are associated with a slightly higher risk of ectopicpregnancy)
• Approximately65–70percentofwomenwhohave
had an ectopic pregnancy go on to have a live birth
following this, but there is a 10–15 per cent chance of a
further ectopic pregnancy
• Early transvaginal scan is indicated at around 5 weeks’ gestation to confirm the location of
any futurepregnancy
• Effective contraception should be used if she does not wish to become pregnant again at
themoment
Ectopic pregnancy - examquestion
18 year Miss Chloe Jones came to the hospital with lower abdominal pain. Her
pregnancy test is positive. Pregnancy test positive.
As per hospital protocol she needs to be admitted for the treatment and USG
should be done the following day.
Talk to her and explain about the further management.
Hello Miss Chloe Jones, I am Dr… one of the junior doctor in the Obstetricsand
Gynaecologydepartment.
How can I help you?
Pt: Doctor I am having pain in my left lowertummy. Dr:
Can you please tell me anything more about it ? Pt:
Doctor, It started few hoursago.
Dr: How severe is the pain – in the scale of 1 to 10 one being the mildest and 10 being the
most severe pain.
Pt: It is about 5 out of 10.
Dr: When was your last menstrual period ? Pt: 6 weeksago. Dr:
Are you sexuallyactive? Pt: Yes
Dr: Any chance that you aepregnant? Pt: I did the pregnancy test today. Itis
positive.
Dr: Do you have any bleeding from vagina? Pt : Yes.
Dr: Since when and how severe is that? Pt: It just started few hours ago. It is just spotting not
very severe.
Dr: Do you feel dizzy or feel like fainting (ruptured ectopic) ? Pt No
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Dr: Do you have fever ? Pt: No

Dr: Do you have burning sensation while passing urine ( UTI)? Pt: No Dr: Do
you have any discharge from the vagina ( STI) ? Pt: No
Dr: Did you see any blood in your urine ( ureteric stone) ? Pt –No Dr: Do
you have diarrheoa or vomiting ( gastroenteritis)? Pt : No
Dr Were you ever pregnant before ? Pt – No ( If yes ask – any previous ectopic,
miscarriage)
Dr: Do you use any sort of contraception ( IUD or IUS are risk factors for ectopic)? Pt: No
Dr: Did you have any infections in your pelvic area before ( risk factor for ectopic) Pt : No
Dr: Did you have any operations in your tummy before ( previous surgery on fallopian tube is
a risk factor for ectopic) ? Pt : No
Examination: Miss Jones I need to examine your tummy and also check your pulse and
blood pressure. ( examiner may give the finding as mild tenderness over left iliac fossa and
pulse and BP are stable).
Diagnosis: Miss Jones with you told me and with the examination findings you have a
condition what we call as ectopic pregnancy. Do you have any idea about this?
Pt : No
Dr: Normally pregnancy happens within the womb as you know. In this condition pregnancy is
not in the womb it is in the fallopian tube which is a tube which connects ovary to the womb.
In this condition pregnancy cannot continue. Sometimes this condition can be dangerous
because the fallopian tube can rupture and cause heavy bleeding inside the tummy. Are you
following me?
Pt : Yes. What is going to happen now ?
Dr: We need to do an ultra sound scan of your tummy to confirm this condition. However this
test can be done only tomorrow morning. ( If she ask why not now – you can say the expert
doctor who does the scan can come only tomorrow morning ). Since at this moment we are not
suspecting you are bleeding heavily inside your tummy we will keep you in the hospital and
keep monitoring you and we will do the scan tomorrow.
Pt: Doctor I can’t stay in the hospital.
Dr: Why?
Pt: If I stay in the hospital my parents will come to know that I am in the hospital and they will
come to know that I am pregnant. I don’t want them to know that I am pregnant.
Dr: Miss Jones, if you go home now - sometimes it can bleed heavily and you may not be able
to come back to the hospital in safe time. We will not tell your parents unless you want us to
tell them. However we strongly advise you to tell your parents because you may need their
support now.
{ sometimes she may agree. If she does not agree – tell her that it is important that some one
knows that you are in the hospital as may need support – she may she I will ask my friend to
come).
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Pt: what are you going to do to treat this condition?

Dr: If the test confirm that it is ectopic pregnancy then there are several ways we can manage it.
We will do another blood test to check a pregnancy hormone called Beta HCG which we
will do now and again after 48 hours. Depending on the level we can decide the treatment
options. If the symptoms do not get worse and the hormone level is decreasing after 48 hours
- we can just wait and watch because sometimes the pregnant gets dissolved by itself.
If the hormone level is high then we will give you an injection ( one injection to the buttock)
called Methotrexate. This medication will stop the pregnancy from growing. You do not need
to stay in the hospital after that but we will keep monitoring you to check the treatment is
working.
If these treatment do not work then we may need to do an operation to remove the
pregnancy. In this procedure we will do a key hole surgery on your tummy and remove
the fallopian tube of that side along with the pregnancy if the other tube is healthy or
remove only the pregnancy if the other tube is not healthy. If we do operation -you may
need to stay in the hospital for few days.
If it all it starts bleeding heavily then we need to do an open operation immediately to stop
the bleeding. Are you following me? Any questions?
Pt: Will there be any complications in the future?
Dr: Sometimes you can have ectopic pregnancy again or it can cause miscarriage or very
rarely it cancauseinfertility. Pt: OK
Dr: Any other question. Pt - No
Dr: We strongly advise you to practice safe sex and effective contraception until you want to
become pregnant again and if you become pregnant again and if you have any pain in your
tummy – which is a sign of ectopic pregnancy again- please come to us immediately.
Thank you verymuch.

PCOS LADY— AMENORRHEA FOR 6 MONTHS Feb 22nd
You are an FY2 in a GP clinic.
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20/24 year old girl has come to the GP with h/o amenorrhea for 6-8 months. Gp had
ordered some test results. She is here to collect the results. Talk to her and address her
concerns.
Test results : (testosterone level not given)
FSH : normal
LH: high ( LH :FSH ratio >2 is significant for pros. Normal is 1:1)
Dr: Hello, Are you Ms? Pt : yes

Dr: I am Dr … one of the junior doctor in GP today. I see that you are here to collect your blood
test results, Can I ask a few questions before we get into this? Pt : yes
Dr: What brought you to the hospital initially?
PT : Dr I havent had my period since the last 6 months.
Dr: that must be quite worrying for you. When was your LMP? Pt..
Dr : This might be a very obvious question to you, but I need to ask. Is there any chance that you
are pregnant? Pt : no
Dr : are you on any form of contraception? (OCP can cause high LH)
Pt: no dr. I don’t have a partner. My last relationship was 3 years ago.
Dr : Alright. Thank you. Did you have irregular periods before this? Pt: yes/no
Dr: did you have heavy bleeding in the past? Pt : yes/no
Dr : Did you feel like there was excess hair growth on your body than usual for example on your
face, chest or back? (hirshutism) pt : yes dr. I was quite worried about that too. ( ressure her), any
thinning of hair from the head? Pt :|…
Dr : do you have acne? Pt : yes dr. It is stressing me out. I cant go anywhere
Dr : Any weight gain? Pt: yes. I gained weight in the last 12 months.
Dr: Is there any chance you were trying to get pregnant and couldn’t? Pt : no dr. I don’t want
kids now. I’m just concerned about my periods and acne.
Dr : we will talk about it shortly. Please bear with a few more questions, if thats alright.
Pt : ok
Dr: Any preference to cold weather?, bowel habits?
Pt |: no
Dr : Any medical conditions? Pt : no (no diabetes or family h/o diabetes) No family history of
PCOS or infertility. Has 3 brothers
Dr : any medications (steroids? For cushings, thyroid medication)? Allergies? Pt : no. doesn’t
smoke or drink.
Dr : any medications (steroids? For cushings, thyroid medication)? Allergies? Pt : no. doesn’t
smoke or drink.
Dr : How about your life style? Pt : likes to sleep a lot, doesn’t exercise, eats fish and chips,
burgers and occasionally vegetables.
Dr : Ms… thank you for answering my questions patiently. I can discuss your results now. Do
you have any idea what this could be?
pt: no
Dr : These are your results and if you see, this is a hormone LH from the ovaries. These are
increased in your body. You also mentioned about your weight gain, we measure weight
against your height. This is called Body Mass Index. It seems to be on the higher side too.
(It is considered healthy to fall between 18.5 to 24.9). With all the symptoms you have
told me and these results, I think you have a condition called Polycystic ovarian
Syndrome. Do you have any idea about this?
Pt : no/yes.
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Dr : Polycystic ovary syndrome (PCOS) is a common condition that affects how a woman's
ovaries work.
The 3 main features of PCOS are:
• irregular periods – which means your ovaries do not regularly release eggs (ovulation)
• excess androgen – high levels of "male hormones" in your body, which may cause
physical signs such as excess facial or body hair
• polycystic ovaries – your ovaries become enlarged and contain many fluid-filled sacs
(follicles) that are not actually cysts.
Dr : are you following me so far? Pt : yes. Dr
Dr : however we need to do some more blood tests to check for your blood sugars, blood
cholesterol, testosterone level, thyroid levels and also a scan of your tummy to see the ovaries.
For this we’ll be referring you to OBG specialists.
pt: why did I get this?/how can you treat me?
Dr : there are medications as well as some lifestyle changes that you can do. Which one do you
want to know first?
Pt : I want on natural remedies dr. I don’t want any medications
Dr : can I ask why? Pt…
Dr : well, there are certainly some measures that can help with this. If you have PCOS and you're
overweight, losing weight and eating a healthy, balanced diet with lesser carbs and more healthy
fats can make some symptoms better. We could refer you to a dietician for that. Is that something
you could do?
Pt : ok dr.
dr: Will I be able to have children in the future?
Dr : that is a very good question. Chances of not being able to bear a child in women with pcosis
high. But the good news is that we have excellent treatment for that. Women with PCOS are
advised on weight control and exercise. Weight loss has been shown to improve fertility. Along
with this there are several medications and procedures that would improve the outcome if done
together. Please inform us when you are planning to get pregnant so that we can guide you
accordingly.
Pt : when will I get my periods?
Dr: well, I can’t confirm about that exactly. since you told me that you dint get your periods after
the weight gain, it could become normal once there is some weight loss. However I can’t
completely assure you that
dr: do you have any other questions for me?
Pt: …..
Hypertension and pregnancy

You are an FY2 in the GP clinic. 42 year old Mrs… has come to see you. Talk to her and
address her concerns. She is on Lisinopril/Ramipril
Dr: Hello Mrs.. My name is Dr...... I'm one of the junior doctors here. How are you doing today?
P a g e | 778
P: Hello doctor, I'm okay. I want to get pregnant
Dr:Well I can certainly help with the queries you might have regarding that. Could you tell me a
bit about your partner?
Pt : Dr I got married a year ago. Me and my husband want a baby now. I just want to know about
the things I should be aware of before getting pregnant.
Dr : Thats a great thing you have come to us and we most certainly will help you. How long have
you been trying to get pregnant now?
Pt: (may say a duration or says we haven’t started trying yet)
Dr : alright. Have you been pregnant before? Pt : no (never wanted a baby before. Trying for the
first time)
Dr : when was your LMP? Pt :…
Dr: Are your periods regular? Painful? Heavy bleeding? Pt : no
Dr : Are you on any form of contraceptives at the moment? Pt :…
Dr : have you ever been diagnosed with any sexually transmitted illnesses before? Pt : no
Dr : have you been diagnosed with any medical conditions in the past? Pt : yes dr, I have high
BP and I am taking Lisinopril / ramipril for that.
Dr: thank you for telling me that. Is your BP well controlled? Do you monitor it at home? Follow
ups? Pt : yes Dr.
Dr : any other medications? Over the counter medications? Folic acid? Pt :no
Dr: Family history of Diabetes or high Bp (mother or sisters during pregnancy), Kidney
diseases? Pt : no
smokes and drinks socially.
Examination : I’d like to check your vitals : bp, pulse and temparature. Examiner : ….
Dr : ms… thank you for answering my questions. I have to advice you that we should change
your BP tablet before you get pregnant.
Pt: (pt is shocked) what doctor! No doctors ever told me that!! Will this harm my baby?
Dr : Please be reassured that we are going to take care of this. I can check in my BNF once to
confirm (doesnt say teratogenic. But ACE inhibitors have an adverse outcome during pregnancy)
I’m afraid we will have to change you medication to another group called beta blockers if its
suitable for you. We may give you other medications depending on whats suitable for you.
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(labetalol, methyl dopa, nifidepine are considered). I will be referring to my seniors and
specialists who could advice you better on that Ms..
Pt : Are you sure that this will harm my baby dr?
Dr : we have research stating that these medications could be harmful to the baby, especially
during and after 4 months of pregnancy. We will change it to a safer group of medicines.
Pt: Is there anything else you’d be giving me dr ?
Dr : Yes we would give you folic acid supplements and other medications. I’d be referring you to
the OBG department. They will run some blood tests and urine tests too.
Pt : is there anything I should know of ?
Dr : It's important that your antenatal team monitors you closely throughout your pregnancy to
make sure your high blood pressure is not affecting the growth of your baby and that you don't
develop a condition called pre-eclampsia. Make sure you go to all your antenatal appointments.
Am I being clear? Pt : yes dr
Dr : Also, During the first half of pregnancy, a woman's blood pressure tends to fall. This means
you may be able to come off your medication for a while. But this should only be done under
your doctor's supervision. Is that alright? Pt : yes dr
Dr : If at all at any point you develop headache, vision problems, swelling of your feet or tummy
pain during your pregnancy, call us or an ambulance immediately. You need urgent care in such
cases.
Pt : is there something I can do to help this dr?
Dr : Keeping active and doing some physical activity each day, such as walking or swimming,
can help keep your blood pressure in the normal range. Eating a balanced diet and keeping your
salt intake low can help to reduce blood pressure. We will also refer you to a dietician if the bp is
not under control.
I’d advice you to stop smoking. Please avoid alcohol during the course of your pregnancy.
Dr : do you have an other concerns? Pt : yes/no
Nice guidelines for treatment of patient with chronic

hypertension in pregnancy
How should I manage a woman with chronic hypertension?
• Offer advice about:
◦ Healthy lifestyle (including work, exercise, and weight) as recommended for all
pregnant women. For more information, see the CKS topic on Antenatal care -
uncomplicated pregnancy.
◦ Restriction of dietary salt intake. For more information, see the CKS topic
on Hypertension - not diabetic.
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• Ensure all women with chronic hypertension are referred for obstetric care at
booking as these women are at high risk of pre-eclampsia.
◦ If the woman has secondary hypertension, also consider referring to a specialist in
hypertensive disorders, or to a renal physician, endocrinologist, or specialist in
connective tissue disease as appropriate.
• While the woman is waiting to see a specialist, if she is taking:
◦ An antihypertensive other than an angiotensin-converting enzyme (ACE) inhibitor
or angiotensin-II receptor antagonist (AIIRA), consider continuing the current
medication, but seek specialist advice if there is uncertainty.
◦ An ACE inhibitor or AIIRA, stop this immediately and prescribe an alternative
treatment if necessary.
▪ Explain that there is an increased risk of adverse fetal outcomes especially
if these drugs are taken during the second and third trimesters of
pregnancy.
▪ Advise women who have continued to take ACE inhibitors during the first
trimester that there is no strong evidence that this is associated with
increased risk to the fetus.
◦ If an ACE inhibitor or AIIRA is stopped, first-line treatment is usually labetalol if
not contraindicated. Alternative treatment is with methyldopa or nifedipine,
taking into account the adverse effect profiles for the woman, fetus, and newborn
infant.

OCP History andcounselling
Mrs Claire Godwin 22 year old lady came to the hospital requesting combined pill for
contraception. Talk to her and advise her about the contraception.
(Very important in this station is to rule out contra indication – patient had DVT one year ago
and was on warfarin at that time. So Combined pill cannot be given to her. However all other
options are available to her because she is not on warfarin now).
Female condoms ae only 95% effective.
Dr: How can I help you ?
Pt: I need combined pills for contraception ?
Dr: Good. Why do you specifically asking for combined pill? Pt: My
friend is using that and she said it is good.
Dr: Are you using any contraception now ?
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Pt: I am using female condom ?

Dr: Why do you want to change it ?
Pt: It is not good because I became pregnant last time because the condom tore. I want
something more reliable this time.
Dr: Ok do not worry we have several options for contraception also more reliable ones. But I
need to ask you few questions to see which type is suitable to you.
Rule out contraindications:
1) Dr: Have you ever had any clots in your lungs or legs? Pt:
Yes I had it one yearago.
Dr: Were you given any blood thinner medication for that Pt: Yes
I was given warfarin.
Dr: Are you still taking warfarin?
Pt: No I finished taking the warfarin many months ago.
2) Any family history of clots in legs orlungs?

3) Sorry to ask you this but have you or any family member been diagnosed with
cancer of thebreast?
4) Have you ever experienced a migraine or a one-sided severeheadache?
5) Do you have any liverdisease?
6) Do you smoke
7) Are you on anymedication?
Dr: Do you have a partner

Pt: Yes, I have husband ( married) Dr:
Do you have children
Pt: Yes 2 children
Dr: Have you taken combined pill before any time ? Pt:
No
Dr: Mrs Godwin, unfortunately the combined pill is not good for you because you had blood
clot in your leg before. If you take the combined pill the blood clot can happen again because
one of the complication of combined pill is that it can give rise to blood clots. Combined pill has
two types of hormone oestrogen and progesterone. It is the oestrogen part which causes blood
clots.
However we have plenty of other options - one of that is male condom – advantage is that is
98% reliable and also it is the only contraception which prevents sexually transmitted
infections also.
I do now want it because it can also slip.
That is true. We have other option which is Progesterone only pill (POP).
PROGESTOGEN ONLY PILL – Sometimes called the ‘mini-pill’. It contains just a
progestogen hormone (it does not contain oestrogen) which works mainly by causing
a plug of mucus in the cervix that blocks sperm, and by thinning the lining of the
uterus. Also prevents ovulation.
Advantages – It is very reliable success rate is 99% with that if taken correctly. It is
easily reversible and convenient. It does not cause clots like oestrogen and it can be
used during breastfeeding.
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Disadvantages – It can cause irregular periods. Some women have side-effects like
headaches, mood swings and weight gain these are common though). They are not
quite as reliable as the combined pill. Also need to remember to take at the same
time every day.
Contraceptive implant – This is a small flexible tube containing progestogen that's inserted
under the skin of your upper arm and lasts for three years. It is 99% effective. The implant
stops the release of an egg from the ovary by slowly releasing progestogen into your body.
Progestogen also thickens the cervical mucus and thins the womb lining. This makes it harder
for sperm to move through your cervix, and less likely for your womb to accept a fertilised egg.
Advantage is that you do not need to remember to take it every day.
Other option is INTRAUTERINE DEVICE (IUD) - A plastic and copper device is

put into the uterus. It works mainly by stopping the egg and sperm from meeting. The
copper also has a Spermicidal effect (means it kills sperms).
Advantages: It is more than 99% effective. Don't have to remember to take pills and it
lasts 5 or more years.
Disadvantages - Periods may get heavier or more painful. It carries small risk of
serious problems including damage to the uterus and infection.
Other option is - HORMONE RELEASING INTRAUTERINE DEVICE

(eg Mirena) – This is a plastic device that contains a progestogen hormoneis put
into the uterus. The progestogen is released at a slow but constant rate. It Works in
a similar way to thePOP.
Advantages: This is also more than 99% effective. Don't have to remember to take
pills. It can remain in place for 5 years. Periods become light or stop altogether.
Disadvantages: Side-effects may occur as with other progestogen methods.

However, they are much less likely as the hormone is mainly confined to the
uterus.
If you have finished family ie do not want to have any ore children – then we have
Permanent method – Female sterilisation – this is a procedure where we block
the part of the fallopian tubes connecting the ovary and uterus. 99% effective.
Disadvantage – very difficult to reverse and NHS may not fund.
Dr:- So Mrs Godwin which one do you prefer ?

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PRE-CONCEPTION COUNSELLING
Question: You are an FY2 in GP Surgery. Paula Anderson is a 35 years-old
lady who has presented with some concerns. Talk to the patient and address
her concerns.
Hello. Paula Anderson? Hi, my name is Dr. ……… I am one of the junior doctors here in
the GP Surgery.
What would you like me to call you? – Hi, Paula is fine

And can you confirm for me your age please? – Yes, it’s 35
How can we help you today Paula? – Doctor, I need some advice about getting pregnant
Ok, I am sure we can help you with that.
Can you tell me a little bit more about the problem it is that you’re having? – Yes, I’ve
been in a long-term relationship now for 6 years, and we think we’re ready to have
children. But now I’m having second thoughts and I’m not so sure
Is there anything in particular that you’re worried about? – No, I’m just worried that I’m
too old to have children and there might be a problem with my child
Ok, so have you ever been pregnant before? – No
Are you aware of any problems that may occur in advanced maternal age? – No
Have you been trying for a baby? Have you been having regular unprotected sexual
intercourse every 2-3 days during your menstrual cycle? – Nodoctor
Are you currently experiencing any symptoms? – Like what doctor?

GUT Symptoms; fever? lower abdominal pain? pain on passing wee? blood in your wee?
discharge from your front passage? heavy/pain menstrual bleeding? pain having sex? – No
Anything I might have missed that you would like to add? – I’m completely fine, I don’t
have any troubles with my health
Ok, so what I would like to do is ask you a few general questions about your health, and
then a few more personal questions about your menstrual cycle and sexual history. Does
that sound alright? – Yes
Have you been diagnosed with any prior medical conditions? DM? HTN? Asthma? – No
Have you ever needed to visit the hospital for any reason? – No
Have you undergone any surgical procedure before? – No
Are you taking any prescription medication at all? – No
Are you taking any over the counter (OTC) medication? - No
Are you allergic to anything at all? – No
Are there any medical conditions that run in the family? DM? HTN? Stroke? CA? – No
Have you travelled anywhere recently? – Yes, I do travel a lot for work
What do you do for a living? – Actress
Do you drink alcohol? Units? – Yes, I have a have a bottle of wine every day. I don’t know
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Do you smoke? How much? Since? – Yes, I’ve been smoking for 15 years now, 10/day
Do you use recreational drugs? – No
Diet? Exercise? Hobbies? Sleep? Stress? Relationships? Work? – All ok
Who else is at home? – It’s just me, my partner and our dogs
A few questions about your menstrual cycle (10)

 LMP? – 3 weeks ago
 Clots? – No
 Regularity? – Regular
 Excessive pain? – No
 Cycle duration? – 30 days
 Contraception? – Pill before, condoms now
 Days you bleed? – 5 days
 Excessive bleeding? – No  Cervical smear? – Yes
 Results of last cervical smear? – Normal
I did use the combined pill only 6 years ago for 4 years but then I stopped taking them, and
the last 2 years we’ve only used condoms
Is there any reason why you stopped taking the pills? – Yes, I got sick of taking them
Did you experience any side effects of the pills? Headache? Nausea? Bleeding in between
cycles? Weight gain? Mood changes? Breast tenderness? – No
How have your periods been since you stopped the pills – They went back to normal in a
couple of months
A few questions about your sexual history (10)

 Sexually active? – Yes
 1 partner or more? – 1
 Kind of sex? (O/V/A) – All
 Stable relationship? – Yes  Safe sex? – Yes
 Male/Female? – Male  Casual? – No
 Last time? – Yesterday  Abroad? – No
 STI? – No
Is there anything else that you would like to add? – No
So just to summarize, you don’t seem to be experiencing any symptoms. You have had a
stable male partner for a few years, and now you’re looking to start a family but you’re just
worried about being pregnant at this age. Is that correct? – Yes
Many factors can affect a couple's chances of conceiving, such as:
 your age
 your general health
 your reproductive health
 how often you have sex
Some women become pregnant quickly, while others take longer. This may be upsetting,
but it's normal.
Do you at all have any idea how the mother’s age can affect pregnancy? – Yes, I think if
you get older your chances of getting pregnant reduce.
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You are right to some extent, however there are other variables to consider too. Every
woman is different, and no 2 women have the same exact reproductive capability. Most
couples (about 84 out of every 100 – 84%) will get pregnant within a year if they have
Regular Sex and Don't Use Contraception. Generally, however, women do
become less fertile as they get older:
 aged 19 to 26 – 92% will conceive after 1 year and 98% after 2

years
years
The effect of age on men's fertility is less clear.
I want to reassure you, that although the data does point towards a reduced likelihood of
conception at the above 35 years age group, the chances of getting pregnant are still
relatively high at above 80% after 1 year and 90% after 2 years.
Do you follow? - Yes
◦ What does 'regular sex' mean?
Having regular sex means having sex every 2 to 3 days throughout the month.Some
couples may try to time having sex with when the woman ovulates (releases an egg).But
guidance from the National Institute for Health and Care Excellence (NICE) advises that
this can be stressful and it isn't recommended.
◦ Could I have a fertility problem?
Fertility problems affect 1 in 7 couples in the UK.Lots of factors can cause fertility
problems, including:
 Hormonal (endocrine) Disorders, such as polycystic ovary syndrome (PCOS) and

problems with the thyroid or pituitary glands
 Physical Disorders, such as obesity, anorexia nervosa or excessive exercise
 Disorders of the Reproductive System, such as infections, blocked fallopian
tubes, endometriosis or a low sperm count
Some of these factors affect either women or men. In around 40% of infertile couples,
there's a problem with both the man and woman.The most common cause is Ovulation
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Failure (which can be caused by lots of different things) and sperm disorders. In 25% of
couples, fertility problems can't be explained.
Infertility is when a couple cannot get pregnant (conceive) despite having

regular unprotected sex.
For couples who have been trying to conceive for more than 3 year without success, the
likelihood of getting pregnant naturally within the next year is 1 in 4, or less.It's a good
idea to see your GP if you have not conceived after a year of trying.Women aged 36 and
over, and anyone who's already aware they may have fertility problems, should come back
to the GP Surgery sooner. We can check for common causes of fertility problems and
suggest treatments that could help. Infertility is usually only diagnosed when a couple have
not managed to conceive after a year of trying.
There are 2 types of infertility:
 Primary Infertility – where someone who's never conceived a child in the past has
difficulty conceiving
 Secondary Infertility – where someone has had 1 or more pregnancies in the past,
but is having difficulty conceiving again
There are also several factors that can affect fertility.These include:
 Age – fertility does declines with age

 Weight – being overweight or obese (having a BMI of 30 or over) reduces fertility;
in women, being overweight or severely underweight can affect ovulation
 Sexually Transmitted Infections (STIs) – several STIs, including chlamydia, can
affect fertility
 Smoking – can affect fertility: smoking (including passive smoking) affects your
chance of conceiving and can reduce semen quality
 Alcohol – the safest approach is not to drink alcohol at all to keep risks to your
baby to a minimum. Drinking too much alcohol can also affect the quality of sperm
(the chief medical officers for the UK recommend adults should drink no more than
14 units of alcohol a week, which should be spread evenly over 3 days or more)
 Environmental Factors – exposure to certain pesticides, solvents and metals has
been shown to affect fertility, particularly in men
 Stress – can affect your relationship with your partner and cause a loss of sex drive;
in severe cases, stress may also affect ovulation and sperm production
There's no evidence to suggest caffeinated drinks, such as tea, coffee and colas, are
associated with fertility problems.
The age of 35 is simply an age that certain risks become more worthy of discussion.While
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these risks become slightly more likely after hitting 35 years old, this does not mean that
they will have a significant impact on everyone in their mid-thirties and older.
People who are pregnant at age 35 or older are often referred to as “Advanced
Maternal Age.”
◦ A. Genetic Risks
◦
Certain genetic risks are also more common in pregnancies of older pregnant people. One
risk is that the embryo will have Down Syndrome, which happens when there is an
extra copy of Chromosome 21. The rate of having a baby with Down syndrome increases
with the mother’s age—this has been seen in large studies of women, as well as in studies
with embryos conceived with In Vitro Fertilization(IVF).
These are the rates of an embryo having Down syndrome at 10 weeks of pregnancy:
1 in 1,064 at age 25
1 in 686 at age 30
1 in 240 at age 35
1 in 53 at age 40
1 in 19 at age 45
These are the rates of having a baby with Down syndrome at term:
1 in 1,340 at age 25
1 in 939 at age 30
1 in 353 at age 35
1 in 85 at age 40
1 in 35 at age 45
The rates of having baby with Down syndrome at term are not as high as the chances at 10
weeks, mostly because these pregnancies have higher rates of miscarriage and stillbirth and
won’t all reach the term period.
◦ B. Risk of Miscarriage
◦
◦ A miscarriage is the loss of a pregnancy during the first 23 weeks.The rate of
spontaneous miscarriage climbs gradually with age, from a 9% miscarriage rate among
22-year olds, to 18% among 30-year olds, 20% at age 35, 40% at age 40, and 84% at
age 48.High rates of miscarriage in older women are more related to egg quality than
the physical ability to stay pregnant. We know this because older women who use
donor eggs from younger women do not have such high rates of miscarriage.
◦
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◦ C. Risk of Stillbirth
◦
◦ A stillbirth is when a baby is born dead after 24 completed weeks of pregnancy. It
happens in around 1 in every 200 births in England.There are two ways to find out
the risk of stillbirth in people who are 35 or older. One way is to look at the absolute
risk; this is the actual rate of stillbirth among women of a certain age group. This
means you can say something like “Among women over 35 years, X number of babies
out of every 1,000 births are stillborn.”The other way is to look at the relative risk. This
means that you compare the risk of stillbirth among older women to the risk
experienced by younger women. This approach will give us a result like, “Compared to
people in their twenties, those over 35 are X% more likely to experience
stillbirth.” With relative risk, if a risk is “50% higher,” this does not mean that an older
woman has a 50% chance (1 in 2 chance) of having a stillbirth. For example, if
someone who is 20-24 years old has a 0.65 out of 1,000 risk of stillbirth at 38-39
weeks, and someone who is 35 years old has a risk of 1.1 per 1,000, then that is a
roughly 50% increase in risk.
◦
◦ Are there any other risks?
◦
Besides genetic risks, miscarriage and stillbirth, researchers have found small increases in a
number of other childbirth risks in people 35 and older. Most risks were found to
increasewith age. The one piece of good news in here is that breastfeeding rates are higher
in people 35 and older than in the younger group.
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There are no studies that answer the question of whether a planned Caesarean birth is better
or not for people 35 or older.
Paula,what I would like to do now is just check your observations, is that alright? I need to
check your: pulse, blood pressure, breathing rate, temperature and levels of oxygen in your
blood.
height.
Ideally, I would also like to check your tummy and your front passage for any discharge,
redness, swelling, skin changes or scars.
Thank-you for letting me examine you, everything seems to be normal.
MANAGEMENT
Firstly, I would just like to reassure you that it is quite common for women in your age
group to be a little worried about starting a family a little later in their life. It's impossible
to say how long it takes to get pregnant because it's different for each woman. You don’t
seem to have any additional risk factor - other than your age and that it’s your first
pregnancy - which is quite reassuring.
 If you would like to start a family and get pregnant, then you can. It’s
important that you have regular unprotected sexual intercourse, especially when you
are ovulating. A sustained period of at least 6-months should be tried before we follow-
up in the Surgery.
How will I know I’m ovulating?
Ovulation is when an egg is released from one of your ovaries. If you want to work out
when you ovulate, there are a number of things you can use:
 the length of your menstrual cycle– ovulation usually occurs around 10 to 16

days before your period starts, so you may be able to work out when you're likely to
ovulate if you have a regular cycle
 your cervical mucus – you may notice wetter, clearer and more slippery mucus
around the time of ovulation
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 your body temperature – there's a small rise in body temperature after ovulation
takes place, which you may be able to detect with a thermometer
 ovulation predictor kits – hormone levels increase around the time of ovulation
and this can be detected using ovulation predictor kits that measure the level of
hormones in your pee
Using a combination of these methods is likely to be most accurate. Some women may
experience other symptoms when they're ovulating, including breast tenderness, bloating
and mild tummy pain, but these are not a reliable way of predicting ovulation.
 Complications – as mentioned before – are Rare today compared to previous decades,

but there are slightly higher rates throughout pregnancy in older women compared to
younger women, and these rates go up at the end of pregnancy. However, the good
news is that the vast majority of people 35 and older who make it to term will have a
healthy baby.
 Intervention rates for your age group may be further lowered by using a Midwifery-
led Model of Care. Here a midwife – a health professional who cares for mothers
and new-borns around childbirth – would be looking after you each step of the journey.
 A Booking Appointment would be performed at 8-12 weeks, and an Anomaly

Scan performed around 20 weeks to check for any abnormality.
 We would conduct USG Scans at regular periods during your pregnancy, including
the 1st and last trimester to check for any potential abnormality (anomaly).
If tests show your baby has a serious abnormality, you can find out as much as possible
from your specialist doctor – an Obstetrician - about the condition and how it might
affect your baby.You may be offered a termination to end the pregnancy. Some couples
wish to continue with the pregnancy and prepare for the needs of their new-born baby,
while others decide to terminate the pregnancy (abortion). There are 2 main types of
termination:
 Medical Termination – taking medicine to end the pregnancy

 Surgical Termination – a procedure to remove the pregnancy
You should be offered a choice of which method you would prefer whenever possible.A
medical termination allows for a detailed examination of the baby (post-mortem) that can
help find out the exact nature of the baby's abnormalities. Tests can be done after both a
medical and surgical termination to see if the baby was carrying a genetic disorder. This
may help your doctor to determine the chance of a future baby having a similar problem.
 Hearing the diagnosis can be very shocking and you may find it hard to take in. You
may need to go back and talk to the doctor with your partner or someone close to you.
 Genetic Counselling and Genetic Testing – sometimes called genomic testing
– finds changes in genes that can cause health problems. It's mainly used to
P a g e | 791
diagnose rare and inherited health conditions and some cancers. This can be
utilized to check for genetic conditions at a very early stage of pregnancy.
 It is important to spend some time thinking things through. The charity Antenatal
Results and Choices offers information and support for people who have received
a diagnosis after antenatal screening. Its helpline is answered by trained staff.
 If after 1 to 2 years, you have been trying for a baby without success, come back to us
at the GP Surgery. As you are 35 going on to 36, it would be better for you to follow-
up with us within 6-months to a year. We may need to refer you to the Infertility
Clinic. At the clinic they may perform some further tests and will go over in detail the
various Assisted Reproductive Techniques (ARTs) available to help you
conceive. Routine Blood Tests may be required. And a Husband Semen Analysis
is usually performed.
 It is important to keep you BMI within the normal range of 18.5-25, so Diet and
Exercise will play an integral role. 5 fruit and veg / day. 8 glasses of water / day. 2
portions of fish / week. Reduce the amount of junk food/fatty foods. Reduce the
amount of cholesterol in diet. At least 30mins of exercise per day, or 2hours 30mins of
exercise per week.
 We may have to consult a Nutritionist to ensure you get an adequate amount of
Iron and Folic Acid in your diet. These are required to help the baby grow.
Supplements may be prescribed.
 Reduce Alcohol Intake to less than 14 units of alcohol per week. This equates to 2
units per day. Cutting down altogether is preferred. Consuming alcohol during
pregnancy can cause problems in your child. Do you think limiting your alcohol intake
is something you would consider? – Yes
 Smoking Cessationcan also be helpful when trying to conceive. Do you think
quitting smoking is something you would be interested in? – Yes
 Reducing Stress from your life is also important. Finding a hobby such as walking,
swimming or yoga can reduce your stress levels and improve your chance of
conceiving.
Was there anything in particular you were expecting to get out of this consultation? –No
 We can book you in a for a follow up with the Midwifewithin the next 6-months.
 Ifyou begin to experience any symptoms, or think you have become pregnant and want
to confirm your pregnancy, please do come back and visit us at the GP Surgery. We
will be more than happy to address any of your concerns. Thank-you very much.
P a g e | 792

Emergency Contraception
Exam question
You are a junior doctor in GP clinic.
14 yr old girl, Miss... has come to clinic with unprotected sexual intercourse.
She is requesting for morning after pill. She is worried.
Dr: Hello. My name is Dr.... I'm one of the junior doctors here in the GP Clinic.. How
may I call you?
P: Hello doctor. You can call me...
Dr: How can I help you? Pt: Doctor I need morning after pills.
Dr: Can you please tell me why do you want those pills ?
Pt: Doctor I had sex with my partner and we did not use protection and I am worried that
I might get pregnant.
Dr: Please do not worry. Let me ask you a few questions and I will tell you what I can
do. Pt: Ok
Dr: Can you please confirm your age ? Pt: I am 14 year old.
Dr: Yes we can give you the pills if that is suitable to you. Can I ask you few more
questions to decide about it ? Pt: Alright.
Dr: When did you last have unprotected sex? Pt: last night about 12 hours ago.
P a g e | 793
Dr: Alright. Was it for the first time that you had unprotected sex or did you have any
unprotected sex before that ? Pt: This was the first time doctor.
Dr: Before this incident, have you been sexually active? Pt: Yes doctor.
Dr: And for how long? Pt: For about a year now doctor.
Dr: And were you using any kind of contraception ?
Pt: Yes doctor, we have been using condoms but last night we didn’t have the condoms.
Dr: Could you please tell me the age of your partner? Pt: He is a year older than me.
Dr: Did you have any sexual encounter with adult (that is anyone who is age is 18 or
more years)?Pt: No doctor.
Dr: Do your parents know about this?
Pt: No doctor. My parents do not know. Please do not tell them. Will you tell my
parents?
Dr: Respecting patient confidentiality is an essential part of good care and this applies
whether the patient is a child or an adult. Please do not worry. Pt: Alright doctor.
Assess mental capacity
Dr: Can you please tell me why did you specifically ask for pills?
Pt: My friend has used that and she said it will work.
Dr: Alright. And what do you know about pills?
Pt: Well, I have been told that it works in emergency cases if one doesn't use any
condoms for protection.
Dr: Do you know what can happen if you do not use contraception?
Pt: Yes doctor, I know that if I not use any protection, I will become pregnant. I do not
want that doctor. Please help me.
Dr: Yes, we will help you, but do you know that if you do not use any condoms, one
might get sexually transmitted infections as well?
P a g e | 794
Pt: Yes doctor. But would you prescribe me the pills? I am really tense. I do not want to
become pregnant.
Dr: Do not worry, we have some options to deal with such cases. I think that you have
capacity to understand the benefits and the risks of contraception so we might be giving
you some morning after pill. But in addition to this, my seniors will talk to you and will
assess your situation a bit further. Are you following?
Pt: Yes doctor. What will you give me?
Dr: We have two types of pills. Levonelle and EllaOne. It works mainly by preventing
or delaying the release of an egg from your ovary, which normally happens each month
(ovulation). It does not interfere with your regular method of contraception. Are you
following me?
Pt: Yes doctor. But when do I take it?
Dr: You will have to take either one of the pill as soon as possible. It has to be taken in a
single dose. The earlier you take the pill, the more effective it is. And I have to tell you
this that if you throw up within two hours after taking the pill, you will have to take it
again.
Pt: How effective are these pills?
Dr: It is difficult for us to say exactly how effective it is. However, there is a good
chance of preventing pregnancy if it is taken within few hours after unprotected sex.
(<72 Hours in Levonelle and <120 hours in ellaOne)
Pt: Are there any side-effects with these pills doctor?
Dr: Side-effects are usually uncommon. However, some women feel sick for some hours
after taking the pill. This may be less likely to happen if the pill is taken with food. But
as I have told you, if you vomit within two hours of taking the pill then take another pill
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as soon as possible.
Other mild side-effects occur in some women for a short time, such as diarrhoea,
dizziness and breast tenderness.
Pt: Will it work doctor? Will I not get pregnant?
Dr: Hopefully it works. However, these pills do not continue to protect you against
pregnancy. This means that if you have unprotected sex at any time after taking the
emergency pill you can become pregnant.
Pt: Do I need to be careful about anything doctor?
Dr: Yes, sometimes the pill may not work and you may become pregnant. So if your
period is more than 7 days due please do pregnancy test or come back we will check
whether you are pregnant.
Also there is a serious condition which can happen rarely is what we call as ectopic
pregnancy where the pregnancy happens outside the womb. The signs of it are having
pain in lower tummy and bleeding from vagina. So if do not have your period within one
week of expected period and having these symptoms please do come back.
Are you following me? Pt - Yes
Dr: Also this is not a regular contraception. It is not good to use morning after pill as a
regular way to prevent pregnancy. It is better to follow a proper regular contraception.
Do you want me to tell you the other ways of contraception ?
Pt: No doctor not now. I will make another appointment for that.
Dr: There are some things that we need to know before prescribing you the pill. Can you
please tell me if you have any medical condition? Pt: Like what doctor?
Dr: Any liver disease? Pt: No doctor.

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Dr: Asthmatic problems? Pt: No doctor.
Dr: Epilepsy? Pt: No doctor.
Dr: Alright. Are you using any medicines at the moment?
(Antiepileptics - Phenytoin and carbamazepine. Antibiotics like rifampicin and rifabutin.

Antacids, omeprazole or ranitidine) Pt: No doctor.
Dr: Alright. Any allergies? Pt: No doctor.
Dr: Okay. Do you have any concerns?
Pt: Doctor will you tell my mother?
Dr: We highly encourage you to tell your parents but keeping patient confidentiality is
very important for us. Though you are a child, because you have mental capacity to
understand the consequences of your actions and mistakes, we cannot divulge your
information to anyone else inclusive of your parents, without your permission. We have
to ask for your consent before disclosing this information. We normally keep disclosures
to the minimum necessary. Is that okay?
Pt: Okay.
Dr: Do you have any other questions? Pt: No doctor.
Dr: My senior will talk to you shortly. And in future, you can come back to us if you
have any other concerns or questions. Pt: Thank you doctor.

Premature Ovarian Insufficiency
193.
You are FY2 in OBG.Sana,aged 26 presented with amenorrhea. She had blood tests
done. Results are as follows:
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FSH and LH high Estrogen

low
Diagnosis of premature ovarian insufficiency was made. Talk to her, explain the
results and address her concerns.
History
Dr:Hello,how can I help you? Pt:I am not having periods Dr:From how long?
Pt:From last 2 years
Dr:Sorry to hear about that. Do you have complete cessation of periods from last 2 years?
Pt:Yes
Dr:Did you do anything for it ? Pt:No
Dr:How were your periods before 2 years? Pt:They were regular
Dr:Do you have any health problems?(Immune problems ,tuberculosis or any infection)
Pt:No
Dr:Do you have hot flushes? Pt:Yes/No
Dr:Do you have night sweats,vaginal dryness,reduce libido,problems with concentration?
(Symptoms of POF)
Pt:Yes/No
Dr:Did you had any fractures?(Osteoporosis, complication of POF)
Pt:No
Dr:Any chest pain, SOB?(Cardiovascular complication of POF)
Pt:No
Dr:Any fever? Pt:No
Dr:Have you gone through surgery of ovaries or womb?
Pt:No
Dr:How is your mood? Pt:It is low
Dr:How is your sleep? Pt:Fine
Dr:Are you using any medication? Pt:No
Dr:Any allergies? Pt:No
Dr:Any one in family with premature ovarian failure? Pt:I don’t know
Dr:Do you use any contraception? Pt:No
Dr:Do you have any kids?
Pt:No,I am planning for pregnancy Dr:With whom do you live ?
Pt:My partner Dr:Do you smoke? Pt:No
Dr:Do you drink alcohol? Pt:Occasionally
Examination
I would like to check your vitals i.e. your BP,pulse,temperature and respiratory rate. Also
general examination of your whole body. Is it ok?
Pt:Ok
Dr:Explain the results.
Dr:From what we have discussed and from your blood results it shows that you are having
a condition called premature ovarian failure unfortunately. It means that your ovaries have
stopped working and that’s why you are not getting periods.
Pt:Doc,I want to have children?
Dr:I understand that but with this condition it can be a bit difficult to have children
naturally,I am sorry.
However, we have a lot of methods by which you can have children like;
o IVF
o Donated eggs from other woman or using your eggs if you had stored
o Surrogacy
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o Adoption
Pt:Ok,what treatment can I have?
Dr:Treatment:
COCP or HRT unless contraindicated in breast cancer Lifestyle changes like
diet,sleep,exercise
Counselling and Support groups
Dr:We will arrange your follow up in a month.in the meantime if you feel any chest pain,
SOB or you feel unwell in anyway, please let us know. Thank you
Early menopause
Early menopause happens when a woman's periods stop before the age of 45. It can happen
naturally, or as a side effect of some treatments.
For most women, the menopause starts between the ages of 45 and 55.
Causes of early menopause The ovaries stop working
Early menopause can happen naturally if a woman's ovaries stop making normal levels of
certain hormones, particularly the hormone oestrogen.
This is sometimes called premature ovarian failure, or primary ovarian insufficiency.

The cause of premature ovarian failure is often unknown, but in some women it may be
caused by:
• chromosome abnormalities – such as in women with Turner syndrome
• an autoimmune disease – where the immune system starts attacking body tissues
• certain infections, such
as t uberculosis, very rare malaria and mumps – but this is
Premature ovarian failure can sometimes run in families. This might be the case if any of
your relatives went through the menopause at a very young age (20s or early 30s).
Cancer treatments
R adiotherapy and c hemotherapy can cause premature

ovarian failure. This may be permanent or temporary.
Surgery to remove the ovaries
Surgically removing both ovaries will also bring on premature or early menopause.
For example, the ovaries may need to be removed during a hysterectomy (an operation to
remove the womb).
Symptoms of early menopause

The main symptom of early menopause is periods becoming infrequent or stopping
altogether without any other reason (such as pregnancy).
Some women may also get other typical menopausal symptoms, including:
• hot flushes
• night sweats
• vaginal dryness and discomfort during sex
• difficulty sleeping
• low mood or a nxiety

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• reduced sex drive (libido)

• problems with memory and con
Women who go through early menopause also have an
increased risk of o steoporosis and c ardiovascular
disease because of their lowered oestrogen hormone levels.
Treatments for early menopause
The main treatment for early menopause is either
the combined contraceptive pill or HRT to make up for your missing hormones.
A GP will probably recommend that you take this treatment long term, beyond the
"normal" age of natural menopause (around 52 on average), to give you lasting
protection.
If you have had certain types of cancer, such as certain types of breast cancer, you may not
be able to have hormonal treatment.
Getting support
Going through the menopause early can be very difficult and upsetting.
Permanent early menopause will affect your ability to have children naturally. This can
be very distressing to women of all ages.
You may still be able to have children by using IVFand donated eggs from another
woman, or using your own eggs if you had some stored. Surrogacy and adoption may
also be options for you.
Counsellingand support groups may be helpful. Here are some you may want
to try:
 The Daisy Network– a support group for women with premature
ovarianfailure
 healthtalk.org– provides information about early menopause, including
women talking about their ownexperiences
 Fertility friends– a support network for people with fertilityproblems
 Human Fertilisation and EmbryologyAuthority
(HFEA)– provides information on all types of fertility treatment
 Adoption UK– a charity for people who are adoptingchildren
 Surrogacy UK– a charity that supports both surrogates and parents
through theprocess
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Pelvic Inflammatory Disease (PID)

Background
us) and Fallopiantubes.
tion usually travels from vagina or neck of womb (cervix) into the uterus andovaries.
m a sexually transmitted infection. Chlamydia and gonorrhoea are the most commonly found causes of PID. Inmanyothercasesitiscause
months after having sex with an infectedperson.
xually transmitted infection. This is more of a risk after having a baby, or after a procedure such as inserting a contraceptivecoil.
Notes
Pelvic inflammatory disease (PID) is an infection of the female upper genital tract, including
the womb, tubes and ovaries.
Symptoms
PID often doesn't cause any obvious symptoms. Most women have mild symptoms that may
include one or more of the following:
• pain around the pelvis or lower abdomen(tummy)
• discomfort or pain during sex that's felt deep inside thepelvis
• pain duringurination
• bleeding between periods and aftersex
• heavyperiods
• painfulperiods
• unusual vaginal discharge, especially if it's yellow orgreen A
few women become very illwith:
• severe lower abdominalpain
• a high temperature(fever)
• nausea andvomiting
Examination
• Abdominal
• Gynaecological,speculum
INVESTIGATIONS
Urinalysis: protein, blood; leucocytes; nitrites
Endocervicalswab
Chlamydial swab
High vaginal swab
Trans vaginal ultrasound report
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Diagnosis
Diagnosis is based on symptoms and examination (the finding of tenderness on a vaginal
(internal) examination).
Swabs are taken from vagina and cervix (neck of the womb), but negative swabs don't rule
out PID.
In some cases, laproscopy (keyhole surgery) may be used to diagnose PID. (This is usually
only done in more severe cases where there may be other possible causes of the symptoms,
such as appendicitis).
Risk factors
• havemorethanonesexualpartner
haveanewsexualpartner
haveahistoryofsexuallytransmittedinfections
there's been damage to the cervix following childbirth or amiscarriage
have had a procedure that involves opening the cervix – such as an abortion,
inspection of the womb, or insertion of ancoil.
havehadPIDinthepast
areunder25
startedhavingsexatayoungage
Complications of Pelvic Inflammatory Disease

Abscesses
Long Term Pelvic Pain ( dyperunia)
Miscarriage
Ectopic Pregnancy
Infertility
StillBirth
PREVENTION
Use of barrier contraception significantly reduces the risk of PID.
Limited evidence suggests that screening for Chlamydia and treating identified
infection pr ior to IUCD insertion reduce the risk of PID.
The English National Chlamydia Screening Programme (NCSP) recommends that
all se xually active men and women under the age of 25 be tested for Chlamydia
annually or on change of sexual partn er.
Visit local genitourinary medicine (GUM) or sexual health clinic for advice.
In case of invasive gynaecological procedure, such as insertion of a coil or an
abortion, have a check-up beforehand.
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Treatment
Antibiotics
Needs to be started quickly, before the results of the swabs are
available. Antibiotics commonly prescribed to treat PID include:
 ofloxacin
 metronidazole
 ceftriaxone
 doxycycline
Ceftriaxone 500 mg as a single intramuscular (IM) dose, followed by

Doxycycline 100 mg orally twice daily and Metronidazole 400 mg twice daily for 14 days
Painkillers
If you have pain around your pelvis or tummy (paracetamol,
ibuprofen)
Avoid intercourse
You should avoid having sex until both you and your partner have completed the course
of treatment- till at least 7 days after treatment is finished.
Follow-up
In some cases, you may be advised to have a follow-up appointment three days after
starting treatment so your doctor can check if the antibiotics are working.
If the antibiotics seem to be working, you may have another follow-up appointment at the
end of the course to check if treatment has been successful.
Treating sexual partners
Any sexual partners you've been with in the six months before your symptoms started
should be tested and treated to stop the infection recurring or being spread to others, even
if no specific cause is identified.
Your doctor or sexual health clinic can help you contact your previous partners and this
can usually be done anonymously, if you prefer.
Advise protected sex after the treatment.
Task
25 year old Mrs Sarah boyer was diagnosed with pelvic inflammatory disease as she presented with
discharge from front passage 4 days ago. She is already on antibiotics and taking OCP as well. US
Scan has been done which shows Hydrosalphinx. Talk to Mrs Sarah Boyer and explain about
possible complications of PID.
Assessment- 8 steps
10. Ask herconcerns
11. Assess her knowledge of hercondition
12. Explain PID and itscauses
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13. Ask if she wants to know about a specific complication orall?

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
Pelvicpain

Deepdyspareunia

Abscess

Menorrhagia

Secondarydysmenorrhoea

Discharge

Miscarriage

Ectopicpregnancy

Infertility
14. Keep checking herunderstanding
Anythingelse?
15. Stress oncompliance

16. Partner notificationprogramme
17. Prevention in thefuture
18. Follow Up- 2 weeks &anythingelse
Dr: hello Mrs Sarah Boyer. I am one of doctor in Gynae/Obs department. How can I help
you?
Pt: doctor I was diagnosed with PID and I am on antibiotics but I am still worried about this
condition.
Dr: Mrs Sarah I am here for this to address your concerns today regarding your condition. I
will try my best to answer your questions. So do you know what it is?
Pt: No/yes
Dr: if No: it is infection (bugs) spreading from vagina or cervix (entrance of the womb) into
the womb and Fallopian tubes and ovaries.
If yes: That is right. May I know why you are worried?
Pt: I want to know why did it happen to me?
Dr: it’s difficult to say right at the moment but risk is always higher in women who are using
coil or had any surgery of womb or any instrumentations. Have you had any of this?
Pt: No
Dr: OK. There are other causes, like this could be a sexually transmitted infection some
times.
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Pt: doc, how it’s possible, do you think my Partner is cheating on me?
Dr: I am sorry if you misunderstood me, I did not mean that as there could be other causes
also as I told you. And also sometimes these types of bugs persist for longer period of time and
symptoms develop later in life if not treated immediately. Usually only one fourth of the time
it is due to sexually transmittedinfection.
Pt: What should I do?
Dr: Do not worry; as long as you complete your treatment everything will be fine. It is very
important for you to complete your treatment.
Pt: is there anything which can happen to me?
Dr: I am afraid if you do not get proper treatment or do not follow proper instructions which
we will give to you, there are chances to get complications like;
6. You may not be able to become pregnant, calledinfertility
7. If you becomepregnant
You can lose your pregnancy called Miscarriage.
It can be on abnormal place called ectopic pregnancy
Your baby can be premature baby.
8. You can get pain duringintercourse
9. Most importantly this infection can spread to other parts of body which isdangerous.
Pt: what can you do for me?
Dr: I just want to tell you please don’t worry as you are already on antibiotics so please
continue your treatment as advised to you. Hopefully you will be alright but few things are
very important for you:
1) Please do not stop treatment early even if your symptomsdisappear.
2) You should avoid even safe sex till you finish complete treatment. (National Chlamydia
ScreeningProgramme:Donothaveanysexwithyourpartner(s)untilsevendaysafter
you have both completedyour treatment.)
3) Your partner should also gettreated.

Pt: why partner:
Dr: I am afraid if he is not treated then you can get infection back and can get complications
what we discussed and I am sure you don’t want that.
Can you bring your partner in?
Pt: Yes. (If patient says No)
Dr: It’s fine. We have something called partner notification program in which we will call
your partner anonymously and treat him without revealing your identity.
Pt: Will it happen again?

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Dr: 1 in 5 women can have it again but if you and your partner both get proper treatment and
follow advice hopefully you will not get it. Would you like me to give you some advice?
Pt: yes doc, sure
Dr: 1: Please avoid multiple sexual partners.
2: Practice safe sex in future.
3: If anytime you are suspicious of getting this infection please come to GUM clinic
immediately
{ If the patient has IUD – it needs to be removed }
Bacterial vaginosis
194.
You are FY2 in General practice.

Young lady named Katherine ford is coming for her follow up. Last time her
vaginal swab was done which is positive for Gardnerella vaginalis but negative for
chlamydia and gonorrhea. Discuss results with her and discuss further
management.
History:
Dr:Hello,my name is dr.XYZ,I am one of the junior doctors in general practice. How
are you doing today?
Pt:I am fine doctor, just want to know about my results.
Dr:Sure,do you have any expectations regarding your results?
Pt:No doctor.
Dr:Alright Katherine, is it ok if I can discuss few things with you so that I can explain
your results in a better way?
Pt:Yes doctor
Dr:So, why did you come to the GP clinic in the first place?
Pt:I was having vaginal discharge.
Dr:Please tell me more about it? Pt:Like what
doctor?
Dr:From how long are you having this discharge? Pt:From last 2 months.
Dr:I am sorry to hear about that. Does it has a smell? Pt:Yes, it has a fishy odor.
Dr:Its color?
Pt:Its greenish white in color. Dr:And its

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amount?
Pt:Its copious in amount.
Dr:Any other symptoms at all with discharge? Pt:No doctor.

Dr:Any fever?(PID) Pt:No
Dr:Any tummy pains?(PID) Pt:No
Dr:Any weight loss or lumps in bumps in body(Malignancy)?
Pt:No
Dr:Any bleeding through vagina?(ectopic pregnancy)?
Pt:No
Dr:By any chance are you pregnant? Pt:No
Dr:Is it the first time its happening to you? Pt:Yes
Dr:Do you have any idea why are you having this discharge?
Pt:Doctor I started using bubble bath from last 2 months. Can it be the cause?
Dr:Yes ,bubble bath can lead to this infection unfortunately.
Dr: Do you have any health problems? Like DM or HTN Pt:No
Dr:A bit of talk on your sex life is it okay? Pt:Ok doctor
Dr:Are you sexually active? Pt:Yes
Dr:Are you in a stable relationship? Pt:Yes
Dr:Is your partner having any symptoms? Pt:No
Dr:Do you practice safe sex? Pt:Yes
Dr: Any other sex partner than this partner? Pt:No
Dr: When was your LMP? Pt:3 weeks
ago
Dr:Are you using any contraception? Pt:I am using IUCD
Dr:From how long? Pt:From
one year
Dr:Any problems with IUCD? Pt:No
Dr:What you do for your living? Pt:Homemaker
Dr:How this is affecting your life?

Pt:I am not able to do sex from last 2 months because of smell.
Dr:I am really sorry about that. We’ll do our best to help you, don’t worry
Pt:Thankyou
Examination:
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Dr:Thanks a lot for talking to me .Now I would like to check your vitals i.e. your
BP ,pulse, temperature and respiratory rate plus your tummy and vagina
examination.is it ok?
Pt:Ok doctor
Dr:Alright,Katherine we have your results with us. Good news is that you don’t
have any sexual transmitted infection like chlamydia or gonorrhea. However,
your swab is positive for a bug called Gardnerella vaginalis unfortunately.
Pt:Oh,what is that doctor?
Dr:It’s a bug which can disrupt normal flora of vagina causing a condition called
bacterial vaginosis, which is bacterial infection of vagina.
Pt:How did I get it doctor?
Dr:You told me that u started using bubble bath 2 months ago, that can be one of the
cause. Moreover,as you are using IUCD,that can also be one of the cause of this infection
I am afraid.
Dr:Did I get it from my husband?
Pt:No ,its not a sexually transmitted infection, so you didn’t acquire it from your
husband.
Pt:So doc,what are you going to do for me?
Management:
Dr:We have some lifestyle measures and medical management that can help
you.do you want me to explain them to you?
Pt:Yes doctor
Dr:Lifestyle measures are
I. Avoid bubblebaths
II. Avoiddouching
III. Avoid antiseptics and perfumedproducts
IV. Use showers instead of baths Are you
followingme?
Pt:Yes doc
Dr:Then we have an antibiotic called Metronidazole 400mg which you can take twice a
day for 7 days. What do you think about it?
Pt:Ok doctor
Dr:One more thing which is concerning me is IUCD.so for that, we will refer you to
gynecologist so that we can make sure that everything is fine with you. How does that
sound?
Pt:Ok doc.
Dr:Alright Katherine ,we will arrange your follow-up in a week, in the meantime, if you
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develop any fever, tummy pains or increased discharge ,please let us know.
Pt:Ok doc.
195. Reference information:
Discharge Possible cause
Smellsfishy bacterialvaginosis
Thick and white, likecottage cheese thrush
Green, yelloworfrothy trichomoniasis
With pelvic painorbleeding chlamydiaorgonorrhoea
With blistersorsores genitalherpes
Premenstrual syndrome
196.
You are FY2 in General practice.

A 32 year old lady wants to talk to you. Talk to her and address her concerns.
History:
Dr: Hello,my name is Dr XYZ.I am one of the junior doctors in GP clinic. How can I help
you?
Pt:Doctor,my husband wants me to talk to you. Actually,I am not feeling myself lately.
Dr:Can you elaborate on it?
Pt:I am getting emotional and angry.I am shouting on my husband and children.I don’t
know what’s going on.
Dr:I am sorry to hear about that. That must be distressing for you. Please don’t worry, we
will look in to this matter.
Pt:Thankyou doc.
Dr:So,from how long you are feeling like this? Pt:From past 8 months.
Dr:That’s a quite long time. Did you do anything to make your situation better?
Pt:Nothing doc.
Dr:Is there anything that makes it worse?
Pt:3 to 4 days before my periods, my mood swings get worse and 1 to 2 days in to periods,
I get a lot better.
Dr:Alright,is it becoming worse or is it the same? Pt:It is same
Dr:Any other symptoms with it at all? Pt:Like what doc?
Dr:Any headaches? Pt:No
Dr:Any breast tenderness? Pt:No
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Dr:Any body pains? Pt:No
Dr:Any tummy bloating? Pt:No

Dr:How is your mood now a days? (Depression) Pt:It is low
Dr:Can you please score your mood on a scale of 1 to 10,where 1 is the lowest and 10 is
the normal, happy mood?
Pt:Around 4 to 5
Dr:By any chance are you having thoughts of harming yourself or others?
Pt:No doc
Dr: How is your concentration now a days? Pt: It is low.
Dr:Is it the first time it is happening to you? Pt:Yes
Dr:Do you feel cold when others are feeling comfortable?(Hypothyroidism)
Pt:No
Dr:Any weight loss ?(Malignancy) Pt:No
Dr:Any lumps or bumps ? Pt:No
Dr:Any stresses in your life? Pt:No
Dr:Do you have any health problems? Pt:No
Dr:Anyone in your family with similar problems? Pt:No
Dr:When was your LMP? Pt:3 weeks ago
Dr: Are they regular? Pt:Yes
Dr:Do you use any contraception? Pt:No
Dr:Did you use any contraceptive in the past? Pt:Yes,I used Depoprovera .
Dr:When did you stop it? Pt:8 months ago

Dr:May I know why?
Pt:I just stopped it without any reason Dr:What you do for your living?
Pt:I am a teacher
Dr:Is this affecting your teaching? Pt:No,I try to control it.
Dr:And how is this affecting your life?
Pt:I am getting distant from family because of these mood swings
Dr:I totally understand that.Please,don’ t worry ,we will try our best to help you.
Pt:Thankyou
Dr:How is your sleep? Pt:It is fine/not fine.
Dr:Do you smoke? Pt:Yes/No
Dr:Do you consume alcohol? Pt:No
Dr:Any sort of recreational drugs by any chance? Pt:No
Examination:
I would like to check your vitals i.e. your BP ,pulse
,temperature and respiratory rate. I would also like to do general physical examination of
your whole body including your thyroid gland and glands in body. Is that ok?
Diagnosis
Dr:From what we have discussed, we think that you are having a condition called
Premenstrual syndrome unfortunately.
Pt:What is it doc?
Dr:It is a common condition in women ,in which due to hormonal fluctuations, women
tend to experience mood swings and angry outbursts especially before periods.
Pt:Oh,so what can you do for me?
Management:
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• Dr:We have a lot of options to tackle this.

• CBT:It helps a lot to manage mood changes.
• COCP(Continuous; if patient wants some contraception as well)
• Antidepressants(SSRI’s)
• Lifestyle measures:
o Yoga/Exercise
o Meditations
o Breathing techniques
o Indulge in to your favorite hobby
o Sleep hygiene measures(if patient has sleeping problems)
o Avoid smoking or alcohol if any.
• Keep diary of your symptoms for at least 2 to 3 menstrual cycles.
(Manage according to patient preference)
Dr:We will also take some blood to check whether you are anaemic and everything is fine
with your liver, kidneys and thyroid.
Dr: we will arrange a follow up in a month, in the meantime, if you experience more mood
swings
,anxiety, thoughts of harming yourself or others, please let us know.
What causes shifts in mood?
I. PMS(A group of symptoms that occur in women 1 to 2weeks before periods)
II. Premenstrual dysphoric disorder(PMDD)
III. Psychiatric causes
IV. Hormonal imbalances
V. Puberty
VI. Pregnancy
VII. Menopause
Preeclampsia
Preeclampsia is a condition that manifests after 20 weeks of gestation,

characterised by high blood pressure (140/90) and presence of proteinuria.
Severe preeclampsia : BP > 160/110 mmHg recorded over two separate occasions
at least six hours apart.
Red flag signs
 Headache
 Puffiness of hands andfeet
 Visualdisturbances
 Vomiting
 Decreased foetalmovements
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 IUGR
Complications
HELLP Syndrome: Hemolysis, Elevated Liver enzymes and Low Platelets
Signs of imminent eclampsia
 Headache
 Blurring ofvision
 Epigastric pain(liver)
 Oliguria
Eclampsia: Seizures +/- neurological deficits, with features of HELLP, Renal
failure
Preeclampsia is an indication for ADMISSION of the patient. The earlier the
diagnosis, the better the outcome for both mother and child.
Who is affected?
Mild pre-eclampsia affects up to 6% of pregnancies, and severe cases develop in

about 1-2% of pregnancies.
Medical conditions that can contribute to developing preeclampsia

 Diabetes
 Hypertension
 Renaldisease
 Lupusorantiphospholipidsyndrome
 Preeclampsia in a previouspregnancy
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Other risk factors

 Family history of the condition (mother orsister)
 Age > 40years
 > 10 years between twopregnancies
 Multiple gestation (twins ortriplets)
 BMI 35 orover
What causes pre-eclampsia?
Although the exact cause of pre-eclampsia isn't known, it's thought to occur when
there's a problem with the placenta (after-birth).
Management
 ADMISSION
Investigations
 Monitor BP Q2H with serial urinalysis forproteinuria
 FBC, LFT,RFT
 USGAbdomen/Pelvis
 CTG
Treatment
 Intravenous antihypertensives- Labetalol, Hydralazine orMethyldopa
 Contact consultant for MgSO4 prophylaxis. If administered, monitor for
side effects (sluggish deep tendon reflexes, decreased urine output,
respiratorydepression)
 If < 34 weeks, consider steroid prophylaxis for foetal lung maturity in
anticipation of pretermdelivery
 Only way to cure preeclampsia is to deliver the baby. If patient is diagnosed
at 36 weeks, admit UNTIL delivery (normally at 37 – 38weeks)
 At 37 weeks, induce labour artificially. If there are signs of eclampsia or
signs of foetal distress, go for emergency C-section. Avoid oxytocin and/or
ergotamines for labour induction (because ofBP)
 Post-delivery, continue to monitor BP and continue oral antihypertensives
ifneeded.
Case Scenario
You are F2 in the maternity clinic.
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◦ 39 year old lady is at her first pregnancy. She has come for her
regular ANCfollow-up.
On examination, midwife found a BP of 150/100 and protein 3+ in her
urine. Her BP during her first ANC checkup was 110/60.
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◦ Take focused history, discuss management and address patient's concerns.

Dr: Hello Mrs.. My name is Dr...... I'm one of the junior doctors here in the
maternity clinic.. How are you doing today?
P: Hello doctor, I'm okay. I came in for a routine check up
Dr: How far along in the pregnancy areyouMrs.....?
P: 36 weeks
Dr: That's great Mrs... Do you have any concerns that you would like me to
address first?
P: Doctor.. The midwife examined me.. And she said that my BP was a little high..
That a doctor would come in to talk to me about it.
Dr: That's correct Mrs.. I am here to talk to you about that. Would you mind if I
asked you a few questions first?
P: No doctor. Sure.
Dr: This is your first pregnancy correct? P: Yes
Dr: Ok. Have you had any issues with this pregnancy? P: No
Dr: Were you told to have a high BP earlier in this pregnancy? P: No
Dr: Have you been following up with the ANC regularly? P: Yes
Dr: That's very good Mrs.... We do advice regular ANC visits. Do you have any
headache? P: No
Dr: Any visual disturbances? P: No
Dr: Any pain in your tummy? P: No
Dr: Have you noticed any swelling of your face, hands or your feet? P: Yes my
shoes feel a little tighter
Dr: Any decrease in urine output? P:No
Dr: Are you able to appreciate your baby's kicks? P: Yes
Dr: Have you noticed any change? P:No
Dr: Ok that is very reassuring Mrs... That indicates that your baby is well.. Were
you found to have any medical conditions prior to this pregnancy? HTN? P: No
Dr: Diabetes? P: No
Dr: Are you on any medications? P: No
Dr: Do you have any family history of a similar condition.. High BP during
pregnancy? P: Not that I'm aware of doctor
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Dr: Mrs.. I have a few questions about your lifestyle.. Do you smoke? P: No
Dr: Do you consume alcohol? P: No
P a g e | 817
Dr: Ok Mrs.. The midwife did note that your BP was high.. It was 150/100. Your
BP during your first visit was 110/60. Additionally, your urine analysis showed
proteins.
This is a condition called preeclampsia. Do you have any idea what that is Mrs...?
P: I think I've heard of it doctor.. But I don't know what it is.
Dr: Mrs.. Preeclampsia is a condition that manifests after 20 weeks of pregnancy.
It is characterised by high BP and the presence of protein in your urine.
P: Why did this happen doctor?
Dr: There are many reasons why this can occur Mrs... but usually this is because
of some problem with the placenta.
P: Is it serious?
Dr: Mrs... at the moment, it does not appear to be serious. But preeclampsia can
be a fairly serious condition if not managed at the right moment. It can progress
to a more life threatening condition called eclampsia if left untreated, where you
could develop fits and that could be critical for both you and your baby. Are you
following me Mrs...? P: Yes doctor
Dr: For this reason Mrs... it is important that we admit you right away. We have
to monitor your BP every two hours and do serial urine tests. We will do a
ultrasound scan of your abdomen to check your baby. We will also do a CTG scan,
where we can make sure that your baby's movements and heartbeat areok.
P: Oh but doctor, I don't know if I can take the time off work.. I am not scheduled
for my maternity leave yet..
Dr: I can understand your concern Mrs... but as I mentioned, if your BP is not
controlled right away, it could progress to something more severe and that could
be dangerous for your baby. It is important that we admit you right away and
manage your situation.
P: How long will I have to be in the hospital doctor?
Dr: Mrs... in preeclampsia, we usually attempt delivery at around 37 weeks. Since
you are already at 36 weeks, we would keep you in the hospital until that time.
We will control your BP with a medication called Labetalol and consider
delivering after 37weeks.
P: I was very much hoping for a normal delivery.. If possible a water birth?
Dr: Mrs... you have every chance of having a normal delivery. If your BP is
controlled and everything is fine with your baby, we can try and induce a normal
delivery. However if before that, there is a sign of any complication or distress for
your baby, we might have to go ahead with an emergency C-section operation.
As for a water birth, we do not advise that Mrs... It is risky in this condition and
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we need to continuously monitor you and your baby.

P: Ok doctor..
Dr: Do you have any other concerns Mrs...?
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P: No doctor.. Thank you..

Dr: Ok Mrs... I will get all the paperwork in order and have you admitted right
away..
( Psychosis) (Schizophrenia) ( Mania)

MSE ( Mental state examination or Psychiatric assessment)
Causes of Psychosis
1) Depression,
2) Bipolar disorder (manic-depressive illness),
3) Puerperal psychosis
4) Drug abuse
5) Alcohol abuse.
6) Neurological conditions
7) Drugs not associated with abuse.
Exam question :
Mr James Smith, 25 years old man was brought to the hospital by police. According to the
police, Mr Smith went to the police station and was convinced that he has done something
wrong. After investigations, Police found that it was a false claim.
You are the FY 2 doctor in Psychiatry department, talk to the patient and do Mental state
examination and talk to him about further management.
Dr : Hello Mr Smith, I’m Dr …. One of the junior doctor in the Psych Dept. in this
hospital. I’m here to talk to you and help you. Can you please tell me what happened?
Mr Smith : Police are after me all the time…see they are standing by the door.
Dr : Do not worry Mr Smith they will not come inside. See I’m a doctor here and I’ll not
allow them to come inside. Please tell me why do you think they are after you?
Mr Smith : I did something wrong, So the police were after me.
Dr:I assure you that you are in safe place,and nobody will harm you.
Mr Simth: they have planted cameras in my room.
Dr:don’t worry mr smith,hospital is secure place,and nobody can see you outside this
room.
Dr : Do you know where you are now? ( Cognition)
Mr Smith : This is hospital.
Dr : Do you know who brought you here?
Mr Smith : The police brought me here.
Dr : Did the police catch you or did you go to them ?
Mr Smith : I was hiding from them for long time but I got tired and I turned myself in.
Dr: Have you been harmed in anyway?
Mr Smith: No
Dr: Since when are you feeling this way?
Mr smith: Since last few weeks
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Dr: were you alright before?

Mr smith: yes
Dr: how do you feel in ur mood?can you please rate your mood on scale of 1-10,1 being
sad,low,and 10 being normal,happy?
Mr smith:4-5
Dr: Are you able to eat/sleep well?carry out daily activities normally?
Mr smith:No/Yes
Dr : Do you ever see or hear things that are not really there, such as voices or visions?
( hallucination/perception)
Mr Smith : No
Dr : Do you feel that someone is plotting anything against you? Mr Smith : Yes.
Dr : Have people been interfering with your thoughts (thought insertion).
Mr Smith : No.
Dr: Do you think someone or some group intend to harm you in some way?
Mr Smith: yes,I feel Police will punish me.
Dr:Do feel like hurting urself/doing harm to self?
Mr smith:NO
Dr : Do you live with family or alone?
Mr Smith : I live on my own (sometimes he may say :I live with my mother).
Dr : Do you have any friends ? Mr Smith : No
Dr : Do you have any problem with finance? Mr Smith : No
Dr : Do you have any legal problems? Have you been in trouble with law anytime?
(Forensic history)Mr Smith : No.
Dr : Do you drink alcohol? Mr Smith : sometimes
Dr: do you smoke? Mr smith:yes/no
Dr:Do you use recreational drugs ? Mr smith:No
Dr : Do you think you have any problem, do you think you need any help? ( Insight)
Mr Smith : No
Dr:do you feel that this has affected your work/family life/social life?(Impact)
Mr smith:No/Yes
Dr : Do you have any medical conditions? Mr Smith : No
Dr : Did you have any mental health conditions before? Mr Smith : No
Dr : Any of your family members have any mental health conditions?
Mr Smith : No
Dr : Do you take any medications? Mr Smith : No
Dr: are you allergic to any medications? Mr smith:No
Dr : Do you have any medical problems at all? Mr Smith : No
Dr : Mr Smith why do you think all this is happening to you?
Mr smith:I don’t know
Dr : Thank you very much Mr Smith, we will try our best to help you.
DIAGNOSIS:From the information you have given me, you have a mental health condition
called Psychosis. Psychosis is a condition where in people loose touch with reality and
start to see,hear and believe things that are not true. It happens due to chemical imbalance
in the brain. It is not an uncommon condition, 1 in 100 people are affected by it. There are
many reasons why people can have this condition like life events, it runs in some families.
INVESTIGATIONS:We will admit you and do some tests to find the reason. This test
would include Blood tests and CT Scan of your brain.
MANAGEMENT:If the investigations are normal and symptoms persist for a long time it
could be a condition called Schizophrenia. We will treat that condition with medications to
help restore the chemical imbalance in the brain.( Risperidone or Olanzapine – no need to
tell the names of medications to the patient).
We will provide all kinds of Psychological help and Social support.

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[ The treatment could be Bio-psycho-social model]
Investigations for Psychosis
 Abnormal LFTs and macrocytosis on FBC are highly suggestive of alcohol abuse.
 Serological tests for syphilis should not be forgotten.
 Screening for AIDS should be preceded by counselling.
 Urine screen for drugs of abuse. Light recreational use of cannabis can produce a
positive test for the subsequent fortnight. Heavy and chronic use can produce a
positive result for months after the last use.
 CT brain scan may be contributory (eg, to exclude a space-occupying lesion or
cerebral atrophy) if focal signs are present but not otherwise.

SCHIZOPHRENIA
Question: You are an FY2 in the Accident & Emergency department. Peter
Bailey is a 26 years-old man who has been brought in by the police. Officer
Andrews who found him in the park states that Peter has not committed any
crime that they are aware of. Take a focused history and discuss management
with the patient.
Hello. Peter Bailey. Hi, my name is Dr. ……… I am one of the junior doctors here in the
A&E department.
What would you like me to call you? – Peter

I understand that you’ve been brought here by the police who found you in the park today,
because they are a little bit worried about you.
Do they have good reason to be worried about you? – No. It’s them, the police. They are
after me. Please don’t let them take me away
It’s alright. You’re at the hospital now, and you’re safe here.
Can you tell me a bit more why the police may be after you? – The police have been after
me because I did something bad
Ok, do you know about anything that you might have done that was bad, that may result in
P a g e | 822
them looking for you? – I don’t know, I can’t remember
That’s fine, if you remember anything just let me know. I do have to ask you some
questions to get a better understanding as to why you’re here.
Are you ok to continue? – No. I want to get out of here. I want to go home
Unfortunately, I have to ask you a few questions about your health and assess your
wellbeing before we can let you go anywhere.
Before we carry on, do you have any items on you like a knife or anything sharp that might
be dangerous or be used as a weapon? – No
Thank you.
So, can you tell me how long it is that the police have been after you? – Almost a year
Throughout this year you believe they have been searching for you? – Yes
Have you ever had thoughts like this before? – No
Did this feeling that they were after you start all of a sudden or did it begin more
gradually? – Gradually
Is this feeling they are after you always there, or does it come and go? – It’s always there.
Just please don’t let them take me to prison. I haven’t done anything wrong
You are safe here in the hospital. As a matter of fact, I understand that one of the police
officers who brought you in today stated that you had not actually committed any crime
that they are aware of.
Is there any other reason you think the police may be after you? – I don’t know
Is this the first time you’ve had the feeling they’re after you, or is this something you’ve
experienced before? – So many times before
Do you have any other firm beliefs which other people may strongly disagree with? – I
don’t know
Do you sometimes hear or see things that are unusual? – No (if yes, ask next questions)
o What do you hear/see?

o How many voices do you hear/things do you see?
o What do they talk about?
o Where do you hear/see it?
o When do you hear/see it?
o How often do you hear/see it?
o Are these voices with you or against you?
o Do they speak directly to you? Or amongst themselves?
o Do they give you any instructions?
Do you ever experience that people know what you’re thinking despite not having told
anyone? – No
Do you ever experience that people are taking thoughts out of your mind? – No
Do you ever experience that people are inserting thoughts in to your mind? – No
Do you have any idea what the problem could be? – The police
Do you think there is any problem with your health? – The only problem is the police
How are you feeling right now?

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(I) Hopeless/Worthless? – No
(II) Disinterested/Little pleasure in life? – No
Have you lost any weight unintentionally? – No
How would you describe your mood on a scale of 1 – 10, 1 being the worst and 10 being
the best? – 6
Have you ever experienced a traumatic or severely stressful event in your life? – No
Have you thought about self-harm? Suicide? – No
Is there anything else that you would like to add that I may have missed? Any symptom?
[Systematic Review] – No
Have you ever been diagnosed with any medical condition before? Mental Health
Disorder? – No
Are you currently taking any prescribed Medication? OTC? – No
Are you allergic to anything? Medication? – No
Any illnesses that run in your Family? Mental health illnesses? – No
Have you travelled anywhere recently? – No
How have you been coping at home? Hobbies? Family? Sleep? Relationships? Job? – Ok
Diet? Exercise? Stress? – Normal
Do you smoke? – No
Do you drink Alcohol? – No
Do you use Recreational Drugs? – No
Are you sexually active? – No
Who else is at home? House/Flat? – Only me in my flat
Hygiene? – Poor
Is there anything else that you would like to add that I may have missed? – No
Are you aware of any crime that you may have committed or run-ins with the law? – No
Do you have any problems with your finances? – No
Is there anyone in your friends or family who we can contact? – My parents are in Devon
Thank you for answering all of my questions.
Ideally, what I would like to do now is take a few observations from you like your pulse
rate, blood pressure, temperature, breathing rate and levels of oxygen in your blood.
From what you have told me, it is quite likely that you have a condition called
Schizophrenia.
Do you have any idea at all what that is? – No
Schizophrenia is a long-term mental health disorder that can cause a variety of

psychological symptoms that can make it hard for a person to distinguish between their
own thoughts and ideas from reality.
Are you following? – Yes

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The symptoms of schizophrenia are usually classified into:
A. Positive Symptoms – any change in behaviour or thoughts, such as hallucinations

or delusions
B. Negative Symptoms – where people appear to withdraw from the world around
then, take no interest in everyday social interactions, and often appear emotionless
and flat
Symptoms of schizophrenia include:
 Hallucinations – hearing or seeing things that do not exist outside of the mind
 Delusions – unusual beliefs not based on reality
 muddled thoughts based on hallucinations or delusions
 losing interest in everyday activities
 not caring about your personal hygiene
 wanting to avoid people, including friends
 Thought Broadcasting/Withdrawal/Insertion – experiencing your thoughts are
being projected, removed or put inside your mind.
Schizophrenia does not cause someone to be violent and people with schizophrenia do not
have a split personality.
The exact cause of schizophrenia is unknown. But most experts believe the condition is
caused by a combination of genetic and environmental factors.
It's thought that some people are more vulnerable to developing schizophrenia, and certain

situations can trigger the condition such as a stressful life event or drug misuse.
Are you following? – Yes
[Chunk & Check]
MANAGEMENT
 Unfortunately, in your current state it would be unwise for you to leave the hospital. I do
believe that there could be some risk that you hurt yourself or someone in the community.
We may have to Admit you for a short period for further assessment until and at least you
are deemed fit for discharged or transferred to a difference department
How does that sound? – Fine
 Schizophrenia is usually treated with an individually tailored combination of talking therapy

and medicine.
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 We may have to perform some Investigations, such as Routine Blood Tests (FBC,
LFT, RFT, S/E, BSR, PT, aPTT & INR)
 Urine Tests, such as urine dipstick, urine drug screen and culture and sensitivity
 We may have to give you some medication in the form of a Sedativeto help you relax
 Involving the Mental Health Team (MHT) may be required. They will come and assess
your mental health status. The MHT will usually consist of a Psychiatrist or a Specialist
Psychiatric Nurse who will carry out a more detailed assessment of your symptoms. They
may then shift and admit you in their department
 They may start you on Anti-Psychotic Medication
 We may offer you something called Cognitive Behavioural Therapy (CBT), which is a
simple Talking Therapy exercise that would help improve your symptoms
 I would like to try and contact any Friends or Family that you can provide details of so we
can get a better insight to your health.
 I would also like to contact your GP and check your medical records for anything that we may
have missed
 It is important that you have regular Follow-Ups with your GP or Psychiatrist
 I would like to get a Second Opinion from my seniors
 I do have some Reading Material for you entitled Schizophrenia.
Crisis Resolution Teams (CRT)
A treatment option is to contact a home treatment or crisis resolution team (CRT). CRTs
treat people with serious mental health conditions who are currently experiencing an acute
and severe psychiatric crisis.
Without the involvement of the CRT, these people would require treatment in hospital.
The CRT aims to treat people in the least restrictive environment possible, ideally in or
near their home. This can be in your own home, in a dedicated crisis residential home or
hostel, or in a day care centre.
CRTs are also responsible for planning aftercare once the crisis has passed to prevent a
further crisis occurring.
Your care co-ordinator should be able to provide you and your friends or family with
contact information in the event of a crisis.
Voluntary and Compulsory Detention
More serious acute schizophrenic episodes may require admission to a psychiatric ward at
a hospital or clinic. You can admit yourself voluntarily to hospital if your psychiatrist
agrees it's necessary.
People can also be compulsorily detained at a hospital under the Mental Health Act (2007),
but this is rare.
It's only possible for someone to be compulsorily detained at a hospital if they have a
severe mental disorder and if detention is necessary:
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i. in the interests of the person's own health and safety

ii. to protect others
People with schizophrenia who are compulsorily detained may need to be kept in locked
wards.
All people being treated in hospital will stay only as long as is absolutely necessary for
them to receive appropriate treatment and arrange aftercare.
An independent panel will regularly review your case and progress. Once they feel you're
no longer a danger to yourself and others, you'll be discharged from hospital. However,
your care team may recommend you remain in hospital voluntarily.
Advance Statements
If it's felt there's a significant risk of future acute schizophrenic episodes occurring, you
may want to write an advance statement.
An advance statement is a series of written instructions about what you would like your
family or friends to do in case you experience another acute schizophrenic episode. You
may also want to include contact details for your care co-ordinator.
If you want to make an advance statement, talk to your care co-ordinator, psychiatrist or
GP.
◦ Psychological Treatment
Psychological treatment can help people with schizophrenia cope with the symptoms of
hallucinations or delusions better.
They can also help treat some of the negative symptoms of schizophrenia, such as apathy
or a lack of enjoyment and interest in things you used to enjoy.
Psychological treatments for schizophrenia work best when they're combined with
antipsychotic medication.
Common psychological treatments for schizophrenia include:
1. Cognitive Behavioural Therapy (CBT)

2. Family Therapy
3. Arts Therapy
Cognitive Behavioural Therapy (CBT)
CBT aims to help you identify the thinking patterns that are causing you to have unwanted
feelings and behaviour, and learn to change this thinking with more realistic and useful
P a g e | 827
thoughts.
For example, you may be taught to recognise examples of delusional thinking. You may
then receive help and advice about how to avoid acting on these thoughts.
Most people require a series of CBT sessions over the course of a number of months. CBT
sessions usually last for about an hour.
Your GP or care co-ordinator should be able to arrange a referral to a CBT Therapist.
197. Family Therapy
Many people with schizophrenia rely on family members for their care and support. While
most family members are happy to help, caring for somebody with schizophrenia can place
a strain on any family.
Family therapy is a way of helping you and your family cope better with your condition. It
involves a series of informal meetings over a period of around 6 months.
Meetings may include:
 discussing information about schizophrenia

 exploring ways of supporting somebody with schizophrenia
 deciding how to solve practical problems that can be caused by the symptoms of
schizophrenia
If you think you and your family could benefit from family therapy, speak to your care co-
ordinator or GP.
198. Arts Therapy
Arts therapies are designed to promote creative expression. Working with an arts therapist
in a small group or individually can allow you to express your experiences with
schizophrenia.
Some people find expressing things in a non-verbal way through the arts can provide a new
experience of schizophrenia and help them develop new ways of relating to others.
Arts therapies have been shown to alleviate the negative symptoms of schizophrenia in
some people.
The National Institute for Health and Care Excellence (NICE) recommends that arts
therapies are provided by an arts therapist registered with the Health and Care Professions
Council who has experience of working with people with schizophrenia.
Are you working for them? The police?
No. I’m one of the doctors at the hospital, and my duty is to look after you and provide you
P a g e | 828
with the best medical care we can offer . I don’t work for the police, but I work at the
hospital caring for patients.
Am I crazy? Are you telling me that I’m crazy?
No. Schizophrenia is a severe long-term mental health disorder. It does not make you
violent, crazy or have a split personality.
If you're experiencing symptoms of schizophrenia, it is important to see your GP as soon as

possible. The earlier schizophrenia is treated, the better.
There's no single test for schizophrenia. It's usually diagnosed after an assessment by a

mental health care professional, such as a psychiatrist.
Will I be ok?
Many people recover from schizophrenia, although they may have periods when symptoms
return (relapses).
Support and treatment can help reduce the impact the condition has on daily life.
If schizophrenia is well managed, it's possible to reduce the chance of severe relapses.
This can include:
o recognising the signs of an acute episode

o taking medicine as prescribed
o talking to others about the condition
There are many charities and support groups offering help and advice on living with
schizophrenia.
Most people find it comforting talking to others with a similar condition.

P a g e | 829
Bipolar disorder
Bipolar disorder, formerly known as manic depression, is a condition that affects moods,
which can swing from one extreme to another.
There will be periods or episodes of:
 depression – feeling very low and lethargic
 mania – feeling very high and overactive
Unlike simple mood swings, each extreme episode of bipolar disorder can last for several
weeks (or even longer), and some people may not experience a "normal" mood very often.
Depression
The depression phase of bipolar disorder is often diagnosed first and manic episode later
(sometimes years later).
Mania
During a manic phase of bipolar disorder, patient may feel very happy and have lots of
ambitious plans and ideas. They may spend large amounts of money on things they cannot
afford and would not normally want.
Not feeling like eating or sleeping, talking quickly and becoming annoyed easily are also
common characteristics of this phase.
They may feel very creative and view the manic phase of bipolar as a positive experience.
However, they may also experience symptoms of psychosis (where they see or hear things that
are not there or become convinced of things that are not true).
Scenario - 14
( This station assesses your ability to take history in a patient with elevated mood).
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Miss Sarah Collins 30 year lady was brought into the hospital with cuts on her wrists.
Medical management has been done and she is medically stable.While she was in the
hospital nurse noticed strange behaviour. You are the SHO in the Psychiatric department.
Talk to the patient and tell your diagnosis to the examiner.
Dr: Hello Mrs Collins I am Dr… How can I help you ?
Pt: I cut my wrists
Dr: I am sorry to hear that. How did this happen?
Pt : Doctor, I have a very nice dress and I wanted to buy a matching shoe. When I went
for shopping for the shoe shop was closed. I saw a pair of perfectly matching shoe on the
glass window of the shop, so I smashed the window to get the shoe and I got hurt on my
wrist.
Dr: I am very sorry to hear that. But why did you smash the window?
Pt: Oh doctor I was in a very good mood.
Dr: Has this happened to you before.
Pt: Doctor I am very happy since the last two weeks.
Dr: Is there any particular reason why you are so happy?
Pt: Nothing special.
Dr: Has this happened to you before ?
Pt: No doctor in fact some time ago I was very depressed and I left going to the
University.
Dr: When was that ?
Pt: This happened about a month ago.
Dr: Why were you so depressed ?
Pt: I do not know why.
Dr: How is your mood now in the scale of one to ten, one being lowest mood and 10 being
the happiest mood ?
Pt: 10 out of 10 doctor.
Dr: Have you ever had low mood ?

P a g e | 831
Pt: I was feeling very low about a month ago.
Dr: Do have any thoughts of harming yourself or ending your life ?
Pt: No doctor. I used to have that feeling before but now I am very happy.
Dr: Have been treated for depression or any other mental health problems before?
Pt: No
Dr: What do you do for living ?
Pt: I work as a waitress in hotel.
Dr: Are you financially stable.
Pt: No doc. I am almost bankrupt.
Dr; Have you ever been involved in any legal problems?
Pt: No
Dr: Who do you live with?
Pt : My parents but we don’t have good communication.
Dr: Do you hear any noises when no one else is around
Pt: No doctor
Dr: Do you think you have any mental health problem?
Pt: No
Dr: Do you have any problems with the sexual life?
Pt: No
D: Do you drink alcohol?
Pt: No
Dr: Do you use any recreation drugs?
Pt: No
Dr: Thank you very for all the information.
Tell you diagnosis to the examiner: Bipolar disorder.

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Depression ( Suicidal attempts)
Scenario - 2 .
Mr Graeme Hick, 35 years old man was brought to the hospital because he had taken
overdose of Paracetamol Tablets. He was admitted and treated for this. His condition is
stable medically. You are the SHO in psychiatric department. Do Psychiatric Assessment
and discuss the Suicidal Risk for Mr Graeme with the examiner. (Question can be do
mental state examination / Please do MSE “OR” please do psychiatric assessment “OR”
please take detailed psychiatric history)
GRIPS ( Do ABS in your mind, Ask about – present, past and future ( Suicidal risk)
Dr: Hello Mr Hick. I am Dr ….. How are you feeling?
Mr Hick: Doctor, I do not want to live.
Dr: Mr Hick, Why do you not want to live?
Mr Hick: I have gone through a lot.
Dr: I am sorry to hear that. Did you try to harm yourself in any way ?
Mr. Hick – I took some paracetamol tablets
Dr - When did you do that?
Mr Hick: Today morning.
Dr: How many tablets did you take?
Mr Hick: I took about 40 tablets.
Dr: Was there anyone with you?

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Mr Hick: No, Doctor.
Dr: Who brought you to the hospital?
Mr Hick: My wife
Dr: Have you done anything like this before? ( Past)
Mr Hick: Yes / No
Dr: Did you plan it?
Mr Hick: Yes
Dr: Did you write suicide note?
Mr Hick: Yes
Dr: Did you inform anyone before doing it?
Mr Hick: No
Dr: Will you do it again? ( Future ) ( How do you see your future ?)
Mr Hick: As I told you, I don’t want to live. / I may do it again / I am not sure.
Dr: How is your mood nowadays? Mr Hick: Not good.
Dr: How would grade your mood, 1 being the saddest and 10 being the happiest?
Mr Hick: Very Sad, I would say 3/ 10.
Dr: It might sound bit irrelevant but I need to ask you few questions, Can you please tell
me what day is today? /Where are you now? ( Cognition)
Mr Hick: --- (He will give you correct answers )
Dr: Do you live with family? Mr Hick: Yes. (But I do not like my
family)
Dr: Do you have friends Mr Hick – No
Dr: Are you currently in financial trouble, are you working?

Dr: Do you have any problem with the law ?
Dr: Do you know why you are in the hospital? Do you need any help (Insight)
Mr Hick: Yes
Dr: 'I'd like to ask you a couple of questions about things sometimes people have but may
find difficult to talk about. I ask everyone these questions. “Have you ever had experiences
of hearing noises or voices when there was nobody around?”
P a g e | 834
Mr Hick: No
Dr: “Are your thoughts actually taken out or sent out of your mind? / Do there seem to be
thoughts in your mind which are not your own; which seem to come from somewhere
else?” “Do your thoughts seem to be somehow public; not private to yourself, so that
others can know what you are thinking?”
Mr Hick: No
Dr: Thank you, Mr Hick.
Give your inference to the examiner( stop Hx at 4 -1/2min and talk to the examiner): -
I will admit the patient. My patient very depressed and has high suicidal risk because
1) He planned to harm himself 2) He made a suicide note 3) he may do the same again in
the future and 4) His mood is very low.
Self Harm – Gay man PCM OD
You are FY 2 doctor in Emergency department.
18/20 years old Mr..... was brought to the hospital because he took over dose of
Paracetamol tablets
Take history from the patient and discuss the management with him
-------------------------------------------------------------------------------------------------
(OFFER CONFIDENTIALITY,IF PATIENT DOESN’T SPEAK)

P a g e | 835
START WITH ONSET,DURATION,THEN DO BEFORE,DURING,AFTER
He took 16 tablets of paracetamol 2 hours ago.
Boy friend brought him to the hospital.
He had an argument with his mother because mother was very upset because she found out
that he is gay.
He is regretting for that now. Not going to do it again. Sees future bright.
Lives alone.
Dr: Is he working what is his job, any financial problems, Any other worries.
MANAGEMENT –Mr.. I am very sorry you have to go through this problem. Do not
worry we are here to help you.
Mr… Unfortunately overdose of Paracetamol can damage and kidneys.
First of all we need to do some blood tests to see if you have any damage to the liver and
kidneys.
Also we need to check whether you need any treatment with antidote medicine for
overdose of Paracetamol. For that we need to test the level of Paracetamol in your blood
after 2 hours ( 4 hours after the ingestion).
I will talk to my seniors about it. Also we will refer you to the Psychiatry specialist. They
will help you further.
Pt: Do I need to be admitted.
Dr: At the moment yes you need to be in the hospital because we need to do the test to see
whether you need any treatment for the overdose of the tablets you have taken.
However if the level of paracetamol is not very high or if there is no damage to the organs
P a g e | 836
then you do not need to be admitted here.
But the Psychiatrist has to see you and then they will tell you about the further
management. However since you are regretting for what you have done and you are sure
you are not going to do such things again they may not admit you. They may advise you
about the help what they can provide and follow up with you later. Is that OK ?
Pt : Ok Dr Any other concerns ? Pt : No
Dr: Thank you very much.

Self Harm –OCP overdose and cut wrist
16 years old Ms Jessica Thompson was brought to the hospital because she cut her wrist
and took overdose of OCP pills. You are FY 2 doctor in psychiatric department. Take
history from the patient and discuss the management with her.
(OFFER CONFIDENTIALITY,IF PATIENT DOESN’T SPEAK)
START WITH ONSET,DURATION,THEN DO BEFORE,DURING,AFTER
Dr: Hello Ms Thompson, I am Dr... one of the junior doctor in the Psychiatry department.
How can call you ?
Jessica: You can call me Jessica.
Dr: Jessica Can you please tell me, what brought you to the hospital?
Jessica: I took pills and cut my wrist.
Dr: I am really sorry to hear that. How are you feeling now?
Jessica: I am okay.
Dr: Alright... can you please tell me why did you do this ?
Jessica: I was stressed because I missed my period and I was worried that I am
pregnant. So I took some OCP yesterday and I was hoping to have my periods today.
Today also I didn’t get the periods –so I told my boyfriend about it. He broke up with me
P a g e | 837
because he didn’t want me to be pregnant. I got upset and cut my wrist.
Dr: I am very sorry hear about this Jessica. When was your last period?
Jessica: It was 5 weeks ago.
Dr: How many OCP pills did you take? Jessica: I took 20 tablets.
Dr: Where did you get these tablets. Jessica: It is my mom’s pills.
Dr: Where did you take these tablets? Jessica: In my room.
Dr - Was there any one with you at that time. Jessica – No
Dr: Where were you when you cut your wrist this morning?
Jessica: I cut my wrist in bathroom.
Dr: Was there any one with you at that time ?
Jessica: I was alone when I cut my wrist
Dr: Who brought you to the hospital?
Jessica: I came to the hospital myself
Dr: I see. Were you under the influence of alcohol when this happened Jessica ?
Jessica: No
Dr: Did you plan to harm yourself at all ?
Jessica: No. It just happened. I was not thinking properly at that time.
Dr: I am sorry to ask this - Did you think of ending your life at all ? Jessica : No
Dr: Okay Did you inform anyone about this? Jessica: No
Dr: Was the wound deep? Jessica: No, it was not deep It is just a graze.
Dr: How do you see your future?
Jessica: Very bright. I am going to university for further studies.
Dr: Are you going to do this again?
Jessica: No, Doctor. I am not happy about what has happened. I am regretting what I did.
Dr: Have you ever tried to harm yourself before? Jessica: No
Dr: Do you have any medical condition?Jessica : No

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Dr: Are you taking any medication?Allergic to any medications? Jessica: No
Dr: How do you feel in your Mood on scale of 1-10,1 being sad,gloomy and 10 being
normal,happy? Jessica:7-8
Dr: Do you see/hear noises when nobody is around?Jessica:No
Dr: Do you feel that someone is telling you to do things? or reading your mind?/making
you do things?Jessica:No
Dr: Do you smoke? / Drink Alcohol?/use recreational Drugs? Jessica:No
Dr: Do you feel that this has affected your family life/social life/work?(ASK
INDIVIDUAL QUESTIONS)
Jessica:YES/NO
Dr: Is she student what is she studying, any financial problems, Any other worries.
Dr:Do you think you need any help from us for your stress or if you are feeling low?
Jessica:I am OK Now
Dr: Do you have any mental health conditions?Jessica: No
Dr: Any of your family members have any mental health conditions?Jessica: No
Dr: were you ever in trouble with Law before?Jessica: No
Dr: Do you live alone or with others?
Jessica: I live with my mother and brother.
Dr: Have you told your mother or brother about this?Jessica : No
Dr: Do you have any financial problem?Jessica : No
Dr: Do you have friends?Jessica : Yes
Dr: Has any one looked at your wound ? Jessica : Yes / No
Dr: Did any specialist doctor talk to you about the chance of pregnancy to you ?
Jessica: Yes/ No
Dr: Thank you very much for all the information.

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MANAGEMENT – Jessica, I am very sorry you have to go through this problem. Do not
worry we are here to help you.
-we will refer you to a Gynecologist as regards the chance of pregnancy ( if not already
sorted out)
-We will also take a look at your wrist and treat accordingly ( if not already sorted out)
-We will also contact the poison information center if you need any treatment for the
tablets you have taken and would treat you accordingly.
However since you said you are regretting for what you have done and you are sure that
you are not going to do this again, I don’t think we need to admit you for any Psychiatric
reasons. I will talk to my seniors and then you can go home.
I sincerely advise you to talk to your mother about this. I am sure she will understand your
problem and support you in the future. What do you say - will you talk to your mother ?
Jessica : Yes doctor. [ If she says no - ask her - Can we talk to your mother and explain
about you. I am sure she will understand your problem – what do you say? Jessica – OK.
If she still says no – then mention that your seniors will talk to her before we discharge her]
We are also here to support you if need any time. We will give the telephone number of a
help line to call if you feel very stressed out like this any time in the future and they will
advise you of what you can do. Also will have a follow up in the community clinic after 2
weeks. Is that OK ?
Jessica : Ok
Dr: Thank you very much.

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Depression-CBT failed
199.
You are FY2 in GP clinic. Steven Douglas, aged 35 has been divorced from his
wife and is in depression. He saw the psychiatrist , was given CBT treatment but
he is not improving on CBT. Talk to the patient and address his concerns.
History
Dr:Hello,how can I help you?
Pt:I am not getting well, I am still depressed Dr:I am sorry, we will try to help you
Dr:From how long you have depression?
Pt:Last 2 months
Dr:Why were you diagnosed with depression? Pt:I got a divorce from my wife 2 months
ago
Dr:I am sorry about that, is there anything other than CBT you are taking?
Pt:No
Dr:How many sessions have you taken for CBT? Pt:6 sessions
Dr:Are you taking them regularly? Pt:Yes
Dr:Are you diagnosed with depression for the first time in life?
Pt:Yes
Dr:How is your mood now? Pt:Low
Dr:Can you score for me on the scale of 1 to 10? Pt:Around 2 to 3
Dr:Are you having any thoughts of harming yourself or others
Pt:No
Dr:Do you have family,friends? Pt:Yes, but I don’t meet them. Dr:Why?
Pt:I don’t feel like meeting anyone. I have lost interest in everything.
Dr:What is in your life that is particularly worrying you? Pt:I don’t know may be my
divorce
Dr:Do you have any idea how can you come out of this worry?
Pt:I don’t know doc

Dr:Do you have any other stress in your life? Pt:No
Dr:How is you sleep?
Pt:I am getting up early in the morning now a days. Dr:What you do for living?
Pt:I am a plumber
Dr:By any chance do you use recreational drugs? Pt:No
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Dr: Do [FAMISHT],ask about smoking, alcohol(drinking heavily)
Examination
I would like to check your vitals i.e. your BP,pulse,temperature and respiratory rate. Also
general examination of your body.
Management
Dr:From what we have discussed, we can see that CBT is not working on you so what we
can do is ,we can refer you to specialist doctor,psychiatrist.What do you think about it?
Pt:Ok what he will do then?
Dr:May be he will start you on Anti depressants. Pt:Does antidepressant have side effects?
Dr:Yes ,it has some side effects but they improve with time like nausea,headaches,dry
mouth.
Pt:Will I get addicted to them?
Dr:No,we will taper the dose of medicine so that you don’t have any addiction.
Pt:For how long I have to take this? Dr:For minimum 6 months
Pt:Does it cause loss of libido?
Dr:Some antidepressants like SSRI’s can cause reduce libido, we can take care of this side
effect by giving you some other antidepressant like TCA(Amitriptyline) which doesn’t
cause reduce libido.
Pt:Ok Dr:
1. Advice patient on cutting down on alcohol ,offer him all replacement and support
options.
2. Tell the patient about Sleep hygiene as his sleep is affected.
Dr:We will do all blood tests as well to make sure everything is fine with you. Also we will
arrange a follow up in 2 weeks.in the meantime if you feel that you are having thoughts of
harming yourself or others, please contact us.
Moderate to severe depression
If you have moderate to severe depression, the following treatments may be recommended.
Antidepressants:
Antidepressants are medicines that treat
the symptoms of depression. There are many different types of antidepressant.
Combination therapy:
A GP may recommend that you take a course
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of antidepressants plus talking therapy, particularly if your depression is quite severe.

A combination of an antidepressant and CBT usually works better than having just one of
these treatments.
Mental health teams:

If you have severe depression, you may be referred to a mental health team made up of
psychologists, psychiatrist and occupational therapists.
Antidepressants:
Antidepressants are medicines that treat
the symptoms of depression. There are many different types available. Most people with
moderate or severe depression benefit from antidepressants, but not everybody does.
You may respond to 1 antidepressant but not to another, and you may need to try 2 or more
treatments before you find one that works for you.
The different types of antidepressant work about as well as each other. But side effects
vary between different treatments and people.
When you start taking antidepressants, you should see a GP or specialist nurse every week
or 2 for at least 4 weeks to assess how well they're working.
If they're working, you'll need to continue taking them at the same dose for at least 4 to 6
months after your symptoms have eased.
If you have had episodes of depression in the past, you may need to continue to take
antidepressants for up to 5 years or more.
Antidepressants are not addictive, but you may get some withdrawal symptoms if you stop
taking them suddenly or you miss a dose.
Selective serotonin reuptake inhibitors (SSRIs):
If a GP thinks you'd benefit from taking an antidepressant, you'll usually be prescribed a
modern type called a selective serotonin reuptake inhibitor
(SSRI).
Examples of commonly used SSRI antidepressants
are p aroxetine (Seroxat), f luoxetine
( Prozac) and c italopram (Cipramil).
They help increase the level of a natural chemical in your brain called serotonin, which is
thought to be a "good mood" chemical.
SSRIs work just as well as older antidepressants and have fewer side effects, although they
can cause nausea, headaches, a dry mouth and problems having sex. But these side effects
usually improve over time.
Some SSRIs are not suitable for children and young people under 18 years of age.
Research shows that the risk of self-harm and suicidal behaviour may increase if they're
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taken by under-18s.
Fluoxetine is the only SSRI that can be prescribed for under-18s and, even then, only when
a specialist has given the go-ahead.
Tricyclic antidepressants (TCAs):
Tricyclic antidepressants (TCAs) are a group of antidepressants used to treat moderate to
severe depression.
TCAs, including imipramine (Imipramil) and amitriptyline, have been around for longer
than SSRIs.
They work by raising the levels of the chemicals serotonin and noradrenaline in your brain.
These both help lift your mood.
They're generally quite safe, but it's a bad idea to smoke cannabis if you're taking TCAs
because it can cause your heart to beat rapidly.
Side effects of TCAs vary from person to person but may include a dry mouth, blurred
vision, constipation, problems passing urine, sweating, feeling lightheaded and excessive
drowsiness.
The side effects usually ease within 10 days as your body gets used to the medicine.
Venlafaxine and duloxetine are known as serotonin- noradrenaline reuptake inhibitors
(SNRIs). Like TCAs, they change the levels of serotonin and noradrenaline in your brain.
Studies have shown that an SNRI can be more effective than an SSRI, but they're not
routinely prescribed because they can lead to a rise in blood pressure.
Withdrawal symptoms:
Antidepressants are not addictive in the same way that illegal drugs and cigarettes are, but
you may have some withdrawal symptoms when you stop taking them.
These include:
• an upset stomach
• flu-like symptoms
• anxiety
vivid dreams at night
• sensations in the body that feel like electric shocks
In most cases, these are quite mild and last no longer than 1 or 2 weeks, but occasionally
they can be quite severe.
They seem to be most likely to occur with paroxetine (Seroxat) and venlafaxine (Efexor).
Withdrawal symptoms occur very soon after stopping the tablets so are easy to distinguish
from symptoms of depression relapse, which tend to occur after a few weeks.
Other treatments:
Mindfulness
Mindfulness involves paying closer attention to the present moment, and focusing on your
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thoughts, feelings, bodily sensations and the world around you to improve your mental
wellbeing.
The aim is to develop a better understanding of your mind and body, and learn how to live
with more appreciation and less anxiety.
Mindfulness is recommended by NICE as a way of preventing depression in people who
have had 3 or more bouts of depression in the past.
Brain stimulation
Brain stimulation is sometimes used to treat severe depression that has not responded to
other treatments.
Electromagnetic currents can be used to stimulate certain areas of the brain to try to
improve
the symptoms of depression.
There are a number of different types of brain stimulation that can be used to treat
depression, including transcranial direct current stimulation (tDCS), repetitive transcranial
magnetic stimulation (rTMS) and electroconvulsive therapy (ECT).
Electroconvulsive therapy (ECT):

Electroconvulsive therapy (ECT) is a more invasive type of brain stimulation that's
sometimes recommended for severe depression if all other treatment options have failed, or
when the situation is thought to be life threatening.
During ECT, a carefully calculated electric current is passed to the brain through electrodes
placed on the head.
The current stimulates the brain and triggers a seizure (fit), which helps relieve the
symptoms of depression.
PANIC ATTACK
Background
Anxiety
Anxiety is a feeling of unease. It can range from mild to severe and can include
feelings of worry and fear.
There are several conditions that can cause severe anxiety including
 phobias – an extreme or irrational fear of an object, place, situation, feeling or
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animal
 generalised anxiety disorder (GAD) – a long-term condition that causes
excessive anxiety and worry relating to a variety of situations
 post-traumatic stress disorder – a condition with psychological and physical
symptoms caused by distressing or frightening events
 A panic attack is a severe attack of anxiety and fear which occurs suddenly, often
without warning, and for no apparent reason. In addition to the anxiety, various other
symptoms may also occur during a panic attack. These include one or more of the
following:
 Palpitations.
 Sweating and trembling.
 Dry mouth.
 Hot flushes or chills.
 Feeling short of breath, sometimes with choking sensations.
 Chest pains.
 Feeling sick , dizzy, or faint.
 Fear of dying or going crazy.
 Numbness, or pins and needles.
Assessment
You must assess the following 4 steps as part of this station/task.
Step 1: Presenting Complaint
Step 2: History of Present Complaint
 Onset
 Symptoms (explore above)
 Description
 Triggers
 Recent change in circumstances
 Severity
 Progression
 Effect on activities of daily living
 4Fs
 Mood (Score 1-10)
 Risk
Step 3: FAMISH History

Step 4: Insight
Suggested Questions
How long have you been having problem?
What happens to you ?
Do you have heart racing, feeling dizzy and numb,
Do you have breathing problems and have a sense impending doom(You feel as though
something extremely bad is going to happen but you are not sure what. You may also feel as
though your world is coming to an end)?
What brings it on?
How long has this been going on?
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Does it occur only when you are faced with such a situation or at any time?
Can you go out of the house at all ?
Are you afraid of crowds and people?
Any special fear?
Is this hampering your daily life?
What do you do to subside them?
Is your family and friends supportive?
Is there stress at work /family?
Do you enjoy your daily activities /interest/otherwise?
Is this problem making you suicidal?
Any other medical /mental condition you wish us to know of? Are you on any medications?
Scenario - 12
Miss Sarah Jones, 25 years old lady has been referred to the hospital by her GP. She went
to GP because she thinks that she is very anxious nowadays. All investigations have been
done and are normal. You are SHO in the hospital. Take history from Miss Jones.
[ This station is only history taking]
Dr: Hello Mrs Jones, I am Dr… one of the junior doctor in the Psychiatry department. How
are you doing ?
Miss Jones: I am very worried doctor.
Dr : What are you worried about ?
Miss Jones: Dr, I become anxious nowadays. I Feel like my heart is racing and mouth is
dry. Sometimes, I even have choking sensation.
Dr: When did it start?
Miss Jones: It started few months ago.
Dr: When was the last time you had symptoms?
Miss Jones: I had these symptoms two weeks ago when I went to the party and I met my
family members.
Dr: Can you please tell me, how did it start at first time?
Miss Jones: It started when I was at shopping centre. And I started having symptoms.
Dr: Do you have any idea what can be the cause of these symptoms, any recent
change/incident in your life?
Miss Jones: Yes doctor. My husband left me 8 months ago, and I got divorced after that.
Dr: Is there any particular thing which makes you anxious?
Miss Jones: No doctor. However, it happens when I go out.
Dr: Does it affect your daily life?
Miss Jones: Yes.
Dr: How does it affect your life?
Miss Jones: I cannot go out nowadays as I am afraid that if I go out I might get these
symptoms.
Dr: Do you have any concerns about your life, any responsibility?
Miss Jones: Yes, Doctor, I am concerned about my three kids.
Dr: Do you have any family to support you?
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Miss Jones: Yes, Doctor my sister supports me.

Dr: What do you do for living?
Miss Jones: I am not working right now; I lost my job 4 months ago.
Dr: How has been your mood?
Miss Jones: It has been good
Dr: Have you ever thought of harming yourself?
Miss Jones: No
Dr: Do u drink alcohol?
Miss Jones: doctor, I am really worried about my heart.
Dr: Don’t worry, my GP colleague did all the investigations and fortunately everything is
fine and there is nothing wrong with your heart. ( Mention this only if the patient ask you
this question, otherwise just say “thank you very much for all the information”).
[This is only history taking station]
ALCOHOL ASSESSMENT
You must assess the following 6 steps and if required discuss your findings with the patient or
the examiner.
 Daily Drinking Pattern: What/How Much/When/Where/Alone/Progression
CAGE Questions: CAGE SCREENING TOOL

• “Have you ever felt that you should Cut down on your drinking?”
• “Have people Annoyed you by criticizing your drinking?”
• “Have you ever felt bad or Guilty about your drinking?”
• “Have you ever had a drink first thing in the morning to steady you nerves or get rid of a
hangover (Eye-opener)?”
• Scoring: Two or more positive responses correlate with substance abuse.


 Cut Down/Annoyed/Guilty/Eye Opener
Step 3: Features of Dependence

 TDW - Tolerance/Dependence/Withdrawal/Previous Treatment
Step 4: Consequences
 Friends/Family/Finances/Forensic
Step 5: Complications
 Physical/Depression(Mood)/Psychosis/Self Harm
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Step 6: Insight
Management
If station/task states present findings/management/counsel, then as a rule, you should discuss:
 Referral to Alcohol Support Worker
 Lifestyle changes
 Outpatient Counselling Groups such as Alcoholics Anonymous
 Outpatient medication management
 Inpatient Detoxification
 Change of occupation if required
Key Points
 Be honest and non-judgemental.
 Do not start station by discussing alcohol directly, mention that their test results may be
due to alcohol intake as well as many other causes and that you want to ask some
questions to rule alcohol out as a cause.
 Many patients drink in secret and may not want to discuss the issue.
 If patient denying drinking alcohol – you can offer confidentiality. ( Mr… “Whatever
you discuss with us will be kept confidential”
 The patient needs to accept that there is a problem before therapy can start.
Government Recommended Allowances

Male and Female:14 UNITS PER WEEK
Alcohol
Exam question: Mrs Tames Parker, 45 years old woman who had hysteroscopy. The
nurse noticed she has got a bad drinking habit and wants you to talk to her about it. You
are the SHO in the Psychiatric department. Take history for alcohol abuse from the patient
and talk to her about the management.
(GRIPS Followed by CAGE,T/D/W)
Dr: Hello, Mrs Parker, I am Dr………., one of the doctors in Psychiatric department. I am
here to talk to you and help you.
Dr: Can you please tell me how are you doing?
Mrs Parker: I am much better just a bit sore but I guess it’s expected.
Dr: I am sorry to hear that
Mrs Parker: I am OK now.
Dr: Mrs Parker I want to talk to you about alcohol, is that okay ?
Mrs Parker: Yes, Doctor.
Dr: Do you drink alcohol Mrs Parker ?
Mrs Parker: Yes
Dr : For how long have you been drinking?
Mrs Parker : I have been drinking for last 20 years.
Dr: How much do you drink? (How frequently?)
Mrs Parker: Doctor, I drink 3 pints of beer and 1 shot whisky daily
( Then ask CAGETDW – cut down, annoyance, guilty, eye opener, tolerance, dependence,
withdrawal questions )
Dr:Have you ever felt you should try to cut down on your drinking?
Mrs Parker: Yes, Doctor, I went to Alcohol Anonymous (AA) Group 6 months ago to cut
down alcohol. But sometimes, I went for drinks because of my friends.
Dr: Does it mean that you still keep drinking.
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Mrs Parker : Yes doctor

Dr: Can you please tell me why did you try to cut down drinking?(INSIGHT)
Mrs Parker : It is not good for health.
Dr: Have people annoyed you by criticizing your drinking?
Mrs Parker: Yes, My husband is really annoyed about it
Dr: Have you ever felt bad or guilty about your drinking?
Mrs Parker: Yes, Doctor, Sometimes
Dr: Have you ever had a drink in the morning (eye-opener) to steady your nerves or get rid
of a hangover?
Mrs Parker : Yes, Doctor.
(Patients with two or more positive responses are likely to be alcohol dependent).
Dr: Doyouthinkthatyouhavetotakemoreandmore alcoholto getthesameeffectasbefore?
(tolerance)
Mrs Parker: No, Doctor.
Dr : Do you feel you cannot do your daily activities without drinking alcohol? (dependence)
Mrs Parker : Yes
Dr: Howdoyoufeelwhenyoudo not drink alcohol for a long time ? ( withdrawal)
Mrs Parker: Doctor, when I do not drink, I feel restless, I start sweating and sometimes I
feel that my heart is racing. It happened to me 1 year ago.
Dr: What do you do for living? Mrs Parker: I own a winery ( a place where wine is made).
Dr: Do you live with your family?
Mrs Parker: Yes, with my husband
Dr : Do you have any financial problems?
Mrs Parker : No
Dr: How is your mood? How would you grade your mood in 1 to 10 scale where 1 being
low and 10 being very happiest mood? ( Mood)
MrsParker: My mood is fine (7/10)
Dr: At any point, THOUGHT of harming yourself or ending your life? ( Suicidal)
MrsParker: No, doctor.
Dr : Do you ever see or hear things that other people seem unable to see or hear?
( HALLUCINATION/PERCEPTION)
Mrs Parker : No
Dr:DO you feel that this has affected your work/family life/social life?(IMPACT)
Mrs parker:NO/YES
Dr:DO you tend to drink alcohol to relieve ur stress?(STRESSOR)
Mrs parker:No
Dr: Do you have any health problem at all apart from the problem for which you had the
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procedure now? Mrs Parker : No
Dr:did you have any mental health problems in ur past?
Mrs parker:NO
Dr:are you taking any medications?/are you allergic to any medications?
Mrs parker:NO
Dr:do you have family history of any mental health conditions?
Mrs parker:NO
Dr:Do you have any legal problems?
Mrs parker:NO
Dr: Thank you very much for all the information. We will try our best to help you.
DIAGNOSIS:Mrs parker ,ur experiencing soreness and withdrawal symptoms because of

ur ALCOHOL use. From the information I think you have alcohol dependence.
*Cause and effect : From what you told me Mrs Parker, You seem to be taking too much
alcohol which is dangerous to you. This can damage your liver and risk your life.
 MANAGEMENT:Stop alcohol : If you stop drinking, it will not only help you in this problem,
but also in your overall health. We can help you on that.
 Medications : We can give medications to prevent withdrawal effects (anti withdrawals -
chlordiazepoxide) and also to help you stop drinking alcohol (anti-craving medications –
disulfiram, Acamprosate).
 Counselling : You can try to attend Alcohol anonymous, or we can help by counselling
sessions ( CBT) or
 Rehabilitation: if needed we can admit for rehabilitation (Job, Finances and
accommodation)
 Avoid going to the winery, triggers ( seeing other people drinking): may be you can try to
change your job ( if he is a bar tender ) or try to avoid going to the bar floor (If he is a bar
owner).
Scenario – 8
A 60 year old man, Mr Smith, was admitted in the hospital because of ingrowing toe nail
infection. Medical Investigation has been done : MCV ↑, LFTs : deranged. Talk to the
patient, take Hx and advice patient to stop drinking.
[ This is a history and counselling station]
Dr : Mr Smith we have done some blood investigations because you have

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infection in your toe nail. The results show there is some abnormalities in
your blood picture. This could be due to several reasons lack of some type of
food in your diet or drinking alcohol.
Dr: Do you think that you eat a healthy balanced diet? (Vit B12 deficiency
causes high MCV)
Mr Smith : Yes.
Dr: Do you drink alcohol?
Mr Smith : Yes.
The rest is similar approach as previous Task.
DRUG ABUSE ASSESSMENT

Assessment
You must assess the following 6 steps and if required discuss your findings with the patient or
the examiner.
 Daily Drug Pattern: What/How Much/When/Where/Alone/Progression
 CAGE Questions: Cut Down/Annoyed/Guilty/Eye Opener
Step 3: Features of Dependence

 Tolerance/Withdrawal/Previous Treatment (Hep B)
Step 4: Consequences
 Friends/Family/Finances/Forensic
Step 5: Complications
 Physical/Depression(Mood)/Psychosis/Self Harm
Step 6: Insight
Management
If station/task states present findings/management/counsel, then as a rule, you should discuss:
• Referral to Narcotic Support Worker and Lifestyle changes
• Outpatient Counselling Groups such as Narcotics Anonymous
• Outpatient medication management (Methadone/needle sharing)
• Inpatient Detoxification
Scenario - 9
You are the FY 2 doctor in the Psychiatry department.
30 year old, Mr Henry Williams, has been referred to the hospital from his GP because he
is opioid dependent and he wants to quit the habit.
Take history from Mr Henry and discuss the further management with him.
{GRIPS-CAGE,T/D/W,Which DRUG,DOSAGE,ROUTE OF INJECTION}
Dr: Hello Mr Williams, I am Dr… one of the junior from the Psychiatry Dept. How can I
help you Mr Williams?
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Mr Williams: Dr I use drugs and I want to stop and I need help.

Dr: It is really good to know that you wish to quit drug habit. I am really glad that you have
come to us. We can surely help you with that.
Can you please tell me, which drugs doyou use?
Mr Williams: Doctor, I use Heroin.
Dr: For how long have you been taking it?
Mr Williams: It has been 10 years; I started taking it when I was 20 years old.
Dr: How much do you take it?
Mr Williams: about 1 gram.
Dr: How often do you take it?
Mr Williams: I take it two times daily.
Dr: How do you use it?
Mr Williams: I inject in my blood channels nowadays, before I used to snort it.
Dr : Do you know of the needle exchange programme?
Mr Williams: Yes, I am aware of it.
Dr: Apart from heroin, do you take anything?
Mr Williams: No doctor ( sometimes he may say - I use cocaine, marijuana and
amphetamine).
(Ask CAGETDW questions)
Dr: Have you thought of Cutting down or quitting them?
Mr Williams: I tried to quit it two times before (5 months and 7 months before) , but it did
not work as I had serious withdrawal symptoms
Dr: Why did you try to Cut down before?
I was having some health problems. I had some infections on my arm where I used to inject
myself.
Dr: Do you sometime get Annoyed when people talk about your habit?
Mr Williams: No (sometimes yes, because of my wife/ girlfriend)
Dr: Do you have any sort of Guilt feeling that you are using opioid?
Mr Williams: Yes, Doctor, Sometimes I feel guilty in front of my wife/ girlfriend.
Dr: Do you take them in the morning as well?(EYE OPENER)
Mr Williams: Yes, Doctor. First thing I do in the morning is to take these drugs.
Dr: Doyouthinkthatyouhavetotakemoreandmore drugsto getthesameeffectasbefore?
(TOLERANCE)
Mr Williams: No, Doctor.
Dr : Do you feel you cannot do your daily activities without taking drugs? (Dependence)
Mr Williams : Yes
Dr: Howdoyoufeelwhenyoudo not take these drugs?(WITHDRAWAL)
Mr Williams: Doctor, when I do not take these drugs, I feel restless, I start sweating and
sometimes I feel that my heart is racing. It happened to me 1 year ago.
Dr: What do you do for living?
Mr Williams: I am on benefits
Dr: Do you live with your family?
Mr Williams: Yes girlfriend who also uses opioids.
Dr : Do you smoke or consume alcohol?
Mr Williams: No
Dr: How is your mood? How would you grade your mood in 1 to 10 scale where 1 being
low and 10 being very happiest mood?
Mr Williams: My mood is fine (8/10)
Dr:do you ever feel that someone is telling you to do things/or controlling your mind?
Mr Wiliams:No
Dr: At any point, thought of harming yourself or ending your life?
Mr Williams: No, doctor.
Dr: At any point, you have gone to wrong side of the law?(FORENSICS)
Mr Williams: No ( sometimes he may say - I was arrested when I was young for pick
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pocketing).
Dr : Do you ever see or hear things that other people seem unable to see or hear?
( hallucination)
Mr Williams: No
Dr:Is there any Stress which is making you take this drug?(STRESSOR)
Mr Williams:NO/Yes
Dr: Do you think this is affecting your health or social life /Family life?(Impact)
Mr Williams: Yes doctor.
Dr : Do you think you need help? (Insight)
Mr Williams: Yes Doctor.
Dr : How do you see your future?
Mr Williams: Good if I can stop this habit
Dr:did you suffer from any mental health conditions in the past?
Mr Williams:NO
Dr:do you have any other medical conditions? Mr Williams:No
Dr:Are you allergic to any medications?are you taking any medicines?
Mr Williams:No
Dr:Do you have family history of any mental health conditions?
Mr Williams:No
Dr : Thank you Mr Williams
Management:
• As you know it is not good for health as well as for your social life.
We can help you to quit the habit if you are willing to do so.
•We have a Drug de-addiction(DETOXIFICATION)programme which can help you where
we can Admit and rehabilitate.WE will Give you drug called LOFEXIDINE,TO HELP
You with the withdrawal effects.
*We will also treat you symptomatically.For example:METACHLOPARAMIDE for
Nausea,LOPERAMIDE for Loose Motions,BENZODIAZEPAMS for
Palpitations.*REPLACEMENT THERAPY:We have some medications called
Methadone or Buprenorphine ( tell the names of the medications to the patient) we can
give you to help you.
*We have talking therapies, such as counselling, can help you to understand and overcome
your addiction and plan for your future.
*We can refer you to a support group( self help group -Narcotics Anonymous ) where
you can meet other people with similar problems and share your experiences which can
help you.
*Talk about NEEDLE EXCHANGE PROGRAM
*Advise about his girlfriend – if your girlfriend wishes to stop her drug habit we can help
her too.
Do you follow me? Any questions ?
MINI MENTAL STATE EXAMINATION (MMSE)

Background
 The MMSE is a brief 30-point questionnaire test that is used to screen for cognitive
impairment, memory impairment.
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 It is commonly used in medicine to screen for dementia.

 It is also used to estimate the severity of cognitive impairment and to follow the course
of cognitive changes in an individual over time, thus making it an effective way to
document an individual's response to treatment.
Key Points
 Perform your assessment for the entire 5 minutes.
 Offer sympathy and empathy. ( this is very important in this station)
 Take time to build a rapport with the patient.
 Do not rush the patient, but if he gets frustrated, support and encourage him.
 Use the pen and paper on the table and you can score if you wish ( eg 1 +2 + 3 + 2 ).

ANOREXIA NERVOSA
You are the F2 in the psychiatric dept. 16/25yr old female referred by her GP on
account of weight loss. BMI of 17. Has no symptoms of depression. Take history and
discuss further management with her.
patient doesn't believe she has problems, losing weight intentionally and still believes
she is overweight.
ANOREXIA NERVOSA
Background

 People with anorexia nervosa have extreme weight loss as a result of very strict
dieting.
 In spite of this, they believe they are fat and are terrified of becoming what is, in
reality, a normal weight or shape. They do not accept that they are losing weight and
they do not believe they need any help.
 Distorted body image and abnormal attitudes to food and weight.
 Amenorrhoea and often other signs of starvation are present.
 Bulimia nervosa – They usually accept they have a problem and they recognise the
need for treatment.

Assessment
You must assess the following 6 steps for assessment of eating disorder in real life.
In the exam only first 3 steps.
Step 1: History of development of the disorder and patient’s ideas (Body Image distortion,
Compensatory mechanisms, Daily diet and exercise)
Step 2: SCOFF
Step 3 : Mental state examination for depression
Step 4 : Interview parents and other informants
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Step 5 : Assess family interaction in especially attitudes in relation to food

Step 6 : Physical examination ( Distribution for body hair, emaciation, vit. deficiency, Organic
cause).

History:
• Onset
• Triggers
• Daily Diet Pattern: What/How Much/When/Where/Alone/Progression
• Binge eating
• Self Induced Vomiting
• Feel fat/Fear of fatness
• Weight loss
• Food domination
• Amenorrhoea
• Medical or psychiatric problems
• Palpitations, fainting
• Role Models
• Baggy clothes
• 4Fs
• Mood
• Risk to themselves or others
Step 3: FAMISH History format
Step 4: Insight
( Pneumonic –
SCOFF
S – Do you make yourself Sick because you feel uncomfortably full?
C – Do you worry that you have lost Control over how much you eat?
O – Have you recently lost more than One stone in a three month period? ( one stone = 6.3 kilos
or 14 pounds) ( 1 kilo = 2.2 pounds)
F – Do you believe yourself to be Fat when others say you are too thin?
F – Would you say Food dominates your life ?
If the patient has 2 or more positive answers it indicates a likely case of Anorexia or Bulimia).

Miss Jessica Thompson, 20 years old girl was brought to the hospital by her parents. On
her recent visit to GP, GP noticed that Miss Jessica has lost some weight and he referred
her to the hospital for this reason. Her Parents are not with her now in the hospital. You are
the SHO in psychiatry department, Take history from Miss Thompson and discuss further
management.

Dr: Hello are you Miss Jessica Thomson ?
Miss: Thompson: Yes
Dr: I am Dr… one of the junior doctor in the psychiatry department. Can you please tell me
what brought you to the hospital?
Miss: Thompson: I am here because of my parents; they think that I have been losing
too much weight.
Dr: Can you please tell me, how much weight did you lose?
Miss: Thompson I have lost about 15 pounds ( more than one stone, 6.8 kg) in the last 3
months.
Dr: Have you been trying to lose weight?
Miss: Thompson: Yes
Dr: Could you please tell me, why are you losing weight?
Miss: Thompson: Dr, I want to be like my friend.
Dr: Can you please tell me, why do you want to be like your friend?
Miss: Thompson: She is slim and good looking. My friend has found boyfriend.
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Dr: Do you think that you are fat?

Miss: Thompson Yes doctor.
Dr What do you do ? Do you work or you are a student ?
Miss: Thompson: I am a university student.
Dr: Can we talk about your general life style?
Miss: Thompson of course, Doctor.
Dr: What is your diet like? / What do you eat in breakfast/ lunch/ dinner?
Miss: Thompson: In breakfast, I eat ----. In lunch, generally I do eat ---- I take ---- at
night.
Dr: Have you any time eating too much food and could not have any control on eating.
(Binge eating)
Dr: Do you do any exercise?
Miss: Thompson Yes, doctor. I enjoy running (doing exercise).
Dr: How often do you do exercise?
Miss: Thompson I do it every day for about 2 hours.
Dr: Do you take any medications to lose weight ?
Miss: Thompson No
Dr: Do you make yourself sick because you feel you are uncomfortably full ?
Miss: Thompson: No
Dr: Do you have any preference for clothes?
Miss: Thompson: Yes, Doctor, I like to wear baggy clothes.
Dr: Do you have any role models?
Miss: Thompson I am very big fan of -----
Dr: Can you please tell me, do you like looking yourself in the mirror repeatedly?
Miss: Thompson : No doctor.
Dr: Do you keep checking your weight frequently?
Miss: Thompson: Yes doctor.
Dr: How has been your mood? Can you please grade it, 1 being the saddest and 10 being
the happiest?
Miss: Thompson: It has not been good. (3/10)
Dr: Have you ever thought of harming yourself?
Miss: Thompson: No
Dr: do you think that you have been losing too much weight?
Miss: Thompson: No, dr. / I feel uncomfortable when I do not follow my daily routine
of diet and exercise.
Dr: How is your general health?
Miss: Thompson Dr, I feel weak nowadays, I want to sleep most of the time.
Dr: How you ever had any mental health problem before?
Miss: Thompson: No.
Dr: Are the family members supportive?
Miss: Thompson: Yes they are supportive.
Dr : Any problems with your colleagues in the university? ( Bullying ?)
Miss: Thompson: No
Dr How is your periods?
Miss: Thompson: I am waiting for my periods; it has not come for last 8 weeks. I am
worried about it.
Dr: Do you have any health symptoms like palpitation, Feeling faint or any other
symptoms?
Miss: Thompson No
Dr: Thank you very much for all the information.
Miss .. We have measured your height and weight. Your weight is far lesser than what it
should be for your height. I think you have lost too much weight. This is not good for you.
In medical terms we call this condition as Anorexia Nervosa.
Do you know anything about this at all? No
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Anorexia nervosa is a serious mental health condition. It's an eating disorder where a

person keeps their body weight as low as possible. If it continues like this it can lead
to lot of other conditions like depression and medical problems like Osteoporosis and
sometimes people with this condition may not be able to conceive children. Do you
follow me? Yes
We can help you to treat this condition.
Treatment
We can help you by combination of psychological therapy and supervised weight gain. We
have a team of specialists like Psychiatrists, Psychologists, dieticians and specialist nurses
here to help you
We as Psychiatrists can help you by Psychotherapy otherwise we call as Cognitive analytic
therapy and Cognitive behavioural therapy. We can involve your family members also if
do not mind to help the treatment.
Our dieticians can teach you what type of food you can eat to gain weight. We do not need
to admit you at this moment. We can do all these as an outpatient and see how things goes.
Is that OK? What do you think about this?
Information about treatment of Anorexia Nervosa

Psychological treatment
A number of different psychological treatments can be used to treat anorexia.
Depending on the severity of the condition, treatment will last for at least 6 to 12
months or more.
Cognitive analytic therapy (CAT)
Cognitive analytic therapy (CAT) is based on the theory that mental health conditions
such as anorexia are caused by unhealthy patterns of behaviour and thinking
developed in the past, usually during childhood.
CAT involves a three-stage process:
reformulation – looking at past events that may explain why the unhealthy
patterns developed
recognition – helping people see how these patterns are contributing
towards the anorexia
revision – identifying changes that can break these unhealthy patterns
Cognitive behavioural therapy (CBT)
Cognitive behavioural therapy (CBT) is based on the theory that how we think about
a situation affects how we act and, in turn, our actions can affect how we think and
feel.
In terms of anorexia, the therapist will attempt to show how the condition is often
associated with unhealthy and unrealistic thoughts and beliefs about food and diet.
The therapist will encourage the adoption of healthier, more realistic ways of thinking
that should lead to more positive behaviour.
Interpersonal therapy (IPT)
Interpersonal therapy (IPT) is based on the theory that relationships with other people
and the outside world in general have a powerful effect on mental health.
Anorexia may be associated with feelings of low self-esteem, anxiety and self-doubt
caused by problems interacting with people.
During IPT, the therapist will explore negative issues associated with your
interpersonal relationships and how these issues can be resolved.
Focal psychodynamic therapy (FPT)
Focal psychodynamic therapy (FPT) is based on the theory that mental health
conditions may be associated with unresolved conflicts that occurred in the past,
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usually during childhood.
The therapy encourages people with anorexia to think about how early childhood
experiences may have affected them. The aim is to find more successful ways of
coping with stressful situations and negative thoughts and emotions.
Family interventions
Anorexia doesn't just impact on one individual – it can have a big impact on the
whole family. Family intervention is an important part of treatment for young people
with anorexia.
Family intervention should focus on the eating disorder, and involves the family
discussing how anorexia has affected them. It can also help the family understand the
condition and how they can help.
Gaining weight safely
The care plan will include advice about how to increase the amount eaten so weight is
gained safely.
Physical health – as well as weight – is monitored closely. The height of children and
young people will also be regularly checked to make sure they're developing as
expected.
To begin with, the person will be given small amounts of food to eat, with the amount
gradually increasing as their body gets used to dealing with normal amounts.
The eventual aim is to have a regular eating pattern, with three meals a day, possibly
with vitamin and mineral supplements.
An outpatient target is an average gain of 0.5kg (1.1lbs) a week. In a specialist unit,
the aim will usually be to gain an average of around 0.5-1kg (1.1-2.2lbs) a week.
Compulsory treatment
Occasionally, someone with anorexia may refuse treatment even though they're
severely ill and their life is at risk.
In these cases, as a last resort doctors may decide to admit the person to hospital for
compulsory treatment under the Mental Health Act. This is sometimes known as
sectioning or being sectioned.
Treating additional problems
As well as the main treatments mentioned above, other health problems caused by
anorexia will also need to be treated.
If you make yourself vomit regularly, you'll be given dental hygiene advice to help
prevent stomach acid damaging the enamel on your teeth.
For example, you may be advised not to brush your teeth soon after vomiting to avoid
further abrasion to tooth enamel, and to rinse out your mouth with water instead.
Avoiding acidic foods and mouth washes may be recommended. You'll also be
advised to visit a dentist regularly so they can check for any problems.
If you've been taking laxatives or diuretics in an attempt to lose weight, you'll be
advised to reduce them gradually so your body can adjust. Stopping them suddenly
can cause problems such as nausea and constipation.
Medication
Medication alone isn't usually effective in treating anorexia. It's often only used in
combination with the measures mentioned above to treat associated psychological
problems, such as obsessive compulsive disorder (OCD) or depression.
Two of the main types of medication used to treat people with anorexia are:
selective serotonin reuptake inhibitors (SSRIs) – a type of antidepressant
medication that can help people with co-existing psychological problems such as
depression and anxiety
olanzapine – a medication that can help reduce feelings of anxiety related to
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issues such as weight and diet in people who haven't responded to other treatments
SSRIs tend to be avoided until a person with anorexia has started to gain weight
because the risk of more serious side effects is increased in people who are severely
underweight. The drugs are only used cautiously in young people under the age of 18.

SSRI Counselling ( Fluoxetine) ( Antidepressant)
Key Points
 In this station, you must emphasise the importance of staying on the medications to
achieve the best beneficial effect.
Scenario - 13
Mr Jeremy Williams 30 years old man has been referred to you from GP. This man was
prescribed paroxetine. Talk to the patient and address patient’s concern.
Dr. Hello Mr Williams I am Dr… One of the junior doctor in the Psychiatry department.
How are you doing today?
Pt: The medicine what you gave me is useless doctor.
Dr: Why do you say that?
Pt: They are not at all helping me.
Dr: Which medication are you talking about ?
Pt: I was prescribed this medication 10 days ago because I was feeling very low.
Dr: Do you take it regularly?
Pt: Yes.
Dr: Are you still taking the medication or have you stopped taking them.
Pt: I am still taking them.
Dr: Mr Williams, unfortunately you may not see the effect of this medication within 10
days. It takes 4-6 weeks to build up its best effects so please continue your medication
regularly. Please do not stop taking this medication on your own. You will see the effect in
the next few weeks.
Dr: Do you have any other concerns about this medication ?
Pt : I heard that it can cause problems with sex life. Is that true ?
Dr: It is true. It can very rarely cause sexual dysfunction like low sex drive or erectile
problems. However we will keep monitoring the medication. Any other concerns ?
Pt: Do they have any other side effects ?

Dr: Yes, Common ones are headache, vomiting, diarrhoea or constipation and sometimes
stomach ache.It can either make you very sleepy or you may not get good sleep at all. This
medication might cause poor sleep. So please don’t take it in night, take it early morning.
Pt: Doctor is it addictive?

Dr: It is not addictive. We will not stop this medication suddenly. We will gradually
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decrease the dose of medication. So you will not experience any side effect.
Dr: Do you have the feeling of harming yourself or ending your life ?
Pt: No ( is he says yes – admit him)
Dr: If at all you get these feelings any time later please do come back to us. We will keep
following you up.
THE MENTAL STATUS EXAMINATION

 It is a structured way of observing and describing a patient's current state of mind, under
the domains of appearance, behaviour, speech, cognition, mood, thoughts, perception
and insight.
( Pneumonic: ABS – MC – SHIT )

I. Appearance (observed)
II. Behaviour (observed)
III. Speech and Language (observed)
IV. Mood (inquired)

V. Cognition (Orientation) (inquired)
VI. Suicidality and Homicidality (inquired)

VII. Hallucination
VIII. Insight and Judgment (observed/inquired)
IX. Thought Process/Form (observed/inquired),
Thought Content (observed/inquired)
Components of the Mental Status Examination

I. Appearance (Observed) - Possible descriptors:
• Gait, posture, clothes, grooming.
 Apparent age
 Ethnicity
 Cleanliness & personal hygiene. Is there any evidence of self-neglect?
 Attire (is it appropriate for weather, surroundings etc... May be important sign in a
manic patient)
 Any abnormal involuntary movements e.g. tics, grimaces, tremors, stereotypies etc
II. Behaviour (Observed) -

 Appropriateness of behaviour
 Level of eye contact
 Rapport
 Is patient easily distracted? (distractibility)
 Restlessness, anxiety
 Socially inappropriate e.g. embarrassing, over-familiar and sexually forward behaviour
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(may be seen in manic patients)

 Aggression, violence etc.....
III.Speech and Language (Observed)
A. Quantity - Possible descriptors:

• Talkative, spontaneous, expansive, paucity, poverty.
B. Rate - Possible descriptors:
• Fast, slow, normal, pressured.
C. Volume (Tone) - Possible descriptors:
• Loud, soft, monotone, weak, strong.
D. Fluency and Rhythm - Possible descriptors:
• Slurred, clear, with appropriately placed inflections, hesitant, with good articulation, aphasic.
 'Flight of ideas' does patient move quickly between subjects
 New or made up words (neologisms) or any other abnormal use of language?
 Logicality
 Is speech appropriate for the situation e.g. does patient answer questions appropriately,
is the content of speech appropriate to the situation?
IV. Mood (Inquired): A sustained state of inner feeling – Possible questions for patient:
• “How are your spirits?”
• “How are you feeling?”
• “Have you been discouraged/depressed/low/blue lately?”
• “Have you been energized/elated/high/out of control lately?”
• “Have you been angry/irritable/edgy lately?”
 Ask about depressed mood e.g. concentration, appetite, feelings of guilt, worry, sleeping
patterns, sexual relationships
 Ask about self-harm e.g feelings about the future, 'have you ever thought that life was
not worth living?', thoughts of ending life, any preparations, any previous attempts at
self-harm/suicide?
How is your mood now? Can you please grade your mood in 1 to 10 scale where 1 being
low and 10 being very happiest mood?
V. Cognition (Orientation) (Inquired) – Possible questions for patient:

• “What is your full name?”
• “Where are we at (floor, building, city, county, and state)?”
• “What is the full date today (date, month, year, day of the week, and season of the year)?”
• “How would you describe the situation we are in?”
VI. Suicidality and Homicidality

A. Suicidality – Possible questions for patient:
• “Do you ever feel that life isn’t worth living? Or that you would just as soon be dead?”
• “Have you ever thought of doing away with yourself? If so, how?”
• “What would happen after you were dead?”
Suicide Risk Assessment
If the station/task also states “perform a suicide risk assessment”, then you must also ask
the following 11 questions
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Pneumonic : FAMISH ( 4 Fs – Family, Finance, Friends and Forensics, Alcohol,

Medications and illness, Insight, Suicidal thoughts, Hallucinations), ( Life - at present,
past and future)
 How do you feel about life at the moment?
 How do you feel about the future?
 Have you felt life is not worth living?
 Do you ever wish it would end?
 Have you thought about ending it?
 Have you thought how you would do this?
 Have you ever attempted to end your life before?
 How is your current social support, do you have many good friends?
 How are things with your family?
 Are you currently in financial trouble, are you working?
 Are you in trouble with the law?
B. Homicidality – Possible questions for patient:

• “Do you think about hurting others or getting even with people who have wronged you?”
• “Have you had desires to hurt others? If so, how?”
VII. Hallucination
Assess the patient’s perception by asking appropriate questions. This may include questions
regarding,
 'I'd like to ask you a couple of questions about sometimes people have but may find
difficult to talk about. I ask everyone these questions?
 Then use questions such as ‘ Have you ever heard voices speaking when there seems to
be no-one around?”
 “Do you ever feel that people are discussing you negatively?” (If so, get context!)
 “Do you fear that people may be ‘out to get you’?”
 “Have you ever felt that something or someone is able to put thoughts into your head?”
(thought insertion)
 “Have you ever felt that something or someone can remove thoughts from your brain?”
(thought withdrawal)
 “Do you ever see (visual), hear (auditory), smell (olfactory), taste (gustatory), and feel
(tactile) things that are not really there, such as voices or visions?” (Hallucinations are
false perceptions)
• “Do you sometimes misinterpret real things that are around you, such as muffled
noises or shadows?” (Illusions are misinterpreted perceptions)
VIII. Insight and Judgment (Inquired/Observed) – Possible questions for patient:

• “What brings you here today?”
• “What seems to be the problem?”
• “What do you think is causing your problems?”
• “How do you understand your problems?”
• “How would you describe your role in this situation?”
• “Do you think that these thoughts, moods, perceptions, are abnormal?”
• “How do you plan to get help for this problem?”
• “What will you do when _____________ occurs?”
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• “How will you manage if ____________ happens?”

• “If you found a stamped, addressed envelope on the street, what would you do with it?”
• “If you were in a movie theatre and smelled smoke, what would you do?”
IX. Thought Processes or Thought Form (Inquired/Observed):

logic, relevance, organization, flow and coherence of thought in response to general questioning
during the interview. - Possible descriptors:
• Linear, goal-directed, circumstantial, tangential, loose associations, incoherent, evasive,
racing, blocking, perseveration, neologisms.
X. Thought Content (Inquired/Observed) – Possible questions for patient:
• “What do you think about when you are sad/angry?”
• “What’s been on your mind lately?”
• “Do you find yourself ruminating about things?”
• “Are there thoughts or images that you have a really difficult time getting out of your head?”
• “Are you worried/scared/frightened about something or other?”
• “Do you have personal beliefs that are not shared by others?” (Delusions are fixed, false,
unshared beliefs.)
• “Do you ever feel detached/removed/changed/different from others around you?”
• “Do things seem unnatural/unreal to you?”
• “What do you think about the reports in papers such as Daily mirror?”
• “Do you think someone or some group intend to harm you in some way?”
• [In response to something the patient says] “What do you think they meant by that?”
• “Does it ever seem like people are stealing your thoughts, or perhaps inserting thoughts into
your head?
Does it ever seem like your own thoughts are broadcast out loud?”

BULLYING AT WORK (LESBIAN)
Question: You are an FY2 in theGP Surgery. Nicky Powell is a 20 years-
old lady who has made an appointment to come and see you. Talk to the
patient and address her concerns.
Hello. Nicky Powell. Hi, my name is Dr. ……… I am one of the junior doctors here in the
GP Surgery.
What would you like me to call you today? – Nicky

How can we help you today Nicky? – Doctor, I moved to a new job recently, and…
Ok. Can you tell me a little bit more? –I started work 6-months ago with a new company.
Some of the people there have been saying things about me…
What sort of things do they say? – Just some mean stuff every now and again about my
sexual orientation. I mean just because I’m a lesbian doesn’t give them the right to say
nasty shit about me
I’m so sorry to hear that. So just that we’re on the same page here, can I ask you a few
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more questions? Is that alright? – Yes
Who has been speaking about you? Are they your co-workers? – Just my colleagues
Since when has this been happening? – For about a month now
And has their attitude improved or worsened? – Last 1 week it’s been getting worse
Is there anything you think that might cause them to behave in this way? – Maybe because
I’m gay and they have a problem with that
How many of them are there? – A couple
Men/Women? – 2 guys
Are they your seniors, junior colleagues or same level staff? – Same level staff
Do they say stuff behind your back or in front of you? – Behind my back
Are they aware you know? – I don’t think so
How exactly do they behave? – Really rude
Do they insult you? – I do feel insulted at times
Can you tell me a little bit more about your job? – I’m a part-time receptionist
Is your job stressful? – It can be at times
Have you ever missed work because of what your colleagues say? – Yes
Have you spoken to anyone about this at work? Manager? Family? Partner? – No
Do you think you have the resources available to you, to get the help you need at your
workplace? – I don’t know
Have you tried speaking to those individuals who speak about you? – No
Do you think you can speak directly to them? – No
Is this the first time you’ve experienced a situation like this at this workplace? – Yes
Have you ever faced this problem elsewhere? – No
Is there anything else you’d like to add? – Yes doctor. I’ve never talked about this to
anyone before, not even my partner Laura. I don’t want her to know, as she’ll get upset.
Can we keep it between us? I’ve also started getting palpitations and anxiety before I head
for work, and I’ve started drinking a lot to calm myself.
Will everything remain between us?
I do want you to know that whatever we discuss here today will remain strictly
Confidential between you and the medical team. – Thanks. I don’t wantLaura to know
How long have you been having palpitations? – Past week

And how did it come about? Sudden/Gradual? – Gradually started
Has it been getting better or worse? – Worse
Is it aggravated by anything you do? Activity? – I guess it precedes going to work
And did it improve with anything? Resting? Medication? – With alcohol, and after work
Rule out common Palpitation causes;

Anxiety/Panic Attacks;Anaemia, Hyperthyroidism, Arrhythmias, Stimulants
(Alcohol/Tea/Coffee), Drug Abuse
Do you have any other symptoms other than the palpitations? – No
Ok. Thank you for answering my questions. Just a few more regarding your health in
general.
Have you ever been diagnosed with any medical condition before? – No
High blood sugar? High blood pressure?– No
Are you currently taking any prescribed medication? OTC?– No
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Any illnesses that run in your family? Mental health illnesses? – No

How have you been coping at home? Hobbies? Family? Sleep? Relationships? – It’s been
difficult at home with my partner as I haven’t been open about my work environment. I’ve
lost interest in cycling. My sleep has been disturbed
Diet? Exercise? Stress? – All ok, except for I’m really stressed
Do you drink alcohol? – Yes, I drink before I go to work to calm myself down. 2 bottles of
wine a day
Do you use recreational drugs – No
Any problems with your menstrual cycles? – None
Are you sexually active? – Yes
Who else is at home? – Me and Laura
 Hopeless/Worthless? – No
 Disinterested/Little pleasure in life? – No
the best? - 3
Have you thought about self-harm? Suicide? – No,Never
Thank you for answering all my questions.
I’m sorry to hear what’s been happening to you at your workplace. What seems to be
happening is Bullying or Harassment, which is completely unacceptable. There are in
fact laws that prevent such discrimination from happening in a working environment. You
have been really brave and done really well by coming to see us today, and there are a few
things we can do to help.
Bullying can involve arguments and rudeness, but it can also be more subtle such as saying
nasty things in private.
Other forms of bullying include:
 excluding and ignoring people and their contribution

 overloading people with work
 spreading malicious rumours
 unfair treatment
 picking on or regularly undermining someone
 denying someone's training or promotion opportunities
Are you following? - Yes

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Bullying can make working life miserable. You can lose all faith in yourself, you can feel
ill and depressed, find it hard to motivate yourself to work and experience physical
symptoms such as headaches and palpitations.
Bullying is not always a case of someone picking on the weak. Sometimes a person's
strengths in the workplace can make the bully feel threatened, and that triggers their
behaviour.
It’s important not to be ashamed to tell people what’s going on. Bullying is serious, and
you need to let people know what’s happening so they can help you. By sharing your
experiences, you may discover that other people may have been similarly affected.
EXAMINATION
Ideally, I would like to
 Take observations
 Examine your thyroid
 Examine your heart
MANAGEMENT
What can I do about my colleagues?
 Counselling. Get advice! Speak to someone about how you might deal with the
problem informally. This person could be:
 an employee representative, such as a trade union official

 someone in the firm's human resources department
 your manager or supervisor
 a family member or partner, if you feel comfortable
The bullying may not be deliberate. If you can, Talk to the person/people in question as
they may not realise how their behaviour has affected you. Work out what to say
beforehand. Describe what's been happening and why you object to it. Recognise that any
criticism or personal remarks are not connected to your abilities. They reflect the bully's
own weaknesses, and are meant to intimidate and control you. Stay Calm, and do not be
tempted to explain your behaviour. Ask them to explain theirs. If you do not want to talk to
them yourself, ask someone else to do it for you.
Do you think talking directly to your colleagues would be of any benefit? – Possibly
Do you think informing your Manager/Supervisor is something we can consider? –

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Yes, I could speak to my boss
Legally, it is the duty of the manager to take action and prevent such incidents from
happening at work.Employers are responsible for preventing bullying and harassment -
they’re liable for any harassment suffered by their employees.
Some employers have specially trained staff to help with bullying and harassment
problems. They're sometimes called "harassment advisers".
 Keep a Diary as a contemporaneous record. It will be very useful if you decide to take
action at a later stage. Try to talk calmly to the person who's bullying you and tell them
that you find their behaviour unacceptable. Often, bullies retreat from people who stand
up to them. If necessary, have a colleague with you when you do this.
 Making a Formal Complaint is the next step if you cannot solve the problem
informally. To do this, you must follow your employer's grievance procedure. If this
does not work and you’re still being harassed, you can take legal action at
an employment tribunal. They could also call the ACAS (Advisory, Conciliation and
Arbitration Service) helpline for advice.
 If the bullying is affecting your health, visit your GP. You did the right thing today by
coming to the surgery. After taking a closer look at you, I don’t think there is any
problem with your thyroid or your heart, which are the commonest organic causes of
palpitations. I do believe that the palpitations are happening as a combination of your
excess alcohol intake and anxiety of going to work. To manage this, we would have to
sort out the underlying cause. By ensuring you have a safe working environment and
reducing your alcohol intake, I believe that your symptoms will improve.
 Reduce Alcohol Consumption. Various methods to help: counselling/support
groups/medications/leaflets etc. Is reducing your alcohol intake something you would
be interested in? – Maybe
 Stress Reduction can be done in various ways. (DATES)
 Sleep Hygiene
Is there any law that prevents discrimination at work?
Bullying and harassment is behaviour that makes someone feel intimidated or offended.
Harassment is unlawful under the Equality Act 2010. Bullying itself is not against the
law, but harassment is. This is when the unwanted behaviour is related to one of the
following:
 age
 sex
 disability
 gender reassignment
 marriage and civil partnership

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 pregnancy and maternity
 race
 religion or belief
 sexual orientation
Are there any support groups available?
Support Groups are available. For example the LGBT Foundation and Broken
Rainbow. I can get some more information about them and pass them over to you.
Can you prescribe me some medication?
Unfortunately, I don’t think I will be able to prescribe you any medication as it won’t fix
the root cause of your problem, which is the bullying you are experiencing at work. I am
confident that if we can resolve that, your physical symptoms will improve too.
Red Flags: Ifyour symptoms worsen, do not hesitate in coming back to the GP surgery.
We will be making a Follow-Up appointment in 1 week.
Meanwhile if the abuse you receive doesn’t stop and you experience any thoughts of self-
harm, I do have a Crisis Card to offer to you, where you can anonymously contact a
trained professional who can help you.
I also have some Reading Materials about Harassment at Work.
Is that alright? - Yes
Thankyou.
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Non accidental injury (sexual harassment)
200.
You are FY2 in GP clinic.Razia,20 year old girl came because of scalded burn on
her tummy. Nurse have seen the patient and have done the dressing. Talk to her
and address her concerns.
History
(In this station, patient will be anxious and worried, she won’t open up easily as well so
keep convincing and supporting her, acknowledge nonverbal cues)
Dr:Hello,how can I help you? Pt:I am burnt
Dr:I am sorry to hear about that, nurse have done the your burn dressing. How are you
feeling now?
Pt:Ok
Dr:How did you get the burn? Pt:Kettle dropped on me Dr:How?
Pt:It was an accident
Dr:Is it the first time it happened? Pt:Yes
Dr:I can see that something is bothering you. Do you want to share something(Offer
confidentiality)?
Pt:No
Dr:Where are you living? Pt:In a house with 2 girls Dr:How are those girls?
Pt:Fine
Dr:With whom you came to the hospital? Pt:A man, I don’t want to go back with him
Dr:May I know why?
Pt:I don’t know(She won’t easily open up) Dr:Do you have any health problems?
Pt:No
Dr:What do you do for living? Pt:Nothing
Dr:Is there anything you want to share with me? We are here to help you
Pt:I don’t want go with that man, he abuses me and my friends
Dr:I am so sorry to hear about that, how he abuses you and your friends?
Pt:He brings man daily to house
Dr:Then what do they do? Do they hurt you?
Dr:Have you ever tried to take help before or to escape?
Pt:No
Dr:Do you know the address of the place where you live?
Pt:I don’t know
(Dig in the story, from how long they are getting abused, where are their parents,family,ask
address of their accommodation to help other girls as well)
Management:
I. Involve social services and police to help her
II. Tell her about the National domestic helpline number
III. Offer support by Women’s aid group
IV. Refer to sexual assault centers (SARCs)
Reference information:Sexual abuse

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Sexual abuse can happen to anyone.

• touch you in a way you do not want to be
touched?
• make unwanted sexual demands?
• hurt you during sex?
• pressure you to have unsafe sex – for example, not using a condom?
• pressure you to have sex?
If your partner has sex with you when you do not want to, this is rape.
Have you ever felt afraid of your partner?
Have you ever changed your behaviour because you're afraid of what your partner might
do?
If you think you may be in an abusive relationship, there are lots of people who can help
you.
Supporting a victim of sexual assault

For relatives and friends of someone who has been sexually assaulted, The advice includes:
• Don't judge them, don't blame them. A sexual assault is never the fault of the
person who is abused.
• Listen to the person, but don't ask for details of the assault. Don't ask them why
they didn't stop it. This can make them feel as though you blame them.
• Offer practical support, such as going with them to appointments.
• Respect their decisions – for example, whether or not they want to report the assault
to the police.
• Bear in mind they might not want to be touched. Even a hug might upset them, so
ask first. If you're in a sexual relationship with them, be aware that sex might be
frightening, and don't put pressure on them to have sex.
• Don't tell them to forget about the assault. It will take time for them to deal with
their feelings and emotions. You can help by listening.

Teenager confused about sexual orientation
Tom Cooper is a 15 year-old boy who has made an appointment to come and see you.
Talk to the patient and address his concerns.
Hello. My name is Dr. ……… I am one of the junior doctors here in the GP Surgery.
Could you please confirm your full name and your age for me?
Yes, I am Tom Cooper and I am 15 years old.
It’s nice to meet you Tom. How can we help you today?
Doctor, I had something to say but can you promise me first that you are not going to tell
my parents about this.
Of course, Tom, even though you are 15 you have the same right to confidentiality as any
adult. Confidentiality means what whatever you discuss here stays between you and our
medical team. We cannot disclose any information without your permission- not even to
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your parents. But of course, we are also going to make sure that there is no risk to your
safety, okay?
Okay.
So, what did you want to talk about today, Tom?
Doctor, it’s kind of embarrassing…
Well, Tom, I know there are certain topics that might be difficult to discuss with other
people but you have come to the right place. Please take your time and be assured that we
are not going to judge you. We are only here to help you and the more information you can
give us about what is concerning you, the better we can help you.
Well, there is boy in my class at school who is gay and everyone bullies him for it.
I see. Please go on, Tom.
Well, I think that might have feelings for him.
It’s natural to start having feelings of attraction to other people at your age, Tom. Has
something been bothering you?
Doctor, I think I might be gay.
When did you first realize this?
A couple of months ago.
What has been going through your mind since then?
I am confused and worried about being treated differently if I tell someone.
I see, that must have been tough. Have you discussed your feelings with anyone?
No, nobody.
Have you talked about this to the boy you like, Tom?
No.
Do you have some friends you can trust, Tom?
I have friends but they won’t understand and I might lose them.
And have you considered talking to a family member?
They are very traditional. They won’t accept it.
Whom do you live with?
My parents and my older sister.
Have you thought about opening up to your sister?

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No. She is traditional like my parents.
How is everything at home apart from this?
It’s fine.
I see, Tom that you are going through a challenging time. Let me just say how glad I am
that you decided to come in and open up to us. Don’t ever feel that you are alone in this.
We are going to help you in every way possible, okay?
Okay, thank you.
Tom, when someone goes though a tough time it can sometimes affect his or her mood.
How has your mood been lately Tom?
My mood is fine.
How is school going?
School is great. I have friends. I do well in studies and sports.
That’s good to hear, Tom. Have you ever been bullied at school?
No, I am pretty popular but I am afraid I might be bullied if tell someone I like another
boy.
I see, Tom.
Are you feeling more anxious or worried than usual?
No, not really.
Have you ever been diagnosed with any medical conditions or any mental health
conditions?
No.
Do you take any medications currently?
No.
Can I ask if you smoke?
No.
Do you drink alcohol?
No.
Have you ever used any recreational drugs?
No.
Tom, have you had a relationship before?

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Only one. I had a girlfriend for a couple of months last year.
I see. May I ask if you have been sexually active?
No, never.
Have you felt attracted towards the opposite gender as well?
I don’t know. I feel confused.
It’s okay to question your sexual orientation, Tom. There's no one fixed way to work out
exactly what your feelings are. All you have to do is be patient and pay attention to your
feelings. Eventually these will show you exactly where you stand. There is no rush. No
hurry at all.
It takes time for us to fully understand who we are and what gender we are attracted to.
Sometimes sexuality is not as simple as being straight or gay but more of a continuum with
straight at one end and gay at the other. People can move along, stay in one place or change
their position as they try to define their own sexuality.
You shouldn’t feel under any pressure to attach a label to your feeling. The important thing
is to allow yourself time and space to explore how you feel. Does that make sense?
Yes.
Have you had classes on sex education and sexuality at school?
I don’t think so.
Is there a counselor at school that you can talk to about this?
No.
Does your school have any LGBTQ support groups or Gay-Straight alliance groups?
No.
You mentioned that your classmate is bullied for being gay. That is called homophobic
bullying. Schools have a legal duty to ensure homophobic bullying is dealt with. Have the
school authorities been made aware that such bullying is taking place?
I don’t know.
It's a sad fact that people get bullied or discriminated against because of their sexual
identity. But that is never okay. Be informed about your right to equality, the law offers
protection in this regard.
Schools have a legal responsibility to make sure you aren’t being bullied and so if you do
experience it make sure you tell a member of the staff.
Maybe you can reach out to your classmate who has been bullied and talk to him about
what you can do to stop it. If you think he is having a tough time, let him know he can talk
to a doctor for help. What do you think?
I can try.
If someone is a victim of homophobic bullying or discrimination, they can report it through

Educational Action Challenging Homophobia's website or helpline number.
Stonewall is the pioneering international organization campaigning for LGBT rights and to
educate in schools and workplaces to eliminate discrimination and homophobia
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I am going to print out some information for regarding these support groups as well as
local LGBT support groups for you, okay?
Okay.
A lot of times, discrimination comes from a of lack access to information. Maybe these
support groups can look into organizing some seminars at your school educating the
students and staff about sexual identities. What do you think about that?
That’s good, I guess.
It’s always good to speak to people who are going through to the same thing or to people
you can trust. You can find people like that through these groups. But we can also arrange
a counselor for you so that you can talk through your feelings and get some clarity. Would
you like that?
Yes, please.
Okay. We will definitely arrange some counseling sessions for you. Tom, you mentioned
that your parents might react unfavorably to this. Would you like us arrange some family
sessions where you can explain gently to your parents what you have been going through
with the help of a counselor?
No, I don’t want them to know.
That’s fine, Tom. Coming out is different for everyone and you’ll know when it’s the right
time for you.If you're not sure how you feel about your sexuality, there's no hurry to make
your mind up or tell people. There’s no right or wrong way or time to tell your family
It’s a good idea to take time to think about what you want to say. Parents might be
shocked, worried or find it difficult to accept at first. Remember, their first reaction isn’t
necessarily, how they’ll feel forever. They might just need a bit of time to process what
you’ve told them. Okay?
Okay.
As for your friends, if and when you choose to tell them is completely up to you. Your
friends may be surprised, have lots of questions or not know what to say. At first choose a
fiend whom you can trust and whom you think might be supportive. If they react badly,
remember that they just might need some time to absorb. If they don’t change their mind
remember it’s not you who is at fault and that you will always find people who support
you. Right?
Yeah.
And if you decide to talk to the boy whom you like, respect his feelings and offer your
support.
Don’t feel pressured to start a romantic or sexual relationship with anyone. Everything will
fall into place with time.
But when you do decide to be sexually active, always use a condom. Remember that you
have access to confidential sexual health advice at our clinics. Okay?
Okay.
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Is there anything else you wanted to talk about today?
No.
Do you have any questions?
I can’t think of any.
How are you feeling now, Tom? Do you think this talk had helped a little?
Yes, thank you.
Okay, Tom. Remember you are not alone in this. It gets better. You deserve respect and
acceptance. Reach out to us whenever you need, we are here for you.
If you feel really low or worried, if you have thoughts about hurting yourself I do have a
Crisis Card to offer to you, where you can anonymously contact a trained professional who
can help you Would you like that?
Okay.
Thank you again Tom for coming in today. I will get your reading material ready and talk
to my senior and arrange a counselor for you. Is that all right?
Thank you.

LESBIAN - WANTS TO HAVE A CHILD
Question: You are an FY2 in GP Surgery. Lena Heaphy is a 36 years-old
lady who has presented with some concerns. Talk to the patient and address
her concerns.
Hello. Lena Heaphy? Hi, my name is Dr. ……… I am one of the junior doctors here in the
GP Surgery.
What would you like me to call you? – Lena is fine

And can you confirm for me your age please? – Yes, it’s 36
How can we help you today Lena? – Doctor, I need some advice about having children
and starting a family
Ok, I am sure we can help you with that.
Can you tell me a little bit more about the problem it is that you’re having? – Yes, I’ve
been in a relationship now for 7 years with my wife Jessie. She and I, we think we’re ready
to have children
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Ok, that sounds fantastic.

Is there anything in particular that you’re worried about? – Well, yes. I’m unsure how all
this is going to pan out. I mean I’m 36 years old and I’m just worried that I’m too old to
have children and there might be a problem with my child if I give birth. I’m also quite
apprehensive about how the process is all going to happen
I understand it can be a little scary. What I would like to do is ask you a few questions
about your health. This may include a few personal questions about you and your partner
Jessie too. I’d also like to gauge your understanding and see how much you already know
about the options available to you, and hopefully put forward some solutions for you to
think over. How does that sound? – Great
Are you currently experiencing any symptoms? – No. Like what doctor?
GUT Symptoms; fever? lower abdominal pain? pain on passing wee? blood in your wee?
discharge from your front passage? heavy/pain menstrual bleeding? pain having sex? – No
Anything I might have missed that you would like to add? – I’m completely fine, I don’t
have any troubles with my health
Have you been diagnosed with any prior medical conditions? DM? HTN?– No
Have you ever needed to visit the hospital for any reason? – No
Have you undergone any surgical procedure before? – No
Are you taking any prescription medication at all? OTC? – No
Are you allergic to anything at all? – No
Are there any medical conditions that run in the family? DM? HTN? Stroke? CA? – No
What do you do for a living? – Housewife
Do you drink alcohol? Units? – Occasionally. I don’t know
Do you smoke? How much? Since? – No
Do you use recreational drugs? – No
Who else is at home? – It’s just me and my wife Jessie
A few questions about your menstrual cycle (10)

 LMP? – 2 weeks ago
 Clots? – No
 Regularity? – Regular
 Excessive pain? – No
 Cycle duration? – 28 days
 Contraception? – None
 Days you bleed? – 5 days
 Excessive bleeding? – No  Cervical smear? – Yes, 1 year ago
 Results of last cervical smear? – Normal
A few questions about your sexual history (10)
 Sexually active? – Yes  Kind of sex? (O/V/A) – All
 1 partner or more? – 1, my wife  Safe sex? – Yes
 Stable relationship? – Yes  Casual? – No
 Male/Female? – Female  Abroad? – No
 Last time? – Yesterday  STI? – No
Just a few questions about your relationship with your partner Jessie.
How old is Jessie? – She’s 27

What does she do? – She is a banker
In your relationship with Jessie, would you classify yourself as the masculine or feminine
one in the relationship? – Definitely the feminine
Does this mean only you would be the one who could get pregnant? – Yes. She has a hectic
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job and she’s terrified of childbirth. I would be the one to give birth
Have you ever been pregnant before? – No doctor

Have you ever tried to get pregnant before? – No. I’venever been in a relationship with
a man before
Are you aware of any options that are available to you to start a family? – Not really
Are you aware of any problems that may occur in advanced maternal age? – No
Is there anything else that you would like to add? – No
So just to summarize, you don’t seem to be experiencing any symptoms. You have had a
stable female partner – your wife of 7 years, Jessie – and now you’re looking to start a
family, but you’re just worried about being pregnant at this age and want to know about the
options that are available to you on how to get pregnant. Is that correct? – Yes
Many factors can affect a couple's chances of conceiving, such as:
 your age
 sexual orientation
 your general health

 your reproductive health
 how often you have sex
The number of LGBT people becoming parents, or thinking about becoming parents,
is increasing.If you're thinking about having children, here's an overview of the various
routes to parenthood available to you.
I would like to discuss 2 principle routes with you.
(I) The first method would involve conceiving a child by doing it yourself at
home.
(II) The second method may involve a fertility clinic.
◦ (I)AT HOME
(a) Sex with a Man
Although it may seem obvious, one way of getting pregnant and starting a family is by
having an unprotected sexual relationship with a man to get pregnant. It is up to you to find
someone whom you feel comfortable with. It may be a friend, colleague or stranger.
Because you’ve never had a relationship with a male before, this may prove difficult.
(b) Donor Insemination at Home
This is where a man donates sperm so a woman can inseminate herself. Donor
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insemination can be performed at home using sperm from a friend or an anonymous donor.
If you decide to look for donor insemination, it's generally better to go to a licensed clinic
where the sperm is screened to ensure it's free from sexually transmitted infections and
certain genetic disorders. Fertility clinics also have support and legal advice on hand.
Thanks to recent changes in the law, lesbian couples who are civil partners at the time of
conception and conceive a child through donor insemination – either at a licensed clinic
or by private arrangement at home – will now both automatically be treated as their child's
legal parents. So too will couples who aren't civil partners at the time of conception but
who conceive through donor insemination at a licensed clinic. But when non-civil partners
conceive through donor insemination by private arrangement at home, the non-birth
mother has no legal parenthood and will have to adopt the child to obtain parental rights.
(c) Co-Parenting
This is when 2 or more people team up to conceive and parent children together. Co-
parenting arrangements can be made between 2 single people, a single person and a couple,
or 2 couples.As a co-parent, you won't have sole custody of the child. It's advisable to get
legal advice at an early stage of your planning. There are many details to be worked out,
such as what role each parent will take, how financial costs will be split, and the degree of
involvement each will have with the child. More information about co-parenting can be
found on the LGBT Foundation website.
(d) Adoption or Fostering for LGBT couples
LGBT couples in the UK can adopt or foster a child together. You can apply to adopt or
foster through a local authority or an adoption or foster agency. You don't have to live in
the local authority you apply to. You will have to complete an assessment to become an
adoptive or foster parent, with the help of a social worker and preparation training. For
more information you can visit New Family Social, the charity for LGBT adoptive and
foster parents. If you feel you are ready to adopt you can find an adoption agency near
you using the first4adoption agency finder.
(e) Trans and Non-Binary parents
When it comes to adoption and fostering, trans people have the same rights as any other
prospective parent. If you're considering starting treatment to physically alter your body or
you've already started treatment, find out about the options for preserving your fertility
from the Human Fertilization & Embryology Authority.
(II) Fertility Clinic
(a) Donor Insemination at a Fertility Clinic [Intra-Uterine Insemination (IUI)]
Intrauterine insemination (IUI) is a fertility treatment that involves directly inserting sperm

into a woman's womb.
You may be offered IUI if:
 you're unable to have vaginal sex – for example, because of a physical disability or

psychosexual problem
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 you have a condition that means you need specific help to conceive. For example, if
1 of you has HIV and it's not safe to have unprotected sex
 you're in a same-sex relationship and have not become pregnant after up to 6 cycles
of IUI using donor sperm from a licensed fertility unit (the Stonewall website has
more information about IUI for same-sex couples)
Bear in mind that the waiting list for IUI treatment on the NHS can be very long in some
areas. The criteria you must meet to be eligible for IUI can also vary.
IUI is also available from some private fertility clinics. The Human Fertilisation and
Embryology Authority (HFEA) has a fertility clinic finder.Costs range from about £700 to
£1,600 for each cycle of IUI treatment.The HFEA website has more information on costs
and funding for fertility treatments.
Before IUI is done, you and your sperm donor will need to be assessed to see whether IUI
is suitable for you.For a woman to have IUI, her fallopian tubes (the tubes connecting the
ovaries to the womb) must be open and healthy.
You and your partner will not usually be offered IUI if you have:
 unexplained infertility
 a low sperm count or poor-quality sperm
 mild endometriosis
This is because there is some evidence to suggest that IUI will not increase your chances of
getting pregnant in these circumstances, compared with trying to get pregnant naturally.
You may be offered IUI in a natural (unstimulated) cycle or in a stimulated cycle.To

increase your chances of success, a cycle of IUI should be done just after ovulation.
Ovulation usually happens 12 to 16 days before your next period. This can vary if you have
an irregular menstrual cycle.You may be given an ovulation prediction kit (OPK) to help
you work out the date of ovulation. An OPK device detects hormones released during
ovulation in urine or saliva.Otherwise, blood tests may be used to find out when you are
about to ovulate.Sometimes, fertility medicines are used to stimulate ovulation before IUI.
In this case, vaginal ultrasound scans are used to track the development of your eggs. As
soon as an egg is mature, you'll be given a hormone injection to stimulate its release.
If a couple decides to have IUI using their own sperm, the male will be asked to provide a
sperm sample at the fertility clinic by masturbating into a specimen cup. This usually
happens on the same day that IUI takes place.The sperm sample will be "washed" and
filtered to produce a concentrated sample of healthy sperm.
An instrument called a speculum is inserted into the woman's vagina to keep it open. A
thin, flexible tube called a catheter is then placed inside the vagina and guided into the
womb. The sperm sample is then passed through the catheter and into the womb.This
process is mostly painless, although some women experience mild cramping for a short
time.The process usually takes no more than 10 minutes. You should be able to go home
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after a short rest.
Sperm Banks are places where frozen sperm can be purchased and stored for future
progeny. Frozen sperm from a donor can also be used for IUI, regardless of whether you
are single or in a partnership, gay or straight.All licensed fertility clinics in the UK are
required to screen donor sperm for infections and inherited diseases.Some infections take a
while to show, so the sperm will be frozen for 6 months to allow time for infections, such
as HIV, to be detected. The sperm is frozen whether it's from someone you know, or from
a registered and licensed sperm bank.Choosing to use donated sperm can be a difficult
decision, and you should be offered Counselling before you go ahead.The HFEA has
more information about using a sperm donor.
◦ Your chances of success with IUI depend on lots of different things, including:
o the cause of infertility

o the woman's age
o the man's sperm count and sperm quality (using fresh sperm leads to higher
conception rates than using frozen sperm)
o whether fertility medicines are used to stimulate ovulation (this can increase your
chances of success)
◦
◦ What are the risks?
There are many different factors involved, so it's best to talk to your fertility team about
your individual chances of success.
Some women have mild cramps similar to period pains, but otherwise the risks involved
with IUI are minimal.
If you have fertility medicine to stimulate ovulation, there is a small risk of developing

ovarian hyperstimulation syndrome. There's also a chance that you will have more than
1 baby, which has additional risks for both you and your babies.
(b) In Vitro Fertilization (IVF)
In vitro fertilisation (IVF) is one of several techniques available to help people with

fertility problems have a baby.During IVF, an egg is removed from the woman's ovaries
and fertilised with sperm in a laboratory. The fertilised egg, called an embryo, is then
returned to the woman's womb to grow and develop. It can be carried out using your eggs
and your partner's sperm, or eggs and sperm from donors.
The National Institute for Health and Care Excellence (NICE) fertility guidelines make
recommendations about who should have access to IVF treatment on the NHS in England
and Wales.
These guidelines recommended that IVF should be offered to women under the age of 43
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who have been trying to get pregnant through regular unprotected sex for 2 years,
or who have had 12 cycles of artificial insemination.
However, the final decision about who can have NHS-funded IVF in England is made
by local clinical commissioning groups (CCGs), and their criteria may be stricter than
those recommended by NICE.
If you're not eligible for NHS treatment, or you decide to pay for IVF, you can have
treatment at a private clinic. Costs vary, but 1 cycle of treatment may cost up to £5,000 or
more.
If you're having trouble getting pregnant, you should start by speaking to us at the GP
Surgery. We can advise on how to improve your chances of having a baby.
If these measures don't work, we can refer you to a Fertility Specialist for treatment
such as IVF.
IVF involves 6 main stages:
1. suppressing your natural cycle – the menstrual cycle is suppressed with

medication
2. boosting your egg supply – medication is used to encourage the ovaries to produce
more eggs than usual
3. monitoring your progress and maturing your eggs – an ultrasound scan is
carried out to check the development of the eggs, and medication is used to help
them mature
4. collecting the eggs – a needle is inserted into the ovaries, via the vagina, to remove
the eggs
5. fertilising the eggs – the eggs are mixed with the sperm for a few days to allow
them to be fertilised
6. transferring the embryo(s) – 1 or 2 fertilised eggs (embryos) are placed into the
womb
Once the embryo(s) has been transferred into your womb, you'll need to wait 2 weeks
before taking a pregnancy test to see if the treatment has worked.
The success rate of IVF depends on the age of the woman undergoing treatment, as well as
the cause of the infertility (if it's known).
Younger women are more likely to have a successful pregnancy. IVF isn't usually
recommended for women over the age of 42 because the chances of a successful pregnancy
are thought to be too low.
Between 2014 and 2016 the percentage of IVF treatments that resulted in a live birth was:
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 29% for women under 35

 23% for women aged 35 to 37
 2% for women aged over 44
These figures are for women using their own eggs and their partner’s sperm, using the per
embryo transferred measure.The Human Fertilisation and Embryo Authority (HFEA) has
more information on in vitro fertilisation (IVF), including the latest success rates.
Maintaining a healthy weight and avoiding alcohol, smoking and caffeine during treatment
may improve your chances of having a baby with IVF.
◦ What are the risks?
IVF doesn't always result in pregnancy, and it can be both physically and emotionally
demanding. You should be offered counselling to help you through the process.
There are also a number of health risks involved, including:
 side effects from the medications used during treatment, such as hot flushes
and headaches
 multiple births (such as twins or triplets) – this can be dangerous for both the
mother and the children
 an ectopic pregnancy – where the embryo implants in the fallopian tubes, rather
than in the womb
 ovarian hyperstimulation syndrome (OHSS) – where too many eggs develop in
the ovaries
(c) Surrogacy
Surrogacy is when a woman has a baby for a couple who can't have a child
themselves. For men, surrogacy can be a route to having a child biologically related to
them. Surrogacy is legal in the UK, but it's illegal to advertise for surrogates and no
financial benefit other than "reasonable expenses" can be paid to the surrogate. It's worth
noting that the baby isn't legally yours until a parental order has been issued after the
child's birth. This means the surrogate could keep the baby if she chose to. For more
information:
 GOV.UK: having a child through surrogacy

 COTS: Childlessness Overcome Through Surrogacy
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 Stonewall: parenting rights

 Surrogacy UK
Some women become pregnant quickly, while others take longer. This may be upsetting,
but it's normal.
Do you at all have any idea how the mother’s age can affect pregnancy? – Yes, I think
if you get older your chances of getting pregnant reduce
You are right to some extent, however there are other variables to consider too. Every
woman is different, and no 2 women have the same exact reproductive capability.
MostHeterosexual couples (about 84 out of every 100 – 84%) will get pregnant within
a year if they have Regular Sex and Don't Use Contraception. Generally, however,
women do become less fertile as they get older:

years
years
The age of 35 is simply an age that certain risks become more worthy of discussion. While
these risks become slightly more likely after hitting 35 years old, this does not mean that
they will have a significant impact on everyone in their mid-thirties and older.
People who are pregnant at age 35 or older are often referred to as “Advanced
Maternal Age.”
◦ A. Genetic Risks
◦
Certain genetic risks are also more common in pregnancies of older pregnant people. One
risk is that the embryo will have Down Syndrome, which happens when there is an
extra copy of Chromosome 21. The rate of having a baby with Down syndrome increases
with the mother’s age — this has been seen in large studies of women, as well as in studies
with embryos conceived with In Vitro Fertilization (IVF).
These are the rates of an embryo having Down syndrome at 10 weeks of pregnancy:
1 in 1,064 at age 25
1 in 686 at age 30
1 in 240 at age 35
1 in 53 at age 40
1 in 19 at age 45
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These are the rates of having a baby with Down syndrome at term:
1 in 1,340 at age 25
1 in 939 at age 30
1 in 353 at age 35
1 in 85 at age 40
1 in 35 at age 45
The rates of having baby with Down syndrome at term are not as high as the chances at 10
weeks, mostly because these pregnancies have higher rates of miscarriage and stillbirth and
won’t all reach the term period.
◦ B. Risk of Miscarriage
◦
◦ A miscarriage is the loss of a pregnancy during the first 23 weeks. The rate of
spontaneous miscarriage climbs gradually with age, from a 9% miscarriage rate among
22-year olds, to 18% among 30-year olds, 20% at age 35, 40% at age 40, and 84% at
age 48.High rates of miscarriage in older women are more related to egg quality than
the physical ability to stay pregnant. We know this because older women who use
donor eggs from younger women do not have such high rates of miscarriage.
◦
◦ C. Risk of Stillbirth
◦
◦ A stillbirth is when a baby is born dead after 24 completed weeks of pregnancy. It
happens in around 1 in every 200 births in England. There are two ways to find out
the risk of stillbirth in people who are 35 or older. One way is to look at the absolute
risk; this is the actual rate of stillbirth among women of a certain age group. This
means you can say something like “Among women over 35 years, X number of babies
out of every 1,000 births are stillborn.” The other way is to look at the relative risk.
This means that you compare the risk of stillbirth among older women to the risk
experienced by younger women. This approach will give us a result like, “Compared to
people in their twenties, those over 35 are X% more likely to experience
stillbirth.” With relative risk, if a risk is “50% higher,” this does not mean that an older
woman has a 50% chance (1 in 2 chance) of having a stillbirth. For example, if
someone who is 20-24 years old has a 0.65 out of 1,000 risk of stillbirth at 38-39
weeks, and someone who is 35 years old has a risk of 1.1 per 1,000, then that is a
roughly 50% increase in risk.
◦
◦
◦
◦
◦
◦
◦ Are there any other risks?
◦
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Besides genetic risks, miscarriage and stillbirth, researchers have found small increases in a
number of other childbirth risks in people 35 and older. Most risks were found to increase
with age. The one piece of good news in here is that breastfeeding rates are higher in
people 35 and older than in the younger group.
There are no studies that answer the question of whether a planned Caesarean birth is better
or not for people 35 or older.
Lena, what I would like to do now is just check your observations, is that alright? I need to
check your: pulse, blood pressure, breathing rate, temperature and levels of oxygen in your
blood.
height.
Ideally, I would also like to check your tummy and your front passage for any discharge,
redness, swelling, skin changes or scars.
I want to reassure you, that although the data does point towards a reduced likelihood of
conception at the above 35 years age group, the chances of getting pregnant are still
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relatively high at above 80% after 1 year and 90% after 2 years.
Do you follow? - Yes
◦ Can you refer me urgently to the Fertility Clinic because I’m

36 and I’m afraid I may get complications? Speed up referral?
 The advice we give to women under 35 years of age is that if after 1 to 2 years, you
have been trying for a baby without success, come back to us at the GP Surgery. As
you are 36 years old, it would be better for you to Follow-UpWithin 6-Months
to a Year and refer you to the Fertility Clinic. At the clinic they may perform
some further tests and will go over in detail the various Assisted Reproductive
Techniques (ARTs) available to help you conceive. Routine Blood Tests may be
required. And a Semen Analysisof the sperm donor is usually performed.
MANAGEMENT
Firstly, I would just like to reassure you that it is quite common for women in your age
group to be a little worried about starting a family a little later in their life. It's impossible
to say how long it takes to get pregnant because it's different for each woman.
 If you would like to start a family and get pregnant, then you can. I
have outlined several options available to you, and I think it is important that you take
some time to think and discuss with your partner which method suits you best.
 Complications – as mentioned before – are Rare today compared to previous decades.
Complications can arise from the advanced maternal age but also from the method of
fertilization. However, the good news is that the vast majority of people 35 and older
who make it to term will have a healthy baby.
 Intervention rates for your age group may be further lowered by using a Midwifery-
led Model of Care. Here a midwife – a health professional who cares for mothers
and new-borns around childbirth – would be looking after you each step of the journey.
 A Booking Appointment would be performed at 8-12 weeks, and an Anomaly

Scan performed around 20 weeks to check for any abnormality.We would conduct
USG Scans at regular periods during your pregnancy, including the 1st and last
trimester to check for any potential abnormality (anomaly).
 It is important to keep you BMI within the normal range of 18.5-25, so Diet and
Exercise will play an integral role. 5 fruit and veg / day. 8 glasses of water / day. 2
portions of fish / week. Reduce the amount of junk food/fatty foods. Reduce the
amount of cholesterol in diet. At least 30mins of exercise per day, or 2hours 30mins of
exercise per week.
 We may have to consult a Nutritionist to ensure you get an adequate amount of
Iron and Folic Acid in your diet. These are required to help the baby grow.
Supplements may be prescribed.
 Reduce Alcohol Intake to less than 14 units of alcohol per week. This equates to 2
units per day. Cutting down altogether is preferred. Consuming alcohol during
pregnancy can cause problems in your child. Do you think limiting your alcohol intake
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is something you would consider? – Yes

 Smoking Cessationcan also be helpful when trying to conceive.
 Reducing Stress from your life is also important. Finding a hobby such as walking,
swimming or yoga can reduce your stress levels and improve your chance of
conceiving.
 We can book you in a for a follow up with the Fertility Clinicwithin the next 6-
months to a year.
Is there anything else I can help you with? – Yes
◦ Can you tell me more about the Fertility Clinics?
Fertility treatment funded by the NHS varies across the UK. Waiting lists for treatment can
be very long in some areas. The eligibility criteria can also vary.
We may refer you to a specialist for further tests after you have decided which method of
conception you have chosen. This referral would usually be between 1 – 2 years, however
in Advanced Maternal Age it is usually within 6 – 12 months.The NHS will pay for this.All
patients have the right to be referred to an NHS clinic for the initial investigation.
If it turns out that you have an infertility problem you may want to consider private
treatment. This can be expensive, and there's no guarantee of success. It's important to
choose a private clinic carefully.You should find out:
 which clinics are available

 which treatments are offered
 the success rates of treatments
 the length of the waiting list
 the costs
Ask for a personalised, fully costed treatment plan that explains exactly what's included,
such as fees, scans and any necessary medicine.
If you decide to go private, we are available for advice. Make sure you choose a clinic
licensed by the HFEA.
The HFEA is a government organisation that regulates and inspects all UK clinics that
provide fertility treatment, including the storage of eggs, sperm or embryos.
There's no evidence to suggest complementary therapies for fertility problems are

P a g e | 888
effective.The National Institute for Health and Care Excellence (NICE) states further
research is needed before such interventions can be recommended.
 If you begin to experience any symptoms please do come back and visit us at the GP
Surgery. We will be more than happy to address any of your concerns. Thank-you very
much.

Dealing with medical error
1) Assess knowledge
2) Inform about the error if the patient is not aware of it.
3) Check any harm happened.
4) Apologize. Reassure if no harm happened. Inform the patient if any harm happened.
5) Rectify the error if possible.
6) Report the incident / Inform patient to complain if they wish ( PALS )
7) Root cause analysis meeting will take place to find the exact cause
8) Take steps to prevent the error happening again.
9) Inform the patient about the reasons for error – apologize and reassure that necessary
steps will be taken to prevent it happening again and appropriate actions will eb taken
against the person who was responsible for the error.

Telephone conversation with mother about child - button in x ray
You are FY2 doctor in A & E Department.
A mother brought her 2 year child to the A&E department for swallowing of foreign
body.
You examined her and did the X Ray. You thought the X ray was normal and
discharged the child.
Later on Radiologist called and said there is some button ( foreign body) in the
Oesophagus of the child.
Call the mother over the telephone who is at her home and tell her to bring the child
back to the hospital.
[ X Ray may be on the table – Look at the X Ray before you call the mother].
Mother’s and child information ( Name and address) may be written on the table – confirm
that with the mother.
Dr: Hello I am Dr ... junior doctor from the accident and emergency department of the
hospital. Are you Amie’s mother speaking?
Mother: yes Dr I am. What is the matter doctor?
Dr: Actually Ms Jane you brought your daughter to the emergency in the morning. Is that
right?
Mother: yes
Dr: I am the same doctor who saw your child and did the X Ray. I told you that her X ray is
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normal and told you that you can take her home. Mother: That is right.
Dr: How is she now ? Mother: She is fine now.
Dr: That’s good. Ms Jane Our Radiologist had a look at Amie’s X ray again. He said that
there is some foreign body in her food pipe. It looks like a button.
I am really sorry that I told you that the X Ray does not show any foreign bodies.
Mother: OK.
Dr: Do you have any idea what she might have swallowed ? Any button from any dress
missing do you know ?
Mother: yes doctor she was wearing a buttoned shirt today. I don’t know now whether any
buttons missing.
Dr: Alright. Is she having any sort of breathing difficulty? Mother : No
Dr: Is there any other problem like drooling from mouth? Mother : No
Dr: Is she eating and feeding well?
Mother: She ate and drank after I brought her back and she is fine.
Dr : Did she vomit ? Mother: No doctor she is completely alright.
Dr: okay That is good. Ms Jane can you please bring her to the hospital for further
assessment. Would that be alright?
Mother: I don’t get it if she is alright why do I have to bring her to the hospital. I am getting
late for work.
Dr: I am really sorry Ms Jane about the problems you have to go through because of the
missed finding. But as it is shown in the X ray that the foreign body is in the food pipe
(oesophagus) so she requires observation and reassessment. We may need to do some
procedures to remove it if required. For that you have to please bring her to the hospital
immediately.
Mother: Is she in any danger?
Dr: I am really sorry to say this because sometimes the object which is in the food pipe
canget stuck there and may not go down or if it is some type of poisonous objects then it can
cause damage to the food pipe.
But as she is having no symptoms so hopefully there is nothing to worry about. When she
will be here we will assess her again. We will treat her depending on the level at which the
foreign body is in the food pipe.
If we think it may cause problems especially if it is still in the food pipe then we will try to
remove it. But if it has already gone down to the stomach then it may not cause any problem
then you can take her back because it will pass out on its own. Is that OK?
Mother: But why this mistake happen ?
Dr: Mrs .. Actually I made the mistake as I told you. I am a junior doctor here and I am not
that experienced in reading the X Ray. It was not easily visible in the X Ray. Only the expert
doctor that is Radiologist could see that. However, I do apologize for the incident I will go
for some courses and learn how to read the X Rays very soon. Also I will always ask my
seniors opinion before I treat or discharge patients. I will reassure that such mistake will
happen again Mrs…
Mother: That is fine. I don’t have a car. I don’t even have money to pay for the taxi. I can’t
come.
Dr: I am really sorry for the incident again. Mrs… We can send an ambulance. Can you
please bring your child in the ambulance ? Mother: Yes doctor.
[ sometimes she may say that she has not time at all – in that case
Is that ok if we send the social services – can you please send Amie with them ?
Mother – Ok ]
Pt: Once again I am really sorry Ms Jane for causing you all the problem to come to hospital
again. I am really regretful and I apologize that it was missed in the morning. I am really glad
to hear that Amie’s is doing alright at the moment. We will see her again soon.
Mother: yes doctor.
Dr: I will be reporting this incident to my seniors. If you want you can also make a formal
complain about this. We have a special department called PALS ( Patient advisory liaison
service) who will assist you regarding this when you come to hospital. Mother: Okay
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doctor.
Dr: do you have any other concern Ms Jane? Mother: No.
Dr: okay hope to see you and Ammie in the hospital again soon.
ADDITIONAL INFORMATION:
SWALLOWED FOREIGN BODIES (FB)

A. BACKGROUND
B. NON-HAZARDOUS SWALLOWED FOREIGN BODIES
C. HAZARDOUS SWALLOWED FOREIGN BODIES
D. INGESTION OF BUTTON BATTERIES
A. BACKGROUND
Ingested foreign bodies rarely cause problems. However when problems do occur it can be
life threatening e.g. oesophageal rupture, aorto-oesophageal fistula, tracheo-oesophageal
fistula. The following guidelines have been developed following multi-disciplinary consensus
agreement based on current best-practice.
• NON-HAZARDOUS, SWALLOWED FOREIGN BODIES
C. HAZARDOUS, SWALLOWED FOREIGN BODIES

Hazardous = sharp object, very large object, button battery or filled balloons
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Additional Points:
• If history of coughing or choking, consider inhalation of foreign body
• If there is evidence of complications, films should be requested.
• A metal detector will pick up aluminium, e.g. can ring-pulls, which may not be seen
on an X-ray.
D. INGESTION OF BUTTON BATTERIES

Background
These batteries can be dangerous if ingested as the seal on them is dissolved by gastric acid
and the contents are toxic. There is also a danger of local erosion of the mucosa by current
passing from the battery, if the battery is a fresh one. If possible obtain the battery details
from the packet of another battery of the same sort and contact the poisons centre via toxbase
for more up to date information.
Management
- All children who have swallowed a battery should have an X-ray of the chest (and
abdomen if not visible on CXR) to locate the battery as soon as possible. A metal detector is
unreliable, as some batteries cannot be detected by the use of a metal detector.
- If the battery is in the oesophagus, urgent referral to the Paediatric Surgeons is
needed.
- If the battery is below the diaphragm, the child can eat and drink normally. Repeat the
AXR after 12 hours, or as soon after this time in order to be done in daylight hours. The child
can go home between films, providing the parents are instructed to bring the child in sooner if
any abdominal symptoms develop.
- If the battery has not moved on the second X-ray, refer to the surgeons urgently. The
battery may have become adherent to the gastric mucosa, leading to a high risk of erosion.
- If the battery has moved position below the diaphragm and is not fragmenting (i.e. out
of the stomach) the patient can be safely discharged.
Do not instruct parents to “look for FB in the stools”.

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Medical error – Rash after Amoxycillin
Exam question
You are an FY 2 doctor in the A& E Department.
8 year child Amie was given oral amoxicillin for chest infection and was sent home
from the A& E department last night. She has developed rash.
Her mother Mrs Jenny Carr has some concerns talk to her.
Dr: Hello I am Dr ... one of the junior doctors in the department. Are you Amie’s mother??
Mother: Yes dr.
Dr: How can I help you?
Mother: Doctor, I brought my daughter last night because she had fever and cough. Doctors
here told me she had chest infection. They gave some medications to her to take at home. I
gave the medicines to her and now she has developed rashes.
Dr: Oh I am really sorry about that Mrs .... Do you know what medications was that?
Mother : Amoxycillin
Dr: How many times did you give this medicine to her ? Mother : Twice.
Dr: Which part of the body she has rashes ? Mother: all, over the body.
Dr: Is the rash spreading? / is it widespread? Mother: No
Dr: Is the rash painful? Mother: .No ( for Toxic epidermal necrolysis-Steven Johnson)
Dr: Is it itching ? Mother : Yes/ No
Dr: Does she have any SOB? Mother: No
Dr: Does she have sore throat( Infectious mononucleiosis) ? Mother : No
Dr: Swelling anywhere in body especially face and lips? Mother: No
Dr: Does she have any fever ( meningitis, Pneumonia)? Mother: No
Dr: Does she have any headache, Neck stiffness ( meningitis) ? Mother: No
Dr: Lumps or bumps anywhere in the body? Mother:... (lymphadenopathy for Drug
hypersensitivity syndrome, infectious mononucleosis)
Sometime the mother may say that her child developed allergic rashes straight away and
ask you - why are you asking other questions ?
Dr: May I know why do you think it is allergic rashes ?

Mother: she had this allergic rash before also.
Dr: May I know when?
Mother: few months ago. She was given the same medicine and she developed rash. I was
told that she is allergic to Amoxycillin.
Dr: You may be right Mrs... It could be allergic rash. I still need to make sure that it is not
due to any other serious medical condition like meningitis because as you may know there
could be rashes even in meningitis.
Dr: has it happened for the first time?

Mother: No actually it happened a five months ago as well....
Dr: Was it the same medication? what problem was the medication given for back then?
Symptoms at that time? Mother : … She was given the same medication. She had rash that
time also.
Dr: Were you told that she is allergic to amoxicillin. Mother: Yes
Dr: Has she been diagnosed with any medical conditions? Mother: No ...
Dr: Does any of her family members have any medical condition such allergies ?
Mother : No
EXAMINE:Tell the examiner - I would do a general physical examination including BP and
Pulse. Also I need to examine her face for any swelling and also have a look at the rash.
Mother shows the picture
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Mother: what has happened to my daughter?

Dr: Mrs .... I think this is allergic rashes due to Amoxicillin.
Mother: Is she going to be fine? Is it dangerous?
Dr: Mrs ... I can understand why you are so worried. Sometimes medication allergies can be
serious but thankfully she is not in danger as the rash is localized with no other symptoms.
She is in good hands we will ensure that she is well treated and completely alright.
Mother: What will you do now?
Dr: We will be admitting her and keeping her under observation for sometime. We will stop
the Amoxycillin immediately. We will look for any worsening of symptoms. Is that alright?
Mother: Yes .
Dr: We will give her some medication known as antihistamine syrup by mouth and some
medication to apply locally on the rash which will be a mild steroid. The rash will take a
week almost to clear out. We will also give some other antibiotic for her chest infection..
Dr: Is she allergic to Erythromycin ? Mother : No
Dr May be we can give Erythromycin to her. I will talk to my seniors and then we will give
that antibiotics for her chest infection.
Dr: Were you asked about any allergies before giving the medication by the staff?
Mother: No one asked me about it.
Dr: Oh, I am really sorry about that. This question is one of the routine and important
questions we should ask before giving any medication.
Mother: Why no one asked me ? Why did they give that medicine to her ?
Dr: As I mentioned earlier, whoever gave the medicine should have asked for allergy before
giving medicine. This is a mistake on our part. I am really sorry for what happened.
Mother: Will it happen again to her Doctor?
Dr: Mrs... We need to be careful because it is likely to happen again if the medication
amoxicillin or any medication from the class penicillin is given to her. We will give you all
the necessary information in written form on discharge paper. In future if you take her to
doctor or hospital please mention about the allergy. We will also update her this
information in all her electronic medical records. Also you should educate her as she grows
up. Would that be alright?Mother: yes
Mother: Can this allergy be prevented any way?
Dr: Yes surely we will be documenting details of everything this incident and also the
previous incident. You should carry this document with you at all times. So that it can be
shown to any health care professional to prevent it from happening again.
We can give test dose before giving any new medicine that is known to cause allergy. If
person is found allergic to it we give an alternative medication. Are you following me?
Mother: yes doctor.What will you do in the future so that these things will not happen again
to others?
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Dr: I really appreciate your concerns. Your feedback is very important. We are constantly
looking for ways to improve our health system. I will inform my seniors about this. We have
something called as root causes analysis meeting where we discuss any such issues and we
take all the steps to rectify any such problems and prevent it from happening again. You can
also help us by reporting the matter. We have a separate unit to deal with such concerns
known as PALS (Patient advisory liaison service)
Mother: okay
Mother: Will she have any scar because of this allergy ?
Dr: Allergic rashes will heal completely without leaving any scar. Please do not be worried
about it.
Dr: is there any other way I can help you?
Mother : No doctor thank You.
Dr: hopefully ... will get better soon. If you have any concerns later on don’t hesitate asking.
Thank You.

Medical Error- Misdiagnosed Pneumonia and Antibiotics
given unnecessarily
You are FY2 Doctor.
65 years old Mr. Pat Harding was diagnosed with Pneumonia 4 weeks ago.
On looking at his notes, you noticed that at the time of his presentation, X-ray Chest
was done. He was told that his X-ray result showed chest infection and he was admitted
for a week and was given given IV antibiotics for 2 days and then later on oral
antibiotics.
Today, you have received a call from the Radiology Department. You are informed
about the mixing of X-ray Reports. Mr. Pat Harding's X-ray report is reanalyzed and is
found to be normal.
Your consultant believes that he was misdiagnosed with Pneumonia and unnecessary
antibiotic treatment was prescribed to him.
Mr. Pat is here with you today for the follow up. Talk to him, tell him about the error
and address his concerns.
Dr: Hello Mr. Harding. I am Dr …. one of the junior doctors in the medical department. How
are you doing today?
Pt: I am OK.
Dr: Can you please tell me in detail what happened last time ?
Pt: I had some chest symptoms. I came here about4 weeks ago and the doctors did the chest
X ray and they told me I have chest infection. I was admitted for a week. They gave me
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antibiotic through my veins. I have improved now.

Dr : Which antibiotic ? Pt : Amoxycillin.
Dr: Any chest symptoms at all now ? Pt : No. I have improved completely now. Thank
you very much for treating me doctor.
Dr: Mr Harding I need to tell you something. A mistake happened at that time of your
previous presentation. Doctors did your Chest X-ray at that time and they told you that you
have infection in your chest because they thought your chest X ray showed chest infection.
But in real this was not the case.
Unfortunately, another patient's report was mixed with your X-ray report. The doctors
misdiagnosed you with pneumonia and you were started on antibiotic which was
unnecessary. Your test result was later on found to be completely normal. I am very sorry to
say this. I sincerely apologise on behalf of the hospital. This should never have happened.
Pt: What !!! But why did this mistake happen ?
Dr: Mr. Harding as I have told you another patient's test results got mistakenly mixed with
your reports. I can only apologise to you now.
Pt: You doctors are very irresponsible. Why did the X Rays gets mixed up ?
Dr: Mr Harding.. I can see that you are very upset. I can perfectly understand that.
Whenever we check any test results like blood test or X Rays we doctors are supposed the
check the identity on the X ray before we read the X Ray. I guess whoever saw the X ray at
that time, did not check the identity properly or some other problem has happened. I am
really sorry about this Mr. Harding. We usually take the maximum caution to prevent such
mistake happening..
Pt: Who is responsible for this mistake ?
Dr: We do not know exactly who is responsible for this at this moment but we are going to
look into all this.
Pt: You people do not care for other’s life.
Dr: I am really sorry for what happened. I can certainly imagine why you are feeling that
way. We do care for everyone but sometimes mistakes do happen. We do take all the
measures so that mistakes do not happen. Mr… did you have any problems because of this
medication what we gave last time ?
Pt: I had sickness and loose stools unnecessarily.
Dr: Mr… you had to go through all those problems unnecessarily. I sincerely apologize for
what happened.
Pt: Will I develop any long term problems with this antibiotics?
Dr: I'd like to reassure you Mr. Harding that no serious complication will happen in long
term. Very rarely bugs can develop resistance to this antibiotic but other than that, there will
be no potential threat to your health at all.
Pt: What will you do so that these mistakes will not happen again ?
Dr: We will investigate this matter further. We have a procedure where we report such
incidents to the appropriate authorities. We have something what we call as “Root Cause
Analysis meeting” where we discuss such matters and take appropriate actions so that these
mistakes do not happen again. Also some actions may be taken over defaulting persons.
We will educate staff, provide better supervision for juniors in every department, We will
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instruct everyone to check the identity properly on any test results and may be a mandatory
training for staff about dealing with such problems.
Mr Harding if you like to escalate the matter further you can do it. We have a dedicated
department for this what we call as “ Patient Advisory Liaison Service” – you can talk to
them about it.
Pt: Thank you doctor I will consider that.

Dr: I will like to reassure again that everything is fine with you now. If you need any help
please let us know. Thank you very much.

Missed - hair line wrist fracture in child
4 year old boy brought into the hospital by his father 2 days ago with wrist injury. His
X ray was done.
He was told that the boy has only soft tissue injury and no bony injury and was
discharged with pain killers. Later on Radiologist saw the X Ray and thought the X
Ray showed hairline fracture in the wrist bone.
His father was asked to bring his son back. Talk to the father and address his concerns.
Dr: Hello Mr … I am Dr… How are you doing?

Father: I am fine. I was told to come back. What happened doctor?
Dr: I was told that your son had wrist injury. Can you please tell me in detail how it happened
and what happened here in the hospital and what was told to you ?
Father: He fell down from sofa / he fell while playing in the garden – 2 days ago and he had
pain and swelling in his wrist. I brought him in here. Doctors did the X Ray and they told me
that he had no bony injury and he has only injured his muscle. They gave some pain killer
medications to give it to him.
Dr: Yes. Mr… That is what I understand from his notes. But Mr… I need to tell you something
about it. After he was discharged from the hospital Radiologist saw the X ray and that your
son’s X Ray showed a small fracture in the wrist bone what we call as hairline fracture.
Unfortunately, the doctor who saw your son did not see that fracture and he thought there is no
fracture. I am very sorry to tell you that this mistake happened.
Father: what …mistake happened!!! How is that doctor did not see the fracture if the other
doctor can see that.
Dr: Mr… I cannot tell you why exactly the mistake happened. That fracture is like what we
call as hairline fracture which is very difficult to see in the X Rays unless one is very
experienced in reading the X rays. Radiologist is the expert doctor in X Rays, so he could see
that. The doctor who saw your son … is not that much experienced in reading X Rays. May be
that is why he missed the fracture in the X ray. Once again I am very sorry the mistake
happened.
Father: This is ridiculous. How can you keep such inexperienced doctors to treat patients ?
Dr: Mr… I can see that you are very upset. You have all the reasons to be upset. We do have
junior to senior doctors in every department. Whenever junior doctors have any doubt about
anything they are supposed to consult the senior doctors before they treat the patients. May be
the doctor who saw your son had no doubt in his mind about the X Ray. May be that is why he
would have missed the fracture. However, at the moment I cannot tell you for sure why this
mistake would have happened.
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Father: So what will happen to my son now?

Dr: Mr… First of all thank you very much for bringing your son … back here. My seniors will
see him now. Depending on the degree of fracture and if the arm has bent then we may need to
manipulate ( do some procedures) to straighten that bone and then we may have to put a cast
( like a plaster or splint) to his wrist and arm to treat the fracture.
Father: How long he will be on cast?
Dr: Usually it takes about 3 to 4 weeks for the fracture to heal. So he may need to be on the cast
for 3 to 4 weeks.
Father: These type of mistakes can keep happening again and again ?
Dr: I can imagine why you are feeling so upset about the incident. I would like to reassure you
that I will report this incident to my seniors. This incident will be taken very seriously. In fact
we have something what we call as “Root cause analysis meeting” where we discuss this type of
issues and take necessary steps so that such incidents will not happen again. Hopefully this type
of mistakes won’t happen again.
Father: I want to complain about this.

Dr: Surely Mr..you have all the rights to complain. We have a dedicated department for this
what we call as PALS( Patient advisory Liaison service). You can talk to them and they will
help you to put formal complaint.
As I said before, I will also talk to my seniors about this. I am sure appropriate action will be
taken. Any other concerns ? Father - No
Dr: Again I am very sorry for what happened. I do sincerely apologize from the hospital’s
behalf for the incident. Thank you very much for bringing your son back to us. I am sure your
son..will recover soon.

Medical error – missed renal biopsy sample
Exam question
21 year old presents with suspected post streptococcal glomerulonephritis. Renal biopsy
was done 2 days ago. Lab said they did not receive the specimen. Talk to the patient about
the missed sample.
Dr: Hello Mr.... I am Dr.... How are you doing? Pt : I am fine doctor.
Dr: Can you please tell me what symptoms did you have ? Pt : ...
Dr: How are your symptoms now are they same or getting worse ? Pt : Same.
Dr: Mr... We did a procedure on you to take sample what we call specimen from the
kidney to test what condition you have 2 days ago do you remember ? Pt : Yes doctor.
Dr: Mr... I am extremely sorry to say this, the specimen what we took is missing. We are
not able to trace it. I sincerely apologize for this.
Pt : What ? How can this happen?
Dr: Mr... After the procedure we have send the specimen to the lab but the lab is now told
us that they did not receive the specimen. We have tried our best to trace the specimen but
we could not trace it. I am very sorry once again.
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Pt : How can you people be so irresponsible?

Dr: Mr.. I can imagine how you may be feeling now. I am really sorry for what happened.
Usually we are very careful so that these mistakes do not happen. But unfortunately some
mistake happened somewhere and the specimen is missing.
Pt : I do not understand – if you are so careful how can the specimen go missing?
Dr: Mr... I can see that you are very upset. I can perfectly understand. You have all the
reason to be upset. Usually after we do the procedure we label the specimen and then
someone takes the specimen to the lab. So the mistake could have happened anywhere like
labelling, or taking the specimen to the lab, or collection at the lab or it could have lost in
the lab. At the moment, I cannot tell you where exactly mistake happened. We are trying to
find out what really happened.
Pt : Who is responsible for this?

Dr: Mr.. At this moment we are not sure who is responsible for this. We have reported the
matter to the concerned department about this incident. They will look into this issue.
Pt : So what will happen now?

Dr: Mr.. I would like to reassure that there is no serious harm has happened. However since
the specimen is missing unfortunately we need to take the specimen again. Will that be OK
Mr...?
Pt : Well I guess it is OK. What will you do so that this will not happen again ?
Dr: I will reassure that we will take utmost care this time so that this mistake will not
happen again.
Pt : I want to complain about this.

Dr: I perfectly understand your feelings. You can surely put a formal complaint about this.
We have dedicated department called PALS that is patient advisory liaison service and
they will help with the complaint procedure. I can reassure that this complaint will be taken
very seriously and appropriate action will be taken.
Pt : What will you do so that this mistake will not happen to others?
Dr: I really appreciate our concerns to others. We have something called as root cause
analysis meeting where we discuss this issue to find out why this happened and we take all
the measures so that this kind of mistakes do not happen again.
Any other concerns ? Pt : No
Dr: Once again I sincerely apologize for the mistake. I will do the procedure again now and
I am sure you will feel better after the treatment. I wish you a speedy recovery. Thank you
again for listening to me.

Unlabelled blood Samples : Medical Error
( tel conversation)

As part of pre-op assessment ( herniorrhaphy) of a patient, you took samples for FBC,
EUCr. The laboratory denies the receipt of the samples. It appears you were too busy in the
clinic and you forgot to label the samples. Call the patient and tell the patient to come back
so you can re-collect the samples. Patient has been informed you will be calling. Patients
name, address, DOB and hospital number given.
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Medical Error – Missed MI
You are the medical FY2 on the cardiology ward.
35 year old Mr Michael was admitted with chest pain 3 days ago and was treated for
Acute Inferior Myocardial infarction, now he is stable and is on medical therapy.
 On looking at his notes you noticed that 2 days before his admission he had attended the
emergency dept complaining of chest pain and he was told that hus ECG is normal and it
was a musculoskeletal pain.
 Your cardiology consultant noticed that he had a high troponin levels at that which no
one checked the result and also there was T wave inversion in the ECG. But despite that
he was sent home. After discharge he had chest pain constantly and then he came back 3
days and then he was admitted.
 Your consultant believes that his diagnosis was missed by the emergency dept. as there
was no follow up to the blood results.
 Asses him clinically and speak to the patient about what happened.
Dr : Hello Mr Michael, I’m Dr ….. one of the junior doctors in the cardiology dept. How are
you doing today? Pt : I’m okay doctor.
Dr : Any chest pain, palpitations, swelling in the legs? Pt : No doctor
Dr : I need to examine your chest. Examiner says: chest is normal
Dr : I’ll check your ECG Examiner says: ECG is normal
Dr : Mr Michael everything seems to be fine now, and you are recovering well.
Dr : I need to talk to you about your condition. Do you know what exactly has happened to you?
Pt : I’m told that I have had a heart attack.
Dr : Yes that is right and we have treated you for that now. I understand that you came to our
hospital A&E dept. 5 days ago. Could you please tell me why did you come to the hospital that
time and what happened in the hospital?
Pt : Doctor I had pain in my chest and I came to the A&E dept. They did some tests and told me
that I have muscle pain and that my heart is fine and I was told to go home.
Dr : Yes that is right, that is what we found out from your notes
Dr : Mr Michael I need to tell you something that there was a mistake that happened at that
time. A&E doctors did the ECG at that time which showed some changes at that time but they
thought the ECG was normal and they also did some blood tests specific for heart attack. They
told you that you do not have any problem with the heart because they thought the ECG was
normal and also they did not check your blood test result which actually showed that you had
heart problem at that time. We should have kept you in the hospital and treated you for the heart
problem at that time itself, I am very sorry to this and I apologise on the behalf of the hospital.
This should not have happened.
Pt : But why did this mistake happen?
Dr : Mr Michael I do not know why this mistake happened, I can only apologise to you now. I
assure you that you are fine now and no serious harm has happened to you.
Pt : Who is responsible for this mistake?
Dr : We do not know exactly who is responsible for this at the moment but we are going to look
in to all this.
Pt : You people do not care for other’s lives, I would have died!
Dr : I’m really sorry for what happened. I can imagine why you are feeling that way. We do
care for everyone but sometimes mistakes do happen. We do take all the measures so that
mistakes do not happen.
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Pt : What will you do so that these mistakes don’t happen again?

Dr : We will investigate this matter further. We have a procedure where we report such
incidents to the appropriate authorities. We have something what we call as ‘Root cause
analysis meeting’ where we discuss such matters and take appropriate actions so that these
mistakes do not happen again. Also some action will be taken over the defaulting persons.
We also educate staff, provide better supervision for juniors in the A&E, may be a mandatory
training for the staff on dealing with chest pain. And may also include asking lab staff to call the
doctors if blood tests results show some serious conditions.
Pt : I would like to talk to your consultant.
Pt : Surely you can talk to my consultant. I’ll let him know about it.
Mr Michael if you wuld like to escalate the matter you can do it. We have a dedicated dept for
this called as ‘Patient Advisory Liaison Service’ and you can talk to them about it.
Pt : Thank you doctor, I’ll consider that.
Dr : I would like to reassure you again that everything is fine with you now. If you need any
help please let us know. Thank you very much.

FY1 Colleague delayed discharge(27th June)
FY1 colleague Dr Gupta is in medical ward covering for other doctor who is on sick
leave. He was supposed to discharge Mrs Storm but her discharge got delayed for a few
hours. Mrs Storm wants to complain.
Management also wants beds for patients in the ER and they repeatedly called the
nurse to enquire for beds.
You are the FY2 doctor in same department. Go and talk to your colleague and find out
what happened.
(You enter the cubicle and fy1 colleague is acting very busy)
Dr : Hi Dr Gupta. I am Dr…. I am in the same department. How are you doing today ?
FY1 : I am fine doctor. You can call me Sam.
Dr : Ok Sam . You seem to be really busy. Is everything alright ?
Sam : Yes doctor, this is my first job. All these things were not taught in medical school.
Dr : I think I can understand your situation. Things are tough at the start of your job and with
time you get used to the system and I believe you will start enjoying then.
If you would like, I can guide you to a few workshops which will make this process easier for
you.
Sam : It is just that this is my first job and I think I am overworked. But if it would help me I
might consider joining a workshop.
Dr : Yes Sam I really think it would help. I can see that you are really busy today but there is
one thing that I would like to discuss. Do you have a few moments to spare?
Sam : Yes doctor. I think we can talk now.
Dr : Alright Sam. It is regarding discharging Mrs Storm. She was supposed to be discharged
few hours back. She has been waiting since then and now she wants to complain.
Sam : Yes doctor. I am aware that I had to discharge her. It is just that I was doing work and
it kept me busy.
Dr : Sam do you feel you have any problem prioritizing jobs ?
Sam : No doctor. I have a to do list and I note things on this. Actually , I was busy with
critical patients/important things and her discharge just kept on going down and down on my
list.
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Dr : Sam do you think if there is a problem or you could have done things in a better way.
Sam : I am not sure of what I could have done better. This is my first job and when I came in
the morning I informed the management that it would be difficult for me as I am the only one
in the ward today.
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Dr : Yes Sam I think I can understand what you are going through. You could have told me
and I would have been happy to share your work load.
Sam : Yes doctor I wanted to but you are the first doctor I am seeing today.
Dr : Well Sam , you should have informed the ward nurse or the nurse in charge that you are
held in an emergency and are bit delayed. What do you think about it ?
Sam : Yes doctor I think I could have done that.
Dr : Yes Sam. What’s important is that this should not happen again and we keep on learning
and improving from every experience.
So I think you should report this incident so that it is discussed in Root cause analysis
meeting and we can find ways to avoid this kind of situation in future.
Sam : Yes doctor I will do that.
Dr : Sam I think you should also go to Mrs Storm and explain your situation. And if she
wants to complain then guide her about PALS.
Sam : Yes doctor I will go to her now but will you tell the consultant ?
Dr : Sam you must tell the consultant yourself. He is going to find about this incident anyway
so it would be better if you did it yourself as you would have a chance to explain the
situation. I am sure he will help you further.
Sam : Yes doctor I will talk to him as soon as possible.
Dr : Sam one more thing if you need help with anything in future, we are always with you.
You cannot expect to do everything yourself. We work as a team here. You should go and
talk to Mrs Storm and I will cover for you in the meantime.
2776 Video availablle

IV cannula – Talk to FY 1
Your junior colleague (FY1 doctor) Dr Wilson did not insert IV cannula to Mrs Williams
who supposed to receive IV antibiotics. Talk to your colleague.
You – Hi Wilson I am Peter. How are you doing? Him-
I am fine Peter
You – How’s the work going on? Wilson - it is good not bad.
You – was it very busyt oday? Wilson – Not so much. I could manage.
Wilson - it is good not bad.
You – was it very busy today? Wilson – Not so much. I could manage.
You – She has put a complaint saying that you didn’t insert a IV cannula and
she is waiting for a long time.
Wilson – oh really. But there is 2 hours’ time for the next antibiotics. I don’t
understand why she has to complain.
You – What did you tell her about the cannula.
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Wilson – Well I told her that I will be back in about 15 min to insert cannula but
then I saw an interesting X ray, I went to the library to read about it.
You – It is good to know that you are interested in learning. But I think since
you had already told her that you will be back in 15 min to insert the cannula
you should had done that first or you could have told her that you will be
back to insert the cannula before the next dose in due.
Wilson – Well yes, I think I should have done that.
You - Do you have any problem in prioritising, because when I started working
I too had the problem of prioritising, then I went to a course, it helped me a lot.
May be you too can attend one course like that if you want to.
Wilson – ok, I will surely try that.
You – I think you need to talk to Mrs Williams and explain to her and may be
apologise to her if you think so.
Wilson – Yes, I will.
You - I think you can insert the cannula now and tell her that no harm has
happened also I suggest you to fill up a clinical incident form.
Wilson – yes, thank for your suggestion. Will you tell the consultant?
You – I guess he may come to know that from others. It may be better you that
to him yourself rather than he hearing it from others.
Wilson – yes,
thank you.
You – thank
you.
Sometimes the colleague says he forgot to insert the cannula.

You can ask him to maintain a diary so that he will not forget the jobs.
Sometimes he says he was caught up in doing CPR.
You can tell Wilson that he could have told you to insert the cannula or he could have
informed the nurses in the ward to tell the patient that he will be late.

14. Alcoholic Colleague
You are FY2 in the medical department.
During ward rounds, you have come across your colleague, Dr. Jonathan smelling of
Alcohol. This is second time you have encountered him in this state. Take your
colleague to a private room and talk to him.
Follow the acronym

S = Seek information
P = Patient safety
I = Initiate
E = Escalate
S = Support
Dr: Hello Jonathan, I am... How are you doing? Colleague: I am fine.
Dr: How’s the work going on? Colleague: It is going alright.
Dr: That sounds good. Have you been able to manage all the duties well?
Colleague: Yes, I could manage.
Dr: I see. Well Jonathan, I'm a bit concerned about something. If you can take some time off
P a g e | 903
of your ward work, I'd like to talk to you privately about it.
Colleague: Yes, it's fine. I am free for now. We can talk now.
Dr: Well Jonathan, I have been noticing something for some time now. Is there anything you
want to share with me?
Colleague: No, everything is alright.
(Seek Information)
Dr: Actually, today during ward rounds, I found you smelling of alcohol. Can we talk about
it?
Colleague: No, you must be mistaken.
Dr: Well, Jonathan, I don't think it could be a mistake because it's the second time I've
happened to notice this. You know, you can share with me if something troubling is leading
you to take Alcohol.
Colleague: I might have taken some last night but not today.
Dr: But Jonathan, I can still sense the smell of Alcohol.
Colleague: I do not think I took too much of it.
Dr: I see. Did you drink in the morning? Colleague: I might have.
Dr: Could you please tell me since when have you been taking Alcohol? (Stressor &
Duration)
Colleague: You see it's not that long. I started taking a few weeks ago when my girlfriend
broke up with me.
Dr: It must be distressing for you.
Colleague: It is. I don't know what to do now when she's gone. I am devastated.
Dr: I am so sorry Jonathan. Colleague: Thank you.
Dr: Could you please tell me how much do you drink daily Jonathan?
Colleague: (?) Just a bottle of whisky and few shots of gin.
63
Dr: Jonathan, I can understand that you are very gloomy but did you try to stop taking it or
reduce the amount? (Cut Down)
Colleague: Not really. I have been miserable you know. I miss my girlfriend.
Dr: Alright. I can realize that your mood is low Jonathan, could you grade it for me on the
scale of 1 to 10? Colleague: 8 out of 10.
Dr: Do you live with your family Jonathan?
Colleague: I live in the hospital accommodation. My parents live in some other part of UK.
Dr: Have you got any friends in here? Colleague: I do hang out with my friends some
times.
Dr: That is good. Could you tell me if you have noticed that drinking has been impacting
your life and work? Colleague: (No?)
Dr: Have you ever come to ward before like this? Colleague: No.
Dr: Have you encountered any similar problems before? Colleague: No.
(Patient Safety)
Dr: Could you please tell me what time did you start working in the ward today?
Colleague: I started in the morning.
Dr: Jonathan, I need to tell you that for the wellbeing of patients, it's important that we review
all the patients you have been seeing since morning. This is because under the effect of
Alcohol, you might have missed some necessary steps in providing the best possible care to
P a g e | 904
patients. Are you following? Colleague: Yes.

Dr: Could you please tell me how many patients did you see Jonathan? Colleague: (?)
Dr: Did you happen to look after any patient who seemed to require an emergency care or
immediate referral? Colleague: (?)
Dr: You see Jonathan, all of us want what is the best for our patients, I feel you should stop
working now and take rest for the rest of the day, what do you say ?
Colleague: That is right. I can understand. What will happen with them?
Dr: Well, I think these patients need to be reviewed. Do not worry. I will take care of that for
now. Colleague: Thank you.
(Initiate)
Dr: I can see that you are having some troubles and that's why you're consuming alcohol. I
would appreciate if you can understand how it can impact our work place. Are you
understanding? Colleague: Yes.
Dr: As you know, our patients could be very sensitive Jonathan and it is important that we are
not under effect of anything toxic that can affect our judgement while dealing with the
patients. What do you think? Colleague: I can understand.
Dr: I am pleased that you understand. I can see that you wish the best of health for your
patients. So, I would like to suggest you that it'd be better for you if you take some time off
from your work. What do you say?
64
Colleague: I still don't think it is that big an issue. Also I have my annual leave starting after
2 weeks. I am going to stay with my parents.
Dr: Jonathan, it is important to us that patients do not get affected by this. In such
circumstances, any negligence, although involuntary, can lead to a complaint against you.
And NHS takes such complains very seriously. A strict action could be taken against you if a
patient gets harmed. It can even cost you your registration with GMC. Now, I know you don't
want that. Isn't that so? Colleague: Yes.
(Escalate)
Dr: Also, I would like to let you know that we need to inform the Consultant about this. It'd
be better that you do that. What do you say Jonathan?
Colleague: Is it really necessary?
Dr: Yes, Jonathan it is really important that our senior know this.
Colleague: Will you tell the consultant?
Dr: If you don't I am afraid I have to because it is crucial for the safety of patients. I think you
will agree with me at this. Also he may come to know from others even if I don't tell him. It
may be better that you tell this to him yourself rather than others. Will you do that?
Colleague: Thank you for your suggestion.
(Support)
Dr: Jonathan, I must remind you that a range of help is available for you to cope with this
difficult time. Would you like me to tell you some options? Colleague: Yes.
Dr: First of all, you should consider taking your time off from work for some days. This will
allow you to relax and will help you deal with your situation with open mind. Would you
consider that?
Colleague: But what about my duties?

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Dr: I can see that you are really concerned about your work but you do not need to worry
because I can provide your replacement until the department makes necessary arrangements
for it.
Colleague: Thank you so much for that.
Dr: Also Jonathan, I think you need support from your loved ones, I would suggest you that
you let your family and friends know about this. They might be able to assist you deal with
this hard time. Also, you might be able to go to your parent's place for some time. It might do
you a great deal of good. What do you think?
Colleague: Yes, I would consider that.
Dr: Also, as you would be talking to consultant, he might also be able to assist you.. Okay?
Colleague: Yes.
Dr: You also know that we do have all kinds of psychiatric help available. Some talking
therapy might help you. Our consultant will be able to assess you for that. Is that okay?
Colleague: Okay.
Dr: Do you have any concerns Jonathan?
65
Colleague: No, thank you for your help.
Dr: You can totally rely on me. Let me know if there is anything troubling you.
Colleague: Okay. Thank you.
Cocaine Abuser - Final Year medical Student

You are FY2 doctor in the ward.
You went to a birthday party last night. There was a final year medical student, Joan
Halas whom you suspect was drinking heavily and was snorting cocaine. In the
morning at work, you have found the medical student agitated and hyper excited. You
overheard the nurses making fun of him, saying that he snorts cocaine at work.
Talk to the medical student, and assess whether or not it is safe for him to stay in the
hospital.
Dr: Hello Joan, I am... How are you doing? Student: I am fine.
Dr: How are the studies going on? Student: It is going alright.
Dr: That sounds good. Are you learning how to taking history or examining patients in the
ward? Student: yes I am.
Dr: I see. Well Joan, I'm a bit concerned about something. If you have some time, I'd like to
talk to you. Student: Yes, it's fine. I am free for now.
Dr: Well Joan, I happen to be at a birthday party last night. It seems that you also have been
at the same party. Isn't that so? Student: Yes, I was out with friends last night.
Dr: I see. Joan, don't mind me asking you this, did you take any drugs when you were
hanging out with friends? Student: No, I did not.
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Dr: Well Joan, I myself saw you snorting drugs. Student: Oh! you were there?
Dr: Yes, Joan I was. Student: It must be someone else. Are you sure you saw me?
Dr: Yes, I am sure. Also, I saw you drinking heavily. Is that right Joan?
Student: Will you keep it confidential if I tell you?

Dr: You see it is very important that we talk about this. I might be able to assess you once
we talk and maybe we can determine how we can solve it right here. Sometimes, we might
need to get some help but in any case, this issue will always remain inside the medical
team.
Student: Okay. I might have taken some drugs. But I have never done drugs at the work.
Dr: I have come to know that nurses have been talking about you snorting cocaine at work
place and that you have been behaving a little different.
Student: I don't think so.
Dr: Well, Joan, have you been feeling agitated or excited more than usual ?
Student: I am feeling completely normal. Besides that, everybody do drugs nowadays. I
don't think it is that big a deal. Don't you do drugs?
Dr: Well, Joan, I do not and also, I think that considering the environment we are working
in, no health care provider could afford to do anything like that. It would be wrong if we are
not careful while being in the vicinity of patients. It, in fact, is a very concerning matter.
Student: But I have never done anything wrong. I am doing very well in studies, you can
confirm from my supervisor too.
Dr: I really appreciate that you are studious about academics Joan but this matter is of a
great ethical importance. I would like to ask you some questions in order to get into the
bottom of this.
Student: But I do not think I took too much of either of the two.
Dr: I see. But did you take it in the morning? (Seek Info)
Student: I might have.
Dr: Could you please tell me since when have you been doing drugs and taking Alcohol?
(Duration)
Student: I have just done it. Not more than once or twice.
Dr: Was there any incident like sad or shocking or anything that might have lead you to start
it? (Stressor) Student: No. Everything is fine.
Dr: Could you please tell me what drugs do you take? Student: Cocaine.
Dr: How much are you taking daily? Student: (?)
Dr: I see. Could you please tell me how much do you drink daily Joan?
Student: Just a bottle of whisky and few shots of gin.
Dr: Joan, I can understand that you are not taking it for very long time but did you try to stop
taking the cocaine and alcohol or reduce the amount? (Cut Down)
Student: Not really. I don't think it is too much.
Dr: Alright. Could you tell me how has been your mood lately? Grade it for me on the scale
of 1 to 10? Student: 10 out of 10.
Dr: I can see that you have friends and you like hanging out with them. Do you live with
your family Joan? Student: Yes/No
Dr: Any trouble with the law? Student: No.
Dr: That is good. Could you tell me if you have noticed that drugs have been impacting your
life and studies ? Student: (No?)
Dr: Have you ever come to ward before like this? Student: No.
Dr: Could you please tell me what time did you come to the ward today?
Student: I started some time ago.
Dr: Joan, I need to tell you that for wellbeing of patients, it's important that we review all the
patients you have been seeing since morning to check any trouble or harm has been caused
P a g e | 907
to patients. Are you following? (Patient Safety) Student: Yes.
Student: That is fine. But I still think I did not do anything wrong.
Dr: I can see that you have the notion that taking drugs is not that big an issue but I would
appreciate if you can understand how immensely it can impact our patients. Are you
understanding? (Initiate) Student: Yes.
Dr: As you know Joan, one day, you are going to get into the professional medical field. It is
very crucial that you learn about patient safety and medical ethics now. You must try to
understand that medical professionals should not be under effect of anything toxic that can
affect their judgement while dealing with diseased patients. What do you think?
Student: Yes, I can understand.
Dr: I am pleased that you understand. I think you also wish the best of health for the
patients. So, I would like to suggest you that it'd be better for you if you do not stay at
hospital today because you are under the effect of drugs and alcohol. What do you say?
Student: I am not harming anyone.
Dr: Well Joan, I understand but it is important that patients do not get affected by your
behaviour in any way whatsoever. Also if you do not rectify your mistakes now, it might
lead you into some trouble later on. Your negligence can lead to a complaint against you.
And such complains could be taken very seriously by NHS. A strict action could be taken
against you if a patient gets harmed. Now, I know you will not want that. Isn't that so?
Student: Yes.
Dr: Also, it is essential that you inform your Education supervisor about this. It'd be better
that you do that. What do you say Joan? (Escalate)
Student: Is it really necessary?

Dr: Yes, Joan it is really important that your education supervisor know about this. I think
you will agree with me at this. Also he may come to know from nurses even if I don't tell
him. It may be better that you tell this to him yourself rather than others. Will you do that?
Student: Okay, I will go straight to my supervisor. Thank you for your suggestion.
Dr: Joan, I must remind you that a range of help is available. Would you like me to tell you
some options? (Support)
Student: Yes. What kind of help are you talking about?
Dr: As I would sincerely advice you to quit this habit Joan, you might need to know that
some medicines are available that could help you if you have trouble dealing with you
cravings and for your withdrawal symptoms once you stop doing drugs. Also Psychiatrist
can help you if you need. Is that okay? Student: All right.
Dr: Joan, I also think you better avoid going out to places that will make you want to do
drugs and drink. I would suggest you that you let your friends know about this and how
important it is for you to not involve in drugs. They might be able to understand your
situation or you might avoid going out to such pubs and parties. This will do you a great deal
of good. What do you think? Student: Yes, I would consider that.
Dr: As you would be talking to your supervisor, he might be able to tell you if you need
some time off from your ward duties or not. Is that alright? Student: Okay.
Dr: Do you have any concerns Joan? Student: No, thank you for your help.
Dr: Once again Joan, you can totally rely on me if you ever encounter any problem in future.
Let me know if there is anything troubling you. Student: Okay. Thank you.
P a g e | 908

Medical student comes late to the hospital. Talk to
him
Reasons for coming late
Traffic problem
Any other job before coming to the hospital
Getting up late – if so why ?
Not getting sleep
Why not getting sleep - pain, noise, bright light, depression, stress, uncomfortable bed
Going to bed late – why – late night parties, reading until late, watching TV, using
computers until late, drinking coffee alcohol late night
SPIES
Seek info – what is the problem?
How are you doing? How do you find medical school ?what about the hospital posting ? do
you like it? Do you talk to patients in the hospital ?do you enjoy that ? Any problems at all ?
do you come regularly ? do you come in time to the hospital?
He may or may not admit to coming late
We noticed that you are coming late to the hospital may I ask why?
He may say that he gets up late. But I am late only few minutes.
Why does he get up late ?any sleep problem?
Any medical conditions?

Any travel problems ?
Anything else bothering him?
How is he in studies? – praise him if he says he is good in studies.
Patient safety – It is not a good habit to come late. We being doctors we should be very
prompt in our work. We should be very punctual in our job. It is better that you develop that
habit now itself. If the habit of coming late to the job continues – once you become a doctor
and come late to the work it may affect patient safety. GMC can take actions which is not
good for you.
Initiate : s professional we need to have good discipline at our work place. It is better to
develop a good discipline from now itself.
Do you keep alarm? I suggest you do that? Make habit of going to the bed early and getting
up early. Once you do it for sometime then you will get used to it and you may even like it.
So you can reach the hospital in time. As doctors we need to set an example to others by
being prompt and punctual in our work.
Escalate:
Do you have educational supervisor? Have you talked to him about this? I think it is better
you inform him about what is happening. If he hears from others it is not good for you.
P a g e | 909
Will tell my Consultant ? No I won’t tell your Consultant.
69..
Support: Is there any way I can help you ? Do you have any other problems ?I am sure your
educational supervisor also will help you in any way possible.
In the exam reasons may be using computes until late, he may say I thought it is the final
year so I thought of taking it easy and enjoy life, or he may say he did not realise he is
coming late or no apparent reason at all,

NAI in adult
• You are the FY 2 doctor in the surgery department.
∙
• MsCarolineAndersonisa35yearsoldfemalewhois12weekspregnantpresented to
the OBG department with the history of bleeding per vagina. On examination
midwife did not find any blood in the vagina but she noticed multiple bruises which
lookedlikefingermarkingonherwristsandotherpartsofbody.Midwifeaskedyou to talk
to the patient. USG done and her baby isfine.
• Talk to the patient.Do not examinerher.
Dr: Hello Mrs Anderson, I am Dr …. One of the junior doctor in the Obstetrics
and Gynaecology department. How are you doing ?
Can you please tell me what brings here to the
hospital ? Pt: I had some bleeding from my front
passage.
Dr: Ok. Did you have any other problem? Pt: No

Dr:MrsAndersonMidwifeexaminedyouandshesaidthereisnobloodinthefrontpassage
and you are fine and your baby is also fine.Is there anything else I can helpwith?
Pt: No doctor I want go home.
Dr:MrsAndersonmidwifetoldusthatshenoticedsomebruisesonyourwrists.Wouldyo
u like to tell us about it? Be assured that we will keep the information
confidential unless you want us to disclose it toanyone.
Pt: No doctor I am fine I just want to go home.
Dr:MrsAndersonweareheretohelpyouandyourbabyandanyoneelseyouareclose
to if needed. You seem to be in some danger. Please do not be worried. If you talk
to us we may be able to help you. Can I have a look at your wrists please? I can
see bruises, can you please tell me how did you get thisbruises?
Pt: I just banged the door that is how it happened?
Dr: Your bruise does not look like it happened because of banging the door. It
looks as if some has pressed with the fingers. Mrs Anderson, don’t be worried.
We are here to help you. You can feel free to talk to me.
Pt: Doctor my partner Derek beats me some times but he is
P a g e | 910
otherwise OK. Dr: How long this ishappening ? Pt: Since my first
child was born?
Dr: You mean you have a child ?

Pt: Yes doctor. I have 3 year daughter Lacy.
Dr: Did you try to stop him in any way ? Did you try to take help from any one
about this? Pt: No doctor?
Dr: Can I ask why you didn’t ?
Pt: I don’t want to put him in any trouble. I don’t want anything bad to happen to
my daughter.
Dr: Has he hurt her also? Pt: No he does not hit her. He
loves her. Dr: Is he the biological father ofyour daughter?
Pt:Yes
Dr: Is he the father of the baby inyour womb?
Pt:Yes Dr: Is this aplannedpregnancy?
Pt:Yes.
Dr: Is your first daughter was a planned pregnancy ? Pt : Yes.

Dr: Is there anyone else at home apart from your daughter ? Pt: No
Dr: Do you know why does he beat you ?Pt: Sometimes he gets too stressed and he
beats me. Sometimes it is my fault. I do not do the work at home properly.
Dr: Is he under the influence of alcohol or drugs when he beats you. ?
Pt: No Dr: Does he hurt you in any other ways like sexually
oremotionally? Pt:No Dr: Do you work ? Pt: No.
Dr: Does he work ? Pt: Yes he is a plumber.( mechanic)
Dr: Mrs Anderson does this problem affect you in any way ? Do you feel low
because of this ? Pt: yes I feel low ( Mood may be5)
Dr: Did you ever think of harming yourself ? Pt: No
Dr: Do you have any emergency plans if something serious happens ? Pt: No
Dr: Have you spoken about this to your family members or friends ? They may
be able to helpyou. Pt: I haven’t told anyone. He has barred me from telling any
ofthem.
Dr: Mrs Anderson I am very sorry that this is happening to you. You do not
deserve this. There are lot of help is available for such problems in the community.
There is national domestic helpline and women’s Aid group. You can talk
to them. We can involve the Police and social services to help you.
Pt: I do not want to inform the police or anyone? Social services may take away
my child. I don’t want them to know. If I inform them then where will I go ? I
don’t have any other place to live.
P a g e | 911
Dr: I can imagine your problems. However, Mrs Anderson this is for your own
safety and child’s safety that social services must get involved. Also if you are not
safe to go back home they can make some arrangements for you and your child to
stay in a safe place. I am sure they will take care of everything. Is that OK?
Pt: Ok Thank you doctor. I will talk to my mother.
Dr: Please do let us know if you need any kind of help in the future. Thank you.

Insomnia and NAI
Scenario
34 year old female complains of insomnia. She has visited GP clinic 6 months ago for
follow up of OCP. Assess the patient and discuss appropriate management.
History- Ask her the primary complaint and how long she has been having this problem.
She complains of insomnia for a period of 2 months. Ask her about sleep hygiene, medical
conditions, medications that she might be consuming.
She is completely anxious throughout the station. Ask her what is bothering her.
Later on after repeated probing ( offering confidentiality), she gives a history of domestic
violence by her husband. Her husband is a businessman and is very stressed. He comes home
and hurts her by pulling her hair.
NAI questions-
• How long has this been going on?
• Who else lives at home?
• Do you have children? If yes, ask the following questions-
-Does he hurt the children?
-Is he the biological father?
-Was it planned pregnancy?
1. Has she confided this to someone else?
2. Do you work?
3. Is he under the influence of alcohol when he beats you?
4. Does he hurt you like sexually or emotionally?
• Ask about mood scale
Husband doesn't drink. Pulls hair and pushes her around.
Management- 1.Offer national domestic helpline and women aids group

1. Police and inform social services
(Insomnia is due to the domestic violence. Explain to her that she should be able to sleep
again as before once this is sorted out. If she still complains of lack of sleep, advise her sleep
hygiene methods.)
(Patient is not interested to discuss about OCP)
. Insomnia: Woman comes in with history of insomnia since 2 months. No positive history
P a g e | 912
for coffee, bed comfort, neighbours, loud noises, flashy lights, exercise. She asks for
confidentiality and then talks about husband abuse. Husband is stressed at work and hence
the abuse. She feels scared to even have children with him. Her parents are down south, so it
is relatively difficult to visit them. She considers Women’s aid group and the hotline service
and a short period of stay with her parents eventually.
NAI - Elderly lady

Elderly Abuse
Elderly lady brought in her by her daughter with history of falls.
Causes of falls
Non Medical Medical
Poor vision Balance problem ( cerebellar)
Poor light Postural hypotension ( medications)
Slippery floor Heart - arrhythmia
tripping Diabetes
Pushed( Abuse) Alcohol
Osteoporosis
Dementia
Causes of bruise
Non medical Medical
Accidental injuries Bleeding disorder
Non Accidental Medications -Steroids, Blood thinners
Social history
Where does she live, with whom. Who looks after, Does daughter work, Is she busy, Are you
able to look after your mother, or do you find it difficult, How does your children get along
with your mother, Any one else at home,
Any past injuries, past medical problems, past Hx of bruises.
Elderly Abuse - New exam question

Mrs Diana Roberts brought in her 85year old mother Mrs Margaret Roberts with the
history of falls. Nurse noticed some bruises on her body including her axilla. Bruises
were of different ages.
You are suspecting some fracture and mother is in the X Ray at the moment.
Take history from the daughter and discuss the further management with her.
Dr: Hello Mrs Diana Roberts . I am Dr… one of the junior doctor in the medical department.
How are you doing ?
Daughter : I am fine doctor.
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Dr: How can I help you Mrs Roberts.?

Daughter : My mother fell down today. I brought her in to have a check up.
(Elaborate on presenting complaint )

Dr: I am sorry to hear that. Can I ask how did she fall ?
Daughter : She is very old and frail. She keeps falling?
Dr: Can you please elaborate about the fall today?
Daughter : She was in the room and she fell on the radiator.
Dr: What time did this happen? Daughter : Few hours ago.
Dr: What did you do immediately after that? Daughter : I brought her in here.
Dr: That is really good. Can you please tell me was she standing when she fell
Daughter : Yes
Dr: Did she lose consciousness and then she fell do you know?
Daughter : No she was conscious
Dr: Did she lose consciousness after she fell? Daughter : No
Dr: Was she able to get up after she fell down? Daughter : Yes.
Dr: Did she slipped or tripped on anything ? Daughter : No

Dr: Was it dark and she could not see anything? Daughter : No
Dr: Does she have any problem with her vision? Daughter : No
Dr: Did she have dizziness just before she fell do you know? Daughter : No
( Past history of falls and injuries)
Dr: Has it happened before ? Daughter : Yes few times/first time.

Dr: Was she brought into the hospital before for this? Daughter : No
Dr: May I know why ? Daughter : She was fine after she fell.
( Past medical history)

Dr: Has she got any medical conditions ? Daughter : No
Dr: Is she on any medications ? Daughter : No
( History for bruises - if it is mentioned in the question)

Dr: Have you noticed any injuries this time? Daughter : I am not sure.
Dr: Nurses noticed some bruises on her body do you know how she got this?
Daughter : I don’t know about that / She fell on the radiator that is how she got it.
Dr: Is she taking any blood thinner medication or steroid medication? Daughter : No
Dr: Has she got any bleeding disorders ? Daughter : No
( NAI questions)
Dr: Can I ask where does she live ? Daughter : She lives with me in my house?
Dr: Who looks after her? Daughter : I look after her
Dr: Do you work? Daughter : Yes I work.
Dr: Who else lives at home ?
Daughter : I have 2 teenage age daughters. They live with me.
Dr: Anyone else at home ? Daughter : No
Dr: Anyone else looks after your mother apart from you? Daughter : No
Dr: How do you and your daughters get along with your mother? Daughter : We are fine.
Dr: You seem to be very busy. Do you find it difficult to manage everything at home?
Daughter : Yes doctor I have to work, look after my kids and my mother and I have to do
house work also.
Dr: I can imagine it must very tiring. Have you thought of keeping her in the care home or do
you think you need any help to look after your mother at home ?
Daughter : That will be very helpful doctor if I can get help to look after her at my home.
P a g e | 914
Management:
Dr: Mrs Roberts, we need to keep your mother in the hospital and examine and treat her
because she could be having some fractures for any injuries and do some test to find out why
does she keep falling and why does she has bruises on her body. We may need to do some
tests like blood tests to check her sugar, for anaemia ECG, her blood pressure and other
things. I will inform my seniors about this.
Daughter : Ok
Dr: We will have to involve the social services also.

Daughter : Why involve the social services?
Dr: We need to involve them because we need to check if there are any other reasons like any
type of physical abuse because we cannot explain the reasons for some type of bruises she
has on her body like bruises under her armpit.
Daughter: That bruises is because I was holding her arms.
Dr: That may be possible. However Mrs. We need to involve the social services just to be on
the safe side for your mother.
Daughter : Are you saying I am abusing my mother.

Dr: I am not saying that Mrs Roberts. I can see that you work and look after your mother and
daughters. That shows that you are a very caring daughter and a caring mother to your
daughters. Your mother may be having fractures which is very serious type of injuries if it is
physical abuse. So it is for your mothers own benefit we need to involve them. They will
look into this issue and they may talk to you and your mother also. They will take further
decisions about your mother. In fact they may even help you by arranging social cares to look
after your mother if you wish.
Daughter : Can I take her home?
Dr: As I mentioned we need to admit her now do tests and treat her and then the social
services will take further decisions after talking to you and your mother.
------------------------------------------------------------------------------------------------------
Same question - another story.
Dr: Hello Mrs Diana Roberts . I am Dr… one of the junior doctor in the medical department.
How are you doing ?
Daughter : I am fine doctor.
Dr: How can I help you Mrs Roberts.?
Daughter : My mother fell down today. I brought her in to have a check up.
(Elaborate on presenting complaint )

Dr: I am sorry to hear that. Can I ask how did she fall ?
Daughter : I hit her and she fell down.
Dr: Can you please elaborate about the whole incident please.
Daughter : We had some argument and I just hit her. She fell down on the radiator.
Dr: What time did this happen? Daughter : Few hours ago.
Dr: What did you do immediately after that? Daughter : I brought her in here.
Dr: Can you please tell me was she standing when she fell
Daughter : Yes
Dr: Did she lose consciousness after she fell? Daughter : No
Dr: Was she able to get up after she fell down? Daughter : Yes.
Dr: Has this incident happened before? Daughter: No/ Yes
Dr Has been brought into the hospital for such incidents before/ Daughter : Yes/ No
Dr: How do you feel about it now ? Daughter : I should not have done that. / I feel bad
about it / I have been bit harsh on my mother.
( Past medical history)

P a g e | 915
Dr: Has she got any medical conditions ? Daughter : No

Dr: Is she on any medications ? Daughter : No
( History for bruises - if it is mentioned in the question)

Dr: Have you noticed any injuries this time? Daughter : I am not sure.
Dr: Nurses noticed some bruises on her body do you know how she got this?
Daughter : I don’t know about that / She fell on the radiator that is how she got it.
Dr: Is she taking any blood thinner medication or steroid medication? Daughter : No
Dr: Has she got any bleeding disorders ? Daughter : No
( NAI questions)
Dr: Can I ask where does she live ? Daughter : She lives with me in my house?
Dr: Who looks after her? Daughter : I look after her
Dr: Do you work? Daughter : Yes I work.
Dr: Who else lives at home ?
Daughter : I have 2 teenage age daughters. They live with me.
Dr: Anyone else at home ? Daughter : No
Dr: Anyone else looks after your mother apart from you? Daughter : No
Dr: How do you and your daughters get along with your mother? Daughter : We are fine.
Dr: You seem to be very busy. Do you find it difficult to manage everything at home ?
Daughter : Yes doctor I have to work, look after my kids and my mother and I have to do
house work also.
Dr: I can imagine it must very tiring. Have you thought of keeping her in the care home or do
you think you need any help to look after your mother at home ?
Daughter : That will be very helpful doctor if I can get help to look after her at my home.
Management:
Dr: Mrs Roberts, we need to keep your mother in the hospital and examine for any injuries
and do some test to find out whether she has any medical conditions. I will inform my seniors
about this.
Daughter : Ok
Dr: We will have to involve the social services also.
Daughter : Why involve the social services?
Dr: Mrs… you said that you hurt your mother - I do appreciate your honesty . I can see that
you work and look after your mother and daughters. That shows that you are a very caring
daughter and a caring mother to your daughters. However we need to involve them in such
incidents of physical abuse. Also if she has fractures then this will be very serious type of
physical hurt. This is for your mother’s own benefit we need to involve the social services.
We have to make sure that she is safe.
They will look into this issue and they may talk to you and your mother also. They will take
further decisions about your mother. In fact they may even help you by arranging social cares
to look after your mother if you wish.
Daughter : Can I take her home?
Dr: As I mentioned we need to admit her now do tests and treat her and then the social
services will take further decisions after talking to you and your mother. Thank you.

NAI – ChildNew exam question
P a g e | 916

Miss Henna Smith brought in her 4 month old son Mitchell with swelling on his left
arm.
X Ray shows spiral fracture of left humerus.
Take history from her and discuss management with the mother.
Dr: Hello Miss Henna Collins, I am Dr …. How are you doing ?

Mother: I am fine thank you.
Dr: Can you please tell me what brings you to the hospital ?
Mother: In the morning, when I came home, I noticed swelling on

Mitchell’s arm. Dr: I am sorry to hear that. Do you know how this
happened ?
Mother: I don’t know.
Dr: Were you not with Mitchell
last night ? Mother: No. I was at
work.
Dr: Who was looking after Mitchell at that time ?
Mother: I asked my boyfriend Connor to look
after Mitchell. Dr: Did you ask your boyfriend
about this swelling?
Mother: I could not ask him because he was sleeping. / I asked him but he
said he did not know anything / I could not ask him because as soon as I
reached home he left for his work.
Dr: What time did you
notice this? Mother: In
the morning at …
Dr: Did he have that swelling before you went for
your work ? Mother: No he didn’t have that
swelling.
Dr: OK. Has he got any other injuries ?
Mother: I don’t think so. I saw only swelling in his arm.
Dr: What did you do immediately after you saw
the swelling? Mother: I brought him here.
Dr: Mrs Collins. You have done very good thing. We will
definitely help him. Dr: Did Mitchell have any injuries in the past
at all? Mother: No
Dr: Has he got any medical conditions at all?
Mother: No Dr: Is he taking any medications?
Mother: No
Dr: Is he allergic to anything ? Mother: No Dr:
Did you have any problem when you were pregnant with
him? Mother: No
Dr: Any problem during birth ? Mother: No
Dr: Was it a planned pregnancy ? Mother: Yes
Dr: Any problem with his development ? Mother: No
Dr: Where is his father ? Mother: I don’t know.
Dr: Do you mean your boyfriend is not Mitchells father ?

Mother: Yes that is right.Dr: Do you have any other children ?
Mother: No
P a g e | 917
Dr: What work do you do? Mother: I work in an Off

license shop Dr: How is your finance – any problem with that
at all ? Mother: No
Dr: What does your boyfriend do ? Mother: He works as .. Dr:
Does anyone of you use drugs or drink alcohol ? Mother: No
Dr: Is there anything else you think you want to tell me ? Mother: No
Dr: Miss Smith, We have done the X ray. Unfortunately it shows that he
has fracture in his left arm bone.
Mother: OK. What are you going to do?
Dr: We will have to keep him in the hospital and treat him. We will
inform the Orthopaedic doctors. They will manage him for the
fracture.
Mother: OK.
Dr: Also we may need to do the X Ray of his whole body and also CT
scan of his head. I will inform my seniors and we need to involve
social services.
Mother: Why involve social services ?
Dr: I am very sorry to say this. This fracture looks very suspicious. This
type of fracture usually do not happen due to injuries. It usually happens
if someone has twisted his arm. So we need to involve the social
services. They will look into this.
Mother: Do you mean to say I am hurting my child. I am going to take my
son back. I am the mother you can’t stop me.
Dr: I am sorry if I made you feel that way. I didn’t mean that. You have
brought your son immediately here. It shows you are very caring mother. I
am very sorry if I hurt your feelings. I mean there are chances that
someone has done this to your son.
Mother: Do you mean to say my boyfriend has done this?
Dr: We do not know who done that. You said you were not there when this
happened. So it is for your son’s benefit that we need to involve the social
services to see how this would have happened ? Don’t you think it is good
to involve the social services so that these things may not happen to him
again? What do you say?
Mother
:OK
doctor.
Thank
you
very
much

Massive stroke – Palliative care BBN
60 year old man was admitted one week ago with ischemic stroke. He had another
ischemic stroke now. GCS is only 3. MDT decided for DNAR and not to ventilate.
Planned for palliative care only.
You talk to the daughter who is pregnant.
Assess knowledge
Break the news. He has a massive stroke ( there is big blood clot in the brain – so
there is no blood supply to the part of the brain. He is unconscious now.
P a g e | 918
Unfortunately he will not recover. Our team has planned not to resuscitate if his heart
stops beating. Also the team has decided not to put him on breathing machine if he
stops breathing because any of these procedures o not help him.
Address concerns
Her main concern
Can you please keep him alive until my baby is born which may be next week ?
First of all congratulations on your pregnancy and having a baby soon.
I really wish we could keep your father alive until your baby is born. But
unfortunately he is in a very critical condition now. He may not survive. And as I
mentioned our team has decided not to do resuscitation if his heart stops beating or if
he stops breathing also.
Ask – any other concerns – Any help required.

Post – Op Stroke ( BBN Station on 16th Oct)
You are a FY2 working in Surgery department.
Mrs. Dollores, 80 year old had been diagnosed with an intracranial tumour. She had
been operated on. While in the recovery after the operation she was noted to have
developed left sided facial weakness. She has been seen by a multidisciplinary team and
all tests have been done (FBC, Urea & Electrolytes, LFTs, RFTs , ECG area all normal.
A CT scan was done and she was found to have had an ischaemic stroke. Her son is
concerned about his mother and would like to speak to you.
Assume consent has been taken to talk to the son
Task : Talk to the son and address his concerns. Discuss further management
Dr: Hello Mr I am Dr…. one of the junior doctor in the surgical department.
How are you doing? Pt: I am OK
Dr: I am one of the team of doctors looking after your mother
I am here to talk to you about her condition. Do you know anything about how her condition
is now?
Pt: She had a surgery for a brain tumor. I don’t know doctor how she is now. How is she
doctor?
Dr: Is it okay if I ask you a few questions about your mother’s health before discussing her
condition? Pt: Okay doctor
Dr: Does your mother have any medical conditions?
Pt: Yes, she has arthritis since few years.
Dr: Do you know what medication she is taking for the arthritis? Pt: No
Dr: Did she have any high blood pressure? Diabetes? Any Kidney or Liver disease? Pt: No
Dr: Any stroke or mini strokes before ? Son: No
Dr: How was she before ? Was she very active? Son: Yes
P a g e | 919
Dr: I am sorry to say I don’t have good news.

Pt: Please tell me doctor, Is my mother okay?
Dr: Mr____, As you know we have done an operation to remove the tumor in her brain.
While she was recovering from the surgery we noticed that she developed weakness on the
left side of her face. Our team of doctors did some blood tests and they came out normal.
However I am sorry to say that when we did a CT scan we noticed that she had an ischaemic
stroke in her brain.
Pt: What does this mean doctor?
Dr: Ischaemic stroke occurs when a blood clot blocks the flow of blood and oxygen to the
brain. This starves the brain of the oxygen and the nutrients it needs, which damages the brain
cells.
Son: Why did this happen?
Dr: There are many reasons why an ischaemic stroke occurs. Blood clots typically form in
areas where the arteries have been narrowed or blocked over time by fatty deposits known as
plaques. As one gets older, the arteries can naturally narrow, but certain things can
dangerously accelerate the process. These include smoking, high blood pressure, obesity, high
cholesterol levels, diabetes, excessive alcohol intake.
Son: How will you treat my mother now?
Dr: We have started her on a combination of medications to treat the condition and prevent it
from happening again. Also at the time of discharge we will review her medicines. We will
start her on Physiotherapy to improve her condition.
Son: Will she recover soon?
Dr: Although some people may recover quite quickly, many people who have a stroke need
long-term support to help them regain as much independence as possible. This process of
rehabilitation depends on the symptoms and their severity.
Son: My mother lives on her own a few houses down the lane from my house. How can we
provide care to her?
Dr: Mr__, I can see that you are a very caring son. We will talk to the Social Services and
they will arrange the appropriate care and support for your mother.

Dementia - Palliative care
 You are the FY 2 doctor the medical ward.
 Mrs Mary Black is an 88 years old female with a diagnosis of advanced dementia.
She was admitted to the hospital 4 weeks ago with general deterioration and poor oral
P a g e | 920
intake as she is refusing to eat or drink. She is losing weight and she is also agitated.
 Your consultant thinks planned not to give any aggressive treatment. He has decided
for palliative treatment.
 Speak to the daughter, Mrs Sarah Black, about her condition and address her
concerns.
Dr: Hello Mrs Sarah Black. I am Dr …. One of the junior doctor in the medical department
looking after your mother Mrs Mary Black.
How are you doing?
Daughter: I am fine doctor ? How is my mother ?
Dr: She is OK now but can you please tell me how much do you about what is happening to
her.
Daughter: I was told that she has dementia.
Dr: Do you know what is dementia ? Daughter: No
Dr: Dementia is a condition of the brain that causes gradual loss of mental ability. This can
cause memory loss, reduced interest in eating enough, Incontinence, Swallowing difficulty,
inability to communicate.
Did she have any other medical condition before ?
Daughter: No
Dr: Do you have any concerns about her.
Daughter: Yes doctor. She is not eating properly. She is losing weight. I am very concerned.
She has looked after me a lot. She has done lot for me. I want to do the best for her.
Dr: I can imagine. How was she at home before she was brought in – was she eating well ?
Was she active in her life ? Was she mobile ?
Daughter: She was eating OK but she was not very active.
Dr: We have examined her and found out that she has no other medical problem apart from
Dementia. Yes we have noticed that she is not eating well and losing weight. This is because
of her dementia which is in advanced stage now.
Because of all these my consultant thinks it is not good to give her any active or aggressive
treatment as her condition is not going to be any better. So he thinks it is better we give her
only palliative care.
Daughter: What is palliative care ?

P a g e | 921
Dr: Palliative care means we do not give active aggressive treatment or any invasive
procedure to the medical condition which is advanced and progressive but we give complete
supportive care for patients and their families. We manage their pain and any other
distressing symptoms. We provide all types of supports like psychological, social and
spiritual support. We try to give the best quality of life for patients and their families. We
offer a support system to help patients live in dignity and as comfortable as possible as long
as they live.
Daughter: Doctor Who Provides Palliative Care ?

Dr: We have a specialist team called Multidisciplinary palliative care team who provides this
type of care. There are specialist consultants and nurses and also physiotherapists,
occupational therapists, dieticians, pharmacists, social workers and those who are able to
give spiritual and psychological support. Someone can even stay at patient’s home to give
care at home.
Daughter: Does this mean it is the end of her life ?
Dr: Palliative care is not just given for end of life care it is also given to those who needs
such help early in the disease means well before many months of expected death.
Daughter: But she is not eating properly. She is losing weight.
Dr: In advanced stage dementia these things do happen. They lose appetite and they refuse to
eat. Also Dementia patients lose weight even if they eat normally.
Daughter: Don’t you have any methods to feed her ?
Dr: We do have lot of methods to feed patients artificially. We can give fluids
subcutaneously that is under the skin and also we can pass a tube from her nose to stomach
( NG tube) and feed her through that and we have another method what we call as PEG
where we make a small hole from the tummy and pass a tube directly from the tummy wall
to the stomach and feed her through that.
P a g e | 922
However all these methods are not good for her because she will only be distressed more
with these types of feeding. Instead we allow them to eat and drink as they like though there
are some risks involved. This is what we call as comfort feeding. If required she can be
hand fed rather than tube feeding.
Daughter: Why it is better ?
Dr: Because dementia patients have reduced appetite and they lose weight despite
feeding artificially. Artificial feeding will not improve appetite. Also even in artificial
feeding there are risks that food may still go into the lungs. It does not improve quality of
life. Survival is not prolonged in artificially fed patients.
Feeding through the nose tube can be applied temporarily for few weeks in someone who’s
swallowing are likely to recover. In your mother’s case we are not expecting her to
improve or recover. It cannot be put for long time and also it is distressing to the patient and
can make them more agitated.
PEG: Disadvantage is that it is invasive procedure, can be dislodged by an agitated patient,

also it needs training to carers or family.
It is better to feed her by hand. Feeding by hand improves the communication and
interaction with the patient by being close to them while feeding. Also they require much
less energy. She can be fed high energy foods or fortified food. Our dietician can advise
what types of food is better for her.
Daughter: Can you feed her forcibly?
Dr: It is not good to do that. As I mentioned she will not improve even if we force feed her.
It will only distress her more.
Daughter: Can I take her home?
Dr: Yes surely you can take her home if you wish to. Have you thought of keeping her in the
hospice – this is similar to home where only this type of patients are cared for.
Daughter: What is hospice ? What do they do there?
Dr: In Hospice there are doctors, nurses, social workers, therapists, counsellors, and trained
volunteers. Hospices aim to feel more like a home than hospitals do. They can provide
individual care more suited to the person who is approaching the end of life, in a gentler and
calmer atmosphere than a hospital.
Daughter: OK. I would like to take her home now and think about the hospice later.
Dr: Ok that is fine. We will make arrangements for that. Do you need any help to take care
of her at home ? If you need we can arrange nurses and social care workers to help you to
look after her.
Daughter: Thank you doctor.
Dr: Thank you.

P a g e | 923

HIV- Discuss Lab results. (16th Oct)
There was no CD4 count. Two tests for HIV were done 2 weeks apart for confirmation.
Discuss the results with the patient.
Take history for symptoms of STI and HIV ( urethral discharge, burning sensation
while passing urine,
fever, weight loss, Diarrhoea. Also check whether the wife also has symptoms of STI
and HIV.
Check whether he had any infections previously.
Any other medical conditions, medications, allergy.
Ask about family, job.
Disclose the diagnosis – what does he think of the results. Then break the news in layers
( BBN)
Paatient may ask is he going to die –
Reassure that nowadays there is good treatment. Most of the people live many years now
without having much problems.
Tell the importance of telling it to his wife ( test and treat her). He may be reluctant initially.
Convince him. If he does not agree to tell the wife tell him we will have to inform her even if
he does not give permission.
He repeatedly asks if we are sure that the results are accurate and he has HIV. Say yes
that the test done
twice and both are positive to HIV.

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Intracranial bleed in adult. BBN

62 year old man Mr Ali presented to the hospital with headache and the CT scan
of his head showed huge intracranial bleed due to berry aneurysm.
He is unconscious but breathing on his own.
Neurosurgeon has decided that active intervention is not useful.
Your Consultant has decided for Palliative treatment.
Talk to his wife Mrs Ali and address her concerns.
Dr: Hello Mrs….. I am Dr. …. How are you

doing? Wife: I am OK.
Dr: I am one of the junior doctors in the medical department looking after your husband
Mr Mohammed Ali. I am here to talk to you about his condition.
Dr: Do you know anything about his
condition? Wife: He had headache and he
collapsed at home. Then we brought him in
here doctor.
Dr: I am sorry to hear about that.
Dr: Can I ask you few questions about his health? Wife: Yes doctor.
Dr : Did he have any medical conditions at all? Wife - No
Dr: Like High blood pressure ? Diabetes? Any heart conditions or kidney problems?
Wife : No
Dr: Any stroke or mini strokes before ? Wife: No
Dr: How was he before ? Was he very active ? Was he working?

Wife : He was very active.
Do you know what happened after you

brought him to the hospital ? Wife : No
doctor.
Dr: Mrs Ali, we did a CT scan of his head and we got the result. Did anyone discuss
the CT scan result with you ?
Wife: No doctor ?
Dr: Before I tell you the result MRs Ali can you please tell me - Do you have any
idea what may be happening to him ?
Wife: No doctor.
Dr: I am very sorry to say this - it is not a good news. He has a very serious
condition. Do you want to know about it?
Wife: Yes doctor.
Dr: Do you want any of your family members to be with you when we discuss this?
Wife: No it is OK doctor.
Dr: Mrs Ali, CT scan of his head showed there is massive bleeding inside his head.
This is a very serious condition.
Wife: But don’t you have any treatment for that?
P a g e | 925
Dr: Sometimes we can do surgery to treat this condition. We have discussed his
condition with the Neurosurgeon but he thinks the surgery or any other treatment
will not help for your husband’s condition because the bleeding is very huge.
Unfortunately, we will not be able to treat his condition. He is in a very critical

condition.
In fact it is a life threatening condition.
Wife: Do you mean to say he is going to die ?
Dr: I really wish I could say it is not true. But unfortunately Mrs Ali that is
true. She may cry – Pause, offer tissues and water.
Wife: Why did this happen doctor?
Dr: Mrs Ali There are various reasons this condition can happen. In his case he had
some abnormal blood vessels in his head which were kind of swollen and thin and that
blood vessel suddenly ruptured and caused this heavy bleeding. Also since he had high
blood pressure sometimes the high blood pressure can contribute to this problem.
Sometimes this condition can run in the family members.
Wife: Are you not going to do anything?

Dr: I really wish we could do something to save his life. But Mrs Ali - unfortunately
we will not be able to save his life because the bleeding is very huge.
Wife: That means you are leaving him to die ?
Dr: I am really sorry if I made you feel that way. I can imagine why you are feeling
that way. Mrs Ali - If at all we could have done anything we would have definitely
done that for him. But our hands are tied because there is no such treatment available
to save his life.
Wife: Are you going to keep him in the Intensive therapy unit ?
Dr: Sometimes if they are not breathing on their own we keep patients in the ITU
and attach a machine which helps them in breathing.
Mrs Ali as you may know he is still unconscious but breathing on his own at the
moment.
I really wish we could keep him in the ITU and treat him. But we keep only such
patients in the ITU to treat - with whom we expect them to recover from the
condition. Unfortunately, we are not expecting that Mr Ali will recover from his
condition.
Keeping him in the ITU even if he stops breathing is not going to help him.
My consultant will discuss these things with you because your opinion is also
very important for us. What do you think Mrs Ali ?
Wife: I can understand. Are you not going to do anything at all for him ?
Dr: Mrs Ali, However we are going to do everything possible from our side to keep
him comfortable. We will provide him palliative care – that is we will be providing all
types of care to keep him comfortable.
Wife: When do you think he may die?
Dr: I really wish that I could say that he can live very long
and healthy life but Mrs Ali he may not live very long. He
may die any day.
Wife: I have 2 sons. Should I tell them to come here ?
Dr: Mrs Ali I think you should tell them to come here
P a g e | 926
because as I mentioned it is a very serious condition now.

Wife: Can I take him home doctor ?
Dr: Yes surely Mrs. Ali. We will make all the arrangements so that you can take him
home and we will provide all types of care and support you may need to look after him
as long as he lives.
Dr: Is there any other
concerns?
Wife: No doctor.
Dr: Once again I am very sorry to give you this bad news.
Wife: Thank you doctor
Dr: Thank you very much Mrs. Ali. If you need any help please do let us know.

Aorto - Femoral bypass surgery. BBN-
You are the FY 2 doctor in the surgery department.
Mrs. … 64 year lady had right sided Aorto-femoral bypass surgery. She developed
heavy bleeding in the brain after the operation. She has been transfused with 6
units of blood.
She is taken to the theatre now. Your Consultant is in the theatre.
Talk to her husband Mr… and address his concerns.
This complication was not unexpected.
Dr: Hello Mr I am Dr…. one of the junior doctor in the surgical department.
How are you doing?
Pt: I am OK
Dr: I am one of the team of doctors looking after your wife Mrs.
I am here to talk to you about her condition. Do you know anything about how her
condition is now?
Pt: She had a surgery. I just came to see her now. I don’t know doctor how she is now.
How is she doctor?
Dr: I really wish I had a good news for you. But Mr..I am very sorry to say this she is in
a very critical condition now.
Pt: Why doctor what happened ?
Dr: After the surgery she was moved to the ward then we noticed that she started
bleeding heavily. We already transfused her 6 bags of blood. Unfortunately bleeding has
not stopped. So we have shifted her to the operation theatre again to try to stop the
bleeding. My Consultant is with her in the theatre. Our whole team is trying our best to
stop the bleeding.
Pt: OK. I need to go for my work now. Shall I come back after she is back from the
theatre?
Dr: Mr. I am very sorry to say that this condition is very serious because we may not
be able to stop the bleeding and it is a life threatening situation now.
Pt: What do you mean ? Do you mean she may not make it ?
Dr: I really wish to I could say she is not in danger but unfortunately that is true Mr...
We are trying our best to stop the bleeding but it is very difficult to stop the bleeding in
such situation and if we do not succeed in stopping the bleeding she will not survive.
Pt: But why this happened?
Dr: Unfortunately sometimes this type of complications does happen after the surgery.
P a g e | 927
Pt: Didn’t you know this problem can happen before the surgery?
Dr: These types of problems are expected to happen after this type of surgery. Usually
we are prepared to handle this type of problems by operating again but in your wife’s
case it is very difficult to control the bleeding.
Pt: If you did expect this problem before then why did you do the surgery?
Dr: Unfortunately her condition was so serious that if we did not do the surgery she
would have lost her leg. That is why we did the surgery.
Husband: If you did not do that surgery she would have just lost her leg but now you
have put her life at risk.
Dr: Mr… It is true that it is a life threatening condition now but the risk of bleeding was
very low. Usually more than 95% of the people recover from this operation without any
complications at all.
We usually inform the patient all the benefits and the risks of the operation before we do
any operation. Since the risk was very low we did the surgery. It is very unfortunate that
this problem happened to her.
Pt: I think you did the operation unnecessarily and you are giving me my wife’s dead
body now.
Dr: I am really sorry if I made you feel that way. I can imagine why you are feeling that
way. It was essential at that time to do the surgery to save her leg.
Pt: Why is that you say it is difficult to stop the bleeding? Where is she bleeding from?
Dr: Let me explain her condition and what operation we did on her and you can
understand where she is bleeding and why it is difficult to stop the bleeding.
We all have a big blood vessel in our tummy called Aorta which branches out into
smaller branches and it continues in to the leg as femoral artery which supplies blood to
the leg. She had blockage in the femoral artery in the top part of her thigh so the blood
was not flowing into her leg.
We had to do an operation to restore the blood supply to her leg. So we connected an
artificial tube from the Aorta in her tummy to the femoral artery in the thigh so as to by
pass the blockage. We have succeeded in restoring the blood supply to the leg but
unfortunately she has bleeding now. Bleeding is happening where we joined the artificial
tube to the original blood vessel. Because blood is under heavy pressure in that area it is
very difficult for us to stop the bleeding.
However my seniors are doing their best to stop the bleeding. Let us hope they will
succeed.
Pt: Doctor I have two sons. Do you think I should inform them?
Dr: Mr … Yes surely you can tell them that she is in a serious situation.
Pt: Should I tell them to come here ?
Dr: Yes, Unfortunately the condition is very serious Mr. I think you should tell them to
come here very soon.
Pt: One of my son is in London other one is in Australia.
Dr: You can tell your sons to come here as soon as possible as she is in a critical
condition. I think they need to be informed about it.
[ sometimes he may say one is in London and the other is in Somerset – both can come
here soon]
Pt: OK. Thank you doctor.
Dr: Once again I am very sorry to give this bad news. Let us hope that she will be fine. If
you need any kind of help please do let me know. Thank you very much.
P a g e | 928

Breast Cancer (DICU)
Exam question
Patient 58 years old female has been called to surgery outdoor clinic to receive
results of her breast screening mammogram and FNAC. Results show ductal
carcinoma in situ (Early cancer).
She has been self-examining her.
You are FY2 in surgery. Talk to her and give her management options.
(when you enter the cubicle patient acts anxious and worried)
Dr: Hello I am dr. ----------Are you Mrs Sharon?

Pt: Yes dr.
Dr: How are you doing today Mrs Sharon?
Pt: Dr. I am really worried. I keep on self-examining. I have not found anything. Few
weeks back I came for routine test they did an X-ray and took some samples. Then
weeks and weeks later I received a letter from your office and I came to get my results.
Dr: It is really good that you kept self-examining it shows how keen you are about your
health. Sharon I know that we have made you wait for quite some time but biopsies
usually take time to be assessed and report to be confirmed. I am sorry we made you
wait for your results but I have your results with me and I would be discussing those
shortly.
Would it be alright if I ask you few questions first so that I can explain test results
better?
Pt: Sure doctor what would you like to know?
Dr: You mentioned that you haven’t found any lump in your breast. Have you noticed
any lump elsewhere in body? No
Dr: Have you noticed any discharge from breast? No
Dr: Any bleeding? No.
Dr: Have you noticed any change in your weight ? No.
Dr: Is there any history of you taking oral contraceptive pills? No
Dr: Have you ever received hormone replacement therapy? No
Dr: Did you have any surgeries in the past? No
Dr: Does anyone else in your family have breast cancer? No
Dr: Do you smoke? no
Dr: Do you drink alcohol? no
Dr: And when was your last menstrual period? Pt: It has been years doctor, may be 6 to
7 years now.
Dr: Sharon is there anything in specific that you are concerned about ?
Pt: Dr. I am worried if I have cancer. I just want to know the results.
Dr: Yes Sharon I do have the results of your tests.
Pt: What is it doctor?
Dr: Unfortunately I don’t have good news for you.
Would you like to hear it alone or shall I call someone to be with you ?
Pt: That is fine you can tell me the results.
Dr: Sharon as you know we did a mammogram and FNAC biopsy,,,,unfortunately the
results show that you have an early form of cancer in your breast.
Pt. Takes a pause (acting as if she is shocked )
Pt: But doctor how it could happen? I have been self-examining since I was young. I
never felt any lump. How is it possible? ( pt starts blaming herself that may be she is not
P a g e | 929
doing test properly)

Dr: Mrs Sharon I can’t even imagine what you must be going through right now. But you
are not to be blamed for this. It is an early form of breast cancer. It usually has no
symptoms. Most cases are found during routine breast screening or if a mammogram
(breast x-ray) is done for some other reason.
Pt: Dr. I am really worried about breast cancer. Is there any hope for me?
Dr: Mrs Sharon your concern is really valid. We would help you in whatever way we can.
Let me reassure you although it is a cancer but luckily it is at an early stage and as far as
I know this particular cancer carries a good prognosis. But I would like you to have
detailed discussion with my consultant Surgeon and he may be able to tell you about
this condition in detail and you can discuss treatment options as well.
Pt: Oh that’s why I got a call from surgery department.
Dr: Yes Mrs Sharon as far as I know treatment usually revolves around surgery. Surgical
removal, with or without additional radiation therapy or tamoxifen, is the
recommended treatment for this type of cancer.
Dr: Once again Mrs Sharon I really wish that I had better news to tell you today. Is there
anything else I can do for you?
Pt: Dr. I have been going through internet and I was reading about lumpectomy and
mastectomy, can you please tell me more about them.
Dr: Mrs Sharon I am really glad that you are so concerned about your health. It’s not
every day that we come across patients who are so well informed and concerned about
their health.
Lumpectomy is a surgical removal of a discrete portion or "lump" of breast. In this
surgery tumour is removed along with the healthy margin surrounding it.
It is considered a viable breast conservation therapy, as the amount of tissue removed is
limited compared to a full-breast mastectomy.
While in mastectomy whole of breast tissue is removed.
Dr: Mrs Sharon is there anything else we can do for you?
Pt: NO doctor, this is all.
Dr: In that case Mrs Sharon I would be arranging an appointment for you with my
consultant surgeon as soon as possible.
Dr: Mrs Sharon I want you to know that you are not alone in this; we are always here for
you.
And as I am very glad to see you so much interested about your health, if you would like
I can give you few leaflets regarding your condition which may help you in
understanding it better.
Thank you very much doctor.

BREAKING BAD NEWS OVER THE PHONE –
INTRACEREBRAL HAEMORRHAGE
Question: You are an FY2 in Acute Medical Unit. George Blackwell, a 75
years-old man, recently collapsed at the park and has been brought in by the
ambulance. Patient is unconscious, but breathing independently. The
neurosurgeons have assessed the patient and have determined his condition as
terminal and feel that he should be placed on palliative care. CT scan brain
P a g e | 930
reveals a massive intracerebral bleed. Talk to his son David over the phone
and address his concerns.
Hello. David Blackwell? Hi, my name is Dr. ……… I am one of the junior doctors here in
the Acute Medical Unit.
 What would you like me to call you? – Hi, David

 Is this an ok time to talk? – Yes
 Can I just confirm your Relationship to George Blackwell? – Yes, I’m his son
 Is anyone with you currently? – No
 Would you like to go to a private place/take a seat? – I’m ok
I am calling regarding your dad George Blackwell’s health. Unfortunately, he is not doing
very well.
 Would you like me to continue over the phone or would you prefer it we had this
conversation face-to-face? – Phone is fine
Is everything alright? Is he okay? How is my dad?
o I understand that you’ll have a lot of questions, and I’ll do my best to answer them to
the best of my knowledge, but before we continue can we just go over a few things? –
Yes
o Do you have any understanding as to what might have happened? – No
o What have you been told so far?– Nothing
o Has anyone contacted you before? – You’re the first
Before I continue,
o Would you like to call someone to be with you? – No
Unfortunately, I have some bad news for you.
What is it?
From what I understand, a short while ago your dad was brought in unconscious by the
ambulance because he suffered quite a nasty fall in the park that resulted in a serious head
injury.
*SILENCE – WAIT for response*
Are you ok to continue? – Yes
Currently, he is unconscious but he is breathing on his own. We performed a CT Scan – a

special X-Ray – of his brain. Unfortunately, the scan was not good and revealed that he had
a significant bleed in his brain.
Unfortunately, the bleed in his brain is quite severe, and upon consultation with the
specialists – the Neurosurgeons - very little can be done about removing the blood
around his brain. Usually, if someone has suffered a bleed, the brain specialist would take
him/her to the operating room to try and remove the clot, but in this situation, due to the
very severe nature of the bleed, it’s not possible to perform an operation. The damage to
his brain is quite significant and it’s difficult to say whether he will regain his
consciousness again.
P a g e | 931
*CHUNK & CHECK*

Are you following – Yes
Is he dying? Has he died?
His condition right now is quite serious. At this time, he is unconscious and breathing on
his own. The specialist have classified his condition as Terminal.
What do you mean by terminal?
Terminal means that unfortunately, he is likely to die as a result of his condition.
*SILENCE – WAIT for response*
How long will he live?
It is difficult for me to say. However, with a terminally ill patient it may take a few hours
to several days for them to pass away.
Why did it happen?
At this point in time, we are unsure as to why this might have happened. It could be
something as simple as an accidental fall or something more serious like a stroke.
Unfortunately, I don’t have much knowledge about the sequence of events that occurred
before, during or after his fall in the park. I do believe any information you can provide
would be greatly beneficial.
Is it ok for you to answer some general questions about your father’s health? – Yes
Has your dad been diagnosed with any prior medical conditions? DM? HTN?– No
Has he ever needed to visit the hospital for any reason? – No
Has he undergone any surgical procedure before? – No
Does he take any prescription medication at all? OTC? – No
Is he allergic to anything at all? – No
Is there any medical conditions that run in the family? DM? HTN? Stroke? CA? – No
Has he travelled anywhere recently? – No
What doeshe do for a living? – Retired Architect
Does he drink alcohol? Units? – Occasionally. I don’t know
Doeshe smoke? How much? Since? – Yes, since he was 20. 10 cigarettes/day
Doeshe use recreational drugs? – I don’t think so
Who else is at home? – He lives with his wife, Bernadette
Is there anything you’d like to add, that I may have missed? – No
Can you take him to the Intensive Treatment Unit? Operation Theatre?
Intubate him?
What we are doing currently, is offering him Palliative Care.
Do you know what that is? – No

P a g e | 932
With palliative care, we are trying to maximize his quantity and quality of life by making
him as comfortable as possible by maintaining his dignity. Unfortunately, intervention
strategies like CPR and assisted breathing are more likely to prolong his suffering and
unlikely to improve his condition. Furthermore, the brain specialists have assessed him,
and they believe that an operation is unlikely to benefit his condition. I can ask the
neurosurgeons to speak to you directly and explain in greater detail why they have decided
not to perform surgery.
Are you giving up on him?
Absolutely not. It is our duty to give him the best end of life care we can provide. What we
are doing is ensuring his pain is controlled. We will be giving him fluids and medications
as prescribed by the senior doctors. We will also be monitoring his vitals, such as his heart
rate, breathing and levels of oxygen in his blood.
Do I need to call my brother in Jamaica?
I do believe that it is important for your dad’s loved ones to be around him at this time.
Is there anyone close to yourself or your dad who you believe should be here at this
difficult time? – Yes, my brother Jamie
Is there anyone you would like us to contact for you? – No. I’ll contact my mum myself
Are you the next of kin? - Yes
Do you know if any advanced plans were made on how he would like to be treated if things
get to the stage where he is now? – I don’t know
I know it is quite a lot to take in all of a sudden, but I suggest that you call them if they are
living far away so they can see him and be with him in this difficult time.
Can I come see him?
You can see him anytime you’d like to. If you’d like to see him immediately you can. I
would just have to make the appropriate arrangements for you when you come.
Would you be able to come anytime soon? – Yes, I will be there within half an hour
I will make sure you have the appropriate details and directions to find your dad in the
correct ward at the hospital.
Can I take him home?
I would need to consult with my seniors if you’d like to take him home.
Has he ever expressed his desire where he would like to be if his health deteriorated? – At
home
Has he ever expressed his desire where he would like to die? – At home with family
Do you feel that this is what he would want at this stage? – Yes
Is there anything further I can do for you/help you with? – No
If there was anything that I was unable to answer, I can try and get that information from
my seniors and get back to you. And if you’d like to discuss your father’s health further
with my seniors or from any other member of our team that are providing care to your dad
- such as the neurosurgeons - you are most welcome to do so.
P a g e | 933
I appreciate this must be a very difficult time for you, and I am very sorry to be giving you
all this information over the phone. If you have any more questions feel free to ask now,
call in to the helpline later or visit us in person.
Thank you.

Lady with Accident asking for a Sick Note [ Station on 3rd Oct ]
You are FY2 doctor in the Accident & Emergency Department
A young female patient (? Name/ Age) had an accident 2 weeks ago.
Records in the Emergency Unit state that she had no injuries and was certified fit then.
She has come now to ask for a sick note.
GRIPS
Pt- Doctor I need a sick note for my job.
Dr- I would definitely do everything to help you. Can you please tell me why you need a sick
note?
Pt- I actually had an accident 2 weeks ago and I want to take time to recover. So I want a sick
note to show at my workplace.
Dr- Can you describe the accident in detail?
Pt- I was actually drunk and was driving my car when I got involved in the accident. So I
took 2 weeks time off from work to recover. But now I want to take a leave for a few more
days and need a Sick note from the Hospital.
Dr- Can you tell me what work do you do? Pt- ???
Dr- I will check the records at the Emergency Unit. It says in the records that you were
certified fit then and that you had no injuries at that time.
Pt- Doctor can you please change the notes and give me a sick note which says that I had
injuries and need rest for few more days.
Dr- Miss, we cannot change what we already wrote in our notes. Can I ask you why do want
us to do that?
Pt- Doctor, I will lose my job if you don’t give me a sick note. I don’t have any support.
Dr- Miss, I am really sorry but unfortunately we cannot give a sick note with changed
findings – We need to be honest when we report the injuries.
Pt– Doctor, you don’t understand. My car was taken away by the police and now I don’t have
any way to go for my work. So please give me a sick note.
P a g e | 934
Dr- Miss, I can imagine that things are very difficult for you. Is there any way for you arrange
another means of transport. Maybe, your colleagues can help you by picking you up.
Pt- Doctor please give a sick note ( the lady is very persuasive and repeatedly mentions that
she doesn’t have any support and that she will lose her job).
Ask about alcohol history ( CAGE). Ask if she needs help for cutting down.
This is an alternate version of the case.

A female patient had a road traffic accident 2 weeks ago and sustained minor injuries.
She has recovered now and has come for a review.
Address her concerns.
The patient had some minor injuries at the time of car accident (some bruises on the upper
limbs). She was under the influence of alcohol while driving. There were no passengers with
her and no one else got injured. She was given a sick note for 2 weeks initially and now she
says she is back to normal but wants a sick note for 6 weeks.
Take some Hx to assess her condition (no pain now/ able to use both limbs normally/ no
sensory or motor deficit / bruises healed)
Dr- I would like to examine your both upper limbs and check motor and sensory functions. I
will ensure privacy and make sure a chaperone is present.
The examiner says Normal / No findings.
Dr- Mrs.____, From the information you have given me and the examination findings I find
that you are fully recovered and don’t need any further treatment. I will inform my seniors. I
am sorry but I cannot give you a sick note for 6 weeks.
Pt – Doctor, you don’t understand. The police have booked a case against me as I was drunk
while I was driving. I will definitely lose my driving licence. I will lose my job. If you give
me a sick note for 6 weeks I will be able to support myself and look for another job. (She
doesn’t specify what her job is, she just says that her job requires her to drive around and
without the driving licence she will lose her job)
Dr – Mrs____, I can imagine that things are very difficult for you. However, we have to be
honest and I cannot give you a sick note as my examination findings show you don’t need
any further treatment.
The patient starts crying and asks why cannot you just write a simple sick note and help her
out. She has two teenage daughters and there is no one to support them. She says she is
paying her taxes and is entitled to the sick leave.
She refuses to take help from Citizens Advisory Bureau or the Jobs centre. She says she can
find a new job on her own. She just needs some time and wants you to give you a sick note
for 6 weeks. She keeps crying in between and is very persistent about the sick note.
P a g e | 935
Ankle Sprain
You are the FY 2 doctor in the A&E department.
30 year Mrs Anna Henley presented to the hospital in the morning because she fell on grass
while she was going home from work. She had pain, swelling and bruise in her ankle. X
Ray was done in the morning.
She has come back to get the X Ray result.
Take history and talk to her about the further management.
Dr: Hello Mrs Henley I am Dr.. How can I help you ?

Pt: I came in the morning to the hospital because I had injury to my ankle. They did X Ray
But I could not wait for the X Ray result at that time. I have come now for the X Ray
result.
Dr: Could you please tell me how did you injure your ankle?
Pt: I work as a cleaner in a school. I fell inside the school premises while working and that
is how I injured my ankle.
Dr: Mrs Henly it is written in our notes that you fell on the grass outside the school
premises !
Pt: Oh Yes I made a mistake in the morning. I was not thinking properly that is why I told I
fell outside the school premises. Doctor can you please change what is written in the notes
and write that I fell inside the school premises.
Dr: Mrs Henly we cannot erase what we already wrote in our notes. However we can write
that you have requested us to change the story of how it happened.
Pt: No doctor don’t write like that. Please erase what you wrote in the morning and write
what I told you now.
Dr: Can I ask you why do want us to do that?
Pt: If I mention that I fell inside the school premises I will be entitled for compensation for
the injury happened at the work place.
Dr: I can imagine why you want to do that. Unfortunately we cannot do that – we should
be honest.
P a g e | 936
P a g e | 937
PRICE stands for:
 Protection – protect the affected area from further injury by using a supportor,
wearingshoes.
 Rest – Avoid activity for the first 48 to 72 hours. We can give you crutches tohelp
you towalk.
 Ice – for the first 48 to 72 hours after the injury; apply ice wrapped in a damp towel
to the injured area for 15 to 20 minutes every two to three hours during the day.
Don't leave the ice on while you're asleep, and don't allow the ice to touch yourskin
directly because it could cause a coldburn.
 Compression – We will put elasticated bandage to the ankle to limit the swelling
and movement that could damage it further. You can use a simple elasticbandage
or an elasticated tubular bandage. Remove the bandage before you go tosleep.
 Elevation – keep the injured area raised and supported on a pillow to helpreduce
swelling.
You should avoid ( HARM )
 Heat – such as hot baths, saunas or heatpacks.

 Alcohol – drinking alcohol will increase bleeding and swelling, and slowhealing.
 Running – or any other form of exercise that could cause moredamage.
 Massage – which may increase bleeding andswelling.
Generally, you should try to start moving a sprained joint as soon as it's not too painful to
do so.
Pt: When can I walk properly doctor?
Dr: Usually you'll probably be able to walk one or 2 weeks after the injury. We can give
you crutches to help you walk until then. You will be able to use your ankle fully after
6 to 8 weeks,
Avoid driving until strength and mobility have returned which may take 6 to 8 weeks.
You can return to sporting activities after 8 to 12 weeks if you do any sports.
Contact your GP if your injury doesn't improve as expected or your symptoms get worse.
Surgery – is not needed to treat sprains unless the injury is very severe.
25
Patient requesting Antibiotics
P a g e | 938
Exam question:
You are the FY 2 doctor in the GP clinic.
22 year old Miss Chris Barns presented to the GP clinic 2 days ago with sore throat.
Practitioner nurse did the throat swab which showed no bacterial growth.
Nurse advised her to take mild pain killers and steam inhalation. She has come back again
and wants to talk to the doctor.
Assess her current condition and address her concerns.
Dr: Hello Miss Chris Barns I am Dr…. How can I help you Miss Barns ?
Pt: I am having sore throat doctor. I came here 2 days ago and the nurse told me to take
pain killers and steam inhalation. I am not getting any better. Can you please give me
antibiotics.
Dr: Can I ask you why are you asking for antibiotics?
Pt: Last time I had some infection and I was given antibiotics and I improved very
quickly. Please give me antibiotics. I have to attend some function in the next few days. I
want to get better before that.
Dr: I can understand your concerns. Do you know what infection you had last time? Pt : I
can’t remember now.
Dr: No problem. Can I ask you few questions to see whether you need antibiotics. If you
need it we will definitely give it. Pt: Yes doctor. Thank you.
Dr: Since when are you having this sore throat ? Pt: Almost 4 days now doctor.
Dr: Do you have any pain while swallowing ? Pt: Yes slightly. Dr: Are you able to
swallow food or drink ? Pt: Yes
Dr: Do you have any breathing difficulties? Pt: No
Dr: Is your symptoms getting any better or the same or getting worse ?
Pt: It is the same doctor not getting better. I feel slightly better when I use steam
inhalation. Dr: Do you have any other problem apart from sore throat?
(page no.10)
(page no.10)
Pt: I am having pain all over the body.

26
Dr: Any other problems? Pt : Like what ?
Dr: Do you have fever ? Pt: No Dr: Do you have cough and cold ? Pt: Yes Dr: Do
you bring out any phlegm ? Pt: No Dr: Do you have pain in the ear ?
Pt: No Dr: Any chest pain ( Pneumonia) ? Pt: No Dr: Any discharge
from the nose ? Pt: Yes Dr: Any headache ( meningitis) ? Pt: No
Dr: Any rashes on the body ( meningitis, glandular fever? Pt: No Dr: Any swellings on
the neck or arm pit ( glandular fever) ? Pt: No Dr: Did you have similar problem before at
all? Pt: No
Dr: Do you have any medical conditions? Pt: No
Dr: Are you taking any medications other than pain killers and steam inhalation? Pt: No
Dr: Are you allergic to any medications ? Pt: No
Examination:
Dr: Miss Barns , I need to examine your throat and chest. Examiner may say –
Examination is normal.
Diagnosis:
Dr: Miss Barns with the information what you have given me and after the examination, I
think you have sore throat due to viral type of bugs. This type of virus infection will
subside on its own without any special treatment. Only treatment required are for the
symptoms like pain killers and the steam inhalation which you are already taking.
Pt: But I am not getting better doctor !
Dr: Miss Barns sometimes it may take about a week for the condition to subside. I advise
P a g e | 939
you to continue taking the pain killers and the steam inhalation for few more days and
you will feel better in the next few days.
Dr: Doctor, I have to attend a function in the next few days. I want to feel better soon to
attend that function. Please give me antibiotics.
(page no.10)
(page no.11)
Dr: Miss Barns Antibiotics are given only for infections due to bacterial kind of bugs not
for infection due to virus type of bugs. They do not help for viral infections. Besides that
antibiotics has its own side effects. So you may develop unnecessary side effects.
Pt: Doctors last time I improved very quickly after taking the antibiotics !
Dr: I am not sure why the antibiotics were given to you last time. May be you had
infection due to bacterial type of bugs. This time it is not bacterial infection. Nurse took a
swab from your throat last time to check whether you have bacterial infection. That test
also shows this is not bacterial infection..
Miss Barns, if we give antibiotics unnecessarily, bugs may develop resistance to these
antibiotics and next time if at all you get bacterial infections these antibiotics may not
work and it may lead to serious complications. If it all you needed antibiotics we would
have definitely given that to you. Your condition does not require it. You will feel better
soon.
Pt: Ok doctor.
Warning signs.
Dr: Thank you miss Barns. You can go home now and continue taking pain killers and
the steam inhalation. However if you are getting very unwell, or start developing chest
pain and high fever or if you see rashes on the body these could be the signs that you are
developing some complications like chest infection, so please do come back.
Hope you recover soon and be able to attend the function.

DIFFERENT COUNCILLOR
Question: You are an FY2 in GP Surgery. Christina Frye is a 28 years-old
woman who has made an appointment to come and see you. Talk to the
patient and address her concerns.
Hello. Christina Frye. Hi, my name is Dr. ……… I am one of the junior doctors here in the
GP Surgery.
What would you like me to call you? – Chris

How can we help you today Chris? – Doctor, it’s about my psychiatrist. I saw him with
another woman last week. That really upset me. So he told me to speak to my GP who
could refer me to a different councillor
Ok. I understand your request. So that we’re on the same page here, can we just start from
the beginning and I ask you a few questions? – Yes
Is there any particular reason why you would like to change your councillor? – I just don’t
P a g e | 940
want to see him again
Do I have to see him again? Can I change councillor?
If you don’t want to see him again, you don’t have to.I would be happy to arrange for you a
different councillor.
Can I have a female councillor?
Yes, you can. I can enter in your notes your desire to have a female councillor. It should
not be a problem and easily be arranged for you.
Is there any particular reason you’d like a female councillor instead of a male on? – I just
don’t trust male councillors any more
Why is that? – I just don’t
Why exactly were you seeing a councillor? – Well, my husband passed away about 2 years
ago, and I was really depressed. So I was referred by my previous GP to see the
psychiatrist. He started me off on some medication called Sertraline for the past year or
so that really helped, and I’ve been following up with him regularly ever since. He was
really sweet at first but now I just don’t want to see him anymore
I’m really sorry to hear about your husband.
How are you now? – Fine

When was the last time you saw your councillor? – Well my last consultation with him was
3 months ago. We did see each other every now and then outside of our consultations. Last
week was the last time I saw him in the town centre. I saw him with another woman and
that really upset me
And is there any particular reason why that upset you? What happened? –I don’t know if I
should be telling you this, but I guess we were in a sort of relationship. But last week I saw
him with another woman. He shouldn’t be seeing other women if he was in a relationship
with me. It’s just disgusting behaviour
Did you speak to him at all about what happened? Who he was with? – I tried. I texted
him, and he said it was his wife. He told me to speak to you and to change psychiatrists as
he doesn’t want to see me anymore. That’s why I want a female councillor
Ok, I understand.
Will everything remain between us?
I do want you to know that whatever we discuss here today will remain strictly
Confidential between you and the medical team. – Yes, please. I don’t want him to get
in to trouble
Is it alright if I ask a few more questions about your relationship with your councillor? –
Yes
How long were you seeing him outside of consultations? – About10 months
How would you describe the relationship? Was the relationship ok? – Good to start with,
P a g e | 941
then it turned for the worst, I guess.Yes, he was really sweet
Was there a physical relationship between you two? – Yes, it started by him holding my
hand. He used to put his arm around me to comfort me. Then we shared hugs. I eventually
kissed him when he said he was serious about me
Did the relationship include sexual intercourse? – Yes. Occasionally
Was it consensual? – Yes
Did he ever abuse you in any way, either; verbally, physically, psychologically or
emotionally? – No, never! As I said, he was a real gentleman. Right up to the point I saw
him with another woman.
Now just a few questions about your general health.
Have you ever been diagnosed with any medical condition before? – Yes. I was diagnosed
with depression a year ago. That’s why I was seeing my psychiatrist in the first place.
Mentally, I feel much better now
High blood sugar? High blood pressure?– No
Are you currently taking any prescribed medication? OTC?– I was taking Sertraline. But
I’ve been off my medication as suggested by my psychiatrist for the past 1 month. I’ve been
fine. No side effects
Any illnesses that run in your family? Mental health illnesses? – No
How have you been coping at home? Hobbies? Family? Sleep? Relationships? Job? – Ok
Diet? Exercise? Stress? – Ok
Do you drink alcohol? – No
Do you use recreational drugs – No
Any problems with your menstrual cycles? – None
Are you sexually active? – Yes
Who else is at home? – Only me
(I) Hopeless/Worthless? – No
(II) Disinterested/Little pleasure in life? – No
the best? - 8
Have you thought about self-harm? Suicide? – Never
Thank you for answering all my questions.
I’m really sorry about the situation that you find yourself in. As medical doctors, it is our
responsibility to maintain professional boundaries. I’m afraid to say that this doctor has
made a serious breech in ethics and he needs to be investigated further for his conduct.
P a g e | 942
Being in a position of trust, as doctors we are expected to adhere to strict guidelines set by
our regulatory body – the General Medical Council.
We must explore if anyone else has faced similar issues to the ones you faced.
Are you following me? – Yes
How do you feel about everything I’ve said and everything we’ve discussed so far? – I
think you have said some very nice things. I’m just really disappointed in myself as well
You shouldn’t be disappointed in yourself. You have been very brave in coming forward
with all this information – and you absolutely did the right thing. It must have been very
difficult to share.
I will document everything that we’ve discussed today, and the conduct of this councillor
will need to be investigated further.
I may need to inform my senior colleagues who would be in a better position to advise you
of appropriate steps to take.
Would you like to file a formal complaint? – I don’t know
As it is a serious offence, we must investigate the conduct of this medical professional.

Investigations are likely to follow 2 paths.
Firstly, through the Practice Manager. The practice manager’s role includes
investigating further into serios allegations such as misconduct from doctors. The practice
manager will continuously be in contact with you along every step of the way.
Secondly, we may have to inform the doctor’s regulatory body – the General Medical
Council (GMC) – regarding his conduct. As an independent body, the GMC are likely
to investigate further your concerns and they may call upon you as a witness to testify.
We will help you every step of the way, and you will receive information, guidance and
support throughout.
Do you understand? – Yes
Do you have any reason to believe that anyone else may be affected in a similar way to
you? – I’m not sure
Do you have reason to believe that another medical professional is involved in similar
behaviour? – No
I will need to take details of the councillor from you, if that is something you’re willing to
do. This includes his name, address of his registered place of work and any other
information that you may have that might be useful in identifying him. – Ok
I do have some information in the form of reading materials to provide you about the
professional standards and medical ethics required of doctors.
Is there anything else I can help you with?
Will he get into trouble? I don’t want him to get into trouble
It’s difficult to say at this time. Any sanctions placed upon the individual would be after a
P a g e | 943
stringent period of investigation to assess his conduct. Working with vulnerable people
such as the young, the elderly and those with mental health issues requires utmost
professionalism. A breach of our code of conduct is taken quite seriously amongst the
medical fraternity, and he could lose his licence to practice and face stricter punishment
such as criminal charges.
Did I make a mistake in telling you?
You have been very brave in coming forward with all this information – and you
absolutely did the right thing. It must have been very difficult to share. We do need to be
proactive about this and investigate if any other individual like yourself has been similarly
affected. Furthermore, it is important to prevent this type of conduct in the future.
Doctor, can you restart the medication (Sertraline)?
From what you’ve told me, your mood seems to be fine and you aren’t really experiencing
any of the symptoms of depression.
Is there any particular reason why you would like to restart the medication? – I just want to
feel like before, better and not have to worry about him
Unfortunately, taking the medication is unlikely to make you feel better as it won’t really
fix the root cause of the issue. Instead, I believe we can be proactive in collecting
information and presenting our case to the practice manager and GMC for them to
investigate the conduct of the councillor. This may give you some solace in knowing that
you’re doing the right thing to prevent anyone in the future being affected in a similar way.
What I’ll do now is get you to share any details you have of the councillor in question, and
I will go and speak to the practice manager. We may need you to fill out some paperwork.
Is that alright? - Yes
Thankyou.
DNAR
P a g e | 944
You are the FY 2 doctor in medicine department.
Mr James Walker 72 year old man recently been admitted to the medical ward for
Pneumonia and has been treated. He is about to be discharged.
He has some concerns. He wants to talk to a doctor.
Talk to him and address his concerns.

P a g e | 945
Dr: Hello Mr James Walker ? I am Dr…. Junior doctor in the medical

department. How are you doingtoday? Pt: I amOK.
Dr: How is your
Pneumonia ? Pt: I am OK
now.
Dr: I was told that you have some concerns and you want to talk to a doctor is
that right? Pt: Yes
Dr: Can I help you?
Pt: Doctor, I don’t want to take this medications
anymore? Dr: Why isthat? Pt: They make
mesleepy?
Dr: Can you please show me which
medications ? Patient shows – Enalapril,
Aspirin and Simvastatin, Dr: Why are you
taking these medications ?
Pt: I was given those medications 12 years ago when I had heart
failure. Dr: Did you have any other medical conditions?
Pt: Yes I had bypass surgery to my heart 20 years ago.
Dr: OK. We will see which one of this medication is making you sleepy. We will
change that medication and give some other medication. Will you take them?
Pt: Doctor I am tired of taking these medications. I don’t want to take
medications any more.
Dr: Why do you say that?
Pt: I had enough in my life. I just want to go without
suffering? Dr: Can I ask you why do you feel that way?
Pt: Doctor, I already had whatever I need in this life. I had enough. I have
accomplished everything in my life.
Dr: Is there any medical problem you have which is making you feel
this way? Pt: No doctor.
Dr: Is there any other reason making you feel this way like are you feeling low
for any reason? Pt: No - Not atall
Dr: Is there anything we can help you with if you want to change your
decision? Pt: No nothing likethat.
P a g e | 946
Dr: Can you please tell me do you do any

job? Pt: No I am retired now.
Dr: What about your family ?
P a g e | 947
Pt: My wife died of cancer few years ago. I have a daughter but she has
Rheumatoid arthritis.
Dr: Do you live with any one at all ?
Pt: I live on my own. My daughter has arranged someone to take care of me.
Dr: She is very caring. What do you mean by you had enough ? What do you
have in your mind?
Pt: Doctor I want to die in dignity.
Dr: What exactly do you mean by that ?
Pt: I was told you doctors do CPR if the heart stops beating. I don’t want that to
be done on me.
Dr: I see. Do you understand what is the meaning of CPR ?
Pt: Yes I was told you compress the chest if the heart stops beating to make
the heart beat again.
Dr: That is right. But do you understand what will happen if we do notdoCPR?
Pt:Yes
I understand then the patient willdie.
Dr: Is that what youreallywant. Pt: Yes that is whatI
want. Dr: Have you discussed this with your family
members at all?
Pt: I don’t need to discuss with them
Dr: Is that you don’t want us not to CPR only or do want us not to give you any
active treatment if you fall ill like giving medications through your veins?
Pt: Well, I don’t mind having active treatment but I don’t want CPR to be done.
Can you please bring that form ?
Dr: Surely, I do respect your views. However this the decision has to be taken
between you and my consultant. I will speak to my consultant and get back to
you. I need to tell you one thing, even if you decide not to have CPR now, you
can always change your decision later on if you feel like it.
Pt: OK thankyoudoctor. Dr: Thank you verymuch
MULTIPLE SCLEROSIS – Fill up the DNAR Form

P a g e | 948
Question:
You are an FY2 doctor of the medical department in a hospital.

75 year old lady diagnosed with MS and she is at the end stage of the condition. She is
under palliative care now. She is aware of her condition and want to talk about her end of
life care wishes.
You are visiting the patient at her home as a part of the palliative care.
Assess the patient, address her concerns and take an informed decision on her DNAR
request.
Hello I am doctor ...... one of the doctors in the medical team who is looking after you. How are
you doing today?
Pt: Not very well, I just want to die doctor!
Dr: I'm sorry to hear that and I know from the notes that you are going through a difficult time
because of your condition [ express sympathy and empathy] but could you please tell me what
do you mean by that you want to die ??
Pt: I had enough in my life doctor
Dr: I'm sorry to hear that. Could you please tell me how much you know about your condition?
Pt: I was diagnosed with MS few years ago and it is very difficult for me to cope up with the
condition. I can’t do anything on my own.
Dr: Mrs...... I can't even imagine what you are going through right now, I wish I could help you.
But as you know that we don't have any specific treatment for the condition. Pt: I know
Dr: Were you on any medications before we started on the palliative care ?
Pt: It was [MS] coming and going in the past years. Sometimes I didn't have any symptoms and
after few months the symptoms will reappear. I was on steroids for few years, but eventually,
the condition progressed and doctors found that now it is the advanced stage of disease and
told me that no medications will work anymore.
Dr: Yes Mrs.... if the conditions has progressed to an advanced stage, no medications will work.
Once again, I'm really sorry to hear that.
Pt: That is why I told you that I want to die and I don’t need any treatment of any kind if I fall
ill.
Dr: Do you mean we should not do CPR if you become ill. Pt: Yes!
Dr: Do you know what is CPR ?
Pt: Yes, doctors will try to restart my heart if it stops beating.
Dr: Yes, you are right. What about any kind of active treatment?
Pt: What do you mean by that doctor ?
Dr: If you fall ill, is it okay if we give medications through your veins to prolong your life?
Pt: I don’t want that either!
Dr: Mrs...... I can see that this condition is affecting your life, but may I ask, if there is any
other medical condition you have that makes you think like that?
Pt: No doctor.
Dr: Do you understand what can happen to you if we do not give you active treatment or do not
do CPR if your heart stop beating ?
Pt: Yes, I do understand the outcomes if you don't do the CPR or any active treatment, I may
die. I know that.
Dr: Have you discussed it with anyone?
Pt: I discussed it with my husband and he is really supportive of me.
Dr: Well Mrs....... patients concerns and wishes are our first priority and I do respect your
wishes. I can see that you are aware of what will happen if we do not do CPR or any active
P a g e | 949
treatment. Let me fill up the form and I will explain you how we do that.
EXAMINER HANDS OVER THE DNAR FORM

( fill up the form)
Mrs....... I have filled and signed the form. But as I am the junior doctor, I cannot take the final
decision on this matter. My consultant will assess you once again and he will counter sign the
form and after that ( Consultant has to counter sign the form within 24 hours). Would that be
okay??Pt: Okay doctor
Dr: Mrs..... I want you to know that this decision is always reversible. If you ever change your
mind, do let us know we can reverse this decision for you. Pt: I understood doc!
Dr: Do you have any other concerns? Pt: No
Dr: Thank you Mrs.... ....
Filling up the form eg:
Does the Patient has the capacity to make and communicate the decision – yes
Summary of main clinical problems and reasons why CPR is inappropriate, unsuccessful or not
in the patient’s best interest – Advanced stage Multiple sclerosis
Summary of the communication with patient or (Welfare Attorney) patient -Patient wishes
DNACPR.
Summary of communication with patient’s relatives and friends – Not discussed
Names of members of multi disciplinary team contributing to this decision – not discussed
Healthcare professional recording this CPR – sign and write position – FY2 doctor, Date
Review and endorsement by most senior professional – Leave blank ( Consultant to sign
later)
P a g e | 950

Post herniorrhaphy wound infection
P a g e | 951
35 year old man underwent herniorrhaphy one week ago. Now he presents with
discharge, swelling, oozing and redness at the site of incision in the groin area.
Talk to the patient.
Infection rate in this hospital is not more than National infection rate.
Dr - I am Dr… one of the junior doctor in the surgery department in the hospital.
How can I help you?
Pt – You are a junior doctor. I don’t want to speak to you. I had surgery a week ago
and see now what has happened? Some dirty discharge is coming out of my wound, it
is smelling horribly, my wife is not coming near to me, I can’t even go to my work.
My wound is healing. I want to talk to your consultant.
Dr – I can certainly imagine how you ae feeling. I’m sorry for what is happening to
you. I do understand that you want to speak to my consultant but my consultant is
busy at the moment. Don’t worry I’m here for you. I will try to explain to you what is
happening and we will do our best to help you. My consultant will see you as soon as
he gets free.
Dr: Can I ask few questions about it? Pt: Yes
Sine when are you having this discharge from the wound ?
Pt: Last few days
Dr: Do you have any pain there ?Pt: Yes / No
Dr: Do you have any fever? Pt : No
Dr: Do you have any other medical conditions ?Pt: No
Dr Do have diabetes ? No
Dr: Are you taking any medications? Pt: No
Dr: Are you allergic to any medications ? Pt : No
Dr: I need to examine your tummy?
[ Patient will show a picture – doctor this is how it looks like]
Dr: I can see your wound is bit red and there is some pus discharge there.
Pt – Why has this happened to me?
Dr – This happens when there is an infection of the wound, which means there are
germs/bugs growing there.
Pt – How/From where did I get this infection?
Dr – Mr…It could be due to many reasons. These bugs could be from inside or
outside the hospital. We do take all the measures to prevent people getting infections
after the operations. We do the operation in a clean theatre, sometimes we give
antibiotics and keep cleaning and changing the dressing regularly to prevent
infections. Unfortunately sometimes people get infections despite all the measure
what we take because new patients keep coming every day and they may bring bugs
with them if they have infections.
P a g e | 952
However, sometimes this infection can happen from outside the hospital. If the
dressing on the wound becomes dirty and if it is not kept clean bugs can get into the
wound.
Can I please ask you were you able to take care of the wound ? Who was changing
the dressing for you? Patient: Yes I was able to take care of the wound properly / I
was not able to take care of the wound properly.
I am sorry this happened to you. You have done a good thing by coming to the
hospital.
Right now what’s important is that we take care of you.
Pt: My friend had some operation in some other hospital and he was given antibiotics
and he did not have infection. Is it because I was not given antibiotics that I got
infection ?
Dr: Mr… I am glad to know that your friend did not have any infection after the
operation. We do give antibiotics after the operation to prevent infection only for the
type of operations where the chances of infection is very high like if it is dirty wound
or if the patient has low body immunity. We do not give antibiotics if the chances of
infection is low. If we give antibiotics even for types of operations where the chances
of infection is low – the bugs can develop resistance and later on if the person has
infection with similar kind of bugs then those antibiotics will not work and the
infection can become very serious. That is the reason we avoid giving antibiotics
unnecessarily. However we do advise those patients to come back if they have signs
of infection as the infection can be treated even later.
Pt – What will you do for me now?

Dr - We need to admit you now. We will clean the wound, change the dressing and
give you pain killers & antibiotics medications. We will also take a blood sample and
sample from the wound to check which exact bugs causing this infection and send it
to lab.
Pt – What! Admit me again? I can’t get admitted again ?
Dr: May I know why you can’t get admitted again?
Pt: I have to work! I have to look after my family.
Dr – I can understand your problems. We are trying to do best for you. If you wish we
can give you a sick note.
Pt – But I am self - employed. I will lose my income.
Dr – I can imagine your problems. You may still be entitled for some benefits.
However your health is more important. We need to give antibiotics through your
vein which cannot be given at home.
If you go to work it might get worse because you may catch other bugs which will be
more difficult to treat then.
You may be entitled to tax benefits and child tax credit. You can take advice from
Citizen Advisory Bureau.
Pt – How long will I be admitted for?
Dr – It may be for few days. As soon as the infection is cleared you can go home
Pt: What will you do so that these things will not happen again?
Dr: We look into all these type of problems very seriously. I will report this matter to
my seniors. We have something called as Root cause analysis meeting where we
discuss these type of issues. If there is anything need to be changed in our practice we
will do that.
Pt – I want to complain
Dr – Yes you can if you wish to do so. You can talk to the Patient Advisory Liaison
Service (PALS) and they will help you.
Pt – OKDr – Any other concernsPt – NoDr – Thank you very much.
P a g e | 953

Wound infection after cyst removal.
25 year old lady underwent an operation to remove a cyst from her knee 2 weeks
ago. She developed infection in her wound after that. She was admitted and
again treated with the IV antibiotics. Infection has cleared now. She wants talk
to a doctor.
Dr - I am Dr… one of the junior doctor in the surgery department in the hospital. I
understand that you want to talk to a doctor. Can I help you Miss… ?
Pt – Yes doctor. I had an operation to remove a cyst from my knee 2 weeks ago.
I was sent home and then I had infection in the operation site. I was admitted again
here and they gave me some medicine. Infection has cleared now. I want to know
why did I get this infection ?
Dr: I am very sorry that you have to go through this problem. Can I ask you little
more details about it so that I can answer your questions better ? Pt : Yes
Dr: Can I ask you did any doctor explain you about the operation properly to you
before the operation ? Pt : Yes
Dr : Did they mention what are the benefits and what problems you may have after
the operation ?
Pt: Yes they told me something but I can’t remember everything now.
DR: No problem Miss… Can you please tell me what happened after the operation –
how long you were in the hospital ?Pt : It was a day case surgery so I was sent home
on the same day.
Dr: I see. What was told to you when you were discharged – did any one explained to
you how to take care of the wound like changing the dressing or how to keep the
operation are clean ? Pt: Yes they told me to change the dressing ….
Dr: Were you given any medications to take at home like any pain killer medication
or any antibiotic medications ?
Pt: I was given pain killer medication but not the antibiotics.
Dr: Ok Thank you for the information. You asked em why you got this infection - Let
me answer your question now Miss…
Usually after almost every operation there are chances of people getting infection. We
take lot of measures so that people do not get infection after the operation we do the
operation in the operation theatre which is very sterile and clean and we keep the
hospital very clean to prevent getting infection from other patients and we change the
dressings on the wound fequently in a very clean manner to prevent the infection.
Also in some type of operations if the chances of infection is very high then we give
antibiotics to prevent people getting the infection. However, despite all our efforts
sometimes people do get infections for so many reasons.
We usually mention about the benefits and risks of operation including the risk of
P a g e | 954
people getting infection after the operation to the people before they undergo the
operation. It is very unfortunate that you got this infection.
Pt: Why the antibiotics was not given to me ? May that is why I got this infection.
Dr: Miss. We usually give antibiotics to only such operations where the chances of
people getting is very high. We do not give antibiotics if the chances of people getting
infection is very low, ecause if we give antibiotics to everyone even when the chance
of infection is very low then the bugs can develop resistance to these antibiotics. In
the future if the people get infections from similar bugs then these antibiotics do not
work and the condition can become very serious and it can even be life threatening.
That is why we avoid giving unnecessary antibiotics. The type of operation what was
done to you – the chance of people getting infection after the operation is very low.
That is why the antibiotics was not given to you.
Pt: But I got the infection.

Dr: It is unfortunate that you got it. We generally advise patients that there is slight
chance of getting infection and we advise them of the signs and symptoms of
infection and ask them to come back if they have such symptoms. We are usually able
to treat the infection if it does develop. That is what was done in your case Miss…
Pt: I am it happy about this.

Dr: I can certainly imagine how you may be feeling about this. I will be reporting
about this incident. I can reassure that the concerned authorities will look at this and
take appropriate steps for this. In the future if lot of patients get infections after this
type of surgery may be we need to think of giving antibiotics to prevent the infection.
Miss.. You have all the rights to put a formal complaint about this if you wish. We
have a dedicated department for this called PALS. They will help you with this.
Pt: Thank you I ill think about that.
Dr Any other concerns Miss.. Pt: No
Dr: Thank you very much Miss. Once again I am sorry that you had this problem.

Lady had Angiogram and had conflict with
Physiotherapist and Nurses
Question:
Elderly lady with MI who had angiography done today morning. Physiotherapist has advised
her to walk but she is concerned. Talk to her.
Assess knowledge – Had angiogram and Physiotherapist told her to walk.

Ask concern
She does not want to walk because she is tired. Also nurses told her not to walk. She is
confused.
Ask her any other reason she can’t walk ( like any pain and imbalance)
Besides that Physiotherapist was very rude.
Does not want that Physiotherapist. Wants some other Physiotherapist.
Apologize for conflict of opinion. This should not have happened. I will talk to the
Physiotherapist and the nurses to find why did they say that to see is there any particular
reason to say that.
Usually patients do walk after few hours of the procedure. However, I will talk to the
Physiotherapist and my seniors and let you know when you can walk.
P a g e | 955
Talk about PALS, incident report.

We will take appropriate action so that this will not happen again.
Child with cerebral palsy………Mother doesn’t want IV cannula.

You are FY2 in Pediatrics department. 4 years old child, Teddie is admitted with severe
pneumonia.
This is the 4th time he is admitted with pneumonia. He has been prescribed course of I/V
antibiotics for 5 days. This is the second day of treatment.
Patient has Fever and Tachypnea. On x-ray there is consolidation.
Talk to mother and address her concerns.
Dr: Hello I am Dr……………., One of the junior doctors in the department. Are you the
mother of Teddie? Mother: Yes.
Dr: How may I call you? Mother: Call me Stacey.
Dr: Alright Stacey, How may I help you today?
Pt: Doctor, I don’t want Teddie to have an I/V Cannula.
Dr: Stacey, is there any reason for you to say that?
Pt: Yes Doctor, He is already in lot of discomfort. He has very thin and small veins. Doctors
and nurses keep pricking him again and again. He cries a lot, it is really hard for me to see
that.
Dr: Stacey your concern is valid, I do understand this process can be painful. You are very
caring mother and I know it is your love for your son which is making you say this… but do
you know why are we trying to pass cannula?
Pt: Yes doctor I know that Teddie has chest infection and you want to give him medicine
through his veins. But it is very painful for him and I cannot allow that. Give him some other
medicine, give him syrup or tablets.
Dr: Yes Stacey you are right, Teddie has pneumonia and I really wish if we could give him
medicine in form of syrups or tablets. But these are not as effective as medicines through
veins. As you know this is the fourth time that he is being admitted with pneumonia and this
time it is severe. So, I am afraid, syrups and tablets won’t help Teddie much with this
condition.
These medicines are antibiotics and they are necessary for Teddie. It is really important that
we complete their course for five days.
Pt: Yes doctor I want Teddie to get better but this is too difficult for me to watch. Doctors and
P a g e | 956
nurses prick him like he is a pin cushion. He doesn’t speak much but pain shows on his face.
Dr: I am really sorry that you have to see all this. We are only doing all this because we want
Teddie to get better as soon as possible. As you are aware that Teddie unfortunately has
cerebral palsy. In this condition muscles of chest wall are weak and if any chest infection is
left untreated or if the treatment is not adequate, it can be very dangerous. So we have to act
very fast. This can only be done if we give him medicines through his veins.
If you would like I would request most senior person to put in the I/V cannula. We would
also apply local anesthetic cream on him arm before the procedure so that he doesn’t feel any
pain. What do you think?
Pt: Okay, doctor you may pass the cannula. I just don’t want to see him in pain.
Dr: Stacey, We will be very careful and once the cannula is in place we will make every
effort that it is maintained and we don’t have to repeat the procedure.
Is there anything else we can do for you?
Pt: No doctor, Thank you.
Dr: Thank you very much Stacey for understanding the need and allowing us to pass I/V line.
If there is anything else, We will be glad to help you.

Unresolved UTI: young female despite treatmentJanuary 16:
17-18yrs old. Treated twice with antibiotics but still has UTI (trimethoprim for 2wks)
culture shows sensitive to nitrofurantoin. Symptoms not improved. No STI symptoms and has
protected sex. Had lower abd pain, painful urination, no fever, no loin pain, no medical
problems, no diarrhea. No discharge front passage, partner has no symptoms.
Rule out pyelonephritis and sepsis
Most important cause is sexual intercourse especially anal sex and then having vaginal sex
Also ask in history: compliant with medication? Any vomiting after taking the antibiotic?
Hygieniclifestyle is she wiping back passage – front to back or back to front? Perfumed
soap or powders? Tight clothing? Urinate after sex? History of kidney or bladder stones?
Previous UTIs ? contact with anyone else with UT
Patient may give history of unprotected sex [ explore the sexual history properly. She may
say she practices safe sex but she uses pills for contraception – means she does not know
what is safe sex] Probable not practicing safe sex is the reason for not improving.
The definition of recurrent urinary tract infection (RUTI) is three UTIs with three positive urine
cultures during a 12-month period, or two infections during the previous 6 months
P a g e | 957

EXPLAIN DISCHARGE MEDICATION
Exam question
70 year old lady getting discharged from the hospital. Explain medications to her.
How to approach medications
Congratulate.
Assess knowledge of the conditions what they are having.
Why she got admitted ? Ho is she now ?
Has she got any medical conditions other than the reason why she was admitted for?
Was she on any medications before she was admitted to the hospital?
Any allergies?
If she is a young lady – ask about pregnancy, breast feeding, pills
Explain the medications :-
Name of the medicine, What is it for,
How to take it – tablet to swallow, injection, ointment to apply on skin, suppository
When to take it – before or after food,
How many times in a day – for how many days, Side effects, What to do if there are side effects
Ask the patient to repeat at least the dose of one or two medicines to check the
P a g e | 958
understanding
( Prescription of medications was given in the cubicle)
1. Amoxiclav
2. Codeine …. 1tab PRN
3. Alendronate 70mg every Sunday 30mins before breakfast
4. Calcitriol + Vit D medication … OD
5. Lisinopril 5mg OD– Previously 10mg and now changed to 5 mg
7. PCM 2 tabs BD/ PRN
8. Atorvastatin 10mg OD previously taking it so no need to explain.
Dr: Hello I am Dr... one of the junior doctor in the medical department . Are you Mrs ...
Pt – Yes Dr: How are you doing today ? Pt : I am fine doctor.
Dr : I understand you are getting discharged today. How do you feel about going home ?
Pt : I am feeling good doctor.
Dr: Mrs... Congratulations. My consultant has prescribed some medications which you need to
take at home once you get discharged. I am here to explain to you how you need to take those
medicines. Is that Okay ? Pt : Yes doctor
Before I explain the medications may I ask you do you know why you are in the hospital ?
Pt: Yes doctor – I had Urine infection or she may say - I had a fracture of my hip bone because
of Osteoporosis
Dr: That is right. Do you have any other medical conditions other than urine infection /
osteoporosis ? Pt : Yes I have high blood pressure
Dr : Were you taking any medications before you got admitted to the hospital ?
Pt : Yes I was taking blood pressure medicines.
Dr : Are you allergic to any medicines ? No

P a g e | 959
Dr: Okay, I will explain the medicines. You have been given 8 medicines
1. Amoxiclav 2. Codeine 3. Alendronate 4. Calcitriol + Vit D
5. Lisinopril 7. PCM 8. Atorvastatin
Is there any medicines which you want to know first ?
Pt: Yes doctor, tell me about this ... [ then explain whichever she is interested in knowing first, if
she says nothing in particular - then you can start with medicines like - alondronate, amoxicillin,
Lisinopril]
1.Amoxiclav… This is an antibiotic given for the infection to resolve soon. You will have to
take this medicine ………. times as day for ……. many days ( check the prescription).
You may get some side effects but they are not serious – like nausea, vomiting or loose stool
after taking this medication. These side effects go away on its own after some time. Please do
not stop taking medication if you have these side effects. You can drink plenty of fluids to
replenish the fluids you lose in loose stools.
Very rarely you may get allergic reaction – if you have this allergy then you may develop skin
rashes, breathing difficulty, swelling of the lips and tongue – if you have any of these symptoms
you must stop taking this medicine and call the ambulance and come to the hospital
immediately.
Do you follow me ? Pt: Yes
Please tell me how many tablets you take and how many days ?
2) Alendronate : This is the medication we give to slowdown the rate of osteoporosis so that
the bone becomes strong and prevent fractures.
You need to take one table which is 70 mg every Sunday 30 min before breakfast.
Tablets should be swallowed whole and should be taken with plenty of water while sitting or standing, on
an empty stomach at least 30 minutes before breakfast (or another oral medicine); Also you should stand
or sit upright for at least 30 minutes after taking the tablet.
Like any medicines this also can give some side effects like hair loss, joint pain,
constipation,muscle pains.
Sometimes it can cause serious side effects like damage to the food pipe – you may have
P a g e | 960
painful swallowing if you have this side effect, or it can cause damage to the jaw – you may
have pain in the jaw if you have this side effect. If you have these side effects you must stop the
medicines and come back to us.
You may need to take it for about 5 years. We will keep monitoring your calcium levels when
you are on this medications.
3. Lisinopril: This is a table to lower the blood pressure and the keep the blood pressure under
control. You have to take one tablet which is 5 mg. Once a day.
You were taking 10 mg of this Lisinopril before you were admitted to the hospital but we
reduced the dose to 5 mg now because your blood pressure was too low with 10 mg. If the blood
pressure is very low it can make people fall ( postural hypotension). [ may be that is the reason
she fell and had a fracture hip bone – tell this to her - if it is given in the question or she gives the
story of fall and fracture]
Side effects of medicine are Cough.Dizziness.Extreme tiredness.Diarrhoea. If these side

effects bothers you please do come back we will sort it out.
4. Codeine: This medication is given for Pain. ( check in the question why she is getting it for ).
Y You can take it as is prescribed ( check the prescription). There are certain side effects of it like
constipation, feeling sick or vomiting, feeling sleepy, Dizziness, dry mouth
so if you have of any these side effects please do come back to us.
Dr: Do you have any concerns? Pt: No Doctor.
5.Calcitriol + Vit D: these are the calcium supplement medications that we give for the bone
strengthening. So please take it every day at same time and for …………… number of days ( as
per prescription). If you get nausea, vomiting, loss of appetite, and drowsiness .
6. Atorvastatin : This is tablet to lower the cholesterol level in the body. You need to take one
table in the night for the rest of your life.
Side effects : muscle pain, Confusion, unusual tiredness, and dark-colored urine.

weight gain, urinating less than usual or not at all.
7. Paracetamol : This is the tablet to reduce the pain.
Dr : Do you have any concerns so far ?. Pt: Yes Doctor its clear to me.
If you have any concerns at all about any of the medications then please come back to us.
I hope I was able to explain everything to you. We will be following you up. I wish you good
health.
P a g e | 961
Thank you.
2912 Video not

available
Asthma discharge medication and
PEFR ( new exam question)
Mr George Harrison was admitted to the hospital 2 days with shortness of breath. He
was diagnosed as Asthma and was treated.
Assess whether he is fit to be discharged and explain him about the medication he has
to take at home.
( You will have to do PEFR also and tell him how to plot the reading s on the chart –
however this part may not be mentioned in the question).
Greet the examiner.
Dr: Hello Mr George Harrison, I am Dr ..... How are you doing today.
Pt: I am OK.
Dr:Wearethinkingofdischargingyoutodayifyouarefine.Iheretocheckwhetheryouare fit
enough to go back home. Is that OK?
Pt: Yes Doctor.
Dr: How is your shortness of breath now ?
Pt : It is much better doctor.
Dr: Any chestpain ? No
Dr: I need to examine yourchest? ( examiner says – chest isclear).
Dr:IneedyoutodoatestcalledPEFRtoseehowwellyourlungsarefunctioningnow.How you done
this test before?
Pt: No doctor.
Dr Let me explain this to you.
Explain PEFR : This is a device called PEFR meter which has 2 parts – one cylindrical
part with readings in litres /min which has a pointer which moves along the reader to show
the reading and the other one mouth piece.
You need to stand or sit straight but not lying down to do the test.
Attach the mouth piece to the devise, hold it in both the hands horizontally without
blocking the pointer in the reader, take few breaths in and out, take deep breath in, keep the
mouth piece in your mouth, make tight seal of your lips around the mouth piece and blow
though that as hard and as fast as possible at one go and the check the reading and note it
P a g e | 962
down. Repeat the test 3 times and record the highest of the 3 readings on a chart which will
give you later.
Demonstrate the test and ask him to do the test and correct if he makes mistakes.
Check the readings, ask his normal readings. If he does not know his normal reading then
ask his/her height and age and determine what should have been normal using the chart
for them and tell the patient this should have been your normal readings but this is your
readings now.
( His PEFR readings may be almost equal to predicted normal readings. PEFR should be at
least 75% of his normal to discharge him)
Dr: Mr Harrison, You are doing fine now. Test shows that your lungs are functions well
now. Congratulations -you are fit to go home now. But you need to do this test at home and
record it in the chart which I will explain later.
You should take the medications also at home.
[Check - a) prescription chart for patient identity and for all the medications .
b) Medicines for expiry date and strength of tablets]
Salbutamol inhaler 2 puffs PRN

Beclometasone BD ( 400 micrograms)
Tab Prednisolone 30mg PO OD for 3 days.
Explain medications
P a g e | 963
Dr: This is called as Salbutamol inhaler which widens your airways. This is blue
coloured. They are called relievers because they relieve Asthma symptoms.
You need take 2 puffs of spray into your mouth whenever you have shortness of breath.
Maximum 4 times in a day.
Dr: Do you know how to use this inhaler ?
Pt: No doctor.
Dr: Let me explain the inhaler techinque

1) Remove the cap and shakewell
2) Take few breaths in and out. Then take a deep breathout
3) Put mouth peice in mouth and make tight seal of your lips around the mouth peice and
take a deep breath in. As you begin to breath in - press this canister down once for one puff
and continue to inhale deeply. Then take it out of yourmouth.
4) Hold breath for 10 seconds and then breathout.
5) For second dose ( Puff) wait for approximately 30 seconds before repeating thewhole
procedureagain.
Can you please show me how you are going to use it !
[ make him repeat – correct if he does any mistakes]
Dr: Make sure that you keep your salbutamol inhaler with you all the time in case you need
to use it.
Like any other medications this can also give some side effects but they are not serious.
You may feel your hands shaking, you may get palpitations and headache but they all
will go away after some time on their own. Are you following me?
Pt: Yes.
Dr: Next medicne is Beclometasone inhaler. This is steriod inhaler which is brown in
colour, this prevents asthma attack. You should take it regularly 2 puffs in the morning and
2 puffs in the evening for two weeks. ( if the strength of each puff is 200micrograms). The
way to use it is the same as the Salbutamol inhaler. You should wash your mouth after using
this inhaler otherwise it will cause fungal infection in the mouth.
Are you following me ?
Pt: Yes
Dr: Next one is Prednisolone tablets ( eg 30mg once day PO for 3 days in the morning)
(If one tab is 5mg - take 6 tablets)
You should take 6 tablets once a day for 3 days by mouth in the morning after food.
This also helps to prevent Asthma.
This may cause pain in the tummy especially if you take it on empty stomch. Usually there
is no other serious side effects since you are taking these for a short period.
Are you with me.
Pt: Yes doctor
P a g e | 964
Explain Asthma Dairy

Please keep takings medicines at home as prescribed and do this PEFR test home every day
twice ( each time 3 times) and plot the highest of the three readings on this chart.
In this chart – please write the dates – at the bottom, and mark it properly for each day
morning or evening line corresponding to the readings. Check patient understanding by
giving him the example reading an asking him to show where will you mark it.
If the readings are going up you are improving, please bring the chart with you in your next
visit which will be after 2 weeks.
If the readings are not going up –you are not improving. Please see your GP or come back
her if you do not see improvement in the next 3 to 4 days.
If the readings are going down that means you are getting worse. If you are severely short
of breath and if the medicines do not help please call the ambulance and come to the
hospital A&E department.

Breast Cancer with Back Pain management
62 year old female, who is a known case of breast cancer presents with back pain.
Talk to her about the pain management.
Sympathy and empathy is very important in this station
P a g e | 965
Dr: Hello I am Dr .... I am one of the junior doctors in the department. Are you Mrs ....?
Pt: Yes doctor.
Dr: How can I help you?
Pt: Dr I have pain in my back for the past four months. I don’t want to have this pain.
P a g e | 966
Please do something doctor.

Dr: I am really sorry about that Mrs ... it must be really distressing for you. We will
definitely help you. Can you tell me more about the pain?
Pt: Yes I have had it for the past four months. I am taking Paracetamol for it - two
tablets 4 times a day. Now I have to attend this wedding in the next few days. I don’t
want to be in pain.
Dr: That must be very difficult for you. Can you grade your pain for me? Like on a
scale of one to ten how will you grade your pain? Pt: …
Dr: Are you comfortable enough to talk to me now? Pt Yes
Dr: Do you have any idea why you have this back pain?
Pt: Patient may say that she had breast cancer 5 years ago and had an operation and
radiotherapy treatment for that and is told that the cancer has spread to her back bones
now.
Dr: I am very sorry to hear that.
If the patient did not know the cause of back pain – Take brief history
Do you know how the pain started ?
Did you left anything heavy ? Did you have any type of injury to your back ?
Do you have pain anywhere else ?
Dr: Mrs. Your back pain can be to cancer which would have spread to the spine. We
will do investigations to confirm that. However, we can still manage the pain while
we wait for the investigations and hopefully you will be able to attend the wedding
pain free.
Dr: Since when are you having this pain? Pt : since ...
Dr: I am very sorry to hear that. Do you have any other problem other than pain ?
Pt : Like what? Dr: Any problem passing urine or opening bowel ? ( bowel and bladder
incontinence due to spontaneous fracture vertebra). Pt : No
Dr: Mrs.. Sometimes people can have fractures in the back bones very easily because the
back bones are very weak if it has cancer cells. Sometimes even minor trauma can cause
fracture. I need to examine your back to check whether you have any chance of having
a fracture.
( examiner may or may not give any findings).
Also we will do some X Ray of your back to see if you have any broken bones? Is that
ok Mrs ..?
Pt : Yes.
Dr: Mrs... please do not need to worry about the pain. We are going to do everything
possible to control this pain and help you to cope with this condition.
We have a whole special team here to help to control your pain.
I will tell you about the various options we have for pain control. Are you following
me? Pt: yes doctor. What are you going to do?
Dr: We are going to give you stronger pain killers than Paracetamol. First option are
the weak Opioids such as codeine. These are tablets which you can swallow. Like any
medications these too have some side effects however we will keep monitoring you all
the time and we will sort out any problems if you develop.
Do you want me to tell you the side effects ?
Pt: Yes doc please tell me.
Dr: This can cause drowsiness.
Pt: Doctor please do not give me any medicine which will make me feel drowsy because
I need to attend my niece’s wedding in the next 2 week time..
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Dr: Mrs.. Unfortunately all the good pain killer medicines makes people feel drowsy.
But most of the time drowsiness wears off after few days of starting the treatment.
Also we can add Paracetamol to the codeine and reduce the content of codeine in the
tablet which gives drowsiness. How do you feel about this ? Pt : That sounds good.
Other option we have is we can add some other medicine like steroids along with
Paracetamol that will not make you drowsy or we can give you some NSAID type of
medication what we call as Diclofenac which also does not make you drowsy. I will
talk to my seniors and let you know what may be best for you. Is that OK? Pt : OK
Dr: In the initial few days you may feel drowsy if you are taking Codiene tablets, so
you should not drive, and work near any heavy machinery. However this drowsiness
will wear off after few days as I told you. You may be able to drive if you are not feeling
drowsy after few days.
Pt: How can I work if I feel drowsy?
Dr: What work do you do? Pt: ...
Dr: As I said drowsiness will wear off after few days you can take a break from your
work if you wish to in the first few days when you may feel drowsy. Pt: Ok doc
Dr: Other side effect is it can cause dryness of mouth you can chew ice cubes or
Pineapple slices or chew sugar free gums. If they do not help we can give some artificial
saliva. Pt: OK doc.
Dr: Constipation is another problem with this medication but if you eat lot of
vegetables and fruits with high fibre then this may not be a big problem. We can also
give some laxatives. Sometimes we may be able to adjust the dose to overcome this
problem.
Are you comfortable with this medication? Pt: Yes
Dr – As the cancer progresses the pain can get worse and if your pain is not controlled
by codeine we will give you strong opioids such as morphine which can also be taken
by mouth. It has the same side-effects as codeine.
You can take this as an injection too what we call as patient controlled analgesia.
There will be a small devise which contains the medication ( morphine ) which you need
to keep it with you. That will be attached to your vein with tube. You can press a button
on the devise and the medication will be delivered to your veins. The advantage is that it
works faster than taking this as a tablet and more effective. You do not need to wait for
someone else to come and give injections to you. This can be used at home too.
Pt: will get overdose if I press the button too many times ?
Dr: You will not get overdose because there is a safety devise.
Pt - Will I get addicted ?
Dr –Unfortunately all the opioid type of medicines causes addiction. However if you if
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you take the medications at the right dose and the right time then there are less chances
of addiction. Pt – Ok.
Dr – Hopefully your pain will be managed by this. If at all your pain gets worse, in that
case we can change morphine to even stronger pain killer what we call as Fentanyl.
which can be worn as patches over your arm. Is that Ok ? Pt – OK doc.
Dr: Do you have any concerns? Pt: No.
Dr: One of the best things you can do to prevent back pain is to exercise regularly and
keep your back muscles strong.
Some people find complementary and holistic medicine like acupuncture, hypnosis,

massagetechniques helpful to control the pain.
Other medications like bisphosphonates can relieve pain.
Other tips for managing back pain:
 Hot or cold packs, or a combination of the two, can soothe a sore back. Heat
can help reduce muscle spasms and cold can help reduce inflammation.
 Eat a healthy diet that includes enough calcium and vitamin D to keep your
spine and bones as strong as they can be.
 Maintain a healthy weight to ease stress and strain on your back.
 Practice good posture and support your back properly when you have to sit for
a long time.
 Avoid lifting heavy items. If you do have to lift something, keep your back
straight (don't bend over to pick up the object). Instead, bend your knees and then
lift the item. This puts the stress on your legs and hips rather than your back.
Keep a pain diary
Please keep a diary of your pain like when do you get pain how long it lasts, how severe
it is what type of pain, what medication you took – this will help us decide what is the
best way to treat our pain.
Dr: You should get urgent medical advice if you feel difficulty walking or difficulty
controlling urine and/or bowel movements (Warning sign of spinal cord compression
common in breast secondaries)
Dr – Do you have any other question?

Pt – No doctor.
Dr –I wish you cope well with this. As I mentioned earlier there is a specialist team
including Psychologists, Macmillan nurses to help you to cope with the pain. We will
make sure you will be comfortable. If you need any help in the future please do contact
us. Thank you very much.
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APIXABAN PRESCRIPTION
Question: You are an FY2 in theAMU. Priti Shah is a 40 years-old lady who
was admitted 2 days ago with leg pain and diagnosed with a deep vein
thrombosis. She is planned to be started on Apixaban. Talk to the patient,
prescribe Apixaban and explain the medication to the patient.
FBC, Blood Glucose, Clotting Profile, LFT, RFT – Normal

D-Dimer – High
Hello. Priti Shah. Hi, my name is Dr. ……… I am one of the junior doctors here in the Acute
Medical Unit.
What would you like me to call you? – Priti

So from what I understand, you have been admitted a couple of days ago for some pain in
your leg. Is that correct? - Yes
 Are you in pain now? – No (if yes, ask next question)

 Are you ok to continue? – Yes (if no, ask next question)
 Have you been offered any painkillers? – No (if no, ask next question)
 Would you like me to give you some painkillers? – No (if yes, ask next question)
 Are you allergic to any medication at all? – No
Ok. So that we’re on the same page, can you tell me a little bit more about what happened? –
Yes, I just started having pain and swelling in my left leg
Do you know what the cause may be? – Yes, I was told I had a clot in my leg
Are you aware of why this may have happened? – I’m not sure
Are you aware of any tests that were done? Has anyone gone over them with you? Would
you like me to go over them with you? – Yes. No. Please, that would be great
So we performed some routine tests of your blood, to check the level of clotting, the function
of your kidney, liver and blood sugar, which all came back as normal. We also performed a
test called D-Dimer, which came back high, that usually rises in conditions associated with
clots.
You’re absolutely right, you have been diagnosed with a condition called a deep vein
thrombosis (DVT). Do you know what that is? – A clot in one of the veins in my leg
Yes, you are right. Do you have any questions regarding your diagnosis of DVT?
Why did this happen to me?

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To get a better understanding as to why this happened, would it be alright if I asked you a few
questions about your symptoms and health in general? – Of course
SOCRATES PDA
2PMAFTOSA
Never been to the hospital in my life before

I’m currently taking Heparin for my leg, which was started in the hospital
Any bleeding from anywhere? Nose/Mouth/Front Passage/Back Passage? Any rash on your
body anywhere? - No
I’m allergic to penicillin
I went to Australia 2 days ago
Do you have an idea as to why this may have happened? – No

Is there anything in particular that concerns you? – Just that it might happen again
RISK FACTORS
A DVT is more likely to happen if you:
 are over 60
 are overweight
 smoke
 have had DVT before
 take the contraceptive pill or HRT
 have cancer or heart failure
 have varicose veins
There are also some temporary situations when you're at more risk of DVT. These include if
you:
 are staying in or recently left hospital – especially if you cannot move around much
(like after an operation)
 are confined to bed
 go on a long journey (more than 3 hours) by plane, car or train
 are pregnant or if you've had a baby in the previous 6 weeks
 are dehydrated
Sometimes DVT can happen for no obvious reason.
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So from what you’ve told me, you travelled to Australia a few days ago. Long-distance travel
for more than 3 hours via plane/car/train can increase the risk of having a DVT. This could be
the cause of why it happened in your case.
EXAMINATION
Ideally, I would like to examine your:
 Observations (HR/BP/RR/O2/Temp)
 Respiratory System
 Heart
 Lower Limbs
Are you the doctors who is supposed to prescribe me Apixaban?
Yes, I am the doctor who is going to be doing that. I’ve been asked to come and write you a
prescription for a medicine called Apixaban.
Do you know anything about it? – No
It is a blood thinning medication. Before I prescribe it, I do need to ask some questions to rule
out any contra-indications.
 Bleeding from anywhere in your body? Nose/Mouth/Gums/Urine/Front&Back Passage

 Stomach ulcer?
 Cancer?
 Recent Surgery?
 Dilated veins in your food pipe? (Oesophageal varices)
 Vascular problems (AV Malformation/Aneurysm)
What I would like to do now if you could just give me a few moments is to take a closer look
at your drugs chart, so I can prescribe you your medication. Is that alright? – Yes
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How long to take the medication?

 10mg x BD x PO for 7 days
 5mg x BD x PO for 3 months – for secondary prevention
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So you will be taking the 10mg of Apixaban twice daily, orally. Is 5am and 5pm ok for you?
– Yes
You will be taking this for 7 days, and then we will review your medication.
You may then be put on 5mg Apixaban, twice a day, orally for the next 3 months.
1mg
1GRAM
1MICROGRAM
Do you have any questions regarding your medication?
Are there any side effects?

o N/V/D
o Bleeding
o Skin reaction/rash
o Anaemia
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 Routine blood tests in 1 week (FBC, Clotting Profile, Liver, Kidney function)
 Medication Review in 1 weeks’ time, and then 3 months.
 Avoid the use of any OTC medications
 If you experience any of the side-effects that we discussed, especially Bleeding from any part
of your body, do come back to get reviewed.
 Accidentally take 2, omit the next dose
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 Forget a tablet?
o <6 hours, take it.
o >6 hours or Unsure, leave 1st and take 2nd as usual.
 Activities (sports/travel) – be careful of any activities that may cause injuries or falls, such as
close contact sports
 Any medical treatments, Dental Treatments especially, notify the healthcare professional
that you are taking Apixaban.
 Anticoagulant Alert Card – that is specific to the patient’s treatment should be carried at all
times.
 Follow up in 7 days
 Leaflet
 Seniors
Link for VTE Treatment Summary:
https://bnf.nice.org.uk/treatment-summary/venous-thromboembolism.html
Insomnia
Causes of Insomnia
long-term pain
sleep disorders – such as snoring and sleep apnoea, restless legs
syndrome, narcolepsy, night terrors and sleepwalking
problems with the genital or urinary organs – such as urinary
Physical
incontinence or an enlarged prostate
health conditions
joint or muscle problems – such as arthritis
hormonal problems – such as an overactive thyroid
1 neurological conditions – such as Alzheimer's disease or Parkinson's
disease
respiratory conditions – such as chronic obstructive pulmonary
disease (COPD) or asthma
heart conditions – such as angina or heart failure
In women, childbirth can sometimes lead to insomnia.
certain antidepressants
medicines for high blood pressure, such as beta-blockers
Medication
2 as a side effect. epilepsy medicines
steroid medication
non-steroidal anti-inflammatory drugs (NSAIDs)
stimulant medicines used to treat attention deficit hyperactivity
disorder (ADHD) or narcolepsy
some medicines used to treat asthma, such as salbutamol, salmeterol
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and theophylline
mood disorders – such as depression or bipolar disorder
Mental health
anxiety disorders – such as generalised anxiety, panic
3 conditions
disorder or post-traumatic stress disorder
psychotic disorders – such as schizophrenia
stressful event, such as a bereavement, problems at work, or
financial difficulties.
Stress and
4 anxiety Having more general worries – for example, about work, family or
health – are also likely to keep you awake at night.
These can cause your mind to start racing while you lie in bed,
which can be made worse by also worrying about not being able to
sleep.
Drinking alcohol before going to bed and taking certain recreational
drugs,
Lifestyle factors stimulants such as nicotine (found in cigarettes) and caffeine (found
in tea, coffee and energy drinks).
5 These should be avoided in the evenings.
Changes to your sleeping patterns can also contribute to
insomnia – for example,
because shift work
changing time zones after a long-haul flight (jet lag).
You may struggle to get a good night's sleep if you go to bed at

Poor sleep inconsistent times,
6 routine
and sleeping nap during the day
environment A poor sleeping environment can also contribute to insomnia – for
instance,
an uncomfortable bed or a
bedroom that's too bright, noisy, hot or cold.
7 Sometimes it's not possible to identify a clear cause.
Exam Scenario for Insomnia
You are the FY2 doctor in the Rhuematology clinic
Mrs Sarah Johnson, 60 years old lady, has come to the Rheumatology clinic for the
follow up because she was diagnosed with Rheumatoid arthritis. She is on Paracetamol
and Methotrexate and Folate for RA. She complains of unable to sleep.
Talk to her and address her concerns
Dr: Hello Mrs Johnson, I am Dr. … of the junior doctor in the medical department.
How are you doing today ?
Mrs Johnson: I am Ok doctor
Dr: What brought you to the hospital?
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Mrs Johnson: I have difficulty in sleeping.

Dr: I am really sorry to hear that. When did it start?
Mrs Johnson: It started 6 months before.
Dr: Can you please tell me about your difficulty in sleeping? Do you find it difficult to
sleep when you go to bed or difficulty in maintaining sleep or you wake up early in
morning?
Mrs Johnson: I get into bed at 9 or 10 o’clock but I can sleep only after 3 o’clock.
Dr: Has anything happened recently which might be the cause of this problem - like any
sad or shocking news ?
Mrs Johnson: Yes doctor, Mr Johnson died.
Dr: I am really sorry to hear that. How did he die?
Mrs Johnson: He Died of heart attack
Dr: How was your mood after your husband died?
Mrs Johnson: I was depressed initially but now I am Ok. Only sometimes when I get into
bed I think about him and I miss the time which we spent together. My mood is very low if
I don’t get sleep ( this is not depression).
Dr: You keep thinking of him in the night ! Is this what is causing lack of sleep?
Mrs Johnson: No doctor.
Dr: Do you have any medical or mental health problems ?
Mrs Johnson: I am diagnosed with Rheumatoid Arthritis.
Dr: Are you in pain nowadays because of this condition?
Mrs Johnson: No doctor. Pain is well controlled with Paracetamol, methotrexate and
Folate. ( non of these drugs cause insomnia)
Dr: Do you take any other medication apart from these medications?
Dr: Do you have any other symptoms like – shortness of breath in the night, have to go to
the loo many times in the night ( incontinence) ?
Dr: How is the sleeping condition at your home? Is there any noise? Too bright lights
disturbing you ?
Mrs Johnson: No problem at all. ( Sometimes she may say neighbours are very noisy
in the night.
Dr: Is the bedroom too hot or cold?
Mrs Johnson: it is fine.
Dr: Are you working?
Mrs Johnson: No
Dr: Do you have any stress or worries ?
Mrs Johnson: No
Dr: Do you drink alcohol? / Do you smoke/Use recreational drugs?
Mrs Johnson: I do not drink alcohol/NO
Dr: Do you drink tea/ coffee before going to bed?
Mrs Johnson: No. (sometimes she says - 2 cups of coffee in the morning), ( sometimes she
says she drinks coffee in the night)
Dr: Is the bed or pillow uncomfortable?
Mrs Johnson: No
Dr: Do you sleep in the day time ?
Mrs Johnson: No ( sometimes she may say -Yes because I do not get sleep in the night I
take a short nap in the afternoon).
Dr: Do you keep watching TV or computer until late in the night ?
Mrs Johnson: No.
ASK QUESTIONS RELATED TO
THOUGHTS,PERCEPTION,IMPACT(Work,Family,Social Life)
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Diagnosis & Management:

Counselling:
Dr: Mrs Johnson -
There are many reasons why people do not get sleep. In your case though the cause is not
very clear sometimes people who have Rheumatoid arthritis do have this problem -
sometimes due to pain, but sometimes it can happen without any known reasons in
patients with this condition.
However you can I improve my sleep by what we call sleep hygiene

• use a sleep diary to keep track of your sleeping habits
If she is doing any of the following then advise accordingly:-
• avoid sleeping during the day ( sometimes she is sleeping in the day time)
• avoid tea, coffee and any other products that contain caffeine after midday
( sometimes she drinks too much coffee in the night time)
• don’t eat or drink large amounts just before bedtime
• avoid drinking alcohol if your sleep is disturbed
• don’t smoke before bedtime or during the night
Sometimes she may say – her neighbours are too noisy – you can request them not to
make too much noise if they do not listen – you can report to the council)
• exercise regularly (but not within three hours of going to bed)

• keep the bedroom dark, quiet and at a comfortable temperature
• check that your mattress and pillows are comfortable
• set up a relaxing routine – try to go to bed and wake up at the same time each day
• take a warm bath before going to bed.
Relaxation techniques and Talking therapy (CBT) may also be help you. We will refer
you to the Psychiatrists who are experts in this.
Mrs Johnson: Doctor will you give me sleeping pills ?
Dr: There are many sleeping pills but they have side effects and they may cause addiction
and also medications may not help in the long term. Medications are not recommended for
more than four or five weeks
However if nothing else helps we can consider giving you sleeping pills
Is it OK ?
Mrs Johnson : Ok doctor I will try.
Dr: We will keep following you up. Thank you very much.

Cannabis abuser with Insomnia asking for sleeping pills (10 April 2019)
You are FY2 in GP Clinic. A young man came with the concern with sleep disturbance
requesting for sleeping pills. Talk to him and address his concern.
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GRIPS plus rapport

Ask for how long he is having this sleep disturbance?
Explore causes of Insomnia
Ask about sleep hygiene/sleeping environment?
Patient plays computer games till late night about 3:30-4am.
Ask about anxiety/stress?Pt says he has anxiety but doesn’t know the cause.
Then explore the cause of anxiety.
Ask about mood? Calculate mood score 1-10?
Ask about Tea/coffee drinking history? Pt: No
Ask about alcohol? Smoking?
Ask about recreational drugs? Pt says he smokes marijuana/cannabis.
Explore for how long he is taking? Any other recreational drugs? Pt: No
Ask about anything significant happened? Any shock news or bad news? Pt: No
To whom he does live/live alone?
Take other social history
MAFTOSA
Any medical Condition? Pt: No
Any medication?
Ask Occupation?
Pt keep saying can you give me sleeping pills!
Give advice sleeping pills have side effects and can develop dependence. Without lifestyle
modification sleeping pills will not help!
Give lifestyle advice
Give advice to quit smoking marijuana
Advice about maintaining good sleep hygiene and keep sleep diary
Also avoid playing computer games till late night (triggers of insomnia).
Talk to seniors for further assessment and whether to give sleeping pills or not.
Offer help for Marijuana smoking (Narcotics anonymous group/support group).

Tiredness--------------------Obstructive Sleep Apnea
You are Fy2 in GP Clinic. Mr. Smith, 45 years old male, has come to clinic today with
sleeping problem for past 2 months.
Talk to him, take history and discuss appropriate management with him.
Hello, Mr. Smith, My name is Dr. ---------------, I am one of the junior doctors in clinic today.
How can I help you today?
Pt: Dr. I feel tired all the time.
Dr: Mr. Smith can you please elaborate, what do mean by tiredness?
Pt: Doctor I feel as if I don’t have any energy to do work during day.
Dr: Since when are you feeling like this?
Pt: It’s been there for about 6 weeks now.
Dr: Do you feel any pain in your body as well? Pt: No (Fibromyalgia)
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Dr: How did it start? Pt: I don’t know doctor.

Dr: Do you think something happened 2 months back which may have started this?
Pt: can’t think of anything doctor.
Dr: Have you tried anything which has helped you with tiredness? Pt: No, haven’t tried
anything.
Dr: Is there anything which makes it worse? Pt: No doctor haven’t noticed anything. It is the
same since it started.
Dr: Mr. Smith you seem to be very worried about this, We will do everything we can to help
you come out of this.
Dr: Mr. Smith have you noticed any change in your weight ? Pt: No. (Hypothyroidism)
Dr: Have you developed preference for any particular weather ? Pt: No. (Hypothyroidism)
Dr: Any changes in your bowel habits ? Pt: No. (Hypothyroidism)
Dr: Do you feel short of breath while doing any work ? (anemia)
Pt: No doctor, I just feel very tired.
Dr: Is there any specific time when you are more tired? (Myasthenia)
Pt: No it stays same, doesn’t change much.
Dr: Do you feel better when you wake up? Pt: No, I am still very tired when I wake up?
Dr: Do you think you get ample sleep? Pt: Yes.
Dr: what about your sleeping environment? Pt: doctor it is very comfortable.
Dr: Do you think you have any trouble sleeping? Pt: No, I don’t think so but my wife is
always complaining that I snore during sleep and my breathing is very loud and noisy.
(Patients don’t know if they snore in OSA)
Dr: Do you regularly fall asleep during the day against your will? Pt: Yes, sometimes I doze
off during the day as well.
Dr: Do you take any sleeping pills? Pt:…….? (risk factor for OSA)
Dr: do you feel difficulty in breathing from your nose? Pt……..? (risk factor for OSA)
Dr: Diabetes? No.
Dr: High blood pressure? No.
Dr: Do you smoke? Pt: Yes/ No.
Dr: Do you drink alcohol? Pt: Yes only occasionally/ No.(drinking alcohol, particularly
before going to sleep, can make snoring and sleep apnea worse.)
Dr: May I know what do you do for living? Pt: I am a taxi driver.
Dr: Mr. Smith is this condition affecting your work in any way?
Pt: Yes Doctor, Sometimes I start dozing off during the day as well and so I am not able to
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drive for whole day.

Dr: Mr. Smith, Is there anything else that you would like tell us? Pt: No doctor.
Mr. Smith from our discussion it seems that you are feeling tired all the time because of a
condition we call as Obstructive sleep apnea. This (OSA) is a relatively common condition
where the walls of the throat relax and narrow during sleep, interrupting normal breathing
and it leads to regularly interrupted sleep. These repeated sleep interruptions can make you
feel very tired during the day.
Pt: But doctor I don’t remember any interruptions.
Dr: Yes Mr. Smith, people with this condition usually have no memory of their interrupted
breathing and they are unaware of having a problem.
But we would like to confirm it before proceeding further and for that purpose we can refer
you to specialist sleep clinic where they will measure your height and weight to calculate
your BMI and they will arrange for your sleep to be assessed over night with help of special
instruments. We would also like to run some blood tests to exclude other conditions like
hypothyroidism, anemia and vitamin D deficiency. What do you think of this?
Pt: I think I shall visit this clinic.
Dr: Okay I will arrange an appointment as soon as possible.
If it turns out to be obstructive sleep apnea then you can do few things which will be of great
benefit. Would you like to know those?
Pt: Yes, What are those?
Dr: These include life style changes like sleeping on your side, losing weight (if over-
weight), reducing the amount of alcohol you drink and avoiding sedatives at night. These all
been shown to help improve the symptoms of OSA.
Dr: How does all this sound to you? Pt: I think I must try these.
I really hope that these strategies will help you. Otherwise I can arrange an appointment with
my consultant and he may guide you regarding further treatment options like CPAP and
mandibular advancement device. In severe cases we have to resort to surgical options.
Mr. Smith I do understand OSA can have a significant impact on the quality of your life and
it has a significant emotional effect as well. If you would like I can refer you to supports
groups like British Lung Foundation and Sleep Apnea Trust. They will help you with
strategies on how to cope with this condition.
Mr. Smith do you have any concerns? Pt: No doctor.
Dr: Well there is one important thing, I think you must inform DVLA regarding your
condition.
As you told me earlier that this condition is also affecting your driving. They may be able to
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provide you with specialist guidance regarding your driving.

Pt:--------------.
Thankyou.

CONFUSION – OXYBUTYNIN SIDE EFFECTS
Question: You are an FY2 in GP Surgery. Beverly McAndrews is a 55
years old lady who has presented with some concerns. Talk to the patient and
Hello. Beverly McAndrews? Hi, my name is Dr. ……… I am one of the junior doctors
here in the GP Surgery.
What would you like me to call you? – Bev, please

Can you confirm for me your age please? – 55
How can we help you today Bev? – Doctor, I’ve been feeling a little confused lately
Can you tell me a little bit more? – What would you like to know?
How long have you been having this sense of confusion? – 3 weeks
What made you notice that you have been confused lately? – I feel as if I’m forgetting
simple things. Like where I put my medication, and what day of the week it is
Is this feeling of confusion getting better or worse? – Worse
Do you think the confusion might be aggravated by something? Activity? Fall? Trauma?
Medication? – I don’t know
And does it improve with anything? Resting? Medication? – No
Do you have any other symptoms other than the confusion? – Yes, I have been having
some problems controlling my wee, but that has improved. I feel really hot sometimes
What type of problem have you been having with your wee? – I’ve not been able to control
my wee, and it spoils my underwear
How long have you been having problems with your wee? – 3 months
Is it getting better or worse? – Better, since I’ve been on my medication Oxybutynin
Do you think the problem controlling your wee might be aggravated by something you do?
Exercise? Coughing? Straining? Passing poo? Medication? – I don’t think so
And does it improve with anything? Resting? Medication? – Yes, my medicine
How long have you been taking this medication? Compliant? – 2 months now. Yes
Has the problem resolved? – Yes, I don’t have any problem with my wee now
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How long have you been feeling really hot for? – 1 week
And how did it come about? Sudden/Gradual? – Suddenly
Is it getting better or worse? – I think worse
Do you think it might be aggravated by something you do? Activity? Medication? – I
don’t know
Is there anything that I’ve missed that you’d like to add? – No

Rule out common Confusion causes;
Medication Side Effects, Infections (Sepsis, UTI, Pneumonia, Meningitis, Encephalitis),
Delirium, Hypoglycaemia, Dementia, Stroke, TIA, Anaemia, Metabolic (Acidosis,
Electrolyte Disturbance, Hepatic/Renal Failure), Hypoxia (Chronic Lung Disease),
Deficiencies (Vitamin B12), Cancer, Trauma, Recreational Drug Abuse,
[COMPLETE SYSTEMIC REVIEW]

Memory Loss/Impairment? (Medication Side Effect,Dementia) – Yes
Fever? Headache?Neck stiffness?Cough? Breathing difficulty? Burning sensation while
passing urine? Sore throat? (Infections) – No
Vision problems? Facial weakness? Problems with speech? (TIA/Stroke) – No
Dizziness?Feeling hungry? (Hypoglycaemia) – No
Feeling very thirsty?Passing less urine? (Diabetes) – No
SOB? Tiredness? Chest Pain?Bruises? Rash?(Anaemia) – No
Nausea or vomiting (Gastro-enteritis and dehydration)? – No
Bowel habits? (Hyperthyroidism&Hypothyroidism) Thyroid Systemic Review
Problems passing wee now? Frequency? Urgency? Hesitancy? Straining? Dribbling?
Incontinence? – No. It’s really improved
Swelling? Bloated tummy/ankle swelling? (Medication Side Effect) - No
Joint pains? –No
Stress or worries (depression)? – No
Lumps and bumps? Weight loss?(Cancer) – No
Injuries/falls? – No
Have you ever been diagnosed with any medical condition before? – Yes, Urinary
Incontinence. I was diagnosed 2 months back when I saw my GP
High Blood Sugar? High Blood Pressure?– No
Are you currently taking any prescribed Medication? OTC?–Yes, I’m currently taking
10mg Oxybutynin tablets for my incontinence. I have them with me here. I usually take
the tablets twice a day. I’ve been taking them for 2 months now since I was prescribed. I
take the prescribed amount – not more or less. I am still taking them
 What do you know about your condition? – I was told everything in my last visit
 What do you know about your medication? – It’s to help me stop spoiling myself
 Did anyone explain to you any potential side-effects of your medication? – No
o Have you noticed any swelling around your eyes/lips/hands/feet/genital? – No
o Have you noticed any drowziness/agitation/hallucinations? – Yes, I do feel drowsy and
confused
o Any problems with your long and short-termmemory – Yes, I do forget things that are
happening in the now. My long-term memory is fine
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Are there any illnesses which run in the Family? DM? HTN?–No
Have you Travelledanywhere recently? Long-distance? – No
What do you do for a living? – I’m a Librarian
Do you smoke/ drink alcohol? – No
Are you still having menstrual cycles? – No, menopause at 51
How would you describe your diet?– I eat very healthily, lots of water, fruit and veg
How have you been coping at home? Family? Relationships? Job? Hobbies? Sleep? – Well
Stress? – None, just my urine problem which is all better now.
Anything else you would to add? – No. I am fit and well
OXYBUTYNIN USE
Oxybutynin is a prescription drugused to treat overactive bladder. It comes as an

immediate-release oral tablet, extended-release oral tablet, oral syrup, topical gel, and
topical patch.
Oxybutynin may be used as part of a combination therapy. That means you need to take it
with other drugs.
Why it's Used
Oxybutynin is used to treat an overactive bladder. Symptoms of this condition can include:
 urinating more often than usual
 feeling like you need to urinate more often
 urinary leakage
 painful urination
 being unable to hold your urine
The extended-release form of this drug is also used to treat children (ages 6 years and
older) with overactive bladder caused by a neurological condition such as spina bifida.
How it Works
Oxybutynin belongs to a class of drugs called anticholinergics/antimuscarinics. A class of

drugs is a group of medications that work in a similar way. These drugs are often used to
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treat similar conditions.
Oxybutynin works by relaxing the muscles of your bladder. This decreases your sudden
need to urinate, having to urinate often, and leaking in between bathroom visits.
Oxybutynin Side Effects
Oxybutynin oral tablet may cause drowsiness as well as other side effects.The more
common side effects that can occur with oxybutynin include:
 being unable to urinate

 constipation
 dry mouth
 blurry vision
 dizziness
 Drowsiness & Confusion
 sweating less than usual (raises your risk of overheating, having a fever, or
getting heat stroke if you’re in warm or hot temperatures)
 trouble sleeping
 headache
If these effects are mild, they may go away within a few days or a couple of weeks. If
they’re more severe or don’t go away, it’s important to come back to us at the GP Surgery.
So you’ve done the right thing today by coming to see us.
Serious side effects and their symptoms can include the following:
 not being able to empty your bladder
 swelling around your eyes, lips, genitals, hands, or feet
It’s important to call 911 right away if you have serious side effects, if your symptoms feel
life-threatening or if you think you’re having a medical emergency.
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Drug Interaction
Oxybutynin oral tablet can interact with other medications, vitamins, or herbs you may be
taking. An interaction is when a substance changes the way a drug works. This can be
harmful or prevent the drug from working well.
Examples of drugs that can cause interactions with oxybutynin include.
I. Depression drugs
Oxybutynin may affect how these drugs are absorbed by your body. Taking these drugs
with oxybutynin may also increase your risk of side effects. Examples of these drugs
include:
 amitriptyline
 nortriptyline
II. Anti-Allergy drugs
include:
 chlorpheniramine
 diphenhydramine
III. Psychosis and Schizophrenia drugs
include:
 chlorpromazine
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 thioridazine
IV. Antifungal drugs
Certain antifungal drugs will increase the level of oxybutynin in your body. This will raise
your risk of side effects. Examples of these drugs include:
 ketoconazole
 itraconazole
V. Dementia drugs
Oxybutynin may worsen your dementia symptoms if you take it with certain dementia
drugs. These drugs, called cholinesterase inhibitors, include:
 donepezil
 galantamine
 rivastigmine
Warnings for Certain Groups
For people with autonomic neuropathy: Oxybutynin can make your stomach problems
worse. Use this drug with caution if you have this condition.
For people with bladder outlet obstruction: Oxybutynin may increase your risk of not
being able to empty your bladder.
For people with stomach problems: Oxybutynin may cause more stomach problems if
you have a history of ulcerative colitis, stomach pain, or reflux.
For people with myasthenia gravis: Oxybutynin may make your symptoms worse.
For people with dementia: If you’re treating your dementia with a drug called a
cholinesterase inhibitor, oxybutynin may worsen your dementia symptoms. Your doctor
can tell you more.
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For pregnant women: Oxybutynin is a pregnancy category B drug. That means two

things:
1. Research in animals has not shown a risk to the foetus when the mother takes the
drug.
2. There aren’t enough studies done in humans to show if the drug poses a risk to the
foetus.
For women who are breastfeeding: It isn’t known if oxybutynin passes into breast milk.
If it does, it may cause side effects in a child who is breastfed. Talk to your doctor if you
breastfeed your baby. You may need to decide whether to stop breastfeeding or stop taking
this medication.
For children: The safety and effectiveness of oxybutynin in children younger than 6 years
haven’t been established.
How to take Oxybutynin
Your dose, form, and how often you take it will depend on:
I. your age
II. the condition being treated
III. how severe your condition is
IV. other medical conditions you have
V. how you react to the first dose
A. Adult (ages 18–64 years)
 Strengths: 5 mg, 10 mg, 15 mg
 Typical starting dosage: 5 mg taken by mouth two to three times per day.
 Maximum dosage: 5 mg taken by mouth four times per day.
B. Child (ages 6–17 years)

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 Typical starting dosage: 5 mg taken by mouth two times per day.
 Maximum dosage: 5 mg taken by mouth three times per day.
C. Senior (ages 65 years and older)
Typical starting dosage: Your doctor may start your dosage at 2.5 mg taken two to three
times per day.
Take as Directed
Oxybutynin is used for long-term treatment. It comes with serious risks if you don’t take it
as prescribed.
What should I do if I miss a dose?
If you forget to take your dose, take it as soon as you remember. If it’s just a few hours
before the time of your next dose, then wait and only take one dose at that time. Never try
to catch up by taking two doses at once. This could result in toxic side effects.If you skip
or miss doses, you may not see the full benefit of this medication.
What if I take too much?
If you take too much: You may experience more side effects if you take too much of this
drug. These include:
 Dizziness, drowziness and confusion
 headache
 not being able to urinate
 constipation
 hallucinations (seeing or hearing things that aren’t real)
If you think you’ve taken too much of this drug it’s important you call your doctor or local
poison control centre. If your symptoms are severe, call 911 or go to the nearest emergency
room right away.
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How to I tell if the drug is working?
Your symptoms of overactive bladder or bladder instability may get better.If you don’t
take it at all, your symptoms of overactive bladder or bladder instability won’t improve.
Important Considerations for taking Oxybutynin
i. General
 You can take oxybutynin with or without food.
 You should take the tablet at about the same time each day.
 You can cut or crush the immediate-release tablet. However, you must swallow the
extended-release tablet whole. Don’t chew, divide, or crush it.
ii. Storage
 Store oxybutynin at a temperature as close to 77°F (25°C) as possible. You can

store it briefly at a temperature between 59°F and 86°F (15°C and 30°C).
 Keep this drug away from light.
 Don’t store this medication in moist or damp areas, such as bathrooms.
iii. Refills
A prescription for this medication is refillable. You should not need a new prescription for
this medication to be refilled. Your doctor will write the number of refills authorized on
your prescription.
iv. Travel
When traveling with your medication:
 Always carry your medication with you. When flying, never put it into a checked
bag. Keep it in your carry-on bag.
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 Don’t worry about airport x-ray machines. They can’t hurt your medication.
 You may need to show airport staff the pharmacy label for your medication.
Always carry the original prescription-labelled box with you.
 Don’t put this medication in your car’s glove compartment or leave it in the car. Be
sure to avoid doing this when the weather is very hot or very cold.
v. Diet
Caffeine may worsen your symptoms of overactive bladder. It may make this drug less
effective in treating your condition. You should limit your caffeine intake while taking
oxybutynin.
Are there any alternatives?
There are other drugs available to treat your condition. Some may be more suitable for you
than others. However, as your symptoms regarding the urinary incontinence seem have
improved, it shows that the drug seems to be effective.
EXAMINATION
I would like to check your mental status by conducting a Mini-Mental State

Examination (MMSE). It’s important for me to also look at the way your brain is
working by performing a quick Neurological Examination.
Finally, I would also like to take a closer look at your tummy.
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From what you have told me and from what I have seen your vitals were normal.
Examination of your mental status was within the normal limits (MMSE 29/30). The
functioning of your nerves and your tummy too were normal.
Bev, do you have any idea at all why you may be having this problem? –No
Unfortunately, it is likely that you could be suffering from Side Effects of the
medication you are taking - Oxybutynin. You’ve done really well in coming to the GP
Surgery to get it looked over.
Oxybutynin is one of the prescription drugs we use to treat an overactive bladder, as in

your case. Oxybutynin oral tablets may cause dizziness, drowziness and confusion as well
as other side effects, such as:being unable to urinate, constipation, dry mouth, blurry
vision, trouble sleeping, headache, and also as in your case sweating less than usual that
results in a person overheating and feeling hot.
If these effects are mild, they usually go away within a few days or a couple of weeks. If

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Unfortunately, medications often do have side effects which are well documented - but
they can be difficult to predict in every individual - as each individual has a unique
metabolism.
Usually these side effects occur due to prolonged levels of the medicine inside your body
that results in a continuous ongoing of their medicinal effect. Sometimes, the prolonged
high concentration of the medicine can result in undesirable side effects as in your case.
MANAGEMENT
 The medication Oxybutynin seems to be effective and has made a positive impact on your
incontinence, relieving your primary complaint. I do believe it’s important to Review
yourMedication.
 We must either
i. Reduce the dose of the medication you are taking, or
ii. Reduce the frequency you are taking the medication each day, or
iii. Stop the Oxybutynin
 Currently, you are taking two 10mg Oxybutynin tablets every day.Because your incontinence has
significantly improved, I do believe that Stopping the Medication will benefit you the most
as it will get rid of the secondary symptoms of confusion and feeling hot.
 We could then have a period of Triallingyour response to stopping the medication, to see if your
primary symptom of incontinence returns or not. It is common forthe incontinence to return;
however we need to find the right balance to make sure we prevent both your primary
symptom that is the incontinence and the secondary symptoms of confusion and feeling hot.
 We may have to half the dose from 10mg to 5mg.
 We may have to change the instructions to take the tablet once daily.
 We may need to start you on a Different Medication altogether if the secondary
symptoms continue to persist.
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 I would like to consult my Seniors for a 2nd opinion

 I do have some Reading Material for you entitled Oxybutynin
 If you experience worsening of your symptoms orserious side effects such as; not being able
to empty your bladder or swelling around your eyes, lips, genitals, hands, or feet it’s
important to call 911 right away, especially if your symptoms feel life-threatening or if you
think you’re having a medical emergency.
Do you think I’ve got dementia?
From what you’ve told me and from what I’ve examined, although you are having
some minor problems with your memory and confusion, I do not believe that you
have Dementia, and it is extremely unlikely to be Dementia.
Dementia is a group of related symptoms associated with an ongoing decline of brain

functioning. It is more common if you’re over the age of 65.
Although people can get dementia before the age of 65 – called Early Onset
Dementia – it is quite uncommon.
Problems that occur in dementia include: memory loss, thinking speed, mental sharpness
and quickness. However, dementia isn’t just about memory loss. It can also affect your
language, understanding, judgement, mood, movement and the way you carry out your
daily activities.
No Allergies. Family Hx. unremarkable. No Travel Hx. Librarian. Unmarried. Sexually

Inactive. Non-Smoker. Occasional Alcohol drinker. Does not use recreational drugs. Lives
alone.
Vitals – Pulse 88/min, BP 130/85mmHg, RR 18/min, O₂ Saturation 98% on room air,

Temp 37.7°C
Neurological Examination – Normal
MMSE 29/30
Abdominal Examination – Normal

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Constipation
1 Intestinal Constipation, vomiting, Pain abdomen
obstruction
2 Bowel cancer Change in the bowel habit, Altered bowel habit, blood
in the stool, Tenesmus ( feeling of opening the bowelbut
nothing comes out when trying to open bowel), pain
abdomen, weight loss, loss of appetite, family history,
smoking, anaemiasymptoms
3 Medication Codeine, Morphine, Antacids, Anti-epileptics, Anti-
depressants,
Calcium, Iron
4 Anal fissure Pain in the back passage on defaecation, fresh blood
sticking to the stool
5 Haemorrhoids Fresh blood flashing on toilet bowl, Lump in the back

passage
6 Medical conditions Hypothyroidism
Multiple sclerosis
Parkinsons disease
7 Immobility
8 Dehydration
9 Diet ( No high fibre
diet)
10 Pregnancy
11 Inflammatory bowel
disease
Question
80 year old lady Mrs Edith Thompson had hip operation one week ago. Since then
she is having constipation. Take history and talk to her about the further
management.
Dr Hello Mrs… I amDr…. Howare you Pt Doctor I am having

doing? constipation ?
Dr Sorry to hear that. Can you please tell me Pt Doctor It is both.
what exactly you meant by constipation –
do you mean you did not open bowel for
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long time or you have to strain more than

usual to open the bowel.
Dr Since when Pt Since about one week now.
I am having it sine this
operation I had on my hip.
Dr Are you passing any stool at all or not Pt I did not open bowel for the
opened bowel at all? last 4 to 5 days.
Dr Do you have any pain in your tummy Pt No but it is very
uncomfortable
( Intestinal obstruction)
Dr Have you vomited ( Intestinal obstruction) Pt No
Dr Are you able to pass wind Yes
( Intestinal obstruction)
Dr Is there any bleeding from your back Pt No
passage
( bowel cancer, anal fissure, haemorrhoids)
Dr Do you have any diarrhoea also along with Pt No
constipation
Dr Have you noticed any change in your Pt No
weight
( bowel cancer)
Dr How is your appetite Pt I don’t feel like eating
Dr Do you get the feeling of opening the Pt No
bowel but nothing comes out when trying
to open bowel
(tenesmus – rectal cancer)
Dr Any pain in the back passage while trying Pt No
to open the bowel ( anal fissure)
Dr Did you feel any lump in your back Pt No
passage
( haemorrhoids)
Dr Did you see any mucus in the stool, any Pt No
joint pains ? ( Inflammatory bowel disease)
Dr Do you have any medical conditions Pt No
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Dr Like diabetes or thyroid problems any Pt No

bowel problems before
Dr Are you taking any medication Pt Yes I am taking Co
codamol.
Dr Since when are you taking co-codamol ? Since after the operation –
one week
Dr Any of your family members have any kind Pt No
of bowel problems or bowel cancer at all?
Dr Do you eat enough of fruits and vegetables Pt Yes
Dr Do you drink enough fluids Pt Yes
Dr Have you been physically resting for long Pt Well after this operation I
time am not moving around that
much.
Dr Examination:
I need to examine your tummy and your back passage. ( examiner may say hard
stool felt in the rectum).
Diagnosis:
Mrs Thompson, I think the Co -codamol medication what you are taking for
pain is causing this constipation because one of the side effects of co-codamol
is constipation.
Treatment:
First of all we will stop giving this medication and we will give you some
other medication which will not cause constipation - maybe we will give you
Paracetamol if you are not in that much pain now.
We can give you some laxatives like senna, bisacodyl and sodium pico-
sulphate to help you to open your bowel.
You should drink plenty of fluids and eat high fibre diet like fruits and
vegetable or whole wheat bread. That will help you to open bowel.
Pt: What if the laxatives do not work.
Dr: We can give you some medication like Bisacodyl as Suppository – this
type of medicine is inserted into your back passage.
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Pt: What if that also does not help ?
Dr: Then we can give enema where a medicine like Docusate andsodium
citrate in fluid form is injected through your back passage into your large bowel.
Pt: What if they do not help

Dr: We can evacuate the stool manually once then you should be able topass the stool.
Dr: Any other concerns. Pt: No Dr: Thank you verymuch.
Dry Cough and Hemoptysis
Differentials for cough for > 3 weeks :
1. Bronchial carcinoma
- Smoking, weight loss. Haemoptysis.
2. Mesothelioma – exposure to asbestosis, building worker ( roofer, plumber,
carpenter) wt loss.
3. Infection T.B – Haemoptysis, night sweat, wt loss, contact with any one with
TB.
4. P.E – SOB, chest pain, haemoptysis, calf pain, travel, surgery. Recent immobilization.
5. Asthma – allergy to pets – wheeze, pollen, exercise.
6. COPD - > 3 month for 2 consecutive years, wheeze.
7. CCF – ankle swelling, orthophnoea, PND.

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8. Diffuse parenchymal lung disease.
9. Drugs – ACE inhibitors, Beta blockers
10. Psychogenic
11. GORD – heart burn, regurgitation.
Acute < 3 weeks
1. Foreign body – sudden onset.

2. Infection. URTF/ Pneumonia/ Infective COPD
Exam question
You are F2 in medicine
60 y/o man presents with complaints of cough since few months. He has coughed up
blood few times in the last week.
Take history, examine and discuss management with the patient
Dr: Hello Mr... my name is Dr... I'm one of the junior doctors in the medicine department.
What brings you to the hospital today?
P: Doctor.. I have been having this bad cough for a few months now.. And for the last few
days I have coughed up some blood as well
Dr: I'm sorry to hear that Mr... Could you please tell me when this problem started?
P: It has been over 6 months now.
Dr: Is the cough associated with any sputum/phlegm?
P: No it is a dry cough
Dr: Have you had any shortness of breath? P: Yes.
Dr: could you please tell me when that started? P: Around the same time
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Dr: Has it worsened since then? P: Yes/No
Dr: You mentioned that you had coughed up some blood few times this week. Could you
please tell me more about it? How much of blood did you cough up?
P: _________________________
Dr: Do you have any chest pain? P: No (Might say yes if mesothelioma)
Dr: Fever? P: Yes/No
Dr: Have you noticed any swellings in your neck or your armpits? P: No
Dr: Do you have any trouble swallowing? P: No
Dr: Do you have any pain in your calves? P: No
Dr: Have you noticed any change in your weight? P: Yes (assess quantity)
Dr: Do you have any other complaints that you wish to report Mr...?
P: No doctor
Dr: Do you have high BP? P: No
Dr: Diabetes? P: No
Dr: Thyroid related illnesses? P: No
Dr: Are you on any medications? P: No
Dr: What is your diet generally like? P: Balanced doctor
Dr: Do you smoke Mr...? P: Yes doctor.. I have been smoking for >20 years
Dr: Could you tell me what you smoke in a day? P: 1 pack of cigarettes/day
Dr: Do you consume alcohol? P: Yes/No
Dr: Do you have any allergies? P: No
Dr: Do you have any family history of medical problems? P: No
Dr: F/H of cancers? P: No
Dr: What do you do for a living Mr...?
P: I work as a plumber/carpenter/roofer (or) Patient might not give a significant

occupational history.
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Dr: Have you travelled anywhere recently? P: Yes/No (look for travel to TB endemic areas)
Dr: Ok Mr... I would like to examine your neck, chest and hands.
( Examiner may give findings of clubbing and /or swelling in the supraclavicular area; and
decreased or reduced air entry in the left or right lung.)
Dr: Mr...Do you have any idea what may be happening to you ? Pt: No doctor.
D: Mr… It looks like you have some serious condition. Do you want to know about it?
Pt : Yes doctor.
Dr: Based the information what you told me it looks like you have cancer in your lungs or
lining of the lung. Pauce
Pt: Oh …. Really … I didn’t expect doctor.
[ Pt may say “ my friend who was working with me had been diagnosed with
mesothelioma. Do I also have the same doctor”.
Dr: I wish it was not true but unfortunately you are right that it is possible that you too may
be having the same problem. ]
Dr: However we will need to do some tests to confirm that. First we will do a chest X ray.
Examiner might show you the chest x ray
Scenario 1 – Lung cancer Scenario 2 – Mesothelioma

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SHOW XRAY TO THE PATIENT
Scenario 1
Lung Cancer
Dr: Mr... I have your Chest Xray with me. Would you like to take a look at it?
P: Ok doctor
Dr: These are your lungs Mr.... and this is your heart. Can you see this round opaque
shadow at the top of your lung here? P: Yes
I am sorry to say that I do not have very good news for you. Mr...
Unfortunately this looks like cancer of the lung...
Dr: We will have to do further tests to confirm the diagnosis, like a CT scan of your chest.
We will also refer you to a specialist... a pulmonologist... who will do a procedure called a
bronchoscopy, where we will have to pass a flexible tube with a camera through your
mouth into your airways to get a better view of the problem. If needed, he might take a
tissue sample and send it for further analysis. Are you following me Mr....?
P: Yes doctor. Why did this happen to me?

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Dr: There are few factors that can increase the risk of developing lung cancer.
This condition is common in those people who smoke for long time.
P: Is it treatable doctor?
Dr: Mr... the treatment depends upon the diagnosis. If it is cancer, then it will depend upon
the stage of the cancer.. how far it has progressed and also the type of cancer. If it is an
early stage, we may be able to offer surgical options to remove the growth. But if the
cancer has advanced too much or if it is a more aggressive type of cancer, I'm afraid there
are no curative options. We might be able to offer treatment measures like radiotherapy or
chemotherapy to prolong life and relieve the symptoms. Are you with me Mr...?
P: Yes doctor I understand. You can go ahead with the tests..
Dr: Ok Mr... I will speak with my consultant and arrange for them right away. Do you have
any other concerns?
P: No doctor
Dr: Once again, I'm sorry I don't have better news for you at the moment... If you have any
doubts, please feel free to ask for me.
Scenario 2
Mesothelioma
Dr: Mr... I have your Chest Xray with me. Would you like to take a look at it?
P: Ok doctor
Dr: These are your lungs Mr.... and this is your heart. Can you see this white opacity over
this lung? P: Yes
I am sorry to say that I do not have very good news for you. Mr... Unfortunately this looks
like cancer of the lining of your lung... called mesothelioma.
We will have to do further tests to confirm the diagnosis, like a CT scan of your chest. We
will also refer you to a specialist... a pulmonologist... who might try to take a biopsy.... or a
tissue sample from the lining of your lung and send it for further analysis. Are you
following me Mr....?
P: Yes doctor. Why did this happen to me?

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Dr: There are few factors that can increase the risk of developing mesothelioma. Exposure
to elements like asbestos which was used extensively in the construction of old houses and
buildings can affect the lining of the lung and cause this condition.
P: Is it treatable doctor?
Dr: Mr... Unfortunately this is a serious type of cancer. I'm afraid there are no definitive
curative options. We might be able to offer treatment measures like radiotherapy or
chemotherapy to prolong life and relieve the symptoms, but I am afraid there is no
permanent cure if you are indeed diagnosed with mesothelioma. Are you with me Mr...?
P: Yes doctor I understand. You can go ahead with the tests..
Dr: Ok Mr... I will speak with my consultant and arrange for them right away. Do you have
any other concerns?
P: No doctor
Dr: Once again, I'm sorry I don't have better news for you at the moment.. If you have any
doubts, please feel free to ask for me.

CONFUSION – OXYBUTYNIN SIDE EFFECTS
Question: You are an FY2 in GP Surgery. Beverly McAndrews is a 55
years old lady who has presented with some concerns. Talk to the patient and
Hello. Beverly McAndrews? Hi, my name is Dr. ……… I am one of the junior doctors
here in the GP Surgery.
What would you like me to call you? – Bev, please

Can you confirm for me your age please? – 55
How can we help you today Bev? – Doctor, I’ve been feeling a little confused lately
Can you tell me a little bit more? – What would you like to know?
How long have you been having this sense of confusion? – 3 weeks
What made you notice that you have been confused lately? – I feel as if I’m forgetting
simple things. Like where I put my medication, and what day of the week it is
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Is this feeling of confusion getting better or worse? – Worse

Do you think the confusion might be aggravated by something? Activity? Fall? Trauma?
Medication? – I don’t know
Do you have any other symptoms other than the confusion? – Yes, I have been having
some problems controlling my wee, but that has improved. I feel really hot sometimes
What type of problem have you been having with your wee? – I’ve not been able to control
my wee, and it spoils my underwear
How long have you been having problems with your wee? – 3 months
Is it getting better or worse? – Better, since I’ve been on my medication Oxybutynin
Do you think the problem controlling your wee might be aggravated by something you do?
Exercise? Coughing? Straining? Passing poo? Medication? – I don’t think so
And does it improve with anything? Resting? Medication? – Yes, my medicine
How long have you been taking this medication? Compliant? – 2 months now. Yes
Has the problem resolved? – Yes, I don’t have any problem with my wee now
How long have you been feeling really hot for? – 1 week
And how did it come about? Sudden/Gradual? – Suddenly
Is it getting better or worse? – I think worse
Do you think it might be aggravated by something you do? Activity? Medication? – I
don’t know
Is there anything that I’ve missed that you’d like to add? – No

Rule out common Confusion causes;
Medication Side Effects, Infections (Sepsis, UTI, Pneumonia, Meningitis, Encephalitis),
Delirium, Hypoglycaemia, Dementia, Stroke, TIA, Anaemia, Metabolic (Acidosis,
Electrolyte Disturbance, Hepatic/Renal Failure), Hypoxia (Chronic Lung Disease),
Deficiencies (Vitamin B12), Cancer, Trauma, Recreational Drug Abuse,
[COMPLETE SYSTEMIC REVIEW]

Memory Loss/Impairment? (Medication Side Effect,Dementia) – Yes
Fever? Headache?Neck stiffness?Cough? Breathing difficulty? Burning sensation while
passing urine? Sore throat? (Infections) – No
Vision problems? Facial weakness? Problems with speech? (TIA/Stroke) – No
Dizziness?Feeling hungry? (Hypoglycaemia) – No
Feeling very thirsty?Passing less urine? (Diabetes) – No
SOB? Tiredness? Chest Pain?Bruises? Rash?(Anaemia) – No
Nausea or vomiting (Gastro-enteritis and dehydration)? – No
Bowel habits? (Hyperthyroidism&Hypothyroidism) Thyroid Systemic Review
Problems passing wee now? Frequency? Urgency? Hesitancy? Straining? Dribbling?
Incontinence? – No. It’s really improved
Swelling? Bloated tummy/ankle swelling? (Medication Side Effect) - No
Joint pains? –No
Stress or worries (depression)? – No
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Lumps and bumps? Weight loss?(Cancer) – No

Injuries/falls? – No
Have you ever been diagnosed with any medical condition before? – Yes, Urinary
Incontinence. I was diagnosed 2 months back when I saw my GP
High Blood Sugar? High Blood Pressure?– No
Are you currently taking any prescribed Medication? OTC?–Yes, I’m currently taking
10mg Oxybutynin tablets for my incontinence. I have them with me here. I usually take
the tablets twice a day. I’ve been taking them for 2 months now since I was prescribed. I
take the prescribed amount – not more or less. I am still taking them
 What do you know about your condition? – I was told everything in my last visit
 What do you know about your medication? – It’s to help me stop spoiling myself
 Did anyone explain to you any potential side-effects of your medication? – No
o Have you noticed any swelling around your eyes/lips/hands/feet/genital? – No
o Have you noticed any drowziness/agitation/hallucinations? – Yes, I do feel drowsy and
confused
o Any problems with your long and short-termmemory – Yes, I do forget things that are
happening in the now. My long-term memory is fine

Are there any illnesses which run in the Family? DM? HTN?–No
Have you Travelledanywhere recently? Long-distance? – No
What do you do for a living? – I’m a Librarian
Do you smoke/ drink alcohol? – No
Are you still having menstrual cycles? – No, menopause at 51
How would you describe your diet?– I eat very healthily, lots of water, fruit and veg
How have you been coping at home? Family? Relationships? Job? Hobbies? Sleep? – Well
Stress? – None, just my urine problem which is all better now.
Anything else you would to add? – No. I am fit and well
OXYBUTYNIN USE
Oxybutynin is a prescription drugused to treat overactive bladder. It comes as an

immediate-release oral tablet, extended-release oral tablet, oral syrup, topical gel, and
topical patch.
Oxybutynin may be used as part of a combination therapy. That means you need to take it
with other drugs.
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Why it's Used
Oxybutynin is used to treat an overactive bladder. Symptoms of this condition can include:
 urinating more often than usual
 feeling like you need to urinate more often
 urinary leakage
 painful urination
 being unable to hold your urine
The extended-release form of this drug is also used to treat children (ages 6 years and
older) with overactive bladder caused by a neurological condition such as spina bifida.
How it Works
Oxybutynin belongs to a class of drugs called anticholinergics/antimuscarinics. A class of

drugs is a group of medications that work in a similar way. These drugs are often used to
treat similar conditions.
Oxybutynin works by relaxing the muscles of your bladder. This decreases your sudden
need to urinate, having to urinate often, and leaking in between bathroom visits.
Oxybutynin Side Effects
Oxybutynin oral tablet may cause drowsiness as well as other side effects.The more
common side effects that can occur with oxybutynin include:
 being unable to urinate

 constipation
 dry mouth
 blurry vision
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 dizziness
 Drowsiness & Confusion
 sweating less than usual (raises your risk of overheating, having a fever, or
getting heat stroke if you’re in warm or hot temperatures)
 trouble sleeping
 headache
If these effects are mild, they may go away within a few days or a couple of weeks. If
Drug Interaction
Oxybutynin oral tablet can interact with other medications, vitamins, or herbs you may be
taking. An interaction is when a substance changes the way a drug works. This can be
harmful or prevent the drug from working well.
Examples of drugs that can cause interactions with oxybutynin include.
VI. Depression drugs
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include:
 amitriptyline
 nortriptyline
VII. Anti-Allergy drugs
include:
 chlorpheniramine
 diphenhydramine
VIII. Psychosis and Schizophrenia drugs
include:
 chlorpromazine
 thioridazine
IX. Antifungal drugs
Certain antifungal drugs will increase the level of oxybutynin in your body. This will raise
your risk of side effects. Examples of these drugs include:
 ketoconazole
 itraconazole
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X. Dementia drugs
Oxybutynin may worsen your dementia symptoms if you take it with certain dementia
drugs. These drugs, called cholinesterase inhibitors, include:
 donepezil
 galantamine
 rivastigmine
Warnings for Certain Groups
For people with autonomic neuropathy: Oxybutynin can make your stomach problems
worse. Use this drug with caution if you have this condition.
For people with bladder outlet obstruction: Oxybutynin may increase your risk of not
being able to empty your bladder.
For people with stomach problems: Oxybutynin may cause more stomach problems if
you have a history of ulcerative colitis, stomach pain, or reflux.
For people with myasthenia gravis: Oxybutynin may make your symptoms worse.
For people with dementia: If you’re treating your dementia with a drug called a
cholinesterase inhibitor, oxybutynin may worsen your dementia symptoms. Your doctor
can tell you more.
For pregnant women: Oxybutynin is a pregnancy category B drug. That means two

things:
3. Research in animals has not shown a risk to the foetus when the mother takes the
drug.
4. There aren’t enough studies done in humans to show if the drug poses a risk to the
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foetus.
For women who are breastfeeding: It isn’t known if oxybutynin passes into breast milk.
If it does, it may cause side effects in a child who is breastfed. Talk to your doctor if you
breastfeed your baby. You may need to decide whether to stop breastfeeding or stop taking
this medication.
For children: The safety and effectiveness of oxybutynin in children younger than 6 years
haven’t been established.
How to take Oxybutynin
Your dose, form, and how often you take it will depend on:
VI. your age
VII. the condition being treated
VIII. how severe your condition is
IX. other medical conditions you have
X. how you react to the first dose
D. Adult (ages 18–64 years)
 Strengths: 5 mg, 10 mg, 15 mg
 Typical starting dosage: 5 mg taken by mouth two to three times per day.
 Maximum dosage: 5 mg taken by mouth four times per day.
E. Child (ages 6–17 years)
 Typical starting dosage: 5 mg taken by mouth two times per day.
 Maximum dosage: 5 mg taken by mouth three times per day.

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F. Senior (ages 65 years and older)
Typical starting dosage: Your doctor may start your dosage at 2.5 mg taken two to three
times per day.
Take as Directed
Oxybutynin is used for long-term treatment. It comes with serious risks if you don’t take it
as prescribed.
What should I do if I miss a dose?
If you forget to take your dose, take it as soon as you remember. If it’s just a few hours
before the time of your next dose, then wait and only take one dose at that time. Never try
to catch up by taking two doses at once. This could result in toxic side effects.If you skip
or miss doses, you may not see the full benefit of this medication.
What if I take too much?
If you take too much: You may experience more side effects if you take too much of this
drug. These include:
 Dizziness, drowziness and confusion
 headache
 not being able to urinate
 constipation
 hallucinations (seeing or hearing things that aren’t real)
If you think you’ve taken too much of this drug it’s important you call your doctor or local
poison control centre. If your symptoms are severe, call 911 or go to the nearest emergency
room right away.
P a g e | 1014
How to I tell if the drug is working?
Your symptoms of overactive bladder or bladder instability may get better.If you don’t
take it at all, your symptoms of overactive bladder or bladder instability won’t improve.
Important Considerations for taking Oxybutynin
i. General
 You can take oxybutynin with or without food.
 You should take the tablet at about the same time each day.
 You can cut or crush the immediate-release tablet. However, you must swallow the
extended-release tablet whole. Don’t chew, divide, or crush it.
ii. Storage
 Store oxybutynin at a temperature as close to 77°F (25°C) as possible. You can

store it briefly at a temperature between 59°F and 86°F (15°C and 30°C).
 Keep this drug away from light.
 Don’t store this medication in moist or damp areas, such as bathrooms.
iii. Refills
A prescription for this medication is refillable. You should not need a new prescription for
this medication to be refilled. Your doctor will write the number of refills authorized on
your prescription.
iv. Travel
When traveling with your medication:

P a g e | 1015
 Always carry your medication with you. When flying, never put it into a checked
bag. Keep it in your carry-on bag.
 Don’t worry about airport x-ray machines. They can’t hurt your medication.
 You may need to show airport staff the pharmacy label for your medication.
Always carry the original prescription-labelled box with you.
 Don’t put this medication in your car’s glove compartment or leave it in the car. Be
sure to avoid doing this when the weather is very hot or very cold.
v. Diet
Caffeine may worsen your symptoms of overactive bladder. It may make this drug less
effective in treating your condition. You should limit your caffeine intake while taking
oxybutynin.
Are there any alternatives?
There are other drugs available to treat your condition. Some may be more suitable for you
than others. However, as your symptoms regarding the urinary incontinence seem have
improved, it shows that the drug seems to be effective.
EXAMINATION
I would like to check your mental status by conducting a Mini-Mental State

Examination (MMSE). It’s important for me to also look at the way your brain is
working by performing a quick Neurological Examination.
Finally, I would also like to take a closer look at your tummy.

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From what you have told me and from what I have seen your vitals were normal.
Examination of your mental status was within the normal limits (MMSE 29/30). The
functioning of your nerves and your tummy too were normal.
Bev, do you have any idea at all why you may be having this problem? –No
Unfortunately, it is likely that you could be suffering from Side Effects of the
medication you are taking - Oxybutynin. You’ve done really well in coming to the GP
Surgery to get it looked over.
Oxybutynin is one of the prescription drugs we use to treat an overactive bladder, as in

your case. Oxybutynin oral tablets may cause dizziness, drowziness and confusion as well
as other side effects, such as:being unable to urinate, constipation, dry mouth, blurry
vision, trouble sleeping, headache, and also as in your case sweating less than usual that
results in a person overheating and feeling hot.
If these effects are mild, they usually go away within a few days or a couple of weeks. If
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Unfortunately, medications often do have side effects which are well documented - but
they can be difficult to predict in every individual - as each individual has a unique
metabolism.
Usually these side effects occur due to prolonged levels of the medicine inside your body
that results in a continuous ongoing of their medicinal effect. Sometimes, the prolonged
high concentration of the medicine can result in undesirable side effects as in your case.
MANAGEMENT
 The medication Oxybutynin seems to be effective and has made a positive impact on your
incontinence, relieving your primary complaint. I do believe it’s important to Review
yourMedication.
 We must either
iv. Reduce the dose of the medication you are taking, or
v. Reduce the frequency you are taking the medication each day, or
vi. Stop the Oxybutynin
 Currently, you are taking two 10mg Oxybutynin tablets every day.Because your incontinence has
P a g e | 1018
significantly improved, I do believe that Stopping the Medication will benefit you the most
as it will get rid of the secondary symptoms of confusion and feeling hot.
 We could then have a period of Triallingyour response to stopping the medication, to see if your
primary symptom of incontinence returns or not. It is common forthe incontinence to return;
however we need to find the right balance to make sure we prevent both your primary
symptom that is the incontinence and the secondary symptoms of confusion and feeling hot.
 We may have to half the dose from 10mg to 5mg.
 We may have to change the instructions to take the tablet once daily.
 We may need to start you on a Different Medication altogether if the secondary
symptoms continue to persist.
 I would like to consult my Seniors for a 2nd opinion
 I do have some Reading Material for you entitled Oxybutynin
 If you experience worsening of your symptoms orserious side effects such as; not being able
to empty your bladder or swelling around your eyes, lips, genitals, hands, or feet it’s
important to call 911 right away, especially if your symptoms feel life-threatening or if you
think you’re having a medical emergency.
Do you think I’ve got dementia?
From what you’ve told me and from what I’ve examined, although you are having
some minor problems with your memory and confusion, I do not believe that you
have Dementia, and it is extremely unlikely to be Dementia.
Dementia is a group of related symptoms associated with an ongoing decline of brain

functioning. It is more common if you’re over the age of 65.
Although people can get dementia before the age of 65 – called Early Onset
Dementia – it is quite uncommon.
Problems that occur in dementia include: memory loss, thinking speed, mental sharpness
and quickness. However, dementia isn’t just about memory loss. It can also affect your
language, understanding, judgement, mood, movement and the way you carry out your
daily activities.

P a g e | 1019
No Allergies. Family Hx. unremarkable. No Travel Hx. Librarian. Unmarried. Sexually

Inactive. Non-Smoker. Occasional Alcohol drinker. Does not use recreational drugs. Lives
alone.
Vitals – Pulse 88/min, BP 130/85mmHg, RR 18/min, O₂ Saturation 98% on room air,

Temp 37.7°C
Neurological Examination – Normal
MMSE 29/30
Abdominal Examination – Normal
Needle stick injury in the nurse
You are the FY2 doctor in the A& E department.

Mrs Andrea Jones 23 year nurse in your hospital came to the A& E department
because she had a needle stick injury while she was drawing blood from a patient.
Dr: Hell Mrs Andrea Jones I am Dr …. How are you doing ?

Nurse: I am not feeling good doctor. I pricked myself with the needle when I was taking
blood from a patient.
Dr: I am very sorry to hear that. Can you tell me anything more about it ?
Nurse: I was just taking the blood from a patient. After that I accidentally pricked
myself with the needle. I happened just half an hour ago.
P a g e | 1020
Dr: Did you prick yourself after you used on the patient or was it a new needle
( not used on anyone)
Nurse: It is the same needle I used on the patient and then I
pricked myself Dr: Was it ahollow-boreneedle? Nurse:
Yes
Dr: Which part of your body did you prick yourself?Nurse: Myfinger
Dr: What did you do afterthat?
Nurse: I washed in soap and water. My senior staff told me to come here.
Dr: Good that you washed it soap and water. You are not supposed to use any
antiseptics to wash and also you are not supposed to put the area in the mouth. Was
the wound deep or superficial ?
Nurse: Just superficial / it is deep.
Dr: Were you wearing gloves atthattime. Nurse: Yes Dr:
When was your last hep B vaccine and tetanusvaccine?
Nurse: I had both about 2 years ago.
Dr: Do you have any medicalcondition? Nurse:No
Dr: Have tested for HIV or Hepatitisrecently? Nurse: No
Dr: Are you taking anymedications? Nurse:No
Dr: Are you allergic to anything at all ? Any chance you are
pregnant?
Dr: Do you practice safe sex?
Nurse: I am married, so don’t practice safe sex / sometimes she may say I have a partner
and practice safe sex.
Dr: Did you have any such incidentspreviously? Nurse:No

P a g e | 1021
Dr: Do you use any drugs and share needles with others ?Nurse
No
Dr: Do you know what is wrong with thepatient?

Nurse: HehasMeningitis? Dr: OK. Is heconscious? Nurse:Yes/No
Dr: Do you know whether he has any infections other than meningitis like
Hepatitis or HIV ?
Dr: Regarding Hep B – since you are already immunised against Hep B chances you
are going to get Hep B infection is almost negligible. Risk is 30% in those who are not
immunised. However we need to do blood tests and check the antibody level for Hep
B. If you do not have enough antibody then we may give you immunoglobulin and
booster dose of the Hep B vaccine. Hep B booster dose can be given within one week
of the incident.
Dr: Any questions about HepB? Nurse:No
Dr: Unfortunately there is no pre or post exposure prophylaxis for Hep C. The risk is
1.8% so very low chance again.
Dr: Since the patient is having meningitis – we will give prophylaxis for the
meningitis also.
Dr: Occupational health department will follow you up. They will check for side
effects and do blood tests: FBC, Us and Es, LFTs, HIV, Hep B and Hep C at 3
months and 6 months.
Occupational Health can also provide you counselling and support
if required. Any other concerns. Nurse: No
Thank you verymuch.
P a g e | 1022

MRSA – COPD patient
Mr Charles Roper 56 year old man has been admitted to the hospital for COPD.
His nose swab showed MRSA.
He has been isolated and been treated appropriately.
His wife Mrs Helen Roper is concerned about him.
Please talk to her and address her concerns.
Dr: Hello Mrs Helen Roper !

Wife: Yes.
Dr: I am Dr. …. One of the junior doctor in the medical department. How are you doing
Mrs Roper?
Wife: I am OK. I am worried about my husband ! I just came to see him. He has been
shifted to some other room. I can see doctors and nurses wearing aprons and gloves. What
is happening to him doctor?
Dr: I can see that you are very concerned, I will explain everything. Before that can you
please tell me how much you know about what is happening to him?
Wife: I know he has COPD !
Dr: Yes, That is right Mrs Roper. He has COPD and was treated as you know. But we did
some swab test on his nose and it showed that he has some bugs in his nose.
Wife: What kind of bugs?
Dr: These bacterial kind of bugs are called MRSA in other words they are called super
bugs. Do you anything about these bugs MrsRoper ?
Wife: Super bugs ! I have heard of them. From where did he get this bugs ? Is it because
the hospital is dirty?
Dr: Sometimes the bacteria normally live on the people’s skin without causing any
problem. Sometimes these bugs are spread through skin-to-skin contact with someone who
has an MRSA infection. These bugs also spread through contact with contaminated objects
such towels, sheets, clothes, dressings, surfaces, door handles and floors.
P a g e | 1023
Sometimes people may get this infection outside the hospital also.
We do keep the hospital very clean to minimise the spread of this infection. When doctors
and nurses enter the room of the patient’s with this of infection they wash their hands
thoroughly and wear aprons and gloves to minimise the chance of spreading the infection.
However, sometimes people can get this infection because new patients keep coming into
the hospital and they may have this bugs on their skin and it spreads to others.
Wife: Is it a serious problem doctor?

Dr: At the moment these bugs are just present in his body and it is not causing any
problems to him. So it is not a serious problem to him at the moment.
However, if the bugs gets inside the body and cause infection then it can become serious
problem. Sometimes the bugs can get inside the body and cause infection if their body
resistance goes down or if they have some break in their skin like operated wounds or it
can enter inside the body through urine catheter or IV cannulas ( the tubes through which
we give medication into the veins).
In your husbands case because he has COPD, his body resistance would be low. So there is
a chance that bugs may get inside his body and cause infection.
Wife: Do you mean to say he may die doctor?

Dr: Mrs Roper, As I told you at the moment there is no problem because the bugs are just
present in is body. It is not very common that people die because of this bugs. It can
happen only if the people gets serious infection with this bugs and bugs do not respond to
any treatment.
Wife: How are you treating him doctor ?
At the moment bugs are just present on his body. So we are treating him appropriately to
get rid of these bugs. Usually we put some antibiotic cream to the nose and use
antibacterial body wash products and powders to get rid of these bugs from the body.
However, if the bugs get inside the body and cause infection it can cause problems because
these bugs are resistant to most of the antibiotics what we usually use to kill the bugs. But
they usually do respond to one type of antibiotics called Vancomycin. We will treat
patients with Vancomycin injections if they have infection with this kind of bugs.
Wife: Why he has been shifted to the other room?

Dr: Mrs Roper, I can imagine why you are so worried. As I explained, this infection can
spread from one patient to another patient easily if they are close to each other in the same
room. We have to keep him in a separate room so that the bugs will not spread. It is
beneficial to him also because there are no other patients in that room, so he may not get
any other kind of bugs from others.
Wife: How long will he need to be in the hospital?

Dr: It may take few days to get rid of this bugs. We will keep checking that. Once he get
rid of this bugs and he has no other problem then we will discharge him.
P a g e | 1024
Wife: Can I see him doctor?

Dr: Surely you can see him. However, we suggest you to wash your hands thoroughly
before and after you enter the room and minimise touching him or anything else inside
the room so that this bugs will not spread. Is that alright Mrs Roper?
Wife: Ok doctor.
Dr: Any other concerns?
Wife: No doctor.
Dr: Thank you very much Mrs Roper, I hope he will recover soon. If you need any other
help please let me know.
Clostridium difficile Infection - Talk to Son.
You are FY 2 doctor in the medical department.
Mr. Andrew Reece 65 year old man had been admitted to hospital for exacerbated
COPD ( or Pneumonia) 10 days ago. He has been treated with the appropriate IV
antibiotics and has now developed acute diarrhoea.
His stool samples are taken and revealed presence of C. difficile Toxin.
He has been shifted to a bay with other people with similar condition and been
started on treatment.
His son is concerned about him.
Please talk to him and address his concerns.
Dr: Hello. Are you Mr. Andrew Reece’s son?
Son: Yes.
Dr: I am Dr. …. One of the junior doctors in the medical department. How can I call
you?
Son: (?)
P a g e | 1025
Dr: How are you doing Mr...?
Son: I am fine. I am worried about my father. I just came to see him. He has been
shifted to some other room. I can see doctors and nurses wearing aprons and gloves.
What is happening to him doctor?
Dr: I can see that you are very concerned, I will explain everything. Before that can you
please tell me how much you know about what is happening to him?
Son: I know that he has COPD. Now, he has developed diarrhoea. I think he has got
food poisoning because of the food that you give him in the hospital.
Dr: You are right that he had COPD and yes, he has developed diarrhoea but it is not
food poisoning and neither it is because of the food that we are giving him in the
hospital. We actually did some tests on him and it showed that he has got some bugs in
his colon.
Son: What kind of bugs?
Dr: These are bacterial kind of bugs called C. Difficile. Do you know anything about
these bugs?
Son: No doctor. I don't know about the bugs but I know that you are responsible for this.
He was perfectly fine before.
Dr: You are a very caring son. I can imagine why you are so anxious. But let me assure
you, we take really good care of all our patients.
Son: Then from where did he get these bugs?
Dr: Please let me explain it to you why your father has developed diarrhoea.
Son: Okay.
Dr: Infection with this bug most commonly occurs in people who are in hospital and
recently had a course of antibiotics like your father. Are you following me?
Son: Yes.
Dr: Actually, this bugis normally present in gut of many people. But it lives harmlessly.
The number of these bugs that live in the gut of healthy people is kept in check by all
the other harmless bugs that also live in the gut. So, in other words, some of us normally
have small numbers of these bugs living in our guts, which do no harm.
If someone takes antibiotics for any infection as in your father's case, this antibiotic that
he took not only killed the bacteria that caused the chest infection, but also killed many
of the harmless bacteria that lived in his gut. C. difficile type of bugs did not get killed
by this antibiotic. When other harmless bacteria are killed then this allowed C. difficile
type of bug to multiply. This bug also started to produce poisons which are called as
P a g e | 1026
toxins and these toxins caused him diarrhoea.
Son: But doctor many other patients have developed diarrhoea as well. It has to be
because the dirty hospital food.
Dr: I can see why you are thinking that it is because of the hospital food. But let me tell
you that we do keep the hospital very clean. We take really good care of hospital
hygiene. The food provided in our ward is prepared under strict aseptic techniques.
Every member of the health care team wash their hands thoroughly and wear aprons and
gloves to minimize the chance of spread of any kind of the infection to patients.
Son: Well, other people get it. Why did they get this bug?
Dr: Despite the good medical care, sometimes, it can spread to other people. It can
happen that the spores produced by the bugs can spread from the faeces of infected
person to a non-living surface and from there can spread to the patients who are prone to
this infection.
Sometimes people can get this infection because new patients keep coming into the
hospital and they may have this infection and it spreads to patients already admitted in
the hospital. These bugs also spread through contact with contaminated objects such
towels, sheets, clothes, dressings, surfaces, door handles and floors. And so regretfully,
sometimes further spread can occur via the hands of healthcare workers despite all the
caution.
Son: Are you sure that he had this bug?
Dr: Yes, as I have mentioned we have tested the blood of Mr. Herman. We have found
C. Difficile type of bug in his blood and it is risen because of the antibiotic that he used
in order to treat his chest infection.
Son: But why did he get this bug?
Dr: Well, as I have told antibiotics are the main cause of this infection. And above 60
years, there is increased threat of getting infected with this bug. Also, in your father's
case because he has COPD, his body resistance would be low. So there is a fair chance
that bugs got inside his body and caused this infection.
Son: How are you treating him doctor ?
Dr: Well, Mr. Herman is closely monitored. We have stopped the antibiotics that we
were giving him previously for his chest illness. This will allow the normal harmless
bugs to thrive again in the gut. The overgrowth of C. difficile should then reduce and
diarrhoea will stop.
However, we will be starting him on a different antibiotic that is known to kill C.

difficile. This is usually vancomycin or metronidazole. Symptoms then usually ease
within 2-3 days.
P a g e | 1027
As with any cause for diarrhoea, it is important that we replace the fluids that are lost in
the diarrhoea. So, we will be giving him fluids through a drip into his veins to keep him
hydrated. Are you following me?
Son: Is it serious doctor?
Dr: At the moment these bugs are just present in his colon and it is not causing any
problems to him. So it is not a serious problem to him at the moment. However, in very
rare cases if the infection is not treated at the right time, it can become very serious.
Son: Can there be any complication?
Dr: In small number of cases, if not managed at the right time, it can progress into a
serious illness in which swelling of intestine develops and for that, surgery may be
needed.
Son: Why he has been shifted to the other room?
Dr: I can imagine why you are so worried. As I explained, this infection can spread from
one patient to another patient easily if they are close to each other in the same room. We
have to keep him in a separate room so that the bugs will not spread. It is beneficial to
him also because there are no other patients in that room, so he may not get any other
kind of bugs from others.
Son: Can't you give him any medicine to stop his diarrhoea?
Dr: Anti- diarrhoeal medicines are not recommended in this infection. This is because it
is thought that they may slow down the rate at which the poisons (toxins) produced by
the bacteria are cleared from your gut.
Son: How long will he need to be in the hospital?
Dr: It may take few days to get rid of this bugs. We will keep checking that. Once he get
rid of this bugs and he has no other problem then we will discharge him.
Son: Can I see him doctor?
Dr: Surely you can see him if you yourself do not have any medical conditions because
if you have any medical conditions then you may catch this bugs easily. You can enter
his room and see him. However, we suggest you to wash your hands thoroughly before
and after you enter the room also you should wear apron and gloves and minimise
touching him or anything else inside the room so that this bugs will not spread. Is that
alright?
Son: Ok doctor.
Dr: Any other concerns?
Son: No doctor.
Dr: Thank you very much, I hope Mr. Herman will recover soon. If you need any other
P a g e | 1028
help please let me know.
Information on C Difficle management
Management of mild, moderate, and severe CDI
1. If a patient has strong a pre-test suspicion for CDI, empiric therapy for CDI
should be considered regardless of the laboratory testing result, as the negative
predictive values for CDI are insufficiently high to exclude disease in these
patients. (Strong recommendation, moderate-quality evidence)
2. Any inciting antimicrobial agent(s) should be discontinued, if possible. (Strong

recommendation, high-quality evidence)
3. Patients with mild-to-moderate CDI should be treated with metronidazole 500

mg orally three times per day for 10 days. (Strong recommendation, high-quality
evidence)
4. Patients with severe CDI should be treated with vancomycin 125 mg four times
daily for 10 days (Conditional recommendation, moderate-quality evidence)
5. Failure to respond to metronidazole therapy within 5–7 days should prompt

consideration of a change in therapy to vancomycin at standard dosing. (Strong
recommendation, moderate-quality evidence)
6. For mild-to-moderate CDI in patients who are intolerant/allergic to

metronidazole and for pregnant/breastfeeding women, vancomycin should be
used at standard dosing. (Strong recommendation, high-quality evidence)
7. In patients in whom oral antibiotics cannot reach a segment of the colon, such as
with Hartman’s pouch, ileostomy, or colon diversion, vancomycin therapy
delivered via enema should be added to treatments above until the patient
improves. (Conditional recommendation, low-quality evidence)
8. The use of anti-peristaltic agents to control diarrhoea from confirmed or

suspected CDI should be limited or avoided, as they may obscure symptoms and
precipitate complicated disease. Use of anti-peristaltic agents in the setting of
CDI must always be accompanied by medical therapy for CDI. (Strong
recommendation, low-quality evidence)
P a g e | 1029

Post-mortem examination
A post-mortem examination, also known as an autopsy, is the examination of a
body after death. The aim of a post-mortem is to determine the cause of death.
Post-mortems are carried out by pathologists (doctors who specialise in understanding
the nature and causes of disease).
Post-mortems provide useful information about how, when and why someone died,
and they enable pathologists to obtain a better understanding of how diseases
spread.
Learning more about illnesses and medical conditions benefits patients too,
because it means they'll receive more effective treatment in the future.
◦ When post-mortems are carried out

A post-mortem examination will be carried out if it's been requested by:
 a coroner – because the cause of death is unknown, or following a sudden,
violent or unexpected death
 a hospital doctor – to find out more about an illness or the cause of death, or to
further medical research andunderstanding
 Sometimes, the partner or relative of the deceased person will request a hospital
post- mortem to find out more about the cause ofdeath.
◦ Coroner’s post-mortem examination
A coroner is a judicial officer responsible for investigating deaths in certain
situations. Coroners are usually lawyers or doctors with a minimum of five years'
experience.
In most cases, a doctor or the police refer a death to the coroner. A death will be
referred to the coroner if:
 it's unexpected, such as the sudden death of a baby (cotdeath)
 it's violent, unnatural or suspicious, such as a suicide or drugoverdose
 it's the result of an accident orinjury
 it occurred during or soon after a hospital procedure, such assurgery
 the cause of death isunknown
The main aim of a post-mortem requested by a coroner is to find out how

someone died and decide whether an inquest is needed. An inquest is a legal
investigation into the circumstances surrounding a person's death.
P a g e | 1030
If someone related to you has died and their death has been referred to a coroner, you
won't be asked to give consent (permission) for a post-mortem to take place. This is
because the coroner is required by law to carry out a post-mortem when a death is
suspicious, sudden or unnatural.
A coroner may decide to hold an inquest after a post-mortem has been completed.
Samples of organs and tissues may need to be retained until after the inquest has
finished.
If the death occurred in suspicious circumstances, samples may also need to be kept
by the police, as evidence, for a longer period. In some cases, samples may need to be
kept for a number of months or even years.
The coroner's office will discuss the situation with you if, following an inquest,
tissue samples need to be retained for a certain length of time.
◦ Hospital post-mortem examination

Post-mortems are sometimes requested by hospital doctors to provide more
information about an illness or the cause of death, or to further medical research.
Hospital post-mortems can only be carried out with consent. Sometimes, a person
may have given their consent before they died. If this isn't the case, a person who is
close to the deceased can give their consent for a post-mortem to take place.
Hospital post-mortems may be limited to particular areas of the body, such as the
head, chest or abdomen. When you're asked to give your consent, this will be
discussed with you. During the post-mortem, only the organs or tissue that you've
agreed to can be removed for examination.
You will be given at least 24 hours to consider your decision about the post-mortem
examination..
◦ What happens during a post-mortem?

◦ A post-mortem will be carried out as soon as possible, usually within two to
three working days
of a person's death. In some cases, it may be possible for it to take place within
24 hours. Depending upon when the examination is due to take place, you may
be able to see the body before the post-mortem is carried out.
The post-mortem takes place in an examination room that looks similar to an operating
theatre.
During the procedure, the deceased person's body is opened and the organs removed
for examination. A diagnosis can sometimes be made by looking at the organs. Some
organs need to be examined in close detail during a post-mortem and these
investigations can take several weeks to complete. The pathologist will return the
organs to the body after the post-mortem has been completed. If you wish, you'll
usually be able to view the body after the examination.
Once release papers have been issued, the undertakers you've appointed will be able
to collect the body from the mortuary in preparation for the funeral.
◦ What happens after a post-mortem ?

P a g e | 1031
After a post-mortem, the pathologist writes a report of the findings.

If the post-mortem was requested by the coroner, the coroner or coroner's officer will
let you know the cause of death determined by the pathologist. If the post-mortem was
requested by a hospital doctor, you'll have to request the results from the hospital
where the post-mortem took place.
That in some cases you will be asked to make some decisions. These may be to
discuss any need for consent, or to decide what happens to organs and tissue samples
that may need to be removed for investigation. Your wishes will be respected.
Any particular needs that you have, which could be cultural, religious or practical,
will be taken into account as far as possible. Where consent is not given for storage
of organs or tissue samples they are disposed of in a timely and respectful manner.
In some circumstances a Coroner may open an inquest into the death of an individual
after a post- mortem examination. If the Pathologist certifies that they have a bearing
on the cause of death, the Coroner may require that any retained organs and tissue
blocks and slides are kept until the Coroner’s function is complete. Similarly if there
is a possibility of criminal involvement in the death, tissue may be needed by the
police as evidence, separate to the Coroner’s requirements.
In both cases, the tissue samples, blocks and slides or organs may need to be
kept for several months, in some cases, years. As a result this may affect what
you want to happen to them.
Why do organs and tissue need to be retained?
In around 20% of adult post-mortem examinations and in most paediatric post-
mortem examinations, the cause of death is not immediately obvious. A diagnosis
can only be made by
retaining small tissue samples of relevant organs for more detailed examination. The Pathologist
may need to retain a whole organ for a full assessment to allow an accurate diagnosis of the
cause of death to be made. When this happens the organ or tissue is normally sent to a specialist
unit.
These full assessments often take weeks or even a few months to complete, depending on the
extent of the investigations required. Once they are complete, the Pathologist will produce a
report for the Coroner or the medical staff responsible for the care of the person before they died.
What happens when the post-mortem examination is complete?
When the post-mortem examination is complete, you will be told whether tissue samples and
organs have been retained. If tissue samples and organs have been retained then you should
expect to be given a choice about what happens to them when they are no longer needed by the
Coroner or the hospital. Your consent will be needed for any tissue samples or organs to be kept
for future use such as research or education and training of medical staff.
Blocks and slides
With your consent, the tissue blocks and slides may be stored as part of the record of the post-
mortem examination, sometimes called the pathology or medical record, in case they are useful
to your family in the future. If the post-mortem examination takes place in a Local Authority
Public Mortuary, rather than an NHS Mortuary, then your consent will be taken to mean that you
agree to the transfer and storage of the blocks and slides within the healthcare sector.
The samples may also be useful for one or more of the following: teaching, research, clinical audit
or quality assurance etc. The organisation storing the blocks and slides may dispose of them.
P a g e | 1032
If a funeral has already taken place, then the blocks and slides can be returned to you, usually
via your funeral director. There may also be health and safety issues that may prevent this
option.
The blocks and slides may be returned with the body before the funeral. It is important to
realise that choosing this option could significantly delay the funeral. Some crematoria do not
allow blocks and slides to be cremated with the body.
Whole organs and tissue samples
Organs and tissue samples cannot be stored as part of the medical record in the same way that
blocks and slides are. They can be re-united with the body, or buried or cremated separately.
Alternatively they can be retained for future use in teaching, ethically approved research, audit
and other clinical purposes, but only with your consent.
Who can give consent for retention of organs?

The most important wishes to consider are those of the person who has died. If it is known that
the person who has died gave consent or specifically did not want to give consent to the retention
of tissue samples or organs, then those wishes must be respected.
If their wishes are not known, then a person nominated by them when they were
alive, or someone in a relationship with them or closely related, must give consent.
The spouse or partner is highest on the list, and a long term friend is at the bottom.
retaining small tissue samples of relevant organs for more detailed examination. The Pathologist
may need to retain a whole organ for a full assessment to allow an accurate diagnosis of the
cause of death to be made. When this happens the organ or tissue is normally sent to a specialist
unit.
These full assessments often take weeks or even a few months to complete, depending on the
extent of the investigations required. Once they are complete, the Pathologist will produce a
report for the Coroner or the medical staff responsible for the care of the person before they died.
What happens when the post-mortem examination is complete?
When the post-mortem examination is complete, you will be told whether tissue samples and
organs have been retained. If tissue samples and organs have been retained then you should
expect to be given a choice about what happens to them when they are no longer needed by the
Coroner or the hospital. Your consent will be needed for any tissue samples or organs to be kept
for future use such as research or education and training of medical staff.
Blocks and slides
With your consent, the tissue blocks and slides may be stored as part of the record of the post-
mortem examination, sometimes called the pathology or medical record, in case they are useful
to your family in the future. If the post-mortem examination takes place in a Local Authority
Public Mortuary, rather than an NHS Mortuary, then your consent will be taken to mean that you
agree to the transfer and storage of the blocks and slides within the healthcare sector.
The samples may also be useful for one or more of the following: teaching, research, clinical audit
or quality assurance etc. The organisation storing the blocks and slides may dispose of them.
If a funeral has already taken place, then the blocks and slides can be returned to you, usually
via your funeral director. There may also be health and safety issues that may prevent this
option.
The blocks and slides may be returned with the body before the funeral. It is important to
realise that choosing this option could significantly delay the funeral. Some crematoria do not
P a g e | 1033
allow blocks and slides to be cremated with the body.

Whole organs and tissue samples
Organs and tissue samples cannot be stored as part of the medical record in the same way that
blocks and slides are. They can be re-united with the body, or buried or cremated separately.
Alternatively they can be retained for future use in teaching, ethically approved research, audit
and other clinical purposes, but only with your consent.
Who can give consent for retention of organs?

The most important wishes to consider are those of the person who has died. If it is known that
the person who has died gave consent or specifically did not want to give consent to the retention
of tissue samples or organs, then those wishes must be respected.
If their wishes are not known, then a person nominated by them when they were alive, or
someone in a relationship with them or closely related, must give consent. The spouse or
partner is highest on the list, and a long term friend is at the bottom.
Post-mortem exam question

Mr Peter Green 64 year old man was treated for Pneumonia by the GP with antibiotics
because he had shortness of breath for 2 weeks. He was hospitalised one week ago because
it got worse. He died of suspected Respiratory failure.
His wife Mrs Green want to talk to a doctor about this
issue. Talk to his wife Mrs Green and address her
concerns.
( post mortem may not be mentioned in the question ).

Dr: Hello Mrs Green, I am Dr …. Junior doctor in the medical department? How are you
doing ?
Wife: I am not feeling good doctor. I don’t know what happened to my husband suddenly he
died.
Dr: I am very sorry about it. Please accept my condolences for the loss of your precious one. I
can’t even imagine how you are feeling. I was told that you want to talk to a doctor about it. Do
you have any concerns?
Wife: I am just wondering doctor why this happened so suddenly. He was doing good.
Dr: We think it could be due to infection in his lungs which has led to failure of the lungs has
led to this. But we are not very sure about it. However we need to know more about this.
Can you please tell me what happened before he was brought into the hospital?
Wife: He was short of breath since last 2 weeks. We went to GP and he said he has chest
infection and gave him antibiotics. He was getting more ill since last one week and we brought
him to the hospital and he was admitted a week ago. Now suddenly this happened.
Dr: Did he have any medical conditions? Any operations done recently? Any medications ?
Any allergies?
Wife: Doctor, He had no medical problems at all. He has never been to the hospitals or GP
before this. He was completely fit and well. Why this happened doctor.
P a g e | 1034
Dr: As I mentioned before. We think it could be due to infection in the lungs. We are not sure.
I think it is a better idea to do the post-mortem and find out about it. What do you think ?
Wife: My niece works as a nurse – she also told me that it is good to have the post-mortem.
Dr: OK, surely we can request for that if you wish to. Do you know what we do in the
post- mortem?
Wife: I don’t know ?
Dr: We do the post-mortem to find the exact cause of death when we are not sure about the
exact cause of death. We do that in an examination room that looks similar to an operating
theatre.
Pathologists ( specialist doctor) does the post-mortem.
During the procedure, they open the body and remove the organs for examination. Sometimes
they know the cause of death by looking at the organs. Some organs need to be examined in close
detail during a post-mortem and these investigations can take several weeks to complete. They
also will take some tissue samples from the organs and keep it for future testing.
The pathologist will return the organs to the body after the post-mortem has been
completed.
Wife: Who decide to hold the post-mortem?

Dr: It can be requested by a coroner (judge) or hospital or the close relative in this
case like you can request for the post-mortem.
Wife: When will you do the post-mortem?
Dr: We usually do the post-mortem within two to three working days of a
person's death. Wife: Can I see him ?
Dr: Surely you can see him before we do the post-mortem if you wish to or you can
see him after the post-mortem also.
Wife: Will it delay the funeral ?
Dr: After the post-mortem they will give release papers and after that you can hold
the funeral. Wife: When will I get the death certificate?
Dr: They usually give the death certificate once they know the cause of death.
However you do not need to wait until you get the death certificate to hold the funeral
for him.
Wife: Will they keep the organs?
Dr: Usually they return the organs back to the body after taking some tissue samples.
If they need to retain any organ they will ask your consent for that. Do you know
what was your husband’s wishes about the organs- did he mention any thing about
what to do for the organs before he died? If he had mentioned anything like that
before he died - then his wishes will be respected.
Wife: We did not discuss about this issue because this happened
unexpectedly. Which parts for the body do you open ?
Dr: We open only head, chest and tummy area only. We do not touch face, arms and
legs. We stitch it up once the organs are returned to the body. Stitched areas are
P a g e | 1035
usually covered by the dressing of the body by the mortician. So there will not be any
disfigurement to the face and arms.
Wife: How will this post-mortem help us
doctor? Dr: It will help you and others a
lot in many ways.
1) First of all you will have a peace of mind and feeling of closure if you know the
cause of hisdeath.
2) If it all he died of some genetically inherited condition, we can check for that
problem in his family members or if you have children we can check your children
also and maybe we will be able to treatthem.
3) Also if it all he died of contagious disease we can protect others who came in
contact withhim.
4) Also it helps us a lot in our studies and future
training. Wife: Will you request to do the post-
mortemdoctor?
Dr: Yes surely. I will talk to my Consultant and then we will request the concerned
authorities to do that.
Dr: Is there anything else I can do for you? Wife: No doctor. You have been kind.
Dr: Thank you very much. We will keep you informed at every stage. I am very sorry
again for
what happened to your husband. If you need any support we have bereavement support
team in the hospital you can contact them. They may be able to help you.
Wife: Ok thank you doctor.
Dr: Thankyou.
4. Colorectal Polyp - Colonoscopy
You are FY2 in Gastroenterology ward. Alice McCoy, 55 years old female has come to
department today with complaint of bleeding per rectum 6 weeks ago.
She had undergone sigmoidoscopy two weeks ago and it showed she had a polyp.
She requires colonoscopy now.
Dr: Hello I am Dr-------------, one of the junior doctors in Gastroenterology, are you Alice
McCoy?
54..
P a g e | 1036
Pt: Yes Doctor, call me Alice.

Dr: How can I help you today?
Pt: Doctor I had a camera test two weeks ago and first they took two weeks to give me results
and now they have asked me to come back and have camera test again. See this note.
(Pt. hands over the letter from consultant)
On the letter it is written
Your sigmiodoscopy showed that you had a polyp. Biopsy
confirms it to be adenoma (Dysplasia: Benign Lesion). You are requested
to come back for colonoscopy.
Signed: Consultant Gastroenterologist.
Dr: Alice do you know about these tests and what is in this letter?
Pt: Yes doctor I know it is a camera test but I don’t understand other things in this letter.
Dr: Yes Alice you are right this is a camera test and I know that we have made you wait for
quite some time for the results but that’s because we also tested few tissue samples under
microscope and it is a very sensitive test and it takes time to be assessed and report to be
confirmed.
I am sorry we made you wait for your results but we have your results now and I am here to
answer if you have any questions or concerns.
Pt: Okay doctor but why do I need another camera test?
Dr: Alice, You have been invited to have a colonoscopy because we found a small growth
called polyp in your rectum in your sigmoidoscopy test. This means there is a chance you
have polyps further up the bowel as well. A sigmoidoscopy is just for lower part of the large
bowel but colonoscopy checks further up the bowel.
Pt: But doctor it was very uncomfortable last time.
Dr: I am really sorry about that, Alice. We can offer you a sedative medication through your
veins before the procedure which is known to make this procedure more comfortable and we
will also apply numbing gel locally so that you don’t feel any pain or discomfort during the
procedure. Would it be right then?
55.
Pt: Okay Doctor, but is it serious?

Dr: Right now the tests show that it is not very serious but we are never too sure until we test
the whole bowel.
P a g e | 1037
In order to tell you more about this condition I need to ask few questions from you, would
you be comfortable with that?
Pt: Yes doctor, what do you want to know?
Dr: Alice what was the reason that you had first camera test?
Pt: Doctor I had bleeding from my back passage 6 weeks back and at first I thought it’s just
hemorrhoids as I had it previously as well, 30 years back when my daughter was born. But I
had bleeding from back passage again 2 weeks back and then I went to my GP and he
suggested camera test.
Dr: Alice, you did really well by going to your GP. It is a very healthy and positive attitude
and it allows us to find things at an early stage and in turn we have better options to offer to
patients.
Alice, you told me about bleeding, how was it like?
Pt: I don’t really know doctor; it’s just that I had it twice.
Dr: Do you have anything else along-with this bleeding?
Pt: Like what doctor?
Dr: Any pain in your tummy? Pt: No.
Dr: Any pain at your back passage? Pt: No.
Dr: Have you noticed any change in your bowels? Pt: Not really doctor.
Dr: What are you usual bowel habits?
Pt: Dr: I have constipation for last 2 years. I take bisacodyl for it and it gets relieved.
Dr: Have you noticed if your constipation alternates with diarrhea? Pt: No.
Dr: Have you noticed any changes in your weight recently?
Pt: No doctor.
Dr: Any mass or lump in your back passage? Pt: No.
Dr: Any mass or lump in your tummy or elsewhere in the body? Pt: No.
Dr: Any surgeries previously? Pt: No.
56
Dr: Are you taking any medications including over the counter medicines? Pt: Just bisacodyl
occasionally.
Dr: Are you allergic to anything? Pt: No.
Dr: Do you smoke? Pt: No.
Dr: Do you drink alcohol? Pt: No.
Dr: Is there any one in your family who has been diagnosed with cancer?
Pt: No, Doctor. Am I having Cancer? (Pt. acts shocked and worried at word cancer)
P a g e | 1038
Dr: I really hope not Alice,,,It is one of routine questions. You know cancer is a very
dangerous condition and we just cannot take risk of missing it. That’s why we always ask
questions and investigate for it.
Pt: Okay. So, doctor what is that I am having?
Dr: Alice, It is really hard to tell for sure without colonoscopy but from our discussion it does
not look to be serious and your biopsy test result also showed that although you had a growth
but it is not a serious one. But there is a chance that it can turn into cancer sometimes.
Also there may be more polyps much higher in the colon – if it is there they also may turn
into cancer. That is why it is important to do this camera test and check and remove them if
they are present.
What do you think?
Pt: Yes doctor I think there is no harm in doing this test.
Dr: That’s perfect; I would be making all the necessary arrangements as soon as possible. It
was really nice talking to you. It pleases us to see patients who are so conscious and
concerned about their health, it makes our work easier.
Is there anything else I can do for you?
Pt: No doctor, Thank you very much.

Coeliac Disease - Pt. Concerned about endoscopy.
Information :
Coeliac disease is a common digestive condition where the small intestine becomes
inflamed and unable to absorb nutrients.
It can cause a range of symptoms including diarrhoea, abdominal pain and bloating.
Coeliac disease is caused by an adverse reaction to gluten, a dietary protein found in three
types of cereal:wheat, barley, rye
Gluten is found in any food that contains the above cereals, including:
Pasta, cakes, breakfast cereals, most types of bread, certain types of sauces, some types of
ready meals. In addition, most beers are made from barley.
Symptoms of coeliac disease

Eating foods containing gluten can trigger a range of gut-related symptoms, such
as:diarrhoea, which may smell particularly unpleasant, abdominal pain, bloating
and flatulence, indigestion, constipation.
Coeliac disease can also cause a number of more general symptoms, including:
fatigue as a result of malnutrition (not getting enough nutrients from food) , unexpected
weight loss, an itchy rash (dermatitis herpetiformis), problems getting pregnant, nerve
damage (peripheral neuropathy), disorders that affect co-ordination, balance and speech.
Children with coeliac disease may not grow at the expected rate and may have delayed
puberty.
What causes coeliac disease?

Coeliac disease is an autoimmune condition. This is where the immune system – the body's
P a g e | 1039
defence against infection – mistakenly attacks healthy tissue.

In coeliac disease, the immune system mistakes substances found inside gluten as a threat to
the body and attacks them.
This damages the surface of the small bowel (intestines), disrupting the body's ability to
absorb nutrients from food. It's not entirely clear what causes the immune system to act in
this way, but a combination of genetics and the environment appear to play a part.
Coeliac disease isn't an allergy or an intolerance to gluten.
Treating coeliac disease

There's no cure for coeliac disease, but switching to a gluten-free diet should help control
symptoms and prevent the long-term consequences of the condition.
Complications of coeliac disease only tend to affect people who continue to eat gluten,
Potential long-term complications include:
osteoporosis (weakening of the bones), iron deficiency anaemia, vitamin B12 and folate
deficiency anaemia
Less common and more serious complications include those affecting pregnancy, such as
having a low-birth weight baby, and some types of cancers, such as bowel cancer.
Transglutaminase Test ( screening test) :
For most children and adults, the best way to screen for celiac disease is with the Tissue
Transglutaminase IgA antibody, plus an IgA antibody in order to ensure that the patient
generates enough of this antibody to render the celiac disease test accurate. For young
children (around age 2 years or below), Deamidated Gliadin IgA and IgG antibodies should
also be included. All celiac disease blood tests require that you be on a gluten-containing diet
to be accurate.
Tissue Transglutaminase Antibodies (tTG-IgA) – The tTG-IgA test will be positive in about

98% of patients with celiac disease who are on a gluten-containing diet. This is called the
test’s sensitivity. The same test will come back negative in about 95% of healthy people
without celiac disease. This is called the test’s specificity. Though rare, this means patients
with celiac disease could have a negative antibody test result.
There is also a slight risk of a false positive test result, especially for people
with associated autoimmune disorders like type 1 diabetes, autoimmune liver disease,
Hashimoto’s thyroiditis, psoriatic or rheumatoid arthritis, and heart failure, who do not have
celiac disease.
There are other antibody tests available to double-check for potential false positives or false
negatives, but because of potential for false antibody test results, a biopsy of the
smallintestine is the only way to diagnose celiac disease.
Scenario -
Middle aged lady is on Iron tablets as she is diagnosed to have iron deficiency anaemia.
Despite the medication, her condition isn’t improving. She had undergone some tests
and found to have tissue transglutaminase test to be positive. Endoscopy to be planned
for the patient. Talk to her and address her concerns.
D- “Hello, I am Dr.------, one of the junior doctors in the department. I was told that you
wanted to talk to me. How can I help you?”
P-“Yes, I was told that I have Iron deficiency anaemia and some test is positive for Coeliac
disease.
P a g e | 1040
D- “Did anyone explain to you regarding your condition?”

If patient says no,
“I understand from my notes that you have iron deficiency anemia and your condition wasn’t
improving despite the medication. Hence we tested for some antibodies in your blood- tissue
transglutaminase. This is an indication for coeliac disease.
“It is a condition of the bowel caused by an adverse reaction to gluten, which is a dietary
protein found in cereals. As a result, you might face some symptoms such as tummy pain,
bowel problems and indigestion.”
“We had tested for the antibodies in the blood which was found to be positive. However, to
confirm the condition and to manage you further, we need to do an endoscopy”
P- “Dr, why do you want to do an endoscopy? Isn’t the blood tests enough?”
D- “The blood tests showed you had antibodies present. However, it is quite a sensitive test
and not necessarily mean that you have this condition. We need to make sure with the help of
an endoscopy so that we can give you the proper treatment”
P – Endoscopy is uncomfortable. I am still concerned about this procedure. Could you tell me
how it is done?”
D- “Sure. I am glad that you asked.
An endoscopy is basically a camera test that will help us to visualise the inside of your body.
This procedure is performed with the help of an instrument called endoscope. An endoscope
is a flexible tube that has a light source and camera at one end. This is connected to a
television screen which will give images.
However, before this procedure is performed, we ask the patient avoid eating and drinking for
several hours beforehand. The diet to be followed is gluten containing diet so that better
results are obtained.
Sometimes we give antibiotics to reduce chances of infection
( Are you taking any blood thinner medications ? No ( it needs to be stopped few days before
the procedure).
I can see that you might be concerned about the pain.
Before the procedure, we give a local anaesthetic in the form of a spray to numb the specific
are of your body. You may also be given a sedative to help you relax and make you less
aware of what is going on around you.
After that, we shall carefully insert the tube from your mouth into the stomach and have a
look inside the stomach and take a tissue sample.
This procedure usually takes between 15 and 60 minutes. You will be allowed to leave on the
same day if there are no complications thereafter.
However, please make sure you have a friend or relative along with you to take you back
home as it take time for the sedation to wear off.
P a g e | 1041
Complications are usually rare. However the possible one could be infection or bleeding.
Warning signs:
When you go back home, please do watch out for any signs of infection-
Fever, Shortness of breath, Vomiting /vomiting blood, Redness, pain or swelling, Chest pain
If you experience any of these symptoms, please do come back to us.
P- “Alright doctor, thank you. But the blood tests already shows that I have anaemia. Can’t
you just treat that rather than going for endoscopy?”
D- “Yes, you are right that you have anaemia. But we need to find out the cause behind it and
treat it accordingly. Most likely it is the Coeliac disease is causing the iron deficiency
anaemia in your case.
P - Alright Doctor. Is there any risk of bowel cancer developing because of this condition?
D – There is a very rare chance that bowel cancer may develop.
D- “Do you have any concerns? No.
D - Will you be happy to go ahead with the procedure? - Yes
D - I would like to tell you that there are some dietary restrictions for celiac disease
P- Yes, Dr, I know that. My cousins have the same condition and I cook for them.
D- “Alright, would you like me to refer you to the dietician so that you have a better idea
about the diet that you can follow? P - Yes, I shall consider that
D - Do you have any concerns ? P- No, Dr. Thank you D - Thank you
--------------------------------------------------------------------------------------------------------
WHY IS ENDOSCOPY DONE FOR COELIAC DISEASE?
-Blood tests are helpful in diagnosing celiac disease but they aren’t perfect. False negatives
and false positives are possible.
- In the small intestine, there are finger like projections called villi that helps absorb nutrients.
In celiac disease, the gluten damages the villi and causes them to flatten. Hence endoscopy
findings will show the following-
1. inflammation or damage to small intestine 2. flattened villi

Lady with fracture wrist – Talk to son.
Exam question:
You are the FY2 doctor in the Orthopaedic department.

84 year old lady Mrs Margaret Edwards had a simple fall at home and sustained fracture
wrist on the non-dominant hand.
She has been treated and the Multidisciplinary team consisting of doctors, Physiotherapists
and Occupational therapists have assessed her and decided to send her home with twice a
day visit by the carers.
She is also been arranged for the follow up at the fracture clinic every week.
She was given walking stick.
P a g e | 1042
She is Lucid. She also wants to go home. She has given consent to talk to her son.
Her son wants to talk to a doctor about her.

Talk to him and address his concerns.
Dr: Hello Mr Edwards ?

Son: Yes
Dr: I am Dr… junior doctor in the Orthopaedic department. Are you the son of Mrs
Margaret Edwards? Son: Yes
Dr: I am one of the team of doctors looking after your mother. I was told that you want to
speak to a doctor about your mother. Can I help you Mr Edwards ?
Son: Yes doctor. How is she ?
Dr: She is doing well at the moment. May I ask - do you know what has actually happened
to her so that I can answer all your questions better ?
Son: I was told that she had a fracture in her wrist.
Dr: That is right Mr Edwards. Do you know what happened after that ?
Son: No
Dr: Okay, let me explain. Fracture has been treated now. Our Multidisciplinary team
consisting of doctors, physiotherapists and occupational therapists have assessed her and
decided to send her home. We have arranged twice a day visits by the carers until she is
better and also we have arranged follow up for her in our fracture clinic every week until
she completely recovers.
Son: Are you sure she can take care of herself at home ?
Dr: Yes we think so. She has been fully assessed by our team including her home
conditions and the team believes she will be able to manage herself at home with the help
of carers visiting her twice a day to help her. Also her fracture was in a non-dominant
hand. We have given her a walking stick also. So we are hoping it should not be any
problems.
Son: What will the carers do?
Dr: They will do everything help her daily activities like cooking, feeding, dressing,
shower, shopping, giving her medications and any other necessary things.
Son : why was she given walking stick?
Dr: Because she has a fracture in one hand she was given walking stick so that she can
support herself if she loses balance while walking. This is given temporarily until her
fracture heals. She may not need it afterwards.
Son: Doctor I live about 50 miles away from my mother’s house. It will be very difficult
for me to visit her and look after her. Can you please keep her in the hospital until she is
completely fine.
Dr: I can understand your concerns. However, Mr Edwards, we have assessed her and she
does not need to stay in the hospital for further treatment. we believe she will be able to
manage herself at home with carers help. We are not expecting you to take care of her on a
daily basis. Beside that she herself want to go to her home. We appreciate if you can visit
her whenever you have time.
Son: She may say that she will manage herself, But I am sure she won’t be able to manage
herself. What if she falls again ?
Dr: May I ask why do you think she will fall again?
Son: She already fell once she may fall again? Are you sure she will not fall again at
home?
Dr: I can understand why you are so worried. Mr Edwards, we have assessed her and we
did not see any medical causes for her fall. Our team has visited her home also and made
sure everything is safe. We do not see any medical reasons for her to fall again ?
P a g e | 1043
Son: Well, I don’t know. But if she falls again then the hospital will be responsible for that.
Dr: Mr Edwards as we have mentioned we have checked for all the medical causes and we
do not see any medical causes for her to fall. If you have any other reasons to believe she
may fall again at home, please do let us know. We will look into that again.
Son: Doctor can you please tell her to go to a care home or residential home ?
Dr: May I ask - why do you want her to go to the care home ?
Son: She lives alone and I live so far away from her home. I have wife and children to look
after. I am too busy. It will be better for her to live in a care home or a nursing home.
Dr: Mr Edwards, I can see that you are a very caring son. I can imagine why you want her
to be in the care home. However, it is her decision because she has a mental capacity to
decide for herself what she wants. Have you discussed this with her ?
Son: No doctor. It is embarrassing for the family members to suggest her this. It is better
you doctors suggest that to her.
Dr: If we have seen any medical reasons that it is not safe for her to live alone in her house
then we could have suggested for to live in the care home or nursing home. I sincerely
advise you to discuss this matter with her.
Dr: Is there anything you expect from us ?
Son: I believe she will not be safe at home. Can you at least arrange 24 carers ?
Dr: Mr Edwards. I can see you are very concerned about her. We also want the best for her
as much as you want that for her. If you wish we can have a meeting again with the whole
team and you can raise any concerns and see if anything more we can do for her.
Son: But you already had a meeting !
Dr: That is right, but at that time you were not in the meeting. We can arrange the meeting
again if your mother agrees for that. Mr Edwards, please be reassured that we will do
everything possible from our side to keep her safe at home. If needed maybe we can
increase the frequency of carer’s visits to her home.
Son: Ok Doctor.
Dr: Thank you very much Mr Edwards. I will talk to my Consultant now and inform him
about your concerns. Thank you very much for coming here and sharing your concerns.
We really appreciate that. Thank you again.
Lady with bowel cancer –

P a g e | 1044
Son does not want mother to know.

72 year old lady Mrs Ali was recently been diagnosed as bowel cancer. She had a
short period of confusion. Information was revealed to her daughter. Now Mrs Ali
has recovered from the confusion and she has the mental capacity.
Her son Mr. Mohammad Ali wants to talk to you.
Talk to her son.
Mrs Ali has given consent to talk to him about her condition.
Dr: Hello Mr. Mohammad Ali, I am Dr…. one of the junior doctor in the medical
department. How are you doing?
Son: I am, fine doctor.
Dr: I am one the team of doctors looking after your mother Mrs Ali. I was told that you
want to speak to me about her. Is that right ?
Son: Yes doctor.
Dr: How can I help you Mr..
Son: How is my mother now doctor.
Dr: She has recovered from her confusion now and she is much better now.
Son: I was told that she has bowel cancer, is that right doctor?
Dr: Yes that is right Mr. Ali. I am very sorry about that.
Son: Have you told her that she has cancer?
Dr: No, not yet. We could not tell her because she was bit confused but she is fine now so
we are just about to tell her now.
Son: Doctor please don’t tell her that she has cancer.
Dr: Why do say that Mr. Ali ?
Son: Doctor my dad also had cancer. She was looking after him for a long time and she has
seen all the suffering what my dad went through. My dad has died now. If she comes to
know that she also has cancer she will be very distressed.
Dr: Mr. Ali I am really sorry to hear about your dad. I can imagine how you are feeling. I
do understand she will be distressed to hear the news. However, Mr. Ali we need to tell her
that she has a cancer because she needs to know about her condition.
Son: Doctor please tell her some other condition other than cancer.
P a g e | 1045
Dr: Mr Ali we need to tell her the truth we need to be honest with our patients. She has a
right to know about her condition.
Son: OK doctor - if you have to tell her then tell her that she has some abnormal growth.
Dr: I can certainly see how caring son you are. I do appreciate your concerns to your
mother. Your opinion really very important for us. However, Mr Ali she is in a right frame
of mind to understand everything now. She has a mental capacity to understand and to take
decision for herself about her treatment. To give her the right treatment we need her
consent. We need to tell the name of her condition to offer the right treatment. Unless we
tell the name of the real condition we cannot get her consent to treat her.
Son: But why can’t tell her abnormal growth?
Dr: Mr abnormal growth has different meaning it can be cancerous or noncancerous
growth. People usually know the word cancer. People may not understand any other
word for this condition other than the word cancer.
Even if we tell her that she has abnormal growth she can ask us what is that abnormal
growth and that time we have tell her that it is cancer type of growth.
Son: Doctor, I am her eldest son. Now I am the eldest in the family. In our culture it is the
elder person who takes decisions. Doctor you don’t need her consent. I am telling you that
you treat her without telling her the word cancer. I am giving you permission. Anywayshe
is going to ask me only about what todo.
Dr: We do respect all cultures and family relationships. However when we take medical
decisions it has to be person’s own decision if they have the mental capacity.
Son; You doctors are only care about your duty but you don’t understand our feelings. You
don’t care for our feelings at all?
Dr: Mr Ali I am really sorry if I made you feel that way that we don’t care about your
feelings. We definitely care for the feelings also. However if we don’t tell her the name of
the condition then we may not be able to offer her right treatment with which we may be
able to prolong her life or if she is in pain we may not be able to provide her right kind of
medication and she will suffer more and she will be more distressed. I am sure you don’t
want her to be distressed a lot isn’t it ?
Son: Doctor I will tell her that she has cancer myself in private.
Dr: Mr Ali Unfortunately we have to tell the diagnosis to the patient our self. It is our duty.
We are trying to do the best for her and I am sure you also want the best for her.
What you say ? You tell me should we tell her or not ?
Son: Yes doctor I can understand. You do whatever you feel is right.
Dr: Thank you very much Mr Ali. As I said your input is very important for us to manage
her condition. If she agrees, you can also join us when we discuss with her about her
condition and all the treatment options. I am sure she needs your support to cope with this
condition. Thank you very much.
2978 Video Available

Mother suspected of cancer bowel.
P a g e | 1046
Son ( surgeon) wants to talk to you.

Exam question
Lady had CT scan of abdomen showed growth in the ascending colon. Suspected of
bowel cancer. Talk to son.
Nothing mentioned about consent in the question.
Son is a surgical Consultant.

Wants to discuss about the test results and further plans.
Enquire – are you working in this hospital or some other hospital? He may say he is working
in Dublin ( not in Manchester). If in the same hospital is he in the same team?
He will say no.
Ask him how much he knows about his mother’s condition?
Apologize – I am sorry I cannot discuss about your mother with you at the moment because
we have not yet taken consent from his mother to talk to son. As you know we cannot divulge
patient information to anyone else unless we have consent from the patient.
You know this better than me.
I will talk to your mother soon and ask for consent to talk to you. If she gives consent I will
surely come back immediately and talk to him about it?
Son: This consent is just a formality, Don’t worry about it. Tell me the test result and we can
make a plan for the further management.
Dr. Unfortunately without having consent I cannot discuss her condition with you Mr..
Son: Even if you don’t tell me she will tell me everything and she will ask for my opinion.
Dr: I do understand that. Your opinion very important for her because you are a surgeon and
your opinion is also important for us to take decisions for her. However, without her consent
we cannot discuss anything right now. I will take consent from her and we can discuss after
that is that Ok Mr...?
Son: You know I have to see lot of patients today. I have to go back soon. How long will it
take for you to take consent?
Dr: I can understand. I will talk to your other right now and come back to you as soon as
possible.
Son: Can I be there when you talk to my mom?

Dr: Let me get the consent first – if she agrees surely you can be there. I am sure she will be
well supported if you are there.
Son: Does she know about the result?
Dr: No not yet. We are just about to discuss the results with her.
Son: Is it a bad news ?
Dr: I am sorry I cannot discuss anything about the results now. As soon as we get the consent
then we can discuss the result and further plans for her.
Examiner may ask what will you do now?
1) I will talk to my senior about the test result and ask for further plans for the
patient
2) Inform the patient about the test result and discuss further investigations like
biopsy to confirm the diagnosis.
3) I will also inform my senior about her son that he is a surgical consultant and
wants to know about his mother and discuss further management with the
team.
P a g e | 1047
4) I will check her mental capacity. I will also ask the patient for the consent to
talk to her son about her condition.

GENDER SELECTION 27TH JUNE
Isabelle 36 years old female has come to clinic. She is on combined oral
contraceptive pills for last 6 years.
She has three daughters of 14, 8 and 6 years of age respectively.
You are FY2 doctor in clinic. Talk to her and find out the reason for her visit?
( When you enter the cubicle patient greets you actively and looks very happy )
Dr: Hello I am Dr. -------------, one of the junior doctors in clinic. How may I call you?
Pt: Call me Isabelle.
Dr: Okay Isabelle how can I help you today?
Pt: Dr. I want a baby boy can you help me with it?
Dr: Isabelle can you please elaborate?
Pt: Doctor me any my husband already have three daughters and now we would like to
have a male baby. My husband wants to continue the family name.
Dr: Is that what you want as well?
Pt: Yes I want the same.
Dr: Isabelle as far as I know from medical point of view, with every pregnancy there is a
50 % chance of it being a male or female. May I know specifically what you want from
us?
Pt: Doctor I want to know if there is any procedure or technique to ensure that my next
child will be male ?
Dr: Isabelle yes although there is a technique of pre implantation genetic diagnosis
which can be used for this purpose but its use for purpose of gender selection is banned
and illegal in U.K.
I am really sorry but we may not be able to help you with this technique.
But I would be happy to help you if you require anything else.
Pt: Ok doctor what about alternative medicine. Is there anything which may help me?
Dr: Isabelle although there have been many claims by people practicing alternative
medicine regarding this like having sex near the ovulation date and eating specific kind
of food but none of those methods have been medically proven and as such have no
scientific basis to them.
Pt: Okay doctor if I get pregnant then how early can you let me know about the gender
of baby?
Dr: Yes we can do an ultrasound scan to know the gender of the baby. We can do this
earliest by 18th to 21st week of your pregnancy. But it is not true all the times as
sonographer will not be able to be 100% certain about your baby's sex.
Dr: Isabelle may I know if you are under any pressure or stress to have a male child?
Pt: No doctor it is just that I want to have a male child.
Pt: Can I abort if it is a girl?
Dr: Isabelle abortion solely on the basis of preference of gender, where there are no
health implications for the baby or for the woman are unlawful and we will not help you
with that.
P a g e | 1048
But isn’t it my right to have an abortion?

Dr: Yes generally it is woman’s right to have abortion but let me tell you the only
conditions in which law permits someone to have an abortion.
Abortions in England, Wales and Scotland are carried out before 24 weeks of pregnancy
only by registered medical practitioners in cases when termination of the pregnancy is
necessary to prevent grave permanent injury to the physical or mental health of the
pregnant woman or if the child when born would suffer from such physical or mental
abnormalities as to be seriously handicapped.
Dr: Do you have any questions regarding this? Pt: No doctor.
Isabelle if you would like I can arrange an appointment with my consultant and he may
be able to guide you further on this subject.
Thankyou

NOISY RELATIVES AT HOSPITAL
Question-
92 year old female was admitted to the hospital after a history of fall. She was
breathless at the time of admission and she is breathless now as well.
She is terminally ill.
Other patients have complained that there are a lot of visitors and they make a lot of
noise all the time. Your task is to talk to the grandson and discuss this matter with
him.
Hospital visitor policy
(No visitors allowed from 2-5pm and only 2 visitors allowed at a time)
Grandson gives a history of his grandmother being unwell at the time of admission. Her
condition is deteriorating and the doctors have decided not to resuscitate. Relatives have
come from far away and wanted to see her and perform the last rites. They are Christian
and want to chant prayers and want their priest to be there. And also wants to keep a Bible
on the bed.
Cover the following points-
1.Respect religion and understand their beliefs
1. State that other patients are disturbed because of the noise (can disturb their sleep
and can also harm their recovery) and offer solutions –
Ask him how many visitor come at a time ? What time do they come ?
- allowing 2 people at a time
- visitors are not allowed from 2pm to 5pm according to hospital policy. The relatives can
see her after that.
He may ask can I keep Bible on the bed – Yes sure. I understand that you have to keep the
Bible very close to the person. We do respect your culture.
(In the exam, grandson repeatedly says that doctors do not respect religion and the only
way that they can perform the last rites is by praying together in front of the patient)
Offer shifting his grandmother to a private room where they can perform the last rites at
peace.
Can I bring priest to the private room? Yes.
P a g e | 1049
16 year old girl trapped in boy’s body
Veronica Smith is a 15 year-old girl who has made an appointment to come and see you.
Talk to the patient and address their concerns.
Values and ethos
Acceptance
To promote non-judgmental acceptance of the range of gender identity
presentations.
Holistic approach
To provide help for behavioural, emotional and/or relationship difficulties that
young people or their families may be experiencing in relation to their
gender identity.
Freedom of expression
To support young people and families to express themselves more freely.
Hope
To sustain hope.
 Take a quick history

 Assess MOOD and suicide risk
 Ask about social support, at home, school or friends
 Encourage her to speak to her family and if she’s scared talk to them, say that you can
set up an appointment with them and speak to them on her behalf.
 She will say that she wants to do a surgery - advise her for social transitioning initially
Management Plan
 Live in your preferred gender (social transitioning)

 If the child or teenager is distressed, refer them to the local Children and Young People's
Mental Health Service (CYPMHS). CYPMHS may be able to offer psychological
support while they wait for their first appointment at the Gender Identity Development
Service.
 The school or college may be able to offer additional support.
 If the child is under 18 and may have gender dysphoria, they'll usually be referred to the
Gender Identity Development Service (GIDS)
Gender Identity Development Service (GIDS)
Your child or teenager will be seen by a multidisciplinary team at GIDS including a:

P a g e | 1050
 clinical psychologist
 child psychotherapist
 child and adolescent psychiatrist
 family therapist
 social worker
 The team will carry out a detailed assessment, usually over 3 to 6 appointments over a
period of several months.
Depending on the results of the assessment, options for children and teenagers include:
 family therapy
 individual child psychotherapy
 parental support or counselling
 group work for young people and their parents
 regular reviews to monitor gender identity development
 referral to a local Children and Young People's Mental Health Service (CYPMHS) for
more serious emotional issues
 a referral to a specialist hormone (endocrine) clinic for hormone blockers for children
who meet strict criteria (at puberty)

Drug Addict wants a Self-Discharge
You are FY2 Doctor in acute medical care unit.
A 27 year old lady, Miss.… has been admitted to the acute medical care unit. Patient is
a known drug addict and a diagnosed case of Infective Endocarditis. Patient has been
started on intravenous antibiotics. To complete treatment, patient needs IV antibiotics
for several weeks as an inpatient.
Nurse has come to you and informed you that patient wants self-discharge.
Talk to the patient, inquire why does she want self-discharge and address her concerns.
Dr: Hello, I am Dr…. I am one of the junior doctors in the medical department. Are you
Miss…? Patient: Yes doctor.
Dr: How are you doing Miss…?
Patient: I do not like this hospital doctor. I want to go home.
Dr: Miss… could you please tell me why you do not want to stay in the hospital?
Patient: The nurses are very rude to me.
Dr: I am really sorry if someone misbehaved with you. I will look into this matter. Please do
not be upset. Could you please tell me what really happened?
Patient: No doctor, I do not want to stay in this hospital any more. I want to get discharged.
Please discharge me.
Dr: Well, Miss… could you please explain to me why you do not want to stay in the hospital.
If you tell me what is bothering you, I will be able to help you.
Patient: No doctor, nurses have been very impolite with me. They are calling me drug abuser.
I want to go home.
Dr: Well, Miss… I can clearly understand that you are very much offended by what happened
and I apologize to you for such behavior but it is very important for you to stay admitted in
the hospital as we need to give you medicines through your veins. However, I want to
reassure you that if you can tell me what happened, all the information you give me will be
kept confidential within our team. Could you please open up to me about the matter?
P a g e | 1051
Patient: Doctor, you see, it is also because nurses object that I cannot smoke cigarettes in the
hospital.
Dr: I see. I can understand that you must be very troubled by all this. I apologize to you
again. However, I would like to tell you that it is important for you to stay admitted.
Could you please tell me how much do you know about your condition?
Patient: I have been told that I have infection in heart.
Dr: Yes, you have been told right Miss… You have a condition called Infective
Endocarditis. This is an infection that affects the tissue that lines the inside of the heart
chambers. This results in significant damage to heart valves. Also, it can cause other serious
complications if it is not treated quickly with antibiotics. Are you following me?
Patient: Yes, doctor. But I do not want to stay in the hospital. Why should I stay in the
hospital?
Dr: You see, Miss… it is a very serious infection and can be even life-threatening if not
treated in time. The earlier the condition is treated, the better the likely outcome.
Patient: But you can give me antibiotic tablets doctor I can take them at home.
Dr: Miss…Unfortunately this condition cannot be treated with just antibiotic tablets. Tablets
are not as effective as injections into veins. That is why we want you to stay in the hospital so
that we can give this antibiotics through your veins.
Pt: I can’t stay here. Nurses don’t let me smoke and it is not bearable for me to continue
without it. Can’t I just pop out and smoke ?
Dr: I can understand why you are so upset. It must really be very distressing for you.
Well you can pop out and smoke but it is not advisable at all.
If you do not mind, I will be asking you some questions about your general health, if that
alright with you. Patient: Okay.
Dr: Could you please tell me how much do you smoke? Patient: 20 cigarettes per day.
Dr: I see, and for how many years? Patient: ?
Dr: Do you take any recreational drugs? Patient: I take heroin. Dr: How much?
Patient:
Dr: For how long have you been taking it? Patient: Years/months
Dr: How do you take it? Patient: I inject it through my veins.
Dr: And do you exchange needles? Patient: No doctor.
Dr: That’s good. And have you ever tried to cut it down or stop it altogether?
Patient: No doctor, I cannot.
Dr: I see. Could you please tell me how has been your mood lately?
Patient: I feel very alone doctor/feel very low
Dr: And why is that? Patient: I do not have any friends.
Dr: I am really sorry about that. Could you please tell me what work do you do?
Patient: I am jobless.
Dr: And where do you live? Do you live with your family?
Patient: I am homeless doctor. I have no family.
Dr: It must be really upsetting for you Miss… I can recognize that you have a very stressful
life. However, I’d like to tell you that a lot of help is available for you to cope with this state
of affairs. Do you know why this condition would have happened to you ?
Patient: Why doctor?

Dr: Miss…. unfortunately, people who inject street drugs may also inject bugs/germs into
their bloodstream if they use dirty or contaminated needles. These bugs may then settle on a
heart tissue. The infection can damage heart valves and may spread to other areas of heart
P a g e | 1052
tissue. Unfortunately, this might have happened and lead you to develop this infection in the
heart.
Pt: But doctor I just want to go home.

Dr: Miss … If you do not get treated now serious complications usually develop -for
example, it can lead to problems such as heart failure. Sometimes the infection can spread to
other organs and can cause damage to the other organs too. It can life threatening too if you
do not stay in the hospital and get treated. That is why it is very important that you stay in the
hospital and get treated.
Patient: But I can’t smoke can’t do anything here.

Dr: I would sincerely advice you to consider quitting smoking. Smoking is not only
hazardous to your lungs but to your heart also. It can worsen your condition in the heart. I
know that it must be really unbearable for you to not smoke. We can give you help to cut it
down and quit it. However, for now if you really want it we can give nicotine patches. Is
that Ok? Pt: May be yes.
Dr: Also, I would like to tell you that we can provide you help to cut down on drugs. We
have a lot of medicines available to help you cope this.
Pt: You will only give Methadone!
Dr: Miss… We have many different options to help you cut down on using drugs. I will tell
you what your options are. In order to reduce the craving of the drug, we can give you
medicines. Also, in order to decrease withdrawal symptoms we can give you another
medicine called Lofexidine. Also, we might later on refer you to some support groups to help
you quit drugs. Would you consider it? What do you think about it?
Patient: Well I will think about it.
Dr: So would you consider staying in the hospital for getting this infection cleared off from
you?
Patient: Yes, doctor I would.
Dr: Is there anything else you want to know?
Patient: No doctor, you are very kind. Dr: Thank you very much Miss…
If the patient still not convinced.

Dr: I am sorry that I wasn’t able to convince you about the importance of you staying in the
hospital for the treatment. You do have the right to refuse any treatment what we advise.
However, I will talk to my seniors and may be they will be able to convince you about it. If
you still do not want to stay in the hospital you can sign a “self - discharge form” and then
you can go home. Thank you very much for talking to me. I really wish all the good health
for you Miss..

Posting patient information on Social media by your
colleague (10 April 2019)
Your Colleague FY1 doctor made a post on Facebook about an elderly lady in the
Emergency Department with confusion considered herself to be the Queen of England,
Elizabeth. Talk to your FY1 colleague and address his concerns.
SPIES (S= Seek information, P= Patient safety, I= Initiate, E=Escalate, S= Support)
When you enter the Cubicle,he is not serious at all. He will start the conversation.
P a g e | 1053
GRIPS plus rapport with your colleague first (Introduce yourself as FY2 and built rapport).
Then asked him if he had any idea why youhave arranged this meeting. He said no.
When you will tell him, I am herebecause I want to talk about the post he made on Facebook
(regarding one of our patient). Then he will start laughing, he might say yeah! what a
funny Story!
FY1 Colleague: She was making some funny comments like she lost her crown and she
was looking for it.
He will talk a lot there and will tell the whole story.(Explore here whether he wrote down
the name of the hospital/department)
Dr: Posting patient information on social media is a breach of confidentiality. Being a
medical professional, we must obey the rules and regulations of NHS.
FY1 Colleague: I didn’t write down the patient’s name and age; I posted it on my
personal account.
Dr: I am afraid, communications intended for friends or family may become more widely
available (sharing the post by your Facebook friends).Although individual pieces of
informationmay not breach confidentiality on their own, the sum of published
information online could be enough to identify a patient or someone close to them. If we
do like this patient will lose trust on our NHS. NHS take this incident seriously. I am sorry to
say, it may even cost your GMC registration!
[According to Good Medical Practice book by GMC (page 21, para 69), when
communicating publicly, including speaking to or writing in the media, you must maintain
patient confidentiality. You should remember when using social media that
communications intended for friends or family may become more widely available]
[Although individual pieces of information may not breach confidentiality on their own, the
sum of published information online could be enough to identify a patient or someone
close to them]
Related Link: https://www.gmc-uk.org/-/media/documents/doctors-use-of-social-media_pdf-
58833100.pdf
FY1 Colleague: Where can I find these principles and regulations you talking about?
Dr: You can get it from Good Medical Practice book. Also, you can attend some
workshops for medical ethics.
He will say I was only joking it's just with my friends in my personal account, I didn't
mean to break confidentiality.
FY1 Colleague: Am I in real trouble? What shall I do then?
Dr: I highly encourage you to delete the post immediately. Write down an incident form as
well. I sincerely advice you not to do it in future.Also, please inform your
seniors/consultant. He might be able to help you. It will be very bad for you if your
consultant hears it from others.(If patient is conscious/have full mental capacity,
encourage him to talk to the patient and apologize for what he did). End station with
offering support.

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2453 Video not available

Cyclical Mastalgia : 12 April 2019

specialist (As she is having this for 18 months)

Pt: What I will do in the future?

 Consider the following treatment options:

2454 Video not available

Prostate Specific Antigen

Question - You are a FY2 at the G.P clinic. A 65 years

Dr - Hello Mr.Samuel… I am Dr……. How are you doing?

Pt - Dr. I am worried about having prostate cancer. I

*You can check his knowledge about the prostate

What is the prostate?

The prostate is a small gland in the pelvis, found only in men.

About the size of a satsuma, it's located between the penis

The main function of the prostate is to produce a thick white

Dr - Well Mr.Samuel please tell me why do you think

Pt - Dr. my best friend, he is also the same age as me

Dr - Mr.Samuel, I am sorry to hear about your friend,

*Patient here is very worried about having cancer. So

Dr - Mr.Samuel have you been checked for prostate

Dr - Do you have any symptoms recently?

Pt - Like what doctor?

Dr - Do you havefever recently? Pt - No Dr.

Dr - Did you notice any change in colour of urine recently? Pt

Dr - Did you notice blood in theurine? Pt - No

Dr - Any pain intummy? Pt - No

Dr - Do you have pain in the loinarea (Peylonephritis)? Pt - No

Dr - Do you pass urine more times thanusual? Pt - No doctor.

Dr - Do you have to get up in the nightto go toloo? Pt - No

Dr - Any dribbling of urine? Pt - No doctor.

Dr - Do you have any back pain (secondaries in the vertebra).

Dr - Have you noticed any weight loss(cancer)?Pt - No

Dr - Any problem openingbowel ? Pt - No

Dr - Do you have anymedical conditions? Pt - No

Dr - Did you have any kidney stonesbefore? Pt - No

He will have no medical conditions and he will be a non

Ask questions related sexual health also.

There will be no strong history or no risk factors in history

Explain to him that from history it does not look like he is

To some he said doctor just in case if I had symptoms then

Just for exam consider prostatic cancer if PSA is

More then or equal to 2ng/ml at age 40-49 years.

There's currently no screening programme for prostate

So basically in this station you have to take history, reassure

He kept on saying that he want to have investigations done

In order to answer any of his other questions information is

Info about PSA

◦ How accurate is the PSA test?

Pros and cons of the PSA test

 it may reassure you if the test result is normal

 it can miss cancer and provide false reassurance

*Information About Prostate Cancer*

Prostate cancer does not usually cause any symptoms until

Symptoms of prostate cancer can include:

 needing to pee more frequently, often during the night

 straining or taking a long time while peeing

These symptoms do not always mean you have prostate

It's not known exactly what causes prostate cancer, although

 obesity – recent research suggests there may be a link

If you have symptoms that could be caused by prostate

There's no single, definitive test for prostate cancer. Your GP

Your doctor is likely to:

Information About Prostate Cancer