Specialty Wise Stations For Plab2

SPECIALTY WISE STATIONS
FOR PLAB2
TABLE OF CONTENTS
No. Specialty Topic Page
1 General Structure 9
2 Medicine Chest Pain-ACS 11
3 Chest Pain-Mastectomy 14
4 Chest Pain-Transgender 17
5 Chest Pain-Musculoskeletal 20
6 Chest Pain-Herpes Zoster 23
7 Chest Pain-Pericarditis 27
8 Chest Pain & SOB-Pulmonary Embolism 30
9 SOB-Heart Failure (post MI) 34
10 Arrhythmia 39
11 Peripheral Arterial Disease 43
12 Post Angioplasty-Hesitant to Walk 46
13 Dry Cough (DD) 48
14 Dry Cough (PCP) 52
15 Cough – Lung Cancer 56
16 Cough & SOB (Pneumonia) 59
17 Cough & SOB (TB) 64
18 Asthma Wheeze (Diagnosis) 69
19 Asthma Discharge 74
20 Spacer 79
21 Obstructive Sleep Apnoea 82
22 Haemoptysis 86
23 Subarachnoid Haemorrhage 90
24 Headache-GCA 94
25 Tension Headache 98
26 Hangover Headache 101
27 Transient Ischaemic Attack 104
28 Migraine 107
29 Trigeminal Neuralgia 110
30 Guillain-Barre Syndrome 113
31 Multiple Sclerosis 117
32 Encephalitis 121
33 Head Injury (Adult) 127
34 Post Herpetic Neuralgia 130
35 Cerebellar Ataxia 132
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36 Citalopram Tiredness 136
37 Chronic Fatigue Syndrome 140
38 Polymyalgia Rheumatica 143
39 Polymyalgia Rheumatica Refusing Steroids 146
40 Steroid Review 149
41 Postural Hypotension 151
42 Fall & Hip Fracture 154
43 Analgesic Nephropathy 158
44 Uraemia & Hyponatraemia 162
45 UTI (Confusion) 165
46 Elderly Confusion TC 168
47 UTI & BPH 170
48 Hypothyroidism 175
49 Hyperthyroidism (Wt Loss/Tremor & Sweating) 179
50 Thyroid Annual Review 183
51 Discuss Blood Results (Hyperthyroidism) 189
52 Hyperparathyroidism 192
53 Indigestion 196
54 Dysphagia 200
55 Haematemesis 204
56 Acute Gastroenteritis 208
57 Barrett’s Oesophagitis 212
58 IBS 215
59 Abnormal LFTs 219
60 Alcoholic Foot 221
61 Discuss Blood Results – Alcoholic Hepatitis 223
62 NHS Health Check (Raised ALT, Macrocytosis) 226
63 ARLD 230
64 Vitamin B12 Deficiency 233
65 Anaemia 237
66 Multiple Myeloma 240
67 Leukaemia 245
68 ITP 247
69 Iron Deficiency Anaemia, Decided Colonoscopy 250
70 Chronic Diarrhoea 251
71 Rheumatoid Arthritis 255
72 Gout 258
73 Pain & Aches 262
74 Carpal Tunnel Syndrome 266
75 De Quervain’s Tenosynovitis 269
76 Raynaud Phenomenon 275
77 Reactive Arthritis 279
78 OPHTHALMOLOGY AACG (Acute Red Eye) 284
79 Subconjunctival haemorrhage 288
80 Cataracts 291
81 ARMD 294
82 Optic Neuritis (MS) 298
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83 Peripheral field of Vision 301
84 ENT Sinusitis 304
85 Facial Drooping 308
86 Mumps Orchitis 312
87 BPPV 316
88 Vestibular Neuritis 320
89 Meniere’s Disease (Dizzy Spells) 325
90 Unilateral Tinnitus 330
91 Cholesteatoma 334
92 Acoustic Neuroma (CN VIII) 338
93 Acute Tonsillitis 341
94 Recurrent Tonsillitis 344
95 Allergic Rhinitis 346
96 DERMATOLOGY Skin Lesion Mole 348
97 Skin Lesion Melanoma 352
98 Skin Lesion Non-Melanoma (BCC, SCC) 355
99 Fungal Infection 359
100 Acne 362
101 Impetigo 366
102 Urticaria 369
103 Herpes Labialis 371
104 Genital Warts 375
105 Syphilis 379
106 Scabies 384
107 Irritable + Low Mood & Eczema 387
108 Concerned Mother – Chickenpox Child 390
109 Mother Wants Sick Note (Chickenpox) 394
110 Seborrheic Keratosis 398
111 SURGERY Back Pain 403
112 Back Pain (IVDP) 407
113 Back Sprain 411
114 Abdominal Aortic Aneurysm 415
115 Acute Cholecystitis 418
116 Diverticulitis 420
117 Post Op Wound Infection 424
118 Intestinal Obstruction 427
119 Neck Lump 431
120 Varicose Veins 434
121 Hydrocele 438
122 Epididymo-Orchitis 441
123 UROLOGY Haematuria 446
124 Haematuria Blood Results 450
125 STI (Male) 453
126 UTI (Female) 458
127 UTI (Female-Transition Female to Male) 462
128 UTI (Pregnant) 466
129 Recurrent UTI 469
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130 Pt With Lymphadenopathy (STI) 473
130 PSA Test Demanding Patient 478
131 Loin Pain 481
132 Erectile Dysfunction 486
133 Feel Unwell – Oxybutynin – Urinary Symptoms 489
134 Urinary Incontinence 494
135 PSYCHIATRY Mini-Mental State Exam (MMSE) 495
136 Concerned Daughter MMSE 500
137 Psychotic Patient 503
138 Psychosis 507
139 Alcohol Dependency 511
140 Drug Dependency 516
141 Suicide 519
142 PCM Homosexual Patient 523
143 Alcohol Colleague 527
144 Cocaine Colleague 529
145 Colleague Coming Late 532
146 Colleague Confidentiality Issue (Facebook Post) 534
147 Anorexia Nervosa 536
148 Depression (CBT failed) 540
149 Depression (Refusing Treatment) 545
150 Depression (Weight Loss) 546
151 PAEDIATRICS Otitis Media Child 552
152 Neonatal Chlamydia 555
153 Febrile Convulsion 559
154 Head Injury Fall Paediatrics 563
155 NAI-Paediatrics 567
156 Vaccination Flu Jab 571
157 MMR 573
158 Intussusception 576
159 Pyloric Stenosis 580
160 Neonatal Jaundice 583
161 Bronchiolitis 586
162 Night Terrors 590
163 Constipation Child 593
164 Autism 596
165 8 Weeks Vaccination 599
166 Primary Enuresis 602
167 Negativism 605
168 Haemangioma (Birth Mark) 611
169 Child Developmental Milestones 617
170 Speech Delay Twins 621
171 Child with Tantrums 630
172 Paediatric Epilepsy 635
173 OB-GYNAE Pre-Eclampsia 638
174 PID RIF Pain 643
175 PID Lower Abdominal Pain 647
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176 Gonorrhoea 651
177 Ectopic Pregnancy 654
178 Miscarriage 658
179 PCOS 663
180 Contraception 666
181 Pregnancy (HTN on Ramipril) 675
182 Premenstrual Syndrome 677
183 Mood Swings (Depo-Provera) 682
184 Post-Partum Psychosis (Telephonic) 685
185 Pregnancy (16 YO) Vomiting 690
186 Bacterial Vaginosis 693
187 Missed Abortion 696
188 Premature Ovarian Insufficiency 702
189 Combined Pill Prescription 706
190 Antenatal Assessment 709
191 Antenatal Checkup (Rubella/Rh Negative) 713
192 Cyclical Breast Pain 717
193 ETHICS BBN-Cerebral Bleeding 721
194 BBN-Talk to Daughter (MDT Discussion) 723
195 EDH Joshua 725
196 Pelvic Fracture 728
197 Post Mortem 731
198 Domestic Violence 734
199 Domestic Violence-Insomnia 737
200 Domestic Violence (Burn) – Sex Trafficking 739
201 Cancer Withhold 744
202 End of Life Care….DNAR 746
203 MS (DNAR) 748
204 Treatment Refusal (SCLC) 750
205 Refusal of Breast CA Treatment (Tel. Conv.) 752
206 Infective Endocarditis-Drug Addict 754
207 Warfarin-Rat Poison 757
208 Herbal Medication 759
209 Dementia 762
210 Dementia Mother 765
211 Elderly Abuse 768
212 Elderly Wrist Fracture 771
213 Concerned Mother OCP 773
214 Emergency Contraception 775
215 Cerebral Palsy 779
216 Insomnia 782
217 Insomnia (Cannabis User) 785
218 Ankle Sprain 788
219 Angry Patient – Change IV Cannula 791
220 IV Cannula-Talk to Dr. Wilson 793
221 Colleague Delay Patient Discharge 795
222 Lung Cancer Missed X-Ray by GP 798
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223 Premature Child Birth-Mother Concerned 802
224 Talk to Consultant Son About Mother 804
225 Medical Error-MI 806
226 Misdiagnosed Pneumonia 809
227 Hairline Fracture 811
228 Amoxicillin Rash 814
229 Foreign Body 817
230 Sample Not Labelled 819
231 Kidney Sample Lost 821
232 Changing Counsellor 824
233 Gender Selection Pre-Conception 826
234 Gender Dysphoria 828
235 Confusion About Sexual Orientation 833
236 Ductal CA in Situ 837
237 Pre-Conception Counselling 840
238 Sick Note 841
239 Elderly Woman Med Review 843
240 Levothyroxine Dose Adjust-Daughter Concerned 846
241 Euthanasia 848
242 NAI (Sexual Harassment) 852
243 COUNSELLING First Seizure 854
244 Epilepsy Discharge 857
245 BP Management 859
246 CDAD (C. Difficile) 862
247 MRSA 865
248 Post MI Lifestyle 868
249 Vascular Dementia (Lifestyle) 871
250 Osteoporosis 875
251 Stroke Assessment 878
252 Obesity Counselling 881
253 Statin 885
254 Diabetic Retinopathy 888
255 Diabetic Review 892
256 Diabetic Foot 895
257 Hypoglycaemia 898
258 Hypoglycaemia Fits 901
259 DKA 905
260 Diabetic Post DKA with Learning Difficulties 908
261 Warfarin 912
262 NSI Nurse 915
263 NSI Child 918
264 COPD Smoking Cessation 921
265 Smoking Cessation 924
266 URTI-Patient Asking for Antibiotics 927
267 Coeliac Disease 930
268 Post-op Hemiarthroplasty 934
269 Pre-op Assessment-Ankle Pin Removal 937
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270 Pre-Operative Care 940
271 Herniorrhaphy 943
272 Dermoid Cyst 948
273 Pain Management Breast Cancer 951
274 Pain Management (Prostate CA) 955
275 Two People Policy 956
276 Colorectal Polyp 958
277 Child TC-Fever, suspected chest infection 961
278 Post-Op Bleeding 963
279 Nipple Discharge 967
280 HIV Test Results 970
281 Measles College Boy 974
282 Fainting 977
283 Prescription Related Stations 980
284 Patient on Apixaban Nosebleed 985
285 COVID-19 Visiting Policy Guidelines 988
286 Cervical Screening (Dyskariosis) 993
287 Cervical Screen (Lesbian) 995
288 Meningitis 998
289 Meningitis Prophylaxis 1003
290 Cystic Fibrosis-Prenatal Counselling 1006
291 Homosexual Counselling 1012
292 Methods of Conceptions for Homosexuals 1015
293 Chickenpox Pregnancy 1019
294 Knee Replacement Follow-Up 1024
295 Heart Failure Medications 1028
296 Epistaxis and Headache (Testosterone) 1032
297 Lap Chole (Jehovah's Witness) 1034
298 Low Mood (Lesbian Miscarriage) 1036
299 Left Ventricular Dysfunction with ED Post MI 1042
300 SIMMAN/SIMWOMAN Primary Survey Conscious 1046
301 Primary Survey Unconscious 1048
302 Asthma 1050
303 Anaphylaxis 1053
304 Death Confirmation with DNAR 1056
305 UTI after TURP 1058
306 Hypoglycaemia 1062
307 Post UTI Sepsis Shock 1063
308 Upper GI Bleed 1067
309 Dizzy Spells 1071
310 Acute Limb Ischaemia 1074
311 PPH 1079
312 TEACHING ECG 1083
313 Breast Exam (Lump) 1086
314 VIIIth CN Exam 1089
315 Knee Examination 1091
316 BLS Adult 1094
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317 BLS Paediatrics 1097
318 Cervical Smear 1100
319 EpiPen 1104
320 Subcutaneous Injection 1109
321 Urine Dipstick 1111
322 PROCEDURES (VIDEOS & PRACTICE) Blood Sampling (PCM) 1115
323 IV Cannulation 1118
324 Catheterization 1120
325 ABGs
326 Blood Culture
327 MANNEQUINS (PRACTICE) Foot Examination (Diabetic, Alcoholic)
328 Cerebellar Exam
329 Exam for Meningitis
330 Cranial Nerve Examination
331 Peripheral Field of Vision
332 Fundoscopy
333 Thyroid Examination
334 Acoustic Neuroma
335 CN VIII Exam
336 Otoscopy (Adult & Child)
337 Abdominal Exam
338 Neck Exam
339 Upper Limb Exam
340 Breast Exam
341 Antenatal Assessment
342 Hip Examination
343 DRE for Prostate Exam
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GENERAL STRUCTURE
STEPS IN HISTORY TAKING
1. Presenting Complaint. Can you tell me more about it.
2. Explore the presenting complaint by ODIPARA for non-pain symptom and SOCRATES for
pain symptom
3. Finding the cause of presenting complaint (by asking DD)
4. PMH (5 Qs)
- Is it the first time you are having this problem?
- Are you having any long-term medical condition?
- Are you using any regular medications or over the counter medications?
- Are you allergic to any medication?
- Have you ever been admitted in the hospital or any surgery done for you?
5. FH (Two Qs).
- Anybody else in the family has same problem? like any thyroid problem or any immune
related problem? (relate the Q to your case)
- Anybody in the family has any long-term condition?.
6. Social Hx (Travel hx, Occ Hx) SADEJSS.
S-Smoking
A-Alcohol
D-Diet
E-Exercise
J-Job
S-Stress
S-Social conditions, whom he does live with?
7. If young person add case related sex history and drugs
8. If young female (18-45)
P-Periods
P-Pregnancy
P-Pills
I will ask you a few Qs about your menstrual and sexual health, is it okay
1. When was your last menstrual period? If 1-2 weeks no need to ask for pregnancy. If 3 weeks
or more ask about pregnancy.
2. Are they regular
3. Any bleeding or spotting in between your periods.
4. Any excessive bleeding or pain during your menstruation.
5. Are you sexually active
6. Are you using any contraception
I would like to check your observations including vital signs. Then I will do your general
physical examination and systemic examination (related to the station).
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I would like to send some basic investigations including FBC, electrolytes, liver and kidney
function tests (name remaining tests case related).
MANAGEMENT
Diagnosis & DD (1 Mark)
Explaining the diagnosis and treatment (1 Mark)
Addressing the symptoms and concerns (1 Mark)
Safety Netting (1 Mark).
CLOSING SENTENCE: I will give you some printed materials and some useful links to websites
so that you can understand your condition better. I will discuss your management plan with
my seniors and if there is any change, I will come back to you.
IPS marks given by simulator (4 marks)
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MEDICINE STATIONS
CHEST PAIN-ACS
You are an F2 in A&E

John aged 49, presented to the hospital with chest pain.
Please talk to the patient, take history, assess the patient and discuss your initial plan of
management with the patient.
D: What brought you to the hospital?

P: I have pain in my chest
D: Tell me more about your pain?
P: Like what Dr.
D: Where exactly do you have the pain?
P: It is in center of my chest (Pt. points towards the chest)
D: When did it start?
P: 2 hours ago
D: What were you doing when you had this pain?
P: I was just sitting
D: Was it sudden or gradual?
P: It was sudden
D: Was it continuous or comes and goes?
P: It was continuous
D: What type of pain is it?
P: It was like someone is sitting on my chest
D: Does the pain go anywhere?
P: It is going to my left arm, shoulder or jaw
D: Is there anything that makes the pain better?
P: It is better now.
D: Is there anything that makes the pain worse?
P: No Dr.
D: Could you please score the pain on a scale of 1 to 10, where 1 being no pain and 10 being the
most severe pain you have ever experienced?
P: It was 7, but now it is better.
D: Do you have any other problem?
P: No Dr.
D: Any sweating?
P: No
D: Any breathlessness?
P: No
D: Any nausea?
P: Yes Dr.
D: Since when?
P: From last 2 hours since the pain started.
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D: Did you vomit?
P: No
D: Any lightheadedness?
P: No
D: Do you feel tired?
P: No
D: Any fever or flu like symptoms?
P: No (Pneumonia)
D: Any cough?
P: No (Pneumonia)
D: Does your pain get relieved on bending forward?
P: No (Pericarditis)
D: Any calf pain, redness or swelling?
P: No (PE)
D: Any history of travel?
P: No (PE)
D: Have you had similar kind of problem in the past?
P: No
D: Have you been diagnosed with any medical condition in the past?
P: No
D: any DM, HTN, Heart disease or high cholesterol?
P: No
D: Are you taking any medications including OTC or supplements?
P: No
D: Any allergies from any food or medications?
P: No
D: Any previous hospital stay or surgeries?
P: No
D: Has anyone in the family been diagnosed with any medical condition?
P: Yes, my dad had heart attack when he was 50.
D: Do you smoke?
P: Yes 20 cigarettes per day since I was 20.
D: Do you drink alcohol?
P: Yes/No
D: Tell me about your diet?
P: I don't eat healthy.
D: Do you do physical exercise?
P: I don't have much time
D: Do you have any kind of stress?
P: No dr.
I would like to check your vitals and examine your chest.

I would like to send for some initial investigations including routine blood test special blood test for
your heart enzymes and ECG.
EX: He will give you an ECG which will be normal and +/- Trop awaited.
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D: From my assessment your chest pain is likely to be from your heart. We did an ECG and
fortunately it came back normal. I will confirm it with my seniors as well. We did special blood test
for your heart enzymes and we are waiting for the result.
We will also do some further investigations to see your blood cholesterol level and your liver and
kidney function.
We will give you Aspirin, Clopidogrel (Blood thinner) to protect you from further attacks and a
spray under your tongue. Glyceryl Trinitrate (GTN) to relieve your pain.
We will keep you in the observation unit and we will repeat special blood test after few hours of
your chest pain. If everything goes smoothly, we will send you home.
We may give you some medication for cholesterol or some other medications to protect your heart
if needed.
Please follow up with the heart specialist and your GP.
You need to make some changes in your life style such as smoking, alcohol, diet, physical activity
because these may lead to the severe complications of your condition. (Give life style advice
accordingly.)
If you develop any sudden severe chest pain, breathlessness, dial 999 and come to the hospital.
PATIENT'S CONCERNS
P: What is going on?
P: What are you going to do for nn
P: Can I go home?
P: when I can go home?
P: why do you want to keep me in
DD:
Myocardial infarction:
Angina:
Pulmonary embolism:
Pericarditis:
Pneumonia
Gastroesophageal reflux disease
13
CHEST PAIN (MASTECTOMY)
You are an FY2 in A&E.

Mrs. Maria Lowe, aged 45, presented with SOB and chest pain.
Take history, assess her and discuss management with her.
D: How can I help you?

P: I was alright few hours back when I had pain in my chest.
D: Tell me more about it?
P: What would you like to know?
D: What were you doing when it started?
P: I was just sitting.
D: What kind of pain?
P: Sharp
D: Has it been continuous, or did it stop after some time?
P: Continuous
P: No
D: Have you experienced a similar pain before?
P: No
D: Has it ever happened before?
P: No
D: Anything else with it?
P: Yes, I also have shortness of breath.
P: With the chest pain.
D: Did you by any chance felt dizzy?
P: No
D: Anything makes your condition better?
P: No
D: Anything that makes it worse?
P: No
D: Do you have pain with breathing in or out?
P: Breathing in (pleuritic chest pain)
D: Anything else?
P: No
D: Do you have any pain elsewhere in the body? DVT
P: No
D: Any lumps or bumps? (cancer)
P: No
D: Any fever or flu?
P: No
D: Has it happened before?
P: No
D: Have you been diagnosed with any medical conditions? (MI, previous VTE)
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P: I had breast cancer and had mastectomy for that.
D: Any diabetes or HTN?
P: Yes, I have diabetes.
D: Are you taking any medications?
P: Yes, I'm taking OCP
D: Since when?
P: 2 years
D: Any other medication?
P: No
D: Do you have any allergies?
P: No
D: Any hospitalizations or surgeries?
P: Yes
D: Has anyone in your family been diagnosed with any medical conditions?
P: No
D: Do you smoke?
P: No
P: No
P: Good
P: Yes/No
D: When was your LMP?
P: 3 weeks ago
D: Have you travelled anywhere recently?
P: No
D: I would like to do GPE, check your vitals & examine your chest. We will also do some initial
investigation including ABG and CXR.
Examination: Vitals. Sats: 90% PR 110 Temp: 37. BP: 120/80

ABG: Respiratory alkalosis
CXR Normal.
D: From what you have told and from my examination, I suspect that you have a condition called
pulmonary embolism. In this condition, blood clot forms in the veins of the lungs & blocks the
veins. We would however, do some investigations to confirm this.
We'll check your blood for d-dimers, which is a special test for this condition, and we might plan a
special radiological test called CTPA. We'll also do an ECG to see if there's any problem that can be
causing this.
P: Is it serious?
D: It can be serious if not treated. But we'll start treatment immediately to prevent that.
P: Why did I get it?
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D: Well, the contraceptive pills you're taking are a risk factor for developing this condition.
People with cancer may have a higher number of platelets and clotting factors in the blood which in
turn cause clots to form.
We are going to keep you at the hospital and give you oxygen & do basic management to you’re
your breathing. We'll start specific treatment as soon as they come out.
Management:
- Initial resuscitation
- Oxygen 100%
- Obtain IV access, monitor closely, start baseline investigations.
- Give analgesia if necessary (e.g. morphine)
- Assess circulation: suspect massive PE if systolic BP is < 90 mmHg or there is a fall of 40
mmHg for 15 minutes, not due to other causes.
- Low molecular weight heparin (LMWH) or fondaparinux to patients with confirmed PE.
- Vitamin K antagonists (VKA) to patients with confirmed PE within 24 hours of diagnosis and
continue VKA for three months. At three months, assess the risks and benefits of continuing
VKA treatment.help clotting and stop bleeding. Having higher than normal amounts of
platelets and clotting factors in the body means the blood is more likely to clot. Some people
with cancer may have lower levels of proteins in the blood that help to keep it thinned.
Hence making cancer a risk factor for developing clots. Since the patient has a positive
history for DM as well that can contribute to forming a clot as well.
Management: Admit and do CTPA along with d-dimer. Begin LMWH immediately and monitor.
Consult Sr for advice on how to manage further and long term anticoagulants with cancer
treatment.
Risk factors: Prolonged Immobilization, Pregnancy, Pills, HRT, Previous PE/DVT, Malignancy à
Thrombophilia
Investigation: FBC, Urine (Pregnancy), ABG, D-Dimer, CXR, ECG, CTPA
Treatment:
O2.
Morphine & Metoclopramide
Anticoagulation Heparin 5 Days
Warfarin à 3-6 Months
Prevention (Compression Stockings, Stop HRT/Pills, Anticoagulation administered to

Immobile patient)
16
TRANSGENDER CHEST PAIN

Chanella Oliver, 28 years old, has come to the hospital with chest pain. He is under transition from
male to female.
Talk to her and address her concerns.

P: I have chest pain.
D: Where is it exactly?
P: Left side
P: I was just sitting
P: Sharp
D: Does it go anywhere?
P: No
D: Has it been continuous, or did it stop for some time?
P: Continuous
P: No
P: No
P: Breathing in (Pleuritic Chest Pain)
P: 7
P: No
P: No
D: Did you by any chance felt dizzy?
P: No
D: Do you have any pain elsewhere in the body? (DVT)
P: Yes, in my leg
D: Since when?
P: For 2 days
D: Any lumps or bumps? (cancer)
P: No
D: Any fever or flu? (pneumonia)
P: No
D: Do you feel out of breath?
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P: No
P: No
D: Have you been diagnosed with any medical conditions? (MI, previous VTE)
P: No
P: Yes, I'm taking oestrogen and spironolactone
D: Since when?
P: 6 months
D: Are you taking your medication as prescribed?
P: No, I take extra oestrogen tablets.
D: Any other medications?
P: No
P: No
P: No
D: Has anyone in your family been diagnosed with any medical condition?
P: No
D: Do you smoke?
P: No
P: No
P: Good
P: Yes/No
D: Do you smoke? (risk factor)
P: No
D: Do you take alcohol?
P: No
P: No
D: Are you currently sexually active?
P: No
D: Who do you live with?
P: Alone
Examination: Examiner said it is normal. BP 120/80, Sats 99%
Mention the treatment and review the medication. Oestrogen and spironolactone by the specialist.
Risk factors: Prolonged immobilisation, pregnancy, pills, previous PE/DVT, malignancy,

thrombophilia
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Investigations: FBC, Urine (pregnancy), ABG, D-dimer, CXR, ECG, CTPA
Treatment
O2
Morphine & Metoclopramide
Anticoagulation Heparin 5 days
Warfarin 3-6 months
Prevention (Compression Stockings, stop HRT/pills, anticoagulation administered to immobile
patient)
Clinical Feature Points

Clinical signs and symptoms of DVT (minimum of leg 3
swelling and pain with palpation of the deep veins)
An alternative diagnosis is less likely than PE 3
Heart rate >100bpm 1.5
Immobilisation for more than 3 days or surgery in the 1.5
previous 4 weeks
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy (on treatment, treated in the last 6 1
months, or palliative)
Clinical Probability Simplified Score
PE Likely >4
PE Unlikely 4 or less
Risks
There’s some uncertainty about the possible risks of long-term masculinizing and feminizing hormone
treatment. You should be made aware of the potential risks and the importance of regular monitoring
before treatment begins.
Some of the potential problems most closely associated with hormone therapy include:
• Blood clots
• Gallstones
• Weight gain
• Acne
• Hair loss from the scalp
• Sleep apnoea – a condition that causes interrupted breathing during sleep
19
MUSCULOSKELETAL CHEST PAIN

Please talk to the patient, take history, discuss your initial plan of management with the patient.

P: I have pain in my chest.
P: Like what Dr.
P: It is in (Patient points toward the chest near the shoulder)
P: It started few days ago.
P: It was sudden.
P: It is continuous
P: It is dull pain
P: No
P: No
P: Whenever I am doing cycling, my pain gets worse. / when I take a deep breath in it hurts
P: It is around 5.
P: No Dr.
D: Any sweating?
P: No
P: No (MI, pneumothorax)
D: Any pain during breathing?
P: Yes, I feel pain when I breathe in (pleurisy, MSK, pericarditis)
D: Any nausea
P: No
D: Any light headedness?
P: No
P: No
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P: No (pneumonia)
D: Any cough?
P: No (pneumonia)
D: Any increase in the pain on lying down?
P: No (pericarditis)
P: No (pericarditis)
P: No
D: Did you hurt yourself anytime recently?
P: Yes, I did actually. I do a lot of exercise as I’m training for my triathlon. 3 days ago. I fell from my
bike during my training session
D: I’m very sorry to hear that. Did you injure yourself anywhere else?
P: No
D: Do you feel pain when you move your arm or shoulder?
P: Yes, I do.
P: No
P: No
D: any DM, HTN, Heart disease or high cholesterol?
P: No
P: No
P: No
P: No
P: My father died of heart attack.
D: Do you smoke?
P: No
P: No
P: I try to eat healthy.
P: Yes, cycling.
P: No dr.
D: What do you do for a job?
P: I'm a triathlon trainer
21
I would like to check your vitals and examine your chest. I will examine the upper chest area for any
tenderness.
Examination:
Inspection- Chest is moving bilateral symmetrical. There is no sign of any trauma or injury. There is
no flail chest. No engorged neck veins.
Palpation- There is no tracheal deviation, trachea is central in position.
Chest expansion'. Patient cannot breathe in because of pain
Tenderness on both sides of the chest.
Percussion- There is no dullness or hy per-resonance.
Auscultation: Chest sounds are normal vesicular. There is no added sound.
I would like to send for some initial investigations including Routine blood test, Special blood tests
for your heart enzymes (troponin). Chest X-ray (pneumothorax) and ECG (MI)
From my assessment, your chest pain is likely to be musculoskeletal pain or we call it

Costochondritis, which is the inflammation of the cartilage that joins your ribs to your breastbone
(sternum).
Costochondritis often gets better after a few weeks, but self-help measures and medications can
manage the symptoms.
We can give you some Painkillers, such as paracetamol to ease your pain.
Taking a type of medication called a non-steroidal anti-inflammatory drug (NSAID) – such as
ibuprofen, two or three times a day can also help control the pain and swelling.
P: I am worried about heart attack?
D: This is a valid concern. From my assessment, your chest pain looks like more of muscle pain, we
will keep you in the hospital and we will do investigations to make sure every thing is fine with you.
Self-help:
Costochondritis can be aggravated by any activity that places stress on your chest area, such as
strenuous exercise or even simple movements.
You can use ICE Pack (after wrapping in a cloth) to improve your pain.
Any activity that makes the pain in your chest area worse should be avoided until the inflammation
in your ribs and cartilage has improved.
Steroid injection
TENS (Transcutaneous electrical nerve stimulation)
If you develop any sudden severe chest pain, breathlessness dial 999 and come to the hospital.
DD:
Myocardial infarction
Angina
Pulmonary embolism
Pneumothorax
Pericarditis
Pneumonia
MSK pain
22
CHEST PAIN-HERPES ZOSTER
You are F2 in GP
Peter aged has presented to the clinic with chest pain.
Talk to the patient, assess her and discuss the plan of management.

P: I am having chest pain.
P: Like what dr.
P: It is in right side of my chest (Pt. points towards the lower right side of the chest)
P: I am having this from last one day.
P: It was gradual.
P: It was continuous.
P: It was dull pain like burning.
P: It is going to my back.
P: No
P: No
D: Could you please score the pain on a scale of 1-10 where 1 being no pain and 10 being the
P: It is 5
D: Anything else with pain?
P: I have skin lesion over my chest.
D: Where exactly in the chest?
P: Right side
D: Since when did you notice it?
P: Since yesterday
D: Does it itch?
P: Yes /No
D: Is it painful?
P: Yes/No
D: Is it spreading?
23
P: Yes
D: Did you come into contact with anyone who had any type of skin lesions?
P: No
D: Do you have skin lesion anywhere else?
P: No
D: Any skin lesions on face near the eyes or ears?
P: No
D: Have you ever had any chicken pox before?
P: Yes / No
D: Anything else?
P:No
D: Any headache?
P: No
D: Any breathlessness or sweating?
P: No.
P: No. (Pneumonia)
D: Any cough?
P: No. (Pneumonia)
P: No
P: No
P: No
D: any DM, HTN. Heart disease or high cholesterol?
P: No
P: No
P: No
D: Any previous hospital stays or surgeries?
P: No
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: I don’t eat healthy.
P: I don’t have much time
24
P: No Dr.
P: No. (Pericarditis)
P: No. (PE)
D: Any history of travel?
P: No. (PE)
I would like to do GPE. Vitals, and want to examine your skin lesion.
From our assessment, you might have this chest pain because of skin lesion which is called
as shingles.
Shingles is a painful, blistery rash in one specific area of your body. Most of us get
chickenpox in our lives, usually when we are children. Shingles is a reactivation of that
chickenpox virus but only in one nerve root. So instead of getting spots all over the place
like in chickenpox, you get them just in one area of your body.
We can prescribe some antiviral medicine to help speed up your recovery and avoid longer
lasting problems.
We can offer you vaccine for shingles.
P: Is shingles contagious?
D: You can catch chickenpox from someone with shingles if you have not had chickenpox
before. But most adults and older children have already had chickenpox and so are immune
from catching chickenpox again. You cannot get shingles from someone who has shingles.
25
Do
• take paracetamol to ease pain
• keep the rash clean and dry to reduce the risk of infection
• wear loose-fitting clothing
• use a cool compress (a bag of frozen vegetables wrapped in a towel or a wet cloth) few
times a day
Don't
• let dressings or plasters stick to the rash
• use antibiotic cream - this slows healing
General Advices:
1. Try to avoid pregnant women who have not had chickenpox before people with a
weakened immune system and babies less than 1 month old — unless it's your own baby,
as they should be protected from the virus by your immune system
2. Stay off work or school if the rash is still oozing fluid and can't be covered or until the
rash has dried out.
26
CHEST PAIN-PERICARDITIS

Please talk to the patient, take history, assess the patient and discuss your initial plan of

P: I have pain in my chest.
P: Like what dr.
P: It is in center of my chest (Pt. points towards the chest)
P: 1 day ago
P: It was gradual.
D: Is it continuous or comes and goes?
P: It is continuous.
D: What ty pe of pain is it?
P: It is sharp pain
P: No
P: When I am leaning
P: When I lie down
D: Has it changed?
P: I think it’s getting worse.
D: Could you please score the pain on a scale of 1 to 10, where 1 being no pain and 10 being
the most severe pain you have ever experienced?
P: 7
P: No Dr.
P: No
P: Yes, I am having fever from last one week.
D: Anything else with fever?
P: Yes, I have a sore throat.
27
D: Did you take anything for it?
P: I took PCM for that.
D: Any cough?
P: No
D: Any sweating?(MI)
P: No
D: Any nausea?
P: No
D: Any lightheadedness?
P: No
P: No
P: No (PE)
D: Any trauma? (Pneumothorax)
P: No
P: No
P: No
D: any DM. HTN. Heart disease or high cholesterol?
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: No Dr.
28
I would like to send for some initial investigations including routine blood test, special blood
test for your heart (Troponin) CXR and ECG.
 From my assessment, your chest pain seems to be pericarditis.

 Pericarditis is inflammation of the pericardium (the fibrous sac surrounding the heart).
 If all the tests came back normal we will send you home.
 We will give you anti-inflammatory medicines such as ibuprofen are usually given to ease
the pain and reduce inflammation.
 If your symptoms persist for more than 14 days then we may give you a medicine called
colchicine, which helps to improve the outcome and reduce the chances of the
inflammation coming back.
 If the pain is severe and you are not getting better with ibuprofen and colchicine, steroid
medicines may be used to reduce the inflammation. The pain and inflammation usually
settle within a few weeks.
 We'll also do routine blood test, special blood test for your heart (Troponin) & a chest x-
ray.
 Please follow up with the heart specialist and your GP.
 Give life style advice accordingly.
 If you develop any sudden severe chest pain, breathlessness dial 999 and come to the
hospital.
If a lot of fluid builds up and causes cardiac tamponade, the fluid needs to be drained with a
needle and syringe. If constrictive pericarditis develops and interferes with the heart's
function, the thickened pericardium may need to be removed by an operation. This is called
a pericardiectomy.
DD:
Myocardial infarction:
Angina:
Pulmonary embolism:
Pericarditis:
Pneumonia
Gastroesophageal reflux disease
29
PULMONARY EMBOLISM
You are an FY2 in GP practice.

Angela 34-year-old has presented to you with complain of breathlessness.
Talk to the patient & address her concerns.
At 6 minutes discuss D/D with the patient.
D: What brings you to the hospital today?

P: Doctor I can’t breathe properly
D: Are you comfortable for me to ask a few questions so as to find out what happened?
P: Yes / No (Stabilise - 02)
D: Can you please tell me what happened?
P: I was alright few hours back when I suddenly became short of breath
P: Was just sitting.
D: Has it been continuous, or did it stop for some time?
P: Continuous
No
P: Yes, I also have pain in my chest
P: Sharp
P: With the breathlessness
P: No
P: No
D: Did you by any chance felt dizzy 2
P: No
P: No
P: No
P: Breathing in (Pleuritic Chest Pain)
D: Do you have any pain elsewhere in the body? (DVT)
P: No
D: Any lumps or bumps? (Cancer)
P: No
D: Any fever or flu? (Pneumonia)
30
P: No
D: Have you ever been to the hospital before? (Surgery)
P: No
D: Have you been diagnosed with any medical conditions? (MI, Previous VTE)
P: No
D: Any diabetes or HTN?
P: No
D: Has anyone in your family been diagnosed with any medical conditions?
P: Yes, my mother had a blood clot
P: Yes. I am taking Combined Oral Contraceptive Pills
D: Since when?
P:
D: Any other medication?
P: No
P: 3 weeks ago.
D: Can you be pregnant by any chance?
P: I don’t think so.
D: Do you have kids?
P: Yes, 1 son.
D: How old? (Recent pregnancy)
P:
D: Do you smoke? (risk factor)
P: Yes/No
P: Yes/No
P: No
D: I would like to check your vitals & examine your chest. I'll have a chaperone present.
Examination normal.
DD:
PE
MI
Pericarditis
Tension Pneumothorax
Pneumonia
COPD
GORD
31
D: From what you’ve told me & from my examination, I suspect that you have a condition
called pulmonary embolism. Have you heard about it?
P: No
D: In this condition blood clot forms in the veins of the lungs & blocks the veins. We would
however do some investigations to confirm this. We’ll do the routine blood tests, urine dip
(have to rule out pregnancy), ABG’s & check the levels of chemicals in your body. We’ll also
check your blood for d-dimers, which is a special test for this condition. We’ll also do an ECG
to see if there’s any problem that can be causing this. We would also do a chest X-ray to see
the lungs.
Do you follow?
P: Yes. Is it serious?
D: It can be serious if not treated. But we’ll start treatment immediately to prevent that. Is
that alright?
D: Well, the contraceptive pills you’re taking are a risk factor for developing this condition.
You also said that your mother had a blood clot, that could also be a reason
P: Can it be anything else?
D: It can be yes. that is why we are going to investigate to confirm it & rule other conditions
out.
For now, were going to give you oxygen & do basic management to ease your breathing
&would send for tests. We'll start specific treatment as soon as they come out.
Management:
 Initial resuscitation
 Oxygen 100%.
 Obtain IV access, monitor closely, start baseline investigations.
 Give analgesia if necessary (eg, morphine).
 Assess circulation: suspect massive PE if systolic BP is <90 mm Hg or there is a fall of 40
mm Hg, for 15 minutes, not due to other causes.
 Low molecular weight heparin (LMWH) or fondaparinux to patients with confirmed PE.
 Vitamin K antagonist (VKA) to patients with confirmed PE within 24 hours of diagnosis
and continue the VKA for three months. At three months, assess the risks and benefits of
continuing VKA treatment.
Clinical Feature Points

Clinical signs and symptoms of DVT 3
(minimum of leg swelling and pain with
palpation of the deep veins)
An alternative diagnosis is less likely than 3
PE
Heart rate >100bpm 1.5
32
Immobilisation for more than 3 days or 1.5
surgery in the previous 4 weeks
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy (on treatment, treated in the 1
last 6
months, or palliative)
Clinical Probability Simplified Score
PE Likely >4
PE Unlikely 4 or less
If WELL’S Score 4 -» CTPA/VQ scan

If WELL’S Score 3 -> D-dimers, if d-dimers raised then CTPA/VQ scan
33
HEART FAILURE (SOB POST MI)
You are FY2 in medicine.

Mr. David Parker aged, 59 presented to the hospital with breathlessness.
Patient has been referred by the GP. Patient had an MI 7years ago. Patient is not regular
with the GP.
Please take history, assess his condition, discuss about management and address his
concerns.

P: I have shortness of breath from the last few weeks.
D: Tell me more about your shortness of breath?
P: What do you want to know?
D: How often do you have it?
P: When I walk/climb stairs
D: Is it getting worse?
P: Yes
D: Does it get worse by doing any tiling?
P: Whenever I walk few steps/climb stairs/ when I am lying down flat
D: Does anything make it better?
P: Taking rest
D: Is there any particular time of the day you experience this problem more?
P: I wake up in the middle of night due to this.
P: Like what Dr.
D: Any fever/ flu like symptoms?
P: No.
D: Any cough?
P: No.
D: Any wheeze?
P: No.
D: Any chest pain/ chest tightness?
P: No.
D: Do you have any dizziness?
P: No.
P: Yes/No
D: Do you have any swelling anywhere in your body?
P: Yes Dr., my legs are swollen.
D: May I know since when?
P: Few weeks.
D: Did the swelling increase from the time it started?
34
P: Yes, my socks are getting bigger.
D: Do you have heart racing?
P: Yes/No
P: Few weeks ago.
D: How often do you get it?
P: I had 4-5 episodes.
D: How long does each episode last?
P: Few minutes
P: It goes away by itself.
D: Have you noticed any changes in the frequency or duration of your symptoms?
P: No
D: Did you have any similar problem before?
P: No.
P: Yes, I had heart attack few years ago.
D: How was it managed?
P: They gave me medications for my heart, blood thinners, statin.
D: May I know how do you take them?
P: One aspirin in the morning and one statin at night.
D: Are you taking your medications regularly and as prescribed?
P: Yes, kind of.
D: What do you mean by that?
P: I miss my medications sometimes
D: Have you got any complications of heart attack?
P: No
D: Any heart failure?
P: No
D: Do you see your GP regularly?
P: No
D: May I know why?
P: I feel fine, I don’t feel the need to see my GP.
D: Apart from you heart attack have been diagnosed with any other medical condition?
P: No Dr.
D: Any diabetes, high blood pressure, high cholesterol, thyroid problems?
P: No
D: Are you currently taking any other medications, over-the-counter drugs or supplements
other than the ones for your heart attack?
P: No
D: Any allergy to any food or any drug?
35
P: No
D: Any previous hospital stays other than for your heart attack?
P: No
D: Have you have any surgeries before?
P: No
D: Any procedure done for your heart attack?
P: No
P: Yes, my father had a heart attack when he was 59.
D: I am sorry to hear that.
D: Anyone with diabetes, high blood pressure, high cholesterol in the family?
P: No
D: Do you smoke?
P: Yes/No
P: Yes, occasionally
P: I eat everything, burgers, chips.
D: Tell me about your physical activity?
P: I try to walk but I get breathless.
D: Do you have any stress in life?
P: No
D: What do you do for a living?
P: Office job/ retired
D: Did you travel abroad recently?
P: Yes/No.
D: Tell me about your home condition?
P: I live in a house with my wife.
I would like to check your vitals and examine your chest, heart and lungs.
I would like to send for some initial investigations, including cardiac enzymes, CXR and an
ECG.
Examiner:
NEWS CHART:
Temperature 37
Pulse Rate 87/min
02 Sat 92% to 93%
BP 130/90 mmHg
RR 12-20
Decreased air entry bilaterally.
36
CXR: Cardiomegaly.
ECG: Normal/ Might find Q waves.
PATIENT'S CONCERNS
P: What's happening doctor?
P: What is heart failure?
P: Why my heart has become enlarged?
P: What are you going to do now?
P: How are you going to treat my heart failure?
 D: From my assessment, you seem to have a condition called heart failure. This means
that the heart is unable to pump blood around the body properly. It usually occurs
because the heart has become too weak or stiff.
 This causes fluid to accumulate in the peripheries and lungs, that explains your swelling
in the legs and shortness of breath.
 This is one of the complication of heart attack.
 D: We did a chest X-ray and as you can see here, this white area here is your heart and
this shows that the size of your heart is enlarged.
 Fortunately, your ECG looks okay, I will confirm it with my senior. [There is minor
abnormality in your ECG (Q waves) this might be because of your previous heart attack, I
will confirm it with my senior}.
 D: This is a complication of heart attack, after an attack some part of your heart muscle is
dead and your heart will get more strain to pump blood. This strain causes the
enlargement of your heart. We call this Remodeling of heart. In order to prevent this, we
usually give some medication called beta blockers to reduce the strain on your heart and
ACE inhibitors to decrease your blood pressure. As you have not been taking these
medication, this could be one of the cause for your heart to enlarge.
 D: We will keep you in the hospital till your symptoms improve.
 We will do further blood tests to check if you have anaemia and the function of your liver
and kidneys.
 We will do US of your heart(Echo) to assess the structure of your heart
 We will also assess the function of your lungs.
 We will give you oxygen and medication to decrease the fluid in your lungs and your legs
(Furosemide), so that your breathing will be improved.
 We will prescribe you beta blockers to reduce the strain on your heart and ACE inhibitors
to decrease your blood pressure.
 Hopefully, your condition should get better with these medication, if not you may have
to have procedure done for your heart or for your heart beat.
 We might refer you to a Cardiac rehabilitation service led by healthcare professionals for
people with heart conditions if needed.
37
 The programme covers the following:
o exercise
o education
o relaxation and emotional support
D: We will discharge you once your symptoms improve.
 You need to take all your medications regularly and as prescribed to prevent further
remodelling of your heart.
 Address life style accordingly.
 Smoking
 Alcohol
 Diet - Cut the amount of salt & fluid intake.
 Physical activity.
D: You need to come for follow ups regularly. You should also see you GP regularly. He can
assess your condition before it gets too bad.
If your symptoms get worse or if you need any help, please come back to us.
38
ARRHYTHMIA
You are FY2 in GP clinic.

Mr. Alexander aged, 57presented to the hospital complaining of chest discomfort. This is patient’s
first visit.
Please talk to the patient, take a focused history, and discuss your initial plan of management with
the patient. Do not examine the patient.

P: I have chest discomfort.
D: I'm so sorry, could you tell me more about it?
Dr: What do you mean by chest discomfort?
P: Like a fluttering sensati
P: 6 months ago.
D: How did it start? What you were doing at that time?
P: Just started.
D: Do you have it all the time?
P: No Dr., time to time
D: How often do you get this feeling?
P: 5-6 times in last 6 m
D: When was the last time you had this feeling?
P: Last week
D: What were you doing at that time?
P: Nothing
D: How long did that feeling last?
P: About 15 minutes.
D: Is there anything that triggers this feeling?
P: I don't think so.
D: Does anything relieve your symptom?
P: No
D: How about the first episode?
P: All the episodes are same Dr.
P: No
D: Any chest pain?
P: No
D: Any chest tightness?
P: No
D: Any shortness of breath?
P: No
D: Any dizziness or light-headedness?
P: No
D: Do you feel tired when you get these symptoms?
39
P: No
D: Do you feel sick when you get this symptom?
P: No
D: Any blackouts?
P: No
D: Do you have any fever/ flu like symptoms?
P: No
D: Do you feel hot when everyone around you is fine?
P: No
Did you lose any weight?
P: No
D: Have you had any of these symptoms before 6 months?
P: No
P: Yes, I have high blood pressure.
D: When were you diagnosed?
P: 5 years ago
D: How do you manage it?
P: I take Ramipril
D: Do you take it regularly?
P: Yes
D: Is it well controlled?
P: Yes
D: Any other medical condition?
P: No
D: Any diabetes, high cholesterol, heart or lung problem?
P: No
D: Do you any other medications, over-the-counter drugs or supplements?
P: No
P: No
P: No
P: My father died of heart attack when he was 60 years old. My brother had a heart attack when he
was 55.
D: Any other problem in the family?
P: No
D: Do you smoke?
P: Yes/No
P: Social
D: What about tea or coffee?
P: I have a lot of them
D: May I know how many cups per day?
40
P: around 5.
P: Try to have healthy diet
P: Quite active
P: No
P: No
D: Have you been taking any recreational drugs?
P: No
D: What you do for a living?
P: Office job
D: Is your job stressful?
P: No
D: Is there anything that you think is important for us to know?
D: I would like to check your vitals and examine your heart and lungs.
D: I would like to send for some initial investigations including routine blood test, special blood test
for your heart enzymes and ECG.
 D: From my assessment, you seem to have a problem in your heart called Arrhythmia, which is
irregular beating of your heart.
 D: The heart rhythm is controlled by electrical signals and arrhythmia is an abnormality of the
heart rhythm and sometimes its rate. It may beat too slowly, too quickly or irregularly.
 D: l am so sorry for what happened to your dad and brother. I can imagine how worried you are.
We are here to help you. We are going to do some investigations to confirm the diagnosis and
to see what is going on exactly.
 D: We will refer you to a specialist.
 We will do some blood tests to see if you have anaemia, to check your kidneys, liver and thyroid
gland function and also to check your blood sugar and cholesterol levels.
 We may need to do an x-ray of your chest.
 The most effective way to diagnose an arrhythmia is with an electrical recording of your heart
rhythm called an electrocardiogram (ECG). If the ECG doesn't find a problem, you may need
further monitoring of your heart.
 This may involve wearing a small portable ECG recording device for 24 hours or longer. This is
called a Holter monitor or ambulatory ECG monitoring.
 If your symptoms seem to be triggered by exercise, an exercise ECG may be needed to record
your heart rhythm while you are using a treadmill or exercise bike.
 You should request a copy of your ECG. Take it with you to see the cardiologist or heart rhythm
specialist and always keep a copy for future use.
 Other tests used in diagnosing arrhythmias include:
 cardiac event recorder - a device to record occasional symptoms over a period of time
whenever you have them
 echocardiogram (echo) - an ultrasound scan of your heart
41
Treatment for arrhythmias:
How your arrhythmia will be treated will depend on whether it is a fast or slow arrhythmia or heart
block. Any underlying causes of your arrhythmia, such as heart failure, will need to be treated as
well.
The treatments used for arrhythmias include giving medication - to stop or prevent an arrhythmia
or control the rate of an arrhythmia
D: Arrhythmia/ heart racing has many causes, but to find out the exact cause in your case we will
run the tests and treat it accordingly.
Sometimes having a family history of heart disease also can lead to this condition.
D: If you experience any heart racing specially if it is fast and irregular accompanied by shortness of
breath, dizziness or fainting, please go to the A&E immediately.
If you develop any sudden chest pain which is heavy and radiating to your left arm, shoulder, neck
or jaw, please come to the A&E.
Please cut down tea or coffee.
PATIENT'S CONCERNS:
P: What is going on doctor?
P: What is arrhythmia?
P: I’m really concerned about this because of what happened to my dad and brother. Is it doctor?
P: What are you going to do for me?
P: Why am I having this problem?
P: Doctor how are you going to treat me?
DD
1. Arrhythmia
2. ACS
3. Angina
4. Pheochromocytoma
5. Hyperthyroidism
42
PERIPHERAL ARTERIAL DISEASE
Mr. James Anderson 55 years presented in GP surgery have some concerns .

Talk to him assess and manage him accordingly.
D: Hi I am Khalil, one of the junior doctors working in this GP surgery. Can I confirm your name and
age please.
P: hello doctor my name is James Anderson and I am 55 years old .
D: how would you like me to call you ?
P: James Dr.
D: nice to meet you James . how may I help you today?
P: Doctor I have pain in front of my leg since last few months
D: tell me more about it
P: I love to play golf and whenever I play golf after a while I have pain started in my leg it remains until
I stop playing and take some rest after a while I feel better .
D: Do SOCRATES
Gradual pain in PAD and sudden severe pain in ACUTE LIMB ISCHEMIA
D: scale the pain 0 to 10
P: 4 OR 5
D: One leg or both legs
P: UNILATERAL
D: Any chest pain
P: NO
D: Dizziness
P: NO
D: Heart racing
P: NO (AF)
D: Swelling on the back of your legs
P: NO (DVT)
D: Lower back pain radiating downward
P: NO (SCIATICA)
D: Swelling of the veins
P: NO (varicose veins)
D: Trauma
P: NO
D: Hairs loss on your legs
P: YES
D: Ulcers on leg
P: NO OR YES
D: Shiny skin
P: NO OR YES
D: Change in color of legs
P: No or Yes
D: Muscles wasting
P: No
43
D: pins and needles like feeling in your legs. ( Paraesthesia-PVD 6p)
D- weakness in any or both your limbs?( Paralysis 6p)
D- do you feel your leg is cold or have you noticed change in temperature of your leg/feet, or one of
you limb feels warmer? ( Poikilothermia-6p)
MAFTOSA
Past medical history of hypertension, DM , heart problems, cholesterol
Are you using any medications
Are you allergic to any medications
Family history of heart diseases
Long air travel history
Social history ( SMOKING, DIET , PHYSICAL ACTIVITY )
Anything else would you like to share that I haven’t asked? Do you have an IDEA what is going on
with you ?
P: No
MANAGEMENT I would like to check your bp, temp, RR , pulse rate and will also do routine blood
tests like CBC, CHOLESTEROL LEVEL, and fasting blood sugar. I will also examine your leg and heart,
we will also like to do the heart tracing( ECG ) and will check height to weight ratio . From what you
have told me and from what we have observed I am suspecting you have a condition called
peripheral arterial disease .
D: Do you have an idea of what PAD is ? (concern) Peripheral arterial disease (PAD) is narrowing of
one or more blood vessels (arteries). It mainly affects arteries that take blood to your legs. (Arteries
to the arms are rarely affected and are not dealt with further in this leaflet.) The narrowing of
blood vessels (arteries) is caused by atheroma. The main symptom is pain in one or both legs when
you walk. I would like to inform my SENIORS who will asses you again. DIAGNOSIS We would like to
do a DOPPLER ULTRASOUND The diagnosis is usually made by the typical symptoms. A simple test
that your doctor or nurse may do is to check the blood pressure in your ankle and compare this to
the blood pressure in your arm. This is called the ankle brachial pressure index ABPI. If the blood
pressure in your ankle is much different to that in your arm then this usually means that one or
more blood vessels (arteries) going to your leg, or in your leg, are narrowed. However, the ABPI can
be normal in some cases. Although this test can help your doctor find out if PAD is affecting your
legs, it will not identify which blood vessels are blocked. A computerized tomography CT SCAN, a
magnetic resonance imaging (MRI) scan or an ULTRASOUND SCAN of the arteries can build up a
map of your arteries and show where they are narrowed. We would like to refer you to a
VASCULAR SURGEON for further treatment . P: How will you treat me ? ( concern )
1. Self-help measure
Stop smoking
Exercise
Lose weight
Healthy diet
2. Medicines PAIN KILLERS ( paracetamol ) A medicine called CLOPIDOGREL is usually advised. This
does not help with symptoms of PAD but helps to prevent blood clots (thromboses) forming in
blood vessels (arteries). It does this by reducing the stickiness of platelets in the bloodstream. If
you cannot take clopidogrel then alternative antiplatelet medicines such as LOW DOSE ASPIRIN
may be advised. A statin medicine is usually advised to lower your cholesterol level. This helps to
prevent a build-up of fatty patches (atheroma). If you have diabetes then good control of your
44
blood sugar (glucose) level will help to prevent PAD from worsening. If you have high blood
pressure (hypertension) then you will normally be advised to take medication to lower it. Other
medicines are sometimes used to try to open up the arteries - for example, cilostazol and
naftidrofuryl. One may be given and may help. However, they do not work in all cases. Therefore,
there is no point in continuing with these medicines if you do not notice an improvement in
symptoms within a few weeks.
3. Surgery Most people with PAD do not need surgery. Your GP may refer you to a surgeon if
symptoms of PAD become severe, particularly if you have pain when you are resting. Surgery is
considered a last resort. There are three main types of operation for PAD:
• Angioplasty - in this procedure, a tiny balloon is inserted into the artery and blown up at the
section that is narrowed. This widens the affected segment of artery. This is only suitable if a short
segment of artery is narrowed. • Bypass surgery - in this procedure, a flexible pipe (graft) is
connected to the artery above and below a narrowed section. The blood is then diverted around
the narrowed section.
• Surgical removal (amputation) of a foot or lower leg - this is needed in an extremely small number
of cases. It is only offered when all other options have been considered. It is needed when severe
PAD develops and a foot has tissue death (becomes gangrenous) due to a very poor blood supply.
RED FLAGS
CHEST PAIN , ULCER , GANGRENE , POOR HEALING come to emergency department.
REGULAR FOLLOW-UP WITH YOUR GP
LEAFLETS
SPECIFIC EXPECTATIONS
WISH YOU A GOOD HEALTH.
DIFFERENTIAL DIAGNOSIS
AF, VARICOSE VEINS , DVT, CELLULITIS , TRAUMA , SCIATICA
RISK FACTORS
SMOKING, DIABETES, OBESITY, HIGH BP , HIGH CHOLESTEROL, INCREASING AGE
COMPLICATIONS
AMPUTATION, POOR WOUND HEALING, PAIN AND DISCOMFORT, STROKE
45
POST ANGIOPLASTY-HESITANT TO WALK
You are F2 in cardio.

Anne Boleyn 65 years old lady was admitted in the hospital with MI 2 days ago. She had
angiography and angioplasty for that. Physiotherapist advised her to walk but she is afraid.
She has asked the nurse if she could talk to you.
Please talk to her and address her concern.
D: How may I help you?

P: I was in the hospital for the last 2 days. This morning during rounds, the physio Sarah told me to
walk. I said No. At first she went away but she came back again and told me rudely that I should walk.
She said this in front of so many people and I felt so humiliated.
D: I am so sorry that you went through this and felt humiliated by the way she spoke to you. I
apologize on behalf of the entire team. I will ask her to come and speak to you.
P: Ok.
D: Let me ask you a few questions. Tell me why you came to the hospital and what was done for
you.
P: Doctor. I came here 2 days ago with chest pain. They did an angiogram and said I needed a surgery
and it was done.
D: ok. so how are you feeling now?
P: I am fine doctor.
D: Any chest pain?
P: No doctor, I am fine
P: No
D: Any swellings in the legs?
P: No
D: Any heart racing?
P: No
D: Have you been diagnosed with any medical conditions in the past?
P: No
D: By any chance do you have DM, HTN, cholesterol?
P: No
D: Any other medications you are taking?
P: No
D: Any previous hospitalization or surgery?
P: No
D: Whom do you live with?
P: I live alone.
D: ok. so could you tell me why you don’t want to walk?
P: I just had a surgery. So I just wanted to rest.
D: ok. I understand that you want to rest at this moment. And you definitely can rest, but you could
take a short walk in between.
P: When I came here the nurse had told me to rest and not to walk.
46
D: When you came to the hospital you had chest pain that is why our nurses staff told you to rest.
Now you have had Angioplasty done, that is why we want you to walk around in the ward.
P: OK
D: Let me explain to you why the physiotherapist advice you to walk. As you said you came here
with chest pain and surgery was done for you. One of the complications of the surgery is a
condition called DVT. which is formation of clots in your legs, which may cause worse life-
threatening complications. That’s why we advise mobilizing our patients as soon as possible to
avoid this particular complication.
P: But doctor I want to rest.
D: Yes you can rest. But. I am sure it would be good for your health if you will take a few steps in
the ward.
D: Do you have any other concern?
P: No '
D: Ok. I am sorry for your experience. 11 inform my colleagues occupational therapist to visit your
house and make necessary changes if needed. I will also inform the ward manager so that they can
also look into this matter. I will also escalate this matter to our seniors.
If patient wants to make a complain
P: I cant accept it. I want to complain?
D: Ok. the other thing I can do is I can get you in touch with PALS service and it is a service where
you can make formal complains if you strongly feel that your care is compromised. They will look
into detail of it.
47
RESPIRATORY PROBLEMS:
DRY COUGH (DD)
You are F2 in respiratory department.

Peter aged, 70 has come to you with cough for past few months.
Please talk to the patient, take history, and assess the patient’s condition.
After 6minutes, discuss about differential diagnosis with examiner and discuss about the
management plan with patient.

P: I have cough from the last few months.
D: Tell me more about your cough?
D: Do you have this cough all the time or is it on and off?
P: It was on and off when it started, but now it is present all the time.
D: Is it becoming worse by anything?
P: It gets worse when I am gardening (Asthma)
D: Is there any phlegm with it?
P: No.
D: Did you notice any blood?
P: No.
D: Is there anything else that's bothering you?
P: I have shortness of breath.
P: Few months now.
D: Does it get worse by doing anything?
P: When I walk/climb stairs/ lying down flat (cardiac asthma).
P: Like what dr.
D: Any chest pain? Any chest tightness? (TB, Mesothelioma, Pneumonia. Asthma)
P: No.
D: Do you have any fever/flu like symptoms? (TB, Pneumonia)
P: No.
D: Any excessive sweating? /Night sweats? (TB)
P: No.
D: Have you lost any weight ? (TB, Mesothelioma)
P: Yes, 1 stone in the last few months.
D: How is your appetite these days?
P: Good/1 don't enjoy my food (TB, Mesothelioma)
D: Do you have any dizziness or heart racing? (Mesothelioma)
P: No
D: Do you feel tired? (TB, Mesothelioma)
P: Yes. just by doing simple activities.
48
P: No.
D: Do you have any fever/ flu like symptoms?
P: No
D: Any chest infection?
P: No
P: No
D: Diabetes, high blood pressure, heart disease, asthma or TB?
P: No
(TB. Mesothelioma, Pneumonia, ACE inhibitors, cardiac asthma)
D: Are you currently taking any medications, over-the-counter drugs or supplements?
P: No
D: Are you taking any long term steroids, antibiotics or chemotherapy?
P: No
(TB. Mesothelioma, Pneumonia)
P: No
D: Any hay fever or eczema in the past?(Asthma)
P: No
P: No
P: No.
D: Anyone with asthma or breathing problems in the family?
P: No.
D: Did you notice any similar symptoms in any of your family members? (TB)
P: My son was coughing a lot while I was talking to him on skvpe.
D: Where does he live?
P: He works in Tanzania.
D: Have you seen him recently?
P: Yes. he came twice here last year. The last time was 3 months ago.
D: Do you smoke?
P: Yes, 25 cigarettes since adulthood
P: Yes, 2-3 bottles of red wine in a week
P: I eat everything; red meat, pork, bacon
P: I try to walk but I get tired soon.
P: I am a gardener now. (Asthma)
D: Where did you work previously?
P: I worked as a woodcutter in wood industry
D: Have you been exposed to asbestos?
49
P: Yes dr. few years ago (Mesothelioma).
D: Did you travel abroad recently? (TB)
P: Yes/No.
D: Tell me about your home condition? (TB)
P: I live in a house.

I would like to send for some initial investigations including routine blood tests, CXR.
Examiner:
All the examination is normal/ Reduced breath sounds on right side.
D/D:
TB (Night sweats, weight loss, fatigue, temperature, loss of appetite, contact with son)
Lung cancer (Weight Loss, Fatigue, Occupational, Loss of Appetite)
Asthma (Gardening)
Pneumonia (Temperature)
Heart failure (SOB on lying down)

 From my assessment, you seem to have a problem in your lungs. It is very difficult for us to give
you a fixed diagnosis about what’s wrong with you. Because all the symptoms you presented
with can have different causes.
 We are going to run further tests to confirm what is going on.
 We will do further blood tests to check if you have anaemia or any infection and to check your
blood gases.
 We will do ECG (Tracing of your heart)
 We will do a chest X-ray (If chest X-ray is not done already) and check your lung function.
 If there is any fluid in the lining around your lungs, we will take sample by introducing a needle
and analyze it in the lab.
 We need examine your phlegm, as you told you don’t have any phlegm/ sputum along with
your cough we may have to do a procedure to get some sputum/ phlegm (saline nebulisation
and chest physiotherapy).
 If we are not able to get a sample of your sputum then we will do bronchoscopy and lavage
(BAL) to get a sample. The sputum sample will then be sent to the lab for examination for any
bugs using a special dye. We may also grow some bugs if there are any.
 We may have to do a procedure called thoracoscopy to have a better look inside your lungs. We
may take a sample of your lung. The sample is then sent to the lab to have a closer look.
Differentials for cough for > 3 weeks:

1. Bronchial carcinoma – smoking, weight loss, haemoptysis
2. Mesothelioma – exposure to asbestosis, building worker (roofer, plumber, carpenter) weight loss
3. Infection – TB – Haemoptysis, night sweats, weight loss, contact with anyone with TB
50
4. P.E. – SOB, chest pain, haemoptysis, calf pain, travel, surgery, recent immobilization
5. Asthma – allergy to pets, wheeze, pollen, exercise
6. COPD - > 3 months for 2 consecutive years, wheeze
7. CCF – ankle swelling, orthopnoea, PND
8. Diffuse parenchymal lung disease.
9. Drugs – ACE inhibitors, beta blockers
10. Psychogenic
11. GORD – heartburn, regurgitation
Differential for cough Acute < 3 weeks

1. Foreign body – sudden onset
2. Infection – URTI, pneumonia, infective COPD
51
DRY COUGH PCP
You are F2 in medicine.

Michael aged 24 presented to the hospital with cough and shortness of breath for the past few
weeks. Patient is homeless and he is losing weight.
Please talk to the patient, assess the patient, do relevant examination and do initial management
with patient.
D: What bought you to the hospital?

P: I have cough and difficulty in breathing.
D: Tell me more about cough?
D: May I know since when do you have cough?
From the past few weeks (5 weeks)
P: It was on and off when it started, but now it is becoming worse
P: Yes/No
D: Do you get any phlegm when you cough?
P: No
D: Any blood
P: No
D: When did your breathing difficulty start?
P: From last few weeks.
D: Is it the same or getting worse with time?
P: It is worse now.
D: Does anything make it worse?
P: Walking or climbing stairs, I even have at rest sometime
D: Is there any other thing that's bothering you?
P: Like what?
D: Any fever?
P: Yes mild temperature but didn’t measure/No
D: Any flu-like symptoms?
P: Yes, I have runny nose also
D: Any chest pain?
P: Yes
P: It is here all over my chest (Pt. shows his chest)
D: Since when?
P: Since few weeks (5 weeks)
P: It is always there
D: Is there any difference from the time it started?
P: It is worse now
52
P: It is sharp pain
No
D: Does anything make the pain better?
I took PCM, but it doesn’t help / rest helps sometimes.
D: Anything makes it worse? P: Coughing/ breathing
P: Coughing / breathing
P: 5
D: Do you feel sick?
P: Yes/No
D: Any vomiting?
P: Yes/No
D: Do you feel lethargic?
P: Yes, in past few days I always feel tired and it is getting worse.
D: Have you lost any weight?
P: Yes, few kgs in few weeks/ No
D: Any of your friends or family told you that you are losing weight? Are your clothes getting loose?
P: My friends/ wife told me that I lost some weight. My clothes are a bit loose than before.
D: Is it intentional?
P: No
D: Do you have night sweats?
P: Yes, in last few weeks / No
D: Any diarrhoea
P: No
D: Any skin changes or mouth infection? (Oral thrush)
P: No
P: No
P: No
D: Any lung problems, any condition called RA?
P: No
P: No
D: Any long term steroids, antibiotics or chemotherapy?
P: No
P: No
P: No
P: No
D: Any family member with similar symptoms or any lung problems?
53
P: No
D: Do you smoke?
P: Yes, 10 cigarettes per day since 17
P: No
P: I eat everything.
P: I try to be active.
P: Yes, heroine for past few years.
D: How do you take it?
P: I inject.
D: Do you share needles?
P: Yes, sometimes.
D: Are you sexually active?
P: Yes
D: Tell me more about your partner?
D: Are you in stable relationship?
P: No, I have many partners.
D: Do you practice safe sex?
P: Sometimes.
D: When was the last time you had unprotected sex?
P: A week ago.
D: What is your sexual orientation?
I am gay / bisexual.
D: What is your preferred route of sex?
P: Oral, vaginal and anal
P: I am Unemployed.
D: Could you please tell me about your home condition?
P: I don’t have home, I live on the streets from the past 2 years
D: Have travelled overseas recently?
P: No

I would like to send for some initial investigations including routine blood tests. ABG and CXR.
Findings:
Vitals - NEWS chart: Temperature-38*C 02 Sats - 90%
Auscultation: Bilateral reduced air entry/ Bi-basal crepitations.
CXR finding: CXR shows pneumonia/ Not done yet.
54
 D: From my assessment, it seems you have a chest infection, as your temperature is high and
oxygen in your blood is low. Your chest X-ray also suggests the same.
 We will do further blood tests to check for any bug and to check your blood gases.
 We will do a chest X-ray (If chest X-ray is not done already) and check your lung function.
 We need examine your phlegm, as you told you don’t have any phlegm/ sputum along with
your cough we may have to do a procedure to get some sputum/ phlegm (saline nebulisation
and chest physiotherapy).
(BAL) to get a sample. We may have to do a biopsy of your lung to get the sample sometimes.
The sample is then sent to the lab for a procedure called PCR (Polymerase Chain Reaction) to
identify the cause of your chest infection.
 This type of infection is sometimes caused because of HIV infection. HIV spreads with unsafe sex
and sharing needles. Can we test for HIV infection in you, so that we can treat HIV also if you are
positive.
 We will admit you and treat you with antibiotics(Co-trimoxazole) through your blood vessel.
 We will give you steroids also to prevent damage to your lungs. We will then taper down the
dose of steroids in next 21 days and stop.
 We will monitor you regularly by doing blood tests, checking your pulse, blood pressure,
temperature and oxygen in your blood.
 Please come back to us if your symptoms worsen.
 Please practice safe sex and also avoid sharing needles. We have needle exchange programme if
you want.
 We will talk to social services and try to arrange accommodation for you.
DD
PCP
Lung cancer
TB
Asthma
Pneumonia
55
COUGH – LUNG CANCER
You are FY2 in Medicine.

60-year-old 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.
D: 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: Dr. 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.
D: I'm sorry to hear that Mr….. Could you please tell me when this problem started?
P: It has been over 6 months now.
D: Is the cough associated with any sputum/phlegm?
P: No it is a dry cough.
D: Have you had any shortness of breath?
P: Yes
D: Could you please tell me when that started?
P: Around the same time.
D: Has it worsened since then?
P: Yes/No.
D: 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:
D: Do you have any chest pain?
P: No (Might say yes if mesothelioma)
D: Fever?
P: yes/No
D: Have you noticed any swellings in your neck or armpits?
P: No
D: Do you have any trouble swallowing?
P: No
D: Do you have any pain in your calves?
P: No
D: Have you noticed any change in your weight?
P: Yes (quantify)
D: Do you have any other complaints that you wish to report Mr….?
P: No Dr.
D: Do you have high BP?
P: No
D: Diabetes?
P: No
56
D: Thyroid related illness?
P: No
D: Are you on any medications?
P: No
D: What is your diet generally like?
P: Balanced Dr.
D: Do you smoke Mr….?
P: Yes doctor, I have been smoking for > 20 years
D: Could you tell me what you smoke in a day?
P: 1 pack of cigarettes/day
D: Do you consume alcohol?
P: Yes/No
P: No
D: Do you have any family history of medical problems?
P: No
D: F/H of cancers?
P: No
D: 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.
P: Yes/No (look for travel to TB endemic areas)
D: Okay 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.)
D: Mr…Do you have any idea what may be happening to you?

P: No doctor.
D: Mr…it looks like you have some serious condition. Do you want to know about it?
P: Yes doctor.
D: Based on the information what you told me it looks like you have cancer in your lungs or
lining of the lung. PAUSE
P: Oh… Really … I didn't expect doctor
(Patient may say, "My friend who was working with me had been diagnosed with
mesothelioma. Do I also have the same doctor".
D: I wish it was not true but unfortunately, you are right that it is possible that you too may
be having the same problem.
D: 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.
SHOW X-RAY TO THE PATIENT
57
D: Mr… I have your chest x-ray with me. Would you like to take a look at it?
P: Ok doctor.
D: 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 or cancer of the lining of your lung
(mesothelioma)
D: 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 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 Dr. Why did this happen to me?
D: 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?
D: Mr… the treatment depends upon the diagnosis. If it is cancer, then it will depend on 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.
D: Okay Mr… I will speak with my consultant and arrange for them right away. Do you have
any other concerns?
P: No doctor.
D: 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.
58
COUGH & SOB (PNEUMONIA)
You are F2 in A & E

Daniel aged, 72 presented with cough and shortness of breath.
He has been referred by his GP. Nurse colleague has seen the patient.
The vitals have been recorded in observation chart.
Chest X-Ray has been taken. You can find the NEWS chart and CXR inside of the cubicle.
Talk to the patient, take relevant history, assess the patient, and discuss about initial management
plan with the patient.

P: I have cough and shortness of breath from the last two weeks.
P: It got worse on its own.
P: No
P: Yes
D: Did the phlegm start with the cough?
P: Yes
D: Colour of phlegm?
P: It was clear
D: Any colour change in the phlegm?
P: No
D: What is the quantity of phlegm you get?
P: Spoonful
P: No.
D: Tell me about your shortness of breath?
P: It started with my cough and is getting worse.
D: Do you have any other problems?
P: Like what Dr.
D: Any chest pain?
P: Yes
D: Tell me more about your chest pain?
SOCRATES:
All over my chest.
Started with my cough.
59
It is always there.
Sharp pain.
Pain increases when I cough or take a deep breath.
Nothing reduces the pain.
Score - around 6.
P: No.
D: Do you have any fever/flu like symptoms?
P: Yes, I have flu like symptoms.
D: Did you do anything for your symptoms from the past 2 weeks?
P: I went to my GP and he told me I have got chest infection and gave me antibiotics.
D: Did you take them regularly?
P: Yes, I took for 5 days.
P: A week ago.
P: It is the same.
D: Do you feel sick? Vomiting?
P: No
D: Any excessive sweating? Night sweats?
P: No
P: No
D: Anyone in the family or friends told you that you are losing weight?
P: No
P: It is fine.
D: Do you have any dizziness or heart racing?
P: No
P: Yes/No
P: No
D: Any chest infection before?
P: No
P: Yes, High Blood Pressure and Diabetes.
D: When was your High BP and Diabetes diagnosed and how do you manage them?
P: Few years ago, and I am taking Amlodipine for High BP and metformin for diabetes.
D: Are they well controlled?
P: Yes
D: Do you check your BP and blood sugar regularly and visit your GP regularly?
P: Yes
D: Any diabetes symptoms like feeling thirsty or going to the loo more often?
P: No.
60
P: No.
D: Have you got any complications of High BP or Diabetes?
P: No.
D: Heart disease, COPD (smokers cough) asthma or TB?
P: No.
P: No.
D: Are you taking any other medication?
P: No.
D: Any long term steroids, antibiotics or chemo
P: No.
P: Yes, Metronidazole
D: Any hay fever or eczema in the past?
P: No.
P: No
P: No
P: No
D: Did you notice any similar symptoms in any of your family members?
P: No
D: Do you smoke?
P: Yes/No
P: Yes, occasionally
P: I eat everything
P: I try to walk but I get breathless.
P: Office job.
D: Have you been exposed to asbestos?
P: No
P: Yes/No
P: I live in a house with my wife.

I would like to send for some initial investigations including routine blood test, CXR.
Examiner:
61
NEWS CHART:
Temperature 38-39
Pulse Rate 110/min
02 Sat <91% or 90%
BP 110/80 mmHg
RR >25/min
Blood sugar 8
CXR:
Prominent hilar markings in central area. Round opacity in the right upper lobe.
P: What’s happening doctor?

From my assessment, you seem to have a chest infection.

We will do further blood tests to check if you have anaemia or any infection and to check your
blood gases.
We will do a chest X-ray (If chest X-ray is not done already) and check your lung function.
We need examine your phlegm. The sputum sample will then be sent to the lab for close
examination for any bugs using a dye. We may also grow some bugs if there
We need to examine your urine and check your urine output as well.
D: We will keep you in the hospital.

We will give you oxygen as your oxygen levels are low in your blood.
We will give you fluids through your blood vessel(vein) as a drip.
We will give you two antibiotics (dual antibiotic therapy) through your blood vessel(vein).
Co-Amoxiclav 1.2 g TDS IV and Clarithromycin 500 mg BD PO or IV for 5-10 days.
Please take plenty of rest and drink plenty of fluids.

If your symptoms get worse or if you develop any confusion or drowsiness, please come back to us.
We will arrange a follow up with your GP in 4-6 weeks.
CURB65 score is calculated by giving 1 point for each of the following prognostic features:
 confusion (abbreviated Mental Test score 8 or less, or new disorientation in person, place or
 raised blood urea nitrogen (over 7 mmol/litre)
 raised respiratory rate (30 breaths per minute or more)
 low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)
 Age 65 years or more
Patients are stratified for risk of death as follows:

• 0 or 1: low risk (less than 3% mortality risk)
• 2?intermediate risk (3 -15% mortality risk)
• 3 to 5: high risk (more than 15% mortality risk).
62
-Use clinical judgement in conjunction with the CURB65 score to guide the management of
community-acquired pneumonia, as follows:
• consider home-based care for patients with a CURB65 score of 0 or 1
• consider hospital-based care for patients with a CURB65 score of 2 or more
• consider intensive care assessment for patients with a CURB65 score of 3 or more.
63
COUGH & SOB (TB)
You are F2 in A&E

Thomas aged, 29, presented with cough and SOB.
Talk to the patient, take relevant history, assess the patient and outline the plan of management
with him.

P: I have cough from the last 2 months.
P: It got worse on its own.
P: No/ Yes (Colour? Quantity?)
P: No/ Yes (Colour? Quantity?)
D: Is there anything else that's bothering you?
P: I have shortness of breath.
D: Tell me more about it please?
P: It started 2 months ago and is getting worse.
P: Like what Dr.
D: Any chest pain?
P: Yes/No
P: No
D: Any wheeze?
P: No
D: Do you have any fever/flu like symptoms?
P: Yes/No
D: Any excessive sweating? Night sweats?
P: Yes
D: May I know since when do you have this?
P: Few weeks
P: Yes, 1 stone in the last few months.
P: I don't enjoy my food.
D: Do you have any dizziness or heart racing?
P: No
64
P: Yes, just by doing simple activities
P: No
D: Any chest infection before?
P: No
P: No
D: Diabetes, heart disease, asthma or TB?
P: No
P: No
D: Are you taking any long-term steroids, antibiotics or chemotherapy?
P: No
P: No
D: Any hay fever or eczema in the past?
P: No
P: No
P: No
P: No
D: Did you notice any similar symptoms in any of your family members?
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
D: Any recreational drugs?
P: No
P: I eat everything, its fine
P: Yes
D: When did you last have sexual activity?
P: Yesterday
D: Do you have any partner?
P: Yes, my wife
D: Have you had any other partners previously?
P: No
D: Do you and your partner use any contraception or protection against STIs?
65
P: Yes Dr. We use condom
D: How often do you use this protection?
P: Always
P: Office job
D: Have you ever been exposed to asbestos?
P: No
P: Yes, I went to South Africa 3 months ago.
D: How long did you stay there?
P: 2-3 weeks
D: Did you come in contact with anyone with cough there?
P: No

I would like to send for some initial investigations including routine blood test. CXR.
Examiner:
NEWS CHART:
Temperature 37.5 (38)
Pulse Rate 100
02 Sat 94-95
BP 110/80
RR >25/min
AVPU Alert
NEWS Score 5-6
X-Ray:
Increased Bronchoalveolar marking in hilar region in both the lungs predominantly on the right
side.
Tuberculosis (TB) is caused by atype of bacterium called Mycobacterium tuberculosis.

It's spread when a person with active TB disease in their lungs coughs or sneezes and someone else
inhales the expelled droplets, which contain TB bacteria.
PATIENT'S CONCERNS
P: What is bronchoscopy?
P: Is bronchoscopy painful?
P: How are you going to treat me?
66
 From my assessment, you seem to have Pulmonary' Tuberculosis in your lungs.
 We are going to run further tests to confirm the diagnosis.
 We will do further blood tests to check if you have anaemia or any infection and to check your
blood gases.
 We will do a chest X-ray(If chest X-ray is not done already) and check your lung function.
 If there is any fluid in the lining around your lungs, we will take sample by introducing a needle
and analyse it in the lab.
 We need to examine your phlegm with a special to look for TB bacteria {If patient said there is
no phlegm - as you told you don't have any phlegm/ sputum along with your cough we may
have to do a procedure to get some sputum/ phlegmfsaline nebulisation and chest
physiotherapy).
(BAL) to get a sample}.
 We will also grow TB bugs in the lab if there are any.
D: You'll be prescribed at least a six-month course of a combination of antibiotics if you're

diagnosed with active pulmonary TB, where your lungs are affected and you have symptoms.
The usual treatment is:
 two antibiotics (isoniazid and rifampicin) for six months
 two additional antibiotics (pyrazinamide and ethambutol) for the first two months of the six-
month treatment period
 It may be several weeks before you start to feel better. The exact length of time will depend on
your overall health and the severity of your TB.
 After taking antibiotics for two weeks, most people are no longer infectious and feel better.
They are able to join work after 2 weeks.
 However, it's important to continue taking your medicine exactly as prescribed and to complete
the whole course of antibiotics.
 Taking medication for six months is the best way to ensure the TB bacteria are killed.
 If you stop taking your antibiotics before you complete the course or you skip a dose, the TB
infection may become resistant to the antibiotics^
 This is potentially serious because it can be difficult to treat and will require a longer course of
treatment with different, and possibly more toxic, therapies.
 If you find it difficult to take your medication every day, your treatment team can work with
you to find a solution.
 D: If your symptoms get worse or if you develop persistent swollen glands, any abdominal pain
or pain and loss of movement in an affected bone or joint or confusion, any persistent headache
or fits (seizures) please come back to us.
Preventing the spread of infection

 If you're diagnosed with pulmonary TB. you'll be contagious up to about two to three weeks
into your course of treatment.
 You won't usually need to be isolated during this time, but it's important to take some basic
precautions to stop TB spreading to your family and friends.
67
 You should:
o stay away from work, school or college until your TB treatment team advises you it's safe
to return
o always cover your mouth - preferably with a disposable tissue - when coughing, sneezing
or laughing
o carefully dispose of any used tissues in a sealed plastic bag
o open windows when possible to ensure a good supply of fresh air in the areas where you
spend time
o not sleep in the same room as other people - you could cough or sneeze in your sleep
without realising it
68
ASTHMA WHEEZE (DIAGNOSIS)
You are F2 in GP.

Adam aged, 22 presented to the hospital with wheeze and chest tightness.
Take a focused history, assess the patient, discuss diagnosis and about management plan.

P: I have chest tightness
P: It started few months ago. I get it when I play football.
D: What about at other times?
P: I am fine
D: Is it the same since it started?
P: It is getting worse
D: Is there any thing that makes it worse or better?
P: Gets better when I rest
D: Do have any other problem?
P: I have wheeze
P: Few months
P: When I get chest tightness
P: 1 get short of breath also when I get these symptoms.
P: Few months
P: When I get chest tightness
It is getting worse.
P: No
D: Any cough?
P: No
D: Any fever / flu like symptoms?
P: No
D: Did you have any similar kind of symptoms before?
P: No
69
P: Yes, eczema
D: Any lung problem, asthma or TB?
P: No
P: No
P: No
P: Yes, my dad has asthma.
D: Do you smoke?
P: No/Yes
D: Tell me about diet?
P: I eat healthy food
D: Any change in your diet recently?
P: No
D: Are you physically active?
P: Yes
D: What do you do?
P: Student
P: No
P: I live in a house
D: Is your home carpeted?
P: No/Yes
D: Any pets at home?
P: No/Yes

I would like to send for some initial investigations including routine blood test, CXR.
D: Do you know about this device?

P: No
D: This is peak flow meter, it is used to take Peak flow reading
(Explain peak flow meter and how to get the readings).
We use this device to perform a test in which we can assess how well your lungs are functioning. By
doing this test we can measure how quickly you can blow air out of your lungs. If your airways are
tight and inflamed, you won't be able to blow out quickly.
D: Could you please do this peak flow for me? P: Sure (correct the patient if he does any mistake).
Patient’s score is XYZ.
D: Normal Peak flow readings depend on your gender, and height.

D: May I know your height?
P: xyz cms
70
D: Could you please confirm you age for me?
P: I am 22
We can find out your normal value on this chart (explain the chart and how to take the reading to
the patient).
Patient’s normal value is xyz.
Patient will have near normal PEFR.
 From our assessment, you seem to have a condition called asthma.

 Asthma is a lung condition that causes occasional breathing difficulties. It is a condition which
affects the smaller airways which carry air in and out of your lungs. That's why it causes
breathing difficulties and other symptoms.
 Asthma has many triggers. In your case exercise triggers it, we call it Exercise Induced Asthma.
 We are going to prescribe you a blue inhaler which is a reliever. This relaxes your airways very'
quickly to allow you to breathe easily.
 You should take 1-2 puffs whenever you have any' symptoms.
 We will review your condition and tell you how long you should take it for.
 Side effects of salbutamol:
o Headache - simple paracetamol
o Muscle cramps
o Heart racing
o Hand shaking
 These symptoms usually pass within a few minutes or for a few hours the most and are not
dangerous.
 If any of these become troublesome, please speak to your GP.
 You can also try' these practical tips:
 Warm up and warm down for 10-15 minutes before and after exercising.
 If you're exercising with someone else, make sure they know you have asthma, and that you
have a reliever inhaler with you.
 If you have symptoms when you exercise, stop, take your reliever inhaler and wait until you
feel better before starting again.
 In colder weather, symptoms are even more likely during exercise because when the air is
cold it can irritate the sensitive airways. One way to avoid this problem is to exercise indoors
during the winter months. Or consider doing less vigorous exercise - go for a power walk
instead of a run, for example.
 Dress appropriately. If it's cold, make sure your chest and throat are covered and keep a
scarf around your nose.
 If you regularly have asthma symptoms when you exercise, speak to your GP or asthma
nurse who can assess your treatment.
 I am going to talk about few important things today:
Your medication and Inhaler
Peak flow meter and reading
 Asthma diary
 Triggers
71
D: Have you got any idea about this device and how to use it?
P: No
D: This is an inhaler which we are going to prescribe you to take your medication. Let me explain
you how to use this one (explain inhaler technique).
D: This is an asthma diary which is used to observe the progression of your condition.
(Explain asthma diary).
You have to record your PEFR readings on this diary twice a day, morning and at night, for two
weeks. You need to take 3 readings every time you record your PEFR and plot the highest reading
you got here (show it on the diary). You need to do it in the same position every time you do it. For
example, if you are sitting upright u have to continue in the same way all the time. Same with if are
standing.
P: What should I record in the diary?

D:
(i) Your morning and evening PEFR readings
(ii) You need to tick this box (show it on the chart) if:
1. You use your reliever inhaler
2. You have any symptoms
3. You wake up at night with asthma symptoms
4. You feel that you can’t keep up with your normal day to day activities
(iii) Note down anything unusual or different that may be the reason for a lower than usual peak
flow score in a week here (show it on the chart).
Eg: You were stressed, you were doing exercise.
If we can identify our triggers and try to control them your asthma can be better controlled. As I
told you earlier exercise is a trigger for your asthma.
Usually, you breathe in through your nose, so the air is warmed and moistened. When you exercise,
you tend to breathe faster and in through your mouth, so the air you inhale is colder and drier. In
some people with asthma, the airways are sensitive to these changes in temperature and humidity
and they react by getting narrower.
The best way to avoid exercise triggering asthma symptoms is to manage your asthma well:
• Take your medication exactly as prescribed and discussed with your GP or asthma nurse.
• Check with your GP or asthma nurse that you're using your inhaler correctly.
• Use an up to date written asthma action plan and keep it where you can see it (on the fridge, for
example).
• Go for regular asthma reviews.
Technique for Peak Flow:

• Stand or sit upright (do it the same way all the time which ever is comfortable for you)
• Hold the device in horizontal position
• Put the pointer on the first line on the scale (usually 60)
• Take a deep breath
• Make a tight seal with your lips around the mouth piece
• Blow out as hard and as fast as you can into the meter
72
• Write down the number next to the pointer which is your score
• Do it 3 times in a row so you get 3 scores (record the highest of the 3 scores in your diary.
The common mistakes are:

 Not closing the lips around the mouth piece properly
 Not blowing out as hard as possible
 Not holding the device horizontally
 Bending forward
Technique for inhaler:

• Check the expiry date
• Remove the cap
• Shake the inhaler well
• Put the mouth piece in your mouth as you begin to breathe in which should be slow and deep,
press canister down and continue to inhale steadily and deeply.
Remove inhaler from your mouth and continue to hold your breath for 10 seconds or as long as it is
comfortable.
73
ASTHMA DISCHARGE
You are F2 in General Medicine.

Mr. Peter Lewis, aged 22, presented to the hospital due to severe asthmatic attack three days ago.
Patient was diagnosed with asthma four weeks ago and this is his first asthma attack. He has
recovered quickly and is stable now.
He is getting discharged today and was prescribed with three medications.
Salbutamol PRN, Beclomethasone 400 microgram BD, Prednisolone 30mg OD 3 days.
Please talk to the patient, assess his fitness for discharge, explain the medications and address his
concerns.
D: Hello Mr. XYZ, how are you doing today.

P: I am fine Dr. I am getting discharged today and I was told that someone is going to talk to me.
D: I am very glad to know that you got better and getting discharged. I am here to talk to you about
your health today.
D: I am going to Assess your fitness for discharge.
D: May I know what exactly happened for you to come to the hospital
P: I had an asthma attack. I had severe shortness of breath, wheeze and chest tightness I called an
ambulance and came here.
D: I am sorry. How are you feeling now?
P: I am fine now.
D: Do you have any symptoms now?
P: No
D: Any' shortness of breath or cough?
P: No
D: Any' chest tightness or wheeze?
P: No
D: Did anything like this happened before?
P: No
D: Did you have any fever/ flu like symptoms/sore throat or runny nose recently?
P: No
D: When was your asthma diagnosed?
P: 4 weeks ago.
D: How is it managed?
I was given a blue inhaler.
D: Did you use it till now?
Yes, 2-3 times per week
D: Did you see you GP after you were diagnosed?
P: No
D: Apart from your asthma have been diagnosed with any other medical condition?
P: No
D: Are you currently taking any other medications, over-the-counter drugs or supplements other
than the ones for your asthma?
P: No
74
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
D: Tell me about diet?
P: I eat healthy food.
D: Any change in your diet recently?
P: No
P: No
P: Office job
P: No
D: Is your home carpeted?
P: No
D: Any' pets at home?
P: No
I would like to check your vitals and examine your chest for any wheeze.
Examiner: Lung sounds normal, no wheeze.
D: This is a peak flow meter. Have you seen this before?

P: Yes
D: Do you know what is it used for?
P: Yes, to check the function of my lungs
(if not explain - We use this device to perform a test in which we can assess how well your lungs are
functioning. By doing this test we can measure how quickly you can blow air out of your lungs. If
your airways are tight and inflamed, you won't be able to blow out quickly).
D: Yes, you are right. Has anyone told you how to use it?
P: Yes
D: Could you do it for me and give me a reading?
P: Yes
Patients PEFR is near normal. Check the reading from the chart after asking patients height and age
(192 cms and 22 years old, the normal is around 620-640 for this patient.
Please explain how you get the normal values by explaining the chart.
D: Great, your peak flow reading is near normal. We are aiming to achieve 75% of the normal.
D: You don’t have any symptoms now, your chest examination is normal and also your peak flow
reading is around 90% of your predicted value. So you are fit to be discharged. I will do necessary
arrangements for your discharge. P: Thank you Dr.
D: But before you get discharged, I would like to talk to you about
75
• Talk about your medications and inhaler
• Peak flow meter and reading
• Asthma diary
• Triggers for asthma
D: If at any point you have any concern, please stop me
D: Has anyone told you about your medications?
P: No
D: No problem. I will explain it to you. You have been prescribed 3 medications:
• Blue inhaler (Salbutamol - 2 puffs when needed)
• Brown inhaler (Beclomethasone - 400ug - 4 puffs - BD)
• A steroid tablet (Prednisolone) (30mg - 6 x 5mg tabs - OD - 3 days)
D: Blue inhaler - This is called reliever inhaler. You need to take this whenever you experience
symptoms like shortness of breath, chest tightness, wheeze or cough.
You need to take 1-2 puffs whenever you have any symptoms.
We will review your condition and tell you how long you should take it for.
D: Side effects of salbutamol:
Headache - take simple paracetamol
Muscle cramps
Heart racing
Hand shaking
These symptoms usually pass within a few minutes or for a few hours the most and are not
dangerous.
If any of these become troublesome, please speak to your GP.
D: Brown inhaler - This is called preventer. This contains a low dose of steroid medication. This
medicine works over time to help prevent asthma symptoms by reducing sensitivity, swelling and
inflammation in your airways.
You need to take 4 puffs twice daily, morning and evening. We will review your condition and tell
you how long you should take it for.
D: Side effects of beclomethasone inhaler:

Common side effects are mouth infection called thrush, sore throat or hoarse voice.
You can avoid these side effects by making sure your medicine gets straight to your lungs and
doesn't stay in your mouth and throat. You can do this by using good inhaler technique. Rinsing
your mouth out and brushing your teeth after using your inhaler will be helpful. Try keeping your
preventer inhaler in the bathroom so you get into a routine of taking it before you brush your
teeth.
You should use your brown inhaler even if you're feeling well and aren't getting any symptoms
because it builds up your asthma protection over time. If you stop taking your preventer inhaler,
you’ll not get the full benefits and will be more likely to react to asthma triggers.
D: Have you got any idea about the inhaler and how to use it?
P: No
D: This is an inhaler which we are going to prescribe you to take your medication. Let me explain
you how to use this one (explain inhaler technique).
D: This is an asthma diary which is used to observe the progression of your condition.
(Explain asthma diary).
76
You have to record your PEFR readings on this diary twice a day, morning and at night, for two
weeks. You need to take 3 readings every time you record your PEFR and plot the highest reading
you got here (show it on the diary). You need to do it in the same position every time you do it. For
example if you are sitting upright you have to continue in the same way all the time. Same with if
are standing.
P: What should I record in the diary?

D:
(i) Your morning and evening PEFR readings.
(ii) You need to tick this box(show it on the chart) if:
1. You use your reliever inhaler
2. You have any symptoms
3. You wake up at night with asthma symptoms
4. You feel that you can’t keep up with your normal day to day activities
(iii) Note down anything unusual or different that may be the reason for a lower than usual peak
flow score in a week here (show it on the chart).
Eg: You were stressed while you were doing exercise.
D: If we can identify our triggers and try to control them your asthma can be better controlled. We
can work on this together for you to get most benefit.
Try to note anything unusual or abnormal that is causing your symptoms so that we can avoid
them.
There are many triggers like any infection, fever, dust, pollen, smoke, fumes, mould, food allergy,
exercise, some medication, stress, etc.
D: You need to see your GP or asthma nurse if:

 You use your blue inhaler three or more times per week.
 You have any symptoms such as shortness of breath, wheeze, cough or chest tightness three
times or more per week.
 You have to wake up in the middle of the night with asthma symptoms even if it happens once
per week.
D: You need to see your GP regularly. Your GP will assess your condition to see if you have any
symptoms and see how your condition is progressing. He will check if you experience any side
effects from your medication. He will also re-prescribe you medication.
D: We will arrange for an appointment for you to be seen and reviewed by the specialist after
about one month.
D: If you have wheeze, you need to use your blue inhaler.
You also need to record it in your diary.
If you experience wheeze three times or more in a week, you need to see your GP.
This means if you use your blue inhaler three times or more in a week you should see your GP.
If you wake up in the middle of the night due to wheeze, even if it happens once please go and see
your GP.
D: If you think you're having an asthma attack, you should:
77
1. Sit down and try to take slow, steady breaths. Try to remain calm, as panicking will make things
worse.
2. Take one puff of your reliever inhaler (usually blue) every 30-60 seconds, up to a maximum of 10
puffs. It's best to use your spacer if you have one.
3. Call 999 for an ambulance if you don't have your inhaler with you, you feel worse despite using
your inhaler, you don't feel better after taking 10 puffs, or you're worried at any point.
4. If the ambulance hasn't arrived within 15 minutes, repeat step 2.
Never be frightened of calling for help in an emergency.
D: You should come to the A&E if:
• The reliever inhaler is not controlling your symptoms
• You are too breathless to talk.
• Your lips turn into blue.
PATIENT'S CONCERNS
P: When should I see my GP
P: Will I have to come back here?
P: What should I do if I have wheeze?
P: When should I come to A&E?
P: What should I do if I have another attack?
Technique for Peak Flow:

• Stand or sit upright (do it the same way all the time whichever is comfortable for you)
• Hold the device in horizontal position
• Put the pointer on the first line on the scale (usually 60)
• Take a deep breath
• Make a tight seal with your lips around the mouth piece
• Blow out as hard and as fast as you can into the meter
• Write down the number next to the pointer which is your score
• Do it 3 times in a row so you get 3 scores (record the highest of the 3 scores in your diary)
The common mistakes are:

1. Not closing the lips around the mouth piece properly
2. Not blowing out as hard as possible
3. Not holding the device horizontally
78
SPACER
You are F2 in Paediatrics.

Rhodes aged, 4 has been admitted to the hospital with breathlessness. His mother Ann is worried
that her son feels well when in the hospital but deteriorates when at home. She wants to talk to
you about her son.

P: I brought my child to the hospital. I want to know why his condition gets worse when I take him
home. This is the sixth admission in the hospital in last few months.
D: I understand your concern. I am sorry that you are going through so much. Let me ask you a few
questions about his health.
Could you please tell me why you brought your child to the hospital?
P: He has asthma and he is taking medications for it. But. he developed breathlessness at home last
night and I brought him here.
D: How is he now?
P: He is fine.
P: No
D: Any cough?
P: No
D: Tell me more about his asthma.
P: What you want to know.
P: He is taking inhaler for that.
D: Could you please tell me which inhaler?
P: I am giving him preventer and reliever.
D: Are you giving these inhalers regularly as prescribed?
P: Yes. but sometimes he doesn’t take it.
D: Could you please show me how are you giving these inhalers to your child?
P: Ok doctor, she may make some mistakes so after that explain her how to use the inhaler.
Explain the Spacer Device:

This is an aero chamber device. It consists of a plastic tube with a mask. At one end is a mask and at
the other end is a hole for inserting the inhaler. The chamber helps delivery of medicine into the
lungs. This increases medicines effectiveness.
Advice to mother about how to use the device:

1. Give treatments when your child is happy and not crying. You may reassure your baby by
cuddling hint in your arms. Please try to talk to your baby and smile.
2. Carefully examine the spacer, missing parts or foreign objects. You can give it a little shake to
make sure there is nothing in there. Remove any foreign objects prior to use.
3. Remove the cap from the mouthpiece on the inhaler.
79
4. Pick up the inhaler and check the expiry date. If the inhaler has not been used for a week or
more, or it is the first time your child is using the inhaler, spray it into the air before it is used to
check that it is working.
5. Shake the inhaler vigorously to mix the medication properly.
6. Insert the inhaler mouthpiece into the hole in the end of the aero chamber. The inhaler should
fit without difficulty.
7. Place the mask over your child ’ s nose and mouth. Ensure an effective seal around lips so that
both the nose and mouth are covered. It is important to create a good seal between the face
and mask so that all medication will be delivered to the airways.
8. Let your child resume normal breathing few times. The valve (inspiratory flow indicator) only
moves if a good seal is created.
9. Press down on the inhaler canister once, to spray one puff of medicine into the aero chamber.
The medication will be delivered into the aero chamber.
10. Hold the mask in place and allow your child to breathe in and out slowly for 6 breaths. The valve
should move with each breath.
11. Use the valve to count breaths. You may count loudly while your child in breathing through the
mask.
12. Don’t spray more than one puff at a time into the aero chamber. This makes the droplets of the
medication to stick together and to the sides of the spacer, so the child actually breathes in a
smaller dose.
13. Remove the mask from your child’s face.
14. If your child requires more than one puff of medication, remove the aero chamber from your
child's mouth, allow him/her to breathe normally for 30 seconds, then repeat the steps again.
Remember to shake the canister well before giving another puff.
P: It gets dirty when I give him the medication, so I scrub it properly and wipe it clean.
D: I understand, let me explain you how you can clean it.
Cleaning and care for the Aerochamber:

1. Make sure you clean the Aerochamber before the first use. Medication collects in the
Aerochamber after repeated use. Therefore, try to clean his Aerochamber once a week or
sooner if needed. Regular cleaning will prevent build-up of medicine residue inside the
Aerochamber.
2. Remove the inhaler port from the Aerochamber.
3. Soak the parts for 15 minutes in luke warm water with liquid detergent/ warm soapy water.
4. Move gently in the water to loosen medication residue.
5. Rinse in clean water. Shake off excess water.
6. Do not mb dry. It should be left to drip dry (air dry in vertical position) rather than dried with a
cloth. Drying with a cloth, or cleaning the Aerochamber more frequently than that, can cause
static to build-up on the inside of the chamber, which can impair its performance.
7. Replace the inhaler port when the unit is completely dry and ready for use.
Cautions:
1. Administer one puff at a time. Do not spray more than one puff at a time into the chamber as it
may exceed the recommend dose.
80
2. If your child is using inhaled steroids, have your child rinse his/her mouth with water after each
use. This will reduce the risk of developing a yeast infection in the mouth or throat.
3. Product may be permanently damaged if boiled, sterilized or cleaned in a dishwasher at high
temperatures.
4. The Aerochamber should be replaced when damaged, if the small inspiratory valve is cracked,
hard or gets permanently curled, or if the rubber opening of the Aerochamber becomes cracked
or torn or if there is any staining inside.
5. Do not leave the chamber unattended with children.
6. Aerochamber device should be replaced every 6 to 12 months.
7. Inform the school nurse about your child s condition. Make sure you give one Aerochamber
device to the school nurse.
81
OBSTRUCTIVE SLEEP APNOEA
You are an FY2 in GP clinic.

Mr. Sloan aged 46 has come with complain of tiredness.
Talk to him, take history & discuss the management plan with the patient.
D: Hello! What brings you to the hospital today?

P: Doctor I feel tired & sleepy all the time
D: Can you please tell me more about it
P: Around 2 months ago.
P: No
D: Is there any specific time of day you feel more tired?
P: No
D: Has it changed?
P: No
D: Anything makes it better or worse?
P: No
D: Anything else with tiredness?
P: I feel sleepy too
D: How has your health been recently?
P: Fine
D: Do you have any lump and bumps anywhere in your body?
P: No (Cancer)
D: Do you have any Loss of Appetite?
P: No.
D: Do you have Shortness of Breath or heart racing?
P: No.
D: By any chance any change in your weight? (Thyroid)
P: No.
D: Do you feel cold when others feel normal?
P: No.
D: Any constipation, diarrhea? (Thyroid. IBD)
P: No.
D: Nausea, vomiting, swelling in legs? (CKD)
P: No.
D: Any headache, muscle cramp and weakness?
P: No.
D: How is your sleep these days?
P: I’m sleeping alright but I feel tired when I wake up.
D: How long do you sleep for?
P: I sleep at 11 pm and wake up at 7 am.
D: How is your sleeping environment? Is your bed comfortable?
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P: Yes, very comfortable.
D: Do you have any trouble sleeping?
P: No
D: Do you wake up during the night?
P: Rarely
D: Do you sleep during the day?
P: I don’t intend to but sometimes I doze off
D: Do you have any trouble concentrating during the day?
P: Yes, I feel groggy all the time
D: Do you take any tea/coffee before bedtime?
P: No
D: Do you smoke or take alcohol before bedtime?
P: No
D: Do you use any sleeping pills?
P: No
D: Do you have any breathing difficulty during sleep?
P: No, but my wife just keeps complaining that I snore a lot at night & breathe noisily
D: Do you not remember that you snore?
P: No
D: How has been your mood recently?
P: Fine
D: Can you score it on the scale of 1 to 10. 1 being the lowest mood & 10 being happiest.
P: 4/6
D: Have you been diagnosed with any medical condition?
P: No
P: No
D: Do you smoke?
P: Yes/No
D: What about your diet?
P: Good/Bad
D: Do you do any physical exercise?
P: No, I don’t get much time.
P: I am a taxi driver
D: Does your problem affect your work
P: Yes it affects it a lot
D: Is there anything else?
P: No
D: I would like to check your vitals, GPE, BMI, Neck, Chest, tummy and heart.
We will do some initial blood investigation including FBC.
D: From our discussion, it seems that you are feeling tired all the time because of a condition we
call as Obstructive sleep apnea. OSA is a clinical condition in which there is intermittent and
83
repeated upper airway collapse during sleep. This results in irregular breathing at night and
excessive sleepiness during the day. You feel so tired during the day because of these repeated
interruptions.
P: But doctor I don’t remember any interruptions.
D: Yes Mr. Smith, people with this condition usually have no memory of their interrupted breathing
and they are unaware of having a problem. Do you understand?
P: Yes. So what will you do now?
D: We would refer you to a specialist sleep clinic to confirm it. 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.
MANAGEMENT:
Oximetry:
This measures the oxygen level in your blood. It’s often the first test for OSA, and is usually done in
your home. You wear an instrument with a sensor called a pulse oximeter. This measures your
blood oxygen level and your pulse. You’ll have a clip on your finger or earlobe and a device on your
wrist.
Limited sleep study:
This overnight test can be done in hospital or at home. It measures your air flow, how your chest
moves as you breathe, your heart rate and the oxygen level in your blood. Some devices register
snoring sounds, body position and leg movements. Equipment will be attached to you with tape,
wires and straps as you sleep.
Polysomnography or PSG:
Gold Standard study. This is an overnight study, done in a quiet hospital room. It assesses sleep and
wakefulness by measuring your brain waves, eye movements and muscle movements. It films you
while you sleep. At the end of the investigation, the number of apnoea/hypopnoea episodes whilst
asleep is quoted as the Apnoea/Hypopnoea Index (AHI). The AHI is used to measure the severity of
OSAS and is calculated by the sum of apnoeas and hypopnoeas divided by the number of hours of
sleep.
Mild: AHI = 5-14 per hour.
Moderate: AHI = 15-30 per hour.
Severe: AHI >30 per hour.
Treatment:
-Lifestyle changes for OSA:
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.
-Mandibular repositioning devices (MRDs)
-Continuous positive airway pressure (CPAP) machines (Gold Standard)
-Surgery for OSA
Informing the DVLA:
84
 You must stop driving and tell the Driver and Vehicle Licensing Agency (DVLA) if you're
diagnosed with OSA and feel sleepy during the day.
 If your job means you have to drive, you might be able to get assessed and treated more
quickly.
Many sleep clinics provide a fast-track service for people who drive for a living so their work is
disrupted as little as possible.
85
HAEMOPTYSIS
You are F2 in in respiratory department.

Jacob aged, 55 has come to the clinic because of cough and hemoptysis.
Please talk to the patient, take relevant history, assess the patient, discuss about initial
management plan with patient and address his concern.
X-ray has been done and you can find it in the cubical.

P: Dr. I am coughing blood again.
D: Could you tell me more about it?
D: When did you notice blood this time?
P:
D: When did you notice it first time?
3 weeks ago.
D: How many times did you notice?
P: 2-3
D: Tell me how much was the quantity of blood?
P: I can see more blood now but when it started it was like a streak of blood with the phlegm
D: Can you tell me more about your phlegm?
P: Clear, but becomes yellow when I get infection. My GP gave me antibiotics and it became clear.
D: Tell me about the cough?
P: It started around 3-4 months ago.
D: Is it the same or getting worse?
P: It was on and off at the beginning but it is worse now, I cough all the time.
D: Any other problem?
P: Like what?
P: Yes
D: Since when?
P: 3-4 months
D: Is there anything makes it worse?
P: When I go for a walk/climbing stairs.
D: Any chest pain?
P: No
D: Any calf pain?
P: No
D: Did you notice any swelling in your neck or armpits?
P: No
D: Do you have any difficulty in swallowing?
P: No
D: Did you notice any weight loss?
P: Yes 1 stone in last few weeks/ No (if no ask close question).
86
P: Good/I don't enjoy my food
D: Any dizziness or heart racing?
P: No
D: Do you feel tired these days?
P: Yes, just by doing simple activities.
D: Any fever /flu like symptoms? (Pneumonia)
P: No.
P: No.
D: Any lung problem?
P: No.
D: Any smoker’s cough?
P: No.
D: Any blood disorder?
P: No.
P: No.
D: Any blood thinner?
P: No.
D: Do you have any allergy?
P: No.
D: Any procedure or instrumentation through your gullet?
P: No.
D: Any previous hospital stays?
P: No.
D: Has any member of your family ever been diagnosed with any medical condition?
P: No.
D: Any lung problem in the family?
P: No
D: Do you smoke?
P: Yes, 20-40 cigarettes per day/No
D: Have you ever smoked?
P: I smoked 20-40 cigarettes per day for the last 30 years. I stopped 3 months ago when 1 started
coughing blood.
P: No/social drinker/weekends
P: I try to have a good diet.
D: Did you travel overseas recently?
P: No
P: I am a plumber.
D: Have you ever exposed to asbestos?
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I would like to send for some initial investigations including routine blood test, Sputum and CXR.
Examiner:
On Inspection of Hand-: clubbing and nicotine stains
On Palpation: Fullness in supra-clavicular area.
On Auscultation: Decreased breath sounds on the right side
CXR finding:
Pleural effusion in the right lung (mesothelioma). Round
lung, about 5cm diameter (lung cancer).
Explain the CXR to the patient:
D: Have you got any idea about what’s going on?

D: Are you concerned about anything?
D: May I know, what made you think of cancer?
PATIENT’S CONCERNS
P: Is it a serious condition
P: Can it be cancer?
P: What is bronchoscopy?
P: Is bronchoscopy painful?
 From our assessment, you seem to have a condition in your lungs.

 We have examined you. did blood tests and chest X-ray and from that, we suspect your
condition could be a serious one. PAUSE
 As you can see the chest X-ray, these are your lungs and heart. Your normal lungs appear black
because of the air in them.
o But can you see the round opacity here, this could be because of many causes like TB,
infections or lung cancer.
o But can you see the white shade in this part of your lungs, this is called Pleural Effusion. This
could be because of many causes like pneumonia, heart, liver and kidney problems or cancer
(lung and mesothelioma - cancer of lining of lungs).
 From the history, you have given us and from the chest X-ray, it looks like cancer but it is very
difficult for us to confirm this at this stage before doing all the tests.
 We need to do further investigations to make sure what exactly is going on. We need to do
further blood tests, check your lung function(spirometry), CT scan of your chest and we may
have to take a sample from your lung if needed.
 If we find any abnormality in the center of your chest then we may have to do a bronchoscopy.
We will be able to take some samples during the procedure if needed.
 We will refer you to a specialist (pulmonologist) and team of doctors (multi-disciplinary team)
who will do the necessary tests and confirm the diagnosis and start treatment depending upon
the condition. We will refer you to the specialist in 2weeks time.
88
 If it is cancer then the treatment depends upon the type, size, position and stage of cancer and
also your overall health. We have surgical options for resection of some tumors (lung cancer).
But in some cases (mesothelioma) we have to give chemotherapy and radiotherapy to extend
the quality and quantity of life.
 Advice for smoking cessation.
 Advice for changing the occupation industrial benefits (if exposed to Asbesto
 In the meantime, if you any concerns before meeting the specialist, please come back to us at
any time.
 Please come back to us if your symptoms worsen or if you have severe breathlessness, coughing
up large amounts of blood, any swelling in the face, any weakness of arms or if you are unable
to swallow food.
DD:
Pulmonary embolism
Pneumonia
Tuberculosis
Bronchiectasis
Bronchogenic carcinoma
Mesothelioma
Bleeding disorders
Blood thinners
Instrumentation
89
CNS-RELATED
SUBARACHNOID HAEMORRHAGE
You are FY2 in A&E.

Michelle aged, 45 presented to the hospital with headache.
Talk to the patient; take history, do relevant examination and plan of management with the
patient.
After 6 minutes give your management plan to the examiner.

P: I have headache.
NOTE: Sometimes in this station patient will show photophobia so we need to address that. Ask the
patient if light is bothering him and ask the examiner for dimming the light.
P: what you want to know.
P: He shows occipital area (Sometimes all over the head)
When did it start?
P: 2 hours ago
What were you doing when you had this pain?
P: I was watching TV and suddenly it started.
P: It was sudden.
P: It is dull pain.
P: No (Sometimes
P: I took PCM, didn’t work"
D: How much did you take?
P: I took 2 tablets didn’t help.
P: I don’t know dr.
P: 9 or 10.
D: Anything else?
P: I feel sick Dr.
D: Since when?
P: Since this pain started.
D: Did you vomit?
90
P: Yes, once
D: Anything else?
P: Like what Dr.?
D: Any problem with the light?
P: Yes (Ask the examiner for dimming the light)
D: Any problem with your vision or blurry vision?
P: No
D: Any speech problems or slurred speech?
P: No
D: Any facial weakness?
P: No
D: Any neck stiffness?
P: No / Yes
D: Any loss of consciousness?
P: No
P: No (Meningitis)
D: Any red eye or watery eye?
P: No (Cluster headache)
D: Any band like headache?
P: No (Tension headache)
P: No
P: Yes, I have migraine from last 5 years but this is different Dr.
D: Are you taking any medications for that?
P: Yes, 1 am taking that ends with trip.
D: Any other medical conditions like HTN. Polycystic kidney disease SLE?
P: No
D: Are you taking any other medications including OTC or supplements?
P: No
P: No
P: No
P: No
Personal history:
D: Do you smoke?
P: Yes 2 packets a day since I was a teenager.
P: Occasionally with my friends.
P: It is fine.
91
P: I don’t get time
P: No
P: No
D: I would like to check your vitals and examine your nervous system. I will do some special
examination to check neck stiffness, kerning sign or brudzinski sign (Meningitis)
EX: T- 37C. PR- 80-90, BP- 150/90, RR- 12-20, o2 sat- 96, BM- 5.2. Alert.
D: I would like to send for some initial investigations including routine blood test and ECG.
 From our assessment, we are suspecting you have a condition called subarachnoid
haemorrhage. It is uncommon type of stroke caused by bleeding on the surface of the brain.
 We will do a CT scan to confirm the diagnosis.
 If CT scan comes negative that we will do a lumber puncture.
 After confirming the diagnosis, we will shift you to a specialist neuroscience unit (In severe
cases we will shift the pt. In ICU)
 We will do further test like CT angiography and MRI scan by using a special kind of dye.
 The blood supply to the brain may get reduced which can lead to disruption in normal brain
function, we will give you a medication called Nimodipine to reduce the chances of brain
damage.
 We will give you pain killer to relieve your pain.
 We will give you some anti sickness medications.
 We will give you some medications to prevent the complications like fits.
 We may give you fluids.
Surgery and procedures

If scans show that the subarachnoid haemorrhage was caused by a brain aneurysm then we have to
do a procedure to repair the affected blood vessel and prevent the aneurysm from bleeding again.
This can be carried out using two main techniques.
1. Neurosurgical clipping
 Neurosurgical clipping is carried out under general anaesthetic, meaning you'll be asleep
throughout the operation.
 A cut is made in your scalp or sometimes just above your eyebrow and a small flap of bone is
removed so the surgeon can access your brain. This type of operation is known as a
craniotomy.
 When the aneurysm is located, the neurosurgeon (an expert in surgery of the brain and
nervous system) will seal it shut using a tiny metal clip that stays permanently clamped on
the aneurysm.
 After the bone flap has been replaced, the scalp is stitched together.
 Over time, the blood vessel lining will heal along where the clip is placed, permanently
sealing the aneurysm and preventing it growing or rupturing again.
2. Endovascular coiling
92
 Endovascular coiling is also usually carried out using general anaesthetic. The procedure
involves inserting a thin tube called a catheter into an artery' in your leg or groin.
 The tube is guided through the network of blood vessels into your head and into the
aneurysm.
 Tiny platinum coils are then passed through the tube and into the aneurysm. Once the
aneurysm is full of coils, blood can't enter it.
 This means the aneurysm is sealed off from the main artery, preventing it growing or
rupturing again.
Brain aneurysm:
An aneurysm is a bulge in a blood vessel caused by a weakness in the blood vessel wall, usually
where it branches.
1. Dr what is going on with me?
2. What is SAH?
3 What are you going to do for me?
DD:
Meningitis
Sub arachnoid haemorrhage
Giant cell arteritis
Space occupying lesion
Migraine
Cluster headache
Tension headache
Trauma
93
HEADACHE, GCA
You are F2 in general medicine.

Maria aged, 55 came to the hospital with headache.
Take a focus history, assess the patient, do examination and discuss further management with the
patient.

P: I have got headache
P: Like what?
P: She points towards left temporal area
P: 10 days ago
D: How did the pain start?
P:
P:
P: Continuous
P:
P:
P:
D: Is there anything that makes the pain better or worse?
P: Pain increases on combing my hair
D: Could you please score the pain on a scale of 1 to 10, where 1 being no most severe pain you
have ever experienced?
P: It was 5.
D: What about now?
P: Now it is 7.
D: Anything else?
P: I have pain on the left side of my jaw while I am talking or chewing something, (claudication pain)
D: Anything else?
P: No
D: Any visual problems?
P: No
D: Any blurry vision?
P: No
D: Any weight loss?
P: No
D: Any decreased appetite?
94
P: No
D: Are you feeling tired these days?
P: No
P: No
D: Do you have any neck- stiffness? (Meningitis)
P: No
D: Do you have Rash?
P: No
D: Do you have worst ever headache in your back of your head? (SAH)
P: No
D: Do you have early morning headache? (SOL)
P: No
D: Do you have projectile vomiting? (SOL)
P: No
D: Do you have any numbness in your arm or leg? (SOL)
P: No
D: Do you have eye pain or red/watery eye? (Glaucoma, cluster headache)
P: No
D: Do you see any line around the light? (Glaucoma)
P: No
P: No
D: Have you ever been diagnosed with any medical condition in the past?
P: No
D: Any heart disease? Any autoimmune disease like Polymyalgia Rheumatica?
P: No
P: No
P: No
P: No
D: Has anyone in the family been diagnosed with any medical condition? P: No
P: No
D: Do you smoke?
P: Yes, 10 cigarettes per day since I was teenager.
P: Yes, occasional on weekends
P: Good
P: Yes
P: No
95
P: No
D: I would like to check your vitals and examine your nervous system
D: I would like to send for some initial investigations including routine blood test.
 D: From our assessment, we are suspecting you have a condition called Giant Cell Arteritis
(GCA).
 This is an autoimmune condition in which medium and large blood vessels mainly in head and
neck area become inflamed. It is sometimes called temporal arteritis as it mainly affects vessels
around the temples.
 We will do some blood investigations to check the inflammation in your body (ESR. CRP).
 We will do further test to take some sample from your artery to check for damage and
inflammation of the lining of the vessels (Temporal biopsy).
 We will give you pain killer for your pain.
 We will start you with high dose steroid (Prednisolone) tablets and gradually we will reduce in
every 2 to 4 weeks depending on your response to the treatment to a maintenance dose.
 You may need to take it for up to 2 years, but some patients may have to take it for life long.
 We will give you aspirin (blood thinners) to prevent the complications like heart disease and
stroke.
 We will also give you PPI (Omeprazole) to protect your stomach from ulcers as steroid and
aspirin increase the chances of ulcers.
 We may also give you some medications to suppress your immune system like methotrexate.
 We will give you a blue steroid card as you are taking steroids for more than 3 weeks. It is very
important to carry that with you at all times, as it will explain that you taking steroids regularly
and your dose shouldn't be stopped suddenly.
 We will follow you up regularly to check your response to the treatment and also if you develop
any side effects.
 If you develop any vision problems or sudden loss of vision or any chest pain or any weakness in
your body or slurred speech, please come back to us immediately.
Side effects of steroids:

High blood pressure
High blood sugar
Thinning of bones (Osteoporosis)
Mood changes
Weight gain
Indigestion and Heart Bum
You have to maintain a healthy life sty le like good diet including calcium rich foods and physical
activity, and also smoking cessation and drinking alcohol in moderation (advice life style
accordingly). You can take some supplements for calcium and minerals.
We will follow you up regularly to check your weight, height, blood sugar, blood pressure and bone
density . We may prescribe you some medication if needed.
96
Side effects of methotrexate:
Nausea, Vomiting
Diarrhoea
Skin rashes
Whenever you are telling about any side effects of any medications to the patient, make sure you
give the treatment as 'well at the same time.
PATIENT’S CONCERNS:
1. Dr what is going on with me?
2. What is GCA?
3. Why do I have this condition?
4. What are you going to do for me?
5. What are the side effects of steroids?
DD:
Meningitis
Giant cell arteritis.
Acute angle close glaucoma
Migraine
Cluster headache
Tension headache
97
TENSION HEADACHE
You are FY2 in GP.

Michelle aged, 45 presented with headache.
Talk to the patient; take history, assess her and discuss the plan of management with the patient.
D: what brought you to the hospital?

P: I have headache.
P: He shows Forehead (Sometimes all over the head, band like)
P: I have it for last 2 months.
P: I was not doing anything. Usually I have this headache after I came back from my work.
D: Was it continuous or comes and goes? P
P: It is continuous during the evening.
D: What type of pain is it? P
P: It is just pain
D: Does the pain go anywhere? P
P: No
D: Is there anything that makes the pain better? P
P: After taking a glass of wine, I am fine.
D: Is there anything that makes the pain worse? P: I don’t know dr.
P: I don't know Dr.
D: Could you please score the pain on a scale of 1 to 10. where 1 being no pain and 10 being the
P: 5
D: Anything else?
P: Like what dr.
P: No (Meningitis, SAH)
P: No (SOL)
D: Any speech problems or shirred speech?
P: No
P: No
P: No/Yes
P: No
P: No
98
D: Any history of any trauma to your head?
P: No
P: No. (Meningitis)
D: Do you see color halos around the light?
P: No (Glaucoma)
P: No
P: No
D: Any other medical conditions like HTN. migraine and kidney disease?
P: No
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes
P: Yes, I told you I am drinking wine after my work
P: It is fine.
P: I don't get time
P: I got promoted in my job and it is becoming very hectic Dr.
P: No
D: I would like to check your vitals, GPE and examine your nervous system.
From our assessment, we are suspecting you have a condition called tension headache.
Tension headaches are called episodic tension headaches if they occur on less than half of the days
in a month. They are called chronic tension headaches if they occur more than half of the time. It
may feel like a constant ache that affects both sides of the head. You may also feel the neck
muscles tighten and a feeling of pressure behind the eyes.
There are certain triggers for tension-type headaches like Stress and anxiety, dehydration, missing
meal, bright sunlight, noise, lack of physical exercise.
99
Treatment:
1. Relaxation techniques can often help with stress-related headaches like yoga, massage, exercise,
applying a cool flannel to your forehead or a warm flannel to the back of your neck, drinking
enough water, less caffeine intake.
2. Taking painkillers over a long period (usually 10 days or more) may lead to medication-overuse
headaches developing. Painkillers such as paracetamol or ibuprofen can be used to help relieve
pain. However, Medication shouldn't be taken for more than a few days at a time.
D: From our assessment, it doesn't seems to be serious condition. In CT scan, we have to use the
radiations which can produce a lot of harmful effects. So it is not advised to go for scans without
any warning symptoms.
Prevention:
1. Keep a diary to try to identify triggering.
2. Alter your diet or lifestyle.
3. Regular exercise and relaxation
4. Maintaining good posture
5. Sessions of acupuncture over a period may be beneficial
Pt. Concern
1. Dr. what is going on with me?
2. What is tension headache?
3.. What are you going to do for me?
4.1 want to have a scan for my head.
DD:
Tension headache
Meningitis
Giant cell arteritis
Migraine
Cluster headache
Trauma
100
HANGOVER HEADACHE
You are FY2 in University Clinic.

Mr. Jack Daniel aged 22 presented with headache.
Talk to the patient, take history, assess her and discuss the plan of management with the patient.

P: I have a headache.
P: I had couple of pints of beer and whisky shots last night and when I woke up this morning I had this
headache.
D: By any chance did you have a fall?
P: No
P: All over my head.
D: Was it continuous or comes and goes? P
D: What type of pain is it? P
P: It is dull pain
D: Does the pain go anywhere? P
P: No
D: Is there anything that makes the pain better? P
P: No.
P: No.
D: Could you please score the pain on a scale of 1 to 10. where 1 being no pain and 10 being the
P: 6
D: Anything else?
P: I feel sick.
D: Since when?
P: Since this pain started.
D: Did you vomit?
P: No
D: Anything else?
P: Like what?
P: No (Meningitis, SAH)
P: No (SOL)
D: Any speech problems or shirred speech?
P: No
P: No
101
P: No
P: No
P: No. (Meningitis)
P: No
P: No
D: Any other medical conditions like HTN. migraine and kidney disease?
P: No
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
P: Yes
P: It is fine.
P: I don't get time
P: No.
P: No
D: I would like to check your vitals, GPE and examine your nervous system.
From our assessment, I am suspecting you have a condition called hangover headache. It usually
occurs when you drink more than your body can handle. To reduce the headache, you will need to
rehydrate your body. You can replace lost fluids by drinking bland liquids that are gentle on your
digestive system, such as water and soda water.
The best time to rehydrate is before going to sleep after a drinking session. Painkillers can help
with headaches and muscle cramps. Sugary foods may help you feel less trembly. In some cases, an
antacid may be needed to settle your stomach first. Bouillon soup (a thin, vegetable-based broth) is
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a good source of vitamins and minerals, which can top-up depleted resources. It’s also easy for a
fragile stomach to digest.
Things to avoid
To avoid a hangover
 Do not drink more than you know your body can cope with. If you’re not sure how much that is,
be careful.
 Do not drink on an empty stomach. Before you start drinking, have a meal that includes
carbohydrates (such as pasta or rice) or fats. The food will help to slow down your body’s
absorption of alcohol.
 Do not drink dark coloured drinks if you’ve found you are sensitive to them. They contain
natural chemicals called congeners which irritate blood vessels and tissue in the brain and can
make a hangover worse.
 Drink water or non-fizzy soft drinks in between each alcoholic drink. Fizzy drinks speed up the
absorption of alcohol into your body.
 Drink a pint or so of water before you go to sleep. Keep a glass of water by your bed to sip if
you wake up during the night.
If you experience any weakness, fever or slurred speech, then please come back to us.
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TRANSIENT ISCHAEMIC ATTACK
You are F2 in A&E

Mrs. Olivia Jones aged, 64 has been brought to the hospital by her husband due to weakness on one
side of body, slurred speech, dropping of the angle of her mouth and difficulty in swallowing.
Patient symptoms improved after 2 hours. Patient is completely fine now.
Patient cannot remember what happen 2 hours ago. BP was measured and recorded as 150/100.
General and neurological examination has been done and there is no finding.
Routine blood test has been done and result is awaited
Please talk to her husband, take history and discuss about your further management with him.
Consent has been taken from wife to talk to the husband.
D: Hello Mr. Jones I am here to talk to you about your wife's condition.
But before that could you please go through what exactly happened?
P: We were just sitting and watching TV. and all of a sudden, she couldn't talk to me properly. I
noticed she had some slurred speech. Her mouth dropped on right side and she couldn’t move her
right arm. I got scared and called the ambulance.
D: You did the right thing, it is very good that you called an ambulance and brought her here.
D: Could you please tell me when did this happen?
P: 2 hours ago
D: For how long the symptoms lasted?
P: 15 min/2 hours
D: How was she after that?
P: She is absolutely fine.
D: Did she complain of headache?
P: No
D: Did she get confused?
P: Yes/No
D: Did she lose consciousness?
P: No
D: Did she have any problem with her vision like blurriness of vision?
P: I don’t think so
D: Did she have any problem with the balance and coordination?
P: No/1 don't think so as we were sitting.
D: Did she understand what you were saying to her?
P: Not properly Dr.
D: Has she had similar kind of problem in the past?
P: No
D: Has she been diagnosed with any medical condition in the past?
P: Yes, she has diabetes
D: How long she has this problem?
P: More than 10 years now.
D: How it is managed?
P: It is controlled on diet.
D: Is she taking any medications for that?
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P: No
P: She is seeing her GP regularly
D: Does she have any diabetes complication such as foot problem or eyes problem?
P: No
D: Has she been diagnosed with any other medical condition?
P: No
D: Any high blood pressure or high cholesterol?
P: No
D: Did she has any abnormal heart beats?
P: No
D: Does she take any medications including OTC or supplements?
P: No
P: No
P: No
P: No
D: Any history of heart disease or stroke in the family?
P: No
D: Does she smoke?
P: No
D: Does she drink alcohol?
P: Yes/no
D: Tell me about her diet?
P: good diet includes fruits and vegetables.
D: Does she do physical exercise?
P: Yes, we move around in our house.
D: Does she have any kind of stress?
P: No
 From our assessment, we found all the general physical examination and neurological
examinations are normal, only her blood pressure was on higher side.
 We are suspecting a condition called TIA (Transient Ischemic Attack). Transient Ischaemic
attacks occurs when there is a temporary disruption in the blood supply to the part of brain due
to narrowing of the blood vessels.
 The disruption in blood supply results in a lack of oxygen to the brain. This can cause sudden
symptoms similar to a stroke, such as speech and visual disturbance, and numbness or
weakness in ointment for the face, arms and legs.
 However, a TIA doesn't last as long as a stroke. The effects often only last for a few minutes or
hours and fully resolve within 24 hours.
105
 We will keep her in the observation unit and we are going to arrange an urgent appointment for
your wife to be seen by a specialist within 24 hours. We will give your wife aspirin.
 We will check her blood pressure, diabetes and cholesterol and will see if we need to give any
treatment for that.
 We will do an ECG.
 We will do some special USG scan (Carotid Doppler) to check if there is any narrowing or
blockage in arteries in the neck leading to her brain. If we found significant narrowing then we
may have to do surgery (Carotid endarterectomy).
 We may consider CT scan or MRI scan of her head (only done if not clear which part of the brain
was affected).
 Give general advice about life style accordingly.
 If your wife have any facial problem, arm weakness, slurred speech please dial 999and ask for
the ambulance immediately (FAST).
If patient asks:
The blockage in the blood vessels responsible for most TIAs is usually caused by a blood clot that's
formed elsewhere in your body mainly in the heart and travelled to the blood vessels supplying the
brain.
Anticoagulants are usually offered to people who have had a TIA if the blood clot that caused your
TIA originated in your heart. This is often due to a condition called atrial fibrillation, which causes
your heart to beat irregularly.
It can also be caused by pieces of fatty material or air bubbles.
PATIENT CONCERNS:
P: Is it stroke?
P: Why did it happen? Why did she have such a problem?
P: What are you going to do for my wife?
P: Can I take my wife home?
106
MIGRAINE
FY2 in A&E
30-year-old lady with headache, second time coming to A&E, came first time 1 week ago
Other info: Pain 8/10. Took ibuprofen + PCM, but it did not help
Take a focused history and discuss management with patient
Patient Info: - One side of the head (left)
- Sudden onset last night
- Dull and static pain, severity 8/10
- Nothing makes it well or better
- Triggers; - Menses
- Stress
- Feels nauseous + blurred vision
- Sees horizontal line
- Had headache several times in the past, can’t remember first time, last time was 1
week ago
- Last time, nothing was done, no investigation, no medications, discharged after
reassurance
- Works in a library
PATIENT’S QUESTIONS / CONCERNS:

Doctor, can it be a tumour => Why do you think it could be a tumour
APPROACH
- Initial Approach / GRIPS
- SOCRATES of pain - one sided
- pulsating
- worse by activity, light
- Offer painkiller
- D/D (SAH, cluster, migraine, meningitis, tension headache)
- Contraception
- Dietary and Sleep Habits (on time, taking cheese, tea, coffee)
- Red flags - Headache worse in morning
- Worst headache of life
- H/O previous episodes
- MAFTOSA
- Effects of Symptoms
- ICE
- Summarize
EXAMINATION
- Observations
- Neurological exam
- Fundoscopy
107
DIAGNOSIS WITH EXPLANATION:
Diagnosis – No specific treatment
MANAGEMENT
- Investigations - Routine bloods
- BSR
- Treatment
- Counseling - Rest and relax
- Sleep or lying in a dark room
- Painkillers - *Do not offer opiates*
- Acute: - PCM, aspirin, Ibuprofen
- Take at aura
- Do not take painkillers all the time because of painkiller-
induced headache
- Antiemetics
- 2nd line: - Diclofenac + Domperidone (rectal)
rd
- 3 line - Sumatriptan (stronger analgesic, constricts vessels in brain)
- Side effects – warm sensation, tightness, flushing, tingling,
nausea
- Antiemetics
- Advice - Migraine diary for diagnosis
-date, time, what patient was doing
-Symptoms, how long
- Refer to neurologist
- Safety Netting - Avoid triggers
- Avoid PCP, increases migraine, IHD
- 2x of IHD
- Migraine Prophylaxis - 1st => Beta blockers (rule out asthma); amitriptyline if asthmatic
- 2nd => Topiramate / sodium valproate
I would like to check your vitals, GPE and examine your nervous system
I would also like to run some routine blood tests.
From my assessment, I am suspecting you have a condition called migraine. Migraine can be
bothersome to deal with but different treatment options for you are:
 Painkillers – including over-the-counter medicines like paracetamol and ibuprofen.
 Triptans – medicines that can help reverse the changes in the brain that may cause migraines.
 Antiemetics – medicines often used to help relieve people’s feeling of sickness (nausea) or being
sick
 During an attack, many people find that sleeping or lying in a darkened room can also help.
In some people, migraine can be triggered by dieting, flashing lights, loud music, strong smells,
periods, shift work, irregular meals, and sleeping pattern.
108
In some people, tiredness, stress and anxiety can also result in migraine. Some medicines like HRT
can also result in migraines.
In case you develop severe dizziness (vertigo), double vision, weakness in any part of the body,
hearing problems and difficulty speaking or swallowing.
109
TRIGEMINAL NEURALGIA
You are FY2 in GP.

Mr. Damian Oldfield, aged 60, has come to you with a facial pain.
Please talk to him and address his concerns.
D: How can I help?

P: I have electric shock like pain on my right side face (teeth, upper jaw and cheek)
D: When did it happen?
P: 1 week ago
D: What were you doing?
P: I was playing golf in the cold weather.
P: Sudden
P: No
D: How often do you get these pains?
P: Frequently
D: How long do they last?
P: Few seconds.
D: Is there anything that makes it better?
P: I took codeine, and it didn’t help
D: Is there anything that makes it worse?
P: No
P: It was 7 but now it is better.
D: Anything else?
P: No
P: No
D: Any weakness in any part of the body?
P: No
D: Any facial trauma?
P: No
D: Any headache? (migraine)
P: No
D: Any pain in the hairline or jaw? (GCA)
P: No
D: Any sweating?
P: No
P: No
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D: Any nausea/vomit?
P: No
D: How is your mood?
P: Fine
D: Can you score the mood with 1 being low and 10 being high?
P: 8
D: Have you had similar kinds of problems in the past?
P: No
P: No
D: Any DM, HTN?
P: No
P: No
P: No
P: No
P: No
D: Do you smoke
P: Yes, 20 cigarettes per day since I was 20
P: Yes/No
P: I don’t have much time.
P: No
I would like to check your vitals and examine head and neck.
I would like to send for some initial investigations including routine blood tests.
From my assessment, you seem to be having trigeminal neuralgia. This is a condition in which
patient usually have sharp shooting pain, or electric shock in the jaw, teeth and gums.
It affects a nerve called as trigeminal nerve which carries sensation from face to brain.
Treatment
- Painkillers (ibuprofen/paracetamol)
- Carbamazepine
- Gabapentin/pregabalin
- Surgery
111
DD
Trigeminal neuralgia
Migraine
GCA
Stroke
MS
112
GUILLAIN-BARRE SYNDROME
You are an F2 in GP Clinic

Andrea Downing aged 33 presents with difficulty in walking since last few days.
Please talk to the patient, take focussed history, and discuss further management.

P: I have weakness in my legs.
D: Tell me more about your weakness?
P: My legs are numb, and I can't walk properly
P: Few days ago.
P: It started with my feet and hands and now I feel numb everywhere.
P: It is continuous. (MS - comes and goes).
D: You said you are not able to walk? What exactly does that mean?
P: My legs feel weak doctor.
D: Are you able to walk with support?
P: Yes/ No
D: Is it getting worse with time?
P: Yes
D: Does anything make it worse or better?
P: Nothing
D: Is the weakness in both the legs?
P: Yes (GBS - bilateral).
D: Is the weakness throughout the day?
P: Yes.
D: Do you feel it is worse in the evening?
P: No Dr. (Myasthenia)
P: Like what Dr?
D: Do you have pain anywhere?
P: I have pain in my back.
D: Where is the pain exactly?
P:
D: Since when have you had this pain?
P: Since last few days.
P: It just started
D: What were you doing when the pain started ?
P: 1 was not doing anything
D: Can you describe this pain for me?
P: Dull
D: Does the pain go anywhere else?
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P: No
P: No
P: Walking
D: Can you score the pain for me?
P: It was 6 but now it is better.
D: Do you have fever? (Vasculitis)
P: No
D: Have you had fever/flu like symptoms recently?
P: Yes. 1 had flu 3 weeks ago.
D: Do you feel cold/hot sensations?
P: Yes/No (no sensory loss in GBS, in myasthenia and polymyositis there is)
D: Any vision problem? (MS. Myasthenia)
P:No
P:No
P:No
D: Any problem in speaking?
P:No
D: Any problem in swallowing?
P:No
D: Did you lose control of your bowel/bladder?
P:No
D: Any problem with balance?
P:No
D: Have you had any similar problems in the past?
P:No
P: No
D: Any DM, HTN. Heart disease or high cholesterol?
P: No
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
114
P: Good/Bad
P: Yes/No
D: Have you recently ate out in or had any canned food? (Botulism)
P: Yes/No
P:
P: Alone
D: Is this weakness affecting your work or day to day life in any way?
P: Yes doctor, it is getting difficult these days.
D: Any chance you are pregnant?
P: Yes/No
I would like to check your vitals and do neurological examination.

I would like to send for some initial investigations including routine blood tests, electrolytes. I
would also like do an X-ray of your back and an ECG.
Ex: Power - reduced in legs (Power is 3)
Reflexes - reduced in GBS (Myasthenia & Botulism will be normal)
Pupil - normal size and react normally in GBS
(ptosis dilated and not reactive in botulism).
 D: From my assessment, there is weakness in your legs. We need to do some further tests to
find out exactly what is causing these problems.
 We will refer you to a specialist (Neurologist).
 We may also do some scans (MRI). We will do LP where we will need to take some fluid from
around your spine and send it off to the lab. We will need to do Nerve Conduction Studies. We
will see how well your lungs are functioning.
 (Most patients have an elevated level of cerebrospinal fluid (CSF) protein, with no elevation in
CSF cell counts. The rise in the CSF protein may not be seen until 1-2 weeks after the onset of
weakness).
 (Nerve Conduction Studies are the most useful confirmatory test and are abnormal in 85% of
patients, even early on in the disease. They should be repeated after two weeks if they are
initially normal. A decrease to less than 20% of predicted normal is associated with a poorer
prognosis).
 (Spirometry - forced vital capacity is a major determinant of the need for admission to ICU and
then the need for intubation).
 D: We suspect you may have a condition called Guillain-Barre Syndrome. It is a rare and serious
condition that affects the nerves. It mainly affects the feet, hands and limbs, causing problems
such as numbness, weakness and pain.
 It can be treated and most people will eventually make a full recovery, although it can
occasionally be life-threatening and some people are left with long-term problems.
 Guillain-Barre syndrome affects people of all ages, but your chances of getting it increase as you
get older.
115
 D: Guillain-Barre syndrome is thought to be caused by a problem with the immune system, the
body's natural defense against illness and infection.
 Normally the immune system attacks any germs that get into the body. But in people with
Guillain-Barre syndrome, something goes wrong and it mistakenly attacks and damages the
nerves.
 It's not clear exactly why this happens, but it can be triggered by:
o an infection, such as food poisoning, flu or cytomegalovirus
o a vaccination, such as the flu vaccine (but this is extremely rare and the benefits of
vaccination outweigh any risk)
o surgery, a medical procedure or an injury
 D: Most people with Guillain-Barre syndrome are treated in hospital. We need to admit you in
the hospital for treatment. Neurologist will come and see you and talk to you.
 The main treatments are:
o Intravenous immunoglobulin (IVIG) - a treatment made from donated blood that helps
bring your immune system under control. It is injected through your veins.
o We may need to do a procedure called Plasma exchange (plasmapheresis) - an alternative
to IVIG where a machine is used to filter your blood to remove the harmful substances
that are attacking your nerves.
o Other symptomatic treatments to reduce symptoms and support body functions, such as
painkillers, a machine to help with breathing and/or a feeding tube.
 D: Most people need to stay in hospital for a few weeks to a few months. Most people with
Guillain-Barre syndrome make a full recovery, but this can take months or even years. Some
people won't make a full recovery and are left with long-term problems such as:
o being unable to walk without assistance
o weakness in your arms, legs or face
o numbness, pain or a tingling or burning sensation
o balance and co-ordination problems
o extreme tiredness
 D: Therapies such as physiotherapy, occupational therapy and speech and language therapy can
help you recover and cope with any lasting difficulties.
116
MULTIPLE SCLEROSIS
You are an F2 in GP Clinic

Mrs. Amelia White, 28, came to the clinic because of a problem with her vision.
Talk to her and explain to her the treatment options.

P: I have trouble seeing things.
P: I can’t see sometimes
D: When did you first notice this?
P: A few days ago.
D: Are you able to see now?
P: Yes, but I see blurry and appears to be double.
P: Yes.
D: Is it in both eyes or one of them?
P: Both.
D: Is it painful or painless?
P: Painful when I move my eyes.
D: What were you doing when you noticed the visual problem?
P: Nothing
P: No
P: No
D: Any other symptoms?
P: I have numbness and tingling in my hands.
D: Tell me more about the problem with your hands?
P: Started few days ago with my eye problem. I feel weakn and stiff all over my body.
D: Anything else?
P: No
D: Have you had fever/flu like symptoms recently?
P: No
D: Do have any problem with bowel or bladder?
P: No
D: Any problem in swallowing?
P: No
D: Any problem with speech?
P: No
D: Do you feel any difficulty in thinking or planning?
P: Yes/No
D: Any problems with hearing or balance?
P: Yes/No
D: How is your mood these days?
117
P: It is fine doctor
D: Can you rate it for me, 1 being the lowest and 10 being the highest.
P: Its around 6.
D: How is your sleep?
P: Okay
D: Any headache? (GCA)
P: No
D: Any cough? (sarcoidosis)
P: No
D: Any shortness of breath? (GBS)
P: No
D: Any back pain (myelopathy)
P: No
D: Have you had any similar problems in the past?
P:No
P: No
D: Any DM, HTN. Heart disease or high cholesterol?
P: No
P: No
P: No
P: No
P: My mother has MS. She was diagnosed in her late 20s
D: Do you smoke?
P: Yes/No
P: Yes/No
D: Do you eat meat? (vitamin B12 deficiency)
P: Yes/No
D: Have you recently ate out or had any canned food? (Botulism)
P: Yes/No
P: Yes/No
P:I am a receptionist
P: Alone
D: Is this weakness affecting your work or day to day life in any way?
P: Yes doctor, it is getting difficult these days.
118
P: Yes
D: Any loss of libido?
P: Yes/No
D: Any chance you are pregnant?
P: Yes/No
I would like to do GPE, vitals and examine your eyes and hands. I would also like to run some
routine blood tests like LFTs, TFTs, KFTs, calcium and vitamin B12.
From my assessment, we are suspecting that you may have a condition known as multiple sclerosis.
It is a disorder of brain and spinal cord. This can cause damage to parts of your brain and lead to
multiple symptoms like vision problems, weakness and stiffness in the body and so on.
We would like to do an MRI (damage and scarring of myelin sheath, evoked potential test
(measures time it takes for nerves to respond to stimulation) and LP to confirm the diagnosis.
(Optic Neuritis => inflammation of optic nerve that is responsible for vision)
Management:
Multiple sclerosis (MS) is a relapsing-remitting disease, which means we cannot treat the disease, but
we can treat the symptoms with medicines and other treatments. Treatment for MS depends on the
specific symptoms and difficulties the person has.
In case, there is a chance of eye getting affected like it is in your case for which high-dose steroids
need to be given.
Steroids:
Treatment for a relapse either:
- Oral – 5-day course of tablets taken at home.
- Infection – given in the hospital for 3 to 5 days.
We will also give PPI alongside the steroids.
The use of steroids on more than three occasions per year, or for longer than three weeks on any one
occasion, should be avoided.
DMARDS
Disease-modifying drugs are the recommended treatment for active relapsing-remitting multiple
sclerosis. It reduces the amount of damage and scarring of myelin sheath and slows the worsening
disability in MS.
A range of therapies will be suggested, depending on what problems or disabilities you develop. They
include:
119
 Physiotherapy
 Occupational therapy
 Speech therapy
 Specialist nurse advise and support
 Psychological therapies
 Counselling
Please inform the DVLA for expert advice.
In case you develop any symptoms such as sexual problems, urological problems, and any other
symptoms are getting worse then please come back to us.
120
ENCEPHALITIS
You are F2 in A&E.

Mr. Peter aged, 22 has been brought to the hospital by his father after having a fit.
They were watching a football match with his father and suddenly he started having a fit. After the
fit he started hallucinating, having odd behavior and saying strange things. He is now confused,
drowsy and agitated. He is not unconscious.
Patient is having fever and headache for the past 2 days.
Please talk to the father, explain the provisional diagnosis to the father and explain about his son’s
condition, discuss your management plan with him and address his concerns.
You will find the clinical findings and investigation reports inside the cubicle.

F: How is my son? Is he okay?
D: Don’t worry, he is fine now. He is in good hands, my colleagues are looking after him, but I need
to ask you a few questions if you don’t mind.
F: Okay Dr.
D: Could you please tell me what exactly happened?
F: Doctor, my son was fine. We were watching a football game and he was really excited about this
football match and suddenly his whole body started shaking.
D: Tell me about it?
F: He started having jerky movements all over his body suddenly.
D: How long did it last?
F: 1-2 minutes.
Before:
D: How was he feeling before the fit?
F: H was a bit unwell and feeling hot in the past 1-2 days.
D: Did he do anything for his fever?
F: He took paracetamol tablet.
D: Did you do anything for it?
F: No, I thought it will go away on its own.
D: Was he experiencing anything else before the fit
F: No
D: Any headache?
F: Yes/No
D: Any sickness or vomiting?
F: No
D: Any difficulty or pain moving his head and neck?
F: No
D: Any rash anywhere on his body?
F: No
D: Was he shy away to light?
F: No
D: Did he have any sore throat or runny nose?
F: No
121
D: Did he hurt his head in the past few days?
F: No
During:
D: Did he lose his consciousness?
F: No
D: Was there any strange feeling before the fit started?
F: No
D: Did he have up-rolling of the eyes during the fit?
F: No
D: Did he bite his tongue?
F: No
D: Did he wet himself?
F: No
D: Did he hurt himself? Were there any in juries on any part of his body?
F: No
After:
D: Could you tell me. what happened after the fit?
F: My son started acting in a weird way. He was saying something weird, it was like he was mumbling
but I couldn’t understand.
D: Was there anything else?
F: Yes, he was confused. He was hallucinating and acting strange.
D: Was he drowsy?
F: Oh yes, he was drowsy.
D: What did you do after that?
F: I got panicked, called the ambulance and brought him to the hospital.
D: Did he have similar kind of problem in the past?
F: No, first time
D: Is he been diagnosed with any medical condition in the past?
F: No
D: Any epilepsy, diabetes or neurological problems?
F: No
D: Is he currently taking any medications, over-the-counter drugs or supplements??
F: No
F: No
F: No
F: No
D: Any family member with similar problem?
F: No
D: Any member of family diagnosed with epilepsy?
F: No
D: Does he smoke?
F: No
122
D: Does he drink alcohol?
F: No
F: No
D: Tell me about his diet?
F: He eats healthy food
D: Tell me about physical exercise?
F: He is quite active.
D: Does he have any kind of stress?
F: No
D: Did he travel abroad recently?
F: No
D: Has he had a contact with any ill patient?
F: No
I would like to check his vitals and do neurological examination.

I would like to send for some initial investigations including routine blood test to check for any
infection.
Examination Report:
Vitals:
BP: 100/80
HR: 90
02 Sat: 95%
Temperature: 38
RR:
Blood s r: Normal
Physical Examination:
Patient is confused and drowsy
Neurologic
GCS is 14.
There is no photophobia.
There are no rashes.
There is no neck stiffness.
Brudzinski’s sign is negative.
Kemig's sign is negative.
Reflexes are brisk.
There is cervical lymphadenopathy.
Investigations:
CT scan is normal.
Fundoscopy is normal.
Blood toxic screen- Negative
Lumbar Puncture:
123
Sugar (Glucose): Normal Normal value: > 60% of serum glucose
Protein: Normal/raised Normal value: < 45 mg/dL
Lymphocytes: 90%
Neutrophils: 10%
Culture not yet out
 From our assessment, it seems that your son has a condition called viral encephalitis,
 which is an infection of the brain. This is a condition in which the brain becomes inflamed and
swollen.
 It is a serious condition but do not worry he is in good hands. Let me tell you what done for him.
 We did a scan of his brain (CT) and fortunately it is normal.
 We did another investigation called lumbar puncture in which we removed some fluid from
around his spine and then we examined the sample under microscope to check for signs of
infection or a problem with his immune system. There are some cells in this fluid which if their
number is raised, it indicates infection in the brain. In your son’s sample, the number of these
cells were increased.
 We checked his eyes and they were perfectly normal.
 We examined the glands (lumps and bumps) in his body and it seems like some glands in his
neck are enlarged.
 Encephalitis can occur if an infection spreads to the brain.
 Infections such as cold sores, sore throat or any infection in and around his head and neck can
spread to brain. However, Encephalitis only occurs in rare cases. The condition is most often due
to a virus.
 It can also happen due to a problem with the immune system.
 Encephalitis needs to be treated urgently. The earlier we start the treatment, there will be a
better outcome. Your son is in good hands. A team of experienced doctors are looking after him.
Don't worry we will do our best to help and give the best treatment possible to your son.
 We need to find the underlying cause, relieve his symptoms and support his bodily functions
and allow the best chance of recovery.
 We have to keep him in the hospital. We may shift him to the intensive care unit (ICU) which is
for people who are ill and need extra care.
 We may have to do some further investigations.
 We will do some blood and urine tests to see if there is any bug in them.
 If we found any blistering rash then we can also take swab sample.
 We may also consider doing a tracing of brain called EEG to look for any abnormal brain activity.
 We may consider doing MRI Scan.
 As I mentioned earlier we took a sample of fluid around his spine. We have sent this sample to
the lab to know which exact bug has been the cause of your son’s condition and the results are
awaited.
 However, like I said in your son’s case, the cause of his infection seems to be a virus.
 If a cause of encephalitis is found, treatment to deal with this will start immediately.
1. We will give him an antiviral medication, through his blood vessels as a drip (3 times a day
for 2-3 weeks) to fight against this bug. (Acyclovir).
2. We may need to give him some steroid injections to reduce the inflammation in his brain
(for a few days).
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 Encephalitis puts a lot of strain on the body and can cause a range of unpleasant symptoms.
 We will give treatment to relieve these symptoms and to support certain bodily functions until
he is feeling better.
 We will give him fluids through his blood vessels as a drip to prevent dehydration. Give him
medication to control his fever, pain and discomfort.
 We will give medication to control seizures (fits) and prevent them from happening again. We
may give him some medication to help him relax if he is very agitated.
 We will monitor him and his vitals. We may consider giving him oxygen through a face mask to
 support his lungs (sometimes a machine called a ventilator may be used to control breathing).
We may give him a medication to prevent a build-up of pressure inside his skull.
 Some people will eventually make a full recovery from encephalitis, although this can be a long
and frustrating process.
 But many people never make a full recovery and are left with long-term problems due to
damage to their brain.
 People usually recover from this condition but some people might suffer from some
complications.
 The chances of successful treatment are much better if encephalitis is diagnosed and treated
quickly.
 Long-term problems can occur after encephalitis as a result of damage to the brain.
 Some of the most common complications include memory problems, personality and
behavioural changes, speech and language problems, swallowing problems, repeated seizures
(fits) – known as epilepsy, emotional and psychological problems, such as anxiety, depression
and mood swings, problems with attention, concentrating, planning and problem solving,
problems with balance, coordination and movement, persistent tiredness.
 We will try our best to prevent complications from happening. We will give him medications to
prevent further fits from happening.
 Recovering from encephalitis can be a long, slow and difficult process. However, specialized
services are available to aid recovery and help him adapt to any persistent problems, this is
known as rehabilitation.
 He can get support from:
o A neuropsychologist who is a specialist in brain injuries and rehabilitation.
o An occupational therapist who can identify problem areas in your son's everyday life and
work out practical solutions
o a physiotherapist who can help with movement problem
o a speech and language therapist who can help with communication
 Before leaving hospital, the health and care needs of your son will be assessed and an individual
care plan drawn up to meet those needs.
 This will involve a discussion with him and anyone likely to be involved in their care, such as his
close family members.
 This can range from a few days to several weeks or even months. As I said we are going to give
him an antiviral medication, through his blood vessels as a drip to fight against this bug. The
complete course of this medication usually takes about 2-3 weeks.
P: What's going on doctor?
125
P: Is it a serious condition doctor?
P: Why has he got this problem doctor?
P: Is he going to die?
P: What are you going to do for him?
P: Are you going to give any medication to my son?
P: Is he going to be fine doctor?
P: Are there any complications of this infection?
P: What are you going to do if such complications happen?
P: How long does he have to stay in the hospital?
DD:
Encephalitis
SOL
Meningitis
126
HEAD INJURY (ADULT)
You are F2 in A&E.

Mr. Peter Smith aged, 40 was brought to the hospital by the ambulance due to having a fall.
Please talk to the patient, take history, assess your patient and discuss your initial plan of

P: I had a fall.
D: Could you please tell me more about the fall?
P: I was with my wife in the restaurant, we came out and suddenly I fall down and become
unconscious.
P: It happened two hours ago.
D: Tell me what exactly happened before the fall?
P: I don’t remember what happened exactly. I fell down I opened my eyes when I was in the
ambulance.
D: Did you drink alcohol in the restaurant?
P: Yes doctor. We drank 2-3 glasses of wine together.
D: How were you feeling before the fall?
P: I was absolutely fine dr.
D: Any headache?
P: No
D: For how long you were unconscious?
P: I am not sure.
D: Any jerky movements during the fall?
P: No Dr.
D: did you wet your pants?
P: No
D: Any bleeding from the ear?
P: No
D: Did you notice any head injury?
P: No/Yes
D: What happened after the fall?
P: Doctor, I regained my consciousness in the ambulance and I was fine that time.
D: Were you feeling sleepy and drowsy?
P: Yes/No
D: Any vomiting?
P: Yes, I vomited twice.
D: After you became conscious, were you able to recall what happened immediately before the
fall?
(Retrograde amnesia)
P: Yes doctor.
D: Any fever or flu like symptoms? (Meningitis)
P: No
127
P: No
D: Any morning headache or visual problem? (SOL)
P: No
D: Any weakness in your arms or legs or slurred speech? (TIA)
P: No
D: Have you had similar kind of fall in the past?
P: No
P: No
D: Any DM, HTN or heart disease?
P: No
D: Any epilepsy or stroke?
P: No
P: No
D: Any blood thinners?
P: No
P: No
D: Any member of the family with any DM, HTN, heart disease, stroke, epilepsy or blood disorder?
P: No
D: Do you smoke?
P: Yes/No
P: Social drinker
P: No
P: No
I would like to check your vitals and examine your heart and nervous system.
I would like to send for some initial investigations including routine blood test and ECG
EX: A small bump on the forehead/Normal.
From our assessment, your head injury is the cause of your loss of consciousness.
Fortunately, all the other examinations were normal, we found a small bump in your forehead.
We have to keep you in the hospital and we have to do a CT scan of your head to check for any
bleeding.
We will shift you to the observation unit for closer look.
If we found any bleeding then we may need to do the operation on your head to remove the blood
clot.
If all the tests including CT scan came back normal we will discharge you but tell your wife or any
family member to stay with you for at least 24 hours.
Please have plenty of rest and don’t take any sleeping pills.
128
Don't play any contact sports like football or rugby for at least 3 weeks.
If you notice any persistent headache, vomiting, drowsiness, double vision call 999 and ask for an
ambulance.
Criteria for performing a CT scan for adults

1. CT scan head should be performed within 1 hour.
2. GCS less than 13 on initial assessment in A&E.
3. GCS less than 15 at 2 hours after head injury on assessment in A&E.
4. Suspected open or depressed skull fracture.
5. Any sign of basal skull fracture (haemotympanum, panda eyes, cerebrospinal fluid leak from
ears or nose, battle sign.)
6. Post-traumatic seizure.
7. Focal neurological deficit
8. More than 1 episode of vomiting.
For patients who have sustained a head injury and the following risk factors;
CT scan head should be performed within 8 hours of the risk factors being identified.
1. Patient on warfarin.
2. LOC or amnesia and any of the following:
a. Age more than 65.
b. Any history of bleeding and clotting disorder.
c. Dangerous mechanism of injury e g Fall more than 1 meter or 5 steps, RTA either is
Pedestrian or Cyclist or vehicle occupant. More than 30 min retrograde amnesia of event
"immediately before the injury”.
129
POST HERPETIC NEURALGIA
You are FY2 in GP.

Benjamin White, aged 72, has come for consultation. He was diagnosed with Shingles 2 months
back and was given Acyclovir. He saw his GP 1 month back for the pain on the right side of his chest
and was given Paracetamol and Codeine.
Talk to him and address his concerns.
Dr: How can I help you?

Pt: I am still in pain.
Dr: Is the pain still in the same place?
Pt: Yes, it’s on the right side.
Dr: Is it always there?
Pt: Yes
Dr: Can you score the pain?
Pt: 3/4 normally but during night the bedsheets touch the area and I get unbearable sharp pain.
Dr: How has it impacted you?
Pt: It is hindering my daily life, as I am taking care of my wife who is on wheelchair and has RA.
Dr: How are you feeling?
Pt: I feel tired all the time.
Dr: Do you have rash on your body?
Pt: No, they are gone.
Dr: Did you have similar condition in the past?
Pt: Yes, I had it 6 months back and was given antibiotics.
Dr: Have you been diagnosed with any medical condition in the past?
Pt: No
Dr: Are you taking any medications including OTC or supplements?
Pt: No
Dr: Any allergies from any food or medications?
Pt: No
Dr: Any previous hospital stays or surgeries?
Pt: No
Dr: Has anyone in the family been diagnosed with any medical condition?
Pt: No
Dr: Do you smoke?
Pt: No
Dr: Do you drink Alcohol?
Pt: No
Dr: Tell me about your diet?
Pt: Healthy
Dr: Are you physically active?
Pt: I try to be
Dr: Do you get any help looking after your wife? Pt: Yes, Nurse comes twice a week.
(Ask about Sleep, depression, rule out Cancer (As age is 72) and other causes of Tiredness)
130
Examination
I would like to check your vitals i.e. your BP, pulse, temperature and respiratory rate. Also rash on
your body.
Diagnosis
Dr: From what we have assessed think that you are having this pain due to a condition called post
herpetic neuralgia. It is lasting nerve pain in an area previously affected by shingles.
Pt: What can you do for me?

Management
• To help reduce the pain and irritation of post- herpetic neuralgia wear comfortable clothing
and use cold packs – some people find cooling the affected area with an ice pack helps.
• We can give you Lidocaine plasters and Capsaicin cream (Capsaicin is the substance that
makes chilli peppers hot. It's thought to work for nerve pain by stopping the nerves sending pain
messages to the brain).
• Antidepressants: Amitriptyline and duloxetine are the two main antidepressants prescribed
for post- herpetic neuralgia.
• Anticonvulsants: Gabapentin and pregabalin are the two main anticonvulsants prescribed for
post- herpetic neuralgia.
• We can also prescribe Tramadol or Morphine if symptoms are not relieved.
• Living with post-herpetic neuralgia can be very difficult because it can affect your ability to
carry out simple daily activities, such as dressing and bathing. Support the patient and talk about
support groups and websites.
PATIENT CONCERNS:
Pt: How to get rid of this Pain?
Pt: How to manage tiredness?
Pt: Can you give something else other than tablets?
Investigations and follow up

We will do some blood tests do check whether you are anaemic and everything is fine with your
liver and kidneys and also your inflammatory markers like ESR and CRP.
We will arrange a follow up in a month time.in the meantime if you feel more pain, any fever, rash
or weight loss please let us know. Thank you
131
CEREBELLAR ATAXIA
You are F2 in General medical ward.

Janet Clarke aged, 65 has been referred by her GP because of suspicion of Cerebellar ataxia.
Patient is diagnosed of Diabetes. Her diabetes is well controlled.
Take history, do relevant examination and discuss a management plan with your patient.

P: I feel clumsy these days.
D: What do you mean by clumsy?
P: I live to knit for my grandchildren, but because of this problem I cannot knit.
D: Since when?
P: From last 3 months.
D: Anything else?
P: Whenever I walk I feel like I will fall but I don’t fall
D: Since when?
P: From last 3 months
D: Anything else?
P: Whenever I hold something in my hand it fell from my hand.
D: Since when?
D: How is your general health?
P: I am fine.
D: Any cough
P: No
P: No
D: Any problem with urine or bowel?
P: No
D: Any weight loss?
P: No
D: Any loss of appetite? (Brain tumour)
P: No
D: Any headache or vomiting?
P: No
D: Any eye problem?
P: No
D: Any head trauma?
P: No
P: No
P: I have DM.
P: Yes, it is well controlled.
132
D: Do you take any medications for DM?
P: No, I am managing with my diet.
P: No
P: No
P: Occasionally
P: I try to eat healthy (vitamin B12 deficiency)
Explain the examination:

I am here to examine your cerebellum which is a part of your brain situated at the back of your
head. I have a chaperone throughout my examination to ensure your privacy. May I proceed.
Exposure
Chaperone
Being gentle
Consent
1. Speech: Ask the patient to repeat these phrases after you.
a. British Constitution
b. Baby Hippopotamus
c. 42 west register street
❖ To patient: I will give you phrases could you please repeat after me.
❖ Verbalize: Speech is normal in my patient.
2. Nystagmus:
a. Ask the patient to look straight ahead and examine the eyes to look for any abnormal movement
such as nystagmus (To and fro movements)
b. Ask the patient to keep their head still and follow your finger with their eyes.
c. Move your finger throughout the various axes of vision (Horizontal and vertical axes)
d. We are looking for horizontal and vertical nystagmus
❖ I am going to move my finger in front of your eyes, please don' t move your head and neck and
follow my finger with your eyes only.
❖ Verbalize: There is no horizontal and vertical nystagmus.
3. Finger nose test:

a. Ask the patient to touch their nose with the tip of their index finger, then touch your fingertip.
b. Position your finger at a distance so that the patient has to fully outstretch their arm to reach to
your finger.
c. Ask the patient to continue to do this finger to nose motion.
d. Then tell the patient to repeat it with their other hand.
e. We are looking for intentional tremor and past pointing or dysmetria.
❖ Could you please touch your nose with the tip of your index finger and then touch my finger tip.
Please continue doing this and I will keep changing the position of my finger.
133
❖ Verbalize: There is no intentional tremor and past pointing.
NOTE:
Don't confuse intentional tremor with action tremor.
Intentional Tremor: Tremor occurs when finger approaches the target.
Action tremor: Tremor occurs throughout the movements.
4. Dysdiadochokinesia
a. Demonstrate to the patient by patting the palm of your hand with the back/palm of your other
hand to the patient.
b. Ask the patient to do this rapid alternating movement.
c. Then tell the patient to repeat this movement on their other hand.
d. We are looking for irregular and slow movements.
❖ Verbalize: There is no dvsdiadochokinesia
5. Tone
a. Support the patient's arm by holding their hand (Shake hand) and elbow.
b. Ask the patient to relax and go floppy.
c. Move the arm 's muscle groups through their full range of movements and check for tone of
shoulder, elbow and wrist.
d. Check it in both the hands.
e. We are looking for movements if tl smooth or if there is some resistance.
❖ Verbalize: Tone is non
6. Gait:
a. Ask the patient if she can stand independently.
b. A broad-based gait is present in cerebellar disease.
c. We are looking patient might veer towards the side of the lesion.
❖ To patient: Could you please take few steps, don’ t worry I will be by your side in case you fall.
❖ Verbalize: Gait is normal in my patient.
7. Tandem gait:
a. Ask the patient to walk in a straight line with their heels to their toes.
b. This test w ill exaggerate any kind of unsteadiness.
❖ To patient: Could you please walk in a straight line with your heels to your toes, don’ t worry I
will be by your side in case you fall.
❖ Verbalize: Tandem Gait is normal in my patient.
8. Romberg:
a. Ask the patient to put their feet together, keep their hands by their side.
b. Tell the patient to close the eyes.
c. It can differentiate sensory ataxia from cerebellar ataxia.
❖ To patient: Could you please stand with by your feet together and arms to your side. Now close
your eyes. Don't worry I will be by your side in case you fall.
134
❖ Verbalize: Romberg is negative in my patient.
9. Heel to shin test:

a. Ask your patient to put heel of one leg on the other knee, run it down the shin, lift it off and
repeat in a again.
b. We are looking for the incoordination.
❖ To patient: Could you please put heel of one leg on the other knee, run it down the shin, lift it off
and repeat in a again.
❖ Verbalize: Heel to shin test is normal in my patient.
MANAGEMENT
D: Your GP was suspecting cerebellar ataxia that is why he referred you to us. Based on the
examination that I have done everything seems to be normal, however, we will do some
investigations to make sure there is no problem.
We will do some urine test and blood test to see if there is any bug which is the cause of your
problem.
We will do blood test to check the level of Vit B12 and also we will do some genetic testing.
We will consider doing some scans like CT scan or MRI of your head to make sure every thing is
fine.
P: Is it cancer?
D: Everything seems to be fine from the history and examination. May I know why you think so?
P: I am old Dr. I just have a feeling that it might be cancer?
D: As I have mentioned everything seems to be fine but we are going to do scans to rule out all
the possibilities.
https://www.nhs.uk/conditions/ataxia/
135
CITALOPRAM TIREDNESS
You are F2 in the GP clinic.

Avery aged 50 has come to the clinic with complaint of tiredness. She was diagnosed with
depression and she is taking Citalopram 10m . Her eGFR is >60ml/min.
Take history, assess her & discuss the management plan with the patient.

P: Doctor I feel tired a lot
D: Tell me more about your tiredness.
P: I have been feeling tired since last 2-3 weeks.
P: No
D: Has it changed?
P: No
P: No
P: No
P: Fine
D: Do you have any fever, flu like symptoms or sore throat?
P: No
P: No (Cancer)
P: No
P: No
P: No
P: No
D: Any constipation, diarrhea? (Thyroid. IBD)
P: No
D: Any blood in stool?
P: No
D: Any tummy pain?
P: No
P: No
D: Any headache, muscle cramp and weakness?
P: No
D: How is your sleep these days?
P: I’m sleeping alright but I am still feeling tired.
136
D: How has been your mood recently?
P: Fine
D: Can you score it on the scale of 1 to 10,1 being the lowest mood & 10 being happiest.
P: 4/6
P: No
P: Depression
D: Since when?
P: Last 3 months
D: Anything happened during that time?
P: My close friend died 3 months ago due to Breast Cancer. I went into depression and I went to my
GP. He started me on Citalopram and I am taking it for last 3 months.
D: Any DM, HTN, cholesterol and Kidney problem?
P: I have high BP and high cholesterol from from last lOyears and I am taking medication for that.
D: Are you taking regularly as prescribed?
P: Yes dr.
P: No
P: No
D: Any hospitalisation & surgeries done in the past?
P: No
P: No
P: Yes/No
D: Do you smoke?
P: Yes/No
P: Good/Bad
D: Do you do any physical exercise?
P: No. I don't get much time.
P: Office work.
D: I would like to check your Vitals including BP. Pulse. GPE & examine your chest and heart.
I would also like to do some investigations including FBC. FBS. LFT. Urea &Electrolytes. Infection
markers, thyroid function test.
Ex:
Na+: 128 (normal 135 to 145 milli equivalents per litre)
K+: 4.8 (normal potassium level - 3.5-5.0 milli equivalents per litre (mEq/L)
137
Urea: 4.2(2 to 6.6 millimoles)
Cl and Hco3 are normal.
eGFR: >60
D: We have your results. Our body has different salts & chemicals, we checked for all of them just
to be sure that they ’re not causing this. The results show, that one salt, sodium, is less in your body
than its normal level. That is actually causing you to feel tired all the time.
The medicine that you’ve been taking. Citalopram, that is probably causing it. Citalopram belongs
to a group of medicines that can decrease the sodium levels in your body. When sodium becomes
less, it causes a person to feel tired & lethargic all the time.
We ll stop Citalopram, as that is the cause of the symptoms.
We will keep you in hospital and we will correct the level of sodium in your body and we will also
send you to the psychiatrist for a review and the psychiatrist will change the medication. But
stopping this medication probably will make your tiredness go away.
Stage of Chronic Kidney Disease eGFR ml/

min/1.73m2
Stage 1: the eGFR shows normal kidney function but you are already known to 90 or more
have some kidney damage or disease. For example, you may have some protein
or blood in your urine, an abnormality of your kidney, kidney inflammation, etc.
Stage 2: mildly reduced kidney function AND you are already known to have 60 to 89
some kidney damage or disease. People with an eGFR of 60-89 without any
known kidney damage or disease are not considered to have chronic kidney
disease (CKD).
Stage 3: moderately reduced kidney function. (With or without a known 45 to 59 (3A)
kidney disease. For example, an elderly person with ageing kidneys may have 30 to 44 (3B)
reduced kidney function without a specific known kidney disease.)
Stage 4: severely reduced kidney function. (With or without known kidney 15 to 29
disease.)
Stage 5: very severely reduced kidney function. This is sometimes called endstage Less than 15
kidney failure or established renal failure.
138
139
CHRONIC FATIGUE SYNDROME
You are F2 in GP.

Mr. Steve Barone, aged 45, presented with the tiredness.
He has been to the hospital 6 months ago with the same problem after having flu. The IT system in
the clinic is crashed. We don’t have any medical records of the patient.
Talk to the patient, take history and discuss about management plan with the patient. Address
patients concerns.
Patient presented to the GP six months ago because of the same problem.
No medication was prescribed for the patient.

P: I am tired always that is why I came back.
D: How long you have been tired?
P: Since my last flu.
D: When you had the flu?
P: It happened six months ago.
P: It went away itself, but even after it was gone I felt tired and I came here to the hospital.
D: What did they do for you?
P: They asked me to come back for some blood test, but I didn’t come.
D: Tell me more about your tiredness?
P: I have been tired all the time in the last six months.
ODIPARA
D: Is there any specific time of day you feel more tired? Has it changed? Anything makes it better
or worse?
P: I have body pain (Points towards different parts of the body)
D: Has it changed? Are you taking anything for it?
D: Anything else?
D: Do you have any sore throat? Any headache? Lack of concentration? Sleep disturbance?
D: How has been your mood recently? Hot flushes?
P: No (Cancer)
D: Do you have any weight loss?
P: No.
P: No.
P: No.
P: No.
P: No.
D: Any constipation or diarrhea? (Thyroid. IBD)
140
P: No.
D: Any tummy pain?
P: No.
P: No
P: No
D: Any DM, Kidney problem?
P: No
P: No
P: Yes/No
D: Do you smoke?
P: Yes/No
P: Doctor, my diet is very good. My wife cooks for me.
P: Office work. I can't concentrate because I am forgetful.
D: Is it stressful?
P: Doctor, I live with my wife and 2 children.
D: Any other partner? Safe sex? (HIV)
D: How are the things at home? How is your relationship with them?
P: Doctors, its good but, I feel guilty because I can’t give my wife and kids enough time because of
tiredness.
P: I have an office job, and I don't do any physical activity. I’m busy at work. I don't have any time to
go for walk or to the gym.
D: I would like to check your vitals and examine your chest, tummy and musculoskeletal
examination.
D: I would like to send for some initial investigations including routine blood test and urine test.
From our assessment, your tiredness doesn’t seem to have any medical cause. However, we will do
some investigation to make sure everything is fine.
If all investigations came back normal, then this condition is called Chronic Fatigue Syndrome
means long-term chronic tiredness without any medical cause. We will refer you to CFS Clinic or
Rheumatologist for further management.
We will do some blood test to check anaemia, liver and kidney function, vitamins level and thyroid
hormone. We will also check blood sugar.
We will also do some urine test.
Have a well-balanced diet, we may also prescribe you some vitamin supplements.
Please manage your rest. You can have rest during the day. Please try to have frequent rest.
141
Please manage your sleep. Please try to have regular pattern of sleep.
Stress can be a trigger for your tiredness. It is important to relieve your stress.
You may try some relaxation techniques or yoga by participating in some classes.
We will give you some simple pain killers to relieve your pain.
Cognitive Behaviour Therapy: In this someone will talk to you about your problem. They try to help
you by improving your mood or by relieving your stress.
Graded exercise therapy: start training with low intensity exercise and then gradually increase the
level of your physical exercise. Gym instructor can guide you in this.
Advice about lifestyle, smoking and alcohol.
DD:
Cancer
Hypothyroidism
IBD
CKD
DM
HIV
142
POLYMYALGIA RHEUMATICA
Elderly lady
c/o shoulder and thigh pain – 3 weeks
History and management
Shoulder and thigh (may show around pelvis also) pains since 3 weeks
Onset – Sudden or gradual (in PMR – it is usually sudden but can be gradual too)
Worse in the morning (in PMR, it is worse in the morning)
D: Any swelling in shoulders?
P: No
D: Any other joint pains?
P: No
D: Other joint swellings (osteoarthritis)?
P: No
D: Swelling and pains in the hand joints (rheumatoid arthritis)?
P: No
D: Any changes in the bowel habits like loose stools diarrhoea?
P: No
D: Fever?
P: No
D: Trauma?
P: No
D: Soreness in eyes?
P: No
D: Skin rashes (SLE)?
P: No
D: Difficulty using shoulder?
P:
D: Can she lift weight?
P:
D: Difficulty in walking?
P:
Pain on the side of the head?
Any vision problems?
Any pain in jaw while chewing (to rule out GCA)
No
PMHx – GORD on omeprazole for 20 years
Any other medications

Allergy?
Family History?
Anything else important?
143
Examination
I want to examine your shoulder joints and other joints and also examine your thighs.
Examiner may say – shoulder movements restricted (abduction limited)

I want to examine for any swellings or muscle wasting? Examiner may say no.
(In PMR – joints movements may be restricted)
Provisional Diagnosis
Mrs…I need to check whether the medication omeprazole what you are taking is causing this
problem. Is it Ok? Check BNF for side effects – it may show long term use of omeprazole causes
vitamin D and B12 deficiencies which may cause body aches.
Mrs… if one takes omeprazole for long term, it may cause vitamin deficiencies which in turn can
cause body pains but they usually do not cause the pains to be worse in the morning and restriction
movements of the joints.
I think you have a condition what we call as Polymyalgia Rheumatica. Do you know anything about
it?
Polymyalgia rheumatic is a form of arthritis – joint condition. It causes pain in the joints and
muscles of the lower back, thighs, hips, neck, shoulder and upper arms, and other parts of the
body.
The condition occurs when the lining surrounding the joints and tendons near the shoulders and
hips become inflamed.
The disease is centered on the joints (especially the shoulders and hips). But the discomfort is felt
in the upper arms and thighs. This type of pain is called referred pain. It arises in one area but
causes symptoms in another.
D: Do you follow me?
P: Yes
D: Typically, polymyalgia rheumatica affects people older than 55. If not treated, it can lead to
stiffness and significant disability. In some cases, symptoms do not get worse. They may even
lessen in a few years.
In a minority of cases, polymyalgia rheumatic is associated with another condition called giant cell
arteritis (temporal arteritis). This is a condition in which blood vessels are inflamed, especially in
the neck and head. If not treated, giant cell arteritis can cause blindness or stroke.
Do you follow me?
P: Yes
D: We need to do some blood tests called ESR and CRP to check whether there are any possibilities
of this condition.
(The ESR and CRP tests may be used both to diagnose the condition and to check whether treatment
is working)
Treatment
 We will refer you to the specialist called rheumatologists.
144
 We can give you painkiller medication like NSAIDs but they are not very helpful.
 We can give you medications called corticosteroids, such as prednisolone. We will give you low
doses of that like 10 mg to 20 mg per day and they are highly effective.
 Long term use of steroids can cause osteoporosis that is thinning of bones. We can give you
medications to prevent osteoporosis like calcium, vitamin D and alendronate (Fosamax)
 If you have serious side effects of steroids and if we cannot just treat with low doses of steroids,
then we may give some other medications called methotrexate.
 We will refer you to physiotherapists. Physical therapy may help to control discomfort. It can
also help maintain the ability to move the joints and function.
Prognosis
Treatment may be required for years. But the outlook for people with polymyalgia rheumatica is
excellent.
Warning Signs:
If you develop any headaches on the sides of the head or vision problems or jaw pain while
chewing please come to us immediately because these are the signs of serious condition called
giant cell arteritis as I mentioned earlier. We may need to treat you urgently with high dose
steroids.
You are an FY2 in GP.

Janet, aged 50, has been diagnosed with polymyalgia rheumatic. She is on steroids, aspirin,
lansoprazole and bisphosphonates. ESR and CRP are normal.

P: I don't want to take the steroids.
(Elaborate the symptoms of PMR)
Ask for GCA/eye problems.
PMH: High blood pressure and diabetes

(Elaborate)
Patient concerns: Weight gain – 13 stones, height -170 cm, diabetes and high blood pressure.
145
POLYMYALGIA RHEUMATICA (PMR) REFUSING STEROIDS

Mrs. Janet James, aged 50, has been diagnosed with polymyalgia rheumatica. She is on steroids,
aspirin, lansoprazole and bisphosphonates. ESR and CRP are normal.

P: I don’t want to take steroids.
D: May I know why?
P: I don’t like the side effects of steroids.
D: What side effects are you experiencing?
P: I have gained 2 stones in last 1 year
D: Let me ask you few questions?
P: Okay
D: Any pain in your neck?
P: No
D: Any pain in your hips?
P: No
D: Do you have a severe headache that does not go away? (GCA)
P: No
D: Do you have pain in your jaw muscles that’s worse when eating? (GCA)
P: No
D: Do you have pain in your tongue when chewing? (GCA)
P: No
D: DO you have vision loss or double vision? (GCA)
P: No
D: Do you have difficulty sleeping?
P: No
D: Any increase in infections?
P: No
D: Any bruising?
P: No
D: Can you tell me about your PMR?
D: When were you diagnosed with PMR?
P: 1 year ago
D: Do you have pain or stiffness in your shoulders after waking up?
P: Not anymore
D: Have you ever been diagnosed with any other medical condition apart from PMR?
P: Yes, I have also developed high blood sugar and high blood pressure in the last 1 year.
D: Have you visited GP about this?
P: Yes
D: Did he advise any medications?
P: I was advised lifestyle modification
146
D: Have you been diagnosed with osteoporosis?
P: No (on bisphosphonates)
D: Are you currently taking any other medications, over-the-counter drugs or supplements other
than the ones for your PMR?
P: No
P: No
D: Any previous hospital stays?
P: No
D: Have you had any surgeries before?
P: No
P: No
D: Do you smoke?
P: No
P: No
P: I eat healthy
D: Tell me about your physical activity
P: I try to walk
P: No
D: What do you do for living?
P: Office job
P: No
D: Tell me about your home conditions?
I would like to check your vitals, do GPE and examine your joints. I would also like to check your
height and weight and see your BMI. I would also like to send for some routine investigations such
as FBC, U&E, creatinine, LFTs and RBS.
Examiner:
Weight: 13 stones (82.5 kg)
Height: 171 cm
From my assessment, it seems that unfortunately you are experiencing some side effects of
steroids. This can happen if you are prescribed steroids for long-term use.
Coping with side effects of steroid tablets:

The following tips may help reduce the side effects of steroid tablets:
- Take your tablets in the morning with breakfast (although some specially coated tablets can be
taken without food) – this may help prevent indigestion, heartburn and sleeping difficulties.
147
- Eat a healthy, balanced diet and exercise regularly – this may help prevent weight gain and
osteoporosis.
- Avoid close contact with people who are ill; especially people who have measles, chickenpox or
shingles – get medical advice as soon as possible if you think you may have been exposed to
someone with an infection
- Ensure your vaccines are up to date – but do not have any “live” vaccines, such as the shingles
vaccine.
We can talk to the consultant, and he may reduce your dose or suggest taking your tablets less
often (for example, every other day) if you are having side effects.
They may also sometimes recommend other medicines to take alongside steroids to protect you
from some of the side effects, such as medicines to help prevent indigestion or heartburn, or
medicines that help strengthen the bones.
As you mentioned you have high blood sugars and blood pressure since starting steroids, we can
recommend that you monitor your readings closely at home and continue with the lifestyle
changes we have advised. Meanwhile, the consultant may reduce the dose of the steroids
accordingly.
P: Can I stop the steroids completely?

D: Although your symptoms for PMR have improved since the treatment, you’ll probably need to
continue taking a low dose of prednisolone for about a total 2 years.
Polymyalgia rheumatica often improves on its own after this time. However, there’s a chance it will
return after treatment stops. This is known as a relapse.
Do not suddenly stop taking steroid medicine unless your doctor tells you it’s safe to stop. Suddenly
stopping treatment with steroids can make you very unwell. Stopping suddenly can cause your
adrenal gland, which makes important hormones for the body to stop working. This is known as
adrenal insufficiency.
148
STEROID REVIEW
Jackson Avery, 40 years old has called you to talk about certain concerns.
He is a known case of polymyalgia rheumatic.
He is on – lansoprazole, bisphosphonates, steroid
GRIPS
D: I see that you have made an appointment to talk to me, how can I help you today?
P: Doctor, I have certain concerns about the medications that I am taking.
D: Alright, I am here to address all your concerns but before that can you tell me a bit more about
why are you taking these medications?
P: For polymyalgia doctor.
D: Since when you were diagnosed?
P: It's been 6 months now doc.
D: How are you doing now?
P: I am fine doctor. Much better.
D: That's good to know.
Ask questions about – pain, joint stiffness (neck, hips, shoulders), tiredness, loss of weight and
appetite, depression. Ask questions about GCA (jaw pain, headache on combing, vision problems)
as it can co-exist with polymyalgia.
All symptoms will be better and under control.
Do a MAFTOSA relevant. Check compliance and side effects of medications.
D: What exact concerns about the medications you have?
P: I want to know the side effects of steroid.
D: Alright. Is there anything specific that is bothering you about steroids?
P: I just wanted to know doctor.
D: That's alright. Well there are quite a few S/E of steroids, can you tell me which steroids have you
been prefixed.
P: It's prednisone doctor.
D: Alright, the side effects can be very overwhelming, however, I would like you to know that not
all side effects happen to all patients taking the medication. And also we have prescribed certain
other medications with prednisone to neutralize the harmful effects.
One of the side effects is stomach ulcers. To prevent this from happening you have been prescribed
lansoprazole. This is PPI and protects your stomach from harmful effects of steroid that cause ulcer.
If you happen to notice any tummy pain, nausea, vomiting, PR bleed and black poo, this should be
considered serious and you shall see us immediately. We will review this medication. Are you
following me?
P: Yes
D: Also it can cause weakening of bones as a side effect of long term use of steroid and hence we
also prescribe medications like bisphosphonates to protect your bones and keep them strong.
However, this medication is supposed to be taken empty stomach in the morning with a full glass
of water and sit upright for 30 minutes, avoid lying down after taking this medication.
Are you taking them the same way?
P: Yes doctor.
149
D: Also steroids can cause increase in appetite which can lead to weight gain, so it is very important
to exercise and keep a watch on your diet so that you remain healthy. Is that something you can
do?
Correct DESA if relevant.
D: Also one more effect of this medicine can be depression or low mood. In case you ever feel low
or sad, this should be concerning, and for this I can give you a crisis card – on which you can call if
you ever feel low. How would you like that?
P: Okay doctor.
P: Doctor why should I take this medication, there are so many side effects.
D: I can see why you are so concerned, however, I would like to tell you that most of the side
effects are being taken care of and we do tell you about certain red flags if you face so that you can
reach out to us immediately. It is very important for the condition you have to be treated as it can
cause disabilities in the future if not treated at the right time, so the benefits of the medications
definitely outweigh the risk of side effects.
P: Alright doctor.
D: Is there anything else that I can answer for you today?
P: No doctor.
D: Okay, Jackson can you tell me how are you coping up with this condition at home/work?
P: Please offer physiotherapy and occupational therapist if required.
D: I hope I was able to answer all your queries. If there is anything else I can help you with please
let me know.
P: Thank you doctor.
150
POSTURAL HYPOTENSION
You are F2 in A and E

Mrs. Marley aged, 72 has been brought to the hospital with fall.
Please talk to the patient, take history, do relevant examination and discuss about
management with the patient. Patient doesn’t have her medications on her.
You will find extra information in the cubical.

P: I am falling frequently these days. It is happening from last few days.
D: Could you please tell me more about it?
P: Dr. I like going out with my friends. But now I am scared to go out with my friends.
Whenever I am standing I feel dizzy and then I fall. This time I was shopping in the mall, I felt
dizzy and fell down and then an ambulance brought me here.
D: How many episodes of fall till now?
D: Was there any difference in all the falls?
P: No
D: Any other symptoms before the fall?
P: No
D: Any light-headedness?
P: No
D: Any headache?
P: No
D: Any visual problem like blurry vision?
P: No
P: No
D: Any vomiting?
P: No
P: No
D: Any feeling of fullness in the ears?
P: No
D: Any balance problem while walking?
P: No
D: Do you feel like the room is spinning
P: No
D: By any chance did you hurt yourself
P: No
D: Any fever/flu like symptoms? (Confusion, pneumonia)
P: No
D: Any chest infection?
151
P: No
D: Any urine or bowel problem? (UTI, Constipation)
P: No
P: Yes, I have high blood pressure from last 5 years.
D: Are you taking medications for it?
P: Yes
D: Are you taking them regularly?
P: Yes
D: Do you know the name of the medication?
P: No
D: Any recent in change of the mediation?
P: Yes my GP changed 3 weeks ago.
D: Did you have all the falls after he changed your medication?
P: Yes
D: Any other medical conditions like DM, heart disease?
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
P: Yes/ No
P: Good Diet
P: I try to walk
P: No
P: I live alone / I live with my husband.
D: I would like to check your vitals. BP while standing and lying down, and examine your
chest and nervous system.
D: I would like to send for some initial investigations including routine blood test, blood
sugar and
ECG.
EX: BP standing- 110/70. BP lying- 150/90, PR- 80. T- 37. RR- 12-20. 02 Sat- 96
152
He will give an ECG which will be normal.
 From our assessment, we are suspecting you have a condition called postural
hypotension.
 It is a condition where BP falls when we change our position to standing posture from
lying down or sitting. This can lead to the symptoms like dizziness and fall like you are
having at the moment.
 We checked your blood pressure and it shows significant difference in lying and standing
BP.
 We also did ECG and fortunately it came back normal.
 This can be because of your new blood pressure medication that your GP has changed 3
weeks ago, so we need to confirm it with your GP about the medication and change your
blood pressure medication accordingly.
 You can’t let her go home if she is living alone.
 Please avoid sudden changes in the posture. Try to pause between changes in posture.
 Wear support stockings as this helps to return blood into the heart. Take them off before
going to bed. Keep the head end of your bed slightly elevated.
 Increase your fluid intake and take small and frequent meal.
 Avoid excess alcohol (If she is drinking).
 Follow up with your GP regularly.
 If you develop any weakness of one side of the body, any chest pain, breathlessness and
swelling in your leg call 999 immediately.
 Please try to be safe and keep any sharp objects away.
DD:
Visual impairment
Transient ischemic attack
Tachyarrhythmias or bradycardia,
Confusion (UTI, Pneumonia, Constipation)
Medications: especially benzodiazepines, antidepressants, and antipsychotics, alpha-blockers,
antipsychotics, antihypertensives, diuretics, beta-blockers.
153
FALL & HIP FRACTURE
You are F2 in Surgery.

Mrs. Sharon aged, 78 has recently had a fall and fractured the neck of her femur. She has
undergone a surgery. Your consultant has asked you to take history and find out the possible
cause behind the fall.
Please talk to the patient, take history, find out the cause of the fall and discuss about the
management plan with the patient.

P: Doctor I had a fall and I fractured my hip. I have been in the hospital and had a surgery two
days ago. Now I am recovering.
D: I'm so sorry to hear that. How are you feeling now?
P: I'm fine doctor, the surgery went well but I just want to know why did I fall.
D: Let me ask you some questions to find out the cause and to see how we can prevent this
from happening.
P: Ok.
D: Could you please tell me when did you have the fall?
P: It happened 3-4 days ago doctor.
D: Could you please tell me how did it happen?
P: Doctor, my husband and I love cooking. We were in the kitchen making lunch together. I was
standing and talking to my husband and I suddenly fell.
D: Did you have any symptoms before this happened?
P: I don’t think so
D: Do you remember what exactly happened during the fall?
P: I don't remember doctor.
D: Did you lose consciousness?
P: No.
D: Did you have any jerky movements/fits?
P: No, I don’t think so.
D: What happened after the fall?
P: I couldn't move my right leg. I was in pain so my husband called the ambulance. I came to
the hospital and they told me I have a fracture and they did a surgery for me.
D: How did you feel after the fall?
P: I was fine.
D: Did you feel confused, drowsy or sleepy before the fall?
P: No.
D: Any headache?
P: No.
D: Did you feel sick?
P: No.
D: Did you vomit by any chance?
154
P: No doctor.
D: Did you have any dizziness or lightheadedness before the fall? (Postural Hypotension)
P: No doctor.
D: Were you sweating before this happened? (Vasovagal Syncope)
P: No.
D: Did you become pale by any chance?
P: No.
D: Did you have any heart racing? (Cardiac Arrhythmias)
P: No.
D: How about any chest pain or chest tightness?
P: No.
D: Did you have any weakness in your face arms or legs. Slurred speech? (TIA)
P: No.
D: Did you have any headache before this happened? (Subdural Hemorrhage)
P: No.
D: By any chance do you have any fever?
P: No.
D: Do you have any cough or phlegm?
P: No.
D: Do you have any problems with your urine?
P: No.
D: Have you recently been constipated?
P: No.
D: Do you have any problems with your vision?
P: No.
D: Have you been short of breath, dizzy or tired recently? (Anemia)
P: No.
D: Has this happened before?
P: No/Yes (If yes then elaborate)
D: Have you ever been diagnosed with any medical conditions?
P: I have high blood pressure and arthritis.
D: May I know since when you have been diagnosed with high blood pressure?
P: I have been diagnosed 6 months ago.
D: How are you managing it?
P: I am taking tablets.
D: Do you know the name of the tablets you have been taking?
P: I don’t remember their names doctor.
D: Do you take them regularly as prescribed?
P: Yes doctor.
D: Have your medications been changed recently?
P: No.
D: Tell me about your arthritis?
155
P: It has been a few years and I take PCM for that.
D: Do you have any heart problems? Any high blood sugar?
P: No.
D: By any chance do you wear any glasses?
P: Yes, reading glasses
D: Was the floor wet or slippery when you fell?
P: It wasn't wet or slippery because every room in my house is carpeted.
D: By any chance, do you have any loose carpets?
P: No.
D: Does the house has enough light?
P: Yes
P: We try to be active.
D: Could you please tell me about your place? Do you have all the facilities on one floor?
P: My bathroom is on the ground floor and my bedroom is on the first floor.
D: Thank you for your cooperation. I would like to examine your vitals including lying and
standing blood pressure. Heart and central nervous system examination.
I would like to do some Routine blood tests, urine dip test and ECG.
From my assessment, we need to do some examinations and run some investigations.

1. The reason for fall is changes in blood pressure in different positions. So, we need to
check your blood pressure lying and standing. (Postural Hypotension)
2. Sometimes anemia or infections can cause fall. So, we need to do check your blood and
urine. (Anemia, Infection)
3. Irregular heart rhythm can lead to fall so we will do ECG.
4. We will check your blood pressure as it can be the reason of fall. We will review your
blood pressure medication.
5. Sometimes fall can happen due to a problem with your vision. We can arrange an eye
test for you.
 If all tests come back normal, the cause of the fall can be weakness in your muscles which
can lead to balance problems and falls.
 In that case, you may be able to receive a special training to improve the strength of your
muscles.
 Our physiotherapist colleague will assess you and see if you need any equipment to aid
you in walking. Sometimes having bone and joint problems can be the cause of fall so we
may need to review your arthritis by doing some imaging such as X-Ray or DEXA Scan.
We may need to give you some supplements such as calcium, vitamin D and
glucosamine.
 Our colleague's occupational therapist can come and visit your place to do the necessary
changes to prevent from falls happening in the future.
DD:
156
Postural hypotension
Anemia
Confusion (UTI, Pneumonia, Constipation)
Cardiac arrhythmias
DM, HTN
Vision Problems
157
ANALGESIC NEPHROPATHY
You are an F2 in GP.

James Anderson aged, 30 came to the clinic with a new problem. His eGFR low and
Creatinine is High.
Please talk to the patient, discuss plan of management with the patient and address his
concerns.
D: Hi I am one the junior doctors in this GP surgery can you confirm me your name and age
please.
P: Yes Dr. my name is James Anderson I am 30 years old.
D: How would you like me to call you ?
P: James Is fine Dr.
D: Ok James, what brought you here today?
P: I am losing blood in my urine
FODPARA
P: It's been happening for the last couple of days when I pass urine.
D: How much blood did you notice?
P: I don't know
D: Any blood clots in urine?
P: No
D: Any pain while passing urine?
P: No
D: Any change in your urine color or smell?
P: No
D: Any fever or flu like illness?
P: No
D: Do you have to rush to the loo?
P: No ( BPH )
D: Are you going to the loo more often?
P: No
D: Any burning sensation while passing urine?
P: No ( UTI )
D: By any chance have you hurt yourself anywhere?
P: No
D: any instrumentation in urethra ?
P: No ( TRAUMA )
D: Any pain in your pelvic area?
P: No
D: Any pain in your tummy?
P: No
158
D: Any bony pain/?
P: No
P: No ( ANEMIA )
D: any dizziness or heart racing?
P: No
D: Any rash or bruise anywhere in the body?
P: No (BLEEDING DISORDER)
D: Any bleeding from anywhere else?
P: No
D: Any change in the color of stool that you noticed?
P: No
D: do you have any blood disorders ?
D: Any lumps or bumps anywhere in the body?
P: No ( CANCER )
D: Any weight loss recently you noticed?
P: No
D: has anyone told you that you are losing weight?
P: No
D: How's your appetite?
P: Good
D: Any swelling in the ankles?
P: No ( CKD )
D: Any tingling or numbness in your arms or legs?
P: No
D: Any nausea or vomiting?
P: No
D: Is there anything else bothering you?
P: Dr I have this back pain for around 2 years, but it's not something new. I have been referred
to the specialist for that and they could not find out any cause for it.
D: How are you managing It?
P: I have been taking Ibuprofen almost every day for more than 2 years now.
D: How are you doing in terms of the pain now?
P: Its under control as I am taking the painkillers.
MAFTOSA
D: any similar problem in the past?
P: No
D have you been diagnosed with any medical condition in the past?
P: No
D: By any chance any kidney or bladder problems?
P: No
159
D: Are you currently on any medication except the painkillers ( CYCLOPHOSPHAMIDE AND
PENICILLIN BLOOD THINNERS )?
P: No
D: Are you allergic to any medication?
P: No
D: Any family history of any significant health issues or kidney problems?
P: No
D: Do you smoke?
P: No
D: Do you drink Alcohol?
P: No
P: Balanced
P: Yes/No
D: Have you ever worked in Aniline, Dyes, Textiles, rubber, plastic or paint industries in the
past?
D: Any strenuous exercises recently? ( risk factor )
D: do you have any IDEA of what is going on with you ?
P: No
EXAMINATION
I would like to do a GPE, check the BP , PULSE , RR , TEMP and Examine your back. I would
like to order initial investigation like routine blood test. Renal function test and Urine dip.
Examiner: BP 145/95
Urine Dip: Protein +; blood+, sediment+,
FBC: Anaemia , WBC increased
MANAGEMENT
From what you have told me and from what we have assessed we suspect you are having a
condition called Analgesics nephropathy. It is a condition that happens due to long term
consumption of painkillers resulting in kidney damage.
The mainstay of treatment is to stop taking all the painkillers right away to prevent further
damage to the kidneys and may help in the normalization of kidney functions.
P : why this happened to me ? (CONCERNS)
D: long term Use of analgesics.
RISK FACTORS
Use of OTC analgesics , self medications
Taking 6 or more pills a day for at-least 3 years
P: what are you going to do for me ? (CONCERNS)
160
I will inform my SENIORS who will review you again and we will be REFERRING you to a
Kidney specialist for further investigation and treating existing kidney problems. They may
also consider doing a CT SCAN to confirm the diagnosis.
P: will I be alright after the treatment? (CONCERNS)
The aims of treatment are to prevent further damage and to treat any existing kidney failure
- e.g., with dietary changes, fluid restriction, dialysis or kidney transplant may also be
considered in advance stages of the disease. Unfortunately they may not reverse the
already established changes in kidneys
P: what about my pain management ? (CONCERNS)
We will be referring you to the pain management team who will help you tackling the long-
term pain that you are having. Some behavioral changes or counseling can help to control
chronic pain.
COMPLICATIONS
Pyelonephritis
End stage kidney disease
RED FLAGS
Uncontrolled bleeding, unable to pass urine, breathing difficulty or swelling in your body
come back immediately
FOLLOW-UP WITH YOUR GP

Leaflets
Specific expectations from this consultation
I wish you a good health.
161
URAEMIA & HYPONATRAEMIA
You are F2 in A&E.

Patient aged, 82 admitted to the hospital because of new problem. He is confused now.
Talk to his daughter and discuss management plan with her and address her concerns.
There are some blood tests inside the cubicle.
Results:
Hb- 122*
WBC- Normal
Na-115
Urea- raised
Creatinine- raised
D: How can 1 help you?

P: I am worried about my father as he is confused.
D: Could you please tell me more about his condition?
P: Actually his problem started 2 weeks back but now it is getting worse and now he is not
even recognizing me.
P: No
D: How was he before that?
P: He was absolutely fine.
D: How was he recently?
P: He was fine.
D: Any fever flu like symptoms?
P: No
D: Any Cough? (Pneumonia)
P: No
D: Any problem with urine? (UTI)
P: No
D: How is his bowel habits? (Constipation)
P: it was ok.
D: Has he been diagnosed with any medical condition in the past?
P: Yes, he has high blood pressure and he had stroke 5 years back.
D: Is he taking any medications for it?
P: He is taking amlodipine, statin and aspirin. She will show you 3 bottles of medications)
D: Is he taking it regularly?
P: Yes
D: How did stroke affected his life?
P: He recovered fully after the stroke.
162
P: No
D: Any thyroid or DM?
P: No
D: Is he taking any other medications including OTC or supplements?
P: No
P: No
P: Yes, recently he was admitted in the hospital and he was given water tablets.
D: May I know why he was admitted recently?
P:
D: Does he smoke?
P: No
P: No
P: Good
D: Is he physically active?
P: Yes
P: No
D: who does he live with?
P: He lives alone.
D: was he able to carry out normal day today activities?
P: Yes, but not from last 2 weeks.
D: who is taking care in last 2 weeks?
P: Carers are coming at home and I was also visiting him.
D: I would like to check his vitals, GPE and neurological examinations.
 From our assessment he has problems with his kidneys.

 We have checked his blood and the Hb was a bit low. We have done kidney function
tests. It shows that urea and creatinine are increased.
 Urea is a waste product which is formed from the breakdown of proteins. A high level
can indicate that your kidneys may not be working properly or it can also mean that he is
dehydrated.
 However, creatinine is a waste product which is formed by the muscles. A high level of
creatinine also shows that your kidney isn’t working properly.
 We also checked his level of Sodium in the blood which is low which can cause confusion.
 He has kidney failure. His kidney is not functioning properly. His high blood pressure
would have caused the kidney failure. Kidney failure causes raised urea which in turn can
cause confusion.
163
 Also you mentioned that he was admitted recently in the hospital and he was given
water tablets which actually can lead to decrease in the sodium in the blood. And also
the other medication Amlodipine which he is taking for his blood pressure can also be
the cause of this problem.
 We will admit him and we will do other tests to make sure that he has no other problems
causing this confusion, we will check his sugar level, thyroid function test, vitamins level
in his body.
 We will give him some fluids which contains sodium IV as a drip. Hopefully he will
recover soon.
 He may require dialysis.
 It is recommended not to drink too much water in this condition.
164
UTI (CONFUSION)
You are F2 in A&E.

Henry aged, 75 brought to the hospital by his wife because of confusion. He was diagnosed
with UTI 3 days ago.
Please talk to them and address their concerns.

P: “Where am I?” “what am I doing here?”
P: I don't know why is he behaving like this?
D: Could you please tell me what exactly is the problem?
P: He is acting strangely Dr. He is not talking to me. He is confused. He is asking questions like
Where am I?” “what am I doing here?”
D: I am so sorry to hear that. May I know since when is he behaving like this?
P: Since yesterday.
P: Why is he behaving like this DR.?
D: Let me ask you a few questions first, so that we can find out why is he behaving like this?
P: Ok Dr.
D: How is health recently?
P: He has got fever Dr 3 days ago.
D: Did you measure the temp?
P: No
D: Did he have any symptoms along with fever?
P: He was having burning sensation while passing urine and also he was going to the loo more
often
D: May I know since when is he having these symptoms?
P: Since 3 days.
P: No Dr.
D: Any blood in his urine?
P: No
D: Any tummy pain?
P: No
D: Any back pain or loin pain?
P: No
D: Is he feeling tired recently?
P: Yes
D: Any chills or shivering?
P: No
P: No
D: Any change in his weight?
165
P: No
D: How about his appetite?
P: Good
D: Did you do anything for his fever and urinary symptoms?
P: We went to the doctor and he told us that my husband has got an infection of his urinary
system (UTI).
D: Was he given any medication?
P: He was prescribed antibiotics (Trimethoprim).
D: Was he taking them regularly?
P: Yes
D: Did he have any similar kind of problem in the past?
P: No
D: Is he been diagnosed with any medical condition in the past?
P: No
D: Is he currently taking any regular medications, over-the-counter drugs or supplements?
P: No
P: No
P: No
P: No
D: Any similar complaints in any member of the family?
P: No
D: Do you smoke?
P: No
P: No
D: How is his diet?
P: Fine but he is not eating or drinking anything now.
D: Don’t worry, we will take care of his eating and drinking.
D: I would like check his vitals, GPE (Temp. Pulse Rate, Resp. Rate. BP) and also examine his
chest, tummy and nervous system.
EX:
BP-80/50, PR-110. T- 38C, Sats-90%
P: What’s going on doctor? Why is he behaving like that?

D: We are suspecting he is having a condition called septic shock. We have checked his
blood pressure which was low and the pulse rate was high. We also checked his oxygen
saturation which is low and his temperature is high.
166
P: Why is he behaving like this?
D: He is in confusion because it is the complication of Urinary Tract Infection.
P: How can UTI cause this Dr.?
D: This is one of the complication of UTI. In fact, any infection at this age can cause
confusion. Our immune system changes as we get older, it responds differently to the
infection. Instead of pain symptoms, sometimes old age people with such kind of infection
like UTI may show increased signs of confusion, agitation or withdrawal.
D: What are you going to do for him now?
D: We are going to admit him and we will do necessary investigations like Bloods
(FBC/U&E’s/LFT/Glucose/ABG/Clotting Screen/Blood Culture). Urine test, ECG. Imaging
(Abdominal USG). We will also measure his urine output.
We will give him oxygen.
You told me he is not eating or drinking anything, we will give him fluids through his blood
vessel as a drip.
We will give him antibiotics through his blood vessel (Vein) to treat the infection.
SEPSIS SIX: within one hour.
Give high flow of 02, IV Antibiotics, IV Fluids to the patient.
Take Blood culture, serum lactate, and hourly urine output.
We will give him pain killers if he has any pain.
Once the infection is controlled, his symptoms should come back to normal.
P: How long are you going to keep him in the hospital?

D: We will keep him in the hospital till he gets better and his infection is treated. We will
confirm this by doing blood tests.
D: May I know if you have any concern for him to stay in the hospital?
P: No doctor
167
ELDERLY CONFUSION TC
You are F2 in AMU.

Mrs. Olive Green aged, 85 has been referred to the hospital from a care home.
Patient is confused and agitated. You are not able to talk to her to take any history. There is
no medical record or reference letter from the care home.
You are not able to examine her.
Vitals has been recorded and are as follows.
BP: 90/60 mmHg, Pulse: 120/min, RR: 2-l/min, Temp: 38.5, 02 Stat: 88%
Call care home, talk to the member of care home and take history about the patient.
After 6 mins talk to examiner regarding the provisional diagnosis and discuss the
management in the best interest of the patient.
D: Hello
N: Hello, I am Sarah, one of the staff in this care home. How can I help you?
D: I'm calling regarding Mrs. Olive Green who was referred from the care home.
N: I've just come to the shift this morning, so let me get the file and check record.
OK, I have the file here with me. What do you want to know?
D: Why she was referred to us?
N: She was confused and agitated. She was not able to breathe properly.
D: How long she was confused?
N: This morning.
D: Has it changed?
N: Yes, that’s why we sent her to the hospital
D: When did the breathing problem start?
N: From last night and it was also getting worse.
N: Like what.
D: Any cough? Phlegm? Any fever or flu like symptoms? Any chest pains? Nausea vomiting?
Loss of appetite? Heart racing? Any headache or body ache? Joint or muscle pain? Urine
problem? Any
diarrhea or constipation?
D: Did she have similar kind of problem in the past?
N: No
D: Have she been diagnosed with any medical condition in the past?
N: She had stroke 3 years ago.
D: Is she taking medications for it?
N: Aspirin, enalapril and simvastatin
D: Does she take the medications regularly?
N: We usually give the medication.
D: How is she managing?
N: She moves around with the help of frame.
168
D: Any problem with speech? Is she able to feed by herself? Is she able to do routine
activities?
D: Any other medical condition? DM. HTN, Heart problem?
N: No
D: is she taking any medications including OTC or supplements?
N: No
N: No
N: Yes. last year because of her chest infection.
D: How was she treated?
N: She was treated with some medications.
D: Is there anyone else in the care home with a similar problem? (CAP)
N: No.
D: Does she smoke?
N: No
D: Does she drink?
N: No
D: Does she eat properly?
N: We give healthy food and she eats OK.
D: Does she drink enough water?
N: Yes/No
D: Does any family member come to see her in the care home?
N: No, she is a widow. No one comes to visit her.
From our assessment, It looks like she is having septic shock due to the chest infection as
she is confused, has tachycardia, hypotension and high temperature and her 02 Sats are low.
She also has shortness of breath.
I would like to do necessary investigations like Bloods (FBC/U&E’s, LFTs, Glucose,

ABG/clotting screen, Blood Culture). Urine test, ECG, Imaging (CXR/Abdominal USG)
SEPSIS SIX: within one hour.

Give High flow of 02, IV Antibiotics, IV Fluids to the patient.
Take Blood culture, serum lactate, and hourly urinary output
I will discuss with my senior and use broad spectrum antibiotic based on the hospital
protocol. We may consider Co-Amoxiclav 1-2g TDS IV & Clarithromycin 500mg BD IV.
169
UTI & BPH
You are F2 in GP
Mr. Arthur aged, 75, presented to the hospital with dysuria.
Please talk to the patient, take history, do relevant examination and discuss about your
initial plan of management with the patient.
D: Hello, this is Dr. XYZ, I am one of the junior doctors over here. Can you please confirm
your name and age please.
P: I am Arthur, 75 years old
D: Nice to meet you Arthur, how are you doing today?
P: I am doing fine doc, how about you?
D: That is great to know. I am doing fine as well. D: What brought you to the hospital?
P: Dr. while passing urine I have burning sensation
P: It is there from last few days and is getting worse.
D: Is there any other symptom that is bothering you?
P: I have tummy pain here (points towards lower tummy) from last few days.
P: It is gradual and becoming worse.
P: It is dull pain.
P: No
P: I tried PCM but it didn’t help.
D: How many did you take?
P: I took 2 tab. Yesterday.
P: It is getting worse.
D: Could you please score the pain on a scale 1 to 10, where I being no pain and 10 being the
P: Around 5 doc
P: lam going to the loo more from last few weeks.
P: No
D: Any fever, chills or flu like symptoms?
P: Yes dr. I had some flu like symptoms.
D: Since when?
170
P: From last few days
D: How are you now ?
P: I am fine now.
D: Any changes in your urine colour or smelly?
P: Yes, it is smelly and cloudy these days.
D: Any blood in it?
P: No
D: Any nausea and vomiting?
P: Yes/ No
D: Do you have increased frequency of urine at night?
P: Yes (Nocturia)
D: How many times you have to wake up during the night?
P: 2-3 times.
P: Yes/No (Urgency)
D: Do you have to Strain while urinating?
P: Yes/No
D: Do you have Difficulty in starting urination?
P: Yes/No (hesitancy)
D: Are you able to hold your urine before going to loo?
P: Yes/No (Incontinence)
D: Do you have Weak urine stream or a stream that stops and starts?
P: Yes/No (poor or weak stream or urine intermittency)
D: Do you feel like that you are not able to completely empty the bladder?
P: Yes/No (Poor emptying)
D: Have you noticed any Dribbling at the end of urination? Does a bit of urine drop and stain
your underwear soon after you finish toilet?
P: Yes/No (Dribbling)
D: Have you noticed any weight loss? (Cancer)
P: No Doctor.
D: Someone your friends or family told you are losing weight?
P: No.
D: How is your appetite?
P: It’s fine doctor
P: I try to eat healthy, mostly fruits and vegetables
D: Any tiredness or SOB?
P: No
D: Any pain, swelling or hotness in your private part? (epidydimoorchitis)
P: No
P: Yes/No
171
P: No
D: Any diabetes, high blood pressure, high cholesterol or heart disease
P: No
D: Any big prostate or history of passing stone in your urinary tract?
P: No
D: Are you taking any medications including OTC or supplements
P: No
D: Any long term antibiotics or steroids?
P: No
P: Yes, I am allergic to penicillin
P: No
D: Any instrumentation in your urinary tract?
P: No
P: No
D: Do you smoke?
P: Yes/No
P: Occasionally
P: I live with my wife.
D: I would like to examine your vitals, examine your tummy and back passage.
D: I would like to send for some initial investigations including routine blood tests, urine dip.
EX: BP- 110/70, HR- 70. T- 38C, 02 sat- 96

Abdomen: Tenderness over suprapubic area.
PR: Both the lobes of prostate are enlarged and prostate is smooth.
Urine dipstick- Nitrates, Leucocytes and Micro-hematuria.
ICE
DIAGNOSIS & MANAGEMENT

 From our assessment, we are suspecting you have a condition called urinary tract
infection due to enlarged prostate.
 Urinary tract infection is a condition in which bugs grow in your bladder and the
surrounding structures and causes the symptoms like you are having. We did a urine test
that shows you have bugs in your urine. We will send your urine sample to find out which
bug is causing your problem.
172
 We will give you some antibiotics. As you told me you are allergic to penicillin so we will
give you some other medications. Hopefully, your symptoms will improve within few
days. If your symptoms do not quickly improve despite taking antibiotics, we may need
to change your antibiotics. We may also change your antibiotics according to the bug that
is causing your infection.
 We will give you some painkiller for your pain and anti-sickness medication for nausea.
However, sometimes it may cause confusion or you may develop some high
temperature, loin pain or shivering. If any of these happen, you need to come back to the
hospital.
 Prostate is a walnut-sized gland that is located under your bladder. The tube connecting
your bladder to your penis goes through this gland. Prostate gets enlarged as your age
increases and it can cause blockage of your urine in your bladder. This can create a good
environment for the bugs to grow and can cause urinary infection. We examined your
prostrate and it is enlarged.
 You will be given a urinary frequency-volume chart. This will give a record of how much
water you normally drink, how much urine you pass, and how often you empty your
bladder on a daily basis, as well as any leakage you have.
 You will be given a IPSS questionnaire which allows us to better understand how serious
your symptoms are.
 We will do a special blood test to measure the amount of substance produced by your
prostate gland (PSA).
 We may do an ultrasound from your back passage to check the size of your prostate and
we may take a sample as well (TRUS).
 We may do a special CT scan to check the blockage in your urinary system (CT Urogram).
 We will give you a medication to relax the muscle in the prostate gland and the neck of
the bladder, making it easier to pass urine (Tamsulosin). We will give you a medication to
shrink the prostate gland (Finasteride).
 If medication didn’t work, we can do surgery and remove a part of your prostate gland to
prevent your symptoms.
 We will tell you about bladder training, it is an exercise program that aims to help you go
for longer without peeing and hold more pee in your bladder.
 Drink less fluids in the evening, please cut down the amount of tea, coffee and alcohol.
Please take more fruits and vegetables that will help you in constipation and ultimately
will not put strain on your bladder.
 Please follow up with your GP regularly.
 If you are not able to pass urine please come to A&E or call 999 and ask for ambulance.
Treatment of UTI:
Nitrofurantoin (100 mg BD for 3 days)
Trimethoprim (200 mg BD for 3 days)
173
S/E of nitrofurantoin and Trimethoprim: Nausea, vomiting, diarrhoea, loss of appetite,
itching and rash.
P: What is UTI?
P: Are you going to give me any medication?
P: What is BPH?
P: What are you going to do for BPH?
P: Are you going to give me any medication?
P: What should I do for my BPH?
P: What if medications are not helpful?
P: Doctor, is it a cancer?
D: May I know why are you concerned about cancer?
P: Doctor, because my friend had prostate cancer.
D: I’m so sorry to hear that! From what you told me, there was not symptom that suggests
you have a cancer. From the examination that we have done, the surface of your prostate
gland was smooth. This means it is most likely a benign condition. However, we are going to
run further investigations to make sure everything is fine.
DD:
UTI
BPH
Prostate cancer
Stones
Pyelonephritis
Epididymo orchitis
174
ENDOCRINE STATIONS
HYPOTHYROIDISM
You are F2 Medicine.

Mrs. Matilda aged, 60 presented to the hospital with feeling of tiredness.
Please take a focused history, assess the patient, give your possible diagnosis to the patient
and discuss your initial plan of management with her.

P: I have been feeling tired recently
P: It all started 2 years ago after my husband passed away.
D: I am so sorry about your loss. Has it changed since it started?
D: Do you have it all the time or time to time?
P: All the time
D: Do you feel tired by doing any activity or even without doing anything?
P: I have it even without doing any activity. I cannot do my daily activities because of this.
D: Is there anything that makes your tiredness worse?
P: No
D: Is there anything that makes your tiredness better?
P: No
D: Any particular time of the day that you feel more tired?
P: Throughout the day.
D: Do you have any other symptoms?
P: No
D: Do you feel dizzy or light headed?
P: No
P: Good
P: No
D: Have you gained any weight?
P: Yes, I feel that I have gained some weight. My clothes are getting tighter.
D: May I know how much weight did you gain and in how much time?
P: Few kilos in last few months.
D: Was it intentional?
P: No
D: Do you feel cold when others are not?
175
P: Yes, I feel cold when others are feeling hot. This happens even in summer when it is warm.
When did this start?
P: Few months.
D: Do you feel any sensation of pins and needles anywhere in your body?
P: No
D: Any dry or rough skin?
P: No
D: Do have any dry hair?
P: No
D: Any pain anywhere in your body?
P: No
D: Tell me about your bowel habits?
P: I have constipation from the past few months.
D: How often do you go to the loo to open your bowel?
P: Twice a week
D: How was it before this?
P: I used to go to the loo once a day.
P: Yes/ getting worse
D: Have you noticed any blood in your stool?
P: No
D: Did you have any diarrhoea in between?
P: No
P: My mood is low all the time. I am always crying since my husband passed away.
D: I am so sorry for your loss. Let assess you by asking few' more questions please.
D: Did you have any fever or flu like symptoms during this period or before your tiredness
started?
P: No
(If patient is young ask menstrual history, look for menorrhagia)
P: No
P: No
D: Any diabetes or Addison’s disease? (Endocrine diseases)
P: No
D: Any thyroid problems before?
P: No
D: Any heart or kidney disease?
P: No
D: Any autoimmune disease like SLE. RA? (Autoimmune diseases)
P: No
176
P: No
P: No
P: No
P: My daughter has anemia.
D: Any thyroid problems in the family?
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: Good
P: Yes/No
P: No
P: I am retired
P: I live alone
P: Fine
D: Do you still enjoy the things that you use to enjoy in the past?
P: Yes
D: Have you ever tried to harm yourself?
P: No
(Depending on the age ask for sexual history, look for loss of libido)
I would like to check your vitals and examine your thyroid gland.
I would like to send for some initial investigations including routine blood test, special blood
test for your thyroid gland and ECG.
 From our assessment, we are suspecting you have a condition called hypothyroidism. In
this, your thyroid gland which is gland in your neck in front of your wind pipe, doesn't
produce enough hormone.
 We will do further investigations, blood tests to check if you have anemia or any
infection and also to check the function of your kidney and liver.
 We will also do blood tests to check the level of sugars and cholesterol in your blood.
177
 We will check the amount of hormone produced by your thyroid gland.
 We will check the amount of some vitamins and minerals in your blood.
 The main treatment option for hypothyroidism is restore the hormone which is low in
your body, we give this in the form of a tablet. This medication is called Levothyroxine.
We will start with lowest doses possible, do serial blood tests and regular follow ups and
increase the dose to the optimum level.
 Levothyroxine should be taken every day with water on an empty stomach and food
should not be eaten for at least 30 minutes after the tablets.
 It takes about 7-10 days for levothyroxine to absorb fully into the body so you may not
feel any improvement for a couple of weeks. Improvement may be slow so patience may
be needed especially if you have been ill for some time. You may need to take it easy for
a while until the correct dosage is achieved.
 You will need to have your thyroid tested on an annual basis once you become balanced.
It's a good idea to keep a diary and include test results, the amount of thyroid medication
and any symptoms you have on a scale of 1-10 so that you can see where you feel best
within the range.
 There's evidence that exercise can help depression, and it's one of the main treatments
for mild depression. You may be referred to a qualified fitness trainer for an exercise
scheme. Talking through your feelings can be helpful. You could talk to a friend or
relative, or you can ask your GP to suggest a local self-help group. Your GP may also
recommend self-help books and online cognitive behavioral therapy (CBT).
 Levothyroxine usually doesn’t have any side effects. Side effects can occur if the dose
you're taking is high. This can cause problems including sweating, chest pain, headache,
restlessness, diarrhoea and vomiting.
 If you get any chest pain, heart racing please tell your GP.
 There are quite a few things that can interfere with levothyroxine, such as foods,
beverages and drugs. Look out for Brussel sprouts, cauliflower, cabbage,, almonds,
peanuts and walnuts, sweetcorn, millet, coffee.
 Consult your doctor before taking any medication.
P: What's going on doctor?
P: What is hypothyroidism?
P: What are you going to for me?
P: For how long do I have to take this medication?
P: Are there any side effects of this medicatio
DD
Hypothyroidism
Depression
Carcinoma
DM
178
HYPERTHYROIDISM (WEIGHT LOSS/TREMOR & SWEATING)
You are the F2 in GP.

Sue Smith, aged 22 presents to Clinic to see you about her problem.
Please talk to patient take a relevant history, assess the patient and discuss about plan of
OR
You are the F2 in GP.
Sue Smith, aged 40 presents to Clinic with Tremor & Sweating.
Please talk to patient take a relevant history, assess the patient and discuss about plan of

P: My boyfriend told me that I am losing weight.
D: What do you think?
P: Yes, my clothes have become looser
D: How much weight do you think you have lost?
P: Around 1 stone
P: No. I am actually eating more these days.
D: In how much time period you think you have lost your weight?
P: In last, few months.
P: I feel hot these days when other people are fine.
D: Since when did you notice this?
P: In last few months.
P: I feel that my heart is racing sometimes.
D: Since when?
P: In last few months.
P: No.
D: Do you feel sweaty?
P: Yes/No
P: Yes/No
D: Do you have any sleep problem?
P: Yes/No
D: Any recent change in your mood?
P: Yes/No
D: Have you noticed any hand shaking?
P: Yes/No
179
D: Have you noticed any hair loss?
P: Yes/No
D: Did you notice any changes in your bowel movements?
P: For last few weeks I am going to loo 3-4 times a day.
D: How was it before?
P: Previously I used to go once a day.
D: Do you need to pee more often than usual?
P: No
D: Do you have any itchy rash?
P: No
D: Could you please tell me about your periods?
P: Dr. In last, few months, my periods has become lighter than before.
D: When was your last menstrual period?
P: 2 weeks back
D: Any lump and bump in your body? (Cancer)
P: No
D: By any chance any tummy pain? (IBD)
P: No
D: Do you any blood in your stools? (IBD)
P: No
D: Any fever or flu like symptoms? (GI Infections)
P: No
P: No
P: No
D: Any diabetes or Addison’s disease? Endocrine diseases)
P: No
D: By any chance any heart or kidney disease?
P: No
D: Any autoimmune disease like SLE, RA? (Autoimmune diseases)
P: No
P: No
P: No
P: No
P: My sister has got the same problem.
D: Do you smoke?
P: Yes/No
180
P: Yes/No
P: Nowadays I am taking 3-4 meals per day which includes sandwich and burgers
P: Yes/No
P: No
D: Did you travel recently abroad?
P: No (TB)
P: Yes
D: Do you practice safe sex? (HIV)
P: Yes
D: I would like to check your vitals and examine your thyroid gland.
D: I would like to send for some initial investigations including routine blood test, special
blood test for your thyroid gland and ECG.
EX: - Vitals: BP-120/80, PR- 120, T-37. RR-12-20, 02 sat-96

TSH- 0.3 (0.5-4.5 mU/1)
T3- 6.2 (3.5-7.8 microgram/dl)
T4- 35 (4.6-12microgram/dl)
 From our assessment, we are suspecting you have a condition called hyperthyroidism. In
this, thyroid gland produces more hormone.
 We will also give a medication called beta blocker to quickly relieve your symptoms.
 We have done some blood test, which shows your thyroid gland is producing too much
hormone.
 We will refer you to Endocrinologist and you may be prescribed some medications, which
will stop the production of excess hormones such as Carbimazole.
 You will have to take the medication for a month or two before you notice any benefit.
 Once your thyroid hormone level is under control, your dose may be gradually reduced
and then stopped. But some people need to continue taking medication for several years
or possibly for life.
 There are some mild side effects like feeling sick, headache, joint pain, tummy discomfort
or rashes but these should pass as your body gets used to the medication.
 You have to take this medication regularly as prescribed and follow up regularly with
your GP.
 In the future if you are planning to become pregnant, please let us know, we can make
some changes in your medications.
181
 If you develop high temperature, diarrhoea, vomiting, yellow discolouration of the eyes
and skin, agitation and confusion call 999 for an ambulance immediately.
If patient asks:
The other treatment is Radio-iodine treatment in which radiation is used to damage your
thyroid, reducing the amount of hormones it can produce. You're given a drink or capsule
that contains a low dose of radiation, which is then absorbed by your thyroid.
There are some precautions you'll need to take after treatment:
D: By any chance are you pregnant, breastfeeding or planning to become pregnant?
P: No
1. You should avoid prolonged close contact with children and pregnant women for a few
days or weeks.
2. You should avoid getting pregnant for at least six months
3. Radio-iodine treatment isn't suitable if you are pregnant or breastfeeding.
Severe side effects of medications:

A less common but more serious side effect is a sudden drop in your white blood cell level
(agranulocytosis), which can mean you're very vulnerable to infections.
Contact your GP immediately if you get symptoms of agranulocytosis, such as a fever, sore
throat or persistent cough, so a blood test can be carried out to check your white blood cell
level.
DD:
Weight loss
Malignancy
GI infections
Hyperthyroidism
Diabetes Mellitus
HIV
TB
IBS
IBD
Anorexia Nervosa
Bulimia Nervosa
Tremor Sweating
Hyperthyroidism
Hyperventilation
Hypoglycaemia
Arrhythmias
Ventricular ectopics
Stress
Anxiety / panic attack
Pheochromocytoma
Medications like Salbutamol
Menopause
182
THYROID ANNUAL REVIEW
You are F2 in the GP

Lucy Talbot aged, 40 came for annual review. She was diagnosed with Thyrotoxicosis and
taking carbimazole from last one year. Talk to her and discuss plan of management.

P: I came for my thyroid review. I had overactive thyroid. I am on medication for that.
D: I am glad that you came for the follow up. Let me ask you a few questions to see every
thing is fine with your condition?
P: Ok
D: How are you now?
P: No
D: Do you have any problems now?
P: No
D: Any weight change? Weight loss or weight gain?
P: No
D: Any change in bowel habits? Any diarrhoea or constipation?
P: No
D: Do you feel that your heart is racing?
P: No
D: Tell me about your periods?
P: It is regular
D: Any problem with the periods?
P: No
P: 2 weeks back
D: May I know what medications are you taking now?
P: I am taking carbimazole
D: May I know how much?
P: I take 5 mg once a day
D: Are you taking it regularly?
P: Yes
D: Since how long you had this problem?
P: From last one year
D: How is your health is general?
P: I am fine
P: No
D: Any rashes?
P: No
D: Any itching or yellow discoloration of your eyes and skin?
183
P: No
P: No
D: Any plans to become pregnant in near future?
P: No, my husband had vasectomy
P: No
D: Are you taking any other medications apart from your thyroid medication?
P: No
Examination:
a. Exposure
b. Chaperone
c. Being gentle
d. Consent
e. Position sitting
INSPECTION
 We are looking for any anxiety or agitation (agitiation, anxiety – hypothyroidism)
 Verbalize: Patient doesn’t look agitated
HANDS
1. We are looking for Dry' skin (hypothyroid). Increased sweating (hyperthyroid). Palmar
erythema - reddening of the palms at the thenar / hypothenar eminences
(hyperthyroidism)
2. Touch patient hand and look for dry skin and increased sweating.
❖ Verbalize: There is no palmer erythema, increased sweating and dry skin.
TREMORS:
Peripheral tremor can be a sign of hyperthyroidism.
1. Ask the patient to place their arms straight out in front of them.
2. Place a piece of paper across the backs of their hands
3. Observe for a tremor (the paper will quiver)
❖ Verbalize: There is no tremor.
PULSE
> We are looking for bradycardia (Hypothyroidism) and tachycardia (1
Rhythm - irregular (atrialfibrillation) - thyrotoxicosis
❖ Verbalize: Pulses are regular.
EYES
184
1 We are looking for any redness, inflammation of the conjunctiva. Exophthalmos and
Ptosis.
2 Inspect from the front, any redness I inflammation of the conjunctiva.
3. Inspect the sides (Exophthalmos)
4. Inspect from behind (Ptosis)
❖ Verbalize: There is no redness or inflammation of the conjunctiva. I am going to your side
or to your back, there is no exophthalmos (From sides). There is no ptosis (From the back)
Bilateral exophthalmos is associated with Graves ’ disease, caused by abnormal connective
tissue deposition in the orbit and extra-ocular muscles.
Exophthalmos (anterior displacement of the eye out of the orbit)
Eye movements
1. Ask the patient to keep their head still and follow your finger with their eyes only.
2. Move your finger in front of eye and make H.
3. Obsei estriction of eye movements and ask the patient to report any double vision or
pain
❖ Verbalize: There is no diplopia or pain on H test.
Eye movement can be restricted in Graves' disease due to abnormal connective tissue
deposition in the orbit and extra-ocular muscles.
LID LAG
1. Hold your finger high and ask the patient to follow it with their eyes, whilst keeping their
head
still.
2. Move your finger downwards
3. Observe the upper eyelids as the patient follows your finger downwards
❖ Verbalize: There is no lid lag.
Lid lag occurs as a result of the exophthalmos (Graves’ disease)
THYROID
1. We are looking for skin changes, scars, masses and swelling.
2. Note any swellings or masses in the area - assess size and shape
3. The normal thyroid gland should not be visible.
❖ Verbalize: There are no skin changes, scars, masses and swelling.
4 Ask the patient to swallow some water.
5. Ask patient to protrude their tongue:
6. Observe the movement of the mass
❖ Verbalize: There is no movement of any swelling on swallowing or tongue protrusion.
Masses embedded in the thyroid gland will move with swallowing. Thyroglossal cyst will
also move with swallowing. Lymph nodes will move very little.
185
PALPATION:
Ask if the patient has any pain in the neck before palpating.
1. Stand behind the patient and ask them to slightly flex their neck (to relax the
sternocleidomastoids).
2. Place your hands either side of the neck.
3. Place the three middle fingers of each hand along the midline of the neck below the chin.
4. Locate the upper edge of the thyroid cartilage ( “Adam s apple ” )
5. Move inferiorly until you reach the cricoid cartilage / ring
6. The first two rings of the trachea are located below the cricoid cartilage and the thyroid
isthmus
overlies this area
7. Palpate the thyroid isthmus using the pads of your fingers
8. Palpate each lobe of the thyroid in turn by moving your fingers out laterally from the
isthmus
9. Ask the patient to swallow some water, whilst you feel for symmetrical elevation of the
thyroid
lobes (asymmetrical elevation may suggest a unilateral thyroid mass)
10. Ask the patient to protrude their tongue once more (if a mass is a thyroglossal cyst, it
will rise
during tongue protrusion)
LYMPH NODES:
Check all groups of lymph nodes
1. Submental lymph nodes.
2. Submandibular lymph nodes.
3. Anterior cervical chain (Tonsillar and deep cervical lymph nodes)
4. Posterior cervical chain
5. Pre auricular lymph nodes.
6. Post auricular lymph nodes.
7. Occipital lymph nodes.
8. Supraclavicular lymph nodes.
TRACHEA:
Note any deviation of the trachea - mav be caused by a large thyroid mass
PERCUSSION:
1. Percuss downwards from the sternal notch.
2. Retrosternal dullness may indicate a large thyroid mass, extending posterior to the
manubrium.
AUSCULTATION
1. Auscultate each lobe of the thyroid for a bruit.
186
2. A bruit would suggest increased vascularity, which occurs in Graves ’ disease.
SPECIAL TESTS
a. Reflexes: Upper limb reflexes: Biceps, triceps and supinator (Biceps reflex - hyporeflexia is
associated with hypothyroidism)
b. Inspect for Pretibial myxoedema (Graves’ disease)
1. Ask patient to roll up trouser.
2. Note for the raised, discoloured appearance over legs.
c. Proximal myopathy:
d. Ask the patient to stand from a sitting position w ith arms crossed
e. An inability to do this suggests proximal muscle wasting (Hyperthyroidism)
From my assessment everything seems to be fine. We will do routine blood test and thyroid
function test (Mainly we do TSH initially if that is deranged then we consider doing T4)
I will talk to my seniors and On the basis of your blood results we will decide about the
dosage of your medication.
D: Do you have any concerns?
P: No
Once your thyroid hormone level is under control, your dose may be gradually reduced and
then stopped. But some people need to continue taking medication for several years or
possibly for life.
Symptoms of an overactive thyroid can include:

1. nervousness, anxiety and irritability
2. hyperactivity - you may find it hard to stay still and feel full of nervous energy
3. mood swings
4. difficulty sleeping
5. feeling tired all the t
6. sensitivity to heat
7. muscle weakness
8. diarrhoea
9. needing to poo more often than usual
10.persistent thirst
11.itchiness
12.loss of interest in sex
Common symptoms of hypothyroidism include:

1. Tiredness
2. Being sensitive to cold
3. Weight gain
4. Constipation
5. Depression
187
6. Slow movements and thoughts
7. Muscle aches and weakness
8. Muscle cramps
9. Dry and scaly skin
10.Brittle hair and nails
11.Loss of libido (sex drive)
12.Pain, numbness and a tingling sensation in the hand and fingers (carpal tunnel syndrome)
13.Irregular periods or heavy periods
188
DISCUSS BLOOD RESULTS (HYPERTHYROIDISM)

Dorothy Perkins, aged 81, has come to you for medication review.
She has been on Amlodipine 10 mg for 2 months. Other medications she is on are
atorvastatin 20 mg and levothyroxine 125 mcg.
Bloods: TSH <0.02
T4 24
Lipid profile, U&E's, LFTs – Normal
Talk to her and review the medications and blood results.

P: I am here for review of my medications and for my blood results.
D: I have got your blood results. I will explain you shortly but before that let me ask some
questions first.
P: Okay
D: Could you please tell me why you had these blood tests.
P: I was having headache.
D: Can you tell me more about it?
P: Like what?
P: Since last 1 week.
D: Does it come and go or is it continuous?
P: Comes and goes.
P: No
D: What kind of pain is it?
P: Dull
P: No
P: No
D: How would you rate it on a scale of 1 to 10?
P: 4
D: Anything else?
P: Like what?
D: Do you feel dizzy or lightheaded?
P: No
D: Feeling tired?
P: No
P: Good
189
D: Any weight changes recently?
P: No
D: Do you feel cold when others are not?
P: No
D: Do you feel any sensation of pins and needles anywhere in the body?
P: No
D: Any dry or rough skin?
P: No
D: Do you have any dry hair?
P: No
P: No
D: Tell me about your bowel habits?
P: No
P: Its ok
P: Hypercholesterolaemia and hypothyroid for many years. Hypertension for last 2 months.
P: Atorvastatin 20 mg and levothyroxine 125 mcg, tab. Amlodipine 10 mg for 2 months.
D: Do you take them as prescribed?
P: I stopped amlodipine after 2 months.
D: May I know why?
P: Because GP gave me only 2 months stock.
P: No
P: No
D: Do you smoke?
P: No
P: No
P: Good
P: No
P: I am retired.
P: I live alone
P: Fine
190
I would like to check your vitals including blood pressure, GPE and thyroid.
Examiner: BP 160/90 in last 3 readings.
Explain the blood reports to the patient.
We have to review your medication

Be compliant with the medication of HTN, take it regularly
Lifestyle advices
Warning sign and follow up
191
HYPERPARATHYROIDISM

Patient aged 55 years old, come in for her results.
CBC, Urea, Electrolytes, HBA1C, ESR Normal
Calcium Corrected: 3.05 (2.2 to 2.6 mmol/L)
Parathyroid Hormone: Increased (10-65 ng/L)

P: I am here for my blood results.
D: I have got your blood results I will explain you shortly but before that let me ask some
questions first.
P: ok
P: I am feeling tired nowadays.
D: Could you please tell me more about your tiredness?
D: Since when?
P: Started when I went to Spain (few months).
D: How did it start?
P: It was gradual.
P: Continuous.
D: Has it changed since it started?
P: it is getting worse.
D: Is there anything that makes the tiredness better?
P:
D: Is there anything that makes the tiredness worse?
P:
D: Is there any specific time of the day when the tiredness become worse?
P: No doctor.
P: I have constipation.
P: It is on and off.
D: Since when?
P: Along with the tiredness.
D: Have you passed any winds?
P: Yes doctor
D: How was your bowel habit before?
P: It was fine doctor
192
P: I am feeling thirsty nowadays
D: Since when?
P: Along with the tiredness.
P: Like what?
D: How has been your mood could you score it for me?
P:
D: Any loss of concentration? Any confusion?
P:
D: Any bone pain?
P:
P:
D: Any tummy pain? (epigastric or loin )
P:
D: Do you go to the loo more often?
P:
D: Any palpitation?
P:
D: Any loss of appetite? Any loss of weight?
P:
P: No
P: No
D: Are you currently taking any medications, OTC drugs or supplements?
P: Yes, I am taking calcium tab over the counter.
D: May I know why? how many tablets are you taking? since when?
P:
P: No
P: No
P: No
D: Do you smoke?
P: No
P: No
D: Tell me about your diet? Any dairy products?
P:
193
P:
D: What Do you do for living?
P:
D: Whom do you live with? are you able to look after yourself?
P:
I would like to do GPE and vitals.

I would like to send for some initial investigations including Routine Blood Tests
I would like to check your vitals and examine you thoroughly.

D: Let me explain you the results first. Show the blood reports to the patient and explain
properly.
1. Your blood count is normal.
2. Your kidney functions are normal, your blood sugar and the level of inflammation in your
body is normal (ESR).
3. Ca level in your blood is high and the hormone secreted by the parathyroid gland which
is situated in the neck is also increased.
 From our assessment we are suspecting you have a condition called primary
hyperparathyroidism. It is where the parathyroid glands which are in the neck near the
thyroid gland produce too much parathyroid hormone. This happens because of benign
tumour of the gland itself. This causes blood calcium levels to rise. If left untreated high
levels of ca in the blood can lead to a range of problems.
 We are going to make referral for you to the hospital. They are going to run some further
tests and scans (USG / Isotope scan) to confirm the diagnosis. We may also consider
doing A DEXA scan. X-rays, CT scans.
 We need to correct dehydration with fluids. Medication called bisphosphonates may also
be given to lower calcium. These are only used as a short-term treatment. Surgery will be
needed once the calcium levels are stabilised.
 For people who are unable to have surgery - for example, because of other medical
conditions or they're too frail - a tablet called cinacalcet may be used to help control the
condition.
Do's:
1. Make sure you have a healthy and balanced diet.
2. drink plenty of water to prevent dehydration
3. You don't need to avoid calcium altogether. A lack of dietary calcium is more likely to
lead to a loss of calcium from your skeleton, resulting in brittle bones (osteoporosis).
Don'ts:
1. A high-calcium diet.
194
2. Medications such as thiazide diuretics.
Secondary Hyperthyroidism:
When there's nothing wrong with the gland, but a condition like kidney failure or vitamin D
deficiency lowers calcium levels, causing the body to react by producing extra parathyroid
hormone
Treatment:
Treatment for secondary hyperparathyroidism depends on the underlying cause.
Tertiary hyperparathyroidism:
Tertiary hyperparathyroidism is a term that describes long-standing secondary
hyperparathyroidism that starts to behave like primary hyperparathyroidism.
Treatment:
Cinacalcet may be used to treat tertiary hyperparathyroidism that occurs in very advanced
kidney failure.
195
GIT STATIONS
INDIGESTION
You ’re an F2 in GP.

Patient aged 55 has come with complaints of indigestion.
Please talk to the patient, assess him, discuss management with the patient and address his
concerns.

P: I have burning sensation in my chest (Points towards epigastric region)
P: It is from last 3 months and it is getting worse.
P: It is there when I eat spicy food.
P: Whenever I burp, there is some fluid that comes up to my mouth and I have to swallow it. It
is very uncomfortable.
D: Is there anything makes it better?
P: I used antacids, it was helpful in the beginning, but now it is not helping. (He was taking
tab Rennie for last 3 months.)
D: Do you any other symptoms?
P: No
D: Any tummy pain?
P: No
D: Any tummy bloating?
P: No
D: Any fever?
P: No
D: Any chest pain?
P: No
P: Yes
D: Since when you are feeling sick?
P: From last few weeks and it is getting worse.
D: Any vomiting?
P: No
D: Any change in bowel habits?
P: No
D: Any change in colour of stool?
P: No
196
D: Any blood in stool?
P: No
D: Any weight loss?
P: No
D: Anyone in the family or friends
P: No
D: Any loss of appetite?
P: No
P: No
D: Any SOB or palpitations ■
P: No
D: Any cough?
P: No
P: No
P: No
D: Any DM, HTN, Cholesterol?
P: No
D: Are you taking any other medications apart from Rennie you told me including OTC or
supplements?
P: Yes, I used many Antacid, I keep changing them but it doesn’t work.
P: No
P: No
P: No
D: Do you smoke?
P: Yes / No
P: Yes / No
D: how about tea and coffee?
P: 2-3 cups a day
P: I eat everything like burger, chips. I mostly eat outside because I don’t have time to cook.
P: I work in an office.
D: Any stress?
P: No
197
P: 1 don’t do much of it.
I would like to do GPE. Vitals, chest and abdominal examination.

We will do some routine blood investigations including FBC. LFT, U&Es, cholesterol level
check.
EX: All examination is normal
 From our assessment, we suspect you have a condition called Gastroesophageal reflux
disease (GORD). It is a burning feeling in the chest caused by stomach acid travelling up
towards the throat (acid reflux). If it keeps happening, it’s called gastro-oesophageal
reflux disease.
 We will do Endoscopy to find out what can be the problem. (IOC)
 We will do Oesophageal pH monitoring which provides direct physiologic measurement
of acid in the esophagus and is the most objective method to document reflux disease,
assess the severity of the disease and monitor the response of the disease to medical or
surgical treatment.
 We will do esophageal manometry is a test to assess motor function of the upper
esophageal sphincter (UES) (muscles around the opening of the food pipe), esophageal
body and lower esophageal sphincter (LES) (muscles around the lower part of the food
pipe).
 To ease your symptoms, we can give you a medication that reduces the amount of acid
your stomach makes, such as, proton pump inhibitors (PPIs) omeprazole, lansoprazole
for one month or two to see if your symptoms stop.
 Go back to your GP if your symptoms come back after stopping your medicine. You may
need a long-term prescription.
GENERAL ADVICE
Do’s
1. Eat smaller, more frequent meals
2. Raise one end of your bed 10 to 20cm by putting something under your bed or mattress –
make it so your chest and head are above the level of your waist, so stomach acid doesn't
travel up towards your throat
3. Try to lose weight if you are overweight
4. Try to find ways to relax
Don’ts
1. Have food or drink that triggers your symptoms
2. Eat within 4 hours before bed
3. Wear clothes that are tight around your waist
4. Smoke
5. Drink too much alcohol
198
6. Drink too much coffee & tea
7. Stop taking any prescribed medicine without speaking to a doctor first
199
DYSPHAGIA
You are F2 Surgery.

Mr. Adam aged, 60 presented to the hospital complaining of difficulty in swallowing.
Please talk to the patient, assess your patient and discuss your initial plan of management
him.

P: I have difficulty in swallowing.
D: Could you please tell me more.
P: When I eat, I feel like food is getting stuck behind my breast bone.
D: Since when?
P: 3 months
D: Is it progressing?
P: In the beginning it was with solid food but not I am not able to even drink properly.
D: Do you have this problem all the time or any particular time of the day?
P: All the time.
D: Do you have any problem to begin swallowing?
P: No, it is throughout.
D: Is it painful?
P: Yes/No
D: Anything else with this swallowing problem?
P: No doctor.
D: Do you have any heart burn?
P: Yes/No
D: Do you have persistent vomiting especially soon after the food?
P: Yes/No
D: Any persistent cough?
P: Yes/No
D: Any blood while vomiting or coughing?
P: No
D: Have you lost weight?
P: Yes 1 stone in the last few months (if no ask close question)
P: I am not able to eat these days dr.
D: Do you feel tired or SOB?
P: Yes/No
D: Any pain in your upper back?
P: No
D: Do you feel thirsty?
P: No
D: Do you have dry mouth?
200
P: No
D: Do you feel your tummy is bloated after taking the food?(Gastric CA).
P: No.
D: Have you noticed that the colour of your stool has become dark or any blood in your
stool?
P: No
D: By any chance have you taken any corrosive agent? (Stricture)
P: No
D: Do you feel like your problem increases as the day progresses? (MG)
P: No
D: Any weakness in any part of your body? (Stroke)
P: No
D: Does your problem increase with hot and cold drink? (Spasm)
P: No
P: No
P: No
P: No
P: No
P: No
D: Any instrumentation in the gullet?
P: No
P: No
D: Has any family history had any problems with gullet?
P: No.
D: Do you smoke?
P: yes
P: yes
P: Not able to eat much these days.
P: I am active
D: I would like to check your vitals and examine your mouth, food pipe and tummy.
201
 From our assessment, you seem to have a problem in your gullet. The symptoms which
you presented with look like you could have a serious condition.
 It looks like cancer but it is very difficult for us to confirm this at this stage before doing
all the tests.
 We need to do further investigations to make sure what exactly is going on.
 We will do further blood tests to check if you have anaemia. We will do endoscopy to
have a look at your gullet for any abnormality, we may have take a sample if needed. We
may have to do a CT scan to have a clear picture.
 We will refer you to a specialist and team of doctors (multi disciplinary team) who will do
the necessary tests and confirm the diagnosis and start treatment depending upon the
condition. We will refer you to the specialist in 2weeks time.
D: Do you want to know how we proceed with your treatment if it is cancer?

If it is cancer then the treatment depends upon the type, size, position and stage of cancer
and also your overall health. The main stay of the treatment would be surgical resection.
There is also chemotherapy and radiotherapy to decrease the size of the tumour to alleviate
your symptoms.
Regarding your eating problem now;

 try eating soft foods along with plenty of fluids. Have small meals rather than large
quantities.
 Try to avoid: Raw fruit and vegetables, tough meat, soft, doughy bread.
 You may need a feeding tube down your nose or into your small bowel if you can’t eat
and drink enough.
COMPLICATIONS OF ENDOSCOPY:
Sore throat, tummy pain - We will give you pain killers if have any.
Infection - We will give you antibiotics if you develop any.
Bleeding - If happens we will treat appropriately.
Damage to lining of the gut - Usually heals by itself.
In the mean time if you any concerns before meeting the specialist, please come back to us
at any time.
Please come back to us if your symptoms worsen or if you are coughing or vomiting blood or
if you develop shortness of breath or if you are unable to swallow any food.
Management:
P: Whats happening doctor?
P: Is it a serious condition?
202
P: I read it somewhere
P: What investigations will you do?
P: What is endoscopy?
P: Is endoscopy painful?
P: Are there any complications of this procedure?
P: What about my eating, it is getting difficult for me to eat
DD:
Oesophageal cancer
Gastric cancer
Oesophageal stricture
Oesophageal spasm
GERD
Myasthenia gravis
Stroke
203
HAEMATEMESIS
You are F2 in A&E.

Maria aged, 27presented to the hospital with haematemesis.
The Vitals have been measured and are as follows:
B.P: 110/70 mmHg, P.R: 100/min, T: 37, RR: 17/min, 02 Sat: 97%
Please talk to the patient, take history, assess the patient and discuss further management
with the patient.

P: I am vomiting blood.
D: Tell me about the content of your vomit?
P: Doctor, there was no food. It was only blood.
P: It started this morning.
D: How many episodes did you have since morning?
P: 3
D: How much blood was it?
P: Each time around a cup dr.
D: What was the colour?
P: It was red.
D: What were you doing when it happened?
P: I was just sitting at home.
D: Do you have anything else?
P: No.
D: Any tummy pain?
P: Yes/No.
D: Have you been feeling sick?
P: No.
D: Any indigestion or heart bum?
P: No.
D: Any blood from your back passage
P: No.
P: No.
P: No.
D: Any tiredness or shortness of breath?
P: Yes/No.
D: Any heart racing or dizziness?
P: No
D: Any fever of flu like symptoms? (Oesophagitis)
204
P: No
D: Any excessive sudden or forceful vomiting?
P: No (Mellory Weiss)
P: No
P: No
D: Any liver or kidney problem?
P: No
D: Any problem with the gut?
P: No
P: Yes. I am taking ibuprofen.
D: Why do you take it?
P: For my hangover headache
D: How long have you been taking it?
P: For the last 6 months.
D: How much and how often do you take it?
P: I take two tablets three times a day.
P: No.
P: No.
P: No
P: No
D: Any instrumentation in your gullet?
P: No
P: No
D: Do you smoke?
P: Yes/No
P: Yes, I drink wine with my food daily
D: Any binge drinking recently?
P: No
P: Good diet
P: Yes, good
205
No
D: I would like to check your vitals and examine your abdomen and back passage.
D: I would like to send for some initial investigations including routine blood tests and ECG.
EX- Mild tenderness in epigastric region.
Vitals: BP-110/70 , PR-100, T-37C, RR-17. 02 sat- 97
From our assessment, we are suspecting you have bleeding in your gut.
We checked your vitals and all are normal. Only pulse rate is on higher side.
You told me that you are drinking alcohol daily and taking pain killer for your headache from
last six months. Both of these increases the chances of bleeding from the gut.
We will admit you in the hospital and we will do blood test to see how much blood you have
lost and how your liver and kidneys are functioning. Depending on your blood results we
may consider giving you some blood products.
We will keep you nil per mouth at this time and give you fluids through your blood vessel.
We will do an X-ray of your tummy to look for any abnormality and we will arrange an
endoscopy to see inside your gullet and your tummy in next 24 hours to find out the exact
cause of bleeding (Perforation). The treatment depends upon the findings we get during
endoscopy. If we see any active bleeding we will stop it during the procedure.
If we see any ulcer, we will do a test called Breath test to see if there is any bug causing this
ulcer. If the test is positive for bugs then we will give you some antibiotics for a week to
eradicate the bug from your gut. After endoscopy we will give you some medications for 4 –
8 weeks to reduce the secretion of the acid from your gut and protect your gut.
The main cause of bleeding in your case is alcohol and pain killers that you are taking. So it
would be great if you can stop drinking alcohol and stop taking painkillers. Your GP will
review your headache medication and give you something which doesn’t cause ulcers in
your stomach.
Please avoid any stress, alcohol, spicy foods and smoking which may reduce your symptoms
while your ulcer heals.
Please follow up regularly with your GP
P: What could be the reason for that?
P: What is endoscopy?
P: Is endoscopy painful?
DD:
CA Oesophagus
Mallory Weiss tear
Oesophagitis
206
Acid peptic disease
Gastric erosion
Liver disease
Bleeding disorders, blood thinners
Instrumentation
207
ACUTE GASTROENTERITIS
You are an F2 in A&E.

Mrs. Alice Parker aged 40 has presented with complaint of vomiting & diarrhea for the last 3
days. Assess the patient & do the relevant management.
You are aware that food poisoning is a notifiable disease.

P: I have diarrhea.
P: It’s been 3 days.
D: How many times you’re going to the loo?
P: 2-3 times a day.
P: No doctor.
D: How was your bowel habit before that?
P: I used to go to the loo once daily.
D: Tell me more about your stools?
P: I am passing loose and watery stools.
D: Is there any mucous or blood?
P: No doctor.
P: I have tummy discomfort.
D: Any pain?
P: No
D: Can you please rate the discomfort on a scale of 1 to 10, 1 being no discomfort & 10 being
extreme discomfort
P: 7/10
D: Any vomiting with it?
P: Yes
D: Since when & how many episodes?
P: For the last 3 days had 4 episodes have not had vomiting in last 24 hours
D: What was the content of vomiting?
P: Whatever I ate, I vomited that.
D: Anything else?
P: No
D: Do you have a feeling of being unable to empty the bowel properly? (Tenesmus)
P: No
D: Any alternate bowel habits? (Bowel Cancer)
P: No (Dehydration)
D: Do you feel thirsty? Dry mouth?
P: No (Dehydration)
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D: Do you feel dizzy by any chance?
P: No
D: Any fever or flu like symptoms? (IBD, Diverticular Disease, GI Infection)
P: No
P: No
D: Have you noticed any eye problems, joint problems, skin changes or mouth ulcers?
P: No
D: By any chance any hand shaking? (Hyperthyroidism)
P: No
D: Do you feel hot when everyone else is feeling okay?
P: No
D: Do you feel bloating in your tummy? (Diverticular Disease)
P: No
D: Have you ever had any similar episode in the past?
P: No
P: No
D: How about any polyp, inflammatory bowel disease, DM, Thyroid?
P: No
D: Do you take any medication, OTC or herbal?
P: No
D: Any long term Antibiotics? (Pseudomembranous Colitis)
P: No
P: No.
D: Anyone in the family suffering from the same problem?
P: We had dinner at a restaurant 3 days ago, it started after that. My husband & child also
have the same problem.
D: How are they now?
P: They are fine now.
D: Do you smoke?
P: Yes/No
P: It is fine.
D: How about red meat or processed meat?
P: Sometimes doctor.
P: Doctor I am a social drinker.
D: Do you have any stress?
P: No
209
P: Yes.
P: Yes
D Have you travelled anywhere recently?
P: No
I would check your vitals, GPE and examine your tummy.

We need to do some blood tests. (FBC, LFTs, U&Es, TFTs, CRP)
We need to take a sample of your stools and send it to the lab.
D: Well Alice, from what you’ve told me & from what I’ve assessed, you’ve got an infection
called food poisoning. We need to do some blood tests. (FBC, LFTs, U&Es, TFTs, CRP)
The food that you had outside couple of days ago, bugs from it went into your tummy &
caused this infection.
Also as this is a case of food poisoning, we would need to inform the authorities about this
incident.
We will tell the designated person in the hospital about it, they’ll notify the ‘proper officer’
at the local council or local health protection team (HPT). I'll also inform the laboratory.
P: Doctor, do you really have to inform them?
D: Can I please know why you ask that?
P: It’s actually my friend’s restaurant, I don’t want them to get into trouble
D: I understand that. But I’m afraid it’s my statutory duty to notify about it.
P: How long it will take to subside diarrhea?
D: Diarrhoea usually lasts for 5 to 7 days and vomiting usually lasts for 1 to 2 days.
Do
• stay at home and get plenty of rest
• drink lots of fluids, such as water and squash - take small sips if you feel sick
• take paracetamol or ibuprofen if you're in discomfort.
• wash your hands with soap and water frequently
• wash dirty clothing and bedding separately on a hot wash
• clean toilet seats, flush handles, taps, surfaces and door handles every day
Don't
• have fruit juice or fizzy drinks - they can make diarrhoea worse
• give young children medicine to stop diarrhoea
• give aspirin to children under 16.
• prepare food for other people, if possible
• share towels, flannels, cutlery or utensils
• use a swimming pool until 2 weeks after the symptoms stop
210
Registered medical practitioners have a statutory duty to notify the 'proper officer' at their
local council or local health protection team (HPT) of suspected cases of notifiable diseases.
They must:
- Complete a notification form immediately on diagnosis of a suspected notifiable disease.
- They should not wait for laboratory confirmation of a suspected infection or
contamination before notification.
- Send the form securely to the proper officer within three days, or notify them verbally
within 24 hours if the case is urgent.
Diarrhoea and vomiting can spread easily

If you have a stomach bug, you could be infectious to others.
You're most infectious from when the symptoms start until 2 days after they've passed. Stay
off school or work until the symptoms have stopped for 2 days.
Inform your GP If:

• keep vomiting and are unable to keep fluid down
• are still dehydrated despite using oral rehydration sachets
• have bloody diarrhoea or bleeding from your bottom
• have green or yellow vomit
• have diarrhoea for more than 7 days or vomiting for more than 2 days
211
BARRETT'S OESOPHAGITIS
You are F2 in Surgery’.

Louis aged 40 had endoscopy and biopsy and is here for his reports.
The diagnosis of Barrett’s oesophagus has been made. He was advised for repeat endoscopy
after 3 years.
Talk to the patient, take history, explain him the diagnosis, discuss the management and
address his concerns.
You can find the reports in the cubicle.

P: I am here for my reports.
Reports:
Louis aged 40 had endoscopy and biopsy.
The diagnosis of Barrett's oesophagus has been made.
It is columnar metaplasia. It is pre-malignant, non-invasive and non- metastatic.
He has to repeat endoscopy again every 3 years.
D: Let me ask you a few questions first?

P: Ok
D: Could you please tell me why you had this endoscopy?
P: I was advised by my doctor due to heart bum.
D: For how long you were having this heart burn?
P: It was there from last 6 months.
D: Is there anything make it worse?
P: When I eat spicy food, it gets worse.
D: Is there anything make it better?
P: I have tried antacids and this Rennie syrup, now it is not helping.
D: Is it all the time or comes and goes?
P: It comes and goes.
P: No
D: Any Nausea, vomiting?
P: Yes/No
D: Do you feel bloated?
P: Yes/No
D: Do you have frequent burping?
P: No
D: Do you notice foul smell from your mouth?
212
P: No
D: Have you noticed any change in your voice?
P: No
P: No
D: Any cough or hiccups?
P: No
D: Do you feel an unpleasant taste in your mouth because of stomach acid?
P: Yes/No
P: No (Cancer)
P: No
P: No.
P: No.
D: Any tummy pain?
P: No
D: Have you had these kinds of symptoms in the past?
P: No
P: No
D: Any problem with the wind pipe or stomach or any peptic ulcers?
P: No
D: Are you taking any other medications apart from Antacids you told me including OTC or
supplements?
P: No
P: No
P: No
P: Yes/No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: Spicy food
P: Yes/No
213
I would like to do GPE, Vitals, gullet and abdominal examination.
I would like to send for some initial investigations including routine blood test.
From our assessment you have a condition called Barrett's oesophagus. In this the cells that
line the affected area of oesophagus become changed. The cells of the inner lining
(epithelium) of a normal oesophagus are pinkish-white, flat cells (squamous cells). The cells
of the inner lining of the area affected by Barrett’s oesophagus are tall, red cells (columnar
cells).
The changed cells of Barrett's oesophagus are not cancerous (malignant). However, these
cells have an increased risk of turning cancerous in time compared with normal cells. In the
majority of cases, the changes in the cells remain constant and do not progress. It is also
known as Precancerous condition. We have repeat endoscopy after 3 years.
Non-medical treatment:
Lifestyle changes include:
1. Losing weight if you are overweight,
2. Stopping smoking if you are a smoker and
3. Reducing your alcohol intake if you drink a lot of alcohol.
4. Go to bed with an empty, dry stomach. To do this, don’t eat in the last three hours before
bedtime and don't drink in the last two hours before bedtime.
5. try raising the head of the bed by 10-20 cm (for example, with books or bricks under the
bed's legs). This helps gravity to keep acid from refluxing into the oesophagus.
6. Foods and drinks that have been suspected of making symptoms worse in some people
include peppermint, tomatoes, chocolate, spicy foods, hot drinks, coffee and alcoholic
drinks.
Medical management:
 A medicine which prevents your stomach from making acid is a common treatment and
usually works well (PPIs). Some people take short courses of treatment when symptoms
flare up. Some people need long-term daily treatment to keep symptoms away.
 An operation to tighten the sphincter muscle is an option in severe cases which do not
respond to medication, or where full-dose medication is needed every day to control
symptoms.
Always come for the follow up. If your symptoms get worse or you develop any weight loss,
breathlessness, dizziness please come to the hospital.
214
IBS
You are an F2 working in GP.

David Lloyd aged 50 has come in with some abdominal discomfort.
Talk to the patient, assess and discuss management plan with him.
D: How can I help you today?

P: Dr. I have some discomfort/dull ache/uneasiness in my tummy
P: like what dr.
D: Where exactly is it?
P: It's in all around my tummy
P: more than a year dr
D: Was it sudden or gradual ?
P: Gradual
P: comes and goes
P: colicky
P: Yes after I pass stool
P: No
D: Has it changed since started?
P: It's getting worse
D: Could you rate the discomfort on a a scale of o to 10, where 0 being no pain and 10 being
the worst you have ever experienced?
P: 5 dr
P: I have a feeling of bloating in my tummy
P: it's been also more than a year and it kind of comes and goes.
D: Anything else?
P: I have been having episodes of diarrhea and constipation every now the then.
D: For how long is that?
P: same dr about a year
D: Have you noticed any weight loss recently?
P: No
D: Any change your appetite?
P: No
D: Any tiredness?
215
P: no
P: no
D: Any bleeding from the back passage or blood in stool?
P: No
D: Any change in the color of urine and stool?
P: No
D: Any lumps and bumps anywhere in the body?
P: No
D: Did you have similar problems in the past?
P: no dr
D: have you been diagnosed with any medical condition in the past or any bowel problems?
P: No dr
D: Any family history of any significant health issues or bowel problems?
P: No dr
D: Are you currently on any medication?
P: No dr
D: Are you allergic to any foods or medication?
P: no dr
D: Do you smoke?
P: No
P: No
D: Do you take tea or coffee?
P: Yes dr. about 5-6 cups of coffee a day
D: tell me about your diet?
P: I eat healthy dr
D: What about physical exercise?
P: Quite active
P: yes dr. I am really stressed about my work
D: What you do for living?
P: I work in a bank as a accountant
D: whom do you live with?
P: I live with my wife
I would like to do a GPE, check the vitals and Examine your abdomen and back passage. I
will be having a chaperone with me.
I will order initial investigation like routine blood test and stool test.
All patients meeting the symptomatic criteria for IBS should have the following
investigations:
216
FBC
ESR
CRP
Coeliac screen anti-tissue transglutaminase/antigliadin antibodies
CA 125 for women with symptoms which could be ovarian cancer
Faecal calprotectin for those with symptoms which could be IBD
Ex: Everything is normal doctor
From our assessment we suspect you are having a condition called Irritable bowel
syndrome. It is a common condition that affects the digestive system.
There's no single diet or medicine that works for everyone with IBS. But there are lots of
things that can help if you have been diagnosed with it.
You mentioned you are under stress and it can be a triggering factor for IBS. We can refer
you for a talking therapy, such as cognitive behavioural therapy (CBT). This can help if stress
or anxiety is triggering your symptoms. It can also help you cope with your condition better.
Do
 cook homemade meals using fresh ingredients when you can
 keep a diary of what you eat and any symptoms you get - try to avoid things that trigger
your IBS
 try to find ways to relax
 get plenty of exercise
 try probiotics for a month to see if they help
Don't
 do not delay or skip meals
 do not eat too quickly
 do not eat lots of fatty, spicy or processed foods
 do not eat more than 3 portions of fresh fruit a day (a portion is 80g)
 do not drink more than 3 cups of tea or coffee a day
 do not drink lots of alcohol or fizzy drinks
How to ease bloating, cramps and farting

 eat oats (such as porridge) regularly
 eat up to 1 tablespoon of linseeds a day
 avoid foods that are hard to digest (like cabbage, broccoli, cauliflower, brussels sprouts,
beans, onions and dried fruit)
 avoid products containing a sweetener called sorbitol
217
 ask a pharmacist about medicines that can help, like Buscopan or peppermint oil
How to reduce diarrhoea

 cut down on high-fibre foods like wholegrain foods (such as brown bread and brown
rice), nuts and seeds
 avoid products containing a sweetener called sorbitol
 ask a pharmacist about medicines that can help, like Imodium (loperamide)
How to relieve constipation

 drink plenty of water to help make your poo softer
 increase how much soluble fibre you eat - good foods include oats, pulses, carrots,
peeled potatoes and linseeds
 ask a pharmacist about medicines that can help (laxatives), like Fybogel or Celevac
218
LIVER PROBLEMS
ABNORMAL LFTS
Adam, aged 25, has come to the clinic to find out his blood test result.
Please talk to the patient, discuss the blood result and address his concerns.
AST 20 (5-401U/L)
ALT 30 (5-401U/L)
ALP - Normal (30-130 umol/L)
GGT - Normal
Albumin - Normal (38-50 g/L)
Bilirubin 39 (<21 umol/L)
Direct bilirubin - Normal
Indirect bilirubin - Elevated
D: What brought you to the doctor?

P: I am here for my blood result.
D: I have your blood results with me but before I discuss the blood result with you, may I ask
you a few questions?
P: Sure
D: May I know why you got these tests done?
P: My wife asked me to get done.
D: May I know why your wife asked you to get them done?
P:
D: Did you have any symptoms?
P: No
D: Did you have any tummy pain?
P: No
P: No
D: Any yellowish discolouration of your skin or eyes?
P: No
P: Good
P: No
D: How is your health recently?
P: Good
D: Any flu like symptoms?
P: Yes/No
219
P: No
D: Anything Liver problems?
P: No
P: No
P: No
P: No
D: Any medical conditions in the family?
P: No
D: Anyone in your family has any liver problems?
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No.
P: I try to have a balanced diet.
P: Student
P: Alone/with family
D: Thank you for answering all my questions. So, the blood test done to check the function
of your liver shows that a substance called unconjugated bilirubin is elevated in your blood.
D: Do you know what that means?
P: No
D: Unconjugated bilirubin is formed by the breakdown of red blood cells in the body. Liver
usually metabolizes this to conjugated bilirubin and facilitates in eliminating this substance
from the body.
From this report, I suspect you have a condition called Gilbert's syndrome.
D: Have you heard of this before?
P: No
D: This is nothing to worry. It is a mild abnormality of how the liver processes a chemical
called bilirubin. This condition does not need any treatment. People with Gilbert's syndrome
lead normal healthy life. Life expectancy is not affected.
D: Mild yellowing of skin and the whites of the eye may present from time to time for short
durations but usually causes no health problems. These symptoms might present if you are
ill by an infection, starvation or stress.
D: Do you have any queries?
P: No
220
ALCOHOLIC FOOT
You are F2 in Medicine.

Juliet aged, 50 presented to the hospital with burning sensation of both feet.
She went to alcohol cessation clinic 6 months ago.
Take focused history, do relevant examination and discuss the management with the
patient.

P: I have some burning sensation in my both legs from last few months.
D: Any other symptom?
P: No
D: Any Pain or weakness in your legs? (Sensory)
P: No
D: Any tingling or numbness?
P: No
D: Any Muscle spasm or cramps?
P: No
D: Any wasting of muscles?
P: No
D: Any balance problem or coordination? (Motor)
P: No
D: Any problem with bowel or urine? (Autonomic)
P: No
P: No
D: Any DM, HTN, Thyroid and kidney problems?
P: No
P: Yes, elaborate.
D: Have you tried to stop it?
P: Yes, I tried.
D: Why you couldn’t stop it?
P: I had some withdrawal symptoms.
D: Tell me about your diet? (Vitamin Bl2)
Examination:
D: I would like to check your vitals and examine your foot.
Examination:
a. Exposure
221
b. Chaperone
c. Being gentle
d. Consent
e. Position patient on an exam

I am here to examine your feet I will be as gentle and as quick as possible. At any point of
time you feel uncomfortable and want me to stop please let me know I will stop my
examination. I have a chaperone throughout my examination to ensure your privacy. May I
proceed.
1. Inspection
2. Palpation
3. Neurological Examination
-Sensory Examination: Fine touch. Pain touch, Vibration, Proprioception.
-Motor Examination: Bulk. Tone. Power. Reflexes.
 From our assessment, you have peripheral neuropathy because you have loss of
sensation below ankle/mid-shin, knee bilaterally.
 There can be many reason for it like DM. VitB12 deficiency or alcohol consumption. In
your case it looks like you have alcoholic neuropathy.
 I would like to send for some initial investigations including routine blood test to see
kidney, thyroid function, and VitB12 level.
 I would like to send urine test and blood sugar level.
 We may consider sending some nerve and muscle tests to see the functioning of your
nerves and muscles, (nerve conduction tests or electro myelography).
 We may need to take the samples from your nerves (nerve biopsy)
 The cause of your problem is alcohol consumption. To stop the progression of the disease
you should stop drinking.
 Have well balanced diet, we will refer you to dietician.
 We will prescribe you some vitamins and minerals.
 We can give you some patches and creams for your problem.
 Advise him about foot care.
 Follow up with your GP.
 If you develop foot ulcers, and blood circulation problems come back to us.
https://www.nhs.uk/conditions/peripheral-neuroDatlr
222
DISCUSS BLOOD RESULTS – ALCOHOLIC HEPATITIS
You are FY2 in GP clinic. A man aged,40 came for the blood reports.
Bilirubin-Normal ALT-Normal
AST-63(Raised)
Explain results to him and discuss further management.
Dr: Hello, I understand you are here for your blood tests. Before we discuss that, can I ask
why did you in the first place?
Pt: Just for my regular blood checkup.
Dr: Alright, do you any symptoms at the moment?
Pt: No
Dr: Any tummy pains?
Pt: No
Dr: Any fever?
Pt: No
Dr: Any yellowish discoloration of body
Pt: No
Dr: Any vomiting or diarrhea(Hepatitis A)?
Pt: No
Dr: Any color change of stools or urine?(Obstructive jaundice)
Pt: No
Dr: Any weight loss or lumps and bumps in body?(Malignancy)
Pt: No
Dr: Any blood transfusions ,tattoos?(Hepatitis B)
Pt: No
Dr: Have you ever been diagnosed with any STI?(Hepatitis B,C)
Pt: No
Dr: Ask sexual history from the patient
Dr: Do you have any health problems?
Pt: No
Dr: Are you using any medication?
Pt: No
Dr: Any allergies?
Pt: No
Dr: Anyone in the family with liver problems?
Pt: No
Dr: Do you smoke?
Pt: No
Dr: By any chance do you use recreational drugs?
Pt: No
Dr: Do you drink alcohol?
223
Pt: Yes, half glass of wine daily from last 20 years (Do CAGE for alcohol consumption)
Examination
I would like to check your vitals i.e. your BP, pulse, temperature and respiratory rate. Also I
will do general examination of you including your tummy examination in particular to liver
and spleen.
Management
Explain results.
Dr: From what you have told me and from your blood results, we think that you are having a
condition called alcoholic hepatitis unfortunately. It means that your liver has been affected
by your excess alcohol intake.
Pt: What can you do now?
Dr: We will do further tests like GGT and Ultrasound scan of your tummy.
Pt: Ok
Dr: We will refer you to specialist doctor called gastroenterologist who will talk to you in
detail. Is that ok?
Pt: Ok
Dr: We would advise you to stop drinking as well. What do you think?
Pt: I love alcohol, I can’t stop
Dr: (Convince the patient on alcohol cessation and offer replacement and support)
Dr: We will arrange your follow up in 2 weeks. In the meantime, if you feel any tummy
pains, any yellow discoloration of your body, bleeding from anywhere in your body, please
let us know.
Reference information:
Symptoms of alcohol-related liver disease (ARLD)
ARLD does not usually cause any symptoms until the liver has been severely damaged.
When this happens, symptoms can include:

• feeling sick
• weight loss
• loss of appetite
• yellowing of the eyes and skin (jaundice)
• swelling in the ankles and tummy
• confusion or drowsiness
• vomiting blood or passing blood in your stools
This means ARLD is frequently diagnosed during tests for other conditions, or at a stage of
advanced liver damage.
Treating alcohol-related liver disease (ARLD)
There's currently no specific medical treatment for ARLD. The main treatment is to stop
drinking, preferably for the rest of your life.
224
This reduces the risk of further damage to liver and gives it the best chance of recovering.
If a person is dependent on alcohol, stopping drinking can be very difficult.
But support, advice and medical treatment may be available through local alcohol support
services.
• spread your drinking over 3 days or more if you drink as much as 14 units a week
A unit of alcohol is equal to about half a pint of normal- strength lager or a pub measure
(25ml) of spirits.
A liver transplant may be required in severe cases where the liver has stopped functioning
and does not improve when you stop drinking alcohol.
You'll only be considered for a liver transplant if you have developed complications of
cirrhosis despite having stopped drinking.
All liver transplant units require a person to not drink alcohol while awaiting the transplant,
and for the rest of their life.
Complications
Life-threatening complications of ARLD include:
• internal (variceal) bleeding
• build-up of toxins in the brain (encephalopathy)
• fluid accumulation in the abdomen (ascites) with associated kidney failure
• liver cancer
• increased vulnerability to infection
Preventing alcohol-related liver disease (ARLD)
The most effective way to prevent ARLD is to stop drinking alcohol or stick to the
recommended limits:
• men and women are advised not to regularly drink more than 14 units a week.
225
NHS HEALTH CHECK (RAISED ALT, MACROCYTOSIS)
You are the junior doctor in the GP clinic.

Mrs. Amanda More has undergone certain tests few days ago. She has called to ask about
her results of the tests.
Hb 11 (normal 11-13)
ALT raised
MCV raised
Address her concerns and discuss appropriate management plan.
D- Hello I am Dr. Jane, one of the junior doctors in the GP clinic. Am I speaking with Mrs.
Amanda More?
P: Yes. It’s Amanda.
D-Thank you Amanda. Can you please confirm your age for me?
P: I am 36.
D- Great. Thank you Amanda. I believe you have called in today to discuss certain results of
the investigations you did a few days ago, is that right?
P: Yes doctor. Do you have my results?
D- Yes Amanda. I do have your results. But before we could discuss them I need to ask you
certain questions so as to understand the results better and address your concerns better as
well. Will that be alright with you?
P: Yes doctor.
D- Firstly if you could tell me why did you take the tests?
P: Just a routine check up doctor. I just wanted to be sure that everything is alright.
D- that’s really great Amanda. Very few people take such good care of themselves and are
proactive about their health. I really appreciate how you are taking care of yourself.
D- Well Amanda, did you perhaps have any symptoms before you did the tests?
P: No Dr. or like what?
D-Any tiredness or weakness recently that you might have noticed?
D- Any pain in your tummy?
D- Any distension/bloating you feel in your tummy?
D- Any nausea?
D- Did you vomit by any chance?
D- Any retching or belching? Or sour taste left behind in your mouth?
D- Any changes in colour of your urine?
D- Any changes in colour of your poo/stools?
D- How are your bowel habits, any constipation or diarrhoea?
D- Any yellow discolouration of your skin or eyes that you may have noticed?
D- Any recent fever or flu like symptoms?
D- Any loss of weight? (cancer)
D- Any loss of appetite? (cancer)
226
D- Have you noticed any lumps and bumps in your body? (cancer)
D- Any pains anywhere in your body? (hepatitis’s or any other infection)
D- Any tingling or burning sensation in your hands or legs? (vitamin b12)
All history questions answer will be no. No significant history.
D- Have you ever been diagnosed with any medical conditions?
(Jaundice, blood disorders, liver problems)
P: No
D- Do you take any medications at all (OTC, OCP, vitamin supplements)?
P: No
D- Has anyone in the family been diagnosed with any medical conditions, liver problems to
be in particular? Or blood disorders?
P: No
D- Did you travel anywhere recently?
A few words about your lifestyle:
D- How is your diet?
P: I eat everything. I try to eat healthy.
D- Did you perhaps recently eat something outside?
P: No doctor.
D- That’s great that you are taking care of your diet. Do you exercise?
P: No, not very much.
D- Alright, do you smoke?
P: No I don’t smoke.
D- Do you drink alcohol?
P: Yes.
D- Would you mind telling me How much do you drink usually?
P: A glass of wine everyday or a bottle of wine on the weekends.
D- Since when?
P: Since a very long time/I was 16.
D- If you have time do CAGE- cutting down, agitated when someone talks about your
drinking habit, guilty about drinking, eye opener.
D- Ideally Amanda I would like to examine you and take your vitals. Is it possible for you pop
by in case you live nearby or if I can fix you an appointment any time soon.
P: Why doctor? Is everything alright?
D- Well Amanda , please do not worry. I do have your results with me. There are certain
things that I would like to talk about, and it would be better if I could also examine you and
send further tests.
P: Ok doctor I will come by later or I will think about that.
D- Would you like me to explain you your blood results on the telephone or would you like
to come by?
P: No doctor please tell me now.
D- Do you have any idea of what your results might interpret?
P: No doctor. I think they should be fine.
227
D- Well Amanda, we did a blood test for you. And I wouldn’t say it’s something very serious
at the moment but it needs attention or it could turn into a serious ailment.
In your reports there are certain enzymes and values in your blood that seem to be
increased. One of them is called MCV. Now this can increase in certain type of anaemia’s but
the indicator for anaemia in your test results is fine. And one of the reason that MCV
increases is when the liver is affected. Also an enzyme that shows How well the liver is
functioning is called ALT- and in your case this is also raised. There can be multiple causes
for this but one of them is alcohol.
D- Are you following me until now Amanda?
P: Yes.
D: Do you have any specific concerns Amanda?
P: Doctor I though everything would be fine. It was just a routine checkup.
D- I understand this has come by like a surprise, Amanda. But on the bright side, we now
know that something wasn’t right and still have the time to fix it.
Don’t you agree?
P: Yes, but doctor Is my liver gone bad doctor?
D- Well Amanda, at this instance it is very difficult for me to confirm the extent of damage
to your liver. But there are certain things that you can do that will help you in this condition,
would you like to know about them?
P: Yes doctor.
D- Well firstly you will have to stop consumption of alcohol, as you said you are consuming
one bottle of wine on every weekends from a long time. This could have been the major
reason behind the results. Is that something you could consider?
P: Yes doctor.
D- We can provide you help on cutting down on alcohol, as we understand it can be difficult
for a person to quit suddenly. We could take another session in detail and I can help you
with certain social groups, an alcohol diary, talking therapy, certain medications as well in
case the rest don’t work.
P: Yes doctor. I would like that.
D- The second best thing to do is to run over your diet. We can refer you to a dietician who
can help you with a diet regime that you can follow to keep your liver from further damage.
Do you think that is something that can help you.
P: Yes doctor, I agree
D- Well Amanda, I would also like to speak to my seniors just to see if I might be missing
onto something important and I want you to come in once for a check up, I would like to
examine you and send certain investigations like a liver function profile, certain vitamin
tests, a HB electrophoresis ,clotting profile and do an USG for your tummy to visualise your
liver and look for how it has been affected. Can you come in for a quick check up?
P: Yes doctor please book me an appointment.
D- Great Amanda, I will book an appointment for you and we can have a detailed session
then once we exactly know what has been going on.
Do you have any other concerns Amanda?
228
P: No doctor. Thank you so much.
D: Thank you Amanda for being so patient. In case you have any tummy pain, nausea
vomiting or any yellowing of your skin do come back to us immediately or call 999.
P: Yes doctor. I will.
The patient will be very cheerful as it was just a NHS check up. Be very polite and appreciate
all the things the patient is doing right. Patient is very cooperative in this scenario.
There are many different types of liver disease. You can help prevent some of them by
maintaining a healthy weight and staying within the recommended alcohol limits, if you
drink.
The 3 main causes of liver disease are:
• Obesity
• an undiagnosed hepatitis infection
• Alcohol misuse
You can reduce your risk of many types of liver disease with some simple lifestyle changes
such as:
• trying to maintain a healthy weight
• not drinking too much alcohol
Vaccines are available for hepatitis A and hepatitis B. These are recommended if you're at
risk.
The most common causes of macrocytosis in the adults are
(1) alcoholism, (2) liver diseases, (3) hemolysis or bleeding, (4) hypothyroidism, (5) folate or
vitamin B12 deficiency, (nutritional-Pernicious anaemia) (6) exposure to chemotherapy and
other drugs, (7) myelodysplasia.
Causes of Increased ALT:
primary liver disease, biliary obstruction, pancreatitis. ALT > AST viral hepatitis, AST> ALT
alcoholic liver disease. What if it’s only raised ALT- it indicates injury to the liver.
Increased ALP: biliary obstruction, primary liver disease (changes parallel GGT), infiltrative
liver disease, bone diseases, hyperparathyroidism, hyperthyroidism
229
ARLD
You are F2 in GP.

Olivia aged, 40 came to hospital because of abdomen distension.
Talk to patient, assess, relevant examination, discuss initial plan of management with
examiner.

P: I have abdomen distension
D: Since when you have this problem?
P: From last 2-3 months
P: It was gradual.
D: Anything else?
P: No
D: Any tummy pain?
P: No
D: Any bloating?
P: No
P: No
D: Any vomiting?
P: No
D: Any yellow discoloration of the skin?
P: No
D: Any loss of weight?
P: No
P: No
D: Any change in bowel habits?
P: No
D: Any blood in stool or dark stool?
P: No
D: Do you feel tired or dizzy?
P: No
D: Do you have fever or flu like symptoms?
P: No
P: No
D: Any liver problem or blood disorders?
230
P: No
P: No
D: Any family history of any medical condition?
P: No
D: Do you smoke?
P: Yes/No
P: Yes, I drink daily, 4-5 pints of beer for 15 years.
P: Yes.
D: Are you in a stable relationship?
P: Yes.
P: Yes, we use condom.
I would like to check your Vitals and examine your tummy.

Explain the examination
Exposure
Chaperone
Being gentle
Consent
Make the couch flat, if it ’ s not already flat.
1. Inspection
2. Palpation:
Left Iliac Fossa pain on both superficial and deep palpations.
3. Liver Palpation
4. Spleen Palpation
5. Liver Span
6. Shifting Dullness
7. Fluid thrill
Practice to reach till hepatomegaly.
From my assessment, you have this distension in your tummy. We will do some blood
investigation including LFT and bleeding and clotting profile.
We will do some scans of your liver like USG. CT or MRI
We may consider some further investigations like liver biopsy and endoscopy.
The main cause of your problem is your alcohol. It would be great if you can stop drinking
alcohol. I know it is not easy but we are here to help you.
D: Let me start with the non-medical options.

1. Self-help groups (Alcohol Anonymous).
231
2. One to One counselling.
3. CBT
4. Family Therapy
5. Alcohol Diary'.
Medical Options
1. Acamprosate
2. Naltrexone
3. Disulfiram
4. Chlordiazepoxide
Take balance diet as you may have malnutrition. Avoid salty foods. Your GP can advise you
on a suitable diet or, in some cases, refer you to a dietitian. In the most serious cases of
malnutrition, nutrients may need to be provided through a feeding tube inserted through
the nose and into the
stomach
232
VITAMIN B12 DEFICIENCY
You are F2 in GP.

Sharon aged 40 came to the hospital with tiredness. She has been to GP and he did some
tests.
Hemoglobin was found low and she was given Folic acid.
She again presented with the same symptoms and blood tests were repeated and Vitamin
B12 levels were found low.

P: I am feeling tired.
P: It is there all the time and I went to my GP and he did blood tests and gave me folic acid last
time, but my condition didn’t improve.
D: May I know since when you are having this problem?
P: From last 1 year.
P: No
P: No
D: Is there all the time or comes and goes?
P: It is always there.
P: No
D: Any tingling or numbness in your hands and feet?
P: No
D: Any muscle weakness?
P: No
D: Any ulcers in the mouth?
P: No
D: Any problem with the vision?
P: No
P: It is fine.
D: Are you able to concentrate on your work?
P: Yes
P: No (Cancer)
P: No
D: Do you have any Loss of appetite?
233
P: No.
P: No.
P: No.
P: No.
D: Any constipation, diarrhoea? (Thyroid, IBD)
P: No
D: Any tummy pain?
P: No
D: Any Nausea, vomiting, swelling in legs? (CKD)
P: No
P: No
D: Any DM, Thyroid, Epilepsy or any skin problem?
P: No
D: Are you taking any other medications apart from Folic Acid Tablets you told me including
OTC or supplements?
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
P: Occasionally
P: I am on vegan diet for last 2 years and before that I was fine.
P: Yes
I would like to do GPE, vitals, and thyroid examination.

D: 1 would like to send for some initial investigations including routine blood test, special
blood tests for your thyroid gland.
 We have done your blood test and we found that vitamin B12 is low in your blood.
 We will do some additional blood tests to check for a condition called pernicious
anaemia which is an autoimmune condition (where your immune system produces
234
antibodies to attack healthy cells). In this, our body is unable to absorb vitamin B12 from
the food we eat.
 At first, you'll have these injections every other day for two weeks, or until your
symptoms have started improving. Your GP or nurse will give the injections.
 You told me that you are on Vegan diet and your symptoms started only after that, so
that might be the cause of your problem. In this case, we will prescribe you vitamin B12
tablets to take every day between meals. Alternatively, you may need to have an
injection of hydroxocobalamin twice a year. Mainly the people on vegan diet may need
vitamin B12 tablets for life.
 Good sources of vitamin Bl 2 include: meat, salmon and cod, milk and other dairy
products and eggs. As you are vegan so you can include vitamin B12, such as yeast
extract (including Mannite), as well as some fortified breakfast cereals and soy products
in your diet. Always check the nutrition labels while food shopping to see how much
vitamin Bl2 different foods contain.
 A blood test is often carried out around 10-14 days after starting treatment to assess
whether treatment is working. This is to check your haemoglobin level and the number
of the immature red blood cells (reticulocytes) in your blood.
 Another blood test may also be carried out after approximately eight weeks to confirm
your treatment has been successful.
 If you've been taking folic acid tablets, you may be tested again once the treatment has
finished (usually after four months).
 Most people who have had a vitamin B12 or folate deficiency won't need further
monitoring unless their symptoms return, or their treatment is ineffective. If your GP
feels it's necessary, you may have to return for an annual blood test to see whether your
condition has returned.
Folate deficiency:
 As you are taking folic acid to treat folate deficiency anaemia, mostly people need to
take folic acid tablets for about four months.
 Good sources of folate include: broccoli, Brussels sprouts, asparagus, peas, chickpeas and
brown rice.
 Before you start taking folic acid, your GP will check your vitamin B12 levels to make sure
they're normal. This is because folic acid treatment can sometimes improve your
symptoms so much that it masks an underlying vitamin B12 deficiency. If a vitamin Bl 2
deficiency isn't detected and treated, it could affect your nervous system.
Non-Diet Related vitamin BI2 deficiency:

 At first, you'll have these injections every other day for two weeks, or until your
symptoms have started improving. Your GP or nurse will give the injections.
235
 If your vitamin B12 deficiency isn't caused by a lack of vitamin B12 in your diet, you'll
usually need to have an injection of hydroxocobalamin every three months for the rest of
your life.
If you've had neurological symptoms (symptoms that affect your nervous system, such as
numbness or tingling in your hands and feet) caused by a vitamin Bl2 deficiency, you'll be
referred to a haematologist, and you may need to have injections every two months. Your
haematologist will advise on how long you need to keep taking the injections.
236
ANAEMIA

Mrs. Mary aged 45 has come to clinic for well women checkup. She had blood test done
three weeks back now she came to receive his test results:
Hb: 110 g/dl (115-165)
TLC: 4000/cmm
PLT: 430,000
MCV: 58 (80-100),
U& E: Normal
LFTs: Normal
Serum Iron: Normal
Serum Ferritin: Normal
Discuss these test results with Mrs. Mary, take appropriate history and discuss the
management with her.

P: 1 came here for my results today.
D: Yes, I have your results with me but please tell me if there is a specific reason you had
these tests.
P: No specific reason doctor. I feel fine, I am very conscious about health and that is why I had
this well women check-up.
D: You did a very good thing by having these tests. Let me ask you few questions first.
P: Ok.
D: Do you feel tired or short of breath?
P: No.
P: No
D: Any weight loss? (Cancer)
P: No.
D: How is your diet?
P: I eat healthy doctor.
D: Any lumps or bumps in your body? (Cancer)
P: No.
D: Any pain in the tummy?
P: No
D: How is your urine or bowels?
P: It is fine
D: Have you noticed any change in your urine or bowels?
P: No.
D: Any alternate bowel habits?
P: No.
237
D: Any dark or black coloured stools?
P: No.
D: Any blood in your urine or stools?
P: No.
D: Any difficulty in flushing your stool? (malabsorption)
P: No.
D: Any bleeding from your back passage? (Hemorrhoids)
P: No.
P: One week ago.
D: Are your periods regular?
P: Yes.
D: Have you ever been diagnosed with any medical conditions in the past?
P: No
D: Are you taking any other medications including OTC or herbal medications?
P: No
D: Do you have any allergies from food or medicines?
P: No
D: Any previous surgery or hospitalizations?
P: No
D: Has anyone in your family suffered from a similar condition in the past?
P: Yes, my sister has thalassemia.
P: I don’t have much idea about it.
D: Do you smoke?
P: No
P: No
P: Yes, I try to be physically active.
D: What do you do for the living?
D: Have you travelled recently?
P: No
D: I would like to check your vitals, GPE and examine your tummy.
We did a series of tests including liver, kidney function, iron level and the level of ferritin
(Protein) in your blood which are normal. However, the level of haemoglobin and MCV are
low.
 From my assessment, you have got a condition called anaemia, we would like to
investigate for the cause of low haemoglobin. There can be many causes for low
238
haemoglobin in blood but mostly it is because of inadequate diet, loss of iron in bleeding
or malabsorption of iron from our gut.
 From our discussion there is no apparent reason for low level of iron and haemoglobin in
your blood. We have done most of these tests already. You told that your sister is having
thalassemia so we will do some tests to find out if you are having thalassemia or you are
a carrier of thalassemia.
 Thalassemia is a condition in which there is either no or too little haemoglobin, which is
used by red blood cells to carry oxygen around the body. This can make them very
anaemic (tired, short of breath and pale).
 The treatment of this condition is regular blood transfusions to prevent anaemia with
chelation therapy treatment to remove the excess iron from the body that builds up as a
result of having regular blood transfusions.
 Eating a healthy diet, doing regular exercise and not smoking or drinking excessive
amounts of alcohol can also help to ensure you stay as healthy as possible.
 A carrier of thalassemia is someone who carries at least one of the faulty genes that
causes thalassemia, but doesn't have the condition themselves. It's also known as having
the thalassemia trait. Thalassemia carriers don't have any serious health problems
themselves, but are at risk of having children with the condition.
 People with this trait won't develop severe thalassemia, but are at risk of having a child
with the condition if their partner is also a carrier.
Causes of Thalassaemia:
Thalassaemia is caused by faulty genes that affect the production of haemoglobin. A child
can only be born with the condition if they inherit these faulty genes from both parents. For
example, if both parents have the faulty gene that causes beta thalassaemia major, there's
a 25% chance of each child they have being born with the condition. The parents of a child
with the condition are usually carriers of thalassaemia. This means they only have one of the
faulty genes that causes the condition.
Types of Thalassemia:
There are a number of types of thalassaemia, which can he divided into alpha and beta
thalassaemias. Beta thalassaemia major is the most severe type. Other types include beta
thalassaemia intermedia, alpha thalassaemia major and haemoglobin H disease.
239
MULTIPLE MYELOMA
You are an FY2 in GP. Mrs. Walker aged 52 years old, come in for her blood results.
Hb:100
MCV: Normal
RA factor: Normal
IgG: Raised
Urine: Bence Jones Protein Positive

D: I have got your blood results I will explain you shortly but before that let me ask some
questions first.
P: Ok
P: I have backache and fatigue.
D: Could you please tell me more about your pain?
P: The lower part of my back.
P: 4 months ago
P: It is gradual.
P: comes and goes
P: It is dull kind of pain.
P: No doctor
P: I have tried some PCM did not help.
D: How many PCM?
P:
P: I am not sure.
D: How severe is the pain? P: Very
D: Could you score the pain on a scale of 1 to 10, where 1 being no pain and 10 being the
240
P: 5-6.
D: How about the fatigue?
P: It starts along with the backache and it is getting worse.
P: Like what?
P: No
D: Any palpitation?
P: No
D: Any dizziness?
P: No
D: Light headedness?
P: No
D: Any fever or recurrent infections?
P: No
D: Any bleeding from anywhere? Any bruising?
P: No.
D: Any loss of appetite? Any loss of weight?
P:
D: Any weakness of the legs?
P:
D: Any loss of control of bowel and bladder?
P:
D: Any loss of sensation around the back passage? (Spinal cord compression)
P: No
D: How has been your mood? Could you score it for me?
P:
D: Any loss of concentration? Any confusion?
P:
D: Any bone pain?
P:
P:
D: Any tummy pain? (epigastric or loin)
P:
D: Any constipation?
P:
D: Do you go to the loo more often? Do you feel thirsty?
P:
D: Any palpitation?
P:
D: Have you noticed any swelling in your face?
241
P:
D: Any Shortness of breath?
P:
D: Any decrease in the amount of urine?
P:
D: Any leg swelling?
P:
D: Any hiccups or itching?
P:
P: No
P: No
P: No
P: No
P: No
P: No
D: Do you smoke?
P: No
P: No
P:
P:
P:
D: Whom do you live with? Are you able to look after yourself?
P:
I would like to do GPE, vitals and examine your back, legs and your tummy.
I would like to send for some initial investigations including Routine Blood Test and X-ray of
the back.
D: Let me explain you the results first.
Show the blood reports to the patient and explain properly.
1. Your blood count (Haemoglobin) is low .it means you are anaemic.
2. The RF is normal. It means it is unlikely you have RA (It is a kind of arthritis which affects
mainly the small joints)
242
3. There is substance raised in your blood called IgG. Elevation of immunoglobulin G may
occur due to the hepatic disease (hepatitis, liver cirrhosis), connective tissue diseases,
acute and chronic infections.
4. There is also specific protein called Bence Jones Positive in your urine. Our plasma cells,
which make the antibodies that fight infection, start to multiply uncontrollably and
release Bence Jones protein.
D: Have you got any idea about what's going on?
 From our assessment we are suspecting you have a condition called multiple myeloma,
which is a type of blood cell cancer. Presence of immunoglobulin G in your blood and
Bence jones proteins in your urine are suggestive of Multiple Myeloma. We need to do
further investigations to make sure what exactly is going on. We will refer you to a
specialist (haematologist) and team of doctors (multi-disciplinary team) who will do the
necessary tests and confirm the diagnosis and start treatment depending upon the
condition. We will refer you to the specialist in 2weeks (urgent referral) time.
 They will do some scans like X-rays of your arms, legs, skull, spine and pelvis to look for
any damage. You will also need other scans, such as CT scans and MRI scans.
 A bone marrow biopsy is usually needed to confirm multiple myeloma. A needle is used
to take a small sample of bone marrow from one of your bones, usually the pelvis. A
small sample of bone may also be removed. This is carried out using a local anaesthetic.
The samples of bone marrow and bone will then be checked for cancerous plasma cells.
 Once they confirm the diagnosis, they will discuss the treatment options with you, but in
general either chemotherapy, radiotherapy, steroids or bone marrow transplantation.
 I am going to provide you with enough painkillers.
 In the meantime, if you any concerns before meeting the specialist, please come back to
us at any time.
 Please come back to us if your symptoms worsen or Any problem with the urine or
bowel, weakness of the legs, loss of sensation around the back passage go immediately
to the hospital.
PATIENT'S CONCERNS:
1. Is it rheumatoid arthritis?
2. Is it cancer?
3. What are you going to do for me?
Treatment
Treatment for multiple myeloma can often help to control symptoms and improve quality of
life. However, myeloma usually can't be cured. This means additional treatment is needed
when the cancer comes back (a relapse).
243
Not everyone diagnosed with myeloma needs immediate treatment - for example, the
condition may not be causing any problems. This is sometimes referred to as asymptomatic
or smouldering myeloma.
If you don't need treatment, you'll be monitored for signs the cancer is beginning to cause
problems. If you do need treatment, the most commonly used options are outlined below.
Bringing myeloma under control:
The initial treatment for multiple myeloma may be either:
• non-intensive -for older or less fit patients (this is more common)
• intensive -for younger or fitter patients
244
LEUKAEMIA

Mr. John Bernard aged, 55 came to the clinic with gum bleeding/Wellman check-up.
concerns.
D: What brought you to the hospital today?

P: I had gum bleeding today morning
D: I am sorry to hear that. Do you have any idea how much blood did you lose?
P: No
D: Is it the first time you had this?
P: Yes
D: How did the bleeding start?
P: On its own
D: By any chance did you hurt yourself?
P: No
P: No
D: do you feel tired these days?
P: No
P: No
D: any dizziness or heart racing?
P: No
P: No
D: Any fever or flu like illness recently?
P: No
D: Any bleeding from anywhere?
P: No
D: Any change in the colour of stool that you noticed?
P: No
P: No
P: No
P: No
P: Its good
D: Have you been diagnosed with any medical condition in the past or any blood disorder?
245
P: No
P: No
D: By any chance any blood thinners?
P: No
D: Any family history of any significant health issues or any blood disorder in the family?
P: No
D: Do you smoke?
P: No
P: No
D: Tell meat about your diet?
P: Healthy
I would like to do a GPE, check the vitals and Examine your tummy. I would like to order
initial investigation routine blood test.
Examiner: Abdomen: Splenomegaly. WBC count: >100,000
From our assessment we suspect you are having a condition called Leukaemia. Leukaemia is
a cancer of the white blood cells of our body, which help us fight against infections. We will
be referring you to a specialist and a team of doctors within 2 weeks' time and they will do
further investigations like taking some sample from your bone marrow to confirm the
diagnosis. The treatment depends on the type of leukaemia. There are chemotherapy and
radiotherapy available for leukaemia. In some cases, intensive chemotherapy and
radiotherapy may be needed, in combination with a bone marrow or stem cell transplant.
246
ITP

Mark Anthony aged, feeling tired for last 1-2 weeks came to the clinic.
concerns.

P: I am feeling tired for last couple of weeks dr.
D: I am sorry to hear that. Can you tell me more about it?
P: I just feel tired dr.
P: Yes Dr. It’s getting worse
D: Is there any particular time of the day you feel tired?
P: No Dr. it is throughout the day
D: Anything that makes it better?
P: No Dr.
P: No Dr.
D: Is it the first time you had this?
P: Yes Dr.
P: No Dr.
D: Do you feel cold when others around feeling normal? (Hypothyroid)
P: No Dr.
D: Any change in your bowel habit recently? (Hypothyroid)
P: No Dr.
D: How's your mood been recently?
P: My mood is fine Dr.
D: How did the bleeding start?
P: It started on its own
P: No Dr.
P: No
P: Yes Dr., I had some cough and fever 3 weeks ago. It got better on its own
P: Yes Dr. I have lots of bruises in my body.
P: I don’t exactly know Dr.
247
P: No Dr.
D: Any bleeding from anywhere?
P: No
D: Any change in the colour of stool that you noticed?
P: No
P: No
D: Any change in weight you recently noticed?
P: No
P: No
D: have you been diagnosed with any medical condition in the past or any blood disorder?
P: No Dr.
D: Any family history of any significant health issues or any blood disorder in the family?
P: No Dr.
P: No Dr
D: By any chance any blood thinners?
P: No Dr
D: Do you smoke?
P: No
P: No
P: Healthy Dr.
I would like to do a GPE, check the vitals and examine your chest, tummy and neck.
I would like to order initial investigation routine blood test.
Examiner: Abdomen: Splenomegaly; Bloods: Thrombocytopenia
From our assessment, we suspect you are having a condition called Idiopathic
thrombocytopenic purpura. It is a bleeding disorder in which the blood doesn't clot normally
because of the shortage of the tiny cells in the blood called platelets.
We will be referring you to a blood specialist and further investigations like taking some
sample from your bone marrow will be done to confirm the diagnosis.
P: It is serious Dr?
D: I can see you are worried. But fortunately there may treatment options available for it.
P: What is the treatment Dr.?
D: Sometimes no treatment is needed if the blood cells are not too low. If your condition
needs treating, usually steroid is the most widely used treatment for ITP. A short course of
steroid is good enough to tackle the symptoms.
248
There are other treatment options like some medicines that act on our body's defense
mechanism (Immunosuppressive, Immunoglobulin, biological therapies). Another option
could be removal of the spleen by a surgery. The specialist will be in a better position to tell
you which kind of treatment would be most suitable for you.
Treatment options are:

- Steroids
- Immunosuppressants
- Splenectomy
249
IRON DEFICIENCY ANAEMIA, DECIDED FOR COLONOSCOPY

John, aged 55, has come to the hospital with per rectal bleeding. Blood reports have been
done and you can find them in the cubicle. Consultant has decided to do colonoscopy.
Talk to him, explain to him the lab reports and address his concerns.
D: How can I help?

P: I just fainted.
I don’t know exactly what happened to me. My wife witnessed the episode.
Anything else?
History of bloody loose stools previously (Fresh Blood)
Rule out cancer and other causes of per rectal bleeding.
Lab Reports:
HB – 100 (low)
LFT, KFT, TLC (normal)
D: We have decided to do colonoscopy to find out the cause.

P: I have already so many tests and I don’t want to do any more.
Convince the patient to do the colonoscopy with proper reasoning.
250
CHRONIC DIARRHOEA
You are F2 in general medicine.

Mr. David Peterson aged, 40 presented to the hospital complaining of diarrhoea.
Patient has been referred by his GP.
Please talk to the patient, take focused history, assess the patient, do relevant examination
and discuss your initial plan of management with the patient.

P: I have diarrhoea.
P: It's been 3 months.
D: How many times you’ re going to the loo?
P: 2-3 times a day.
P: No doctor.
D: How was your bowel habit before that?
P: I used to go to the loo once daily.
D: Tell me more about your stools?
P: I am passing loose and watery stools.
D: Is there any mucous or blood?
P: No doctor
P: No
P: No
P: No
D: Do you have any tummy pain?
P: Yes
(IF NO ASK ANY TUMMY DISCOMFORT (CA Bowel, IBD, Diverticular Disease)
D: Where do you have it?
P: It’s here doctor (shows his LIF)
D: For how long you have this problem?
P: I have got this in the last few weeks.
P: Doctor, it’s becoming worse.
D: Could you please describe the pain for me?
P: It is a dull pain.
P: No
251
P: No
P: No
D: Could you please score the pain for me. from 1 being the lowest and 10 being the highest
pain you have ever experienced?
P: Doctor, it’s just a discomfort.
D: Any fever or flu like symptoms? (IBD. Diverticular Disease. GI Infection)
P: No
D: Have you lost any weight? (IF PT. SAYS NO ASK CLOSE QUESTION)
P: Yes. I have lost 2-3 kg in the past 2-3 months.
P: It is fine.
D: Do you have any shortness of breath or tiredness?
P: No
D: Do you feel dizzy or lightheaded nowadays?
P: No
D: Any alternate bowel habits? (Bowel Cancer)
P: No
D: Do you have a feeling of being unable to empty' the bowel properly? (Tenesmus)
P: No
D: Have you noticed any eye problems, joint problems, skin changes or mouth ulcers?
P: No
D: By any chance any hand shaking? (Hyperthyroidism)
P: No
D: Do you feel hot when everyone else is feeling okay?
P: No
D: Do you feel bloating in your tummy? (Diverticular Disease)
P: No
D: Have you had any episodes of constipation in the last 2-3 months?
P: No
D: Any bleeding from the back passage? (Diverticular Disease)
P: No
D: Have you ever had any similar episode in the past?
P: No
P: No
D: How about any polyp, inflammatory bowel disease. DM. Thyroid?
P: No.
D: Do you take any medication. OTC or herbal?
P: No
D: Any long term Antibiotics? (Pseudomembranous Colitis)
P: No
252
P: No.
D: Do you smoke?
P: Yes/No
P: Doctor I eat everything.
D: How about red meat or processed meat?
P: Sometimes doctor.
P: Doctor, I am a social drinker.
D: Do you have any stress?
P: No
P: Yes
D: Do you use condoms?
P: Yes
I would check your vitals and General Physical Examination.

I would like to examine your tummy.
Exposure
Chaperone
Being gentle
Consent
Make the couch flat if it is not already flat.
Left iliac fossa pain on both superficial and deep palpation
From my assessment you have some problems with your bowel. We need to do some
further
investigation to find out the exact cause.
We need to do some blood tests. (FBC, LFTs, U&Es, TFTs, CRP)
We will do a procedure called colonoscopy. We may also take some sample.
P: Doctor is it cancer?
D: There is a possibility of cancer but May I know why do you think so?
P: Doctor I’m just worried about it.
D: Like I said it’s very difficult to say at this moment but it could be a possibility.
253
DD:
Bowel Cancer
IBD
Diverticular Disease
Gl Infections
Hyperthyroidism
Pseudomembranous Colitis
HIV
IBS
254
RHEUMATOID ARTHRITIS
You are FY2 in GP.

Maria aged 50 has presented with the complain of hand pain.
She is a known smoker for the past 20 years.
Take history, assess her and discuss management with her.

P: I have pain in my both hands.
D: tell me more about your pain?
P: I have pain in my fingers and wrist joints.
P: It is there for past 6-7 weeks.
P: It was sudden.
P: It is dull pain.
P: No
P: I take ibuprofen, it helps a bit.
P: It is worse in the morning and decreases as the day progresses.
D: Could you please score the pain on a scale of 1 to 10. where 1 being no pain you have
ever experienced?
P: 7
P: No Dr.
D: Any pain in any other joint?
P: No
D: Any pain in the neck?
P: No
D: Any pain in the knee or ankle?
P: No
D: Any joint stiffness?
P: Yes
D: Is it more in the morning or throughout?
P: In the morning time, it is more.
D: Any swelling?
P: No
255
D: Any redness, hotness of the joints?
P: No
P: No
D: Do you feel tired or lack of energy ?
P: No
D: Any loss of weight and appetite?
P: No
D: Any rashes?
P: No
D: Any problem with the eyes?
P: No
D: Any redness or vision problem?
P: No
D: Any problem with your breathing?
P: No
P: No
P: No
D: any DM. HTN. Heart disease or high cholesterol?
P: No
D: Are you taking any medications apart from ibuprofen including OTC or supplements?
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes 20 Cigarette per day since I was 20
P: Yes/No
P: I don’t eat healthy
P: No Dr
P: I am a secretory'
256
D: Has it impacted your work?
P: Yes, I am having difficulty' in typing.
D: I would like to check your vitals and examine your hand

We will do some initial investigation including FBC, ESR, CRP. LFT, uric acid and rheumatoid
factor.
 From our assessment, you have a condition called rheumatoid arthritis.

 Rheumatoid arthritis is a autoimmune condition that causes pain, swelling and stiffness
in the joints. The symptoms usually affect the hands, feet and wrists.
 We will do some further investigations like Anti CCP antibody test and X ray of your
hands and wrist joints. There are various ways and options by which we can control
these symptoms and you will be able to live a healthy life.
 We will give you some painkillers to help you out with your pain. We will also give you
steroids as a short course of steroids is always given in the beginning.
 We will give you medications like DMARDS (Methotrexate, Leflunomide, Sulfasalazine)
which may help in controlling these symptoms and slowing down its progression.
 Sometimes DMARDs are combined with corticosteroids.
 Biological treatment (Etanercept, infliximab, Adalimumab) is new treatment used when
only DMARDs are not effective.
 We will refer you to our rheumatologist so that you can discuss these options at length.
We will refer you to occupational therapist and physiotherapist to help you out at your
work place.
 Give life style advice for the smoking as she is a heavy smoker.
Methotrexate side effects:

feeling sick, loss of appetite, a sore mouth, diarrhoea, headache, hair loss.
Biological treatment side effects:

skin reactions at the site of the injections, infections, feeling sick, a high temperature
(fever), headaches.
DD
Rheumatoid Arthritis
Psoriatic Artropathy
Osteoarthritis
Gout Arthritis
Septic Arthritis
SLE
257
GOUT

James Horton aged 45 has come to you with the complaint of pain in the big toe. He is
hypertensive and on Amlodipine and Bendroflumethiazide.
Talk to him, address his concerns and discuss the management with him.

P: I have pain in my big toe.
D: Tell me more about it.
P: I have had it for few weeks.
D: How did the pain start'?
P: It started suddenly
D: What were you doing when the pain started'?
P:
D: Is the pain always there or comes and goes?
P: Always
D: Can you describe the pain.
P: Sharp
D: What time of the day do you experience this pain?
P: Always
D: Anything making it worse/better?
P: Walking
D: Can you score the pain on scale of 1 to 10?
P: Around 6/7/8
D: Does it affect both the feet?
P: No. only one
D: Do you have a similar problem in other joints?
P: No
P: Like what doctor?
D: Any swelling/redness?
P: Yes
P: Same time with my pain
P: Yes/No
D: Any fevers/flu like symptoms? (Septic Arthritis)
P: No
D: Any excessive sweating?
P: No
D: Do you have any ulcer in your foot? (PAD)
258
P: No
D: Did you have any trauma?
P: No
D: Have you ever injured your foot recently?
P: No
P: No
P: I have high BP
P: I am on amlodipine and bendroflumethiazide.
D: Since when?
P: 6 months
D: Are you regular with it?
P: Yes
D: Anything other medical problem else? kidney Stones?
P: No
P: No
P: No
P: No
D: Any family history of similar condition?
P: No
D: Do you smoke?
P: Yes/No
P: Yes.
D: What do you drink?
P: Beer
D: How often and how much?
P: 3 to 4 times a week & 4/5 pints.
P: I have a balanced diet.
D: Does it include meat or diary products?
P: Yes, I'm fond of steak.
P: Driver
D: Is this pain affecting your work?
P: Yes doctor, I am not able to drive.
259
P: Alone/with family
I would like to check your vitals and examine your foot.

I would like to send for some initial investigations like routine blood tests including Uric
Acid.
Renal function (U&E's) and X-Ray of your foot.
From my assessment, you seem to have a condition called Gout. It is a type of arthritis that
causes sudden severe pain. It mainly affects the big toe. or fingers, wrists, elbows or knees.
We will check Monosodium Urate Crystals in synovial fluid of your joints.
It happens due to buildup of crystals within the joint space. These crystals irritate the joint
causing pain and discomfort. They are usually made up of chemicals known as Uric Acid that
is normally found in your blood. Some foods and drinks can cause the levels to rise and
cause painful flare ups.
Attacks of gout are usually treated with anti-inflammatory medicine like ibuprofen.
Sometimes, your blood pressure medications can affect the function of your kidneys and can
increase the level of these substances in your blood. We will check your kidney function and
we will review your blood pressure medications.
Drinking beer and eating meat can also increase the amount of uric acid in your blood and
can predispose to these attacks.
Lifestyle modification plays an important role in reducing these attacks. 1 advise you to
drink in moderation and sometimes drinking alcohol other than beer also helps. I also advise
to avoid meat products in your diet.
Gout can come back every few months or years. It can come back more often over time if
not treated or depending on your lifestyle.
P: What's happening?
P: Why did it happen?
P: How will you treat it?
To reduce pain and swelling:

Do
 take any medicine you have been prescribed as soon as possible - it should start to work
within 3 days
 rest and raise the limb
 keep the joint cool - apply an ice pack, for up to 20 minutes at a time
 drink lots of water (unless advised not to by your GP)
 try to keep bedclothes off the affected joint at night
Do
260
• get to a healthy weight, but avoid crash diets - you could try the NHS weight loss plan
• aim for a healthy, balanced diet, with plenty of vegetables and some low-fat dairy foods
• have at least 2 alcohol-free days a week
• drink plenty of fluids to avoid getting dehydrated
• exercise regularly - but avoid intense exercise or putting lots of pressure on joints
• stop smoking
• ask your GP about vitamin C supplements
Don't
• do not eat a lot of red meat, kidneys, liver or seafood
• do not have lots of fatty foods
• do not drink more than 14 units of alcohol a week (and do not have it all on 1 or 2 days)
• do not knock the joint or put pressure on it
To prevent gout coming back:

It's important to take uric-acid-lowering medicine regularly, even when you no longer have
symptoms.
If you have frequent attacks, please come back to us and we will do the tests and if it shows
you have a high level of uric acid in your blood, then we may prescribe medicine called
allopurinol or febuxostat. This is to lower levels of uric acid.
261
PAIN & ACHES
You are F2 in GP.

Mrs. Olivia, aged 68, presented to the clinic with pain and aches.
She has been diagnosed with GE reflux 20 years back and she was taking Omeprazole.
Please talk to the patient discuss your initial plan of management with the patient and
address her concern.

P: I am having pain and aches here (pointing towards thighs and shoulders)
P: What you would like to know?
P: It started 4 weeks ago.
P: Yes, it is continuous
P: It is dull pain Dr.
P: No
P: I tried PCM but it didn't help.
D: How much PCM did you take?
P: I used to take 2 per day but they were not helping so I am not taking now.
P: It is becoming worse.
D: Could you please score the pain on a scale of 1 to 10, where l being the low pain and 10
being the most severe pain you have ever experienced?
P: Around 7.
P: No
D: Any joint stiffness?
P: Yes
D: Since when are you having this problem?
P: It started with the pain.
D: Any morning stiffness?
P: No
D: Are you able to move around?
P: I can't move my arm above my head and it is difficult for me to walk my dog. I really want to
walk my dog.
D: How is your health, any fever or flu like symptoms?
P: No
262
D: Any rashes?
P: No (sub-acute cutaneous lupus)
D: Any weight loss?
P: No (cancer, thyroid)
P: No
D: Do you feel tired
P: No
D: Any headache?
P: No (some symptoms matches with GCA)
D: Any problem with your vision?
P: No
P: No
P: I have GORD and I am taking omeprazole for that.
D: For how long you have been diagnosed with that?
P: 20 years.
P: No
P: No
P: No
P: No
D: Do you smoke?
P: No/Yes
P: No
P: fine
P: I can't doctor. I can't move around with my dog.
P: It is fine.
D: Could you please score the mood for me on a scale of 1 to 10?
P:
P: It is ok
D: Do you think this pain is affecting your sleep?
263
P: No
P: I live alone. But my children live nearby and they take care of me.
D: I would like to check your vitals and examine your musculoskeletal system.
EX: All the examination is normal

D: I would like to send for some initial investigations like routine blood test.
 From my assessment, you might have a condition called Polymyalgia rheumatica. It is a

condition that causes pain, stiffness and inflammation in the muscles around the
shoulders, neck and hips.
 We will do some blood test to check if there is any infection or inflammation in your
body. We will check ESR and CRP. Mainly the level of these markers is high in your blood
if you have got this problem. We will also check your kidney function test and thyroid
gland hormone.
 We will also do some urine test to check your kidney.
 We may consider doing some scans like X-ray or USG for your bones and joints.
 We will give you pain killer for your pain.
 We will give you steroid tablets (prednisolone). You'll be given a high dose of
prednisolone to start with, and the dose will be gradually reduced every one to two
months. We will refer you to Rheumatologist.
 Although your symptoms should improve within a few days of starting treatment, you'll
probably need to continue taking a low dose of prednisolone for about two years. In
many cases, polymyalgia rheumatica improves on its own after this time. However,
there's a chance it will return after treatment stops, known as a relapse. So, don't
suddenly stop taking steroid medication unless your doctor tells you it's safe to do so.
Suddenly stopping treatment with steroids can make you very ill.
 Side effects of steroids High blood pressure
o High blood sugar
o Thinning of bones (Osteoporosis)
o Mood changes
o Weight gain
o Indigestion and Heart Bum
 You have to maintain a healthy life style like good diet including calcium rich foods and
physical activity, and also smoking cessation and drinking alcohol in moderation (advice
life style accordingly). You can take some supplements for calcium and minerals.
 We will follow you up regularly to check your weight, height, blood sugar, blood pressure
and bone density. We may prescribe you some medication if needed.
 We will give you a blue steroid card as you are taking steroids for more than 3 weeks. It is
very important to carry that with you at all times, as it will explain that you taking
steroids regularly and your dose shouldn’t be stopped suddenly.
264
 Whenever you are telling about any side effects of any medications to the patient, make
sure you give the treatment as well at the same time.
 We may also give you some medications to suppress your immune system like
methotrexate.
Side effects of methotrexate: Nausea, Vomiting

Diarrhoea
Skin rashes
IN CASE SHE GIVES THE HISTORY OF RASHES:

joint pain along with a red skin rash, especially in parts of your body exposed to the sun,
such as your arms, cheeks and nose - these can be signs of a rare condition called subacute
cutaneous lupus erythematosus that can happen weeks or even years after taking
omeprazole.
DD:
Polymyalgia Rheumatica
Dermatomyositis
Polymyositis
Osteomalacia
Malignancy
Hypomagnesemia (due to PPI)
Thyroid Disorders
DM
265
CARPAL TUNNEL SYNDROME

Lucy aged, 34 came to the clinic with pain in both the wrist and hand.
Please talk to the patient, discuss plan of management with the patient and address her
concerns.

P: I have pain in my hands and wrists
P: Like what
P: 7 days ago
P: Gradual
P: Continuous
P: Electric shock like pain
D: Does it move to any anywhere else?
P: It's moving from my wrists to hands
P: Changing hand posture or shaking the wrist
P: Gets worse at night/repetitive movements of hand or wrist
D: Could you rate the pain on a scale of o to 10, where 0 being no pain and 10 being the
worst you have ever experienced?
P: 7
P: No
D: Any pain in other joints in the body?
P: No
P: No
D: Any redness or swelling in the joints?
P: No
D: Do have any tingling or numbness in your Hands?
P: No
D: Do you have any difficulty gripping things by your hand?
P: No
266
D: Any nausea, vomiting or swelling in the ankles?
P: No
D: Do you feel cold when others around feeling normal? (Hypothyroid)
P: No
D: Any change in your bowel habit recently? (Hypothyroid)
P: No
D: Do you feel more tired? (Hypothyroid)
P: No
D: Did you have similar condition in the past?
P: No
D: have you been diagnosed with any medical condition in the past?
P: No
D: Any joint problems?
P: No
P: No
P: No
D: Any family history of any significant health issues or joint problems?
P: No
D: Do you smoke?
P: No
P: No
P: Balanced
P: I worked as a typist in an office.
P: I delivered the baby one month back.
P: With my husband
I would like to do a GPE, check the vitals and Examine your hand and wrist.
Examiner: Examine doctor
• Tinel's sign. In this test, the physician taps over the median nerve at the wrist to see if it
produces a tingling sensation in the fingers.
• Wrist flexion test (or Phalen test). The doctor will tell you to press the backs of your hands
and fingers together with your wrists flexed and your fingers pointed down. You'll stay that
way for 1 -2 minutes. If your fingers tingle or get numb, you have carpal tunnel syndrome.
267
From our assessment we suspect you are having a condition called Carpal tunnel syndrome.
It occurs due to pressure on a nerve in your wrist. It causes tingling, numbness and pain in
your hand and fingers.
P: Why did I have it?
D: There could be many reasons for it. But as it seems in your case it could be due to your
pregnancy or your job.
P: What's the treatment?
CTS sometimes clears up by itself in a few months, particularly if you have it because you're
pregnant.
 Wear a wrist splint
A wrist splint is something you wear on your hand to keep your wrist straight. It helps to
relieve pressure on the nerve. You wear it at night while you sleep. You'll have to wear a
splint for at least 4 weeks before you start to feel better. You can buy wrist splints online or
from pharmacies. If a wrist splint does not help, your GP might recommend a steroid
injection into your wrist. This brings down swelling around the nerve, easing the symptoms
of CTS.
 Stop or cut down on things that may be causing it. Stop or cut down on anything that
causes you to frequently bend your wrist or grip hard, such as using vibrating tools for
work or playing an instrument.
 Painkillers like paracetamol or ibuprofen may offer short-term relief from carpal tunnel
pain.
Surgery
If your CTS is getting worse and other treatments have not worked, your GP might refer you
to a specialist to discuss surgery. Surgery usually cures CTS. You and your specialist will
decide together if it's the right treatment for you. An injection numbs your wrist, so you do
not feel pain (local anaesthetic) and a small cut is made in your hand. The carpal tunnel
inside your wrist is cut so it no longer puts pressure on the nerve. The operation takes
around 20 minutes and you do not have to stay in hospital overnight. It can take a month
after the operation to get back to normal activities.
268
DE QUERVAIN'S TENOSYNOVITIS

Patient presents with pain in thumb.
Talk to the patient, assess him and discuss management plan

P: Dr. I have pain in the thumb.
P: Like what?
P: In my left hand at the base of thumb
P: It started few days ago
P: I was vacuuming/gardening
P: It is continuous
P: It is dull
P: It goes to my index finger
P: Painkillers
P: Using the laptop makes it worse.
P: It is around 5
P: I have a snapping feeling when I move my thumb.
P: I have numbness along the back of my thumb and index finger.
D: Did you hurt yourself anytime recently?
P: No
D: Any bruising on your hand?
P: No
D: Any stiffness in the hand joints?
P: No.
P: No
269
D: Any DM, HTN, heart disease or high cholesterol?
P: No
D: Have you ever been diagnosed with arthritis?
P: No
P: No
P: No
P: No
P: No
D: Do you smoke?
P: No
P: No
P: Yes, I play tennis.
P: No
P: 2 weeks
D: Have you been pregnant recently?
P: No
D: What do you do for a job?
P: I'm a receptionist
I would like to check your vitals and examine your hands. I will examine the left hand for
any tenderness. I will also do a test on your hand called the Finkelstein test.
Examiner: Finkelstein Test - Positive
From my assessment, your thumb pain is likely to be because of inflammation of two

tendons in your hand or as we call it De Quervain's tenosynovitis.
These symptoms can be managed with self-help measures and medications. You can start by
applying heat or ice to the affected area at home.
We can also give you some painkillers, such as non-steroidal anti-inflammatory drug (NSAID)
– such as ibuprofen, two or three times a day can also help control the pain and swelling.
270
You should avoid activities that cause pain and swelling. Especially avoid those that involve
repetitive hand and wrist motions, such as playing tennis, or using your laptop/using a
mouse. We will also advise you to wear a splint 24 hours a day for 4 to 6 weeks to rest your
thumb and wrist.
If necessary, we can also suggest injections of steroids or a local anaesthetic (numbing

medicine) into the tendon sheath. These injections are very effective and are used
regularly.
A physical therapist or occupational therapist can show you how to change the way you
move. This can reduce stress on your wrist. He or she can also teach you exercises to
strengthen your muscles.
Most people notice improvement after 4 to 6 weeks of treatment. They are able to use
their hands and wrists without pain once the swelling is gone.
DD:
Trauma
Osteoarthritis
Septic Arthritis
Reference Information:
S/S
1. pain or tenderness at the base of your thumb.
2. Swelling near the base of your thumb.
3. Numbness along the back of your thumb and index finger.
4. A catching or snapping feeling when you move your thumb.
Risk Factors:
• You are a woman.
• You are 40 years of age or older.
• Your hobby or job involves repetitive hand and wrist motions. This is a very common
cause.
• You have injured your wrist. Scar tissue can restrict the movement of your tendons.
• You are pregnant. Hormonal changes during pregnancy can cause it.
• You have arthritis.
To diagnose de Quervain’s tenosynovitis, your doctor may do a simple test. It is called the
Finkelstein test.
271
Treatment for de Quervain’s tenosynovitis focuses on reducing pain and swelling. It
includes:
 Applying heat or ice to the affected area.
 Taking a nonsteroidal anti-inflammatory drug (NSAID). These include ibuprofen (Advil,
Motrin) or naproxen (Aleve).
 Avoiding activities that cause pain and swelling. Especially avoid those that involve
repetitive hand and wrist motions.
 Wearing a splint 24 hours a day for 4 to 6 weeks to rest your thumb and wrist.
Getting injections of steroids or a local anesthetic (numbing medicine) into the tendon
sheath. These injections are very effective and are used regularly.
A physical therapist or occupational therapist can show you how to change the way you
move. This can reduce stress on your wrist. He or she can also teach you exercises to
strengthen your muscles.
Most people notice improvement after 4 to 6 weeks of treatment. They are able to use their
hands and wrists without pain once the swelling is gone.
Hand & Wrist Examination

Rapport
Assess his knowledge.
GIPPEEC
Look:
Inspect hands from Dorsum:
There are no skin, nail changes, scar marks, swelling, deformities or muscle wasting.
Palms up:
There are no scars and swelling, Dupuytren’s contracture or thenar and hypothenar muscle
wasting.
Elbows:
There are no evidence of psoriatic plaques or rheumatoid nodules
Feel:
Palms up
Temperature:
Assess and compare the temperature of the wrists and small joints of the hand.
Radial and ulnar pulse:

Palpate the radial and ulnar pulse to confirm there is adequate blood supply to the hand
Thenar/hypothenar eminence bulk:

The muscle bulk of the thenar and hypothenar eminences is normal. There is no palmar
thickening
272
Median, ulnar and radial nerve nerve sensation:
median nerve sensation over the thenar eminence and indexfinger
ulnar nerve sensation over the hypothenar eminence and little finger
Radial nerve sensation over the first dorsal web space
Dorsum:
Assess and compare temperature using the back of your hand:

Wrist and MCP joint.
Gently squeeze across the metacarpophalangeal (MCP) joints, Bimanually palpate the joints
of the hand (MCPJ/PIPJ/DIPJ/CMCJ)
Assess and compare joints for tenderness, irregularities and warmth:
Metacarpophalangeal joint (MCPJ), Proximal interphalangeal joint (PIPJ), Distal
interphalangeal joint (DIPJ), Carpometacarpal joint (CMCJ) of the thumb (squaring of the
joint is associated with OA). Palpate the wrists for evidence of joint line irregularities or
tenderness
Palpate the anatomical snuffbox: Tenderness may suggest scaphoid fracture.
Palpate the elbow: Along the ulnar border to the elbow feel for any rheumatoid nodules or
psoriatic plaques (extensor surface).
Move:
Active movements:
Finger flexion – Make a fist.
Finger extension – Open your fist and splay your fingers
Wrist extension – Put the palms of your hands together and extend your wrists fully.
Wrist flexion – Put the backs of your hands together and flex your wrists fully
Passive movement:
Assess movements passively, feeling for crepitus and noting any pain.
Motor assessment
Wrist/finger extension – radial nerve
Finger ABduction of the index finger – ulnar nerve
Thumb ABduction – median nerve
Function
Assess the patient’s hand function using the following screening tests:
Power grip – “Squeeze my fingers with your hands”
Pincer grip – “Squeeze my finger between your thumb and index finger “
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Pick up a small object or undo a shirt button – “Can you pick up this small coin out of my
hand?”
Special tests
Tinel’s test:
Tinel’s test is used to identify nerve irritation and can be useful in the diagnosis of carpal
tunnel syndrome.
Tap over the carpal tunnel with your finger. If the patient develops tingling in
the thumb and radial two and a half fingers this is suggestive of median nerve irritation and
compression.
Phalen’s test:
Ask the patient to hold their wrist in complete and forced flexion (pushing the dorsal
surfaces of both hands together) for 60 seconds.
patient’s symptoms of carpal tunnel syndrome are reproduced then the test is positive (e.g
burning, tingling or numb sensation in the thumb, index, middle and ring fingers)
To finish the examination, I will do full neurological examination, I will examine one joint
above.
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RAYNAUD PHENOMENON

Mr. Smith, age 35 years presented with pain in his fingers.
Take history , assess and manage him according.
D: Hello I am James one of the junior doctors in this GP surgery . can I confirm your name
and age please ?
P: Yes Dr. my name smith and I am 35 years old
D- how may I call you.
P: James is fine dr.
D: What brought you here today
P: Dr I have pain in my fingers for the last few months
D : tell me more about it
P: Dr it usually more common in winter season or when I’m exposed to cold .
Do SOCRATES
Last for few mins to hours
Main complaints of Raynaud’s- pain, pins and needles, numbness, difficulty in moving
affected parts , change in color)- ask these questions in data gathering.
Anything else
P: Dr I have difficulty moving my fingers as well during the same time and my fingers become
white .
D: anything else
Differential diagnosis- GHRROSST ( gout, reactive arthritis, rheumatoid arthritis,
osteoarthritis, scleroderma, SLE, trauma)
Questions about differentials-
Joint pain
Stiffness
Pain and stiffness at particular times of day
Hot tender joints
Wee- discharge/burning
Eye discharge
Rashes if yes itchy
Have you notice certain kind of stress or anxiety brings in the pain or color change in your
fingers? (Stress/Anxiety)
D: Fever or flu like symptoms (vasculitis/reactive arthritis)
D: Chest pain (hyperviscosity)
D: Itching of fingers
D: Swelling of finger
D: Loss of weight (cancer)
D: Loss of appetite
D: Any history of trauma
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D: Joint pains ( SLE ) (SCLERODERMA)
D: Any rashes
D: Autoimmune diseases like SLE, RA , SCLERODERMA ( POSITIVE FOR RAYNAUD’S
PHENOMENON.
D: Any medical condition (atherosclerosis, DVT)
MAFTOSA
D: Are you taking any medications ( beta blockers, migraine medications)
D: Allergy to any medications
D: Family history of diseases
D: Occupations (typist , heavy use of hand tools)
D: Are you smoking (risk factor)
D: Are you taking alcohol
D: Diet ( increase intake of caffeine)
D: Physical activity
Past medical history
MANAGEMENT
I would like to examine your fingers and will do routine blood tests , CRP , ESR , ANA , RA
factor to rule out other causes .
No diagnostic test for Raynaud’s phenomenon
From what you have told me and what we have observed we are suspecting you have a
condition called Raynaud’s phenomenon .
D: Do you have any idea what Raynaud’s phenomenon is ? (Concern)
P: No
It is a localized intermittent episodes of interruption of blood flow to the extremities
(vasoconstriction of small arteries) of the feet and hands that causes color and temperature
changes leading to pain in the fingers, usually unilateral but it can be bilateral as well.
I would like to inform my seniors who will review you again.
Refer to Rheumatologist
PREVENTION OF ATTACKS
DO’s
• keep your home warm
• wear warm clothes during cold weather, especially on your hands and feet
• exercise regularly – this helps improve circulation
• try breathing exercises or yoga to help you relax
• eat a healthy, balanced diet
DON’Ts
• do not smoke – improve your circulation by stopping smoking
• do not have too much caffeine (found in tea, coffee, cola and chocolate) – it may trigger
the symptoms of Raynaud's
• relieve stress
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SEE YOUR GP
• Your symptoms are very bad or getting worse
• Raynaud's is affecting your daily life
• Your symptoms are only on 1 side of your body
• You also have joint pain, skin rashes or muscle weakness
• You're over 30 and get symptoms of Raynaud's for the first time
• Your child is under 12 and has symptoms of Raynaud's
TREATMENT FROM THE GP

Keep your hands warm by putting Raynaud’s gloves on your hands to keep them warm.
During the attack you can put your hands in a warm not hot water can alleviate the
symptoms.
• If your symptoms are very bad or getting worse, a GP may prescribe a medicine to help
improve your circulation, such as nifedipine, which is used to treat high blood pressure.
• Some people need to take this medicine every day. Others only use it to prevent
Raynaud's – for example, during cold weather.
• A GP may arrange tests if they think Raynaud's could be a sign of a more serious condition,
such as rheumatoid arthritis or lupus.
A variant of vitamin B like Niacin can be given as well which will improve the circulations
Use of FISH OIL is good for patients having Raynaud’s phenomenon Support from SRUK.
SRUK is a Charity for people with scleroderma and Raynaud's. It offers:
• further information and advice about living with Raynaud's
• information on how to find support groups
• advice about coronavirus and Raynaud's
RED FLAGS if you have

ULCERS
GANGRENE COME BACK TO US
FOLLOW-UP WITH YOUR GP.
ANY SPECIFIC EXPECTATIONS FROM THIS CONSULTATION
LEAFLETS FOR RAYNAUD’S
I WISH YOU A GOOD HEALTH.
HYPERVISCOSITY
VASCULITIS
SLE
SCLERODERMA
TRAUMA
CANCER
RISK FACTORS
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Smoking, Repetitive typing ,side effects of certain medications, stress and cold.
COMPLICATIONS
ULCERS, SCARRING, TISSUE DEATH
278
REACTIVE ARTHRITIS
You are F2 in Orthopaedics.

Mr. Peter Randal, aged 27, came to the hospital with the pain in the joints.
Please take history, do relevant examination and discuss the management with the patient.

P: I have pain in my joints.
D: could you tell me in which joints you are having pain?
P: In my ankle and knee joint (patient points to both joints)
D: when did it start?
P: 2 weeks back.
P: I can't remember.
D: is the pain continuous or does it come and go?
P: It comes and goes
D: Could you please describe the pain for me?
P: It is just a mild
D: is there anything making it worse?
P: No
D: is there anything making it better?
P: No
D: Apart from this pain are you experiencing anything else?
P: I have some discomfort in my eyes.
D: is it in your both eyes?
P: Yes
D: when did it start?
P: It started with joint pain.
D: Have you noticed any redness in your eyes?
P: No
D: Do you have pain in your eyes?
P: No
D: Do you have noticed any discharge from your eyes?
P: No
D: Are your eyelids swollen?
P: No
D: is your vision impaired?
P: No
P: No
D: Are your knees, feet or ankles
P: No
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D: Do you have pain in any of your other joints?
P: No
D: Do you have any stiffness in your joints in the morning?
P: No
D: Are you able to walk independently?
P: Yes, I can walk.
D: Do you go to the loo more frequently?
P: No
D: Have you noticed any discharge from your front passage?
P: No
P: This is the first time.
D: Apart from what you have told me, how has your health been recently?
P: I have been fine but I developed diarrhoea after my trip to France.
D: When was that?
P: It was 3 weeks ago.
D: Was there any blood in your stools?
P: No, it was not bloody.
D: How did you treat that?
P: it got better by itself.
D: Anything else?
P: No
P: No
D: Are you taking medications including any over the counter, herbal remedies or
supplements?
P: No
P: No
D: Any surgeries or procedures in the past?
P: No
P: No.
P: No
D: Do you smoke?
P: No
P: It’s fine, I try to eat healthy.
D: How about your physical activity?
P: I think it’s fine.
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P: Yes
D: Are you in stable relationship?
P: No
P: Not really, sometimes.
P: When I was in France, about 3 weeks ago.
D: I would like to check your vitals and musculoskeletal examination
Articular involvement in reactive arthritis is typically asymmetric and usually affects the
weight bearing joints (knee ankles and hips). Joints are examined, described as tender,
warm, swollen and sometimes red.
D: I am going to have a look at your eyes.

EX: redness, oedema, purulent discharge.
B: Joints.
LOOK:
Anatomical position
Symmetry of joints
Inspection:
There is no redness, swelling, muscle wasting. deformity or any skin patches bilaterally.
FEEL:
1. Temp (Ankles, Knees)
2. Tenderness (Knees, Heel, Achilles Tendon)
3. Ankle Oedema / Swelling
4. Patellar Tap: Large Effusions.
MOVE:
1. Active Movements:
- Knees: Flexion, Extension
- Ankles: Plantar Flexion. Dorsiflexion
 From our assessment, we are suspecting a condition called reactive arthritis.

 Reactive arthritis is a condition that causes redness and swelling in various places in the
body.
 This condition develops after few weeks of an infection to our body. Your immune
system is your body defence against illness and infection. When our body faces any bug.
our immune system sends substance called antibodies to fight against the infection.
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 One of the most common types of infection linked to reactive arthritis is tummy bug or
food poisoning. You told me you had diarrhoea when you travelled to France 3 weeks
ago. This is most probably the cause of your condition. Another common type of
infection linked to reactive arthritis is sexually transmitted infections. You also told me
that you had unprotected sex when you travelled to France 3 weeks ago. This also could
be the cause in your case.
 We did a general physical examination
 We will do some Routine Blood Tests (ESR, CRP. FBC). We will also do some specific blood
tests to look for a specific substance (HLA-B27) which can be found in majority of the
cases. We will check the antibodies to exclude some other causes of joint pain (absence
of rheumatoid factor and anti-nuclear antibody) To detect the cause of infection
(Serology of Chlamydia, Campylobacter, Salmonella, Shigella). We may need to do an X-
Ray of your joints (usually normal in early stage)
 Reactive arthritis is usually temporary and the treatment can help to relieve your
symptoms.
 Most people will make a full recovery in 6 months. Your eye problem will hopefully
resolve spontaneously within 2 weeks.
1. You need to get plenty of rest for a few days.

2. Please avoid using the affected joints for some time.
3. Gradual exercise will be helpful. As your symptoms improve, you should begin a gradual
programme of exercise to strengthen the affected muscles and improve the range of
movement in the affected joints.
4. We may refer you to a physiotherapist, if needed.
5. Ice packs or heat pads may be helpful in reducing joint pain and swelling.
 We are going to give you a medication called NSAIDS such as ibuprofen. These are the
main medication used for reactive arthritis to reduce inflammation and relieve pain.
 The other medication is steroid (corticosteroids such as prednisolone)
 This is usually prescribed if your symptoms don’ t respond to NSAIDS or NSAIDS cannot
be used because of some medical illness or other treatment. Steroids work by blocking
the effects of some of the chemicals our immune system uses to trigger inflammation. It
can be given as an injection into the joint or as a tablet.
 Eye drops can also be prescribed if there is any eye problem.
 We can also prescribe you medications called DMARDs (Disease modified anti rheumatic
drugs).
 These act at the same way as steroids. It can take up to a few months before you notice a
DMARDS working, so it is important to continue taking medication even if vour
symptoms do not improve.
Common side effects of sulfasalazine:
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Feeling sick, loss of appetite and headache. However, they usually improve once the body
gets used to the medication.
It may also cause changes in your blood or liver, so regular blood tests will be done during
the course of medication
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OPHTHALMOLOGY STATIONS
AACG (ACUTE RED EYE)
You are F2 in A&E.

Karishma aged, 50 came to the hospital with redness in her eye.
Take history, assess the patient and discuss about the management with patient.

P: I have pain in my left eye.
P: It started few hours ago.
P: It is continuous and becoming worse.
P: It is continuous and becoming worse
P: It was sudden
P: It is dull pain
P: No
P: I took PCM but didn’t help
P: I took two tablets
P: No
P: It is 7 Dr.
D: What about your other eye?
P: It is fine.
D: Any other symptoms? (Open question).
P: I have headache in my left side of the head and eyebrow.
D: Since when?
P: Since my eye pain started.
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P: It was sudden.
P: It is dull pain.
P: No
P: It is 9
P: No
D: Any problem with your vision?
P: I have blurry vision, I can’t see properly with my left eye.
P: No
D: Any nausea?
P: Yes, I feel nausea
D: Did you vomit?
P: Yes, I vomited two times.
D: Do you see any rings around lights?
P: No
D: Have you noticed any redness in your eyes?
P: No
D: Any burning sensation, any gritty sensation or any sticky discharge?
P: No (Conjunctivitis)
D: Any joint pain? Wee problem? (Reiter’s)
P: No
P: No
P: Yes. I have depression.
D: Since when?
P: 6 months
P: I am taking Amitriptyline.
D: Are you taking the medication regularly?
P: Yes
D: Any other medical condition such as IBD, AS or RA?
P: No
P: No
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P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
D: What you do for the living?
P: Office work.
I would like to check your vitals and examine your eye.

Patient will show a picture of her eye - RED EYE AND DILATED PUPIL. Patient might show
this picture in the beginning.
From our assessment, we are suspecting you have a condition called Acute Angle Closure
Glaucoma. It is condition in which, part of the eye that drains fluid becomes blocked causing
pressure to build up in the eye.
This leads to pressure on the nerve that transmits the signal to the brain. This is what causes
the pain.
Tonometry: An eye pressure test uses an instrument called a tonometer to measure the
pressure
inside your eye.
We will give you some painkiller to relieve your pain and some anti-sickness medication for
your sickness
We will give you some eye drops to decrease fluid production in your eye (Timolol)
We may consider giving you a IV medication as drip after discussion with my senior
(acetazolamide)
We may need to give you a need to give you a medicine to constrict your pupil so the fluid
can flow freely in your blood vessels. (Pilocarpine).
In your case, the medication you are taking for depression seems to be the cause of your
problem. This medication can dilate your eyes which causes the problem.
We can talk to your GP to review your drugs.
Please remove your glasses as glasses can worsen your condition.
The outlook is good if treatment is started immediately. Also, the further treatment you are
receiving can prevent recurrence of the problem.
We will refer you to specialist for further treatment. They will confirm your diagnosis by
measuring the pressure in your eye.
Patient concern:
1. Will Igo blind?
2. Why do I have this problem?
286
Prevention:
 You should avoid watching TV in the dark room.
 We are going to refer you to the specialist when the pressure in your eye has decreased.
 Further treatment is needed to prevent this from happening in the future.
 This usually involves laser treatment or surgery to make a hole in the eye so that fluid
can
 flow inside the eye.
 The treatment can be advised for the other eye to prevent the same condition in your
other eye.
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SUBCONJUNCTIVAL HAEMORRHAGE
You are an F2 in the A&E.

Luis a 75 year old has presented to the hospital with complaint of red eye.
Take history, discuss the management with the patient and address his concerns.

P: Doctor my eye has suddenly become red
D: Tell me more about your eye?
P: It's my left eye.
D: What about the other eye?
P: That is fine.
D: Do you have any pain?
P: No
D: Do you have any irritation?
P: Yes
D: Are you able to see clearly?
P: Yes
D: When did you notice it?
P: This morning.
D: What were you doing when u noticed it?
P: I was just washing my face & looked in the mirror & saw that my eye was red.
D: Anything else?
P: No
D: Any discharge from the eye?
P: No
D: Did you hurt your eye by any chance?
P: I don't remember hurting my eye doctor.
D: How have you been recently?
P: Fine
D: Any headache?
P: No
D: Any fever, flu, sneezing, cough or constipation?
P: No
D: Do you use contact lenses?
P: No
D: Any burning sensation, any gritty sensation or any sticky discharge?
P: No (Conjunctivitis)
D: Any joint pain? Wee problem ? (Reiter’s),
P: No
P: No
288
P: No
D: Any condition such as DM, HTN, Blood Disorder, Cholesterol or Heart Disease?
P: No
D: Any other medical condition such as IBD, AS or RA?
P: No
P: No
D: Any blood thinners or steroids?
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
P: My wife died couple of years back. I’m ok. I spend my time playing bowling and golf.
D: I would like to check your vitals including your blood pressure and examine your eye.
Patient will show a picture of her eye - RED EYE.
D: From what you’ve told me & what I’ve examined you have a problem in your eye called a
subconjunctival haemorrhage.
Conjunctiva is actually a thin membrane that covers part of the front surface of the eye.
Conjunctiva contains many small & fragile vessels. Sometimes it happens that these vessels
rupture or break & blood leaks in the space under the conjunctiva and the eye appears red
as in your case. This is not a serious condition; it doesn’t affect your eye or your vision in any
way & usually gets better in a week or two on its own.
A subconjunctival usually occurs without any reason.
The good thing is that it resolves on its own & does not need any specific treatment as you
do not have any underlying medical condition.
289
We will give you some artificial tears for your irritation in your eyes.
Please do not use any pain killers without consulting your GP
We will give you some leaflets regarding your condition.
If you develop this kind of redness in both the eyes, please do come back to the hospital and
we will do further investigation and refer you to the eye specialist.
PATIENT'S CONCERNS
P: Will I go blind?
P: How long before it goes back to normal?
DD:
Trauma
Foreign body
Conjunctivitis
Acute congestive glaucoma
Cluster headache
Reiter's syndrome
Inflammatory bowel disease
290
CATARACTS
You are an F2 working in Medicine.

Evelyn Addison 65 years old has some concerns. She went to her GP last week who advised
her not to drive.

P: I have some problem with my vision and my GP advised me not to drive.
D: Can you tell me more about the vision problem?
P: I don't know.
D: Ok let me ask you few questions to have a better understanding of your vision.
P: No
D: Any pain in the eyes?
P: No
D: Do you have any blurry vision?
P: No
D: Any loss of vision?
P: No
D: Any double vision?
P: No
D: Do you find it harder to see in low light?
P: No
D: For how long is that going on?
P: 1 year
D: Do you see too bright or any glaring?
P: No
D: Any faded colour in vision?
P: No
D: Do you have any pain at the back of the eye? (Glaucoma)
P: No
D: Do you have any coloured haloes around light? (Glaucoma)
P: No
D: Any headache? (Glaucoma/ ICSOL)
P: No
D: any nausea or vomiting? (Glaucoma/ ICSOL)
P: No
D: Any discharge or redness in the eye? (Conjunctivitis)
P: No
D: Any trauma to the eye?
P: No
D: Do you see objects smaller? (ARMD)
291
P: No
D: Do you see colours less bright? (ARMD)
P: No
D: Do you have any trouble with the central vision? (ARMD)
P: No
D: Do you see wavy lines instead of straight lines? (ARMD)
P: No
D: Do you wear glasses or contact lenses?
P: No
D: Have you had similar kind of problems in the past?
P: No
P: No
D: Any DM, HTN, Glaucoma or visual problems in the past?
P: No
D: Are you taking any medications including OTC orsupplements?
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: Healthy
P:
P: My husband
I would like to examine you, do GPE, check vitals and I would like to examine your eyes.
Examiner: Bilateral cataract
From our assessment it seems that you are having a condition called Cataract. A cataract is a
condition in which the lens of an eye becomes cloudy and affects vision.
P: Why did I have it?
D: There could be reasons for it. But in your case, it looks like due to age.
P: What's the treatment?
292
D: Cataracts can usually be treated with a day-case operation, where the cloudy lens is
removed and is replaced with an artificial plastic lens. Day case surgery means you can come
to the hospital on the day of the surgery and leave the hospital on the same day if
everything goes on smoothly after the surgery.
P: Tell me about the surgery please?
D: A typical cataract operation takes about an hour and requires local anaesthesia only.
Surgeons will make a small cut and take the cloudy lens out and put an artificial lens in.
P: Dr It sounds very scary! They will operate in my eye without putting me on sleep! Please is
there any other way that the surgeons can take care of my anxiety?
D: I can see you are worried. I will be referring you to an eye specialist and they will be in a
better position to explain about the surgery. And they might give some medication during
the operation to sedate you or relieve your anxiety.
P: Will they operate both eyes at the same time?
D: Usually the surgeries of both eyes are done 6-12 weeks apart.
P: Thank You
D: Do you have any other concerns?
P: No
You don't need to tell the DVLA if you have cataracts in only one eye, unless you:
 also have a medical condition in the other eye
 drive fora living
 If you drive a bus, coach or lorry, you must inform the DVLA if you have cataracts in one
or both eyes.
293
ARMD
You are an F2 working in Medicine.

Monica Ball 85 has come with some visual problem.

P: I see wavy lines instead of straight lines even with spectacles.
D: Can you tell me more about the vision problem?
P: dr I don't know.
D: Ok let me ask you few questions to have a better understanding of your vision.
D: For how long is that going on?
P: 1 week
D: Do you see objects smaller? (ARMD)
P: No dr
D: Do you see colors less bright? (ARMD)
P: No dr
D: Do you have any Black/gray patch affecting your central vision? (ARMD)
P: no dr
D: Do you see any flashing of the lights? (ARMD)
P: No dr
D: Does it happen that you see objects those are actually not there? (ARMD)
P: No dr
D: Can you tell me do you have any blurry vision? (Cataract)
P: No dr
D: Do you find it harder to see in low light? (Cataract)
P: no dr
D: Do you see too bright or any glaring? (Cataract)
P:No dr
D: Any faded colour in vision? (Cataract)
P: No dr
D: Do you have any pain at the back of the eye?(Glucoma)
P: no dr
D: Do you have any colored haloes around light?(Glucoma)
P: No dr
D: Any headache? ( Glucoma/ ICSOL)
P: No dr
D: any nausea or vomiting? ( Glucoma/ ICSOL)
P: No dr
D: Any discharge or redness in the eye? (Conjunctivitis)
P: No dr
D:Any trauma to the eye?
294
P: No dr
D: Do you wear glasses or contact lenses?
P: yes dr. reading glasses
D: Have you had similar kind of problems in the past?
P : no dr.
P: Yes dr. I have DM.
D: tell me more about it
P: Its been 20 years . It has been well controlled.
D: how are you managing it?
P: I am taking insulin mixtard 2 times a day. 20 in the morning and 10 in the evening.
D: Do you check your blood sugars regularly?
P: yes dr. today morning it was 6 before meal.
D: any symptoms of DM?
P: No dr
D: any complication related to DM ? like any eye or foot problem?
P: no dr
D: Any HTN, Glaucoma or visual problems in the past?
P: no dr
D: Any family history of any significant health issues or visual problems?
P: No dr
D: Are you currently on any medication except Insulin?
P: No dr
D: Do you smoke?
P: No
P: No
P: Healthy dr
D : How about physical exercise?
P: I am quite active dr
D: Do you drive?
P: No dr
P: retired
D: Whom do you live with? P: My husband dr
I would like to examine you, do GPE, check vitals and I would like to examine your eyes.
Examiner: Drusen in macula
From our assessment we are suspecting you have a condition called macular degeneration.
It is the distortion or loss of sight of the middle part of a person's visual field and is caused
295
by damage or degeneration to the macula. The macula is the part of the retina that is
responsible for clear, sharp vision and acts as the body's natural sunglasses, absorbing any
excess light that enters.
P: Why did I have it Dr?

D: there could be reasons for it. But in your case it looks like due to advancing age, and you
mentioned you have DM which is one of the risk factors as well.
P: What will you do for me dr?
D: I will be referring you to an eye specialist within a day and he will do further
investigations like scan of the back of the eyes to confirm the diagnosis. The treatment of
this condition depends on the type of Macular degeneration.
Treatment depends on the type of AMD you have.

Dry AMD - there's no treatment, but vision aids can help reduce the effect on your life.
Wet AMD - you may need regular eye injections and, very occasionally, a light treatment
called "photodynamic therapy" to stop your vision getting worse.
Anti-VEGF medicines - ranibizumab (Lucentis) and aflibercept (Eylea) Injections given

directly into the eyes.
- stops vision getting worse in 9 out of 10 people and improves vision in 3 out of 10 people
usually given every 1 or 2 months for as long as necessary
- drops numb the eyes before treatment - most people have minimal discomfort
- side effects include bleeding in the eye, feeling like there's something in the eye, and
eyes being red and irritated
Photodynamic therapy (PDT)

- A light is shined at the back of the eyes to destroy the abnormal blood vessels that cause
wet AMD.
- may be recommended alongside eye injections if injections alone don't help
- usually needs to be repeated every few months
- side effects include temporary vision problems, and the eyes and skin being sensitive to
light for a few days or weeks
 Speak to your eye specialist about a referral to a low-vision clinic if you're having
difficulty with daily activities.
 Staff at the clinic can give useful advice and practical support. For example, they can talk
to you about:
o useful devices - such as magnifying lenses
o changes you can make to your home - such as brighter lighting
o software and mobile apps that can make computers and phones easier to use
 If you have poor vision in both eyes, your specialist may refer you for a type of training
called eccentric viewing training.
296
o This involves learning techniques that help make the most of your remaining
vision.
 In addition to support from your specialist, you may find it useful to use support groups
such as:
o the Macular Society - which has a range of support services
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OPTIC NEURITIS (MS)
You are FY2 in GP.

A middle aged lady wants to see you.
Talk to her, address her concerns and discuss further management.
Dr: Hello, how can I help you?

Pt: I have pain in my eye from yesterday.
Dr: Sorry to hear about that, please tell me more about it
Pt: I can’t differentiate between colors as well.
Dr: From how long?
Pt: From yesterday
Dr: How is your right eye? Any symptoms?
Pt: No
Dr: Are you experiencing it for the first time?
Pt: it happened 3 months ago as well but it resolved on it is own after a week.
Dr: Ask all eye symptoms like vision, discharge, colored haloes, redness, floaters, pressure in
eyes.
Pt: (In this case everything is negative)
Dr: Ask all symptoms of MS
• fatigue
• difficulty walking
• vision problems, such as blurred vision
• problems controlling the bladder
• numbness or tingling in different parts of the body
• muscle stiffness and spasms
• problems with balance and coordination
• problems with thinking, learning and planning
Dr: Do you have any other health problems?
Pt: No
Dr: Are you using any medicine?
Pt: No
Dr: Any one in your family with MS?
Pt: My mom has.
Dr: Sorry for that
Dr: What you do for living?
Pt: Homemaker
Examination
I would like to check your vitals, i.e., your BP, pulse, temperature and respiratory rate. Also,
I would like to examine your eye (do eye examination)
Examiner may give you findings, i.e., decreased visual acuity and blurred optic disc.
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Management
Dr: From what you have told me and from what we have assessed we think that you are
having a condition called optic neuritis unfortunately. It means that by mistakenly your
immune system is attacking nerve of your eye.
Dr: We will refer you to eye specialist urgently so that he can further assess and manage
you.
Pt: Do I have MS like my mother?
Dr: I am afraid it is related to multiple sclerosis but we need to do more tests to confirm
your condition
Pt: Ok
Dr: We will also do your blood tests to make sure everything is fine with your liver, kidneys,
and we will also check inflammatory markers like ESR, CRP.
Pt: Ok
Dr: We will arrange a follow up in a month. (Safety net regarding MS symptoms including
eye problems mentioned above)
REFERENCE INFORMATION:
Multiple sclerosis (MS) is a condition that can affect the brain and spinal cord, causing a
wide range of potential symptoms, including problems with vision, arm or leg movement,
sensation or balance.
It's a lifelong condition that can sometimes cause serious disability, although it can
occasionally be mild.
It's most commonly diagnosed in people in their 20s and 30s, although it can develop at any
age. It's about 2 to 3 times more common in women than men.
Treatments for multiple sclerosis (MS)

There's currently no cure for MS, but a number of treatments can help control the condition.
The treatment you need will depend on the specific symptoms and difficulties you have.
It may include:
• treating relapses with short courses of steroid medicine to speed up recovery
• specific treatments for individual MS symptoms
• treatment to reduce the number of relapses using medicines called disease-modifying
therapies
Disease-modifying therapies may also help to slow or reduce the overall worsening of
disability in people with a type of MS called relapsing remitting MS, and in those with a type
called secondary progressive MS who have relapses.
Unfortunately, there's currently no treatment that can slow the progress of a type of MS
called primary progressive MS, or secondary progressive MS in the absence of relapses.
Living with multiple sclerosis (MS)
If you have been diagnosed with MS, it's important to take care of your general health.
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Charities and support groups for multiple sclerosis (MS)
There are 2 main MS charities in the UK:
• MS Society
• MS Trust
These organisations offer useful advice, publications, news items about ongoing research,
blogs and chatrooms.
They can be very useful if you, or someone you know, has just been diagnosed with MS.
There's also the shift.ms website, an online community for younger people affected by MS.
Social care and support guide
If you:
• need help with day-to-day living because of illness or disability
• care for someone regularly because they're ill, elderly or disabled, including family
members
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PERIPHERAL FIELD OF VISION
You are F2 in GP.

Mr. Andy aged, 43 has been presented to the GP with visual problems. This is the patient's
first visit. You don't know about patients past medical history.
Please talk to the patient, assess the patient, examine his vision and discuss about next step
of management.

P: I am fine, my wife thinks I have got some problem with my vision.
D: Why your wife think like this?
P: Because I scratched my eye
D: Which side?
P: Both side of my car;,
P: It happened yesterday.
D: How did it happen?
P: I was parking my car and I scratched it.
P: Yes/No
D: Do you usually bump into people or things?
P: No
D: Any car accidents?
P: No
D: Any headache?
P: No
D: Any blurry or double vision?
P: No
D: Do you see any colour halos?
P: No
P: No
D: Have you been diagnosed with any medical conditions?
P: No
D: Any eye problems?
P: No
P: I am a driver.
EXAMINATION:
FIELD OF VISION (CN
1. Explain the procedure, Exposure, consent
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2. Visual acuity
a. Glasses / Contact Lenses
b. Snellen's chart
c. Colour vision Ishihara (ideally)
3. Peripheral field of vision (X-Test) – without glasses
4. Central field of vision (Blind Spot) – without glasses
5. Pupillary reflexes
SNELLENS
Big chart - 20 feet distance.
Small chart - 6 feet distance.
1. Glasses / Contact Lenses - Yes.

2. Do with & without Glasses both (Do without glasses in case patient is using reading
glasses)
Read from top to bottom

Until 2 mistakes - 20 /40 - 2 or 20/40 - 1
3 or more mistakes - exclude or skip that line, go to the one above it. 20/50.
1. This is Snellen's chart I want you to look at this and read to the bottom.
2. My patient has normal VA (mostly) or examiner will say it is normal.
Ideally, I would check my patients color vision using ishihara chart.
Sometimes examiner stops you in the beginning saying “VA is normal” . Jump to next step.
3. Peripheral field of vision.
-U.T - L.T - UN - L.N
- stop when patient says he can see it. Bring all the way to center if he cant.
- bring down the pin slowly, (the pin should be in imaginary wall).
* Command: This is white head pin and I will make an irnagi

You have to look straight ahead on my nose and do not move you
see the tip of this pin and Say Yes
c. Cover your eye opposite side.
- it is a white head pin. I am going to use it to draw an imaginary
- R U.T - cover with Left hand left eye. When you see it first. I want you to say yes.
Repeat for Left eye
TUNNEL VISION
RIGHT HOMONYMOUS HEMIANOPIA
LEFT HOMONYMOUS HEMINANOPIA
4. Central field of vision.

- make a + VERY SLOWLY.
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- use red pin at the same level as nose of patient.
- do it with patient (check yours as well)
1. it is a red pin. I am going to make a + sign.
2. look at my nose and do not move your head.
Cover your right eye.
Say “disappear” when you can't see it and “reappear” when you can.
3. My patients blind spot matches mine / does not match or inconclusive.
Pupillary' Reflexes:
1. I am going to shine a bright light into your eyes using the torch.
2. Command: place the base of the thumb on the bridge of your nose (show) & look straight
ahead.
I would like to dim the light.
It would be a bit uncomfortable, please bear with me.
3. Shine light on right eye - look at right eye (Direct).
Be at the same level as of patient’s eyes when standing)
Shine light on Right eye - look at Left eye (Consensual)
REPEAT ON LEFT EYE.
“Both direct and consensual reflex are normal"
Tunnel Vision: It is a type of partial blindness where vision is restricted in a way that you can
only see in front of you.
Bi-Temporal Hemianopia: It is a type of partial blindness where vision is missing in the outer
half of both.
Homonymous Hemianopia: It is a type of partial blindness where there is loss of half of the
field of view on the same side in both eyes.
Causes:
Tunnel Vision: Glaucoma. Pituitary tumours, retinal detachment, optic neuritis
Bi-temporal Hemianopia: Pituitary adenoma, meningioma, craniopharyngioma
Homonymous Hemianopia: Stroke, Space occupying lesions, Trauma, infection
We will refer you to specialist for further examination and investigations to find out the
cause.
They may consider doing some scans like CT or MRI.
Please do not drive and inform DVLA.
They will carry out further tests.
P: How long will it take?
D: It may take few months.
D: How did you come to the hospital?
P:
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ENT STATIONS
SINUSITIS
You are FY2 in GP surgery

Mr. James Rickman presented with pain in forehead and cheeks started a few days ago.
Talk to him, take history and address his concerns.
D: Hi I am Khalil one of the junior doctors working in this GP surgery. Can I confirm your
name and age please.
P: Hello doctor my name is James Rickman and I am 55 years old.
D: How would you like me to call you ?
P: James Dr.
D: Nice to meet you, James. How may I help you today?
P: Doctor I have pain in my forehead and my cheeks .
D: Tell me more about it
P: Like what Dr.
D: Do SOCRATES
D: Gradual pain or sudden pain?
P: Gradual onset.
D: Character of pain?
P: Dull pain
D: Radiation of pain?
P: Forehead and cheeks only
D: Scale the pain 0 to 10
P: 4 or 5
D: Is it the first time happening ?
P: Yes Dr.
D: Any discharge from the nose ?
P: No.
Anything makes it better or worse?
The pain is constantly present or on and off?
Finding it difficult to breathe through your nose? Are you breathing from your mouth more
often? Green or yellow mucus from your nose?
Have you noticed bad breath recently?
D: Any loss of smell ?
P: No
D: Anything else would you like to share with us ?
P: That’s it Dr.
Differential diagnosis
D: Any fever and flu like symptoms? ( bacterial or viral)
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D: Repeated respiratory infection? ( cystic fibrosis)
D: Repeated gastrointestinal infection?
D: Do you feel pressure in your ears?
D: Do you have throat pain? ( Common cold and rhinitis)
D: Do you sneeze?
D: Headache? ( cluster headache)
D: Secretions from nose?
D: Any dental pain? Any pain in your teeth? ( Dental pain)
D: Any lumps and bumps in your body ? ( cancer)
D: Any weight loss ?
Rashes, watery eyes, ( hay fever and eczema and atopy)
D: Past medical and surgical history
P: No
MAFTOSA
D: Are you taking any medications ?
P: No
D: Are you allergic to any medications, OTC, steroids or food?
P: No
D: Family history of chronic illness?
P: No
D: Do you have any IDEA of what’s going on with you?
EXAMINATION
I would like to check your BP, pulse, RR, and temperature.
I will examine your nose and mouth ( pharynx for any discharge), any facial tenderness and
swelling. We would like to perform X RAY sinuses.
The diagnosis of sinusitis is solely based on the history
MANAGEMENT
From the information you have given and from the assessment that we have done it seems
like you have a condition called SINUSITIS.
D : Do you know what is sinusitis ? ( concern )
P : No
Sinusitis is swelling of the sinuses, usually caused by an infection. It's common and usually
clears up on its own within 2 to 3 weeks. But medicines can help if it's taking a long time to
go away.
I would like to inform my senior who will further assess you.
P: How you are going to treat me now ? ( concern )
TREATMENT
I would advise you to have
• plenty of rest • plenty of fluids • taking painkillers, such as paracetamol or ibuprofen
(do not give aspirin to children under 16) • avoiding allergic triggers and not smoking
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• cleaning your nose with a salt water solution to ease congestion
A pharmacist can help with sinusitis
• decongestant nasal sprays or drops to unblock your nose (decongestants should not be
taken by children under 6)
• salt water nasal sprays or solutions to rinse out the inside of your nose
You can buy nasal sprays without a prescription, but they should not be used for more than
1 week.
NON URGENT ADVICE , SEE YOUR GP if :
• your symptoms are severe
• painkillers do not help or your symptoms get worse
• your symptoms do not improve after 1 week
• you keep getting sinusitis
• Treatment for sinusitis from a GP If you have sinusitis, a GP may be able to recommend
other medicines to help with your symptoms, such as:
• steroid nasal sprays or drops – to reduce the swelling in your sinuses
• antihistamines – if an allergy is causing your symptoms
• antibiotics – AMOXICILLIN if a bacterial infection is causing your symptoms and you're very
unwell or at risk of complications (but antibiotics are often not needed, as sinusitis is usually
caused by a virus) If pregnant and allergic or intolerant to penicillin — erythromycin
You might need to take steroid nasal sprays or drops for a few months. They sometimes
cause irritation, sore throats or nosebleeds. A GP may refer you to an ear, nose and throat
(ENT) specialist if,
• still have sinusitis after 3 months of treatment
• keep getting sinusitis
• only have symptoms on 1 side of your face
They may also recommend surgery in some cases.
Surgery for sinusitis Surgery to treat chronic sinusitis is called functional endoscopic sinus
surgery (FESS). FESS is carried out under general anaesthetic (where you're asleep)
RED FLAGS
• Severe headache
• Visual changes
• Periorbital edema
• Altered mental status Although the majority of ABRS cases are uncomplicated,
complications may cause significant morbidity. The severity of these complications is due to
the proximity between the paranasal sinuses and other intracranial structures, including the
orbit, cavernous sinus and meninges. The following symptoms may be present in patients
with a complicated bacterial infection SPECIFIC EXPECTATIONS LEAFLETS WISH YOU A GOOD
HEALTH
OTHER SYMPTOMS OF SINUSITIS

Sinusitis is common after a cold or flu.
Symptoms of sinusitis include:
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• pain, swelling and tenderness around your cheeks, eyes or forehead
• a blocked nose
• a reduced sense of smell
• green or yellow mucus from your nose
• a sinus headache
• a high temperature
• toothache
• bad breath
• Signs of sinusitis in young children may also include irritability, difficulty feeding, and
breathing through their mouth.
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FACIAL DROOPING
FY2 in GP Surgery
Mr. Alexander aged 40 years presented to you with a complaint of drooping of the mouth.
Take a history and manage him accordingly.
Or
Mr. Alexander aged 40 years old presented with some concerns.
Take history and assess him accordingly.
D: Hi, I am Khalil one of the junior doctors working in this GP surgery. Can I confirm your
name and age please?
P: Hello doctor my name is Alexander and I am 40 years old .
D: Nice to meet you. What brought you here today.
P: Doctor I have some problem with my face.
P: Right side of my face started drooping on one side.
D: I see this must be quite a situation. Don’t worry not that you are here, we will assess you
and
try to help you out.
Can you tell me a bit more about it?
P: What do you want to know doctor?
D: When did it start? (onset of Bell’s palsy is very important, as it is best treated of the
patient presents within 72 hours of symptoms?
P: It started one day before
D-How has it been since?
P: It’s increasing doctor.
D: Have you tried doing anything for it before coming here?
P: No
D: Has anything made it better or worse?
P: No doctor I just came here as it started worrying me.
D: I can understand why you feel so worried alexander. You did a great job alexander by
coming to the clinic.
A few more questions and we will know why this happened, will that be okay with you?
D Was it: Gradual or sudden in onset?
P: Suddenly
D Did you notice it on: One side of both side of the face.
P: One side
D: Right or left?
Is the weakness more prominent at specific time of the day? (MS)
Chief complaints of Bell’s:

D: any drooling
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a dry mouth
a loss of taste
eye irritation, such as dryness or more tears
DIFFERENTIAL DIAGNOSIS.
Could you please tell me have you had any fever or flu like symptoms before ?
P: No
Any weakness in other parts if the body (TIA) RESOLVES WITHIN 24 HRS
Any slurred speech (TIA, stroke)
Peripheral Limb weakness (GB, Stroke, TIA)
Hearing loss (cholesteatoma)
Painful ear and discharging ear (otitis media)
Any recent fever or flu (ear infections can cause inflammation in the nerves)
Rash or joint pain (Lyme disease and sarcoidosis)
Recurrent vision problem (MS)
Recurrent weakness (MS)
Dry mouth (problem in parotid gland)
Trauma
MAFTOSA
D:Are you taking any medication
P: No
D: Any chronic illness like DM , HTN , SARCOIDOSIS, IMMUNOCOMPROMISED , CANCER .
P: No
D: Are you allergic to any medication
P: No
D: Family history of illness (Bell’s palsy)
P: No
D: Are you a smoker ?
P: No
D: Are you taking alcohol?
P: Sometimes
D: How is your diet ?
P: Balanced diet
D: Do you have any IDEA what is going on with you ?
MANAGEMENT
I would like to check your BP , PULSE RATE , RR and TEMPERATURE . I will also do
neurological examinations. The physical examination should include careful inspection of
the ear canal, tympanic membrane, as well as evaluation of peripheral nerve function in the
extremities and palpation of the parotid gland. Laboratory testing is not usually indicated.
However, because diabetes mellitus is present in more than 10 percent of patients with
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Bell's palsy, fasting glucose or A1c testing may be performed in patients with additional risk
factors (e.g., family history, obesity, older than 30 years).
From what you have told me and what I have observed I suspect you have a condition called
Bell’s palsy.
D: Do you know what is Bell’s palsy?
P: No
Bell's palsy is a peripheral palsy of the facial nerve that results in muscle weakness on one
side of the face. Affected patients develop unilateral facial paralysis over one to three days
with forehead involvement and no other neurologic abnormalities I would like to INFORM
MY SENIORS to assess you again.
P: How are you going to treat me? ( concerns )
Patients with Bell's palsy should be treated within three days of the onset of the symptoms.
1. Oral acyclovir. Because of the possible role of HSV-1 in the etiology of Bell's palsy, the
antiviral drugs acyclovir and valacyclovir have been studied to determine if they have any
benefit in treatment. Either acyclovir 400 mg can be given five times per day for seven days
or valacyclovir 1 g can be given three times per day for seven days.
2. Oral prednisolone. Oral corticosteroids have traditionally been prescribed to reduce facial
nerve inflammation in patients with Bell's palsy. Prednisolone is typically prescribed in a 10-
day tapering course starting at 60 mg per day. Do not stop the medication on your own. In
case you have any side effect of the medication or worsening please come back to us
immediately. We will keep a close check and regular monitoring of your progress and
decrease the dose accordingly.
(If she throws a concern steroids are dangerous)- tell her yes they have certain side effects,
but it’s not necessary she will have one. Treating the condition at the moment outweighs
the risk of side effects as she has come within 72 hours. Also it’s a short duration of steroid
course and not a lifelong course so she need not worry about long term effects. Patients
should be monitored for eye irritation and be prescribed eye lubrication. Patients with
corneal abrasions should be referred to an ophthalmologist. Surgery In the past, surgical
decompression within three weeks of onset has been recommended for patients who have
persistent loss of function (greater than 90 percent loss on electroneurography) at two
weeks. The most common complication of surgery is postoperative hearing loss. Patients
with complete paralysis who do not improve in two weeks on medication should be referred
to an otolaryngologist for evaluation for other causes of facial nerve palsy.
P: Will i be alright after the treatment ? (concerns)
Approximately 70 to 80 percent of patients will recover spontaneously; however, treatment
with a seven-day course of acyclovir or valacyclovir and a tapering course of prednisone,
initiated within three days of the onset of symptoms, is recommended to reduce the time to
full recovery and increase the likelihood of complete recuperation.
P: How long Bell's palsy lasts? (Concerns)
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D: Most people make a full recovery within 9 months, but it can take longer. In a small
number of cases, the facial weakness can be permanent.
Go back to see a GP if there are no signs of improvement after 3 weeks. Some cases might
need to be treated with surgery.
Living with Bell's palsy can make you feel depressed, stressed or anxious. Speak to a GP if it's
affecting your mental health.
P: How can I prevent Bell’s palsy? (concern)
Because it's probably caused by an infection, Bell's palsy cannot usually be prevented. It
may be linked to the herpes virus.
You'll usually only get Bell's palsy once, but it can sometimes come back. This is more likely
if you have a family history of the condition.
Concerns:
Should I go for brain scan?
Will my face be symmetrical again?
RED FLAGS
CALL 999 and come to EMERGENCY if you have
Slurred speech
Weakness in your limbs
Confusion.
Follow-up with GP if symptoms do not improve in 2-3 weeks.

Leaflets.
Specific expectation from this consultation
DIFFERENTIAL
TIA, STROKE, GBS, CHOLESTEATOMA, OTITIS MEDIA, LYME DISEASE , MS.
RISK FACTORS
HERPES SIMPLEX, DIABETES, HIGH BP, FLU, COMMON COLD, HIV.
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MUMPS ORCHITIS
You are FY2 in GP clinic

A mother of 9 years old boy is here with us with some concerns.
Talk to her, take history and manage him accordingly.
D: Hi I am Khalil one of the junior doctors working in this GP clinic.

P: Hello doctor.
D: What brought you to here today?
P: Doctor I’m here for my son.
D: Can you confirm his name and age please ?
P: Yes doctor, his name is James and he is 9 years old.
D: Is he with us today?
P: No doctor
D: Okay. Could you please tell me what happened to James?
P: Doctor my son has swelling near and below his ear?
D: Could you please tell me more about it ?
P: Doctor it started a few days ago but it is now increased and I’m afraid it might be something
serious.
D: I can understand you are concerned about your son we are here to help you out.
P: Thank you doctor
D: I need to ask few more question
D: Is it the first time he is having it?
P: Yes Dr.
D: Could you please tell me which side it is ?
P: Doctor it’s the left side only
D: when it was started ?
P: Few days ago doctor.
D: Is it painful ? ( MUMPS )
P: Yes Dr. it is painful.
How big is the swelling?
Has it changed since it started or is the same?
Any redness or rash over the swelling?
Any discharge from the swelling?
Any breathing difficulty or swallowing difficulty due to the swelling?
Any weakness in his face?
Any hearing loss that he has complained of?
D: headache
P: No
D: Any joint pain ? ( MUMPS )
P: No
D: Fever or flu like symptoms
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P: Yes Dr. he have FEVER , started a few days before the swelling .
D: Any medications given for the fever or anything else ?
P: Yes Dr. I am giving paracetamol twice a day .
D: Any improvement in his condition
P: No doctor.
D: Any lumps and bumps in his body ? ( infection/CANCER )
P: no doctor
D: Is he thirsty most of the time (SJOGREN SYNDROME – dry eyes, itchy eyes, dry mouth)
P: No doctor
D: Any rash in the body ? (MENINGITIS)
P: No
P: No
D: Rule out tonsillitis (any lumps and bumps in his neck besides the swelling? Any white
patches over his tonsils? Recently did he have a sore throat?, change in voice?)
MAFTOSA
Did he come in contact with someone who has similar symptoms?
Did he travel anywhere recently?
D: Is he taking any medications?
P: No Dr.
D: Any past medical condition?
P: No
D: Is he allergic to any medications?
P: No
BIRD HISTORY
D: How was the birth of the baby?
P: NVD
D: Is he up-to date with his jabs?
P: No doctor (main cause)
D: Are you happy with the red book?
P: Yes Dr.
D: How’s his development?
P: Nothing wrong with the development .
D: Do you have any IDEA of what is going on with your son?
P: No
MANAGEMENT
Ideally, I would like to check your son’s vitals, will do a GPE and will also examine the
swelling .
From the information you have given us and what we have assessed I suspect your son
might have a condition called mumps.
D: Do you know anything about mumps?
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P: No
Mumps is a contagious viral infection that used to be common in children before the
introduction of the MMR vaccine.
Other Symptoms of mumps
Mumps is most recognizable by the painful swellings in the side of the face under the ears
(the parotid glands), giving a person with mumps a distinctive "hamster face" appearance.
Other symptoms of mumps include headaches, joint pain, and a high temperature, which
may develop a few days before the swelling of the parotid glands.
P: How are you going to treat me ? (concern)
D: There's currently no cure for mumps, but the infection should pass within 1 or 2 weeks.
Treatment is used to relieve symptoms and includes:
• getting plenty of bed rest and fluids
• using painkillers, such as ibuprofen and paracetamol – aspirin should not be given to
children under 16.
• applying a warm or cool compress to the swollen glands to help relieve pain.
Mumps is a notifiable condition. If your GP suspects mumps, they should notify your local
health protection team (HPT). The HPT will arrange for a sample of saliva to be tested to
confirm or rule out the diagnosis.
P: How mumps can spread ? ( concern )
D: Mumps is spread in the same way as colds and flu: through infected droplets of saliva
that can be inhaled or picked up from surfaces and transferred into the mouth or nose.
A person is most contagious 1 – 2 days before the symptoms develop and for 9 days
afterwards. During this time, it's important to prevent the infection spreading to others,
particularly teenagers and young adults who have not been vaccinated.
RED FLAGS - Neck stiffness, rash, high non-subsiding fever, difficulty in breathing and
swallowing due to the swelling.
Mumps is a contagious viral infection that used to be common in children before the
introduction of the MMR vaccine.
Symptoms of mumps
Mumps is most recognisable by the painful swellings in the side of the face under the ears
(the parotid glands), giving a person with mumps a distinctive "hamster face" appearance.
Other symptoms of mumps include headaches, joint pain, and a high temperature,
Prevention:
• regularly washing your hands with soap
• using and disposing of tissues when you sneeze
• avoiding school or work for at least 5 days after your symptoms first develop
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MMR vaccine Your child should be given 1 dose when they're around 12 to 13 months and a
second booster dose at 3 years and 4 months.
Treatment:
• getting plenty of bed rest and fluids
• using painkillers, such as ibuprofen and paracetamol – aspirin should not be given to
children under 16.
• applying a warm or cool compress to the swollen glands to help relieve pain.
Complications:
Meningitis
Swelling of testes and ovaries
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BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV)

Mr. Liam Jackson, aged 45, has come to you with dizziness.
Please talk to him, assess him and address his concerns.

P: I feel dizzy.
D: What do you mean by feeling dizzy?
P: I feel everything around me is spinning.
D: Since when have you been feeling dizzy?
P: Since 4 to 5 days.
P: Sudden
D: How many times has it happened?
P: 3 times.
D: How long did the episode last?
P: 30 seconds
D: Anything that triggers the dizziness?
P: When I move my head right, left or upwards, I feel dizzy.
D: Anything else?
P: I felt sick
D: Any vomit?
P: No
D: Anything else?
P: No
Before
D: Any fever or flu like symptoms recently? (vestibular neuritis)
P: I had a cold a month ago.
D: Any motion sickness?
P: No
D: Any balance problem?
P: No
D: Any blurry vision or double vision? (Acoustic Neuroma)
P: No
D: Any numbness on your face (Acoustic Neuroma)
P: No
D: Any hearing loss?
P: No
D: Any ringing sensation in your ears? (Meniere's/Acoustic Neuroma)
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P: No
D: Did you hurt yourself?
P: No
D: Any weight loss
P: No
During
D: Any jerky movements?
P: No
P: No
After
D: How did you feel after the incident?
P: Fine
D: Any confusion?
P: No
D: Any drowsiness?
P: No
P: I felt nauseous but didn't vomit.
D: How is your health in general?
P: I am fine
D: Any other medical conditions?
P: No
P: No
P: No
D: Any surgeries or hospitalizations apart from your heart condition admission?
P: No
D: Any family history with similar conditions?
P: No
P: Yes/No
D: Do you smoke?
P: Yes/No
P: My diet is very good.
P: Travel agent.
D: Is it stressful
P: Yes/No
317
I would like to check your vitals and do the neurological, ear examination and perform Dix-
Hallpike maneuver.
Examiner: Ear examination is normal and Dix-Hallpike manoeuvre is positive upward and
left direction.
From my assessment, you are experiencing something which we call benign paroxysmal
positional vertigo (BPPV). BPPV is a condition of the inner ear. It is a common cause of
intense dizziness (vertigo). It is unpleasant but it is not serious. It is triggered by certain
movements.
BPPV is a condition that goes away on its own after several weeks or months.
Epley Manoeuvre: This is done by a series of 4 movements of the head. After each
movement, the head is held in the same place for 30 seconds or so. Epley manoeuvre is
successful in controlling the symptoms in about 8/10 cases with just 1 treatment.
Otherwise, repeated treatment session in a week after may be recommended.
Brandt-Daroff Exercises: It is recommended if Epley manoeuvre does not work. These

exercises involve a different way of moving the head as compared to the Epley manoeuvre.
 If you have sudden and unexpected attacks of dizziness, DVLA recommends that you
should stop driving.
 If you use ladders, operate heavy machinery or drive, you should inform your employer
as it could pose a risk to you or others.
 Get out of bed slowly and avoid jobs around the house that involve looking upwards.
 Take care in moving your head during daily activities
 Sit down immediately when you feel dizzy.
 Try to relax as anxiety can make vertigo worse.
 Do not bend over to pick things up, squat to lower yourself instead.
PATIENT'S CONCERNS
Is it serious?
Will it go away?
Is there any treatment?
DDs
Benign paroxysmal positional vertigo (BPPV)
Meniere's disease
318
Labyrinthitis
Vestibular Neuronitis
Acoustic Neuroma
Alcohol intoxication
Multiple Sclerosis (MS)
Ototoxic drugs
Space Occupying lesion
BPPV is a specific diagnosis, and each word describes the condition:

Benign: this means it is not life-threatening, even though the symptoms can be very intense
and upsetting.
Paroxysmal: It comes in sudden, short spells.
Positional: Certain head positions or movements can trigger a spell.
Vertigo: Feeling like you're spinning, or the world around you is spinning.
Dizziness is a term used by patients to describe many different sensations, including being off
balance, light-headedness, and vertigo.
Vertigo is an illusion of movement, often rotatory, of the patient, or his surroundings.
319
VESTIBULAR NEURITIS
You are F2 in A&E.

Harlow aged 22, was out shopping in a supermarket, she turned her head and had a sudden
episode of dizziness.
Talk to the patient, assess her condition. Discuss about the initial plan of management with
the patient.

P: I was at the supermarket and when I turned my head I felt dizzy, I tripped and fell,
someone
helped me to get up and then she called the ambulance.
D: How are you feeling now?
P: I feel dizzy
ODIPARA
D: What do you mean by dizziness?
P: It was like the room was spinning.
D: When did this happen?
P: 1-2 hours ago
D: Is it continuous or does it come and go?
D: Has it changed?
P: No
D: Anything that makes it better?
P: No
P: No
D: Does it change when you move your head and neck?
P: No
Brief Elaboration of the fall
D: Any other symptom before having the fall?
P: No
D: Did you go unconscious after having the fall?
P: No
D: Did you have any jerky movements?
P: No
D: Did you feel sleepy or confused?
P: No
D: By any chance did you injure yourself?
P: No
D: Did you bang your head to the floor?
P: No
320
D: Is there any other symptoms?
P: I am feeling sick.
P: It started with dizziness
D: Did you vomit?
P: No
D: Anything else?
P: No
D: Any fever or flu like symptoms? (Vestibular neuritis)
P: No
P: Doctor. 10 days ago I had a sore throat and I took Paracetamol for it.
P: No
D: Any ear pain? Labyrinthitis
P: No
D: Any feeling of fullness in the ear? Labyrinthitis
P: No
D: Any ringing sounds in the ear? Meniere's Disease
P: No
D: Any problem with hearing? Meniere’s Disease
P: No
D: Do you have any headache? (Meningitis, Migraine)
P: No
D: Any rash by any chance? (Meningitis)
P: No
D: Any numbness, pain or weakness on one side of the face? SOL (Acoustic Neuroma
P: No
D: Any visual problem such as blurry vision or double vision? SOL (Acoustic Neuroma)
P: No
D: Any weakness in your arm or speech problem? (TIA) P: No.
P: No
D: Has anything like this happened before?
P: No
D: Have you been diagnosed with any medical condition in the past? DM? Heart diseases,
ear problem?
P: No
P: No
P: No
D: Do you smoke?
P: No.
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P: Occasionally.
P: It’s fine.
P: Not much
P: I work as state agent.
NOTE: This is important to know to give the patient general advise about work place.
D: With whom do you live?
P: I live with my family.
D: I would like to check your vitals and examine your heart, ENT examination, hearing test
and central nervous system examination.
EX: ECG is normal and blood test results are awaited.
 From our assessment, it seems like you have a condition called vestibular neuritis. In
this condition one of the nerves in the brain, which send signals from the inner ear to
the brain, 'is inflamed. This nerve is responsible for maintaining our balance and our
hearing.
 You had the flu a few days ago. Sometimes the bug that causes the flu can affect this
nerve and that's why you may be experiencing these symptoms.
 We did some examinations and everything seems to be normal. We did an ECG and it
was fortunately normal.
 We will do some blood tests to check anaemia or if there is any bug in your blood. We
will keep you in the A&E for a while to take a closer look at you and reassess your
symptoms.
 The symptoms of vestibular neuritis usually settle over a few weeks, even without
treatment.
 However, there are some self-help measures you can take to reduce the severity of
your symptoms and help your recovery. Medication doesn't speed up your recovery,
but may be prescribed to help reduce the severity of your symptoms.
 Self-help for vestibular neuritis:
 If you're feeling nauseous, drink plenty of water to avoid becoming dehydrated. It's
best to drink little and often.
 If you have quite severe vertigo and dizziness, you should rest in bed to avoid falling
and injuring yourself. After a few days, the worst of these symptoms should have
passed and you should no longer feel dizzy all the time.
 You can do several things to minimise any remaining feelings of dizziness and vertigo.
For example:
322
 avoid alcohol, avoid bright lights and try to cut out noise and anything that causes
stress from your surroundings
 You should also avoid driving, using tools and machinery, or working at heights if
you're feeling dizzy and unbalanced.
 Once the dizziness is starting to settle, you should gradually increase your activities
around your home. You should start to have walks outside as soon as possible. It may
help to be accompanied by someone, who may even hold your arm until you become
confident.
 You won't make your condition worse by trying to be active, although it may make
you feel dizzy.
 While you're recovering, it may help to avoid visually distracting environments such
as:
supermarkets, shopping centres and busy roads etc.
 These can cause feelings of dizziness, because you're moving your eyes around a lot It
can help to keep your eyes fixed on objects, rather than looking around all the time.
 Medication for vestibular neuronitis
 Your GP may prescribe medication for severe symptoms, such as:
o Benzodiazepine - which reduces activity inside your central nervous system,
making your brain less likely to be affected by the abnormal signals coming
from your vestibular system
o Antiemetic - which can help with symptoms of nausea and vomiting
 Once your symptoms improve and you can tolerate fluids we will be able to send you
home with the medication as this condition can be managed at home.
 If your symptoms persist or you develop any other symptom, your GP can refer you to
the specialist and they may need to do some further investigations such as CT Scan or
MRI, to exclude other causes.
D: Is there anyone who can pick you from the hospital and get you home safely?
If you develop Double vision. Slurred speech. Gait disturbances, weakness or numbness
please
come back to the hospital.
P: When can I go home?
P: Do I need any further tests or treatment?
DD:
Vestibular neuritis
Labyrinthitis
Meniere’s Disease
Meningitis
Migraine)
323
Acoustic Neuroma
SOL
TIA
Ototoxicity
Gentamicin/anticonvulsants
Anaemia
Postural hypotension
Hypoglycaemia
324
MENIERE'S DISEASE (DIZZY SPELLS)
You are an FY2 in Medicine.

Mr. Benjamin Rao, aged 30, has come to you with complaint of dizziness.
Talk to him, manage and address his concerns.
D: How can I help?

P: I’m feeling dizzy for the last few days.
D: Did it start suddenly or gradually?
P: Suddenly
D: Does it come and go?
P: Yes
P: It gets worse when I stand up suddenly.
P: It gets better when I lie down.
P: Like what?
D: Any nausea?
P: Yes
P: I had hearing loss couple of days back which lasted for few hours.
D: Was it in one ear or both?
P: In my left ear.
D: Any ringing in your ears?
P: Yes
D: Any earache?
P: No
D; Any discharge from your ear?
P: No
D: Has anything like this happened to you before?
P: Yes, 1 week ago
D: How did it resolve?
P: It resolved on its own.
P: No
D: Any DM and HTN?
P: No
P: No
P: Mp
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P: No
P: No
D: Do you smoke?
P: Yes/No
P: Yes/no
D: Do you take any caffeine?
P: Yes/No
P: Yes/No
P: I eat everything, its fine.
P: I am active
P: Office job
P: I live alone.
D: Have you travelled anywhere recently? (flight)
P: No
D: Do you drive?
P: Yes/No
D: I would like to check your vitals, do GPE, and examine your ear. I will be using an
instrument called an otoscope to look inside the ear, and I would also like to do hearing
tests and balance tests along with a specialised test called audiometry.
Meniere’s disease is a condition of the inner ear that causes sudden attacks of vertigo,
tinnitus and hearing loss.
Symptoms:
 Progressive episode of severe vertigo, tinnitus, hearing loss.
 Feeling of fullness or congestion in the ear.
 Usually, unilateral, comes on in middle age.
Stages:
 Early-stage disease: vertigo attacks, which are sudden, unpredictable, and accompanied
by nausea, vomiting, and aural fullness lasting 20 mins to 24 hrs.
 Middle-stage disease: vertigo and fluctuating hearing loss. Tinnitus may worsen. Periods
of remission are variable.
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 Late-stage disease: progressive hearing loss that is non-fluctuant. Balance issues
particularly in the dark. Tinnitus may be a significant symptom.
Causes:
The exact cause of Meniere’s disease is unknown, but it is associated with a problem with
pressure deep inside the ear.
Factors that are thought to increase your risk include:
1. Poor fluid drainage in your ear
2. immune system disorders
3. Allergies
4. Viral infection, such as meningitis
5. A family history of Meniere’s disease
6. A head injury
7. Migraines
A GP should refer you to see an ear, nose and throat (ENT) specialist to confirm whether or
not you have Meniere’s disease.
The ENT specialist will check if you have:

1. Vertigo, with at least 2 attacks lasting 20 minutes within a short space of time.
2. Fluctuating hearing loss, which is confirmed by a hearing test
3. Tinnitus or a feeling of pressure in your ear.
A GP or specialist may also do a general physical examination and blood tests to rule out
other possible causes of your symptoms.
Treatment: There is no cure for this disease. However, symptomatic treatment will be
given.
ENT referral for confirmation and formal audiology assessment. Those with frequent,
sudden attacks should keep medication readily accessible, and to consider the risks before
starting potentially dangerous activities like driving, swimming, or operating machinery.
The 2 medicines usually recommended by GPs are;

 Prochlorperazine, which helps relive severe nausea and vomiting
 Antihistamines, which help relieve mild nausea, vomiting and vertigo
If symptoms are severe enough, people may require hospital admission for intravenous (IV),
labyrinthine sedatives and fluids to maintain hydration and nutrition.
A trial of Betahistine can be considered to reduce the frequency and severity of attacks of
hearing loss, tinnitus, and vertigo.
327
You may be offered:
 Counselling – including cognitive behavioural therapy (CBT)
 Relaxation therapy – including breathing techniques and yoga
Meniere’s disease can cause you to lose balance.
At the first sign of attack, you should:

 Take your vertigo medicine if you have some
 Sit or lie down
 Close your eyes, or keep them fixed on a still object in front of you
 Do not turn your head quickly
 If you need to move, do so slowly and carefully
Once the attack is over, try to move around to help your eyesight and other senses
compensate for the problems in your inner ear.
Foods to avoid:
 Eating a low-salt diet
 Avoiding alcohol
 Avoiding caffeine
 Stopping smoking
Consider the risks before doing activities such as:

 Driving
 Swimming
 Climbing ladders or scaffolding
 Operating heavy machinery
You may also need to make sure someone is with you most of the time in case you need
help during an attack.
Driving
You should not drive when you feel dizzy or if you feel an attack of vertigo coming on. You
must inform DVLA.
Flying
Most people with Meniere’s disease have no difficulty with flying.
These tips may help any anxiety you feel about flying, which may reduce the risk of an
attack:
328
- Get an aisle seat if you’re worried about vertigo – you’ll be away from the window and
will have quicker access to the toilets.
- Sit away from the plane’s engines if noise and vibration are an issue.
- Drink water regularly, to stay hydrated, and avoid alcohol
- Ask if the airline can offer food for a special diet that suits your needs.
DD
Migraine
Ear infections
Vestibular neuronitis and labyrinthitis
329
UNILATERAL TINNITUS

Mr. Kieran Richards, aged 40, has come to you with complaint of hearing noises.

P: I have been hearing noises (ringing sensation) in my ear.
D: Which ear?
P: Right ear.
P: What do you want to know
P: It started 3 years ago.
D: Did it start suddenly or gradually?
P: Gradually.
P: Does it come and go?
P: No, it is present all the time.
D: What does the noise sound like?
P: Like a ringing sound.
P: Is it becoming worse by anything?
P: It gets worse when I go to sleep.
P: Yes/No
P: Like what?
P: No
D: Any vertigo/dizziness?
P: No
D: Any earache?
P: No
D: Any discharge from the ear?
P: No
D: Does the ringing sound coincide with your pulse?
P: No
D. Have you been diagnosed with any medical condition in the past?
P: No
D: Any DM and HTN?
P: No
P: No
P: No
330
D; Any previous hospital stay or surgeries?
P: No
P: No
D: Do you smoke?
P: No
P: No
D; Tell me about your physical activity?
P: I am active.
P: Office job
D: Any recent travel? (flight)
P: No
D: I would like to check your vitals, do GPE, and examine your ear. I will be using an
tests and balance tests. We will also do some initial investigations.
D: From what you have told me and from my examination, I suspect that you have a
condition called tinnitus. Tinnitus is the name for hearing noises that are not caused by
sounds coming from the outside world. It is common and not usually a sign of anything
serious. It might get better by itself and there are treatments that can help.
Causes:
 Some form of hearing loss
 Meniere's disease
 Chronic illness: diabetes, thyroid disorders or multiple sclerosis
 Anxiety or depression
 Taking certain medicines – tinnitus can be a side effect of some chemotherapy
medicines, antibiotics, NSAIDs and aspirin
Non-urgent advice:
See a GP if
 You have tinnitus regularly or constantly
 Your tinnitus is getting worse
 Your tinnitus is bothering you – for example, it's affecting your sleep or concentration, or
is making you feel anxious and depressed
 You have tinnitus that beats in time with your pulse.
331
Urgent advice:
Call 999 or go to A&E if you have tinnitus:
 After a head injury
 With sudden hearing loss, weakness in the muscles of your face, or a spinning sensation
(vertigo)
What happens at your appointment?
The GP will look in your ears to see if your tinnitus is caused by something they can treat,
like an ear infection or a build-up of earwax.
They might also check for any hearing loss.
You may be referred to a specialist for further tests and treatment.
Schwannoma until proven otherwise, cancer of nerve that carries sensation from ear to
brain
Treatment:
Things you can try to help cope with tinnitus.
Do
 Try to relax – deep breathing or yoga may help
 Try to find ways to improve your sleep, such as sticking to a bedtime routine or cutting
down on caffeine
 Try to avoid things that can make tinnitus worse, such as stress or loud background
noises.
 Try self-help books or self-help techniques to help you cope better from the British
Tinnitus Association (BTA)
 Join a support group – talking to other people with tinnitus may help you cope.
Don't
 Do not have total silence – listening to soft music or sounds (called sound therapy) may
distract you from the tinnitus
 Do not focus on it, as this can make it worse – hobbies and activities may take your mind
off it
Treatments for tinnitus:

If the cause of your tinnitus is unknown or cannot be treated, your GP or specialist may refer
you for a type of talking therapy.
This could be:
332
 Tinnitus counselling – to help you learn about your tinnitus and find ways of coping with
it.
 Cognitive behavioural therapy (CBT) – to change the way you think about your tinnitus
and reduce anxiety.
 Tinnitus retraining therapy – using sound therapy to retrain your brain to tune out and be
less aware of the tinnitus.
Tinnitus retraining therapy may be available on the NHS for people with severe or persistent
tinnitus. It's unclear if tinnitus retraining therapy works for everyone. It's widely available
privately.
If tinnitus is causing you hearing loss, hearing aids may be recommended.
Tinnitus in one ear

A tumour called an acoustic neuroma occasionally causes tinnitus; this is usually persistent
and in one ear only. If you get the noise only in one ear, it is particularly important that you
consult a doctor, so this can be ruled out.
ENT->Audiometry->MRI/CT scan
333
CHOLESTEATOMA
You are FY2 in GP.

Mr. Josh Andrews, aged 26, came to the clinic complaining of pain in the ear.
Talk to the patient and discuss the management with the patient.
D: How can I help?

P: I have pain in my ear for 1 month.
P: Right side.
P: Dull
P: No
D: Has it been the same?
P: Anything makes your condition better?
P: I have been having this pain for 1 month, I took paracetamol, but it is not improving.
P: No
P: 6
P: No
D: How about the other ear?
P: It is fine
P: I can’t hear properly with my right ear.
D: Any fever? (OM, meningitis)
P: Yes/No
P: Yes
D: Since when?
P: For 1 month, it comes and goes.
D: What kind of discharge?
P: It is watery and grey
D: How much is it?
P: Scanty
D: Is it foul smelling?
P: Yes
334
D: Vertigo, tinnitus, numbness or tingling in the face? (cranial nerve involvement)
P: No
D: Aural fullness?
P: No
D: Any trouble with the vision? (blurring)
P: No
D: Have you been swimming recently? (OE)
P: No
P: No
D: Any DM and HTN?
P: No
P: PCM
D: Do you have any allergies from any food or medications?
P: No
P: No
P: No
D: Do you smoke?
P: No
P: No
P: I am active
P: Office job
D: Any recent travel? (flight)
P: No
D: I would like to check your vitals, do GPE and examine your ear. I will be using an
tests and balance tests. We will also do some initial investigations.
Examiner:
Examiner: Conductive hearing loss.
Otoscopy: Perforation in the Middle Ear usually pars flaccida.
335
D: From what you’ve told me and from my examination, I suspect that you have a condition
called cholesteatoma.
D: A cholesteatoma is an abnormal condition of skin cells deep inside your ear. They’re rare
but, if left untreated, they can damage the delicate structures inside your ear that are
essential for hearing and balance. We would however, do some investigations to confirm
this. We’ll do some routine blood tests, and we might plan special radiological tests called a
CT scan or an MRI.
D: Well, it can happen because of trauma to the middle ear, or a chronic ear infection. Some
people are born with it. Since you have had an earache since 1 month, it might be because
of an infection.
P: Can it happen again?
D: It can recur again in 5-30% cases. Around 10% can get it in another ear as well. If you
develop discharge or significant bleeding from your ear or wound, fever, and severe pain,
come to the hospital immediately.
Treatment
As it is an abnormal collection of skin cells, we will need surgery to remove the
cholesteatoma under general anaesthesia.
After the cholesteatoma has been taken out, your ear may be packed with a dressing. This
will need to be removed a few weeks later.
The surgeon may be able to improve your hearing by a tiny artificial hearing bone
(prosthesis). In some cases, it may not be possible to reconstruct the hearing, or a further
operation may be needed.
The benefits of removing a Cholesteatoma usually far outweigh the complications. However,
as with any type of surgery, there's a small risk of facial nerve damage resulting in weakness
of the side of the face.
Medical treatment where surgery is not possible, that will be antibiotics and regular ear
cleaning.
Prognosis:
It can recur again in 5-30% cases
Around 10% can get it in other ear as well.
If you develop discharge or significant bleeding from your ear or wound, fever, and severe
pain come to the
336
Symptoms
Ear infection sometimes can lead to brain abscess or meningitis
Hearing loss
Vertigo
Tinnitus
Facial nerve damage
Risk Factors
Trauma, otitis media, tympanic membrane perforation
Differential Diagnosis:
Otitis media with effusion
Otitis externa
Tympanosclerosis (seen after grommet insertion)
Osteonecrosis
337
ACOUSTIC NEUROMA (CN VIII)
You are F2 in GP.

Mrs. Selina Richards, aged 50 presented with a problem in her ear. She has come to you for
the first time.
Please talk to the patient, take focused history, do necessary examination and discuss about
your initial plan of management with the patient.

P: I can't hear properly from my left ear.
D: Could you please tell me more?
P: Like what.
D: Since when are you having this problem?
P: From last few months.
D: Is it same or getting worse?
D: Did anything happen when it started?
P: No
D: Any loud sound?
P: No
D: What about your other ear?
P: Other ear is fine.
D: Anything else?
P: Like what?
D: Any dizziness?
P: I feel unsteady when I am standing on the ground. I feel wobbly.
P: No
D: Any motion sickness?
P: No
D: Do you often have to ask people to repeat themselves what they are saying?
P: I am fine.
P: No
D: Do you have any sore throat, fever or flu like symptoms?
P: No
D: Do you have any pain or discharge from your ear?
(Infection-otitis media or other viral illness)
P: No
D: Any numbness or weakness on one side of your face?
P: No
D: Any blurry vision or double vision? Vertigo? (Acoustic neuroma)
338
P: No
D: Any ringing sounds in your ear? (Meniere’s disease)
P: No
D: Swimming?
P: No
D: Recent Flight travel? (Barotrauma)
P: No
D: Have you been diagnosed with any medical condition in the past? Any ear problem?
P: No
P: No
D: Have you undergone any surgical procedures in your ear?
P: No
EXAMINATION
D: I would like to check your vitals and examine your ear.
Exposure
Chaperone
Being gentle
Consent
Inspection
Palpation (Temperature. Tenderness. Tragus Test)
Otoscopy (SKIP)
Auditory Acuity
Rinne’s and Weber’s Test
(Air conduction is more than the bone conduction in both the ears and weber is lateralized
to the right, so my patient has sensorineural hearing loss in the left ear)
Romberg's test
Marching test
MANAGEMENT
D: From my assessment it seems like you have a condition called sensorineural hearing loss.
It is a problem of your inner ear and the nerves that supplies this part of the ear. There can
be many reasons for it and one of them could be Acoustic Neuroma.
An acoustic neuroma is a type of non-cancerous (benign) brain tumour. It can cause
problems with hearing and balance.
We need to do some tests like MRI and CT scan of the brain to confirm. We will refer you to
specialist. Small tumours often just need to be monitored with regular MRI scans, and the
treatments are generally only recommended if scans show it's getting bigger. This is because
these growths are very slow-growing and may not cause any problems for a long time. If it is
big then we may do surgery or radiotherapy.
339
It is difficult for people with sensorineural hearing loss to regain their hearing. But most
people find sensorineural hearing aids very helpful. We can offer you a large variety of
hearing aids.
Patient needs to inform the DVLA if they drive.
340
ACUTE TONSILLITIS

Samaira, aged 34 came to the clinic with sore throat.
Please talk to the patient, discuss plan of management with the patient and address her
concerns.

P: 1 have sore throat dr.
P: like what dr.
P: 7 days ago
P: Gradual
P: Continuous Dr
P: Dull pain
P: No
P: When I swallow
D: Could you rate the pain on a scale of o to 10, where 0 being no pain and 10 being the
worst you have ever experienced?
P: 7 Dr.
P: 1 feel feverish Dr
D: tell me more about it.
P: It's been 7 days Dr
D: Did you measure the temp?
P: No dr
D: Did you do anything for it?
P: 1 took paracetamol and it helped
P: 1 tab 3 times daily
D: Any other problems?
P: yes dr. 1 have some lumps and bumps in my neck.
D: For how long are those?
P: 5 days Dr.
341
D: Are those painful?
P: Yes Dr. when 1 touch them
D: Any lumps and bumps elsewhere in the body?
P: No Dr.
P: No Dr.
D: Any ear pain or hearing problems?
P: No Dr.
P: No Dr.
D: Any tiredness? (Infectious mononucleosis)
P: No Dr.
D: Any headache? (Infectious mononucleosis)
P: No Dr.
D: Any tummy pain? (Infectious mononucleosis)
P: No Dr.
D: Any diarrhea? (HIV)
P: No Dr.
D: Did you have similar condition in the past?
P: Yes Dr. last time I had it 6 months back and was given antibiotics.
P: No Dr.
D: Any family history of any significant health issues?
P: No dr
P: No dr
P: Yes dr. Allergic to penicillin
D: Do you smoke?
P: No
P: No
P: Healthy Dr.
P: Yes
P: Yes Dr.
D: Do you use practice safe sex?
P: Yes Dr.
I would like to do a GPE, check the vitals and Examine your throat.
342
From our assessment we suspect you are having a condition called tonsillitis. It is an
infection and inflammation of the tonsils caused by a bug or virus.
For your condition we will be giving you painkiller and we will start you on antibiotics.
As you are allergic to penicillin, we will be giving you something else (Erythromycin or
Clarithromycin).
To help ease the symptoms:
• get plenty of rest
• drink cool drinks to soothe the throat
• gargle with warm salty water
343
RECURRENT TONSILLITIS
You are F2 working in GP.

Anne, mother of 6-year-old boy, who is diagnosed with Tonsillitis has come to you to talk
about her son's referral to ENT surgery that was rejected. The child previously 5 episodes of
infections over 6 months.
Talk to the mother and address her concerns. On request of the mother, GP made the
referral to the ENT Surgery.

P: I am here for my son. He had recently been referred to ENT surgery from GP and the referral
got rejected.
D: I am really sorry for your experience. Would you mind if I ask you a few questions
regarding your son to have better understanding of your son's health?
P: Ok
D: Could you tell me why he had been referred to the ENT surgery?
P: He had 5 episodes of tonsillitis in the last 1 year
D: Could you give a brief recap of the episodes?
P: The first episode was about 10 months ago. He had sore throat and fever and was advised
to have steam inhalation. The 2nd and 3rd episodes the symptoms were more severe, and he
was given antibiotics. And the last 2 episodes was like the first episode and it got better with
steam inhalation as well.
D: I can understand It must be very tough for him.
P: Yes, so why did the referral get rejected?
D: As you already know the referral was made upon your request. But to be honest with you
your son doesn't meet the criteria to have the surgery for the tonsil removal.
P: What criteria are you talking about?
D: I do understand your concern. Let me explain this to you further. There are few criteria
that has been set to decide which patients need tonsil removal surgery. One of those criteria
is having at least 7 attacks in a year. You mentioned your son had 5 attacks. Possibly that's
why the referral got rejected.
P: Dr. forget about the criteria. I can't see him suffer like that. Please arrange the surgery
anyhow.
D: I can really see you are worried about your son. But let me tell you the criteria are made
in a way to avoid unnecessary surgery and ensure better care for the patients. And every
surgery has a lot of complications. We don't want your son to go through the unnecessary
stress of the surgery without any strong reason. Another thing is that tonsils are very
important part of the defence mechanism of our body that fight against infection. That is
why we don't want to remove them unless it's necessary.
P: Dr I just think NHS is doing it for budget cutting. Don't you think so Dr.?
D: I am really sorry you felt this way. But NHS has planned those surgeries and set those
criteria for delivering the best possible care to the patients.
344
P: Alright
D: For now, we will give him painkillers to relieve the pain. Please ensure he is taking plenty
of rest. And gurgling with warm salty water can be helpful. By any chance if your son's
condition gets worse or he develop neck stiffness or he can't even swallow, please bring him
back to us.
If you have repeated (recurring) tonsillitis you may wonder about having your tonsils
removed. Guidelines suggest it may be an option to have your tonsils removed
(tonsillectomy) if you:
• Have had seven or more episodes of tonsillitis in the preceding year; or
• Five or more such episodes in each of the preceding two years; or
• Three or more such episodes in each of the preceding three years.
• And...
• The bouts of tonsillitis affect normal functioning. For example, they are severe enough to
make you need time off from work or from school.
345
ALLERGIC RHINITIS

Luke aged 25 has come with complaints of runny nose from the past 2 days.
Take history and address his concerns.

P: I have got runny nose.
P: It has been 2 days I am having this, and it is getting worse.
D: What is the colour of the fluid?
P: Clear watery fluid
P: It gets worse in the winter season.
D: Anything else?
P: No
D: Any itching?
P: No
D: Any swelling or redness?
P: No
D: Any fever and flu like symptoms?
P: No (Infective rhinitis)
D: Any pain or discharge from ear? (Ear Infection)
P: No
D: Any numbness or tingling on the face?
P: No (Cranial Nerve Tumours)
P: No
P: I have got skin allergy (Atopy)
D: Any DM, history eczema or asthma?
P: No.
P: No.
P: No.
D: Any allergy to the pollens or dusts?
P: No
P: No.
P: Siblings have Eczema and Asthma
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D: Do you smoke?
P: Yes/No
P: Yes/No
P: No.
P: I am a driver.
I would like to check your vitals and examine your eye, ear, nose, throat.
The main lines of treatment are education, allergy avoidance, antihistamines and topical
steroids.
Please regularly rinse your nasal passages with a salt water solution to keep your nose free
of irritants.
I may send for some initial investigations including routine blood test (IgE), skin prick test.
Nasal Endoscopy might be done in case we suspect any Polyp.
As the patient is driver so we will make sure we will prescribe non-drowsy antihistamines.
There are many types of antihistamine.
They're usually divided into two main groups:
 older antihistamines that make you feel sleepy – such as chlorphenamine, hydroxyzine
and promethazine
 newer, non-drowsy antihistamines that are less likely to make you feel sleepy – such as
cetirizine, loratadine and fexofenadine
We can prescribe a stronger medication, such as a nasal spray containing corticosteroids.
Inhalers and nasal sprays such as beclomethasone and fluticasone can be used.
347
DERMATOLOGY STATIONS
SKIN LESION MOLE
You are F2 in Surgery Clinic.

Mrs. Maria aged, 32 presented to the hospital due to the presence of a lesion on her right
shoulder. She has a letter from her GP. The letter states that patient has some concerns
about the lesion and wants to remove it from her shoulder.
Please talk to the patient, take focused history, assess your patient, discuss about different
options of management and address her concerns. Discuss about day case surgery and take
relevant consent for the surgical procedure, if needed.
Consent form is not available inside the cubicle.

P: I have a lesion on my right shoulder. I want it to be removed. My GP referred me here.
D: That’s fine. We will assess you first and see what can be done.
P: Okay Dr.
D: When did you first notice it?
P: I had it from many years.
D: Can you tell me more about the lesion pleas
P: Like what
D: May I know the size of the lesion?
P: It’s about 1x1 cm.
D: What shape is it?
P: Round
D: What is the colour of the lesion?
P: Brown
D: Any pain or itchiness?
P: No/Yes, when it catches my clothes.
D: Any bleeding or discharge from the lesion?
P: No
D: Did you notice any ulcer on the lesion?
P: No
D: Have you got any idea how the lesion started?
P: No
D: Have you noticed any change in its size, shape or colour since it started?
P: No
D: Do you have any other skin lesion anywhere else?
P: No.
D: Any lumps or swelling in your neck or armpit?
P: No
348
P: No
P: No
P: Good
P: No
P: No
D: Have you been diagnosed with any medication condition in the past?
P: No
D: Any previous skin conditions, diabetes?
P: No
P: No
D: Any long term steroids or antibiotics?
P: No
P: No
D: Any previous hospital stays or surgeries
P: No
P: No
D: Anyone with any skin problems or any skin cancer in the family?
P: No
D: Do you smoke?
P: No
P: Occasionally
P: Good diet
P: Office job.
D: Any long term exposure to sun or tanning sessions?
P: No
D: I would like to check your vitals and examine your lesion

D: I would like to send for some initial investigations including routine blood tests.
D: Have you got any idea what the lesion could be?
P: No
349
D: From our assessment, we are suspecting your lesion is a mole which is a benign condition.
D: Have you done anything for it so far?

P: No
D: Have you got any particular concern for the lesion to be removed now?
P: I have my wedding coming up and my wedding dress won't cover it. It looks ugly. Also,
sometimes it gets stuck in my dress and is quite uncomfortable.
D: Ok.
D: What do you expect us to do?
P: I want it to be removed doctor.
D: I will discuss it with my senior and we may be able to remove the lesion. D: Do you want
me tell you how are we going to remove it?
P: Yes'
D: We have few options to remove such lesions. Shave excision, freezing with liquid nitrogen
and laser removal. We can do it as a day case surgery'.
P: Dr. What is day case surgery?
D: In this type of surgery you will be given a date for the procedure and you will come to the
hospital on the day of the surgery and if everything goes well you will be able to go home on
the same day.
P: Will the surgery leave a scar?
D: The procedure will be done by experts very carefully but however there will be a thin scar
left any the site.
P: Will the lesion come back once it is removed?
D: There are chances for the lesion to come back unfortunately. However we are going to
take all the precautions while performing the surgery to prevent it from coming back.
You can also take some measures like using sunscreens and wearing protective clothing to
cover yourself properly when you go out in the sun. This can prevent other lesions and also
the lesion from coming back.
P: What if I decide to keep the lesion as it is without any treatment?
D: As I told you, your lesion looks like a benign one so it wont be a problem if you leave it
without any treatment. It can stay as it is for the rest of your life. But however there is a rare
chance of moles turning to be cancerous.
P: How is the procedure done doctor?
D: A shave excision is a simple procedure used to remove growths, such as moles. The
primary tool used in this procedure is a sharp razor. You doctor may use also use an
electrode to feather the edges of the excision site to make the scar less noticeable.
Once they've removed the growth, your doctor may send it to a laboratory for analysis. This
can help them learn whether it’s cancerous.
P: Shave excision? Is the surgery painful? Local anaesthesia? Why not put me to sleep?
Pain/See/Hear? Complications?
If the patient doesn’t say that it catches her clothes and her only concern is her wedding
dress.
350
Ask -
D: Does it cause any kind of problem to you in any way?
P: No
D: Okay. Most moles are harmless. Harmless moles are not usually treated on the NHS.
The NHS wouldn’t be able to cover for the expenses to remove it for cosmetic reasons.
P: Can I do it privately?
D: Yes of course. You can pay a private clinic to remove a mole, but it may be expensive.
Your GP can give you advice about where to get treatment.
P: How will they remove it Dr.?
D: Explain Shave excision and day case surgery.
351
SKIN LESION MELANOMA
You are F2 in GP.

Mrs. Maria, aged 39, presented to the clinic with a skin lesion on her shoulder.
Please talk to the patient, take focused history, assess your patient, discuss about different
options of management and address her concerns.

P: I have a lesion on my right shoulder. I want it to be removed.
D: That is fine. We will assess you first and see what can be done.
P: Ok Dr.
P: I had it from many years.
D: Can you tell me more about the lesion please
P: Like what
P: It’s about 2 x 3 cm.
P: Round
D: What is the color of the lesion?
P: Brown/black
D: Is it painful?
P: No/Yes, it became so recently
D: Is it itchy?
P: It was not itchy before, but now it is
P: No/ Yes little bleeding recently.
P: No
P: No
D: Have you noticed any change in its size since it started?
P: Yes Dr. It's getting bigger.
D: Have you noticed any change in its shape since it started?
P: I am not sure.
D: Have you noticed any change in its colour since it started?
P: It is getting darker from past few months.
P: No.
P: No
352
P: No
P: No
P: Good
P: No
P: No
P: No
D: Any previous skin conditions?
P: No
P: No
D: Any long term steroids or antibiotics?
P: No
P: No’
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
P: Occasionally.
P: Good diet
P: Work in the garden and sell fruits and vegetables in the market.
P: Yes
P: I live in a house with my partner.
D: Does it affect your day to day activities?
P: No
D: Have you got any particular concern for the lesion to be removed now?
P: I have my wedding coming up and my wedding dress won’t cover it. It looks ugly. Also, it
gets stuck in my dress and is quite uncomfortable.
353
D: Ok
D: I would like to check your vitals and examine your lesion.

P: No
D: From our assessment, we are suspecting your lesion is a melanoma which is a serious
condition. Unfortunately, this is a type of cancer of skin. PAUSE
We will refer you to a dermatologist and team of doctors (multi-disciplinary team) who will
do the necessary tests and confirm the diagnosis and start treatment depending upon the
condition.
We will refer you to the specialist in 2 weeks’ time.
They may remove it and send it for testing to check whether it's cancerous (excisional
biopsy).
and also your overall health. If cancer is confirmed, you'll usually need another operation,
most often carried out by a plastic surgeon, to remove a wider area of skin. This is to make
absolutely sure that no cancerous cells are left behind in the skin. We call it wide local
excision.
Depending on how deep your melanoma is, you might need tests to find out if it has spread
to another area of your body.
If you don't have melanoma, you do not need any further tests or treatment.
They might take a sample from the glands in your neck or armpit to see whether melanoma
has spread there.
They may also do some scans CT, MRI or PET CT scans.
Your doctor or nurse will show you how to check your skin for melanoma. We will also
follow you up regularly to see -
• melanoma coming back around your scar (local recurrence)
• melanoma spread to your lymph nodes or other part of your body
• new primary melanomas that may develop.
354
SKIN LESION NON-MELANOMA (BCC, SCC)
You are F2 in GP.

Mr. Donald aged, 60 has some concerned about his skin lesion/problem.
Please talk to the patient, assess his condition, discuss your management and address his
concerns.

P: I have a lesion on top of my head. I want it to be checked as my wife is concerned about it.
(patient shows left temporal or parietal area).
D: That is fine. We will assess you first and see what can be done.
P: Ok Dr.
P: I had it from the last 2-3 months.
D: Can you tell me more about the lesion please
P: Like what
P: It’s not that big.
P: Irregular
P: Pink/ Purple.
D: Is it painful?
P: No/ Yes, it became so recently.
D: Is it itchy?
P: Yes/No'
P: Yes, started little bleeding from the last few days.
P: No
P: No
D: Have you noticed any change in its size since it started?
P: Yes Dr. t’s getting bigger.
D: Have you noticed any change in its shape since it started?
P: Yes, it was not like before
D: Have you noticed any change in its colour since it started?
P: It is getting darker.
P: No
Do you have any other skin lesion anywhere else?
P: No
355
Did you have any skin lesion in the past?
P: Yes. I had a lesion on the right side of my head few years ago
D: May I know what was done for that?
P: I went to the doctor and he froze it.
P: No
P: No
P: Good
P: No
P: No
P: No
D: Any previous skin conditions, diabetes?
P: No
P: No
D: Any long-term steroids or antibiotics?
P: No
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
P: Occasionally
P: Good diet.
P: I used to work in Australia but now I am doing an office job.
P: Yes/No
P: I live in a house with my partner.
356
D: Does it affect your day to day activities?
P: I used to go for swimming but now I don’t go because of this.
D: I would like to check your vitals and examine your lesion

P: No
D: From our assessment, we are suspecting your lesion is a non-melanoma which is a serious
condition. Unfortunately , this is a type of cancer of skin. PAUSE
We will refer you to a dermatologist and team of doctors (multi disciplinary team) who will
do the necessary tests and confirm the diagnosis and start treatment depending upon the
condition.
We will refer you to the specialist in 2weeks time.
They may remove a small area of the lesion or all of the lesion and send it for testing to
check whether it's cancerous (excisional Biopsy). This is done under local anaesthesia.
and also your overall health. If cancer is confirmed, you'll usually need another operation,
most often carried out by a plastic surgeon, to remove a wider area of skin. We have many
other options like radiotherapy, chemotherapy creams, cryotherapy, photodynamic therapy
but surgery is the widely used and most effective way. This is to make absolutely sure that
no cancerous cells are left behind in the skin. We call it wide local excision.
Depending on the extent of your lesion, you might need tests to find out if it has spread to
another area of your body.
If your lesion is not cancerous, you do not need any further tests or treatment.
They might take a sample from the glands in your neck or armpit to see whether it has
spread there.
They may also do some scans CT, MRI or PET CT scans.
Your doctor or nurse will show you how to check your skin for any changes that might
happen. We will also follow you up regularly to see -
• lesion coming back around your scar (local recurrence)
• Lesion spread to your lymph nodes or other part of your body
• New lesions that may develop
357
358
FUNGAL INFECTION

John Smith aged 45 has come to you with some concerns.
Talk to him & address his concerns.

P: Doctor, I have this rash on my forearm
D: Which arm
P: Left
D: Since when?
P: From last few weeks.
D: Can you please describe the rash for me?
D: What color is it?
P: Red
D: Does it itch?
P: Yes
D: Any pain around it?
P: No
D: Any bleeding or discharge?
P: No
D: Has it increased in size?
P: Yes, it has become bigger.
P: No
P: No
D: Have you used anything for/on it?
P: No
D: Have you shown it to a doctor before?
P: No
D: Have you seen anyone around you with a similar rash?
P: No (Eczema, Psoriasis)
D: Any similar rash elsewhere in the body?
P: No
D: Anything else with the rash?
P: Like what?
D: Any fever?
P: No (Meningitis, Infections)
D: Did you hit your forearm anywhere?
P: No
359
D: Did you notice any insect bite?
P: No (Lyme)
P: No (Cancer)
D: Any pain in your joints?
P: No (Sarcoidosis, Psoriasis)
D: Any bowel problems?
P: No (I.B.D)
D: Has it ever occurred before?
P: No
P: No
D: By any chance DM. Lung ds, Liver ds or heart ds?
P: No
D: Are you taking any medications including OTC or herbal medications?
P: No
D: By any chance any steroids? (Immunosuppressants)
P: No.
D: Are you allergic to any food or medication?
P: No
P: Office, (contact sports)
D: Do you Smoke?
P: No.
P: No
P: No
P: Yes
D: Do you by any chance have any pets in your house?
P: No (skin infections)
P: No (warm, humid)
D: I would like to do GPE, Vitals and need to examine your rash.
P: Sure Doctor. (Pt. Shows picture)
360
From what you have told me & the rash that you have shown me, it appears that you have a
skin infection caused by fungal type of bugs. These bugs actually grow outwards on skin. &
produce a ring-like pattern, so it’s also called as a ring worm. They are very common and can
affect different parts of the body. We would however need to confirm it for which we would
have to take some skin scrapings from the area of rash.
This type of skin infection spreads from contact from another infected person, animal or
even soil. It can affect any part of the body, more than one part too.
P: Doctor, I have a wife who is pregnant, will it affect her?
D: Unfortunately, yes. As it spreads through contact, there is a possibility that your wife can
also get it. However, we can reduce the chances of it spreading if we start treatment
immediately. In addition to that, try that you keep your clothes, towels & bed sheet
separate so that it doesn’t come into contact with anyone else. Also try to keep your skin as
clean as possible, that would also help it to become better soon. If you see any person or
animal with a similar condition, try to avoid contact with them.
P: Ok. Can it harm my baby doctor?
D: No. it cannot. It is a skin infection & only affects the skin. It cannot pass on to the baby
through the womb. (Rarely it can cause a complication of a secondary bacterial infection.
***)
Do you understand?
P: Yes. How are you going to treat it doctor?
D: It is treated by antifungal agents (cream, gel or spray). Oral antifungal medicines may also
be needed. They will however be prescribed by a dermatologist. If you wish I can arrange an
appointment for you. Do you understand?
P: Yes. How long will I have to take the medicine for?
D: Well, the total treatment can take around 4 weeks. It takes up to 2 weeks for the rash to
go away but treatment is continued 1-2 weeks after the rash has vanished.
P: Yes doctor
361
ACNE
You are F2 in GP.

Mariah aged 24 came to the clinic. She is having Acne and wants Isotretinoin medications
for it.
Talk to the patient and discuss the plan of management with the patient.
NOTE: Instructions paper is given in the cubicle. It is given in it as Retinoid - Gel for Mild to
moderate acne treatment and Severe Acne require Oral meds. Start as early as possible.

P: I want Isotretinion (Roaccutane) for my acne
D: May I know why?
P: Yes, my friend had been taking it & her acne is much better now, she had a similar problem
as mine, I want mine to get better too.
D: Okay! Can I ask you a few questions before we get to that?
P: Yes sure
D: Since when have you had it?
P: I’ve had it for a long time but it has become worse recently.
D: Any itching?
P: No
D: Did you notice any discharge coming out of it?
P: No
D: Is it painful?
P: No
D: Does it become better/worse with anything?
P: No
D: How often do you wash your face?
P: I wash my face twice daily
D: Do you use any cosmetic products on your face?
P: Yes, I used cosmetic pads & Clearasil face wash (benzoyl peroxide & salicylic acid)
D: How often do you use it?
P: Twice daily
D: Did you notice your acne becoming worse after that
P: I’m not sure
D: Did you by any chance notice that it becomes worse near menstruation?
P: No
D: When was your last LMP? (Period Pregnancy)
P:
D: Any problem with the periods?
P: No
D: By any chance are you pregnant?
362
P: No doctor, I'm taking combined pills.
D: Have you noticed any weight gain or more facial hair recently? (PCOS)
P: No
P: No
D: Any kidney, liver, Epilepsy or Depression problems?
P: No
P: No
D: Any steroid use?
P: Yes/No
P: No
P: No
D: Does anyone in your family have a similar problem?
D: Do you smoke?
P: Yes/No
P: Yes/No
P: Good/Bad
P: I work in a drama club and this ACNE bothers me a lot.
D: How does it make you feel?
P: Yes doctor, it’s very distressing for me, all these spots on my face, I want clear skin, I feel
down because of it.
D: I’m sorry that you have to go through that. I can see that it’s causing you a lot of stress.
P: Yes doctor.
D: Can you rate your mood for me please on a scale of 10, 1 being the lowest & 10 being
happiest?
P: 5
D: Are you sleeping alright these days?
P: Yes
D: Anything else you would like to tell me about your condition?
P: No Doctor
I would like to check your vitals and examine your chest. 1 will be examining the skin on
your face, chest and back for the different types of spot, such as blackheads or sore, red
nodules.
363
I would like to send for some initial investigations including routine blood test, FBC, FSH, LH
and Testosterone.
O/E: Patient shows picture of forehead with -red acne spots on it.
Acne is caused when tiny holes in the skin known as hair follicles become blocked.
D: From my examination, it seems that you have mild/moderate/severe form of acne.

Grades of Acne
Grade 1 (Mild)
Acne is mostly confined to whiteheads and blackheads, with just a few papules and pustules
Grade 2 (Moderate):
There are multiple papules and pustules, which are mostly confined to the face
Grade 3 (Moderately Severe):
There’s a large number of papules and pustules, as well as the occasional inflamed nodule,
and the back and chest are also affected by acne
Grade 4 (Severe):
There’s a large number of large, painful pustules and nodules
Medications that can be used to treat acne include:

• Topical Retinoids
• Topical Antibiotics
• Azelaic acid
• Antibiotic Tablets
• In women, the combined oral contraceptive pill
• Isotretinoin tablets
Mild Acne:
1st line - topical retinoid or salicylic acid + topical antibiotic (Erythromycin, Clindamycin,
Tetracycline)
Adjunct - topical benzoyl peroxide (if side effects then use topical azelaic acid)
Moderate Acne:
1st line - topical retinoid or salicylic acid + oral antibiotic (Tetracycline, Erythromycin)
Adjunct - topical benzoyl peroxide (if side effects, then use topical azelaic acid)
Severe or Resistant acne

1st line - topical retinoid or salicylic acid + oral antibiotic if doesn’t work -> oral retinoid
(Isotretinoin)
Adjunct - topical benzoyl peroxide (if side effects then use topical azelaic acid)
It is usually seen to affect females more.

It can be because of a hormonal imbalance but you told me that there’s no change in it
before menstruation.
364
Sometimes poor sleep can cause it but you said that your sleep is alright.
Cosmetic products can be the cause of acne, but now most products are tested so it is
unlikely to cause spots.
You are using the combined pills, which is good actually, because in some people acne
becomes better with the use of COCP’s.
If its milder form we give topical isotretinoin gel and if it’s severe form we give tablets. We
will refer you to a skin specialist who will decide which is the action for you.
Side Effects of Isotretinoin:

 Inflammation, dryness and cracking of skin, lips and nostrils.
 Inflammation of Eyes and Eye lids.
 Depression (Psychosis, Mood Swings, Suicidal attempts)
 Pancreatitis (pain in tummy, nausea and vomiting).
 Liver & Kidney problem.
 Muscle ache & pain on strenuous exercise.
 Hair thinning
Misconception about Acne:

1. Acne is caused by having dirty skin or poor hygiene;
2. Squeezing blackheads, whiteheads and spots is the best way to get rid of Acne:
3. Acne is caused by poor diet;
4. Having sex or masturbating will make acne better or worse;
5. Sunbathing, sunbeds and sunlamps help improve the symptoms of acne;
6. Acne is infectious.
365
IMPETIGO

Mary Stokes 24 years old has come with rashes on her face. She is concerned about it.

P: Dr. I have some rashes around my lips
D: Can you tell me more about the rash?
P: Dr. those are there for the last 1 week
D: What is the size of the rash?
P: Its spreading Dr.
D: What is the shape of the rash?
P: I don't know
D: What is the color of the rash?
P: honey crusted
D: Is there any discharge from the rashes?
P: No Dr
D: Is there itching in the lesion?
P: yes Dr sometimes
D: Is it painful?
P: yes sometimes Dr
D: Any other skin lesions in the body?
P : no Dr
P: No Dr
P: No Dr
D: Any lumps or bumps in the body?
P: No Dr
D: Any weight loss?
P: No Dr
P: No
D: Any tiredness?
P: No Dr
D: any long term exposure under the sun or skin tanning sessions?
P: No Dr
D: Have you been exposed to someone having similar skin lesions?
D: By any chance any insect bite?
P: No Dr
D: Did you have similar health condition in the past?
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P: No Dr
P: No Dr
P: No Dr
P: No Dr.
P: Yes Dr. allergic to penicillin
D: Do you smoke?
P: No
P: No
D: Has there been any recent changes in your diet?
P: No Dr
I would like to do a GPE, check the vitals and Examine your skin rashes.
From our assessment, we suspect you are having a condition called Impetigo. It's an
infection of the skin caused by a bug.
We can prescribe antibiotic cream to speed up your recovery or antibiotic tablets if it
doesn’t get better in a week. Do not stop using the antibiotic cream or tablets early, even if
the impetigo starts to clear up.
Impetigo can easily spread to other parts of your body or to other people until it stops being
contagious.
It stops being contagious:
• 48 hours after you start using the medicine your GP prescribed
367
• when the patches dry out and crust over (if you do not get treatment)
You can do some things to help stop it spreading or getting worse while it's still contagious:
Do
• stay away from school or work
• keep sores, blisters and crusty patches clean and dry
• cover them with loose clothing or gauze bandages
• wash your hands frequently
• wash your flannels, sheets and towels at a high temperature
• wash or wipe down toys with detergent and warm water if your children have impetigo
Don't
• do not touch or scratch sores, blisters or crusty patches - this also helps stop scarring
• do not have close contact with children or people with diabetes or a weakened immune
system (if they're having chemotherapy, for example)
• do not share flannels, sheets or towels
• do not prepare food for other people
• do not go to the gym
• do not play contact sports like football
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URTICARIA

Mother of 5-year-old Daniel has got some concerns.
Dr: Hello my name is Dr XYZ,I am one of the junior doctors in GP clinic. How can I help you?
Pt: My son has rash on his whole body
Dr: I am sorry to hear about that. Please tell me more about it.
Pt: It has happened 2-3 times. Once, after shower and this time he was playing in the garden.
Dr: For how long it stays?
Pt: Disappears after few minutes to hours.
Dr: Is it ichy?
Pt: Yes
Dr: Any one in family with similar symptoms?
Pt: No
Dr: Is it painful?
Pt: No
Dr: Is it bleeding?
Pt: No
Dr: Any fever?
Pt: No
Dr: Any shortness of breath(Anaphylaxis)?
Pt: No
Dr: Any wheeze?
Pt: No
Dr: Any swelling of face?
Pt: No
Dr: Any dizziness?
Pt: No
Dr: Does he have any health problems any asthma or allergy?
Pt: No
Dr: Is he using any medication?
Pt: No
Dr: Any allergies to food or medicine?
Pt: No
Dr: Family history of asthma or allergy?
Pt: No
Dr: How was his birth?
Pt: Fine
Dr: How is his development overall?
Pt: It is normal
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Dr: Is he up to date with his jabs?
Pt: Yes
Examination
Image was given when asked to examine. (Lateral view of head with rash all over face).
Diagnosis
Dr: From what we have assessed we think that he got this rash due to a condition called
urticaria. It is allergic rash that develops on exposure to some allergen.
Pt: Is it contagious?
Dr: No it is not contagious
Pt: Can my child go to his school?
Dr: Absolutely once he feels better
Pt: So what can you do for him?
Management
In many cases, treatment isn't needed for urticaria, because the rash often gets better
within a few days.
If the itchiness is causing discomfort, antihistamines can help.
A short course of steroid tablets (oral corticosteroids) may occasionally be needed for more
severe cases of urticaria.
For persistent urticaria, refer to a skin specialist (dermatologist). Treatment usually involves
medication to relieve the symptoms, while identifying and avoiding potential triggers.
Certain triggers for Urticaria:
• drinking alcohol or caffeine
• emotional stress
• warm temperature Causes of Urticaria:
• an allergic reaction – such as a food allergy or a reaction to an insect bite or sting
• cold or heat exposure
• infection – such as a cold
• certain medications – such as non-steroidal anti- inflammatory drugs (NSAIDs)or
antibiotics.
Dr: We will arrange a follow up In a month .in the meantime if he feels any shortness of
breath, fever or if the rash is spreading, please let us know. Thank you.
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HERPES LABIALIS
You are an F2 in GP Clinic.

A 24 years old lady came with rashes in her lower lip. She is concerned about it.
Please talk to the patient, take history and address her concerns.

P: I have got a rash on my lip.
D: May I know where exactly is the rash?
P: Lower lip.
(Pt will show a picture of the rash when you try to ask questions to elaborate the rash).
D: When did you notice the rash?
P: 2 weeks back
D: What is the colour?
P:
D: What is the size?
P:
D: Is the lesion painful?
P: Yes/No
D: Is the lesion itchy?
P: Yes, it is itchy sometimes.
D: Any discharge or bleeding?
P: No
D: Is it getting worse in any way?
P:
D: Any other rashes/lesions anywhere in the body?
P: no
D: Any change in your weight recently?
P: No
Any lumps/bumps anywhere in the body?
P:
Do you have any other symptoms?
P: No
Any fever?
P: Yes/No
D: Have you had similar kind of rash in the past?
P: No
P: No
D: Any skin condition or STIs?
P: No
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P: No
P: Yes, I am allergic to Penicillin.
P: No
P: No
P: Yes/No
D: (If No) Were you sexually active before?
P: Yes
D: When was the last time you had sexual activity?
P:
P: Yes/No
D: Which routes of sex do you practice?
P: Oral and vaginal
D: Kissing?
P: Yes/No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: Good/Bad
P: Yes/No
P: Yes/No
D: Have you been exposed to sun lately?
P: Yes/No
P:
P:
D: I would like to examine the lesion. (Picture).
372
D: From my assessment, it seems like you have cold sores. Cold sores are painful blisters
that form on or near the lips and inside the mouth. They are caused by an infection with a
virus called "herpes simplex virus."
P: How are you going to treat this?
D: Cold sores are usually mild and self-limiting and so can be managed symptomatically.
(Reassure the patient that lesions will heal without scarring). They resolve on their own in
10-14 days.
D: Pain control remains the main stay of treatment of cold sores. Paracetamol and ibuprofen
are effective in relieving pain and pyrexia. Gels for pain control of cold sores are also
available.
D: Antiviral medication:
Topical - May speed up the healing process. Needs to be started as soon the symptoms
begin.
Oral and Intravenous antivirals are given in severe cases and immunocompromised patients.
D: Laser therapy also decreases pain and reduces the number of recurrences
P: Will I get this again?
D: Treatments can help ease the symptoms of cold sores, but no treatment can cure cold
sores for good. Once you have the virus that causes cold sores, you will have it for the rest
of your life. That means that cold sores can keep coming back.
P: Why did I get a cold sore?
D: The virus that causes cold sores spreads easily from person to person. You might have
caught it from an infected person if the 2 of you shared a fork or knife, kissed, or had some
other type of close contact.
People who give oral sex to people with genital herpes can get cold sores on their mouth.
D: Cold sores are highly contagious. Cold sores are contagious from the moment you first
feel tingling or other signs of a cold sore coming on to when the cold sore has completely
healed.
D: Advice to reduce the risk of transmission:

 Avoid touching the lesions.
 Wash hands with soap and water immediately after touching the lesions, such as after
applying medication.
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 Topical medications should be dabbed on rather than rubbed in, to minimise trauma.
 Topical medications or other items that come into contact with a lesion area - eg, lipstick
or lip gloss - should not be shared with others.
 Avoid kissing until the lesions have completely healed.
 Avoid oral sex until all lesions have completely healer
 There is a risk of transmission to the eye if contact lense ome contaminated.
 Children with cold sores do not need to be excluded from nurseries and schools
Consider admission to hospital if the person:

 Is unable to swallow due to pain and is at risk of dehydration (especially in children).
 Is immunocompromised with severe oral herpes simplex infection - they may need
intravenous antiviral drug treatment.
 Has a suspected serious complication of oral herpes simplex infection - they may need
intravenous antiviral drug treatment.
Arrange a suspected cancer pathway referral (for an appointment within 2 weeks) if there
are any red flags suggesting oral cancer.
374
GENITAL WARTS

John aged 25 has made an urgent appointment.
Talk to him and address her concerns.

P: I have some skin lesions on the genital area.
D: Can you tell me more about the lesion please?
P: Like what?
P: I noticed it a few days ago
P:
P:
P:
D: Any pain?
P: No
D: Any itching?
P: yes
P: No
P: No
P: No
D: Have you noticed any change in its size, shape or colour since it started?
P: No
P: No
P: No
P: No
D: Have you got any fever or flu like symptoms?
P: No
D: Do you have any bleeding or Discharge from your penis?
P: No
D: Any pain or discomfort in your lower tummy or your private parts?
P: No
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D: Any pain or burning sensation while passing urine?
P: No
D: Cloudy or smelly urine. Frequency, Haematuria, Incontinence?
P: No
D: Any redness, hotness or swelling around your private parts or groin area?
P: No
P: No
D: Any previous skin condition, sexually transmitted infections?
P: No
D: Are you currently taking any medications, otc or supplements?
P: No
D: Any long-term steroids or antibiotics?
P: No
P: No
P: No
P: No
Now I am going to discuss your sexual history, some of these questions are quite in depth
and personal. We ask these questions to everyone so please don't take it personally. If you
feel uncomfortable and would prefer not to answer, just let me know.
P: Yes
P: Yesterday
P: Yes, I had two other partners previously
D: What kind of sexual contact do you have? (Genital? Anal? Oral)
P: Genital/Oral
D: Do you and your partner(s) use any contraception or protection against STI?
P: Sometimes Dr.
D: What is your sexual preference?
P: I am bisexual.
D: Was there any issues with the contraception used?
P: No
D: Any pain during or after sex?
P: No
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D: Any similar kind of symptoms in your partner?
P: No
D: Do you smoke?
P: Yes/no
P: No.
P: No
I would like to check your vitals, GPE and examine your private area.
Examination picture given with several bumps on the genital area, no scrotal swelling.
Treatment:
1. cream or liquid: applied directly to warts few times a week for several weeks, but some
cases may need to go to the clinic every week for a doctor or nurse to apply it (these
treatments can cause soreness, irritation or a burning sensation).
2. Surgery: a doctor or nurse can cut, burn (Electrocautery) or laser the warts off-this can
cause irritation or scarring.
3. freezing: a doctor or nurse freezes the warts, usually every week for 4 weeks – this can
cause soreness
It may take weeks or months for treatment to work, and the warts may come back. In some
people the treatment does not work. There's no cure for genital warts, but it's possible for
your body to clear the virus over time.
377
It may heal on its own with time as it is viral, but this can take few days to months.
1. It Can spread from skin to skin contact, sex (vaginal and anal sex rarely by oral sex)
2. Avoid perfumed lotions, soaps and avoid sex until the warts have gone if you do use
condom.
3. It doesn't spread via towels, kissing, toilets seats, or sharing cups
4. Genital warts are not cancer and do not cause cancer.
It is very important to complete the treatment by bringing in your partner and treating him
as well, if he has got the infection. If you are not able to bring your partner, we can contact
him through Partner Initiation Programme.
D: We usually offer HIV test for those who have sexually transmitted infections. Do you wish
to have one?
P: Yes/No
D: If you develop any fever or redness, hotness, swelling around your private parts or groin
area, any burning sensation while passing urine, any cloudy or smelly urine please come
back to us.
Concern:
Is it cancer?
Can it spread?
What are warts?

Ans: 1 or more painless growths or lumps around the genital area caused by HPV and can
develop again later on in life, may cause itching or bleeding from genitals or anus and can
also Change the flow of urine (towards the side)
Prevention:
1. HPV vaccine can help protect against genital warts.
2. Not having sex while you're having treatment for genital warts
3. Using a condom every time you have vaginal, anal or oral sex - but if the virus is present
in skin not protected by a condom, it can still be passed on.
4. The HPV vaccine offered to girls in the UK to protect against cervical cancer also protects
against genital warts.
5. Since April 2018, the HPV vaccine has also been offered to men who have sex with men
(MSM), trans men and trans women who are eligible.
378
SYPHILIS

Stuart Broad 24 years old has come with a skin lesion on private part. He is concerned about
it.
Talk to him, discuss management and address his concerns.
D: Hi I am Dr. Khalil one of the junior doctors working in this GP surgery. Can I confirm your
name and age please .
P: hello doctor my name is Stuart Broad I am 24 years old
P: Stuart is fine doctor
D: OK . How can I help you today?
P: Dr I feel so embarrassed
D: I can understand but we are here to help you . Can you please tell me what's going on?
P: I have a small ulcer on my penis.
D: Can you tell me more about that?
P: like what .
Explore the ulcer question of lesion or ulcer
1. location
2. Shape
3. Size
4. Color
5. Discharge
6. Painful
7. Itchy
D: How long it's been there?
P: past 2 weeks
D: What is the size of the ulcer?
P: like a coin
D: What is the shape of the ulcer?
P: I don’t know
D: What is the color of the rash?
P: Red
D: Is there any discharge from the rashes?
P: NO
D: Is there itching in the ulcer?
P: NO
D: is it painful?
P: NO
D: any other skin lesions in the body?
P: NO
379
D: any fever or flu like illness recently?
P: NO
D: Any lumps or bumps in the body?
P: yes, I have some around my groin for almost 2 weeks now .
D: Does those hurt?
P: no
Differential diagnosis
D: Any weight loss? ( CANCER )
P: No
P: No
D: Any headache? ( Neuro syphilis )
P: No
D: Any joint pain?
P: No
D: Any tiredness? ( HIV )
P: No
D: Any rash on the palms or soles?
P: No
D: Any white patches in the mouth? ( Immunocompromised )
P: No
D: any rashes anywhere else in the body? (Generalized syphilis)
D: any weakness in any part of the body? (Neuro/meningosyphilis)?
D: Any long-term exposure under the sun or skin tanning sessions?
P: No
D: Have you been exposed to someone having similar skin lesions?
P: No
D: Did you have similar health condition in the past?
P: No
P: No
P: NO
P: NO
D: Any family history of any significant health issues or skin problems?
P: No
D: Do you smoke?
P: yes dr ( what do you smoke , how many , for how much time )
P: NO
D: tell me about your diet?
380
P: I am taking a balanced diet
Sexual history
P: yes dr I am sexually active
P: No , I have multiple partners
D: May I ask about your sexual orientation?
P: I am a GAY
D: Do you use any contraception?
P: no dr I don’t use any contraception
D: Preferred route of sex
P: anal and oral .
P: No
MANAGEMENT
I would like to do a GPE, check the bp, temp, RR. Pulse rate and Examine the ulcer
From what you have told me and from what I have assessed, we suspect you are having a
condition called syphilis.
D: do you know what syphilis is ? (concerns) Syphilis is a bacterial infection that's usually
caught by having sex with someone who's infected.
We will be doing further investigation, like an antibody test (treponema serology test) in GP
practice to confirm the diagnosis and
we will refer you to the GUM clinic. They might take a swab from the lesion and some more
blood work up.
P: How are you going to treat me ? (concern)
TREATMENT
Syphilis is usually treated with either:
• an injection of antibiotics(For syphilis lasting more than 2 years) into your buttocks - most
people will only need 1 dose of Penicillin, although 3 injections given at weekly intervals
may be recommended if you have had syphilis for a long time
• a course of antibiotics tablets if you cannot have the injection - this will usually last 2 or 4
weeks, depending on how long you have had syphilis
You should avoid any kind of sexual activity or close sexual contact with another person
until at least 2 weeks after your treatment finishes.
It is very important to complete the treatment by bringing in your partners and treating
them as well if they have got the infection.
If you are not able to bring your partners, we can contact them through partner notification
program.
We usually offer HIV test to those who have any kind of sexually transmitted infections.
D: Do you wish to have one?
381
P: No
P: CAN I HAVE IT AGAIN ? (concern)
D: You can catch syphilis more than once, even if you have been treated for it before.
P: How can I prevent syphilis ? (concern)
D: Syphilis cannot always be prevented, but if you're sexually active you can reduce your risk
by practicing safe sex:
use a male condom or female condom during vaginal, oral and anal sex
use a dental dam (a square of plastic) during oral sex
avoid sharing sex toys – if you do share them, wash them and cover them with a condom
before each use
These measures can also reduce your risk of catching other sexually transmitted infections
(STIs).
If you inject yourself with drugs, do not use other people's needles or share your needles
with others.
RED FLAGS If you develop any

sore throat
white patches in the mouth
any tingling or numbness in your hands or feet
any vision problems please come back to us.Leaflets
Specific expectations
Wish you a good health
MORE INFORMATION
Symptoms of syphilis
The symptoms of syphilis are not always obvious and may eventually disappear, but you'll
usually remain infected unless you get treated.
Some people with syphilis have no symptoms.
Symptoms can include:
small, painless sores or ulcers that typically appear on the penis, vagina, or around the anus,
but can occur in other places such as the mouth
a blotchy red rash that often affects the palms of the hands or soles of the feet
small skin growths (similar to genital warts) that may develop on the vulva in women or
around the bottom (anus) in both men and women
white patches in the mouth
tiredness, headaches, joint pains, a high temperature (fever) and swollen glands in your
neck, groin or armpits
If it's left untreated for years, syphilis can spread to the brain or other parts of the body and
cause serious long-term problem
How syphilis is spread
Syphilis is mainly spread through close contact with an infected sore.
382
This usually happens during vaginal, anal or oral sex, or by sharing sex toys with someone
who's infected. Anyone who's sexually active is potentially at risk.
It may be possible to catch syphilis if you inject yourself with drugs and you share needles
with somebody who's infected, or through blood transfusions, but this is very rare in the UK
as all blood donations are tested for syphilis.
Syphilis cannot be spread by using the same toilet, clothing, cutlery or bathroom as an
infected person.
Pregnant women with syphilis can pass the infection to their unborn baby.
Syphilis in pregnancy
If a woman becomes infected while she's pregnant, or becomes pregnant when she already
has syphilis, it can be very dangerous for her baby if not treated.
Infection in pregnancy can cause miscarriage, stillbirth or a serious infection in the baby
(congenital syphilis).
Screening for syphilis during pregnancy is offered to all pregnant women so the infection
can be detected and treated before it causes any serious problems.
Complications of syphilis
Meningitis Stroke Dementia Heart diseases
Syphilis is divided into stages (primary, secondary, latent, and tertiary), with different signs
and symptoms associated with each stage. A person with primary syphilis generally has a
sore or sores at the original site of infection.
Sore on penis
Generalized or secondary syphilis
383
SCABIES

Parents of Sacha aged 2 have come to you with some complaint. Sacha had gone for a pit
walk with her father.
Talk to the mother and address her concerns.

P: Sacha is scratching all over.
D: Since when?
P: 1 week.
D: Is there any rash?
P: Yes
P: It started between her fingers and now it’s all over her body.
P: Like what?
D: Any Fever?
P: No
D: Any Discharge?
P: No
P: No
D: Is she taking any medications including OTC or supplements?
P: No
P: No
P: No
D: Is Sacha the only child?
P: Yes
D: How was the birth of Sacha?
P: It was normal vaginal delivery.
P: Yes.
D: Is she up to date with all her jabs?
P: Yes.
D: Has she received any recent jab?
P: No
D: Is she feeding well?
P: Yes. She is feeding very well.
D: Does she have any problems with her wee?
384
P: No.
D: Is Sacha a playful child?
P: Yes
D: Is Sacha playing well?
P: Does not go out to play
D: Has Sacha come in contact with anyone with same complaint?
P: No
D: I need to have a look at Sacha.
P: I have a picture of the rash.
(Red rashes on knuckles and web spaces)
Investigation:
skin infection caused by mites. This infection is known as scabies. These bugs actually
burrow into the skin and can cause rashes.
We can usually confirm the diagnosis with a clinical examination and may use a magnifying
glass to help with identification of the rash.
We may also do an ink burrow test where ink is rubbed over the rash and then wiped out
with an alcohol swab to outline the burrow track. Lastly, we may also need to take some
skin from the area of the rash for biopsy.
P: How are you going to treat it doctor?

D: It is treated by a topical medicine called Permethrin which is an insecticide that kills the
mites. We will also be prescribing antihistamines and low dose steroid creams to help with
the symptoms.
P: How long will I have to take the medicine for?

D: It is treated by a topical medicine called Permethrin preparation overnight to the whole
body from head to toe. You need to apply treatment to the whole body, including the scalp,
neck, face, and ears, and especially between the fingers and toes and under the nails.
385
Treatment should not be applied after a hot bath as this increases systemic absorption and
removes the drug from treatment site. If the hands are washed, the liquid or cream must be
reapplied. This should be repeated a week later.
DO:
- Wash all bedding and clothing in the house at 50 C or higher on the first day of
treatment.
- Put clothing that cannot be washed in a sealed bag for 3 days until the mites die
- Stop babies and children sucking treatment from their hands by putting socks or mittens
on them.
DON'T:
- Do not have sex or close physical contact until you have completed the full course of
treatment.
- Do not share bedding, clothing or towels with someone with scabies.
You or your child can go back to work or school 24 hours after the first treatment.
Complications:
1. Scabies can cause flaring or reactivation of eczema or psoriasis
2. Secondary bacterial infection
Risk factors:
Overcrowding, poverty, poor nutritional status, Homelessness, Poor hygiene, Institutions.
Residential care homes in the UK, refugee camps in some parts of the world, Sexual contact,
Children, especially in developing countries, Immune suppression.
Concerns:
P: How many days will it take to go away?
P: What will you do for her?
P: What happens if it gets worse?
Differentials
Impetigo
Tinea
Dermatitis herpetiformis
Psoriasis
SLE
386
ECZEMA
You are F2 in GP.

John Smith, aged 15, came to the hospital with his mother with some concerns. He is a
diagnosed case of Asthma.
Please talk to them, take history, discuss your plan of management with them and address
their concerns.

P: I have got rash on the back of my legs.
D: Since when?
P: 1 week
P: It started on its own.
D: Does the rash come and go?
P: No
D: Has the rash spread anywhere else?
P: Yes, it’s also at the back of my neck, and in front of my elbows.
P: No
P: No
P: Like what?
D: Any fever?
P: No
D: Any discharge?
P: No
D: Any itchiness?
P: Yes, it is itchy
D: Any bleeding?
P: No
D: Any ulceration?
P: No
P: Yes, when I was a kid
Mother: He had some rash on his hand, and we put some cream E45 and he was fine.
P: Asthma since childhood.
D: Does anything trigger it?
P: It sometimes gets worse when playing
D: Does it get triggered by dust, pollen, cold weather, pets? (rule out triggers)
387
P: No
D: How is it controlled?
P: I am on salbutamol inhaler and it is well controlled.
P: No
P: No
P: No
P: No
P: My father and sister have asthma.
D: Do you smoke?
P: Yes/No
P: Yes/No
P: No
I would like to check your vitals and examine your lesion.

skin infection called eczema. It is a type of condition that causes skin to become dry and
irritated.
We can usually confirm the diagnosis with a clinical examination.

Allergy test; are not usually needed, although they're sometimes helpful in identifying
whether a food allergy may be triggering symptoms.
Management:
Eczema is a chronic condition that can be managed by prevention and by using some topical
medications.
Try to reduce scratching whenever possible. You could try gently rubbing your skin with your
fingers instead. You can avoid common triggers that you are aware of such as irritants (such
as soaps and detergents, including shampoo, washing-up liquid and bubble bath),
388
environmental factors or allergens (such as cold and dry weather, dampness, and more
specific things such as house dust mites, pet fur, pollen and moulds) to avoid a flare up of
eczema.
We can prescribe emollients (moisturizing treatments) that can be used on a daily basis for
dry skin for prevention.
If needed, topical steroids can be advised to reduce swelling, redness and itching during
flare-ups.
1. Self-care techniques, such as reducing scratching and avoiding triggers.

2. Emollients (moisturizing treatments) – used on a daily basis for dry skin.
3. Topical steroids – used to reduce redness and itching during flare-ups.
Differentials:
-Psoriasis
-Fungal infection
-Lichen simplex chronicus
389
CONCERNED MOTHER - CHICKENPOX CHILD

Andy Charles, aged 4, was brought into the GP by his mother, Maggie Charles, because of
her son not feeling well.
D: How can I help?

M: My child is unwell (fever and rash all over the body for the last one day)
P: He was fine 3 days ago until he got a fever.
D: Did you measure his temperature?
P: No doctor
D: What did you do for that?
P:We went to the GP and he gave her Calpol and referred us to the hospital.
D: Does he have any cough? Sputum?
P:No
D: Have you noticed any rash?
P:Yes
P:3 days ago.
D: Where in your body did it start?
P:Chest
D: How has it progressed?
P:All over
D: Does it have any discharge? Bleeding?
P: No
D: Is there any itching?
P: Yes
D: Is he crying?
P: Yes, a lot.
D: Have you noticed that your child is shy to light or cries while moving his neck?
P:No
D: Have you noticed any difficulty in breathing?
P:I just feel that his chest is full.
D: Any vomiting?
P:No
D: Do you feel that his mouth is dry?
P: No
P:No, this is the first time.
390
P: No
D: Is he taking any medications including OTC or supplements?
P: No
P: No
P: No
P: No.
D: How was the birth of your baby?
P:It was normal vaginal delivery
D: Was he born at term?
P:Yes
D: How much was the birth weight?
P: Normal
P: Yes
D: Is he up to date with all the jabs?
P: Yes
D: Has he received any recent jabs?
P: No
D: Is he feeding well?
P: Yes/No
D: Since when?
P: Since his fever
D: Does he have any problems with his wee?
P: No
D: Have you noticed any tummy pain or change in his poo?
P: No
D: Any diarrhoea?
P: No
D: How is the urine output?
P: It is fine
D: Who looks after him?
P: It’s me.
Signs and symptoms:

Chickenpox starts with red spots. They can appear anywhere on the body and might spread
or stay in a small area. The sports fill with fluid and become blisters. The blisters may burst.
The spots scab over. New spots might appear while others are becoming blisters or forming
a scab.
391
It takes 1 to 3 weeks from the time you were exposed to chickenpox for the spots to start
appearing.
Other symptoms:
1. a high temperature.
2. aches and pains, and generally feeling unwell.
3. loss of appetite
How to treat chickenpox at home:

You’ll need to stay away from school, nursery or work until all the spots have crusted over.
This is usually 5 days after the spots appeared.
Chickenpox is infectious from 2 days before the spots appear until they have all crusted over
– usually 5 days after they first appeared.
Do
 Drink plenty of fluid (try ice lollies if your child is not drinking) to avoid dehydration
 Take paracetamol to help with pain and discomfort
 Put socks on your child’s hands at night to stop scratching
 Cut your child’s nails
 Use cooling creams or gels from a pharmacy
 Speak to a pharmacist about using antihistamine medicine to help itching
 Bathe in cool water and pat the skin (do not rub)
 Dress in loose clothes
 Check with your airline if you’re going on holiday – many airlines will not allow you to fly
with chickenpox.
Don’t
 Do not use ibuprofen unless advised to do so by a doctor, as it may cause serious skin
infections
 Do not give aspirin to children under 16
 Do not be around pregnant women, newborn babies and people with a weakened
immune system, as chickenpox can be dangerous for them.
Shingles is caused by the same virus that causes chickenpox and is a very delayed
complication of chickenpox. Anyone who has had chickenpox in the past may develop
shingles. Shingles is an infection of a nerve and the area of skin supplied by the nerve. It
causes a rash and pain in a local band-like area along the affected nerve.
Some children have a higher risk of developing complications from chickenpox. In addition
to the above treatments, they may need extra treatment such as acyclovir (an antiviral
medicine) or vaccination. If your child has not already had chickenpox and is in one of the
392
following groups, you should see a doctor urgently if they have contact with chickenpox or
have symptoms of it:
 Children (babies) less than 1 month old
 Children with a poor immune system. For example, children with leukaemia, immune
diseases or HIV/AIDS
 Children taking certain medication such as steroids, immune-suppressing medication or
chemotherapy
 Children with severe heart or lung disease
 Children with severe skin condition
Antiviral medication is also used for adults and teenagers who develop chickenpox, as they
too have a higher risk of complications. However, antiviral medication is not normally
advised for healthy children aged over 1 month and under 12 years who develop
chickenpox.
393
MOTHER WANTS SICK NOTE (CHICKENPOX)

Mrs. Janet May, aged 26, has come to you with some concerns. Her daughter has got
chickenpox.
Talk to her and negotiate with her.
D: How can I help?

P: I need a sick note.
D: May I know why?
P: My daughter has chickenpox for the past 3 days.
D: How is she doing?
P: She is fine.
D: Any fever?
P: Yes
P: Yes
D: Is she playful?
P: Yes
D: Any rashes?
P: No
D: Is your daughter shy to light?
P: No
P: No
P: No
P: No
P: No
D: Was your baby delivered at term or post term?
P: At term.
P: Yes
P: Yes
P: No
D: Who looks after her?
394
P: Me and my husband but my husband is away at the moment on business.
D: Does your daughter go to nursery/school?
P: Yes
D: Do you have other kids?
P: No
D: Is there anyone who can look after your daughter?
P: No
D: Is there any friend or family nearby who can look after her?
P: No
D: When will your husband be back?
P: After a week.
D: Can he come back early?
P: Yes/No
D: Is there anyone else who can look after your child?
P: Yes/No
D: Can you arrange a carer for your daughter?
P: Yes/No
P: I am a lecturer in the university
D: Have you spoken to the university for some time off?
P: Yes/No
D: Have you spoken to your employer regarding changing work environment? (Phased work,
amended duties, altered hours, workplace adaptations)
P: Yes/No
MOTHER'S CONCERNS
Will I get chickenpox?
Can the students at the university get it also because of me?
D: Have you had chickenpox in the past?
P: Yes
P: How long will the chickenpox last?
Chickenpox starts with red spots. They can appear anywhere on the body and might spread
or stay in a small area. The spots fill with fluid and become blisters. The blisters may burst.
The spots scab over. New spots might appear while others are becoming blisters or forming
a scab.
It takes 1 to 3 weeks from the time you were exposed to chickenpox for the spots to start
appearing.
Treatment
You'll need to stay away from school, nursery or work until all the spots have crusted over.
395
This is usually 5 days after the spots appeared.
Chickenpox is infectious from 2 days before the spots appear, until they have all crusted
over – usually 5 days after they first appeared.
Do
 Drink plenty of fluids (try ice lollies if your child is not drinking) to avoid dehydration
 Take paracetamol to help with pain and discomfort
 Put socks on your child's hands at night to stop scratching
 Cut your child's nails
 Use cooling creams or gels from a pharmacy
 Speak to a pharmacist about using antihistamine medicine to help itching
 Bathe in cool water and pat the skin dry (do not rub)
 Dress in loose clothes
 Check with your airline if you're going on holiday – many airlines will not allow you to fly
with chickenpox
Don’t
 Do not use ibuprofen unless advised to do so by a doctor, as it may cause serious skin
infections
 Do not give aspirin to children under 16
 Do not be around pregnant women, newborn babies and people with a weakened
immune system, as chickenpox can be dangerous for them.
Shingles is caused by the same virus that causes chickenpox and is a very delayed
complication of chickenpox. Anyone who has had chickenpox in the past may develop
shingles. Shingles is an infection of a nerve and the area of skin supplied by the nerve. It
causes a rash and pain in a local band-like area along the affected nerve.
Some children have a higher risk of developing complications from chickenpox. In addition
to the above treatments, they may need extra treatment such as acyclovir (an antiviral
medicine) or vaccination. If your child has not already had chickenpox and is in one of the
following groups, you should see a doctor urgently if they have contact with chickenpox or
have symptoms of it:
 Children (babies) less than 1 month old
 Children with a poor immune system. For example, children with leukaemia, immune
diseases or HIV/AIDS
 Children taking certain medication such as steroids, immune-suppressing medication or
chemotherapy
 Children with severe heart or lung disease
 Children with severe skin condition
396
Antiviral medication is also used for adults and teenagers who develop chickenpox, as they
too have a higher risk of complications. However, antiviral medication is not normally
advised for healthy children aged over 1 month and under 12 years who develop
chickenpox.
397
SEBORRHEIC KERATOSIS
You are FY2 in GP.

Nancy James, aged 70, emailed you a picture of skin lesion.
Talk to her and address concerns.

Pt: I noticed the lesion on my chest
Dr: Tell me more about it
Pt: Like what?
Dr: When did you notice it?
Pt: 2 months ago
Dr: Has it changed in shape, size or colour?
Pt: It has increased in size
Dr: Has the lesion appeared anywhere else?
Pt: No
Dr: Does anything make it better?
Pt: No
Dr: Does anything make it worse?
Pt: No
Dr: Any other symptoms?
Pt: Like what?
Dr: Any fever?
Pt: No
Dr: Any discharge?
Pt: No
Dr: Any itchiness?
Pt: No
Dr: Any bleeding?
Pt: No
Dr: Do you go out in sun more often?
Pt: No I don’t
Dr: Any tanning beds?
Pt: No
Dr: Any recent weight loss?
Pt: No
Dr: Any lumps or bumps?
Pt: No
Dr: Loss of appetite?
Pt: No
Dr: Have you been diagnosed with any medical condition in the past?
Pt: No
398
Dr: Any DM, HTN, heart disease or high cholesterol?
Pt: No
Dr: Are you taking any medications including OTC or supplements?
Pt: No
Dr: Any allergies from any food or medications?
Pt: No
Dr: Any previous hospital stay or surgeries?
Pt: No
Dr: Has anyone in the family been diagnosed with any medical condition?
Pt: My mother had skin cancer.
Dr: Do you smoke?
Pt: Yes/No
Pt: Yes/No
Dr: Tell me about your diet?
Pt: I try to eat healthy.
Dr: Do you do physical exercise?
Pt: I don’t have much time.
Pt: I am retired
Dr: With whom do you live?
Pt: My wife
Dr: Do you have any kind of stress?
Pt: No
Examination
I would like to check your vitals, i.e., your BP, pulse, temperature and respiratory rate. I
would also like to examine your breasts for lesion (Picture is in the cubicle)
From what you have told me & the picture you have emailed me, it appears that you have a
skin lesion called seborrheic keratosis. They are harmless growths on the skin and can vary
in colour from skin coloured to almost black.
I would like for you to come visit the GP clinic for examination of the lesion with a special
tool called a dermatoscope. If needed, we can refer you to the hospital for the biopsy.
Treatment:
Seborrheic warts do not require treatment, as they are usually harmless, but you may want
them to be removed for cosmetic reasons. This is best done by scraping the wart away
under local anaesthetic (where the skin is made numb) or by freezing it with liquid nitrogen
Concerns:
399
Is it cancer?
Cryosurgery
Liquid nitrogen, a very cold liquid gas, is applied to the growth with a cotton swab or spray
gun to “freeze” it. A blister may form under the growth which dries into a scab-like crust.
The keratosis usually falls off within a few weeks. Occasionally, there will be a small dark or
light spot that usually fades over time.
Curettage
The keratosis is scraped from the skin. An injection or spray is first used to anaesthetise
(numb) the area before the growth is removed (curetted). No stitches are necessary, and the
minimal bleeding can be controlled by simply applying pressure or the application of a
blood-clotting chemical.
Electrosurgery
The growth is anaesthetised (numbed) and an electric current is used to burn the growth,
which is then scraped off.
Pt: Ok doc, any other precautions ?
Dr: If you have this keratoses it's important to avoid any further sun damage. This will stop
you getting more skin patches and will lower your chance of getting skin cancer.
Do
• use sunscreen with a sun protection factor (SPF) of at least 30 before going out into the
sun and reapply regularly
• wear a hat and clothing that fully covers your legs and arms when you're out in the
sunlight
Don’t
• do not use sunlamps or sunbeds as these can also cause skin damage
• do not go into the sun between 11am and 3pm – this is when the sun is at its strongest.
Dr: We will also arrange your referral to skin specialist so that he can also assess you. Is that
ok?
Pt: Ok doc
Dr: We will book your follow up appointment in a month in the meantime if you feel that
your lesion is growing, changing its color, any bleeding from it or any weight loss, please let
us know. Thank you.
 Seborrhoeic keratoses are often confused with warts or moles, but they are quite
different. Seborrhoeic keratoses are non-cancerous growths of the outer layer of skin.
There may be just one growth or many which occur in clusters. They are usually brown,
400
but can vary in colour from light tan to black and range in size from a fraction of an inch
in diameter to larger than a £2 coin. A main feature of Seborrhoeic
 keratoses is their waxy, “pasted-on” or “stuck-on” appearance. They sometimes look like
a dab of warm brown candle wax that has dropped onto the skin or like barnacles
attached to the skin.
 Causes of Seborrhoeic Keratoses:
o The exact cause of seborrheic keratoses is unknown; however, they seem to run in
families. They are not caused by sunlight and can be found on both sun- exposed and
non-exposed areas. Seborrhoeic keratoses are more common and numerous with
advancing age. Although seborrheic keratoses may first appear in one spot and seem
to spread to another, they are not contagious.
 Development of Seborrhoeic Keratoses:
 Anyone may develop seborrhoeic keratoses. Some people develop many over time, while
others develop only a few. As people age, they may simply develop more.
 Facts about Seborrhoeic keratoses:
o Seborrhoeic keratoses are most often located on the chest or back, although they also
can be found on the scalp, face, neck, or almost anywhere on the body. The growths
usually begin one at a time as small, rough, itchy bumps which eventually thicken and
develop a warty surface.
o Seborrhoeic keratoses are benign (non-cancerous) and are NOT serious and are not
generally treated by a dermatologist in secondary care, you can speak with your GP
who can offer you the treatment. Removal may be recommended if they become
large, irritated, itch, or bleed easily.
 Treatments
o Creams, ointments, or other medication can neither cure nor prevent seborrheic
keratoses. Most often seborrhoeic keratoses are removed by cryosurgery, curettage,
or electro surgery.
 Cryosurgery
o Liquid nitrogen, a very cold liquid gas, is applied to the growth with a cotton swab or
spray gun to “freeze” it. A blister may form under the growth which dries into a scab-
like crust. The keratosis usually falls off within a few weeks. Occasionally, there will be
a small dark or light spot that usually fades over time.
 Curettage
o The keratosis is scraped from the skin. An injection or spray is first used to
anaesthetise (numb) the area before the growth is removed (curetted). No stitches
are necessary, and the minimal bleeding can be controlled by simply applying
pressure or the application of a blood-clotting chemical.
Electro surgery
The growth is anaesthetised (numbed) and an electric current is used to burn the growth,
which is then scraped off.
401
If you have this keratoses it's important to avoid any further sun damage. This will stop you
getting more skin patches and will lower your chance of getting skin cancer.
Do
• use sunscreen with a sun protection factor (SPF) of at least 30 before going out into the
sun and reapply regularly
• wear a hat and clothing that fully covers your legs and arms when you're out in the
sunlight
Don’t
• do not use sunlamps or sunbeds as these can also cause skin damage
• do not go into the sun between 11am and 3pm – this is when the sun is at its strongest.
402
SURGICAL STATIONS
BACK PAIN
You are F2 in GP.

Peter Smith, aged 58 years presents to the clinic complaining of back pain.
Talk to the patient, take history, assess patient and discuss further management with
patient and address patients concerns.

P: I have pain here (Pointing towards lower back)
P: It is there from last 3 months.
P: Nothing
P: Continuous
P: Gradual
P: Dull
P: No
P: I tried PCM but it didn't help that much.
P: I took 2 tablets every 6 hours?
P: No
P: 6
D: Do you have anything else along with pain?
P: Yes in past few months I am going to loo more often these days/No
D: Anything else?
P: No
P: Yes/No (Nocturia)
P: No (Urgency)
D: Do you have Difficulty in starting urination?
403
P: No (Hesitancy)
D: Are you able to hold your urine before going to loo?
P: No (Incontinence)
D: Do you have Weak urine stream or a stream that stops and starts?
P: No (Poor or weak stream or urine intermittency)
P: No (Poor emptying)
D: Have you noticed any Dribbling at the end of urination?
P: No (Dribbling)
D: Any blood in urine?
P: No
D: Have you noticed any weight loss?
P: Yes 1 stone in last few months./ No (if no ask close question)
P: I am not eating as before.
D: Do you feel tired or short of breath?
P: Yes/ No
D: Any heart racing or dizziness?
P: No
D: Any pain in upper back or pain in your tummy? (Pancreatic CA)
P: No.
D: Any heart burn or indigestion?
P: No (Gastric CA)
D: Any yellowish discoloration of skin or eyes?
P: No
D: Any fever, flu like symptoms or shivering?
P: No (Pyelonephritis)
D: Any mass in the loin area?
P: No (RCC)
D: Any persistent cough?(Lung CA)
P: No doctor.
D: Is this pain radiates from back to your legs? (Disc prolapse)
P: No
D: Any trauma to your back?
P: No
P: No
P: No
D: Any enlarged prostate?
P: No
404
P: No
P: No
P: No
P: No
D: Family history' of prostate problem?
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: Good
P: Quite active
P: No
P: I’m a builder.
D: I would like to check your vitals and examine your back, your back passage and straight
leg test.
D: I would like to send for some initial investigations including routine blood test, urine dip,
CXR and X-Ray of your back.
EX- Normal.
Management:
D: Have you got an idea about what is going on?
PATIENT'S CONCERNS
P: What is happening doctor?
P: Is it a serious condition?
P: What about my pain Dr.?
 D: From our assessment, we are suspecting you have a condition in your prostate, which
is a small gland which lies beneath the neck your bladder.
 We suspect your condition could be a serious one. PAUSE
405
 But it is very difficult for us to confirm this at this stage before doing all the necessary
tests.
 We are going to do further blood tests to see if you have weak blood and to see the
function of your liver and kidneys. We will also check the amylase (special test for the
pancreas gland).
 Special blood test to see the amount of substance produced by your prostrate.
 We will also test your urine for infection.
 Depending on the results of your examination, initial and special blood tests along with
the scans, we may have to refer you to a specialist and team of doctors (multi disciplinary
team) who will do the necessary tests and confirm the diagnosis and start treatment
depending upon the condition. We will refer you to the specialist in 2weeks time.
 The specialist might have to do some scans. An US scan of your prostate and may have
take a sample if necessary.
 A bone scan of your back to look for any abnormality.
 A CT or an MRI scan.
 If it is cancer then the treatment depends upon the type, size, position and stage of
cancer and also your overall health. We have many options to treat prostate cancer.
Watchful waiting, Surgical resection, Radiotherapy, Brachytherapy, Cryotherapy,
Chemotherapy. The specialist doctor will talk and discuss about various options with you
and will give the suitable treatment for you.
 For now we will prescribe pain killers for your pain. As you are already taking
paracetamol and it doesn’t help, we will prescribe you another medication called Co-
codamol (paracetmol + codeine).
 In the meantime if you have any concerns before meeting the specialist, please come
back to us at any time.
 Advice about smoking cessation.
 Please come back to us if your symptoms worsen or if you are not able to pass urine at
all.
DD:
Prostate cancer
Pancreatic cancer
Lung cancer
Renal cell carcinoma
Osteoarthritis
Osteoporosis
Kidney Stones
Pyelonephritis
Disc Prolapse
406
BACK PAIN (IVDP)

Jermaine aged 40 year old has presented to the hospital complains of back pain.
Talk to him. assess him and discuss the management plan with the patient.

P: Doctor, 1 have this pain my lower back.
D: Tell me more?
P: I have this pain since last 2 weeks on and off, but since yesterday its very painful.
D: What were you doing when you had this pain? P: I was at my job, moving heavy boxes,
and then the pain started
D: Was it sudden in onset?
P: Yes
P: Sharp
P: Yes, it goes to my both thighs & legs till the tip of the big toe.
D: Do you feel any tingling or numbness in your feet?
P: Yes/No
D: Any weakness in the lower limb?
P: No
P: Yes, it gets better when I take diclofenac.
D: How many tablets did you take?
P: Two
P: Yes, when 1 try to bend.
D: Could you the pain on a scale of 1 to 10, 1 being no pain & 10 being very severe pain?
P: 7/8
D: Anything else?
P: No
D: Have you noticed any redness or swelling in your back or feet?
P: No
D: Have you experienced any nausea or vomiting with the pain?
P: No
P: Fine
D: Any fever, flu like symptoms or cough?
P: No
D: How is your urine and bowel habits?
P: It is normal.
407
D: Are you able to control your urine and stool since the pain started?
P: Yes
D: Any numbness or tingling at your back passage?
P:No
D: Have you noticed that you have to go to the loo more often recently?
P: No
D: Have you by any chance noticed that you have to rush to the loo?
P: No
D: How has your appetite been recently?
P: It’s been fine
D: Have you by any chance noticed that you’ve lost any weight recently?
P: No
D: Any SOB, Palpitation or dizziness?
P: No
D: Have you noticed any discolouration of your eyes or skin?
P: No
D: Has such a thing ever happened before?
P: No
P: No
D: Are you taking the medication regularly?
P: Yes
D: Have you been diagnosed with any medical condition such as enlarged prostate, IBD, AS
or RA?
P: No
D: Are you taking any other medications other than Diclofenac including OTC or
supplements?
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
D: Do you do any physical activity?
P: Yes
P: Office work.
D: I would like to check your vitals, GPE, back, lower limb examination and SLR test.
408
D: I would also like to send for some initial investigations, including routine blood test, FBC,
urine dip. X-ray of your back.
Ex: Findings:
Local Tenderness in the Lower Back
Straight Leg Raise Test: Positive
From our assessment, we are suspecting you have a condition called slipped disc.
The backbone is actually made up of small bones called vertebrae, joined together by
muscles & tissue like structures. Between two adjacent smaller bones there’ s a disc like
structure that actually acts as the spine’ s shock absorber system. But sometimes it can slip
or prolapse, as it might have happened in your case because of lifting heavy weight. • AL
There are nerves in the back, which go to different body pails. As you have lower back pain,
so probably the disc that prolapsed is in the lower back region. The nerves that arise from
the lower part of the backbone go into the lower torso. When the disc prolapsed, the space
between 2 adjacent vertebrae finished, so the nerves that were present in that region got
compressed between the 2 bones. It is because of that you are experiencing pain & tingling
sensation in your legs.
You’re already taking a pain killer (NSAID).
We’ll add another (paracetamol) to that so that your pain becomes better.
If your pain is not relieved by these pain killers, your GP can prescribe you stronger pain
killers such as Co-codamol.
In addition to that we’ll prescribe you a muscle relaxant so that the muscles surrounding
your backbone relax, which will also help with the pain.
If your pain is not relieved in next few days, we will give you some other medication such as
Amitriptyline or Pregabalin.
We’ll also refer you to a physiotherapist, who would help ease your pain. Exercise not only
reduces the pain of the prolapsed disc but also reduces the chances of it happening again.
An epidural is an injection given into the back. It is usually given into the area in the back
around where the sciatic nerve comes out of the spine. It is performed by a specialist. The
injection
contains a type of local anaesthetic and a steroid, which is a very strong anti-inflammatory.
It is essentially a long-term painkiller that can give you enough pain relief that you can start
or continue to exercise.
The pain from a slipped disc usually resolves in about 6 weeks. In case it doesn’t get better
or you experience any numbness in your lower back or there is loss of control of your wee or
poo, please do come back to us immediately. We will run other specialized tests to see
what’s causing it. We might even have to do an MRI scan of your back.
If the pain is unbearable, then you should take some rest initially. Once your pain becomes
somewhat better, start some light exercise. Swimming is a good exercise which you can try.
It will help you get better faster. Heat application and massage in your lower back may
relieve muscle stiffness in your lower back. And please do try to avoid activities like lifting
any weight or sitting for long periods of time, as it can worsen your pain.
409
CAUDA EQUINA SYNDROME
D: How is your urine and bowel habits?
P: I am not able to pass urine since morning.
D: Any tummy pain?
P: Yes, I have some discomfort here (patient points towards suprapubic).
Symptoms of Cauda Equina Syndrome:
1. Lower Back Pain
2. Bowel Problem (constipation)
3. Bladder Problem (Urine Retention)
4. Sexual Problems may also occur (impotence in men).
5. Numbness in the saddle area, which is around the back passage (anus), and weakness in
one or both legs.
Investigation:
1. MRI
2. Myelography and CT are also sometimes used.
3. Urodynamic studies: may be required to monitor recovery of bladder function following
decompression surgery.
Management:
1. Neurosurgical Referral
2. Urgent Surgical Decompression to prevent permanent neurological damage
3. Surgery is indicated to remove bone fragments, tumours, herniated disc. If surgery can ’ t
be performed, radiotherapy may relieve cord compression caused by malignant disease.
4. Anti-Inflammatory agents
5. Post-operative care including physiotherapy, occupational therapy and addressing
lifestyle issues.
410
BACK SPRAIN

John aged, 30 came to you with acute back pain.
Talk to the patient, assess him and give the further plan of management.

P: I have back pain.
D: Are you comfortable to talk?
P: Yes, I can manage.
P: In my lower back.
P: Since yesterday, I have this pain.
P: I was playing squash and after the game finished it started.
P: It was sudden.
P: It is dull pain.
D: Does the pain go anywhere? (radiation to legs)
P: No
D: Did you experience any weakness of the legs?
P: No
P: Nurse gave diclofenac. I am feeling better now.
D: How many did she give you?
P: I took 2 tablets
D: Anything else that makes it better?
P: I felt a little better when I was lying down.
P: No
D: Could you please score the pain on a scale of 1 to 10. where 1 being the low pain and 10
P: 3
D: Have you felt any numbness or tingling sensation in your legs?
P: No
D: Anything else?
411
P: No
P: No. this time I was playing squash for longer time that is why I have this pain.
D: Any swelling?
P: No
D: Any muscle spasm or cramps?
P: No
D: Any fever, flu like symptoms or cough?
P: No
D: Any history of lifting heavy weight?
P: No
D: Are you able to control your pee & woo since the pain started?
P: Yes
D: Any difficulty while passing urine or motion? (Cauda-equina)
P: No
D: Have you noticed any changes in the colour of urine & stool?
P: No
P: No
P: No
P: No
P: No
D: By any chance do you have DM, HTN or bone problem?
P: No
P: No
D: Any use of steroids?
P:
P: No
P: No
P: No
D: Do you smoke?
P: No
P: Occasionally
412
P: I eat healthy diet.
P: Yes, I am quite physically active.
P: No
P: No
I would like to check your vitals, do a GPE and examine your back, your tummy & back
passage (DRE). I would also like to do straight leg test. (SLR test) & neurological examination
of the lower limb
(NOTE: Sometimes examiner asks which examinations you want to do in this patient.)
Examination: There is pain on moving the legs & tenderness in the lumber area of the back.
There is tenderness in right paraspinal muscles.
I would like to do some investigations: x-ray lumbosacral spine
 From our assessment, we are suspecting you have a condition called sprain in your lower
back.
 Sprains and strains happen when you overstretch or twist a muscle. Not warming up
before exercising, tired muscles and playing sport are common causes.
 It might have occurred after sudden movement of the back after playing squash after a
long period of time.
 This is not a serious condition. We shall give you pain killers for your pain. The pain
should subside after few days. You can also use hot compresses: they will help you with
your pain.
 If it doesn’t subside, we will refer you to a physiotherapist. If it does not subside after
few days, please come back.
 You can start with some normal activities initially, try doing simple activities that won't
cause much of pain.
P: Will you give me physiotherapy?
D: If you have a sprain or strain that's taking longer than usual to get better, your GP may be
able to refer you to a physiotherapist.
P: When can I resume my exercise?
D: It is advisable to avoid strenuous exercise such as running for up to few weeks as there is
risk of further damage.
P: Can I play squash?
D: As I mentioned it is recommended not to play such kind of sports until your injury heals
and it will take few weeks.
Please follow up with your GP regularly.

413
If at any time you have any problem, please do come back to the hospital.
 Any problem with urine or bowel (Spinal cord compression)
 Pain radiating to your legs
 Numbness or tingling around your buttocks
 High temperature
 Any swelling in the back region
414
ABDOMINAL AORTIC ANEURYSM
You are FY2 in A&E.
Mr. Robert aged 60 has presented to you with complain of back pain for the last 1 day.
Patient has been diagnosed with HTN for last 10years.
Talk to the patient, take history, assess the patient & discuss the plan of management.
D: Hello! What brings you to the hospital today?

P: Doctor I have back pain since yesterday.
P: It was sudden
D: What were you doing when the pain started?
P: I was just sitting when the pain started
P: It is throbbing pain.
P: No
P: I take ibuprofen it didn’t help.
P: No
the
P: 7
P: No
D: Any pain or numbness in the legs?
P: No
D: Any tummy pain?
P: No
D: Any dizziness or SOB?
P: Yes/No
D: Any fever?
P: No
D: Any nausea vomiting?
P: No
D: Did you hurt yourself by any chance?
P: No
D: How are your bowel movements?
415
P: Fine
D: Any burning during micturition
P: No
D: Do you feel that you have to go to the loo more often, especially at night?
P: No
D: How’s your appetite?
P: It’s fine.
D: Have you experienced any weight loss recently?
P: No (cancer)
P: No
P: I have HTN from last 10 years.
D: How you are managing this?
P: I am taking medicine for that.
D: any DM. Heart disease or high cholesterol, kidney problem?
P: No
D: Any bone or joint problem?
P: No
D: Are you taking any medications apart from ibuprofen including OTC or supplements?
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: I eat healthy diet.
P: No Dr
P: I am working in an office
D: I would like to examine you. I’ll check your vitals, GPE, examine your back and abdomen
and back passage. We will do some initial investigation including FBC. ESR. CRP, LFT, ECG
and chest
416
X-Ray.
Examiner: Pulsating and expansile mass in the abdomen
D: From our assessment, you seem to have a condition called Abdominal Aortic Aneurysm.
We have a main artery in our abdomen called the aorta which is the main blood supply of all
organs. Sometimes it can swell up like a small balloon & causes pressure to the blood
flowing through it. That's why you’re feeling the pain in your back. The pressure of the
blood, if it becomes too much, it has a risk of bursting, which can be a life-threatening
condition.
P: Why did I get it doctor?
D: Mostly it has no identifiable cause. There are some risk factors like male sex, smoking,
increasing age. hypertension, high cholesterol, family history.
We will check your vitals & do routine blood tests.
We will do Ultrasound to assess the size of the aorta. It is used for initial assessment and
followup
We will be doing CT scan that can provide more anatomical details - eg. it can show the
visceral arteries, mural thrombus, and para-aortic inflammation. CT with contrast can show'
rupture of the aneurysm.
We may consider doing MRI angiography for more details.
Treatment depends on the size of the aneurysm:

small AAA (3cm to 4.4cm across) - ultrasound scans are recommended every year to check if
it's getting bigger; you'll be advised about healthy lifestyle changes to help stop it growing
medium AAA (4.5cm to 5.4cm) - ultrasound scans are recommended every three months to
check if it's getting bigger; you'll also be advised about healthy lifestyle changes
large AAA (5.5cm or more) - surgery to stop it getting bigger or bursting is usually
recommended
General advice:
Give general advice about Smoking, alcohol, diet, BP control physical exercise and
maintaining healthy weight.
Surgery:
There are two main types of surgery for an AAA:
1. Endovascular surgery: - the graft is inserted into a blood vessel in your groin and then
carefully passed up into the aorta
2. Open surgery - the graft is placed in the aorta through a cut in your tummy
AAA Screening:
Screening by ultrasound is feasible to allow early diagnosis. The idea is to offer a single scan
in men aged 65. If negative, this effectively rules out AAA for life.
417
ACUTE CHOLECYSTITIS

John Smith, aged 57, came to the hospital with pain in the abdomen.
Please talk to him, assess and discuss your plan of management with him and address his
concerns.

P: I am having pain (right hypochondrium)
SOCRATES
P: Radiates to shoulder
D: Anything else?
P: No
D: Any fever, N/V, loss of appetite, sweating, jaundice and abdominal mass?
P: No
P: No
P: HTN for last 10 years and taking amlodipine.
D: Any DM, heart disease or high cholesterol?
P: No
P: No
P: No
P: No
D: Has anyone in the family been diagnosed with any medical conditions?
P: No
D: Do you smoke?
P: Yes/No
P: Yes
P: I don't have much time.
P: No Dr.
Social: Living with wife
418
I would like to check your vitals, GPE and examine your abdomen.
I would like to send for some initial investigations including Routine Blood Test, kidney
function and liver function tests. I would also like to do a special test called CRP.
Examiner: Temperature: 38.5

Do abdominal examination
CRP-Very high (100)
Examination: Extremely painful in right hypochondrium
From our assessment, we are suspecting you may have a condition called acute
cholecystitis. It happens when something like a gall stone blocks the cystic duct of the gall
bladder. Gallstones are small stones, usually made of cholesterol that form in the
gallbladder. The cystic duct is the main opening of the gallbladder.
We will have to plan further investigations such as an ultrasound of the abdomen, an

abdominal x-ray and perhaps a CT and MRI scan
Management:
We will have to keep you in the hospital for observation. During this time, we will have to
discontinue food and water by mouth. Instead, we will be giving IV fluids, painkillers and
antibiotics.
After the initial treatment, we will be discussing with the senior doctor and may need a
surgery referral.
1. NPO
2. IV fluids
3. Painkiller
4. Antibiotics if needed
5. Surgery Referral (cholecystectomy can be planned after initial treatment)
CAUSES
1. Gallstones
2. Bile duct block (kinking of tumour)
3. Infections
4. Alcohol
419
DIVERTICULITIS
You are FY2 in A&E.

Aleena aged, 42 female came with lower abdominal pain. Nurse has taken the vitals and
sent patient to you.
Talk to patient. Do examination. Discuss about management plan with patient.

P: I have pain here. (Pointing towards LIF)
P: What you want to know?
P: 2 days ago.
P: Nothing. I was just sitting & it just started.
P: Initially on and off but now always there.
P: It is just painful.
P: No
P: No. I took some PCM, didn’t help that much.
P: No
D: Could you please score the pain on a scale of 1 to 10, where 1 being the low pain and 10
P: 7-8.
P: I feel hot these days.
D: Since when?
P: From last 2 days.
D: Did you measure the temperature?
P: No
P: I feel sick.
D: Since when?
P: Since yesterday.
D: Did you vomit?
P: No
D: Anything else?
P: I have constipation.
420
D: Since when?
P: From last 2 days.
D: Are you passing wind?
P: Yes.
D: When did you pass last time?
P: This morning.
D: How was your bowel habit before?
P: Fine.
D: Anything else?
P: No
D: Do you have any bloating?
P: No
D: Do you feel that pain increases after eating?
P: No
D: Any bleeding PR?
P: No
D: Does emptying the bowel or passing urine eases your pain?
P: Yes/No
D: Do you have any burning micturition?
P: No
D: Any cloudy or smelly urine?
P: No
D: Any discharge from your front passage? (PID)
P: No
P: No
P: No
D: Any bowel disease such as IBD/Polyp?
P: No
P: No
D: Any pain killer or codeine?
P: No
P: No
P: No
P: It is fine
D: Do you take enough fiber diet?
P: Yes
421
D: Do you take enough water?
P: Yes
D: When was your Last Menstrual Period? (Ectopic)
P: 3/52
D: Are they regular?
P: Yes
D: Any bleeding between the periods?
P: No
P: Yes
P: Yes
I would like to check your Vitals and examine your tummy.
EX: T-38-39C PR- 110/min BP- 130/80 RR- 12-20 O2 sat – 96%
Exposure
Chaperone
Being gentle
Consent
Make the couch flat, if it’ s not already flat.
Left Iliac Fossa pain on both superficial and deep palpations.
Note: During abdomen examination, on superficial tenderness there is marked tenderness
on suprapubic and LIF. so you won’ t be able to do deep.
P: What is going on with me?
 D: From our assessment you have some problem with your bowel.
 we are suspecting a condition called “diverticulitis” which affects your large bowel. In
this disease, small bulges or packets (diverticula) develop in the lining of the intestine.
Diverticulitis is when these packets become inflamed or infected.
 In order to give you the best treatment we need to keep you in the hospital to monitor
you and do some further investigations to make sure everything is fine with you.
 We will do some blood tests. We will consider doing X-ray of your chest and tummy, and
ultrasound of your tummy.
 We may consider doing a CT scan.
 We will give you a painkiller such as paracetamol for pain.
 We will also give you some anti-sickness medication for your sickness.
 We may need to give you some fluids through your blood vessels as drip.
 I will discuss with my senior and we might need to give you some broad-spectrum
antibiotics (usually co-amoxiclav) (If Penicillin allergy- consider ciprofloxacin and
metronidazole).
422
 We will also prescribe some laxative, to relieve the constipation.
 Depending on your investigation results you may need to be seen by our surgical
department.
 They may consider some further investigations if needed. We recommend you drink
plenty' of clear fluids.
 It is advisable to have high fibre diet including fresh fruits and vegetables.
DD:
Diverticulitis
Diverticulosis
Ectopic pregnancy
Appendicitis
PID
IBD
423
POST OP WOUND INF.
You are F2 in A&E.

Mr. Albert Green, aged 50, presented to hospital with pain and swelling in the site of his
operation. He had an open operation for his right inguinal hernia three weeks ago, which
was a day care surgery. The nurse told you that the patient is angry.
Please talk to the patient, assess the patient, discuss about management with him and
address his concerns.
Post-surgical infection rate in this hospital is within the national guidelines.

P: I had an operation for my hernia three weeks ago but I have pain and swelling here
(showing the site of operation)
SOCRATES
P: I have discharge from the wound.
D: When did you notice?
P: A few days back.
D: What was the colour?
P: Yellow colour
D: Any pus
P: No
D: Any bleeding?
P: No
D: Any redness?
P: No
D: Anything else?
P: No
P: No
D: Any nausea, vomiting?
P: No
D: Any cough?
P: Yes Dr. sometimes.
D: Any reason of cough?
P: May be because of my smoking.
D: How is your bowel habits? Any diarrhea or constipation?
P: It is fine.
P: No
P:No
424
D: How did your operation go three weeks ago?
P: Doctor, it went well.
D: Have you been told how to look after your wound?
P: Yes. they told me to remove the dressing after a few days and they told me to clean and dry
the wound with towel after having a shower.
D: Did you follow what you have been told?
P: Oh yes doctor.
D: You mentioned about smoking. How much do you smoke?
P: 1 packet a day.
P: No
P: Fine
D: May I know what do you do for living?
P: I work in a building construction company.
D: Does your job involve any physical exercise or heavy lifting?
P: Oh yes doctor.
D: Did you start working after your operation?
P: I started working a week after I was discharged from the hospital. I went to office and they
gave me office work.
I would like to check your vitals and examine your wound.

There is a picture showing swelling and discharge from the wound site.
From my assessment, it seems like you have a wound infection, which is a complication of
surgery.
P: Why did I have it
D: That can be because of many things.
 One reason can be smoking, because smoking decreases the level of immunity, decreases
healing power and this can delay wound healing and cause infection.
 Coughing can put some strain on the site of the incision and may also be the cause of
wound infection.
 And you started working a week after your procedure. Any physical activity after the
operation can also put strain on the site of incision and lead to poor wound healing and
infection. But don’t worry whatever is the reason treatment will be the same.
P: Doctor is it possible to catch this bug from the hospital?
D: There are very little chances because it was a day care surgery so you didn’t stay
overnight and you developed the infection 3 weeks after the operation. If it was because of
surgery, you may have got it earlier.
P: Doctor is it happening a lot in your hospital?
D: Actually the rate of infection after operations in our hospital is within the national
guidelines. This means it is not happening a lot in the hospital.
425
P: Ok doctor what are you going to do for me?
D: On examination there was some swelling and discharge because of the wound infection.
We will keep you in the hospital and we will do some routine blood test to see the level of
infection in your blood and we will also take swab sample from the wound and send it to
the lab to find out which bug is causing the infection. We will give you painkillers and IV
antibiotics and we need to clean the wound and do proper dressing.
P: I have to work. Who will look after my wife and kids?
D: If you don't receive proper treatment your infection may persist and this can further
delay your return to work. If you have a concern about your job. we can provide you with a
medical certificate. You can give it to your employer and you will be paid during the time
you have to rest because of your operation.
If patient says that I am self-employed then answer your health comes first. If you don’t stay
in the hospital to complete your treatment, your infection cannot be properly treated and
this can further delay your return to work.”
P: Doctor I want to complain. I am not happy.
D: I totally understand your frustration. As I explained to you. wound infection is one of the
complications of surgery and I am sure my colleagues in surgery department must have
explained to you all possible complications of the surgery.
P: Doctor, I don’t want this to happen to anyone else.
D: I really appreciate your concern about other people. Like I said, wound infection is one of
complications of surgery. However, my colleagues in surgery department can discuss about
your case in the Monthly Meeting in order to improve the quality of service we provide to
our patients and minimise the risk of such adverse events.
P: What is this meeting?
D: This is a monthly meeting, which is attended by our consultant surgeons and other
surgical staff. These meeting are used to learn from clinical outcomes such as yours so we
can learn why this happened, and implement what we learn to drive improvement in our
service delivery to the patients wherever it is needed.
In this meeting, a brief clinical history' of the patient such as the age, any existing medical
conditions, previous investigations, the diagnosis, the decisions taken, details of procedures,
and details of adverse outcomes will be discussed without disclosing the patient’s name. In
this meeting, the team will have a thorough discussion on the incident that occurred and
they explore any factors that may have contributed to the outcome. That will help us to
improve the service provided to our patients.
P: I am still not happy. I want to complain.
D: No problem at all. That’s your right to make a complaint if you wish to. What I can do is I
can get you in touch with PALS service and it is a service where you can make formal
complaints if you strongly feel that your care is compromised. They will look into detail of it.
426
INTESTINAL OBSTRUCTION
You are FY2 in emergency department

Mr. Peter Smith presented with abdominal pain for the past 2 days.
Talk to him , take history , and manage him accordingly.
D: Hi my name is Dr. Khalil I am one of the junior doctors in this EMERGENCY department
can you please confirm me your name and age please
P: yes dr my name is peter smith I am 30 years old
P: peter Is fine dr
D: ok peter, What brought you here today?
P: I am having pain in my abdomen .
P: It's been happening for the last couple of days and is colicky pain .
SOCRATES
D: Site of pain ?
P: generalized pain in whole abdomen
D: Anything which makes the pain better ?
P: No
D: Is there anything else which makes it worse
P: Dr. its getting worse by its own.
D: Is it radiating some where?
P: no its in my abdomen only.
D: scale your pain 0 to 10
P: 4 or 5 Dr.
D: How are you managing It?
P: I have been taking Ibuprofen for it but its not working .
D: anything else ?
P: I am also having vomiting
FODPARA
D: when it started ?
P: it started one day after the pain in my abdomen
D: how many times per day ?
What is the content of your vomit?
Any blood in vomit? (NSAIDS)
P: 4 to 5 times per day
D: anything making it better
P: no doctor
D: anything making it worse
P: Its getting worse dr.
D: anything else
427
P: like what dr
D: nausea?
P: no
D: have you passed stools?
P: I haven’t since last few days
When was the last time you passed stools?
D: have you pass wind?
P: no doctor since last day .
How were your bowel habits before this problem? (IBD)
Did you notice any bloating, fullness in your tummy before?
D: fever and flu like symptoms? ( intra abdominal infections )
P: no doctor
D: Loss of weight?
P: no
D: loss of appetite? ( cancer )
P: no
D: lumps and bumps in the body ?
P: No doctor.
Have you noticed any bleeding from your back passage?
D: weather preference , weight gain ( hypothyroidism )
D: Any past history of surgical procedures in your abdomen ? ( adhesion )
P: no doctor
D: rule out IBD as it can lead to narrowing and finally obstruction .
MAFTOSA
D: any past medical history of chronic illness like DM, PERIPHERAL VASCULAR DISEASE ,
P: NO
D: are you taking any medications ? TCA , ANTI DEPRESSANT
( risk factor )
P: no
D: allergic to medications ?
P: no
D: Family history of dvt
P: no
D: are you smoking alcohol ?
P: Yes doctor , 20 cigarettes for the last 10 years
D: are you taking alcohol ?
P: yes dr I am taking alcohol 10 pints for the last 5 years
D: hows your diet ?
P: I am taking a lot of meat in my diet ( less fiber diet ) ( risk factor for constipation )
D: Physical activity ?
P : not that active .
D: Anything else that you would like to share with us
428
P: That’s it doctor .
D: Do you have any IDEA whats going on with you ?
No doctor .
I would like to check your bp, pulse, RR, temperature , GPE and we will also be doing some
blood tests like FBC, U&Es and creatinine as well as a plain abdominal x-ray. We may plan an
MRI, ultrasound and CT scan if needed.
I would also like to examine your abdomen .
We will also check for blood group and crossmatch in case major surgery is required
Examiner findings Distended abdomen, tympanic sound on the percussion of the abdomen
due to an air-filled stomach and high-pitched bowel sounds
From our assessment, we are suspecting you may have a condition called intestinal
obstruction. It happens when something blocks your bowels, either your large or small
intestine.
Treatment
1. Uncomplicated obstruction: Management is conservative, including passing an NG
tube, fluid resuscitation and monitoring fluid input/output, electrolyte replacement,
intestinal decompression and bowel rest.
2. When gastrointestinal obstruction results in ischaemia, perforation or peritonitis,
then emergency surgery is required. Laparotomy may be required.
In view of the risk of perforation and absorption of toxins from ischaemic bowel,
prophylactic antibiotics for gut surgery are advised.
D: Do you have any idea of intestinal obstruction ? P: No An intestinal obstruction occurs

when your small or large intestine is blocked. The blockage can be partial or total, and it
prevents passage of fluids and digested food. If intestinal obstruction happens, food, fluids,
gastric acids, and gas build up behind the site of the blockage. D: I would like to inform my
seniors and we will ADMIT YOU IN THE HOSPITAL Is that okay ?
D: they may consider doing an X RAY ABDOMEN and ULTRASOUND ABDOMEN and CT SCAN
to confirm the diagnosis. P: What are the RISK FACTORS for intestinal obstruction ? D: May
be due to adhesions. strangulated hernia malignancy or volvulus. The majority (75%) of
small bowel obstructions are attributed to intra-abdominal adhesions from prior operations.
Malignancy usually means a tumor of the caecum, as small bowel malignancies are P: How
are you going to treat me now?
TREATMENT
I would like to give you some pain killers
I will also inform my seniors to further assess you .
Uncomplicated obstruction management is conservative including
• fluid resuscitation
429
• electrolyte replacement
• intestinal decompression
• bowel rest.
Complicated obstruction
Surgery can be done in complicated cases to relieve the obstruction
Red flags
Severe unbearable pain
Unconsciousness
Dizziness -Inform the nurses and let us know .
Further information about the operation

In some cases, an operation can be performed to unblock the bowel. This may involve bowel
resection, adhesiolysis (release of adhesions)bypass procedure and/or stoma formation.
Surgeons may remove the affected part of the bowel and suture (join) the two ends
together. If it is not possible to connect the two ends together, they will bring out the end of
the bowel through an incision in the abdomen and a stoma bag will collect your stool.
Stents Self-expanding metal stents (SEMS) are metallic tubes (or stents) used to hold open
the bowel if it is obstructed by a tumor so that stools can pass through. 3 They can provide
rapid relief of distressing symptoms in patients not considered fit for surgery, or for those
who have symptoms of bowel obstruction which need to be treated urgently.
430
NECK LUMP
You are FY2 in GP.

Mr. William Harding, aged 35, has come to you with a neck swelling.
D: How can I help?

P: I have noticed swelling on my neck.
P: This morning.
P: On my right side of the neck
D: What is the size of the swelling?
P: Like a coin
D: Has the swelling increased in size?
P: No
D: Does it feel warm when you touch it?
P: No
D: Did you hurt yourself?
P: No
D: Does the swelling go away if you press it?
P: No
D: Is it painful?
P: No
D: Is the swelling moving on deglutition or tongue protrusion?
P: Yes/No
D: Any discharge?
P: No
D: Have you got any idea how the swelling started?
P: No
P: No
D: Anything else?
P: No
P: No
D: Any night sweats (TB)
P: No
P: No
431
P: Good
P: No
P: No
P: Yes
P: Yes, my partner uses condoms
P: No
P: No
P: No
P: No
D: Has anyone else in the family been diagnosed with any medical condition?
P: Dad died because of cancer.
D: Do you smoke?
P: Yes/No
P: yes/No
P: Yes/No
I would like to check your vitals, do GPE and examine your neck.
Examiner:
Swelling is 1x1 cm, hard and fixed.
Swollen glands are usually caused by common illnesses like cold, ear or throat problems. In
some cases, it could be serious as well. You have told us that your father died because of
cancer, so we suspect your condition could be a serious one as your swelling is hard and
fixed.
We need to do further investigations to make sure what exactly is going on. We need to do
more blood tests and refer you to a specialist. The specialist and a team of doctors
432
(multidisciplinary team) will do the necessary tests and confirm the diagnosis and start
treatment depending upon the condition. We will refer you to the specialist in 2 weeks'
time. They may consider doing a biopsy of swollen gland and other investigations.
If it is cancer, then the treatment depends not only on the type, size, position and stage of
cancer and also your overall health. We have surgical options for resection of some
tumours. But in some cases, we have to give chemotherapy and radiotherapy to extend the
quality of life.
Management (refer to specialist)

- Your swollen glands are getting bigger, or they have not gone down within 2 weeks
- They feel hard or do not move when you press them
- You're having night sweats or have a very high temperature (you feel hot and shivery) for
more than 3 or 4 days
- You have swollen glands and no other signs of illness or infection
- You have swollen lymph glands just above or below your collarbone (the bone that runs
from your breastbone to each of your shoulders)
DDs
Infections
Cancers
Autoimmune conditions
433
VARICOSE VEINS
You are FY2 in GP.

Mrs. Amelia Arden, aged 42, has come to you with painful swelling in both of her legs.
Talk to her about her symptoms and explain to her the treatment options.

P: I have painful swelling in both of my legs.
P: A few weeks ago.
D: Is it painful?
P: Yes
D: Is it getting better or worse?
P: Worse
D: Is there anything making it better?
P: No
P: No
D: Can you score the pain on a scale of 1 to 10, with 1 being the least painful and 10 being
the most painful?
P: 6
D: What were you doing when your pain started?
P: I was at work
D: What do you do for work?
P: I work as a hairstylist
D: Does it involve you standing for long periods?
P: Yes, around 8 hours daily.
D: Anything else?
P: No
D: Any muscle cramps in your legs?
P: No
D: Any burning or throbbing sensation in your legs?
P: No
D: Any bluish discoloration?
P: Yes/No
D: Do you have any pain in the calf? (DVT)
P: No
P: No
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P: No
P: No
P: No
P: Yes, my older sister had the same condition after gave birth a few years ago, she had to get
a surgery to treat it.
D: Do you smoke?
P: Yes/No
P: yes/No
P: Yes/No
P: No
(Mood scale, depressed, low self esteem)
D: Have you ever been pregnant?
P: Yes, I just had a baby 4 months ago.
D: Did you notice any swelling in your legs during pregnancy?
P: Yes, I had swollen ankles during the third trimester of my pregnancy, along with cramps in
my leg muscles.
I would like to check your vitals, do GPE and examine your legs. I would also like to run
some routine blood tests like kidney and liver function tests, as well as duplex ultrasound.,
clotting profile, D-dimer.
From my assessment, I suspect that you may have a condition known as varicose veins,
which is quite common in occupations like yours. It can be managed easily, with a few
lifestyle changes and basic management options.
Management
 Using compression stockings

 Exercising regularly
 Avoiding standing up for long periods
 Elevating the affected area when resting
 Endothermal ablation (high-frequency waves that seal the vessel)
 Radiofrequency ablation (heating the wall of your varicose veins)
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 Endovenous laser
 Sclerotherapy
 Surgery (ligation and stripping)
In mild cases, it can be easily manageable, with basic lifestyle alterations like eating healthy,
losing excess weight as being overweight contributes significantly to its formation.
Exercising regularly and avoiding long periods where you are on your feet is crucial. It is
advisable to think about a profession where you would not be required to stand for long
period.
Using compression stockings will reduce your discomfort and pain, as it will help the
swelling to go down. Furthermore, whenever you rest, elevate your legs to further reduce
the swelling.
However, if the swelling persists, we may need to go for ablation of the veins. Endovenous
ablation is a simple non-surgical procedure, which involves inserting a needle and wire into
the vein, heating and closing off the affected vein, which helps with symptoms like swelling,
pain and irritation. You can return to your normal activities within a week, taking care to
avoid strenuous exercise, heavy lifting and extreme sports activities.
An alternative solution to varicose veins would be to treat it with sclerotherapy, which is

another minimally invasive procedure. It involves the insertion of a saline solution into the
vein, which causes the vein to become irritated and collapse, causing the swelling to go
down.
In severe cases, the condition requires surgery, using ligation and stripping of the affected
veins. It is performed under general anaesthesia, which means you will be asleep during the
process. However, NHS only covers surgery when it is a requirement, and not for cosmetic
purposes.
When to refer to a vascular specialist.

 Varicose veins that are causing pain, aching, discomfort, swelling, heaviness or itching
 Changes in the colour of the skin on your leg that may be caused by problems with the
blood flow in the leg.
 Skin conditions affecting your leg, such as eczema, that may be caused by problems with
the blood flow in the leg.
 Hard and painful varicose veins that may be caused by problems with the blood flow in
the leg.
 A healed or unhealed leg ulcer (a break in the skin that has not healed within 2 weeks)
below the knee
436
(Skin colored compression stockings)
DDs
Peripheral Arterial Disease
Cellulitis
Thrombophlebitis
DVT
437
HYDROCELE

Dr. Daniel Finnish, aged 23, came to the GP surgery with testicular discomfort.
Talk to him, assess him and address his concerns.
D: How can I help?

P: I have discomfort in my testis
D: Can you tell me more?
P: It’s on my right side
D: What do you mean by discomfort?
P: I feel like there’s a heaviness present.
D: Since when?
P: 1 week
D: Does it come and go?
P: It’s always there now.
P: No
P: No
P: Like what?
D: Any pain?
P: No
D: Any discharge?
P: No
D: Any fever?
P: No
D: Any mass in the testis?
P: No
D: Any lumps or bumps?
P: No
D: Any weight loss?
P: No
P: No
P: No
D: Are you taking any medications including OTC or herbal supplements?
P: No
P: No
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P: No
D: Any blood transfusion in the past?
P: No
D: Has anyone in the family been diagnosed with any medical condtion?
P: Yes/No
D: Do you smoke?
P: Yes/No
P: No
D: Do you take any recreational drug?
P: No
P: It is ok
P: Yes/No
P: Student
P: Yes
P: No
Preparation and introduction:

1. Identify and Explain procedure
2. Explain the purpose of the examination
3. Explain that it will involve undressing fully from the abdomen to the thighs.
4. Gain consent and offer a chaperone.
Inspection:
Inspection of Genital region and the surrounding areas (penis, groin & lower abdomen)
What causes hydroceles (fluid filled sac in the scrotum)

Causes of hydrocele:
1. Idiopathic
2. Infection
3. Inflammation
4. Trauma
5. Tumours
Tests
439
1. Transillumination test.
2. Fluid may be drained with a needle and syringe to examine testes more easily.
3. Ultrasound scan
Treatment:
1. Leaving it alone is an option
2. Surgery: Surgery may be recommended if your hydrocele is large or uncomfortable. The
operation for a hydrocele involves making a very small cut in the scrotum or lower tummy
(abdominal wall). The fluid is then drained from around the testicle (testis).
This is a minor operation and is performed as a day case, so does not usually involve an
overnight stay in the hospital. A hydrocele may return after surgery but this is very
uncommon.
3. Drainage. The fluid can be drained easily with a needle and syringe. However, following this
procedure, it is common for the sac of the hydrocele to refill with fluid within a few months.
Draining every now and then may be suitable though, if you are not fit for surgery or if you do
not want an operation.
4. Sclerotherapy: Sclerotherapy is the injection of a solution to stop the hydrocele recurring
after having it drained. This is not commonly undertaken but may be offered to some people
who are not suitable to have an operation.
440
EPIDIDYMO-ORCHITIS
You are FY2 in GP.

Mr. Daniel White, aged 23, came to the GP surgery with testicular pain.
D: How can I help?

P: I have pain in my testis.
P: It’s on my right side.
D: Since when?
P: 2 days.
D: What kind of pain is it?
P: Dull
D: Does it radiate anywhere?
P: No
P: No
P: Its painful.
D: Can you rate it on a scale of 1 to 10?
P: 6
P: Like what?
D: Any fever?
P: Yes
D: Since when?
P: 2 days
D: Did you take anything to relieve it?
P: PCM, but didn’t help
D: Any pain?
P: No
D: Any discharge?
P: No
D: Any mass in the testis?
P: No
D: Any lumps or bumps?
P: No
D: Any weight loss?
P: No
D: Any recent infection or swelling of facial glands?
P: No
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P: No
P: No
P: No
P: No
P: No
P: No
P: Yes/No
D: Do you smoke?
P: Yes/No
P: No
P: No
P: It is ok
P: Yes/No
P: Student
P: Yes
P: Yes
D: Since when?
P: 1 year
D: Do you practice safe sex? Do you use condoms?
P: No
D: Do you have a stable partner?
P: No
D: Any recent partner?
P: Yes
P: Normal
Preparation and introduction:

442
1. Identify and Explain procedure
2. Explain the purpose of the examination
3. Explain that it will involve undressing fully from the abdomen to the thighs.
4. Gain consent and offer a chaperone.
Inspection:
Inspection of Genital region and the surrounding areas (penis, groin & lower abdomen)
There are no skin changes (rash, bruising, erythema, swelling), scars and any obvious masses.
Inspection of the scrotum: Ask the patient to hold their penis out of the way to allow easier
inspection of the scrotum. Inspect the scrotum from the front and posterior sides.
There are normal scrotal rugosities, no skin changes, scar, obvious masses, swelling, sinuses
and necrotic tissue. I don’t see any scar mark, any discharge.
Palpation:
Temperature: compare both the testicles with the thigh.
Phren’s Test: If testicular pain is relieved by elevating the testes, this is suggestive of
epididymitis.
Testicular torsion (if pain is not relieved)
Palpation: (Palpate with thumb and index finger)

Superficial: check for tenderness in both the testicles.
Deep: palpate for spermatic cord, epididymis
Feel for any mass (site, size, shape, surface, consistency, contour, tenderness, mobile,
attached to underlying structure or not)
Special Tests
Cough Impulse:
Presence of cough impulse suggests hernia/varicocele.
Fluctuation Test:
Cystic, fluid filled masses fluctuate. Fluctuation is elicited by holding the mass firmly with
thumb and two fingers of both hands. Firmly press the mass with one finger while observing
for displacement of the other finger.
Transillumination Test:
Place a pen torch behind the scrotal swelling (trans-illumination suggests the mass is fluid
where there will be red glow-hydrocele)
443
Cremasteric Reflex:
Stroke the patient’s medial thigh which leads to stimulation to cremaster reflex and elevate
the testicles (loss of cremaster reflex may suggest testicular torsion)
Aetiology of epididymo-orchitis:
 Sexually transmitted pathogen – e.g. chlamydia trachomatis and Neisseria gonorrheae.
 Specific factors include recent instrumentation or catheterisation.
 However, there is an overlap between these groups and a thorough sexual history is
imperative for all age groups.
 Mumps should be considered as an aetiology since the epidemic in 2005.
 Extrapulmonary TB
Aetiology of acute orchitis

 Viral: Mumps orchitis is most common. Coxsackie A, varicella and echoviral infections are
rare.
 Bacterial and pyogenic infections: E. coli, Klebsiella, Pseudomonas, Staphylococcus and
Streptococcus species are unusual.
 Granulomatous: syphilis, TB, leprosy, Actinomyces spp. And fungal diseases are rare
 Trauma
 Idiopathic
Symptoms and signs:

 Unilateral scrotal pain
 Fever
 Erythema and swelling in the scrotum
 Urethritis or a history of UTI
 Mumps usually presents with headache, fever and unilateral or bilateral parotid swelling
but may present with epididymitis. Scrotal involvement occurs without systemic
symptoms.
Examination: Groin and rectal examination

Investigations
 Urine dip
 STI screening
 Consider HIV testing
 Colour Doppler ultrasound
 R/O TB (sputum AFB, CXR)
 Mumps IgM/IgG serology
Treatment for epididymitis

If you have an infection, you’ll usually be given antibiotics.
444
Do
 Take painkillers
 Hold a cold pack (or a bag of frozen peas wrapped in a tea towel) on your groin.
 Wear underwear that supports your scrotum.
445
UROLOGY STATIONS
HAEMATURIA
You are F2 in GP.

Mr. Zimmerman, aged 57, presented to the clinic with haematuria.
Please take history, assess the patient and discuss management plan with the patient.

P: I have noticed blood in my urine.
P: From last 2 weeks I had 4 episodes.
D: When did you have each episode?
P: First time 2 weeks back, then 1 week back, 3 days back and it happened yesterday.
D: How much blood did you notice?
P: I don’t know Dr. as it was mixed with blood.
D: Any clots in blood?
P: No
D: Any change in blood since it started coming?
P: Yes nowadays I am noticing more blood in my urine.
D: Any pain while passing urine? (Painless hematuria)
P: No
P: No
P: No
D: Any changes in your urine colour or smell?
P: No
D: Are you going to loo more often these days?
P: Yes/No
P: Yes/No (Nocturia)
P: Yes/No (Urgency)
P: No
P: No doctor.
D: Any of your friends or family told you that you are losing weight?
P: No
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P: It’s fine doctor.
P: No
D: Any pain in your pelvic area?
P: No.
D: Any bony pain?
P: No
P: Yes
P: No
D: Any diabetes, high blood pressure, high cholesterol or heart disease?
P: No
P: No
P: No
D: Any chemo or radiotherapy?
P: No
P: No
P: No
P: No
P: No
P: No
D: Any bladder problems in the family?
P: No
P: Yes/No
P: Active
D: May I know what do you for a living?
P: I work in office.
D: Have you ever worked in aniline, Dyes, textiles, rubber, plastic or paint industries in the
past?
P: No
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D: Have you travelled overseas recently?
P: No(Schistosomiasis)
D: I would like to check your vitals and examine your tummy and your back passage.
D I would like to send for some initial investigations including routine blood test and urine
dip.
EX: prostate is slightly enlarged and is smooth in surface and consistency.
In urine dip +++ hematuria
 From our assessment, you seem to have a problem in your bladder and prostrate (if
prostate findings positive).
 The symptoms which you presented with look like you could have a serious condition.
 It looks like cancer but it is very difficult for us to confirm this at this stage before doing
all the tests.
 We need to do further investigations to make sure what exactly is going on.
 We will do further blood tests to check if you have anaemia. We need to do urine tests to
see if there is any bug or any abnormal cells.
 We need to do measure the amount of substance produced by your prostate (if prostate
findings positive).
 We will refer you to a specialist and team of doctors (multidisciplinary team) who will do
the necessary tests and confirm the diagnosis and start treatment depending upon the
condition. We will refer you to the specialist in 2 weeks’ time.
 We will do cystoscopy to have a closer look inside your bladder to see if there is any
abnormality. We may have take a sample if needed.
 We may also do a CT/MRI scan to have a clear picture.
 We need to do a scan to see if you have any obstruction in your urinary system(CT
urogram).
 A special ultra sound scan(TRUS) of your prostrate may be done to measure the size and
take sample if needed(if prostate findings positive).
D: Do you want to know how we proceed with your treatment if it is cancer?

 If it is cancer then the treatment depends upon the type, size, position and stage of
cancer and also your overall health. The main stay of the treatment would be surgical
resection of the tumour{Transurethral resection of a bladder tumour (TURBT)} or
bladder(cystectomy). Chemotherapy and radiotherapy is also offered before or after the
operation to prevent recurrence.
 In the meantime if you have any concerns before meeting the specialist, please come
back to us at any time.
 Please come back to us if your symptoms worsen or if you are not able to pass urine at
all.

448
P: What is happening doctor?
P: What can it be doctor?
DD:
Bladder cancer
UTI
Kidney stones
Enlarged prostate
Blood thinners
Instrumentation
449
HAEMATURIA BLOOD RESULTS
You are an F2 in GP. Mrs Maria Aged 62 has come to the clinic for her lab reports. She was
asked to see a doctor by the nurse. She went to well woman clinic for a regular check-up
2weeks back. A urine dip was done which showed +RBC. Another urine dip was repeated
yesterday which showed +RBC. Her blood pressure is 120/80. She was diagnosed with AF 5
years ago and is on Bisoprolol and Warfarin. Her Warfarin dose is managed according to
her INR. Her last INR is 2.0. Please talk to the patient, explain the test results and address
her concerns.

P: I have come for my test results.
D: I understand, I have your test results. Before I tell you your results, could you briefly tell
me why you got this test done?
P: I usually go for regular check-up in well women clinic. They have done my urine test and
asked me to see a doctor.
D: Did you have any symptoms that made you go to the well women clinic?
P: No, I regularly go to general health check-ups.
D: Okay, I understand that they have tested your urine 2 weeks back and also yesterday.
P: Yes.
D: Unfortunately, we found microscopic traces of blood in your urine. We call it Microscopic
Haematuria.
P: What do you mean by that?
D: This means you are passing blood in your urine which cannot be seen with human eye.
P: Why did I have this?
D: That's a very valid concern. Let me ask you few questions to see why this is happening
and to address all your concerns.
P: Okay
D: Could you please tell me how has your health been?
P:
D: Any fever?
P: No
P: No
D: Any tummy pain or discomfort?
P: No
D: Did you have any urinary problems?
P: No
P: Like what?
P: No
P: No
450
D: Any change in colour of your urine?
P: No
P: No
P: No
P: No
P: No
D: Any dizziness or shortness of breath?
P: No
D: Any blood in your stool?
P: No
D: Any bruising?
P: No
P: Yes. I was diagnosed with atrial fibrillation.
D: May I know when were you diagnosed with AF?
P: 5 years now
D: May I know how is it managed?
P: I take Bisoprolol and Warfarin
D: Are you taking them regularly?
P: Yes
D: Any missed dose?
P: No
D: Any other medical conditions DM, Heart/Kidney disease or high cholesterol?
P: No
D: Are you taking any other regular medications including OTC or supplements?
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: Good/Bad
451
P: Yes/No
P:
P:
D: I would like to examine you. Check your vitals and perform a GPE.
NEWS chart:
RR 18
Sats 99%
BP 110/80
HR 96
Temp 37.6
P: Why did I have this blood in my urine doctor?

D: From my assessment, I did not find any obvious cause for this. But do not worry we are
going to do some investigations to see why this happened.
D: There are many causes like infection or stones in your urinary system. We are going to
send urine for investigation to see if there is any infection. We may also consider doing
some scans and a procedure called cystoscopy to see inside of your bladder for any
abnormality.
P: Is this because of warfarin?
D: One of the side effects of warfarin is bleeding. But we have checked your blood tests and
your INR is with in normal range.
D: If this bleeding is not severe and not going to affect your health, then we don't have to
stop warfarin. In the meanwhile, if we find any other cause then we will treat it.
D: Please come back to the hospital if you experience any severe bleeding or any urinary
symptoms (frequency/urgency/pain).
452
STI (MALE)

Mr. Mark Jones, aged 23, has come to you with burning sensation whilst passing urine.

P: I am having burning sensation when I pee.
P: Since the last few days
D: Is it continuous or does it come and go?
P: Continuous
P: No
P: No
D: Anything else?
P: I noticed some discharge from my private area.
D: What does it look like?
P: Green
D: Does it have a foul smell?
P: Yes
P: Yes, fever
D: Any sore throat or cough
P: No
D: Any night sweats?
P: No
D: Any rash?
P: No
D: Any joint or muscle pain?
P: No
D: Any diarrhoea, nausea or vomiting?
P: No
D: Any headache or fatigue?
P: No
D: Any weight loss?
P: No
D: Any tummy ache?
453
P: No
D: Any SOB or tiredness?
P: No
P: No
P: No
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No.
P: Occasionally
P: No
P: It is okay
P: Yes/No
P: Office work
P: Yes
P: Yes
D: Since when?
P: Last 5 years
P: No
P: I have a wife
D: Any other recent partner?
P: I have another female partner.
P: Vaginal sex
454
I would like to check your vitals, GPE and your private region.
We will also do some routine blood investigations like liver and kidney function and urine
test.
From our assessment, we are suspecting you may possibly have a sexually transmitted
infection. It may happen if you have unprotected sex. To confirm this, we will screen you for
sexually transmitted infections. If you agree, we will also offer HIV screening.
If the tests show an STI, we will be giving you some antibiotics after the results are back, and
some painkillers to help ease the pain.
If tests show you have an STI, you should tell your sexual partner and ex-partner so they can
get tested and treated as well.
If you don’t want to do this, we can usually do it for you without naming you through the
clinic.
It’s important that your current sexual partner and any other recent sexual partners you
have had are also tested and treated to help stop the spread of the infection.
You should not have sex until you and your current sexual partner have finished treatment.
You are most at risk if you have a new sexual partner or do not use a barrier method of
contraception, such as a condom, when having sex.
You can help to prevent the spread of an STI by:

 Using a condom every time you have vaginal or anal sex
 Using a condom to cover the penis during oral sex
 Using a dam (a piece of thin, soft plastic or latex) to cover the female genitals during oral
sex or when rubbing female genitals together
 Not sharing sex toys
EX: Abdomen: Tenderness over suprapubic area.

Urine dipstick- Nitrites, Leucocytes and micro-haematuria.
infection.
surrounding structures and causes the symptoms like you are having.
 We did a urine test that shows you have bugs in your urine. We will send your urine
sample to find out which bug is causing your problem.
 We will give you antibiotics for now. Write it on the prescription pad (FP10 form).
 Drug of choice for UTI:
455
o Nitrofurantoin 100 mg BD days OR
o Trimethoprim 200 mg BD for 3 days
 Hopefully your symptoms will improve within few days. If your symptoms do not quickly
improve despite taking antibiotics, we may need to change your antibiotics. We may also
change your antibiotics according to the bug that caused your infection.
 Please take the medication regularly and finish the full course even if your symptoms get
better.
 Place a hot water bottle on your tummy, back or between your thighs.
 It is advisable not to do any sexual activities until your symptoms subsides.
 Take plenty of rest and drink plenty of water.
 Avoid coffee, alcohol, spicy food and smoking.
 Please wipe from front to back when you go to toilet.
 Take shower instead of bath.
 Try to fully empty your bladder when you go to pee.
 Wear loose and cotton underwear.
 If your symptoms doesn’t subside with the antibiotic therapy come back to us. If you
notice any pain on your lower back or your loin, vomiting, high grade fever or shivering,
please call 999 and ask for the ambulance or come to the hospital immediately.
 Alternative medication:
o Amoxicillin (250-1000mg QDS) usually 500mg BD.
o Oral Cephalosporin (250-1500mg QDS)
o In the BNF it says the duration of treatment is for seven days but short course is
enough in most of the cases.
 The usual antibiotics we give for UTI have some effect on the levels of folic acid. As you
told you are taking folic acid and you are planning to get pregnant. I will discuss with my
senior and prescribe you with some other antibiotics.
Side Effects:
Nitrofurantoin: Loss of appetite. Nausea and vomiting. Diarrhoea, Hypersensitivity' reaction
such as rash, difficulty breathing.
Trimethoprim: Nausea and vomiting. Diarrhoea, Rashes
Amoxicillin: Nausea & Vomiting, Diarrhoea, Rashes, Antibiotic associated colitis
P: Are you going to give me medication ?
P: What are the side effects of medication?
P: Can I have sex with my husband?
Fill the FP10 form with:

456
Name, address, Date of birth and age of the patient.
Name, dosage, route, frequency and duration of medication
Put date, your name and sign.
DD:
UTI
Pyelonephritis
Ectopic pregnancy
Appendicitis
PID
Calculi
457
UTI (FEMALE)
You are F2 in GP.

Janet aged, 27 has presented to the clinic with abdominal discomfort.
Please talk to the patient, take history, assess the patient, discuss about management and
address patient’s concerns.
Please write for her a complete prescription of appropriate medication.

P: I have tummy pain here (points towards lower tummy) from last few days
D: Tell me more about your tummy pain?
D: Was it continuous or gradual?
P: It was gradual and it is becoming worse.
P: It is dull pain.
P: No
P: Around 5 doc
P: Dr. While passing urine I have burning sensation.
P: It started with my pain and is getting worse.
P: No
D: Any fever, chills or flu like symptoms?
P: Yes Dr., I had some flu like symptoms
D: Since when?
P: From last few days.
D: How are you now?
458
D: Any changes in your urine color or smell?
P: Yes, it is smelly and cloudy these days
D: Any blood in it?
P: No
P: Yes/No
D: Do you have to go to loo more often these days?
P: Yes/No
P: Yes (Nocturnal)
P: 2-3 times.
P: Yes/No (Urgency)
D: Any loin pain?
P: No (pyelonephritis)
P: Yes/No
P: No
D: Any diabetes or passing stone in your urinary tract?
P: No
P: Yes, I am taking folic acid as I want to become pregnant.
P: No
P: No
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No.
P: Occasionally
P: 2 weeks ago.
459
P: Yes
D: Any discharge from your front passage?
P: No (PID)
Any pain during or after sex?
P: No
D: I would like to check your vitals and your tummy.

D: I would like to send for some initial investigations including routine blood tests and urine
test.

infection.
better.
460
Side Effects:

DD:
UTI
Pyelonephritis
Ectopic pregnancy
Appendicitis
PID
Calculi
461
UTI IN FEMALE (TRANSITION FEMALE TO MALE)

Miss Natalie Robbins, aged 18, has come to you with burning sensation whilst passing urine.
She is under transition from female to male.

P: I am having burning sensation
P: It started 4 days ago.
P: No.
P: No
D: Do you have any fever?
P: Yes
D: Since when?
P: Last 2 days.
D: Did you measure it?
P: 38.5
D: Did you take anything to relieve it?
P: Paracetamol
D: Any back pain?
P: No
P: No
D: Any blood in your urine?
P: No
P: No
D: Do you have any discharge from your front passage?
P: No
D: Do you have any lumps or bumps around your private parts?
P: No
D: Is this the first time you are experiencing such symptoms?
P: Yes
D: Anything else?
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P: I have lower tummy pain from last 2 days
D: Was it continuous or gradual?
P: It is dull pain.
P: No
P: Around 5 doc
P: No.
P: I have irregular menstrual periods due to PCOS.
D: Do you have any previous history of DM, renal stones, STIs or UTIs?
P: No
P: No.
P: No
P: No
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No.
P: No
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P: Occasionally
P: 2 weeks ago.
P: Yes
D: Any discharge from your front passage?
P: No (PID)
Any pain during or after sex?
P: No
D: I would like to check your vitals and your tummy.

D: I would like to send for some initial investigations including routine blood tests and urine
test.

infection.
better.
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Side Effects:

DD:
UTI
Pyelonephritis
Appendicitis
PID
Calculi
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UTI (PREGNANT)

Miss Samantha Truce, aged 30, has come to you with burning sensation whilst passing urine.
She is 29 weeks pregnant.

P: I am having burning sensation while passing urine.
D: Tell me more about this?
P: It started 4 days ago.
P: No
P: No
P: No
D: Any back pain?
P: No
P: No
P: No
P: No
P: No
P: No
P: Yes
D: Could you confirm the age of your pregnancy?
P: 29 weeks
D: Is this your first pregnancy?
P: Yes
D: How was the pregnancy confirmed?
P: Home Pregnancy Test
D: Were you using contraception?
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P: No
D: Estimated date of delivery (EDD)?
P: No
D: Can you feel the movements of your baby?
P: Yes
D: Planned method of delivery?
P: Normal
D: Medical illness during pregnancy?
P: No
D: Any medications during pregnancy such as iron or folic acid?
P: No
D: Have you attended all your antenatal check-ups?
P: Yes
D: Do you know your blood pressure at your first visit?
P: 110/70
D: Have you gotten any scans done?
P: Yes
D: Do you have twins in your pregnancy?
P: No
D: How has your pregnancy been so far?
P: Fine
D: Did you develop any complications?
P: No
D: Have you got any symptoms now?
P: No
D: Do you feel sick? Any vomiting?
P: No
D: Any tummy pain?
P: No
D: Vaginal bleeding?
P: No
D: Do you feel tired? (anaemia)
P: No
D: Any headache/visual changes/swelling of feet, ankles or face? (pre-eclampsia)
P: No
D: Fever or flu like symptoms?
P: No
P: No
D: Any high blood pressure, diabetes or kidney problems?
P: No
D: Are you currently taking any regular medications including OTC or supplements?
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P: No
P: No
P: No
P: No
D: Did your mother or sister have any complications during their pregnancies?
P: No
D: Do you smoke?
P: No.
P: No
P: No
P: Office job
D: May I know whom do you live with?
P: My partner
I would like to check your vitals including blood pressure and do antenatal examination. I
would like to send for some initial investigations including routine blood tests and urine
test.
EX: Nitrates and leukocytes positive
 From our assessment, we are suspecting you have a urinary tract infection. Urinary tract
infections (UTIs) affect your urinary tract, including your bladder (cystitis), urethra
(urethritis) or kidneys (kidney infection)
 This could be due to multiple reasons like pregnancy, unprotected sex and not
maintaining proper hygiene. Sometimes, this can also be due to the structure of your
urinary tract or some medical problems like renal stones.
 We will have to give you antibiotics to clear the infection and will also give some pain
killers to manage your symptoms.
 Please drink plenty of water so you pass pale urine regularly during the day, especially
during hot weather
 It may also help to avoid having sex until you feel better
 You cannot pass a UTI on to your partner, but sex may be uncomfortable
 In the meanwhile, please do let us know if you have any symptoms like severe loin/back
pain with fever, chills and rigors.
Patient concerns:
Will these medications harm my baby.
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RECURRENT UTI
You are an F2 in GP Gen. Med.

Sandra aged 24 years has history of dysuria 2 weeks. Her urine culture was negative. She
was prescribed Trimethoprim and her symptoms did not subside. She went her GP and was
prescribed with Nitrofurantoin for another week. Her urine culture is negative. Her dysuria
has still not resolved.
Talk to the patient, assess her and address her concerns.

P: My symptoms are not resolved.
D: May I know what symptoms you have?
P: I have pain while urinating and lower tummy pain.
D: Could you please tell me more about your symptoms?
P: I had an UTI 2 weeks back and I have symptoms since then.
D: What did you do for your UTI?
P: I went to a GP and he prescribed me antibiotics for 2 weeks.
D: Did you take them regularly?
P: Yes, I completed the course.
D: Is there any improvement in your symptoms?
P: No, it didn't subside at all.
D: Every time you pass urine, is there pain?
P: Yes
D: Where exactly is your tummy pain?
P: It is around my lower tummy.
D: Is it continuous or intermittent?
D: Could you describe this pain for me?
P: No
D: Could you score the pain for me on a scale of 1-10?
P: It is around 4-5
P: Yes, I am going to the loo more often these days.
D: How many times?
P: 4 to 5 times.
D: And during the night?
P: Yes, I am going to the loo during night time as well.
P: No
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P: No
D: Any back pain?
P: No
P: No
P: No
P: No
P: No
P: No
P: Yes
D: Have you been diagnosed with any other medical conditions in the past?
P: No
D: Do you have any previous history of DM. renal stones, STIs or UTIs?
P: No
P: No
P: No
P: No
P: No
P: 3 weeks back.
P: Yes
P: Yes
P: Yes
P: Yes / No
D: What routes of sex do you practice?
P: Vaginal and oral.
D: Does your partner have similar symptoms?
P: No
D: Do you wear tight under wears or tight clothes?
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P: No
D: When you go to the loo. do you wipe from front to back or back to front?
P:
D: Do you smoke?
P: Yes/No
P: Yes/No
D: What do you drink?
P: Beer
D: How often and how much?
P: Occasionally
P: I try to have a balanced diet.
P: I am a student.
P: With my partner
I would like to check your vitals and examine your tummy.

I would like to send for some initial investigations like routine blood tests including Renal
function (U&E’s) and urine test.
D: Do you have any idea what is going on?

P: No
P: No
 From my assessment. I suspect you have repeated UTIs. This could be due to multiple
reasons like under treated UTIs. recurrent source of infection like unprotected sex and
not maintaining proper hygiene. Sometimes this can also be due to the structure of your
urinary tract or some medical problems like renal stones.
 Repeated or untreated UTIs can cause complications. We will have to give you antibiotics
through your veins to clear the infection. We will have to do a scan of your urinary
system to see if there is any abnormality or stones. We may consider giving you
prophylactic antibiotics to prevent recurrent infections.
 Please drink plenty of water.
 Maintaining proper hygiene is very important including while having sexual intercourse
and also wiping front to back after the loo.
 In the meanwhile, please do let us know if you have any symptoms like severe loin/back
pain with fever, chills and rigors.
PATIENT'S CONCERNS
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P: Dr., what’s going on?
P: Why do I have recurrent UTIs?
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PT WITH LYMPHADENOPATHY (STI)
You are FY2 in General practice.

A 23 year old male is coming with some complaints.
Address them and discuss further management.
Dr: Hello, my name is Dr. XYZ. I am one of the junior doctors in GP clinic. How can I help
you?
Pt: I felt some swellings/lumps in my groin area.
Dr: I am sorry to hear about that. Please tell me more about it.
Pt: Like what doc?
Dr: From how long are you having these swellings?
Pt: From last 2 weeks
Dr: How many swellings are there in groin area?
Pt: Around 2 to 3
Dr: Swellings on any other part of the body?
Pt: No
Dr: Do you any idea how did it happened?
Pt: No
Dr: Are these swellings painful or itchy?
Pt: No
Dr: Any discharge through penis?
Pt: No
Dr: Any burning sensation while passing urine?
Pt: No
Dr: Any fever?
Pt: No
Dr: Any rashes over the body?
Pt: No
Dr: Any weight loss?
Pt: No
Dr: Is it the first time it is happening to you?
Pt: Yes
Pt: No
Pt: No
Dr: Any allergies?
Pt: No
Take sexual history:
Dr: Are you sexually active?
Pt: Yes
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Dr: Do you have stable partner?
Pt: No
Dr: Do you practice safe sex?
Pt: Sometimes
Dr: What is your sexual preference?
Pt: I am bisexual
Dr: What route of sex do you prefer?
Pt: Mostly anal
Dr: Is any of your partners having similar symptoms?
Pt: I don’t know
Dr: Have you ever been diagnosed with STI?
Pt: No
Dr: Did you travel anywhere recently?
Pt: Yes, I travelled to Thailand
Dr: When did you travel?
Pt:3 weeks ago
Dr: What did you do there?
Pt: I had sex with my partner
Dr: Was it protected?
Pt: No
Pt: I am a student
Dr: Do you have tattoos?
Pt: No
Dr: Do you smoke?
Pt: No
Pt: Occasionally
Pt: No
Examination
I would like to check your vitals i.e. your blood pressure, pulse, temperature and respiratory
rate. Also, general examination of your whole body.
(Examiner will give findings)
Findings: Generalized lymphadenopathy in whole body including axilla, groin and neck.
Tell the findings to the patient.
Diagnosis
Dr: From what we have discussed and assessed, we think that you may be having a
condition called sexually transmitted infection unfortunately. I am afraid that it could be
something like HIV.
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Pt: Are you sure?
Dr: We are not sure at the moment, we will some of your blood tests for HIV, Gonorrhea,
syphilis and then we can say anything for sure.
Pt: How did I get it?
Dr: Unfortunately, you may have gotten this from one of your partners.
Dr: We will do some blood tests and also discuss with seniors.
Pt: Ok
Dr: Any concerns?
Pt: No
Dr: I would advice you to avoid/practice safe sex until everything is sure about your
condition. Is that ok?
Pt: Ok
Dr: We will arrange a follow up in 2 weeks’ time. In the meantime, if you feel any fever,
discharge through penis, weight loss or increased lumps, please let us know. Thankyou
REFERENCE INFORMATION
D/D’s of lymphadenopathy plus sexual history +ve.
• HIV seroconversion illness(Acute presentation)
o Fever
o Sore throat
o Diarrhea
o Weight loss
o Rashes
o Lymphadenopathy
• Other STI’s like Chlamydia ,Gonorrhea, Syphilis
o Discharge through penis/vagina
o Burning in genital tract.
o Penile ulcer
HIV (human immunodeficiency virus) is a virus that damages the cells in your immune
system and weakens your ability to fight everyday infections and disease. To confirm this,
we will be advising 2 blood tests to check for HIV called HIV antibody and p24 antigen test.
How it spreads:
1. Sexual Contact: The most common spread is through unprotected vaginal or anal sex. It
may also be possible to catch HIV through unprotected oral sex, but the risk is much lower.
2. Sharing needles: Sharing needles, syringes and sex toys with someone infected with HIV.
3. Blood transfusion: It is very rare in the UK, but still a problem in developing countries.
Regular blood test:
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You’ll have regular blood tests to monitor the progress of the HIV infection before starting
treatment. Two important blood tests are:
1. HIV viral load test: Blood test that monitors the amount of HIV virus in your blood.
2. CD4 lymphocyte cell count: It measures how the HIV has affected your immune system.
Antiretroviral drugs:
HIV is treated with antiretroviral medications, which work by stopping the virus replicating in
the body. This allows the immune system to repair itself and prevent further damage. A
combination of HIV drugs is used because HIV can quickly adapt and become resistant.
Recently some HIV treatments have been combined into a single pill, known as a fixed dose
combination.
The amount of HIV virus in your blood (viral load) is measured to see how well treatment is
working. Once it can no longer be measured, it is known as undetectable. Most people taking
daily HIV treatment reach an undetectable viral load within 6 months of starting treatment.
Treatment as prevention
When patient with HIV takes effective treatment, it reduces their viral load to undetectable
levels. This means the level of HIV virus in the blood is so low that it can’t be detected by a
test. Having an undetectable viral load for 6 months or more means it isn’t possible to pass
the virus on during sex. This is called undetectable = untransmittable (U=U), which can also be
referred to as “treatment as prevention”.
Condoms:
Both male condoms and female condoms are available. They come in a variety of colours,
textures, materials and flavours. A condom is the most effective form of protection against
HIV and other STIs. It can be used for vaginal and anal sex, and for oral sex performed on men.
HIV can be passed on before ejaculation through pre-come and vaginal secretions, and from
the anus. It’s very important condoms are put on before any sexual contact occurs between
the penis, vagina, mouth or anus.
Lubricant:
Lubricant, or lube, is often used to enhance sexual pleasure and safety by adding moisture to
either the vagina or anus during sex. Lubricant can make sex safer by reducing the risk of
vaginal or anal tears caused by dryness or friction, and can also prevent a condom tearing.
Only water-based lubricant (such as K-Y jelly) rather than an oil-based lubricant (such as
Vaseline or massage and baby oil) should be used with condoms. Oil-based lubricants weaken
the latex in condoms and can cause them to break or tear.
Sharing needles and injecting equipment:

Many local authorities and pharmacies offer needle exchange programmes, where used
needles can be exchanged for clean ones.
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Telling your partner and former partners
It is important to inform your current sexual partner and any sexual partners you’ve had since
becoming infected are tested and treated.
We may be able to offer pre-exposure prophylaxis (PrEP) medication to reduce your risk of
getting the virus to your partner.
Telling your employer:
There’s no legal obligation to tell your employer you have HIV, unless you have a frontline job
in the armed forces or work in a healthcare role where you perform invasive procedures.
Screening for HIV in pregnancy:
All pregnant women are offered a blood test to check if they have HIV as part of routine
antenatal screening. If untreated, HIV can be passed from a pregnant woman to her baby
during pregnancy, birth or breastfeeding.
Many of the medicines used to treat HIV can interact with other medications prescribed by
your GP or bought over-the-counter. These include some nasal sprays and inhalers, herbal
remedies like St. John’s Wort, as well as some recreational drugs. Always check with your
HIV clinic staff or your GP before taking any other medicines. Also we can give you leaflets
regarding this.
477
PSA TEST DEMANDING PATIENT

Jason Roy aged, 55 came to the clinic requesting PSA.
Please talk to the patient and address his concerns.

P: I want to have the PSA test done
D: May I know why?
P: Dr one of my friend is having prostate cancer
D: I am sorry to hear about your friend. How's he doing now?
P: He is under treatment
D: Let me ask you few questions to assess your health better.
D: Do you have any kind of symptoms?
P: Like what
D: Are you going to the loo more often these days?
P: Yes
D: Can you tell me more about it.
P: I have to go to the loo 10-12 times a day now.
P: No
P: No
P: No
D: Do you have to wake up at the middle of the night to go the loo?
P: No
D: Do you have to strain while passing urine?
P: Yes/No
D: Do you have difficulty in starting urination?
P: Yes/No
D: Are you able to hold your urine before going to the loo?
P: Yes/No
D: Do you feel like you are not completely able to empty your bladder?
P: Yes/No
D: Have you noticed any dribbling at the end of urination?
P: Yes/No
D: Do you have weak urine stream or stream that stops and starts?
P: No
D: By any chance any blood in your urine?
P: No
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P: No
P: No
D: Has anyone told you that you are losing weight?
P: No
P: Its good
P: No
P: No
P: No
D: Did you have similar symptoms in the past?
P: No
D: have you been diagnosed with any medical condition in the past or any prostate
problems?
P: No
D: By any chance any kidney or bladder problems?
P: No
P: No
P: No
D: Any family history of any significant health issues or prostate problems?
P: No
D: Do you smoke?
P: No
P: No
P: Balanced
I would like to do a GPE, check vitals and examine your back passage. I will be having a
chaperone with me.
D: Can you tell me how much you know about the test?
P: I know it indicates prostate cancer
D: PSA is a protein produces by normal and cancerous cells of the prostate. PSA is an
inaccurate marker for prostate cancer. Because cancer can be present without increased
PSA levels and there are many other causes of increased PSA levels (BPH, Prostatitis, UTI).
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1. So, before you make a decision about PSA testing you need to consider benefits and
risks:
 Benefits can be early detection and early treatment of Prostate cancer
 Limitations and risks could be false positive results about (85%) and false negative
results (about 15%). False positive result can further lead to invasive investigation
such as taking sample from your prostate (biopsy) and there may be adverse event
like infection or bleeding after the procedure.
2. We can offer PSA testing to Men>50 years old as long as they are symptomatic
3. Routine screening for prostate cancer is not in the national policy because the benefits
have not been shown to clearly outweigh the harms. Therefore, we don't offer it to those
who doesn't have symptoms.
4. We can provide you with some leaflets before you decide from the Prostate cancer UK
organization.
P: Dr I want to have the test done please.
D: Yes, in that case we can do it for you.
Before doing PSA, test men should not have-

■ Active urine infection
■ Ejaculated in previous 48 hours
■ Exercised vigorously in previous 48 hours
■ Had a prostate biopsy in previous 6 weeks.
Inform choice programme
480
LOIN PAIN
You are F2 in A&E.

Mr. Patterson aged 27years, presented to hospital with loin pain.
The patient was given Diclofenac by nurse.
Please talk to the patient, take history, assess the patient and discuss management with the
patient.

P: I have got pain here (Pointing towards left loin).
P: I was watching TV suddenly it started
P: 3 hour ago
P: Continuous
P: I don’t know
P: Left groin
P: Your nurse gave me painkiller it helped a bit.
P: No
P: Around 8
P: I am feeling sick since my pain started.
D: Did you vomit?
P: Yes, I vomited once.
P: No
D: Do you have a dry mouth?
P: No
D: Anything else?
P: No
P: No
D: Do you have any problem with your urine?
P: No
D: Did you pass any stone with your urine?
481
P: No
D: Do you have burning sensation while passing urine?
P: Yes/No
D: Have you noticed any blood in your urine .’
P: No
D: Are you going to loo more often these days?
P: No
D: Any changes in your urine colour or smell?
P: Yes it is smelly and cloudy these days.
P: No
P: No
D: Any HTN or kidney disease? gout or hyperparathyroidism?
P: No
P: No
D: Any calcium or vitamin supplements?
P: No
D: Any blood thinner or antacids?
P: No
P: No
P: No
P: No
D: Any family history of kidney problems or stones?
P: No
D: Do you smoke?
P: No
P: No
P: Good.
D: Any high protein containing only meat or low fibre diet?
P: No
D: Do you drink enough water?
P: Yes
P: Good
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P: Yes.
P: Yes
1 would like to check your vitals and examine your tummy.

D: I would like to send for some initial investigations including routine blood test and urine
dip.
EX: T-37, HR- 90, BP- 110/70, RR- 12-20, 02 sat- 96%.
Tenderness in left flank area.
Urine dip: Hematuria++
 From our assessment, we are suspecting you have stone in your urinary tract
 We have done urine test and we found there was some blood in your urine.
 We will do blood test and urine test to see if there is any bug and also to check your
kidney function.
 We need to check the level of certain chemicals in your blood like calcium which could be
the cause of your stone.
 We will do a CT scan to confirm the size and location of the stone (CT KUB gold standard).
 We may consider doing other investigations as well like X-ray, USG or IVP.
 We will give you pain killer to relieve your pain and some anti sickness medications for
your sickness.
 Also we may give some fluid through your blood vessels if you are not able to drink.
 If your pain is relieved and you are able to eat and drink we will let you go home.
 However, if you develop any fever, if the pain is not relieved and you keep vomiting
continuously and if scan shows some abnormalities in the kidneys then we will keep you
in the hospital.
 We will give you some medications to facilitate the passage ol' urine by relaxing the neck
ol' the bladder and the tubes (Tamsulosin).
 Treatment depends on the size of the stone:
o If it is less than 4mm then it will come out on its own.
o If the stone is big then we have to do some intervention, (extracorporeal shock
wave lithotripsy (ESWL), ureteroscopy, percutaneous nephrolithotomy (PCNL),
open surgery)
 If any sign of UTI then give the patient antibiotics.
 Drink plenty of water it helps for the stone to pass down. You should drink enough water
to make your urine colourless. If your urine is yellow or brown, you're not drinking
enough.
 You should try to collect the stone from your urine. You can do this by filtering your urine
through gauze or a stocking and then give the stone to your GP so that he can have it
analysed to help determine any further treatment you may need.
 Take high fiber diet, reduce salt intake, reduce the amount of meat.
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 If you have a high temperature of 3 8C or more, sudden severe pain in your loin,
shivering and you are not able to pass urine please come to the hospital.
DD:
Urinary stone
UTI
Pyelonephritis
Renal Cell Carcinoma
Pneumonia
Causes of kidney stones:

 high-protein, low-fibre diet
 are inactive or bed-bound
 have a family history of kidney stones
 have had several kidney or urinary infections
 have had a kidney stone before, particularly if it was before you were 25
 have only one fully working kidney
 have had an intestinal bypass (surgery on your digestive system) or a condition affecting
the small intestine, such as Crohn's disease.
Medication:
There's evidence to suggest that certain medications may increase your risk of developing
recurrent kidney stones. These include:
 aspirin
 antacids
 diuretics (used to reduce fluid build-i
 certain antibiotics
Types of kidney stones:
Kidney stones can develop for a number of reasons. The causes of the four main types of
kidney stone are outlined below.
 Calcium stones-
Calcium stones are the most common type of kidney stone and form if there's too much
calcium in the urine, which can be due to:
o an inherited condition called hypercalcuria, which leads to large amounts of calcium in
urine
o Hyperparathyroidism
 Struvite stones-
Struvite stones are often caused by infections, and they most commonly occur after a
urinary tract infection that's lasted a long time.
 Uric acid stones-
Uric acid stones can form if there's a large amount of acid in your urine. They may be caused
by:
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eating a high-protein diet that includes lots of meat
a condition such as gout that prevents the body breaking down certain chemicals
 Cystine stones
Cystine stones are the rarest type of kidney stone. They're caused by an inherited condition
called cystinuria, which affects the amount of acid that is passed in your urine.
P: Are stones a serious condition doctor?
P: How did I get this stone?
485
ERECTILE DYSFUNCTION
You are FY2 in GP.
A middle aged man wants to talk to you.
History
Pt: Doc, it is little bit embarrassing but it is about my erection
Dr: Please tell me more
Pt: I am not able to do sex
Dr: From how long are you having this problem?
Pt:2,3 months ago
Dr: Do you get erections in the morning or during masturbation?
Pt: No
Dr: Any weight loss or lumps or bumps in body?
Pt: No
Pt: I am hypertensive
Dr: What are you taking for it?
Pt: Labetolol
Dr: From how long?
Pt: 15 years
Dr: Are you using any other medication like Nitrates?
Pt: No
Pt: Accountant
Dr: Do you smoke?
Pt: No
Dr: What about alcohol?
Pt: Occasionally
Dr: By any chance, any recreational drugs?
Pt :No
Examination
Dr: I would like to check your vitals i.e. your BP, pulse, temperature and respiratory rate
.also examination of your genitals. Is that ok?
Pt: Ok
Management
Dr: From what you have told me most likely you are having this erectile dysfunction due to
labetalol unfortunately (check BNF).It is a very common problem, so you don’t have to
worry about that.
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Pt: So what can we do now?
Dr: We will talk to our seniors and then we will change labetalol to some other anti
hypertensive medicine like amlodipine, what do you think?
Pt: Ok, will it cause the same problem?
Dr: It is very rare with amlodipine, also we can offer you some medicine called Viagra to
help you in erection
Pt: Ok
Dr: It usually takes 30 to 60 minutes for sildenafil to work for erectile dysfunction. You can
take it up to 4 hours before you want to have sex.
• Taking sildenafil alone will not cause an erection. You need to be aroused for it to
work.
• The most common side effects are headaches, feeling sick, hot flushes and dizziness.
Many men have no side effects or only mild ones.
Dr: Any other concerns?

Pt: No
Dr: We will do your blood tests to see if everything is fine with your liver,kidneys,your sugar,
cholesterol and hormones levels.
Pt: Ok
Dr: We will arrange your follow up in a month.in the meantime, if you feel that you are not
improving, any chest pains, prolong and painful erections,please come back to us. Thank you
Treatment for erection problems depends on the cause
Treatments for erectile dysfunction are usually effective and the problem often goes away.
There are also specific treatments for some of the causes of erectile dysfunction.
Treatments for some causes of erectile dysfunction
Possible cause Treatment
Narrowing of penis blood vessels, Medicine to lower blood pressure, statins to

lower
high blood pressure, high cholesterol cholesterol
Hormone problems Hormone replacement (for example
testosterone)
Side effects of prescribed medicine
Change to medicine after discussion with GP
Things you can do to help with erectile dysfunction Healthy lifestyle changes can sometimes
help erectile dysfunction.
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Do
• lose weight if you're overweight
• stop smoking
• eat a healthy diet
• exercise daily
• try to reduce stress and anxiety
Don’t
• do not cycle for a while (if you cycle for more than 3 hours a week)
• do not drink more than 14 units of alcohol a week
Emotional (psychological) problems

It's more likely to be an emotional problem if you only have erection problems some of the
time. For example, you get an erection when waking up in the morning, but not during
sexual activity.
Anxiety and depression can be treated with counselling and cognitive behavioural therapy
(CBT).
Do not take sildenafil if you:
• have had an allergic reaction to sildenafil (Viagra) or any other medicines in the past
• are taking medicines called nitrates for chest pain
• have a serious heart or liver problem
• have recently had a s troke or a heart attack
• have low blood pressure
• have a rare inherited eye disease, such as retinitis pigmentosa
Check with your doctor before taking sildenafil if you:

• have sickle cell anaemia (an abnormality of red blood cells), leukaemia (cancer of
blood cells) or multiple myeloma (cancer of bone marrow)
• have a deformity of your penis or Peyronie's disease (curved penis)
• have a heart problem. Your doctor should carefully check whether your heart can take
the additional strain of having sex.
• have a stomach ulcer or a bleeding problem like haemophilia
Stop taking sildenafil and call a doctor straight away if you get:
• chest pains - if this happens during or after sex, get into a semi-sitting position and try
to relax; do not use nitrates to treat your chest pain
• prolonged and sometimes painful erections - if you have an erection that lasts for
more than 4 hours, contact a doctor immediately
• a sudden decrease or loss of vision
• a serious skin reaction - symptoms may include fever, severe peeling and swelling of
the skin, blistering of the mouth, genitals and around the eyes
• seizures
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FEEL UNWELL – OXYBUTYNIN – URINARY SYMPTOMS

A 50 year old lady is coming with some concerns.
Dr: Hello my name is Dr XYZ, I am one of the junior doctors in GP clinic. How can I help you?
Pt: Doc, I am feeling confused now a days.
Dr: Please elaborate it
Pt: I am forgetting things, I forgot that I had to go to lunch at 2pm today and then my
daughter reminded me.
Dr: From how long are you feeling like this?
Pt: From last 2 weeks.
Dr: Were you completely fine before it?
Pt: Yes
Dr: Any other symptoms at all?
Pt: Like what?
Dr: Any fever?(Any infection)
Pt: No
Dr: Any cough or shortness of breath?(Pneumonia)
Pt: No
Dr: Any rashes over the body?(Meningitis)
Pt: No
Dr: Any change in bowel habit?(Gastroenteritis)
Pt: No
Dr: Any burning while passing urine?(UTI)
Pt: No
Dr: What else are you forgetting?
Pt: I am losing track of time and forgetting my daily routine chores.
Dr: Sorry to hear about that
Dr: Any concentration problems?(Dementia)
Pt: Yes, mild
Dr: Any planning problem?
Pt: No
Pt: I have urinary incontinence.
Dr: What are you taking for it?
Pt: Oxybutynin
Dr: From how long? Pt: From last 3 weeks
Dr: Do you feel that you have started feeling like this after taking oxybutynin?
Pt: May be doc
Dr: Are you using any other medication?
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Pt: No
Dr: Any allergies?
Pt: No
Dr: Any one in family with memory problems?
Pt: No
Pt: I am a teacher
Dr: Is it affecting your teaching?
Pt: Yes doc
Dr: Don’t worry we will try to help you as much as we can.
Pt: Ok doc
Pt: My husband
Examination
I would like to check your vitals now i.e. your blood pressure, pulse, temperature and
respiratory rate, also general physical examination of your body. Is that ok?
I would also like to do Mini mental state examination of you which involve checking
cognitive function of your mind.(Examiner will give you normal MMSE score=26)
Diagnosis
Fortunately, your cognitive function is intact. From what we have assessed, we think that
you may be having this confusion as a side effect of oxybutynin unfortunately.
(Check the BNF)
Dr: So now, we will refer you to your specialist doctor, Urologist so that he will take care of
this side effect and may be switch you to some other med for incontinence.
Pt: Ok doc
Dr: We will also take your blood to check for anaemia, any infection and whether your
kidneys and liver are fine.
Pt: Ok
Dr: We will also arrange your follow up in 2 weeks. In this time if you feel any fever ,cough,
burning sensation while passing urine or if your forgetfulness is getting worse ,please let us
know. Thank you
How to tell if someone is confused If a person is confused, they may:
• not be able to think or speak clearly or quickly
• not know where they are (feel disorientated)
• struggle to pay attention or remember things
• see or hear things that aren't there (hallucinations)
Try asking the person their name, their age and today's date. If they seem unsure or can't
answer you, they probably need medical help.
490
Do
• stay with the person – tell them who you are and where they are, and keep reassuring
them
• use simple words and short sentences
• make a note of any medicines they're taking, if possible
Don’t
• do not ask lots of questions while they're feeling confused
• do not stop the person moving around – unless they're in danger
Causes of sudden confusion

Some of the most common causes of sudden confusion include:
• an infection – urinary tract infections (UTIs) are a common cause in elderly people or
people with dementia
• a s troke or T IA ("mini-stroke")
• a low blood sugar level in people with diabetes – read about treating low blood sugar
• a head injury
• some types of prescription medicine
• alcohol poisoning or alcohol withdrawal
• taking illegal drugs
• carbon monoxide poisoning – especially if other people you live with become unwell
• a severe asthma attack – or other problems with the lungs or heart
SCENARIO 2
Mr. Peter Smith, aged 72, came to the clinic 2 weeks ago for urinary symptoms and was
prescribed oxybutynin 5 mg for that. After one week, his symptoms were not relieved and
the dose was doubled. Now he has booked for the urgent appointment.
Please talk to him, assess him and discuss your plan of management with him and address
his concerns.

P: 2 days ago, I had a funny sensation.
D: What do you mean by that?
P: I was not myself. I was out with my friends and I was confused for a few minutes. We were
playing cards and I suddenly didn’t know how to play the game. I didn’t know where I was.
Everything started after I doubled the dose.
D: Why did you come to the hospital 2 weeks ago.
P: I was going to the loo more often and it was very difficult for me to hold the urine. I was
prescribed oxybutynin, and I was told if symptoms don’t improve you can double the dose.
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P: No
D: Any fever, chills, or flu-like symptoms?
P: No
D: Any changes in your urine color or smelly?
P: No
D: Any blood in it?
P: No
P: No
D: Do you have any pain while passing urine?
P: No
P: Yes (nocturia)
P: 2-3 times.
D: Do you have to strain while urinating?
P: Yes/No
D: Do you have difficulty starting urination?
P: Yes/No (hesitancy)
D: Are you able to hold your urine before going to the loo?
P: Yes/No (incontinence)
D: Do you have weak stream or stream that stops and starts?
P: Yes/No (poor emptying)
D: Have you noticed any dribbling at the end of urination? Does a bit of urine drop and stain
P: Yes/No (Dribbling)
D: Have you noticed any weight loss? (cancer)
P: No doctor
D: Someone your friends or family told you are losing weight?
P: No
P: No
P: No
P: No
P: No
P: No
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P: No
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: I try to eat healthy
P: No
I would like to check your vitals and examine your urinary system and perform a PR. I would
like to send for some initial investigations including routine blood tests.
From our assessment, we are suspecting you may possibly be experiencing a side effect of
oxybutynin, which is a medicine used to treat urinary incontinence.
As you mentioned that your dose was increased recently, and that you have developed
confusion, we will reevaluate the dose of the medicine for you.
Side effects of oxybutynin

Anxiety, arrhythmia, cognitive disorder, depressive symptom drug dependence,
gastrointestinal disorders, glaucoma, hallucination, heat stroke, hypohidrosis, mydriasis,
nightmare, paranoia, photosensitivity reaction, seizure, urinary tract infection.
Oxybutynin use may lead to cognitive side effects and increased dementia risk. This is
troubling because elderly patients are already more at risk for dementia, and oxybutynin
may worsen the situation.
During this time, I will advise some conservative treatments, which do not involve medicines
or surgery. These include:
- Lifestyle changes (reducing caffeine, drinking an optimal amount of water, losing weight)
- Pelvic floor muscle training (Kegel exercises)
- Bladder training
We can also set up a meeting with NHS continence services which includes special nurses
and physiotherapists who can help you with your issues.
Patient concern:
Is it dementia
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URINARY INCONTINENCE
Grips
How can I help you today?
Complain: I wee on myself before I have to run into the toilet...
ODPARA
ICE
Rule out stress incontinence, UTI, STI,
P3mafosa
(Prev pelvic surgery, trauma, medication hx)
JARS
Exam
Diagnosis: overactive bladder
Mgt: lifestyle modification: , bladder training, pelvic floor exercise, wt loss
If not effective: offer oxybutynin meds
Ask for concerns and address along
Arrange for follow up
Involve senior
Safety net: if worsens or fever
Offer leaflet
Any other thing??
Thank patient
Urge Incontinence Stress Incontinence

Sudden very intense need to pass urine and you It is when you leak urine when bladder is
are unable to delay going to toilet put under sudden extra pressure, e.g.,
Rx cough, sneezing, laughing, exercise, heavy
- Lifestyle changes lifting
- Losing weight Rx:
- Reducing coffee/tea intake - Duloxetine
- Oxybutynin - Pelvic floor exercises (Kegel Exercises)
- Bladder training exercises - Vaginal tape (for heavy lifters)
- Sling Surgery: Sling made around the neck of
bladder to support it to prevent leakage.
494
PSYCHIATRY STATIONS
MINI-MENTAL STATE EXAM (MMSE)
You are F2 A&E.

Albert Peterson, aged 77, has been brought to the hospital by the police. He was wandering
in the park and he was confused. He doesn’t know why he is in the hospital.
Please talk to the patient and assess the cognitive function.
Explain your findings and your further plan of management to your examiner.
Do not take psychiatric history. After 6 minutes, stop talking to your patient and talk to your
examiner.
Note:
Sometimes patient may not allow you to introduce yourself and he will start asking
questions.
P: Where am I?
Dr: You are in the hospital.
P: Why am I here?
Dr: You were wandering in the park. Police found you and brought you to the hospital.
P: Did I do something wrong?
Dr: No at all. You were just a bit confused.
P: Who are you?
D: My name is Dr. XYZ. I’m one of the junior doctors at the hospital. May I ask your name?
P: My name is Albert Peterson.
Dr: Pleasure to meet you.
P: Doctor, what am I doing here?
Dr: I am here to ask you so:
P: Okay, no problem.
D: I am here to ask you some questions to assess your memory. I hope that is okay with
you?
Time Orientation
You need to ask five questions of time form broadest to most narrow (year, season, month,
date and day) and for each correct answer you should give one score.
Dr: What year are we in?
P: It is 1956.
We are in the year (the correct year). Never mind.
Dr: What season is it?
P: Doctor, it should be summer because the weather is so cold. (CORRECT IF WRONG)
Dr: What month is it?
P: It is June. (CORRECT IF WRONG)
Dr: What day is it?
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P: It’s Monday doctor. (CORRECT IF WRONG)
Dr: What would be today's date?
P: It's 25th doctor. (CORRECT IF WRONG)
Place Orientation
You need to ask five questions of place form broadest to most narrow (Country, county,
town/city, street and building) and for each correct answer you should give 1 score.
Dr: May I know what country are we in?
P: UK. (CORRECT IF WRONG)
Dr: What county are we in?
P: Yorkshire!!! (The correct answer is Greater Manchester) (CORRECT IF WRONG)
Dr: What town/city are we in?
P: London. (CORRECT IF WRONG)
Dr: What street are we in?
P: I don't know. (Hardman Street)
Dr: No Problem We are at Hardman Street
Dr: Which building we are now?
P: I don't know.
Dr: That’s okay, we are in the GMC building.
Registration
You should name three unrelated objects clearly and slowly and then ask the patient to
repeat them after you. You may remind him to remember them since you will be asking him
to recall
them later.
Dr: I’m going to give you three words and I would like you to repeat them after me. Try to
remember them because I’m going to ask you to recall them later. The words arc: apple,
table, penny.
P: Apple, table, penny.
Dr: That's great
Attention
In order to assess attention, give your patient a 5-letter word and ask him to spell it
backwards.
You may use the word ’‘WORLD". The correct answer is: D-L-R-O-W.
For each correct answer, give him one score.
Dr: I would like you to spell the word WORLD backwards for me?
P: D... (Patient will take a pause and starts thinking.)... .It is difficult doctor.
Who are you?
What am I doing here?
Why am I doing this thing? / Why are you asking me these questions?
Dr: My name is XYZ, I'm one of the junior doctors in this hospital. I am assessing your recent
memory.
P: Who brought me here?
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Dr: You were wandering in the park. The Police were worried about you and so they brought
you to the hospital.
P: Oh okay doctor.
Note: An alternative way of assessing attention, mainly used if English is not their language,
is:
“I would like you to count backward from 100 by sevens.”
If patient makes a mistake, do not stop them. Let the patient carry on and check his
answers.
Stop after five answers.
The correct answers, will be: 93, 86. 79. 72, 65.
Please give one score for each correct answer
Recall
You should ask your patient to recall the three words you asked him to remember earlier.
For each word that he could remember, give him one score.
Dr: Earlier I had asked you to remember the three words, could you repeat that for me?
P: Which 3 words?
Dr: Try to remember.... (After a small 1 pause) the words were Apple Table Penny (tell the
answer and don’t give the marks)
Dr : Its okay, moving on.
Language
You should show your patient simple objects, such as pen and pencil and ask him to name
them. For each correct answer, please give him one score.
Dr: Could you please name this object (pen) for me?
P: It’s a pen.
Dr: How about this one (Paper)?
P: (Patient is pushing himself.) It's on the tip of my tongue but I cannot remember.
Dr: Are you looking for the word, paper?
P : Yes Doctor.
Dr: That's good (However do not give them the mark.)
Repetition
Ask the patient to speak back a phrase. You may use this phrase “No ifs, ands. or buts”. If
could repeat it after you correctly, give him one score.
Dr: Could you please repeat this sentence for me. No ifs. ands. or buts.
P: No ifs. ands, or buts.
Dr: That's good.
Complex Command (3 Stage Command)
You need to give your patient 3 commands. Give one score for each correct answer.
Dr: Take the paper in your right hand, fold it in half, and put it on the floor.
P: Okay doctor.
497
(Sometimes patient does as you said. Sometimes he keeps folding the paper and sometimes
he puts the paper back on the table instead of giving it back to you.)
Complex Command (Reading)
You should give your patient a written instruction and ask him to read it and do what it says.
If he follows your instruction correctly, please give one score.
Dr: Could you please follow the task written on this paper.
(You may write: “Close your eyes” on a piece of paper.)
P: (He will close his eyes.)
Dr: That's great, you may open your eyes.
Complex Command (Writing)
You should give your patient a pen and a piece of paper and ask him to make up and write a
sentence about anything. If he writes a meaningful sentence that contains a noun and a verb
without any spelling or grammar mistake, please give him one score. (Usually he writes a
meaningful sentence, however, sometimes he may make spelling mistakes.)
Dr: Could you please write a meaningful sentence about anything for me?
P: (Patient writes different sentences every time.)
- The sun is shining today.
- It is a nice day.
- Sky is blue today.
Complex Command (Drawing)
You should draw the following picture on a piece of paper. Give your patient a pen and a
blank
piece of paper and ask him to copy your picture. If he draws it correctly, please give him one
score. (All ten angles must be present and two angles must intersect.)
MINI MENTAL STATE EXAMINATION

24-30—NORMAL 10-19—MODERATE IMPAIRMENT
20—23 MILD IMPAIRMENT 0-9—SEVERE IMPAIRMENT
ORIENTATION TIME YEAR, SEASON, MONTH, DAY, 5

DATE
PLACE 5
COUNTRY, CITY, TOWN, STREET,
BUILDING
REGISTRATION 3 OBJECTS APPLE, TABLE, PENNY 3
ATTENTION WORLD WORLD (SPELL, SPELL 5 (correct order
AND BACKWARDS) for all 5 letters in
CALCULATION reverse)
RECALL 3 WORDS APPLE, TABLE, PENNY 3
LANGUAGE NAME 2 OBJECTS PEN, PAPER 2
NO IFS ANDS OR BUTS 1

498
REPEAT
SENTENCE 3 STEP ACT (FOLD PAPER) 3
3 STEP
COMMAND
READ READ AND PLEASE CLOSE YOUR EYES 1
FOLLOW
COMMAND
WRITE WRITE A ANY SENTENCE (IGNORE SPELLING 1
SENTENCE ERRORS)
COPY COPY THIS 2 INTERSECTING PENTAGONS 1
DIAGRAM
Examiner: MMSE 21, Routine Test – Normal

Examiner: Which investigation you want to do:
These include some laboratory tests such as FBC, U&Es, LFT, calcium, vitamin B12, thyroid
function tests and random or fasting blood sugar, CT scan or MRI of the brain.
1. Neurodegenerative disorders for example Multiple sclerosis.
2. Other CNS disorders for example Brain tumours, Epilepsy and Trauma.
3. Infectious disease such as HIV.
4. Metabolic disorders such as Hypercalcemia, Hyponatremia.
5. Endocrine disorders such as Addison disease, Cushing syndrome and thyroid problems.
6. Vitamin deficiencies such as vitamin B12, folate, thiamine, niacin deficiency.
7. Medications such as anabolic steroids, corticosteroids, cimetidine and some antibiotics such
as penicillin.
8. Substance abuse such as Amphetamines, Cocaine, Alcohol, Cannabis.
9. Related psychiatric disorders such as Schizophrenia, delirium, Mood disorders with
delusional symptoms (manic or depressive type), Obsessive-compulsive disorder.
According to the NICE guidelines,

25-30 - Normal.
21-24 - Mild Cognitive Impairment
10-20 - Moderate Cognitive Impairment
< 10 - Severe Cognitive Impairment.
What Investigation will you do Doctor?
499
CONCERNED DAUGHTER MMSE

Mariah Smith, aged 55, came to the clinic with some concern.

P: My daughter wanted me to see you.
D: Why?
P: She said I keep forgetting things.
D: Do you think there has been any changes in you?
P: No
D: Are you able to remember things?
P: Yes, I remember most of the things.
D: Do you have to ask multiple times for information?
P: No
D: Do you need notes to remember things?
P: No
D: Do you have trouble following conversations?
P: No
D: Do you find yourself confused mid-conversation?
P: No
D: Do you lose things or feel like someone has stolen them?
P: No
D: Have you noticed difficulty walking and keeping balance?
P: No (Vascular dementia)
D: Have you had any trouble with your vision?
P: No (vascular dementia)
P: No
D: Any DM, HTN or stroke?
P: No
P: No
D: Are you taking any birth control pills?
P: No
P: No
D: Any previous surgeries or procedures done?
P: No
D: Do you smoke?
P: No
500
P: No
P: Good/Bad
P: Yes/No
P: Work from home.
P: With my daughter
I would like to check your vitals, do GPE, MMSE and Neurological examination.
Examiner: MMSE 26
From my assessment, the MMSE score is normal.
I will do some routine and special blood tests. These include some laboratory tests such as
FBC, U&Es, LFT, calcium, vitamin B12, thyroid function tests and random or fasting blood
sugar, CT scan or MRI of the brain.
Routine Test – Normal.
Note:
According to the NICE guidelines,
25-30 - Normal.
21-24 - Mild Cognitive Impairment
10-20 - Moderate Cognitive Impairment
< 10 - Severe Cognitive Impairment.
My management plan would include:

 Take complete medical history including social history from the patient.
 Perform necessary physical examinations.
 Order the routine blood tests
 I would make a referral to the Psychiatric team once the patient is medically settled.
 There is a possibility of referral to Neuropsychiatry as well.
 They may involve the social services team and Homeless team if need be.
Full examination looking for possible cardiac or neurological abnormalities should be
performed.
Some advanced cognitive assessment should also be done.
Some further investigations may be done in order to rule out physical causes
501
Confusion Screen: CT Scan, UA, TFT, Ca, B12, folate
2. Other CNS disorders for example Brain tumours, Epilepsy and Trauma.
7. Medications such as anabolic steroids, corticosteroids, cimetidine and some antibiotics such
as penicillin.
9. Related psychiatric disorders such as Schizophrenia, delirium, Mood disorders with
delusional symptoms (manic or depressive type), Obsessive-compulsive disorder.
502
PSYCHOTIC PATIENT
You are F2 A&E.

Gordon aged, 29 has been brought to the hospital by the police. He thinks he has been
followed by the police so he went to the police to give himself up.
Police investigated hint and confirmed that he has not done anything wrong and there is no
evidence of his claim. He works in the post office.
Please talk to the patient, take history, explain the diagnosis to the patient and discuss your
initial plan of management with him.
Note:
Sometimes he looks anxious.
Sometimes he shows his anxiousness and agitation by moving his hands while talking to you.
Sometimes this patient doesn’t give good eye contact.
Sometimes he keeps looking at the door or on the floor.

P: Doctor, I don’t know... the police brought me to the hospital.
Dr: May I know why?
P: I don't know doctor. I noticed that the police have been following me. So I went to the police
to give myself up and they brought me here but they didn’t tell me why.
Dr: That’s a very good thing that you did, police were worried about you so they brought
you here. We are going to take good care of you. The police have told us that you have done
nothing wrong and there is nothing to be worried about.
P: No. Doctor. I am must have done something wrong, which is why they have been following
me.
Dr: I see. why do you think they are following you?
P: I don’t know doctor! I must have done something wrong! That’s why I went to the police
today! (Or may be some other delusion).
Dr: Alright, may I know since when do you have this feeling?
P: Doctor, I noticed it three months ago but it might have been longer than this. I'm not sure.
Dr: Has it ever happened before?
P: No. doctor.
Dr: Could you please elaborate as to what do you mean by “the police follow you”?
P: Doctor, they are everywhere. I can feel them... they are following me... they are watching
me! They have targeted me!
Dr: Have you ever confronted them?
P: No Doctor. Its just today that I gave myself up.
Dr: That’s alright. I will ask you some questions, it may sound strange however kindly bear
with me. is that okay?
P: Sure Doctor
Dr: Do you hear the voice of these policemen?
503
P: No. I don’t but I’m sure they are following me.
Dr: Do you get a strange sense of smell that you get but nobody else
P: No Doctor
Dr: Do you feel that you can hear voice talking to you or talking about you when there is
nobody else in the room?
P: No Doctor.
Dr: Do you feel someone is putting thoughts in your brain?
P: No.
Dr: Do you feel people can read your mind?
P: No.
Dr: Do you think people can steal your thoughts?
P: No
Dr: Do you feel you have any special talents?
P: No Doctor.
Dr: Could you please tell me today’s date?
P: It's 22rd of January doctor. (If incorrect, do correct)
Dr: Do you know which city we are in?
P: Manchester. (If incorrect, do correct)
Dr: Could you please spell the word WORLD backwards for me? OR “I would like you to
count
backward from 100 by sevens.”
P: D-L-R-O-W& 100.93,86,79,72
Dr: How has your mood and energy been recently?
P: I feel fine doctor.
Dr: Could you please score your mood for me. on a scale of 1-10, one being the worst you
have ever felt and ten being the best you have ever felt?
P: It s around 6-7 doctor.
Dr: Have you ever tried to harm yourself?
P: No.
Dr: Whom do you live with?
P: I live alone doctor.
Dr: Do you feel safe at home?
P: Yes, Doctor.
Dr: Do you feel safe here?
P: Yes, Doctor.
Dr: Do you have any partner or children?
P: No.
Dr: Did you have any partners in the past?
P: No, I love to be alone.
Dr: Do you have any family living nearby?
P: My mom lives far away doctor
Dr: How is your relationship with
504
P: Its fine doctor
Dr: Do you have any friends?
P: No. I prefer/want to be alone.
Dr: What do you do for living?
P: I used to work at a post-office but I am not working there anymore.
Dr: Are you on any benefits?
P: No doctor. I have my savings.
Dr: Have you ever had any problems with the law?
P: No. I haven’t had any problems so far.
P: No.
Dr: Any recreational drugs?
P: No.
Dr: Have you ever been diagnosed with any medical condition?
P: No.
Dr: Are you taking any medications?
P: No
Dr: Has any member of your family ever been diagnosed with any mental health problems?
P: No doctor.
Dr: Thank you for being patient and answering my questions, it seems like you may have a
condition called delusional disorder.
P: What is it?
Dr: It's a condition in which a person has a firm false belief.
P: Okay, but I don’t think this is my case doctor!
Dr: How about lets just agree to disagree and let me tell you what I can do for you.
As we are worried about you we would like to keep you in the hospital for sometime
 To run some blood test (to rule out medical cause)
 One of my colleagues from the mental health team will come and talk to you and if
need be we will get you some medications.
P: Will the police come and catch me here, doctor?
Dr: No my dear, do not worry you will be safe here. We are going to help you.
P: Okay, I’ll stay in the hospital if the police doesn’t come.
Dr: Okay, let me tell you what we can do for you.
RELATED THEORY
CAUSES
1. History of delusional disorder or schizophrenia in the family.
2. Biochemical factors such as imbalance in neurotransmitters (which can interfere with the
transmission of messages, leading to symptoms.)
3. Environmental/Psychological factors such as:
- Excessive stress
- alcohol
505
- drug abuse
- Social isolation
- Being unmarried
- Being unemployed
- Low socioeconomic status
2. Other CNS disorders for example Brain tumours, Epilepsy and Tra
7. Medications such as anabolic steroids, corticosteroids, cimetidine and some antibiotics
such as penicillin.
9. Related psychiatric disorders such as Schizophrenia, delirium. Mood disorders with
delusional symptoms (manic or depressive type). Obsessive-compulsive disorder.
PLAN
1. Psych referral.
2. Complete medical history should be taken.
3. Complete physical examination {neurological and cardiovascular examinations}.
4. Blood tests
• infectious disease
• metabolic and endocrine disorders
• vitamin deficiencies.
5. Imaging
• CT scan or MRI of the brain {tumours}.
TREATMENT
1. Individual Psychotherapy.
2. Cognitive-Behavioural Therapy (CBT).
3. Support Therapy.
4. Insight-Oriented Therapy.
5. Family Therapy.
6. Address social stressors (Living alone, social isolation).
Possible Medication such as Anti-psychotics, atypical anti-psychotics
506
PSYCHOSIS
You are F2 in GP.

Mother is concerned for her son, Michael Smith, aged 40, as he has been behaving strange
for 3 weeks. The other day she made an appointment for face-to-face consultation for her
son.

P: I don’t have any clue why I am here. I am absolutely fine.
D: That’s alright, I will ask you some questions, it may sound strange however, kindly bear
with me, is that okay?
P: Sure Doctor
D: How has your mood and energy been recently?
P: I feel fine doctor.
D: Could you please score your mood for me, one a scale of 1-10, 1 being the worst you have
ever felt and 10 being the best you have ever felt?
P: It’s around 6-7 doctor.
D: Do you get a strange sense of smell that you get but nobody else around seems to smell
it?
P: No doctor.
D: Do you feel that you can hear voices talking to you or talking about you, when there is
nobody else in the room?
P: Yes, they are telling me to kill someone.
D: Do you feel someone is putting thoughts in your brain?
P: No
D: Do you feel people can read your mind?
P: No
D: Do you think people can steal your thoughts?
P: Yes, the radio is stealing my thoughts.
D: Do you feel you have any special talents?
P: No Doctor
D: Could you please tell me today’s date?
P: It’s 22nd of January doctor
D: Do you know which city we are in?
P: Manchester
D: Could you please spell the word WORLD backwards for me? OR “I would like you to count
backward from 100 by sevens.”
P: D-L-R-O-W & 100,93,86,79,72
D: Have you ever tried to harm yourself?
P: No
507
P: Mother
D: Do you feel safe at home?
P: Yes, doctor
D: Do you feel safe here?
P: Yes, doctor
D: Do you have any partner or children?
P: No
D: Did you have any partners in the past?
P: No, I love to be alone.
D: Do you have any friends?
P: No, I prefer/want to be alone.
P: I used to work at a post office, but I am not working there anymore
D: Are you on any benefits?
P: No doctor, I have my savings.
D: Have you ever had any problems with the law?
P: No, I haven’t had any problems so far.
D: Have you ever been diagnosed with any medical condition?
P: No
D: Are you taking medications?
P: No
D: Has any member of your family ever been diagnosed with any mental health problems?
P: No doctor.
P: No
P: No
D: Thank you for being patient and answering my questions, it seems like that you may have
a condition called delusional disorder
P: What is it?
D: It’s a condition in which a person has a firm false belief.
P: Okay, but I don’t think this is my case doctor!
D: How about let’s just agree to disagree and let me tell you what I can do for you.
As we are worried about you, we would like to keep you in the hospital for sometime to do
some blood test (to rule out medical cause)
One of my colleagues from the mental health team will come and talk to you and if need be
we will get some medications.
Causes:
1. History of delusional disorder or schizophrenia in the family.
508
2. Biochemical factors such as imbalance in neurotransmitters (which can interfere with the
transmission of messages, leading to symptoms)
3. Environmental/psychological factors such as:
- Excessive stress
- alcohol
- drug abuse
- social isolation
- being unmarried
- being unemployed
- low socioeconomic status
1. Neurodegenerative disorders for example multiple sclerosis
2. Other CNS disorders for example brain tumours, epilepsy, trauma
3. Infectious diseases such as HIV
4. Metabolic disorders such as hypercalcaemia, hyponatraemia.
5. Endocrine disorders such as Addison disease, Cushing syndrome and thyroid problems
7. Medications such as anabolic steroids, corticosteroids, cimetidine, and some antibiotics
such as penicillin.
8. Substance abuse such as amphetamines, cocaine, alcohol, cannabis
9. Related psychiatric disorders such as schizophrenia, delirium, mood disorders with
delusional symptoms (manic or depressive type), obsessive-compulsive disorder.
Plan:
Psychiatry referral.
Complete medical history should be taken
Complete physical examination (neurological and cardiovascular examinations)
Blood tests
Infectious disease
Metabolic and endocrine disorders
Vitamin deficiencies
Imaging
CT scan or MRI of the brain (tumours)
Treatment:
Individual psychotherapy
Cognitive behavioural therapy (CBT)
Support Therapy
Insight-Oriented Theory
Family Therapy
509
Address social stressors (living alone, social isolation)
Possible medication such as anti-psychotics, atypical anti-psychotics)
510
ALCOHOL DEPENDENCY
You are F2 Surgery.

Mrs. Samantha Gray aged, 50, has undergone Hysteroscopy. The result of the test is normal.
She is about to be discharged.
Please talk about her alcohol consumption and discuss the management with the patient.
Nurse has some concerns about her alcohol intake and asked you to talk to her regarding
her alcohol habits.

P: Doctor. I am going home (Patient looks happy). I was told that someone is going to talk to
me.
Dr: May I ask why did you come into the hospital in the first place
P: I came to the hospital to do a test. What is the result of my test?
Dr: That’s right we did an investigation to have a closer look at your womb and result came
back normal and you are good to go home.
P: Oh that’s wonderful, may I go home?
Dr: Yes, we will let you go home, however, if you do not mind, may I ask a few question?
P: Sure Doctor.
Dr: So what as been your recent health apart from the reason why you came into the
hospital?
P: Its been fine.
Dr: That's great. Any chance that you suffer from any medical conditions?
P: No Doctor.
Dr: Any family history of medical condition?
P: No Doctor.
Dr: Do you take any regular medications?
P: No Doctor.
Dr: Are you allergic to any medications/OTC/Herbal Remedies?
P: No Doctor.
Dr: That's great, moving on let me ask you some questions about your personal habits?
Dr: Do you smoke?
P: No Doctor.
Dr: Do you do any recreational Drugs?
P: No doctor?
Dr: How about Alcohol?
P: Oh Yes Doctor. I mainly drink wine.
Dr: How much do you drink?
P: Doctor not that much.
Dr: Could you please tell me how much you drink in a day or in a week approximately?
P: Doctor, as much as my friend does.
511
Dr: How about could you give me a rough estimate how much you drank in the last week,
before you came into the hospital?
P: a) I drink around 6-7 bottles of wine per week / one bottle of wine every day 11 drink a
couple of glasses/ 2-3 glasses of wine a day.
Dr: May I know since have you been drinking?
P: Since I was 16 years old doctor.
Dr: Has it always been this much?
P: No doctor, earlier it was less, with the matter of time, it has gone on to increase.
Dr: I understand that, and honestly alcohol is not harmful to the body, if drank in
moderation, however having a bottle of wine a day will have some effect on your body.
Thus, have you ever considered cutting down on your drinking?
P: Yes. about 7 months ago. I went to alcohol anonymous (AA) but I could not stop.
Dr: May I know what happened that you could not stop?
P: a) Doctor. I got many symptoms. I had diarrhoea, tummy pain and my hands started to
shake. I was so agitated.
Dr: Are there any symptoms if you don't drink alcohol?
P: I start to sweat a lot when I don't drink.
Dr: I am glad that at least you made some efforts. Let me ask you another question? Do you
feel
annoyed when people talk about your alcohol habit?
P: No doctor.
Dr: Have you ever felt guilty about your drinking habit?
P: Yes, doctor.. . sometimes I feel guilty.
Dr: Have there been days where in you a drink first thing in the morning?
P: a) Yes. Sometimes I need a drink in the morning else my hand starts to shake
Dr: Does not having alcohol affect your daily activity?
P: I have to drink doctor; otherwise. I cannot do my job.
Dr: Do you have to increase the amount of your alcohol intake to get the same feeling?
P: Doctor, a long time ago I had to increase the amount to get the same feeling, but now I stick
to the same amount.
Dr: Thank you for answering these difficult questions, very quickly let me ask you a few
more general questions that we happen to ask anyone.
Dr: How has your mood been recently?
P: It has been fine doctor.
Dr: Could you please score your mood foj
P: Doctor. I would say 7-8.
P: I live with my husband.
Dr: How do you get on with him?
P: Doctor, we are fine but sometimes we fight.
Dr: Well, I suppose that’s marriage, how about do you have any kids?
P: Yes, doctor I have one daughter. She got married and she lives with her husband.
512
Dr: That's wonderful, do they live nearby?
P: Oh yes doctor...we see each other time to time.
Dr: Wonderful, how about any other relatives who live nearby?
P: Yes, doctor. My mom and my brother live in the town and we meet each other time to time.
Dr: I am glad you have a loving family, how about your friends?
P: I have many friends doctor.
Dr: That’s good, how do you spend your time with them?
P: We go out a lot. We gather to drink.
P: I work in a wine bar.
Dr: Oh I am sure you must be loving your job then, so how are things at work?
P: Doctor, I am happy to be there. It is not stressful and I have many friends there.
Dr: Right, so are your finances sorted?
P: Oh yes doctor. I get paid enough.
Dr: Do you drink after work at the work place?
P: Yes. Doctor, me and friends drink after work.
Dr: Have you ever had any trouble with the law?
P: No Doctor.
Dr: By any chance, have you ever thought of hurting yourself?
P: No
Dr: Thank you for being so patient with me. By the looks at it, your report is normal so that
is sorted, however, your alcohol consumption has been a bit off the recommended
allowance limit. Which is 14 units for females (14 for males), spread over the week.
P: Doctor, I know…but it is not easy for me to stop.
Dr: Well we are here to help you.
P: Yes, doctor please help me.
Dr: As per the conversation, it does NOT seem that there is
1. History of severe withdrawal symptoms.
2. Risk of self-harm.
3. Or family or social support.
So essentially we will not admit to you in the hospital and we will refer to one of the
services and if need be use some medical interventions as well.
So there are Medical and non-Medical options.
What would you like me to talk about?
P: Whichever you want doctor.
Dr.: Let me start with the non-medical options.
1. Self-help groups (Alcohol Anonymous)
2. One to One counselling.
3. CBT
4. Family Therapy
5. Alcohol Diary.
513
Medical Options
1. Acamprosate
2. Naltrexone
3. Disulfiram
4. Chlordiazepoxide
NON-MEDICAL OPTIONS
 In Alcohol anonymous group, you will meet many people who used to drink but have
stopped now. They will share their experience with you. which will motivate you Such
groups help you to realize the problem and assist you to find a solution for it.
 You can also have one to one counselling sessions.
 You will have a talking therapy (CBT) with a solving approach towards alcohol
dependence. It involves identifying the beliefs that may possibly cause the obstacles in
quitting alcohol. For example, if you think that you are not able to work, without taking
alcohol.
 The therapists will help you set a motivational goal. You may not be asked to stop
immediately instead you will be asked to reduce gradually and then eventually stop.
 They try to identify and help to avoid and eliminate the triggers. For example, you told
me that you work in a wine bar; this may make help to address this issue.
 I am sure you agree that family support will have a positive impact on you and will
improve the efficiency of your treatment. Our colleagues can talk to your family about
the problem and the approach we are taking towards solving it if you wish to (Family
therapy).
 You may be asked to complete a diary in which you will be recording your alcohol intake
regularly. This will help to show you and your therapist how well you are doing and how
soon you reach to your target (Alcohol diary).
MEDICAL OPTIONS
Now I am going to talk about medical options you have got:
There are some medications that help to reduce your craving for alcohol (Acamprosate).
There are some other medications that block the receptors in our body that are sensitive to
alcohol. This will help to reduce the amount of alcohol intake and prevent relapse. These
medications are usually prescribed along with counselling and other therapies (Naltrexone/
Nahnefene).
There is another type of medication that, reacts with alcohol and leads to an unpleasant
feeling. So you might not want to drink again since you may have some symptoms like
feeling sick, vomiting, dizziness or chest discomfort when you drink alcohol (Disulfiram).
You may be prescribed some medications to reduce the withdrawal symptoms such as
agitation and hand shaking (Diazepam/Chlordiazepoxide).
P: Thank you Doctor.
514
Dr: You're Welcome. The major credit goes to one of our nurses as she picked up that you
may have an alcohol issue.
Dr.: Before I leave, any questions for me?
P: No Doctor.
Dr. Take care
515
DRUG DEPENDENCY
You are F2 in Psychiatry.

Mr. Jack Sparrow aged, 35 has been referred to you. He wants to quit taking drugs.
Please talk to the patient, take history, talk about his opioid abuse and discuss about
management options with him.
Note:
The patient is sitting on a chair and doesn’t have good eye contact.
GREETINGS
P: Doctor. I am taking drugs and I am addicted to it. I want to give it up! I went to my GP and
he sent me to the hospital.
D: That's a great decision that you have made. We are going to help you however in order to
provide you with the best treatment, how about I ask a few of questions first.
P: Sure!
D: So firstly what drug are you referring to?
P: I take heroin doctor.
D: How do you take it?
P: I used to sniff it doctor, but now I am injecting myself.
D: Do you share the needle?
P: No doctor. I am on a needle exchange program.
D: That’s good. May I know, how much do you take?
P: I take 1 gm per day doctor. It costs me “X” every day.
D: How many times per day do you use it?
P: I take it 2-3 times per day doctor.
D: Could you please tell me since when have you been doing it?
P: Since I was 17 doctor / Since 4-5 years ago doctor.
D: Any other drugs apart from heroin?
P: Yes, I have tried Cannabis, Amphetamine and Cocaine.
READ THE TASK
(Dr: I will address these issues later if we have time, let’s focus on the heroin problem at the
moment.)
D: So when did you start taking Heroin
P: It was just a mistake doctor.
D: However, its great you want to stop, so that's great, however I want to know why do you
want to stop?
P: Because of my family doctor. 11 can't afford it any more doctor. / Doctor, there is no vein
left in my body to inject.
D: I understand. Have you ever tried to cut it down or stop?
P: a- Yes. but I couldn't maintain it doctor.
b- Not really.
516
D: May I know why?
P: Doctor, I developed many symptoms, like tummy pain/discomfort. I would feel sick. My
hands began to shake and I also felt my heart racing. I would become nervous as well.
D: I'm so sorry to hear that. Do you feel annoyed when people talk about your addiction?
P: Yes doctor. I feel uncomfortable.
D: Have you ever felt guilty about your addiction?
P: Yes, I do and that's why I want to stop.
D: Do you need it first thing in the morning?
P: I always need it doctor. It doesn't really matter what time of the day it is.
D: That must be every difficult for you, so tell me are you able to manage your daily
activities without talking it?
P: No doctor.
Note: Please don’t ask for withdrawal symptoms if he answered earlier.
D: Do you have to increase the amount to get the same feeling?
P: No
D: Thank you for answering those difficult questions, let me ask you a few general questions
that we tend to ask everyone, for starters how has been your mood recently?
P: It’s been alright doctor.
D: how about you help me by scoring it for me. one being the lowest and ten being the
highest?
P: It’s been around 3-4 doctor.
D: May I know, whom do you live with?
P: I live with my partner and kids.
D: How is the relationship with your partner?
P: It's good doctor. I love her and I want to stop for her. I It’s alright but sometimes we fight
doctor.
D: May I know why?
P: Because of my heroin habit doctor. I Doctor, she also does drags.
D: How is the relationship with your kids?
P: Great! We all love each other doctor.
D: That’s wonderful, having a motivation will help you quit, and one of the best support is
the support from family. Talking about support tell me about your friends?
P: I have a few doctor.
D: How do you spend time with them?
P: Doctor, we do drugs together.
P: I am not working at the moment doctor. I am on benefit. I was self-employed earlier.
D: How do you buy heroin?
P: My friends help me doctor.
D: Have you ever had any trouble with the law?
P: I was arrested once for shop lifting and stealing.
517
P: No.
D: Any allergies?
P: No
D: Any Medical Condition?
P: No
D: Okay let me tell you what we can do for you.
Considering the fact that I do not see any warning signs so mostly we will not be admitting
you in the hospital and we will offer you one of the services and along with some
medication.
P: I am not working at the moment doctor. I am on benefit. I was self-employed earlier.
MANAGEMENT
Non-medical
1. Narcotic Anonymous
2. One to One Counselling
3. Talking Therapy (CBT)
Medical
1. Methadone along with non-medical treatment
There are some things that you can do and some things that we can do to help and support
you.
You can try' the self-help groups. Narcotics anonymous is one of them. You will meet many
people who had similar problem and have stopped. They will share their experiences which
will motivate you as well.
You can also try one to one counselling sessions.
You can go for a talking therapy with a solving approach towards drug dependence (CBT).
Medical
D: We can give you a medication called methadone. It will reduce the craving as well as
your withdrawal symptoms.
D: Any questions for me?

P : No doctor?
Sometimes patient will tell you that Social service is taking care of my child
NOTE:
If both the parents are taking drugs and they didn’t mention that social service is taking care
of the children, then you need to mention about the social service for the safety of the
children.
518
SUICIDE

Anastasia aged, 16 has taken some tablets last night and cut her wrist this morning. Medical
management has been done and patient is medically stable.
Please talk to the patient, take history and discuss about management with the patient.
Note:
Patient has a bandage on her wrist. She looks unhappy and she has poor eye contact.
♦GREETING*
Dr: Hello my dear, what brings you to the hospital?
P: Doctor. I want to go home.
Dr: I understand that you want to go home but let me first ask you a few questions and then
if everything is fine you can go home. Is that alright?
P: Okay.
Dr: I see there is a bandage on your wrist, may I ask what ha
P: Doctor, I took some tablets and cut my wrist.
Dr: I’m sure it must have been a stressful situation that y at I am very sorry to hear
that. We are here to help you, you can trust me on this, whatever we speak will be
between you and your health care system. PAUSE Could you please tell me why did you do
that?
P: Doctor. I missed my period and I realised that I’m pregnant. I called my boyfriend to let him
know and then we had a fight over the phone. Doctor, he broke up with me. . .he left me.
Dr: Relationships can be difficult. I’m really sorry to hear that. If you are comfortable to
proceed
may I ask a few more questions?
P: Sure
D: You mentioned that you took some tablets, may I know what did you take?
P: I took some OCP pills.
D: How many?
P: 21 doctor.
D: Where did you get them from?
P: I took my mom’s pills.
Dr: When did you take them?
P: I took them last night before going to bed.
Dr: Okay... You told me that you cut your wrist, how deep did you cut?
P: It wasn’t that deep doctor.
Dr: May I know when did you do that?
P: I woke up this morning and realised that nothing has happened then I cut my wrist.
Dr: Where did you do that?
P: I went to the bathroom and cut my wrist.
519
Dr: Who was there at the time?
P: No one was there doctor. I was there by myself. My mom was at work.
Dr: May I know what did you do after that?
P: I was so scared doctor! I held my wrist and tried to press it to stop the bleeding and then I
called a cab and came here.
Dr: That’s a wonderful thing that you did. Did you inform any member of your family?
P: No doctor, I just rushed to the hospital.
D: Would you like us to inform your parents?
P: No. Please don’t let them know.
Dr: That’s okay, if you don’t want me to call them. By any chance did you take any alcohol
when you took the pills or you cut your wrist?
P: No doctor.
Dr: How about any recreational drugs?
P: No
P: Doctor, I am fine. I don’t want to stay in e hospital. Can I please go home?
Dr: I understand that you want to go home just a few more questions to make sure that
everything is fine.
P: Okay fine.
Dr: Has this happened before?
P: No doctor.
Dr: Do you think you are going to do it again?
P: It was so stupid of me doctor. I’m embarrassed about what I did.
Dr: How do you feel about what you did?
P: (She keeps quiet.)
Dr: Would you say you feel bad?
P: Yes
Dr: Did you plan for it?
P: No doctor.
Dr: Did you tell anyone before doing it?
P: No doctor.
Dr: By any chance, did you leave any note?
P: No"
Dr: Doctor. . . please let me go home. I'm fine.
Dr: I can imagine how frustrated you are. Just bear with me for a couple of months.
Dr: How has your mood been recently?
P: Doctor not too bad.
Dr: Could you please score your mood for me, with 1 being the lowest and 10 being the
highest?
P: Doctor. I would say 5-6.
P: I live with my mom doctor.
Dr: Does anyone else live with you and your mom?
520
P: My little brother.
Dr: How is your relationship with your mother?
P: I’m very close to her but I haven’t told her about my boyfriend.
Dr: Do you get on well with your brother?
P: He is just a little kid so we don’t have much to talk.
Dr: How about your dad? Where does he live?
P: Doctor, my parents got divorced a few years ago. He doesn’t live with us anymore.
Dr: I'm so sorry to hear that. Are you in touch with him?
P: I see him once in a while.
Dr: What do you do? Are you going to school or you work?
P: Doctor, I’m going to school.
Dr: How are things at school? Are you catching up well?
P: Not really doctor. I’m a bit lagging behind from my classmates.
Dr: Do have any friend in school? Are you getting on well with your friends?
P: Yes, doctor. I have many friends at school.
Dr: How about any friends outside school?
P: Yes, I’ve got a few.
Dr: Do you mind if I ask you a few questions about your boyfriend?
P: That's alright doctor.
Dr: May I know for how long you have been together?
P: It s been a few months now.
Dr: How did you guys meet?
P: We go to the same school doctor.
Dr: May I know how old he is?
P: He is 16 years old.
Dr: By any chance have you ever had any trouble with the law?
P: No.
Dr: Have you ever been diagnosed with any medical conditioi
P: No doctor.
Dr: Have you ever took advice from mental health experts?
P: No.
Dr: Has any member of your family ever been diagnosed with any mental health illness?
P: No.
P: No. ’
Dr: How about any recreational drugs?
P: No.
P: Doctor, Can I please go home?
Dr: I totally understand your situation, definitely hospital is not the right place you want to
be in and clearly you have been through a lot, and all seems like situational. It is indeed a
difficult situation and I think bringing in the family in the picture would help, what do you
have to say about that?
521
P: Doctor, if I ask my mom to come, can I go home?
Dr: How about we call your mother, talk to your mom. address the safety issues, and
meanwhile my colleagues will come and talk to you regarding the help they can provide
from their side. Once everything is fine, we will send you ASAP.
P: Okay.
Dr: My colleagues will come and repeat a pregnancy test, just to make sure everything is
fine and if need be what are the possible interventions needed.
Dr: Any questions for me?
P: No Doctor.
Dr: Let me call your mother, would you mind waiting here till then?
P: No problem doctor.
D: Great, I will see you in sometime.
522
PCM OVERDOSE HOMOSEXUAL PATIENT
You are F2 in A&E.

James, aged 19, took 16 paracetamol tablets.
Please talk to him and do initial plan of management.

P: I took some tablets.
D: May I know which tablets?
P: PCM
D: May I know how many tablets did you take?
P: 16
D: When did you take?
P: 2 hrs ago.
D: Did you take them in one go or did you take them at different times?
P: I took them in one go.
D: Did you take anything else with it?
P: I took it with a glass of water.
D: Did you take alcohol with it?
P: No
D: Did you take any other medications with it?
P: No
D: By any chance did you take any recreational drugs?
P: No
D: Did you try to throw them up?
P: No
D: How do you feel now? Do you have any symptoms?
P: I am fine and I don't have any symptoms.
P: No
P: No
D: Any vomiting?
P: No
P: No
D: Do you have any liver, kidney diseases?
P: No '
D: Any blood disorders?
P: No
D: Do you take any regular medications, OTC or herbal remedies?
P: No
523
P: No
D: May I know why you took PCM tablets?
P: I had an argument with my mother after she found out that I am gay and I have a boyfriend.
She is not accepting this.
D: I am so sorry to hear that. Where were you when you took the tablets?
P: I was in the hostel accommodation.
D: Who was there with you?
P: I was alone.
D: Who brought you to the hospital?
P: I called the ambulance.
D: What did you do afterwards?
P: I called my boyfriend and he told me to go to the hospital.
D: Have you ever tried to harm yourself in the past? Has it happened before?
P: No
D: Do you think you are going to do it again?
P: No. I feel bad for what I have done.
D: How do you feel about what you did?
P: I feel bad/stupid I guilty for what I have done.
D: Did you plan for it?
P: No
D: Did you tell anyone before doing it?
P: No
D: Did you leave any note?
P: No
D: How has your mood been recently?
P: Not too bad. It is been fine.
D: Could you please score your mood for me with 1 being the lowest and 10 being the
highest?
P: 6-7
P: I live with my bf in the hostel.
D: Do you have any other family members apart from your mother?
P: No
D: how about your dad?
P: My parents got divorced.
D: How is your relationship with your mother?
P: She hates me being gay.
D: What do you do?
P: I just started studying in university
D: Do you work?
P: I am a student.
524
D: Are you financially stable?
P:
P: Yes, I have many friends.
D: Tell me about your boyfriend?
P:
D: How long have you been together?
P:
D: How is your relationship to your boyfriend?
P:
D: Have you ever had any mental health problems?
P: No
D: Do you smoke?
P:
P: No
D: Do you use recreational drugs?
P: No '
EXAMINATION
I would like to check your vitals, examine your tummy.
As you told me, you took some paracetamol tablets. We are going to keep you in the
observation unit to keep monitoring you. We also need to do some necessary investigations.
We will do some blood tests:
LFT, KFT, Bleeding and clotting profile and the level of PCM.
Depending on the level of paracetamol, you may need to receive some treatments.
Dr: I totally understand your concern. Like I said, it is very important for you to stay in the
hospital since we need to check the level of paracetamol in your blood in the next couple of
hours and then treat you accordingly (after 4 hours of paracetamol ingestion). If this is left
untreated, it can cause many complications.
We are going to give you a medication called N-Acetyl cysteine also known as NAC, If the
level of PCM was found high in your blood, we need to give you this medication through
your blood vessel as a drip. So. you need to be in the hospital while we are giving you the
medication.
If you need any treatment, the course of medication usually takes around 21 hours. Once
the course of treatment has been completed, we need to reassess you. We may do some
blood tests to make sure everything is fine.
When we have made sure that you are medically fine, you need to be referred one of our
colleagues. I will arrange for you to be seen by our psychiatric colleague. Our colleague will
talk to you to find out if you have any stress in your life that may have caused this event.
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Their aim is to support you. They will help you out in relieving your stress and improving
your mood.
Don’t you think you need someone to be with you? Do you want to inform your mother or
your boyfriend to be with you? You may need their help and support?
We can also have a talk with your mother if you wish to.
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ALCOHOL COLLEAGUE
You are an F2 started your Surgery Rotation.

Your colleague Peter Roocroft aged 23 is F2. He has also started his surgery rotation. You
saw him on the ward round last week and he smelt of alcohol. You have noticed it again
today this morning that he smells of alcohol. A few other people have also noticed this.
Talk to your colleague about his problem and assess his situation. You have asked your
colleague to meet with you. You have arranged a meeting in a quiet room with your
colleague after you have finished your work.
D: Hello Peter. Thank you for meeting with me on such short notice.
P: That's okay
D: How's your day going?
P: Great. Thank you
D: Lovely. Peter, do you know why am I here for?
P: No
D: No worries. So how has been your life in general?
P: Actually I broke up with my girlfriend recently. I'm drinking to drown my feelings.
D: I’m very sorry that you are going through such a difficult period. If you don't mind, could
you please tell me how much you are drinking these days?
P: One bottle of wine and/or few pints of beer.
D: At what time of the day do you usually drink?
P: I drink at night only.
D: Peter. I am here to help you. please be honest with me. it is just that I could smell alcohol
when I walked past you this morning. Have you been drinking in the morning before coming
to work?
P: Last night I had some beer left so I drank it in the morning.
D: Thank you for having trust in me. Let's talk about how things were in the past. I mean
how much you use to drink before?
P: Occasionally
D: So as I understand things so far. this drinking habit has been a recent event and not a
chronic problem. However. Peter would you agree with me that working under the
influence of alcohol would hinder your decision making skills especially as a doctor, when
patient's lives are at stake? (INSIGHT)
P: Yes. I'm sorry I was just very stressed because of the break up.
D: I completely understand what you are going through. However, have you been seeking
any
other substances to help yourself? (DRUGS)
P: No
D: With whom do you live?
P: I live alone.
D: Any close relatives live nearby? (FAMILY)
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P: No. My parents live a few hours away.
D: How would you describe your relationship with them?
P: It's fine. I plan to meet them next week.
D: How about your friends? (FRIENDS)
P: I have many.
D: That’s great peter, I am sure this is just a phase and it will pass by the help of your friends
and family.
I am going to ask a question, it may sound silly however, have you thought of harming
yourself?
(SUICIDE)
P: Absolutely not.
D: Good. BAC are you aware of any incident that has happened so far as a result of your
drinking?
P: No.
D: Have you ordered any investigations, prescribed medication or discharged any patient
today?
P: I did prescribe some medication to a few patients.
D: Okay. Nothing personal however, in the interest of patient safety one of our team
members will need to review those patients. Could you please provide me with a list of the
activities you have undertaken today ?
P: Okay.
D: Peter, I'm afraid I have to inform one of the seniors about this situation. Although I can
appreciate you are going through a hard time, it's important to remember that we value
patient safety more than anything else and that's why wc must handle this in a professional
way.
P: What will happen next?
D: You may be required to have a test and depending on your test result, you may have an
interview with one of the senior managers to discuss the matter further.
P: Okay
D: I'm sorry that you've had to go through such a stressful period. It would be great to seek
help from your GP for confidential advice. You can also consult with your educational
supervisor for some help. Our senior will also help you overcome this difficult period. At the
same time, if you need somebody to talk to I would be glad to hear you out.
P: Thank you.
D: For the time being, it's best not to remain in the clinical area or drive for a while. May I
ask how you plan to get home?
P: I will take a taxi.
D: Thank you Peter for your time, and as I said before, it’s a phase and it will certainly pass,
take it easy and I'll see you around.
P: Thank you
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COCAINE COLLEAGUE

John Figo, 25years old, is a final year medical student. You saw him at a birthday party last
night. He was drinking heavily and taking cocaine.
The following morning you overheard the nurse colleagues talking about his behaviour.
During the ward round they noticed that he was agitated and hyper-excited.
Please talk to your colleague, assess his condition and manage the situation appropriately.
D: Hello John. Thank you for meeting with me on such short notice.
C: That's okay
D: How’s your day going?
C: Great. Thank you.
D: Lovely. John, do you know what I am going to talk to you about?
C: No
D: Never mind, so I saw you at last night’s party?
C: Oh, you saw me there?
D: I did and it is just that I am a bit concerned as you were probably drinking too much.
C: It was just a party.
D: Fair enough. However, by any chance did you take anything else besides alcohol last
night?
C: No
D: How about any recreational drugs?
C: No. Why do you think so?
D: It is just that this morning our colleagues noticed that you were a bit agitated and hyper
excited.
C: No I wasn’t. I was perfectly normal. What do you mean?
D: Actually, last night at the party I saw you taking something.
C: Like what?
D: I may be wrong however by the looks of it I think what you taking looked like cocaine. Is
that true?
C: Is this conversation confidential?
D: Yes, Absolutely it will be remain within the system. However, I do have to inform at least
one of the seniors in order to make the best decision for you and the care of our patients.
C: Okay. I took cocaine.
D: I appreciate your honesty. May I ask how long you've been doing cocaine for?
C: Not long. Just a few months.
D: How often do you take it?
C: Only on my night out with friends.
D: Is there any particular reason why you take it?
C: Just recreational use. Everyone does it. Even you've probably tried it at some point.
D: Well not really. Anyway, lets get back to our discussion. So how much do you us
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C: Not much, just a line or two.
D: Have you ever taken it during work hours?
C: Never. I make sure it doesn't affect my work.
D: Well John as I said, this morning our colleagues noticed that you were a bit agitated and
over excited. Don’t you think that it has affected your workplace already (INSIGHT)
C: But I take it in my personal time.
D: Agreed, however I believe it may affect your decision making skills, and soon you may get
addicted to it as well. Thus, have you ever thought of cutting down or stop completely? (CUT
DOWN)
C: I don't do it that often.
D: Do you feel guilty about it? (GUILTY)
C: No.
D: How's your mood recently? (MOOD)
C: It's fine.
D: Apart from cocaine, are you using any other recreational drugs? (DRUGS)
C: No
D: Could I ask briefly about your drinking? How often do you drink? How much do you
drink? (ALCOHOL)
C: I drink 1-2 glasses of wine every day. I drink with my friends after work. But it doesn’t affect
my work. I don’t take it in the work place.
D: May I ask who you live with? (FAMILY)
C: I live with my parents.
D: How's your relationship with them?
C: It's fine.
D: How about friends? (FRIENDS)
C: I have many.
D: Thank you for having the converstation with me John. I'm sure you are aware that
cocaine is a very strong stimulant. It results in overconfidence that can lead to you taking
risks. This compromises patient safety which is our most important value. It will also affect
your behaviour and performance. Such behaviour is not consistent with the values of good
medical practice. This can have a very negative effect on your image as a doctor.
Aside from this, cocaine can cause some severe medical complications to you. It can lead to
heart attacks, seizures, strokes, coma and many other unexpected effects. I do not want this
for you and that’s why I’m here to help and support you in this matter.
C: I understand.
D: Are you aware of any incident that has happened so far as a result of taking cocaine?
C: No.
D: Have you ordered any investigations, prescribed medication or discharged any patient
today?
C: I did prescribe some medication to a few patients.
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D: Okay. I hope you don't take this personally but in the interest of patient safety I need to
review those patients myself. Could you please provide me with a list of the activities you
have undertaken today?
C: Okay.
D: John, As I mentioned. I'm afraid I have to inform one of the seniors about this situation.
It's important to remember that we value patient safety more than anything else and that's
why we must handle this in a professional way.
C: What will happen next?
D: You may be required to have a test and depending on your test result, you may have an
interview with one of the senior managers to discuss the matter further.
C: Okay
D: This decision is what is best for not only our patients, but also for you. We are here to
support you. It would be great to seek help from your GP for confidential advice. You can
also consult with your educational supervisor for some help. Our senior will also help you
overcome this difficult period.
C: Thank you.
D: For the time being, it's best not to remain in the clinical area or drive for a while. May I
ask how you plan to get home?
C: I will take a taxi.
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COLLEAGUE COMING LATE

Darren, a final year student who is a part your medical team, is coming late to the ward.
Your colleague has also noticed this.
Please talk to him.
D: Hello Darren. Thank you for meeting with me on such short notice.
C: That's okay
D: How's your day going?
C: Great, Thank you
D: How is your hospital posting going?
C: it is fine.
D: Are you enjoying talking to the patient in the hospital?
P: Yes.
D: Glad to hear that. Darren, do you have any idea what I'm going to talk to you about?
P: No
D: Actually I'm a little bit concerned about your time-keeping. I noticed you came late to the
ward today. This is not the first time I've noticed.
C: (Stays quiet)
(Pause briefly and allow Darren some time to open up. If he does not, then speak about it)
D: There's no need to worry at the moment. Is there any particular reason why you are
coming
late?
C: Actually I was stuck in traffic this morning
D: OK. How about the other days?
P: I'm usually on time. I was only late this morning.
D: Actually my colleague has also noticed that you are coming late quite often and brought
it to
my attention.
C: Yes. I think I've been late a few times this week.
D: Thank you for your honesty. Is everything okay at home?
C: Yes. It won't happen again.
D: is there anything bothering you?
C: No
NOTE - He doesn't have any personal problem which can be the reason. Rather, he
mentioned that he came late only today because he was stuck in traffic and usually he is on
time.
D: May I ask how far away you live from here?
C:
a) It takes me one hour to reach by train and bus.
b) I live very far away. It takes me 2 hours to reach by train.
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(In case of b) NOTE - an employee who is unable to get to their normal place of work should
discuss the possibility of working from an alternative place of work with their supervisor.
D: If you are finding it difficult to get to your normal place of work you should discuss the
possibility of working from an alternative place of work with your supervisor.
D: OK. I'm sure you know that it is very important for doctors to be punctual and maintain
good time-keeping skills. By coming late, we may not be present at a crucial time when a
patient
needs us and this can compromise our care to patients.
C: I understand.
D: As a medical student it's very important that you demonstrate to all staff that you are
capable of coming on time and hence, we can rely on you. You will also find that you will be
able to learn a lot more if you come on time because the morning ward rounds offer a great
opportunity to learn.
C: OK. I'm sorry for coming late. I will not repeat it.
D: That's fine. It would be a good idea to attend a time-management training course. It will
enable you to manage priorities and schedule tasks more effectively. Anyone at any level,
including myself, will benefit from the strategies and techniques discussed in these courses.
You can find out more from your educational supervisor
C: Okay
D: Do you keep alarms?
C: No
D: I suggest you to do that. It will help you in waking up early. And also In the future, if you
anticipate any travel problems or if you are unable to reach your place of work, you must
telephone your educational supervisor as soon as possible to explain the circumstances.
Does that sound okay?
C: Yes.
D: I think it would be better if you inform your supervisor because if he will come to know
from somewhere else then it won’t be good.
D: Regarding this matter, do you have any concerns or questions that I may be able to help
with?
C: No.
D: OK. Feel free to talk to me if I can help in any way. Have a good day.
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COLLEAGUE CONFIDENTIALITY ISSUE (FACEBOOK POST)
You are F2 working in A&E.

Your colleague Peter an FYI doctor made a post on Facebook about an elderly lady in the
emergency department with confusion who considered herself to be the queen of England.
D: Hello Peter. Thank you for meeting with me on such a short notice.
P: That's okay.
D: How's your day going so far?
P: Great. Thank you.
D: Peter do you know what I am going to talk about?
P: No
D: Did you recently make a post on social media regarding one of our patients?
P: Oh yes doctor. You know I could not stop laughing while seeing the patient. Her name was
Diana. She was confused and she was thinking herself to be the Queen of England. Hilarious.
She was making funny comments like she lost her crowns and she was looking for it. So, I made
a video of her and posted it.
D: Ok. Where did you put in on Social Media?
P: I posted it on my Facebook profile.
D: Did you post her name and other details as well on Facebook?
P: No, I just posted the video.
D: Peter I don't think you did the right thing. Posting patient information on social media is a
breach of confidentiality. Being a medical professional, we must obey the rules and
regulations of NHS. Before putting patient information online, think about why you are
doing it. You should definitely take the consent of your patient if you want to post
something. Don't you think so?
P: Yes. But I didn't mean to break the rules. It was just for fun
D: I do understand what you are trying to say. Many people are unaware that how easily
this information can spread on Facebook. Even if using the most stringent privacy setting,
information on social networking sites may still be widely available in search engines.
Deleting information is not sure-fire protection. It is almost stored in cyberspace and
theoretically permanently accessible.
P: To be honest I didn't think that much before posting it.
D: Yes, I know. You wouldn't have done it if you had thought about the consequence.
Breaching confidentiality can result in complaint to GMC and legal actions. Moreover, it can
erode public trust on the medical professionals, and it can hinder us getting the information
from the patients to treat them better.
P: Yes, you are right. I am so sorry for what I have done. What should I do now?
D: I highly encourage you to delete the post immediately. I sincerely advice you not to do it
in future. How's she doing now?
P: She is much better and fully conscious.
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D: I am really happy to hear that. I would request you to talk to her and apologise to her for
the incident.
P: Ok. I will talk to her.
D: And It is very important to inform our seniors specially our consultant about the incident.
It will be bad if he gets to know about it from others. To be honest, he is the best person to
help us if we are in trouble. If you want, I can be there with you while you talk with our
consultant and we both can explain him a better way.
P: Thankyou
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ANOREXIA NERVOSA

Emma, aged 18, is sent to the hospital by the GP because she was losing weight for the past
6 months. She has not been diagnosed with any medical condition.
She is not taking any medication. Her BM1 is 17.
Talk to the patient and discuss initial plan of management with her.
D: What brought you to the Hospital?

P: My parents have some concern about my weight loss. They took me to GP and he sent me to
the hospital.
D: Are you losing weight?
P: Yes
D: How much weight have you lost?
P: 2 stones
D: In how much time have you lost this weight?
P: In last few months
P: No doctor.
P: Yes, I want to lose weight
D: How are you losing weight? Do you have any diet or exercise plan?
P: Yes, I have a diet plan.
D: Tell me about you diet plan, what do you eat?
P: Every morning I eat apple, I don’t eat lunch. I only eat biscuit or salad in dinner.
D: Do you do any exercise?
P: Yes, I go to gym twice every day, morning and evening.
D: How long is each session?
P: Each session lasts for around one and a half hour.
D: Do you check your weight?
P: Yes. I check my weight few times a day.
P: Fine but I am tired all the time
D: Do you feel hungry?
P: Yes
D: Do you feel lightheaded?
P: Yes
D: Do you feel dizzy?
P: Yes Dr., but I want to lose weight
D: How are your periods?
P: I’m not having periods since last few months.
D: Are you on any contraceptives?
536
P: No
D: Could it be possible that you’re pregnant?
P: No
D: May I know why you want to lose weight?
P: Dr. I want to look thin and attractive. I want to wear nice clothes. I have a friend who looks
attractive and is slim and she also found a new boyfriend. I want to be just like her. She is not
hanging around with me.
Empathy Try and find out if there is insight, and if she would be willing for treatment.
D: Do you have any role model?
P: Jennifer Lopez
P: I don’t have a good mood Doctor
D: Score your mood?
P: 1-3/10
P: I have been upset since it is affecting my studies.
D: How are things at school?
P: I’m a bit behind my classmates, as I am unable to study because of this.
D: Do you get along well with your parents?
P: Yes, doctor.
D: Have you ever thought of harming yourself?
P: No
D: Considering your BMI is 17 and from the conversation we had it seems like you have a
condition called as Anorexia Nervosa and it is important to start treatment right away. Is
that okay?
P: Yes
D: We are going to admit you in the hospital and run a series of initial blood investigations
that includes; FBC, BMI, U&Es, TFT, LFT. Along with that one of my colleagues will help you
with diet plan as well. In addition to that, we will arrange for some talking therapy as well
so that we can have a holistic approach towards the situation.
Once we feel you are well enough to be discharged from the hospital, we will refer you to
suitable services such as:
1. Diet Advice
2. CBT
3. Family Therapy
DIET ADVICE:
During your treatment you will probably be given advice on healthy eating and your diet.
However, this advice alone will not help you recover from anorexia, so you will need to have
talking therapy as well as dietary advice.
537
Your doctors will probably also advise you to take vitamin and mineral supplements so you
get all the nutrients you need to be healthy.
Anorexia can make your bones weaker, which can make you more likely to develop a
condition called osteoporosis. This is more likely if your weight has been low for a year or
more in children and young people, or 2 years or more in adults.
Because of this, your doctor may suggest you have a special type of X-ray called a bone-
density scan to check the health of your bones.
Girls and women are more at risk of getting weak bones than men, so your doctor may
prescribe you medicine to help protect your bones against osteoporosis.
Cognitive behavioural therapy (CBT):

If you are offered CBT, it will usually involve weekly sessions for up to 40 weeks (9 to 10
months), and 2 sessions a week in the first 2 to 3 weeks.
CBT involves talking to a therapist who will work with you to create a personalised
treatment plan.
They will help you to:
1. cope with your feelings
2. understand nutrition and the effects of starvation
3. make healthy food choices
They will ask you to practice these techniques on your own, measure your progress, and
show you ways to manage difficult feelings and situations so you stick with your new eating
habits.
Treatment for children and young people

Children and young people will usually be offered family therapy. You may also be offered
CBT or adolescent-focused psychotherapy. CBT will be very similar to the CBT offered to
adults.
Family therapy
 Family therapy involves you and your family talking to a therapist, exploring how
anorexia has affected you and how' your family can support you to get better.
 Your therapist will also help you find ways to manage difficult feelings and situations to
stop you from relapsing into unhealthy eating habits once your therapy ends.
 You can have the sessions together with your family or on your own with the therapist.
 Family therapy is sometimes offered in a group with other families.
 You will usually be offered 18 to 20 sessions over a year, and your therapist will regularly
check that the schedule is still working for you.
Where treatment will happen
538
Most people with anorexia will be able to stay at home during their treatment. You will
usually have appointments at your clinic and then be able to go home.
However, you may be admitted to hospital if you have serious health complications. For
example, if:
• you are very underweight and still losing weight
• you are very ill and your life is at risk
• you are under 18 and your doctors believe you don’t have enough support at home
• doctors are worried that you might harm yourself or are at risk of suicide
Your doctors will keep a careful eye on your weight and health if you're being cared for in
hospital. They will help you to reach a healthy weight gradually, and either start or continue
any therapy.
Treatment for adults:

A number of different talking therapies are available to treat anorexia. The aim of these
treatments is to help you understand the causes of your eating problems and feel more
comfortable with food so you can begin to eat more and reach a healthy weight.
You may be offered any of the following types of talking therapy. If you feel one isn't right
for you or isn't helping, you can talk to your doctors about trying a different kind of therapy.
539
DEPRESSION (CBT FAILED)

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.

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.
Pt: I am a plumber
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Pt: No
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 Antidepressants.
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
541
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;
 paroxetine (Seroxat), fluoxetine (Prozac) and citalopram (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
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):

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 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.
SNRIs
• 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 (Effexor).
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 thoughts, feelings, bodily sensations and the world around you to improve
your mental wellbeing.
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• 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.
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DEPRESSION (REFUSING TREATMENT)

Maria Douglas, aged 35, has been on CBT treatment for her depression for 8 weeks. She has
come in at 6 weeks and does not want to continue with it.
Speak to the patient, take focused history and address the patient’s concerns.
Low mood because of the divorce.
F
A Drinking heavily
M
I
S
H
Refer
Admission
Medication??
Refer to depression scenario.
1. Side effects of antidepressants?
2. Will it cause loss of libido
545
DEPRESSION (WEIGHT LOSS)

Diana Whales, aged 30, came to the clinic because of concern of weight loss.
Please talk to her and discuss your plan of management with her and address her concerns.

P: I am losing weight
D: Since when have you been losing weight?
P: For the past 1 year
D: Is it intentional or unintentional?
P: It is unintentional
D: Have other people noticed it?
P: Yes, people around me telling me about it.
D: How much weight have you lost?
P: I have lost half a stone.
D: Anything else?
P: Like what?
D: Do you have any lumps or bumps?
P: No
D: Are you eating well?
P: Yes
P: Yes
D: Do you feel a swelling in your neck?
P: No
D: Do you have an irregular and/or unusually fast heart rate?
P: No
D: Do you feel hot when others around you feel cold?
P: No
P: No
D: Any diarrhoea or vomiting?
P: No
D: Can you score your mood?
P: 3 or 4
D: Since when has your mood been this way?
P: For the past 1 year
D: Do you have a loss of interest in everyday activities?
P: Yes/No
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D: Do you have feelings of emptiness or worthlessness?
P: Yes/No
D: Do you have a disturbed sleep pattern?
P: Yes/No
D: Do you have recurrent thoughts about dying?
P: Yes/No
D: Do you feel suicidal/like hurting yourself?
P: Yes/No
D: Are these feelings constant?
P: Yes/No
P: No
D: Any history of depression and comorbid mental health or chronic physical disorder?
P: No
P: No
P: No
D: Any allergies from any food or medication?
P: No
P: No
D: Any family history of mental illness?
P: No
D: Do you smoke?
P: No
P: Yes
D: Do you use recreational drugs?
P: No
P: Good/Bad
P: Yes/No
P: I have a 2-year-old child
D: How are things at home with your child?
P: Fine
D: Do you get along well?
P: Yes
D: Is the child eating well?
P: Yes, I make sure he eats healthy
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P: Yes
D: Has he received his jabs?
P: Yes
D: Do you have any other family members around?
P: Yes/No
D: Are they supportive?
P: Yes
D: How about friends?
P: Yes
D: Do you work?
P: No
D: Is there a reason?
P: I have to take care of my child at home.
P: No, I am on benefits at the moment.
I would like to do GPE and vitals.
From the history you have given me, it appears you may be suffering from depression.
Depression is more than simply feeling unhappy or fed up for a few days.
Most people go through periods of feeling down, but when you’re depressed you feel
persistently sad for weeks or months, rather than just a few days.
Depression
Doctors describe depression by how serious it is:
 Mid depression – has some impact on your daily life
 Moderate depression – has a significant impact on your daily life
 Severe depression – makes it almost impossible to get through daily life; a few people
with severe depression may have psychotic symptoms.
Risk assessment and psychological history:
Most people with depression will get better without treatment. However, this may take
several months or even longer. Relationships, employment, etc., may be seriously affected.
There is also a danger that some people turn to alcohol or illegal drugs. Some people think
of suicide. Therefore, may people with depression opt for treatment.

Cognitive therapy is based on the idea that certain ways of thinking can trigger, or fuel,
certain mental health problems such as depression.
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Antidepressant medicines:
Antidepressant medicines are commonly used to treat moderate to severe depression.
Antidepressant medication is not usually recommended for the initial treatment of mild
depression. However, an antidepressant may be advised with mild depression that persists
after other treatments have not helped, associate with a physical illness and patient had an
episode of moderate or severe depression in the past.
Interpersonal therapy (IPT):

This is sometimes offered instead of CBT. IPT is based on the idea that your personal
relationships may play a large role in affecting your mood and mental state. For example,
IPT may focus on issues such as bereavement or disputes with others that may be
contributing to the depression.
Electroconvulsive therapy (ECT): may sometimes be recommended if the person has severe
depression and other treatments, including antidepressants, have not worked.
I will be referring you to a psychiatrist, who may plan to put you on antidepressants.
1. Side effects of antidepressants?
2. Will it cause loss of libido?
For people starting an antidepressant:

 Consider suicide risk and toxicity in overdose
 Explain that symptoms of anxiety may initially worsen
 Explain that antidepressants take time to work
 Explain that antidepressants should be continued for at least 6 months following
remission of symptoms, as this greatly reduces the risk of relapse.
SSRIs and SNRIs side effects:

Agitation, sickness, indigestion
Loss of appetite
Dizziness
A sedating effect
Headaches
Low sex drive (difficulties achieving orgasm during sex or masturbation)
(erectile dysfunction)
These side effects should improve within a few weeks, although some can occasionally
persist.
549
Tricyclic antidepressants (TCAs) side effects:
Dry mouth
Slight blurring of vision
Constipation
Problems passing urine
Drowsiness
Dizziness
Weight gain
Excessive sweating (especially at night)
Heart rhythm problems, such as noticeable palpitations or a fast heartbeat (tachycardia)
The side effects should ease after a couple of weeks as your body begins to get used to
medicine.
Don'ts
1. Don't bottle things up and 'go it alone'. Try to tell people who are close to you how
you feel. It is not weak to cry or admit that you are struggling.
2. Don't despair – most people with depression recover. It is important to remember
this.
3. Don't drink too much alcohol. Drinking alcohol is tempting to some people with
depression, as the immediate effect may seem to relieve the symptoms. However,
drinking heavily is likely to make your situation worse in the long run. Also, it is very
difficult either to assess or treat depression if you are drinking a lot of alcohol.
4. Don't make any major decisions whilst you are depressed. It may be tempting to give
up a job or move away to solve the problem. If at all possible, you should delay any
major decisions about relationships, jobs, or money until you are well again.
Do's
1. Do try to distract yourself by doing other things. Try doing things that do not need
much concentration but can be distracting, such as watching TV. Radio or TV is useful
late at night if sleeping is a problem.
2. Do eat regularly, even if you do not feel like eating. Try to eat a healthy diet.
3. Do tell your doctor if you feel that you are getting worse, particularly if suicidal
thoughts are troubling you. See the separate leaflet called Dealing with Suicidal
Thoughts.
Sometimes a spell off work is needed. However, too long off work might not be so good, as
dwelling on problems and brooding at home may make things worse. Getting back into
hurly-burly of normal life may help the healing process when things are improving. Each
person is different and the ability to work will vary.
550
Sometimes a specific psychological problem can cause depression but some people are
reluctant to mention it. One example is sexual abuse as a child, leading to depression or
psychological difficulties as an adult. Tell your doctor if you feel something like this is the
root cause of your depression. Counselling may be available for such patients.
551
PAEDIATRIC STATIONS
OTITIS MEDIA CHILD
Daisy 15 months old, was brought to the hospital by her father with fever, shortness of
breath and was pulling her left ear. They went to the GP and he gave her PCM and referred
her to the hospital. Her father is concerned about her condition. On examination, there is
redness over her left ear drum. Her right ear drum is pink.
Please talk to her father, take history, discuss plan of management with the father and
address
his concerns.
Nurse colleagues are looking after her in the next room.

NEWS chart:
Before: Temp - 38, HR -130 (80-130), RR-40 (25-35)
After: Temp -37, HR-100 (80-130), RR -30 (25-35)
D: Hello, what brings you to the hospital?

P: How is my daughter?
D: She’s in good hand, our nurse colleagues are looking you bring your daughter to the
hospital?
P: She’s been having fever and shortness of breath.
D: Since when?
P: Last 2 days.
D: Did you measure her temperature?
P: No Doctor.
P: We went to the GP and he gave her Calpol and referred us to the hospital.
D: Anything else?
P: She was having cough.
D: Any Phlegm?
P: No
D: Anything else?
P: Yes, she was tugging her left ear
D: Since when'.’
P: Last 2 days
D: Any discharge
P: No
D: Hearing loss?
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P: No
D: Was she feeling sick?
P: No
D: Have you noticed any jerky movements?
P: No
D: Have you noticed any rash on her body? (Meningitis)
P: No
D: Have you noticed that your daughter is shy to the light or cries whilst moving her neck?
P: No
D: Any similar episodes before?
P: No
D: Has she been diagnosed with any medical conditions in the past?
P: No
D: Is she taking any medication’s including OTC or supplements?
P: No
D: Any allergy to medications or food?
P: No
P: No
P: Normal vaginal delivery
D: Are you happy with Red Book?
P: Yes
P: Yes
P: Yes
D: Does she have any problem with her wee and poo?
P: No
D: By any chance have you noticed change in colour and smell of her wee? (UTI)
P: No
D: Have you noticed any tummy pain or changes in her poo?
P: No
P: Me and my wife.
D: We have examined your daughter, she had high fever but after paracetamol it has come
down.
We also checked her heart rate and respiratory rate which were high but after giving her
paracetamol they have also settled.
On examination of her ear. there is redness over her left ear drum.
553
From our assessment, we suspect your child has a condition called OTITIS MEDIA.
It looks like your child has got viral infection which usually subsides on its own in the next
few days. We will prescribe her some paracetamol for her fever and pain.
Please give her plenty of fluids to drink. Hopefully, she will completely recover in the next
few days.
P: Are you going to give her antibiotics?
D: At the moment, there is no need to give her antibiotics as it is a viral condition, but if her
fever lasts for more than 4 days we will give her antibiotics.
 Please bring her back to the hospital if she develops high fever, rash, neck stiffness and
discharge from her ear.
 If the fever does not subside by 4 days then please come back to us.
 Drug of choice: Amoxicillin for 5 days, (if Allergic to Penicillin, then give Erythromycin or
Clarithromycin for 5 days)
 Antibiotics are usually only considered if your child:
- has a serious health condition that makes them more vulnerable to complications,
such as cystic fibrosis or congenital heart disease.
- is less than three months old.
- is less than two years old with an infection in both ears
- has discharge coming from their ear.
554
NEONATAL CHLAMYDIA
You are an F2 in Paediatrics.

A female patient aged 16, having 10 days old boy (PAT Murphey) with (chlamydia) infection
in the eyes. Pt was admitted and after 3 days treatment, he was discharged with his father.
Swab has been taken from the eyes and Chloramphenicol eye drop is being given to the boy.
Mother is here to discuss the results of the swab.
Talk to the mother and address her concern.
D: Hello, how can I help you today?

P: I have come for the results of the swab taken from my son's eye.
D: Okay, I have the results with me, but before I proceed let me ask you few questions, so
that I would be in a better position to answer everything you need.
P: Okay dr.
D: Could you please confirm the age of your son?
P: He is 10 days old
D: Why did you bring your son to the hospital?
P: He was having red and sticky eyes
D: Is it in one eye or in both the eyes?
P:
P: For the last 3 days
D: Any other symptoms
P: No
D: Did he have any kind of discharge from the eyes?
P: Yes/No (If yes elaborate colour, quantity, smell, time of the day, early morning/especially
after sleep)
D: Any swelling of the eye lids?
P: Yes/No
D: Any swelling or redness around the eyes?
P: No
D: Any fever?
P: No
D: Any neck stiffness or pain while moving neck?
P: No
D: Any shyness towards light?
P: No
D: Is he drowsy or tired?
P: No
D: Any cough or phlegm?
P: No
D: Any breathing difficulty?
555
P: No
D: Did you notice any health-related problems in these 10 days?
P: No
D: Is he allergic to anything?
P: No
D: Have you or his father ever had any medical conditions?
P: No
P: Yes
D: What do you feed him?
P: Just milk
D: How is his wee and poo?
P: Its fine
D: Thank you for answering all my questions.
P: Could you please tell me about the results
D: Yes. We have done the swab to check which type of bug has caused him this eye
infection. Unfortunately, the swab results came back positive for a bacteria called
Chlamydia. We call this condition Ophthalmia Neonatorum. It can happen in the first 28
days after birth.
D: As the swab is positive for Chlamydia, we need to treat him with oral antibiotics
(Erythromycin or Azithromycin) for 2 weeks to treat the infection completely and to prevent
the complications.
P: But, why did he have this infection?
D: If you have chlamydia that's not treated while you're pregnant, there's a chance you
could pass the infection on to your baby during the delivery.
P: But I don't have any symptoms?
D: Most people who have chlamydia don't notice any symptoms. For some people they
don't develop until many months later. Sometimes the symptoms can disappear after a few
days. Even if the symptoms disappear you may still have the infection and be able to pass it
on.
D: Chlamydia is a sexually transmitted bacterium, that means this bug is transmitted by
having unprotected sex.
D: Let me ask you few questions to see if you have had this infection?
D: Have you or partner ever been diagnosed with STIs?
P: No
P: Did you ever have symptoms like pain when urinating or unusual vaginal discharge or
pain in the tummy or pelvis?
P: No
D: Any pain during sex?
P: No
D: Any bleeding after sex or bleeding between periods?
556
P: No
D: Multiple sexual partners increases the risk of STIs. Have you had any other sexual
partners before?
P: No dr, I only have one sexual partner from last 2/3 years.
P: Dr, does this mean my partner is cheating on me, because I have only one sexual partner?
D: As you told me that you only have one sexual partner, there is a possibility that you might
have got this bug from your partner. This does not necessarily mean that your partner is
cheating on you. As I told you earlier, Chlamydia can stay in our body for many months
without causing any symptoms. He might have got this infection from his previous
relationships.
D: We need to test you both for this infection and treat both of you even if of you are
positive for Chlamydia.
(If pt says cannot bring partner - talk about partner notification programme).
D: We need to refer you to Genito-Urinary Medicine (GUM) Clinic.
D: Please bring your son immediately to the hospital if he develops any high fever,
drowsiness, neck pain/stiffness, shyness to light, cough, phlegm or breathing difficulty.
■ Gonorrhoea and Chlamydia are the most common bacterial causes of neonatal
conjunctivitis.
INITIAL MANAGEMENT:
 Sticky eye/blocked tear duct: 4-6 hrly eye toilet using sterile saline
 Suspected conjunctivitis:
Swab for: Gram stain and bacterial culture and sensitivities
If other suspicions of HSV (e.g. vesicles etc.), viral swab
Chlamydia swab (specific for Chlamydia PCR)
Treat with
 frequent eye toilet as necessary
 chloramphenicol 0.5% eye drops
 Presentation within first 24 hr suggests gonococcal infection
 inform senior paediatrician
 Neisseria gonorrhoeae suspected:

Request Gram stain and culture
Assess neonate for systemic infection
 Neisseria gonorrhoeae confirmed:
Give single dose ceftriaxone 125 mg IV if IV access present, otherwise IM (40 mg/kg for low-
birth-weight babies).
If signs of systemic infection (e.g. sepsis, meningitis), give course of IV ceftriaxone.
Refer to ophthalmology.
 Chlamydia result positive:
557
Treat with azithromycin 20 mg/kg single dose or erythromycin 12.5 mg/kg/dose orally 6 hrly
for 2 weeks. This will treat the conjunctivitis and prevent most cases of chlamydia
pneumonitis. Monitor for signs of Pyloric stenosis as Macrolides can cause infantile
hypertrophic pyloric stenosis when given before 6 weeks.
 Gonococcal or chlamydia infection detected
Refer mother and partner to genito-urinary medicine for immediate treatment
GONOCOCCAL VERSUS CHLAMYDIAL CONJUNCTIVITIS.
Gonococcal Chlamydial
2-5 days incubation 5-14 days incubation

Transmission vaginal or from contaminated Transmission vaginal or from contaminated
fingers after birth fingers after birth
Mild inflammation with sero-sanguineous
Discharge Varies from mild inflammation to severe
swelling of eyelids with copious purulent
Progression to thick, purulent discharge discharge
with
tense oedema of eyelids
Complications include corneal ulceration Corneas rarely affected
and perforation 1 in 5 untreated will develop chlamydial
Meningitis and sepsis pneumonitis
558
FEBRILE CONVULSION
You are F2 in Pediatrics.

Maria aged, 2 has been brought to the hospital by her mother because she had a fit. She has
been managed in the A&E department and has been referred to you. Her temperature is
38.9 C. On examination, there is redness over her left eardrum.
Please talk to her mother, Mrs. Diana Julie, take history, discuss your plan of management
with the mother and address her concerns.
The mother is very concerned. The child is not in the cubicle.

P: I was playing with my daughter and suddenly she started having jerky movements.
D: Tell me more about the jerky movements?
P: Dr she was having shaky movements all over her body
P: It happened 2 hours ago.
D: Is it the first time?
P: Yes
D: Did you notice anything strange before she had this jerky movements ?
P: She became pale and sweaty.
D: Any other symptoms before the jerky movements?
P: No doctor
D: For how long she was having jerky movements?
P: Around 2 minutes
D: Did she become unconscious?
P: No
D: Any symptoms during the fit?
P: No
D: Did her eyes appear to roll backwards';
P: Yes/No
D: Did she wet herself?
P: No
D: Did she bite her tongue
P: No
D: How was she after the fit?
P: she was sleepy and drowsy.
D: For how long?
P: For few mins
P: I called the ambulance and brought her to the hospital
D: Did she injure herself?
P: No
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D: Did she vomit?
P: No
P: Yes she was having fever from last 2 days.
D: Did you measure the temperature?
P: No
D: Have you noticed anything unusual about her?
P: Yes she was tugging her left ear.
D: Since when?
P: From last 2 days
P: No
P: No (Meningitis)
D: Have you noticed that your child is shy to light or cries while moving her neck?
P: No
D: Any cough?
P: No
D: Has she been diagnosed with any medication condition in the past?
P: No
D: Any Diabetes?
P: No (DM)
P: No
P: No
P: No
D: Any family history of epilepsy?
P: No
P: Yes
P: Yes
P: No
P: Yes, she is feeding very well.
P: No
560
D: By any chance have you noticed any changes in the colour or smell oflTer urine? (UTI)
P: No doctor.
D: Have you noticed any tummy pain or change in her poo?(Gastroenteritis).
P: No
D: Any diarrhoea?
P: No
P: It’s me.
We have checked your child and we found that her temperature was high.
 From our assessment, we suspect your child has a condition called febrile convulsion.
 Febrile convulsions is a type of fit that happens in children aged between 6 months to 5
years due to high temperature.
 On examination of the ear we found there was redness in the left ear which is known as
otitis media.
 We will keep your child in the observation to make sure everything is fine. If everything
goes smoothly you can take her home.
 For now we will give her paracetamol to reduce her temperature.
 We will give her antibiotics if signs of infection such as fever lasts for more than 4 days. If
we are prescribing any antibiotics please rule out any allergy. DOC- Amoxycillin for 5
days. If allergic to penicillin then erythromycin or clarithromycin for 5 days.
 It is not dangerous as the fit lasted for less than 5 mins and she recovered fully after the
incident.
 Febrile convulsions and epilepsy are two different things. As I told you febrile convulsions
is because of feverish condition. However epilepsy is some abnormal activities in the
brain without any high temperature.
 It can happen again. Since your child is 2 years old and I have already mentioned that it
usually happens in children who has fever and aged between 6 months to 5 years. Mostly
children grow out of this condition after 5 years of age.
 You can prevent febrile convulsions by keeping your child's temperature down. You can
give her paracetamol to lower down her temperature. Keep her lightly dressed and
remove excessive clothing. Give her lots of cold fluids to drink.
 If your child is having a febrile seizure, place her in the recovery position. Stay with your
child and try to make a note of how long the seizure lasts. Don't put anything into your
child's mouth during a seizure - including medication - as there's a slight chance it bite
their tongue or they aspirate.
 Please call an ambulance if;
o the fit lasts more than five minutes.
o She doesn't improve quickly after the seizure or
o She has difficulty breathing.
 Child should be seen by a doctor after the seizure.
561
P: Doctor, My friend s kid had the same problem and the doctor gave her a medicine to put
through her back passage.
D: There are some medications that can be used to stop the fit.
 We can prescribe it only if
 child has recurrent fit or the fit lasts for more than 5 mins.
 And also if you live far from the hospital(More than 2 hours).
P: Can my son also have the same problem?
D: Tell me his age.
P: He is 4 years old doctor.
D: There are some evidences that suggest that the chance of having febrile convulsions
increases in close family members aged between 6 months and 5 years.
Please bring her back to us if she develops any high fever, rash, neck stiffness or any
bleeding or
discharge from the ear. If the fever doesn't subside by 4 days please come back to the
hospital.
P: Oh okay doctor. Can I take my baby home?
P: Is it dangerous?
P: Is it epilepsy?
P: Can it happen again in the future?
P: How can I prevent it?
P: Thank you doctor. What should 1 do if it happens again?
562
HEAD INJURY FALL PAEDIATRICS

9 months old child, Jane had a fall from the sofa. She is happy and playful now.
She is moving her four limbs. She has a bruise on her forehead.
Please talk to her mother and discuss your management with her and address her concerns.
Your nurse colleague is looking after the baby in the next room.
D: Hello Mrs. Xyz, I am Dr. Xyz. are you the mother of Xyz. ,P: Yes Dr.
D: I am going to talk to you about your child's health today, could you please give me a
summary of what EXACTLY happened and why did you bring your child to the hospital?
P: Doctor, I brought my little one to the hospital because she had fall from the sofa two hours
ago.
D: How did it happen?
P: Doctor. I was changing my other kid’s nappy. Jane was behind me and I heard her crying and
turned around. 1 found her on the carpet.
D: Did you notice if she banged her head on the floor.
P: I’m not sure doctor.
D: Did she become unconscious?
P: No
D: Any symptoms after the fall?
P: No she was crying and went pale for few seconds.
P: No
D: Did she wet herself?
P: No
D: Did she bite her tongue?
P: No
D: How was she after the fall
P: She was sleepy and drowsy.
D: For how long?
P: For few seconds
D: Did she vomit?
P: Oh yes doctor. She vomited.
D: how many times she vomited?
P: Just once in the ambulance doctor.
D: Did she injure herself?
P: Oh yes doctor there is a bruise on her forehead/at the back of her head.
D: Could you tell me how big it is?
P: It is as big as this doctor, like a coin. (She shows the size of the bruise using her fingers.)
D: Any other injuries?
P: No doctor
563
D: Have you noticed any injury in the neck? Was she dy ing while moving her neck?
P: No
P: I called the ambulance and brought her to the hospital.
P: No
P: No doctor.
D: Any rash?
P: No doctor.
P: No
D: Any Diabetes/ heart disorder/ blood disorder/ epilepsy?
P: No
P:No
P: No
P: No
D: Any family history of epilepsy?
P: No
P: Yes
P: Yes
P: No
P: Yes, she is feeding very well
D: Does she have any problems with her wee? P: No.
P: No
D: By any chance have you noticed any changes in the poo?
P: No
P: It’s me.
D: Is there anyone else to help you?
P: Sometimes my sister is helping me.
D: How about her dad?
P: I got separated from her dad. Our relationship didn't work.
564
P: No left my job. I am looking after my kids.
D: How do you cope with that?
P: Doctor, it is difficult but it is fine.
D: I would like to check the vitals, general physical examination and neurology examination.
EX: There is a bruise on her forehead, rest of them are normal doctor.
From our assessment it seems like your baby has head injury.
D: On examination of your little one: we did physical examination to look for any injury in
any part of her body. We also performed neurological examination to check how well her
brain and spine is working.
Fortunately she is fine now. She is playful and is moving her four limbs. The only thing we
found was a bruise on her forehead. However, we need to keep her in the hospital I may ask
one of my seniors to come and review your little one.
P: Doctor, if she is fine, then why are you going to keep her here?
D: I do understand your concern as a mother but is there any particular reason that is
bothering you regarding admission?
P: Doctor. I have another kid. I left him with my neighbour.
D: I understand but we need to observe her a little longer to reassess her condition and to
make sure she is fine. We will keep her under our observation and if everything goes
smooth you can take her home. However, we might need to do CT head if we feel that
needs to be done.
Fortunately she is fine now but as you told me she was a bit drowsy/sleepy after the
incident and that's why it is important to have your little one for a while in the hospital.
Hopefully it won't be more than a few hours (four hours), if by any chance she looks drowsy,
or she has any further vomiting, you need to bring her to the hospital to perform a CT Scan
of her brain. I totally understand your situation and how difficult could it be for you to look
after your little ones. That would be great if you keep an eye on them while they are
playing.
P: How long will she be here doctor?
P: Why CT head?
P: How long to I need to stay?
Criteria for performing a CT scan for children

CT scan head should be performed within 1 hour.
1. Suspicion of NAI.
2. Post-traumatic seizure but no history of epilepsy.
3. On initial assessment GCS less than 14. or for children under 1 year GCS less than 15.
565
4. 2 hours after the injury, GCS less than 15.
5. Suspect of basal skull fracture or tense fontenella.
6. Any sign of basal skull fracture.
7. Focal neurological deficit.
8. For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on
9. head.
NOTE
For children w ho have sustained a head injury and have more than one of the following risk
factors a CT scan should be performed within 1 hour.
1. LOC more than 5 mins.
2. Abnormal drowsiness.
3. Three or more discrete episode of vomiting.
4. Dangerous mechanism of injury (high speed RTA either as pedestrian or cyclist or vehicle
occupant, fall from a height of greater than 3 metres, high speed injury' from projectile
or other object)
5. Amnesia (antegrade or retrograde) lasting more than 5 mins.
NOTE
Children who have sustained a head injury and have only 1 of the risk factor should be
observed for minimum of 4 hours after head injury.
NOTE
If during observation any of the risk factors below are identified, a CT scan head should be
performed in 1 hour.
1. GCS less than 15.
2. Further vomiting.
3. A further episode of abnormal drowsiness.
566
NAI-PAEDIATRICS

4 months old Daniel has been brought to the hospital by his mother this morning. She rushed
to the hospital after she noticed a swelling on his right arm. X-ray has been done and spiral
fracture of right humerus has been diagnosed.
Please talk to the mother, Mrs. Diana Wales, take history and discuss about initial plan of
management with her.
Your nurse colleague is looking after the child in the next room. The mother is really worried.
D: Hello Mrs. Xyz, I am Dr. Xyz, are you the mother of Xyz.
P: Yes Dr.
D: I am going to talk to you about your child’s health today, could you please give me a
summary of what happened and why did you bring your child to the hospital?
P: Doctor, there was a swelling on his arm, which worried me and I brought him to the
hospital.
D: That must be very stressful for you, as you mentioned the purpose of visit was swelling
on his arm, we examined him and did an X ray which revealed a fracture in one of his bones
in his arm unfortunately.
P: Is my baby okay? Is he in pain now?
We can disclose the fracture later on as well. It depends on the situation if you have to
disclose it in the beginning or in the last.
D: Don’t worry, he is in good hands. We are managing his broken bone. We gave him
enough painkillers and he is not in pain now.
D: May I know how did it happen?
P: I am a nurse by profession and I had shift last night. When I came back home this morning, I
realized he was crying more than often and not moving his arm as well. Later while changing
the nappy I realised the swelling on his arm and I rushed to the hospital. OR I was working in
the kitchen when I heard my baby crying and I rushed to the room where I saw he has fallen
from the cot and I rushed to the hospital.
D: How did you come to the hospital?
P: I took a bus and came to the hospital.
D: How long did it take for you to get here?
P: It took me about an hour
D: Okay. So you were not present when this happened?
P: No Dr.
D: Was there anyone with the child when this happened?
P: Yes Dr. My partner
D: Was he looking after your child last night/ when you were in the kitchen?
P: Yes
D: Does he usually take care of your little one while you are at work OR away?
567
P: Yes. When I am away he is the one taking care.
D: Did you talk to your partner about this?
P: No doctor.
D: May I know why?
P: I did not get the chance, he was ready to go to his work when I came back home and later I
had to rush to the hospital.
D: Is he the biological father of your little one?
P: No, I got separated 1 year ago.
D: How long have you been with your new partner?
P: It’s been six months doctor.
D: Is there anyone else at home living with you?
P: No Dr.
D: Does he get on well with your baby?
P: They get on well.
D: Has it ever happened in the past?
P: No doctor.
D: How has been his health been recently?
P: He has been fine doctor.
D: Any trauma recently?
P: No doctor.
D: Has he ever been diagnosed with any medical condition?
P: No
D: Does he have any bone disease?
P: No
D: Have you noticed any bluish discoloration of your little one’s eyes/hearing problem,
blood disorder?
P: No
D: Is he on any medications?
P: No.
D: Has any member of your family been diagnosed with any medical condition?
P: No.
D: Any bone disease in the family?
P: No
P: I had normal vaginal delivery
D: Was there any complication or birth-related concern?
No doctor.
D: Did you use any medications before giving birth (perinatal drug history)?
P: No
D: Is he up-to-date with all his jabs?
P: Yes
D: Are you happy with his red book?
568
P: Yes
P: Yes
D: Is he gaining weight?
P: Yes doctor
D: Is he bottle-fed or breast-fed?
P: He is bottle-fed doctor.
D: Does he have any problems with his wee?
P: No
D: How about poo?
P: No
D: I would like to check his Vitals, do general physical examination, eyes, ear and
Musculoskeletal examination
As I mentioned, your baby has fractured bone so we have to keep him in the hospital.
P: But doctor, why do you want to admit my baby?

D: The fracture needs to be taken care of.
 As part of initial management we have given him painkillers and stabilised the fracture
but we will refer him to a bone specialist so that they can manage the fracture.
 We also need to do some further investigations to look for the cause of fracture.
 I will also ask my senior colleague to come and review your baby. Since your little one is
just 4 months old its better for him to be reviewed by a senior doctor. We want to make
sure your little one is fine before going home.
 My senior is the better person to determine what can be the possible cause of this
fracture.
 Moreover, we'll be doing some further investigations which includes blood tests to check
the levels of some minerals such as Calcium and Vitamin D and check levels of some
other substances that can be related to such a problem. (ALP)
 Other than that we need to see if there is any other fracture in his body for which we will
be doing detailed X rays. Bone scan could be another possibility. We might need to do CT
head to see if there is any head injury'. There is also a possibility of injury to other organs
in the tummy so we will check how well they are working by doing some specific blood
tests. (LFT’s. S. Amylase. U&Es).
 All these investigations should be done because this sort of fracture at this age is a bit
unusual. Children at this age have very flexible bones. This sort of injury usually doesn’t
happen due to simple mechanisms such as fall. Moreover, your baby is only 4 months old
and he is not mobile enough to have such incidents on his own. This sort of fracture
usually suggests an external force such as twisting.
 P: Doctor, do you mean someone(my boyfriend) did this? D: We are not sure of that yet
but it is one of the possibilities. That's why we need to do all the investigations to rule
569
out all the possible causes that might have led to this. We are not trying to blame or
accuse anyone. As children's doctors, we need to follow certain protocols and consider
many possibilities. This is a possibility that we have to look for. This is a very sensitive
matter and that’s why facts need to be confirmed by a senior doctor.
 If it is confirmed, as a part of hospital protocol. Social Services should be involved. They
will talk to you and your partner about the incident.
 They might come to your house to do further assessment and get to the bottom of how
incident happened.
 All we are trying to do is help your baby and keep him safe.
 I want to reassure you that we are trying to help and support you and your baby.
 We want to make the best decision for your child. That's why Social Services is going to
be involved. It is not their goal to take your child away from you. However, they have to
do a complete assessment and make sure that there is no risk to the baby.
P: What is going to be the next step if it is confirmed?
P: Are they going to take my child away from me?
P: Can I take him home?
P: Doctor, why do you need to do so many investigations?
P: Doctor, why is it unusual?
570
VACCINATION FLU JAB
You are F2 in GP.

3 year old child Luke is due for Flu vaccination in one week. Mother wants to talk to a
doctor.
D. How can I help you?

P: Doctor my son Luke is going to get a flu jab & I am very worried about him?
D: May I know why you worried?
P: Doctor I’ ve heard that flu jab causes seizures; I don't want that to happen to my son.
D: I can see that you care about Luke. Can I ask few questions? What is his age?
P: 3 years old
D: Is this his 1st flu jab or has he had it before?
P: It’ s his 1st flu jab.
D: OK. Do you know what the flu is exactly?
P: Yes. it’ s the common cold that we sometimes get in the winters.
D: Well yes, it happens seasonally, but flu is not exactly the same as a common cold. In
common cold people usually get mild symptoms only like a stuffy or a runny nose. Whereas
flu is actually worse than the common cold & the symptoms are more intense. There are
different viruses that cause flu & there are usually body aches, fever, tiredness, cough,
tummy pain in flu.
P: Oh alright. Does Luke really need the flu jab?
D: Well, the flu virus is a very unpredictable virus & can cause unpleasant illness in children,
severe illness, older people, pregnant women or people who have some other health
problem/ disease. Flu jab is actually a vaccine for flu. which is the best thing we have to
protect people from the serious illness cause by these viruses.
P: Oh okay. So. docs this mean that my son will never have flu after he gets the flu jab?
D: There are different viruses identified in the start of each year that cause flu. some might
even be new, & the vaccine might not protect the person from the effects of the new
viruses. However, in case young Luke does get flu after having had the vaccine, the illness
will be much milder & shorter than the original one. Also, the protection given by the
injected flu vaccine decreases over time as the viruses causing flu change every year. To
counteract that, new vaccines are produced every year & people ae advised to get the flu
jab every year too.
P: Oh. okay, so will he have to get it every year then?
D: Yes, to protect him against the new disease causing viral strains.
P: But what about the seizures doctor? I don’t want my son to get seizures.
D: The flu illness can cause high fever. If it happens then we can decrease the chances of
having seizures. Children usually don’ t get these seizures as they get older.
P: Yes doctor.
D: Great
571
P: Are there any other side effects of the jab doctor?
D: Yes, there are. It’ s very rare to get any serious side effects from the flu vaccine.
Occasionally people may get a mild fever or aching muscles for a couple of days, and it might
happen that your arm might be a bit sore where you were given the injection but these will
subside in few days.
P: Is it given as an injection doctor?
D: Yes, it’ s available as an injection. However, nasal spray is also available. Children are
usually given nasal spray. In fact, it’ s more effective in the spray form as it gets absorbed
through the skin in the nose real quick.
D: Can I ask if young Luke has had any stuffy or runny nose in the past
P: No, he hasn’t.
D: That’s good because we don t give the nasal spray if the person is having a runny or stuffy
nose because that would prevent absorption of the vaccine in the nose.
P: Oh, alright.
D: Has he ever been diagnosed with any medical condition in the past?
P: No doctor
D: Is he taking any medications?
P: No
D: Does he have any allergies?
P: No doctor
D: Any egg allergy?
P: No
D: That’ s good, we also don’t give it if the person has had any egg allergies
P: Right!
P: Doctor, does he have to get the jab now though? Can he not get it in spring maybe? It will be
a bit warmer too then.
D: I can understand that you’ re concerned. But, the best time to get a flu jab is in the
autumn, from the beginning of October to early November. That’ s when flu affects people
more.
P: Where can I get the flu jab for Luke?
D: These jabs are available at your GP Surgery or in some local pharmacy.
P: Oh. okay doctor.
D: Do you have any more questions?
P: Okay, thank you doctor.
https://patient.info/health/influenza-and-flu-like-illness/immunisation-for-flu
572
MMR
You are F2 in GP.

12 months old child is due to be given her MMR vaccine in the next two weeks.
Mrs. Gabriela Evans, Jenny’s mother, presented to the GP surgery to discuss about her
daughter’s MMR vaccination. You haven’t seen Jenny since birth.
Please talk to the mother and address her concerns.
It is a non-emergency visit.
D: If I am not wrong, we are here to discuss MMR vaccination as I suppose Jenny is due for
that in next two weeks?
P: Yes doctor.
D: Where should we start from? Is there anything particular you want me to talk about?
P: Doctor. I read an article which says there is a link between MMR and autism. Is this true?
 D: There is no evidence to suggest that there is a link between MMR and autism. The jab
was linked to autism in 1998 when a study of 12 children was published in a medical
journal (Lancet) which said MMR jab could cause autism. Since then, many other
research studies have been conducted and showed there is no link between MMR Jabs
and Autism. There is no evidence that supports a link between MMR and any problems
with the gut (enterocolitis, which is inflammation of the small bowel causing diarrhoea,
vomiting and weight loss).
 MMR is a safe and effective combined vaccine that protects against three separate
illnesses:
o measles, mumps and rubella.
 It is a single injection. We ideally give two doses of this vaccination.
 The first dose of vaccine is usually givenbetween 12 and 13 months.
 A second dose is usually given at age 3 years and 4 months to 5 years. It is usually given
at the same time as the DTaP/IPV injection. (DTaP stands for diphtheria (D), tetanus (T)
and acellular pertussis (aP) which is whooping cough. 1PV stands for inactivated polio
vaccine. Polio is short for poliomyelitis).
 MMR are highly infectious conditions that can cause complications such as meningitis,
deafness and swelling of the brain (encephalopathies).
 It is rare for children in the UK to develop these serious conditions. However, outbreaks
may happen and the chance increases when children are not vaccinated. There have
been cases of measles in recent years. Therefore, it is important to ensure that you and
your children are up to date with the jabs. Moreover, you may travel to countries where
MMR is still present and your child may catch these infections if not vaccinated.
 Between 2001 and 2013 there was a sharp rise in the number of UK measles cases (and
three people died). Numbers of cases fell in 2014 and 2015. but have started to increase
again in 2016. Between January and September 2016, 488 measles cases were confirmed.
573
This is more than five times as many as the total number of cases in 2015. The majority of
cases of measles have been in people who are unvaccinated.
 As I mentioned earlier, MMR is made up of three different vaccines (measles, mumps and
rubella) and each of these cause reactions at different times after the injection.
o After six to ten days, the measles vaccine starts to work and may cause a fever, a
measles-like rash, and loss of appetite. Individuals with vaccine-associated
symptoms are not infectious to others.
o Two to three weeks after the injection, the mumps vaccine may cause mumps-like
symptoms in some children such as fever and swollen glands.
o The rubella vaccine may cause a brief rash and possibly a slightly raised
temperature, most commonly around 12 to 14 days after the injection, but a rash
may also rarely occur up to six weeks later.
 Call the doctor immediately if, at any time, your child has a temperature of 39-40°C or
above, or has a fit. If the GP is closed and you cannot contact your doctor, go to the
nearest hospital with an A&E.
 There are no licensed alternatives to MMR in the UK (individual vaccines)
 For those who have untreated malignant disease. MMR vaccine is contraindicated.
 In immunocompromised patients such as those who are on immunosuppressant
medications, steroids, radiotherapy, cytotoxic drugs or for those who received such
treatment within six months, MMR vaccine is contraindicated
 Having previous history of infection with pertussis, measles, rubella or mumps or having
conditions such as asthma, eczema, hay fever or rhinitis is not a contraindication.
 Neurological conditions such as epilepsy are not a contraindication although, if the
condition is poorly controlled, immunisation should be postponed.
 Treatment with antibiotics or locally acting such as topical or inhaled steroids is not
contraindicated.
P: Doctor, what is MMR? I What is the use of this vaccine?
P: How many shots of this jab should be given doctor?
P: Why do we give MMR vaccine doctor?
P: Doctor, are these diseases still present in the UK? / Doctor, these diseases are not that
common in the UK, so why my little one should receive this vaccine?
P: Doctor, you said there were cases of measles in the UK in recent years. When was the last
time?
P: Doctor, is there an alternative to MMR?
P: Docs MMR cause any problems with the gut?
P: Any contraindications to ii?
D: Since I haven't seen your daughter since birth if you don't mind let me ask you a few
questions about her health to make sure there is no problem in giving her MMR jabs.
D: How has been your little ones health recently?
574
P: It has been fine doctor.
D: Has she had any fever recently?
P: No doctor.
D: Has she ever been diagnosed with any medical condition?
P: No.
D: Does she take any medications?
P: No.
D: Does she have any allergy?
P: No doctor.
D: Has she received any blood products recently?
P: No. ( MMR is contraindicated for those who have received any blood products such as
immunoglobulins, within three months.)
P: Normal Vaginal delivery
D: Is she up-to-date with all her jabs?
P: Yes.
D: Has she received any jabs recently?
P: No doctor
D: Any complication after previous jabs?
P: No doctor.
D: Are you happy with her red book?
P: Yes.
P: Yes.
P: No.
D: How about poo?
P: No.
P: No doctor
575
INTUSSUSCEPTION

20 months old child was brought to the hospital by his mother due to abdominal pain. GP
has seen the child and send him to the hospital with the following letter:
Thank you for seeing this child. I have seen this 20 months old child with abdominal
discomfort.
On examination: The child looks pale. His peripheries are cold. He looks lethargic. Abdomen
is not distended. There is a mass in the right hypochondrium.
Vitals have been recorded and are as follows:
PR 140 bpm, BP 90/60 mmHg, RR28
Please talk to the mother, take history, give possible diagnosis to her, explain the next steps
of management and address her concern. Baby is in the next room.
D: As we understand that you took your child to GP and he has sent you to us. May I know
what made you take your child to GP?
P: Doctor, my baby had tummy discomfort.
D: How did you notice that?
P: Doctor, he has been crying a lot and whenever I want to change his nappy and I touch his
tummy, he cries even more.
D: When did he start crying?
P: 10 hours ago
P: It has become worse. He was crying on and off initially but then he started crying
continuously around 2 hours ago and that’s why I took him to the GP.
D: Have you noticed anything unusual other than crying?
P: He pulls his legs towards his chest and that’s why I think he has some problem in his tummy.
D: Does he have any other symptoms?
P: He is passing loose stools. I need to change the nappy more often.
D: How long has he had this problem?
P: Since yesterday doctor.
D: How many episodes?
P: 4-5 times a day.
D: Have you noticed any blood in his stools?
P: I have also noticed some red jelly materials
D: When did you first notice that?
P: A few hours ago.
D: How many times?
P: A few times.
D: Does he have any other symptoms
P: Yes doctor, he has been vomiting also
D: How many times he has vomited?
576
P: Around 2-3 times in the last few hours
D: Tell me about the colour of his vomit?
P: Doctor, it was green.
D: Have you noticed that his mouth is dry?
P: I’m not sure doctor.
D: Is he as playful as before?
P: No doctor.
D: By any chance has he become drowsy?
P: Yes doctor.
D: Has he become floppy?
P: He is pale and he is floppy and that’s why I took him to the GP
D: Is your baby able to eat and drink?
P: No doctor. In the past few hours he could not tolerate any food or drink.
D: Does he have any fever?
P: I haven’t noticed doctor.
D: Did he have any recent infection such as flu or diarrhoea?
P: No doctor.
D: By any chance did he hurt himself?
P: No doctor
D: Has he ever been diagnosed with any other medical conditions?
P: No.
D: Any polyp/cystic fibrosis/bleeding disorder/Meckel's diverticulum by any chance?
P: No doctor.
D: Is he on any medications?
P: No.
D: Has any member of your family been diagnosed with any medical condition.
P: No.
D: Any member of the family has been diagnosed with any bowel problems such as
Polyposis?
P: No doctor.
D: Has any member of your family got similar symptoms recently? (Diarrhoea, blood in the
stool, vomiting and tummy pain)
P: No.
P: Yes.
P: Yes.
P: No.
D: Is she feeding well other than recently?
577
P: Yes, she is feeding very well.
D: Have you changed her milk recently?
P: No.
P: No.
D: By any chance has your child taken any food from outside recently?
P: No doctor.
D: Have you recently travelled anywhere with your child?
P: No.
P: It's me
D: As your child was seen by GP who performed Physical Examination and he found your
little one looks pale, and his hand and feet are cold. He also looks lethargic. That can be
because of fluid loss as a result of diarrhoea and vomiting, which can be compensated. On
Examination of his tummy, there was a mass on the right side. We also checked your little
ones Pulse. Blood Pressure and breathing rate, which is fine, but his heart was beating a bit
fast.
I would like to send for some initial investigations including routine blood test. Serum
Electrolytes, urine and stool test.
From our assessment your child has a condition called Intussusception. Intussusception
occurs when one part of the bowel slides into another part of the bowel like a telescope.
This causes the bowel to become blocked.
We did some routine blood tests to see if there are any changes in the level of chemicals in
the body. We have also sent urine test and stool sample to the lab.
We will do an abdominal X ray to check if there is any dilated gas-filled proximal bowel,
paucity of gas distally and multiple fluid level. More importantly we ll be doing abdominal
ultrasound to confirm diagnosis.
The cause is unknown but it may be linked to infections.
This condition is the most common tummy emergency in small children, mostly between the
ages of 3 months and 2 years.
As part of initial management we have started giving him pain killers for tummy pain and
fluids to compensate for the fluid loss. We may give him other medication such as
antibiotics. Since he is vomiting and not able to tolerate food and drinks, we need to give
this through his blood vessel as a drip.
When this happens, it is unlikely for it to be resolved by itself and medical intervention is
usually required.
A tube called nasogastric tube’ is often passed from his nose into his stomach to drain any
stomach or bowel contents and get rid of any pressure that may build up due to the bowel
blockage.
578
If the ultrasound scan confirms the diagnosis, we will first try a treatment called air enema’.
In this procedure air is introduced through a tube into your child’s bottom, while X-ray
pictures are taken. The pressure of the air pushes back the telescoping parts of the bowel
('reduction'), which can be seen directly on the X-ray images. This is successful in 8-9 out of
10 patients.
If air enema is unsuccessful in reducing the intussusception (several attempts may be tried)
your child will need an operation. It is unlikely that it will subside on its own.
An operation will also be required if your child gets very unwell on admission to the
hospital, or if the doctors suspect that the bowel has perforated (burst) already.
During the operation an incision is made to open the tummy and the bowel is exposed. The
surgeon gently separates the telescoping segments of the bowel. If any bowel tissue has
died due to lack of blood supply, or if any obvious cause (‘lead point) of the intussusception
is found, this affected segment needs to be cut out (‘resection’). The two surrounding ends
are then stitched back together (‘Primary anastomoses’).
PATIENT'S CONCERNS
P: Doctor, how do you do the operation?
P: Doctor. Will it subside on its own?
P: When can I go home?
P: How is he going to be put to sleep before operation?
P: When can he start feeding after operation?
579
PYLORIC STENOSIS

6 weeks old baby has been brought to the hospital by her mother because of vomiting.
Vitals have been recorded and are as follows
Pulse: 140, Respiratory rate: 40, Blood pressure: 100/70mmhg, SpO2: 96%, Temp: 36.8.
Please talk to the mother, take history, discuss plan of management and address her
concerns.
Baby is not in the cubicle
D: What brought you to the hospital? P: My baby has been vomiting for 2 days every time I
fed her.
D: How long does she take to vomit after you have fed her? P: After a few minutes, (usually
30-60 minutes after feed)
D: Could you describe the vomiting?
P: Doctor it is like a fountain.
D: How much is it in amount?
P: I’m breastfeeding and whatever I am giving she is vomiting it out.
D: What's the content of vomit? What is the colour?
P: It’s just the milk that she had from me.
D: Is it digested or undigested milk?
P: Doctor it is liquid.
D: Any blood in there?
P: No doctor
D: Have you noticed anything else?
P: No
D: Docs your baby look hungry?
P: Yes doctor.
D: Any dry mouth?
P: I didn’t notice.
D: Is your baby playful as before
P: He hasn’t been as playful as before since yesterday.
D: Does your baby seem floppy?
P: Yes, since this morning.
D: Tell me about the little ones poo Jis the baby passing stool?
P: Last time, he passed stool was two days ago.
D: Have you noticed any mass in your baby's tummy?
P: No
D: Any temperature or flu like symptoms?
P: No
D: Any diarrhoea?
P: No
580
D: Have you noticed any tummy pain?
P: No, I don’t think so.
D: Has your baby been diagnosed with any medical condition?
P: No
D: Any medication including OTC medicines?
P: No
D: Does any member of family have any medical conditions?
P: No doctor.
D: Any member of the family had any similar complaints in childhood?
P: I am not aware of any one.
D: How was the birth?
P: Normal vaginal delivery.
D: Is he up to date with his jabs?
P: Yes doctor
P: Yes doctor
D: How is your baby’s feeding generally?
P: It was okay initially but since two days she has been vomiting out milk
D: How is your baby’s wee (if you forgot)?
P: Doctor baby’s nappy is dry'.
D: I would like to check your baby’s vitals and examine his tummy.
I would like to send for some initial investigations including routine blood test. Serum
electrolytes, ABG
pH: 7.5 (7.35-7.45)
pCO2: Increased (4.5-6 kPa) OR (35-45 mmHg)
pO2: Decreased (>10.6 kPa) OR (80-100 mmHg)
HCO3: 37 mEq/L (19-25 mEq/L)
Na: 129 mmol/L (135-145 mmol/L)
K: 2.7 mmol/L (3.5-5 mmol/L)
 From our assessment, it seems your child has condition called pyloric stenosis. In this
condition, the outlet of stomach into the small intestine is called the pylorus. Stenosis
means narrowing. Pyloric stenosis means a narrowed outlet of the stomach.
 A narrowed or blocked outlet from the stomach doesn’t let milk pass from the stomach
and that’s why your little one has been vomiting undigested milk.
 A narrowed or blocked outlet from the stomach doesn't let mil ?rom the stomach and
that’s why your little one has been vomiting undigested milk.
 It is common in babies at the age of 2-8 weeks. It affects 2-4 out of 1000 new -born
babies. Let me tell you what we have done and what we w ill do for your little one.
581
 We did some blood test. Since your baby has been unwell and vomiting for a few' days,
your baby has become dehydrated. Dehydration usually leads to an alteration in the
chemical balance of your baby's blood. This condition is called metabolic alkalosis.
 To correct this, we need to keep your little one in hospital. We are going to give your
baby fluids through a small tube into one of the blood vessels as a drip.
 In this condition the muscle in the w all of the outlet of the stomach into the small
intestine (pylorus) is abnormally thick. This causes the outlet to become narrowed
(stenosed). Although it is not known exactly why this occurs, genetics can have a role. To
confirm the diagnosis, we will feel your baby’s tummy. Sometimes the thickened pylorus
can be felt as a small hard lump during this examination. This is easier if the baby is
feeding. This is known as "test feed." We may have to do this more than once to confirm
the diagnosis.
 We may consider doing an ultrasound scan to confirm the diagnosis.
 Like I said, we are already giving your child fluids to correct the dehydration. Your baby
will need to have an operation under General Anaesthesia to cut some of the muscle
fibres that are causing the problem.
 However, before your baby can be operated on, we will need to have another blood test
to see if the chemical balance in the baby’s blood has been corrected.
 All feeds will be stopped until after the operation as your baby's stomach needs to be
empty for the surgery. We will place a small tube into your baby’s nose and slide it down
into the stomach. It allows any fluid that collects in the stomach to be removed helping
to prevent your child from feeling sick before and after the surgery.
 A small operation will normally solve the problem. This operation will be done after
putting your little one to sleep.
 |A small cut is made in the skin over the stomach outlet (pylorus). This operation is called
“pyloromyotomy. ”
 The pylorus is found and the muscle in the pylorus is then cut. This allows the pylorus to
widen into a normal size. This means that food and milk can pass easily out of the
stomach into the bowel. This operation is usually done by keyhole surgery.
 This uses only a tiny cut to the skin to allow fine instruments into the tummy to cut the
pylorus muscle.
 Open surgery is also a possibility, but the surgeon w ill discuss these options with you
and help you make the best decision for the baby. The operation is usually totally
successful, normal feed is started again shortly after the operation, most babies recover
quickly and have no further problems.
P: Doctor, it seems like something serious
P: Is she going to be all right?
P: How surgery is done?
P: When Can I go home?
582
NEONATAL JAUNDICE
You are an F2 in Paediatric ward.

Mrs. Laleh Hussain, the mother of 15 days old child referred to the paediatrics ward by
midwife. Weight of the child is 3.7 kg.
Talk to the mother, asses the child and keep the initial plan of management.

P: My midwife observed that my child has yellow discoloration of the eyes. She told me he has
jaundice.
D: Since when?
P: I don't know, the midwife noticed it.
D: Did you notice any other symptoms?
P: No doctor
D: Have you noticed yellowish discoloration of the palms or soles?
P: No.
D: Have you noticed any yellow discoloration inside the mouth?
P: No
D: Any change in the color of urine and stool?
P: No
D: Any fever or flu like illness?
P: No
D: Any vomiting?
P: No/Yes
D: Diarrhea? Constipation?
P: No
D: Did you notice any abdominal distension?
P: No
D: Is she playful?
P: Yes
D: Is she breast fed?
P: Yes
D: Any change in the amount of milk he is taking?
P: No
P: No
P: No
583
P: No
P: No
D: Was your baby delivered at term or post term?
P: At term
P: Yes.
P: Yes.
P: No
P: I do.
D: Do you have other kids?
P: Yes
D: Did anyone of them have such a condition?
P: No
I would like to examine the child. I would like to check vitals, GPE, eye examination and
gums, tummy. We will also look for the colour of the urine and poo.
I would like to do some routine blood investigation to see if there is any bug. We will also do
blood grouping. LFT. direct and indirect bilirubin level in the blood of your child and
depending on that we will give him the treatment.
EX: Abdominal examination is normal.

Total Bilirubin is 10 mg/dL
Unconjugated Bilirubin is 1.5mg d/L
 There is yellow discoloration of the eyes and skin.

 We have examined your child and his tummy is fine, and there is yellow discoloration of
the eyes and skin. It is called Neonatal Jaundice.
 Newborn babies have a large number of red blood cells in their blood. They are broken
down & replaced frequently. When the red blood cells are broken down a yellow
substance is produced called bilirubin, which is removed from the body by the liver. The
liver of new born babies is not fully developed so cannot remove all the bilirubin from
the body thus it gives a yellow colour to the skin & eyes. When the baby is older, the liver
works better & starts removing the bilirubin & thus the yellowness of skin disappears.
584
 Treatment is usually only necessary if your baby has high levels of a substance called
bilirubin in their blood. We have checked the level of bilirubin in your child’s blood which
is below the treatment level.
 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 few
weeks 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 v i s i tor or
GP.
 Please keep your child under observation. If you notice any change in the colour of the
skin, eyes, wee or poo then please immediately come back to us.
 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.
 Breast milk jaundice can last for 3-12 weeks after birth, but as long as the baby is feeding
well and bilirubin levels are monitored, it rarely leads to serious complications.
 Breast milk jaundice must also be differentiated from breastfeeding jaundice, which is
jaundice resulting from an insufficient intake of milk.
 Normal physiologic jaundice of the newborn typically appears between the 2nd and 5th
days of life and clears on its own within two weeks.
Further blood tests may need to be carried out if your baby's jaundice lasts longer than two
weeks or treatment is needed. The blood is analyzed to determine:
 the baby's blood group - this is to see if it's incompatible with the mother's
 whether any antibodies (infection-fighting proteins) are attached to the baby's red blood
cells
 the number of cells in the baby's blood
 whether there's any infection
 whether there's an enzyme deficiency
 These tests help determines whether there's another underlying cause for the raised
levels of
 bilirubin.
585
BRONCHIOLITIS
You are an FY2 in Paediatric emergency.

Mother Saira has brought her 4 month old child Abdullah for an emergency appointment.
Please talk to her and address her concerns.

P: Doctor, my son has been snotty for the last 2-3 days.
P: He was fine 3 days ago. and then he just became snotty. I gave him paracetamol syrup but
that didn't help. Now I feel that his chest is also full.
D: Does he have any cough? Sputum?
P: No (CF)
D: Any fever?
P: He does feel a little hot but I haven’t checked
D: Is he crying?
P: Yes a lot.
P: No (Meningitis)
D: Have you noticed that your child is shy to light or cries while moving her neck?
P: No
D: Have you noticed any difficulty in breathing?
P: I just feel that his chest is full
D: Any vomiting?
P: No
D: Do you feel that his mouth is dry?
P: No (Dehydration)
D: Has it ever happened before? (CF)
P: No, this is the first time
P: No
D: Is he taking any medications other than PCM including OTC or herbal medications?
P: No
P: No
D: Is there any other child around him with a similar condition?
P: No (siblings)
D: Was he born at term?
586
P: No, he was born at 35 weeks.
D: How much was the birth weight?
P: Normal
P: Yes.
P: Yes.
P: No
P: No.
D: Since when?
P: Since her nose became stuffy
P: No.
D: Have you noticed any tummy pain or change in her poo? (Gastroenteritis).
P: No
D: Any diarrhea?
P: No (CF)
D: How is the urine output?
P: It is fine.
P: It’s me
D: I would like to examine little Abdullah to assess him better. I would do a general physical
examination & would examine his chest.
Ex:
Bilateral wheeze & crackles on auscultation
We would also like to do a few investigations. I would like to do pulse oximetry. We would
also take some swab/specimen from the nose & send for viral cultures.
 We will keep him in the hospital as he was born 35 weeks of gestation. If needed we will
give him oxygen. If the child has the virus (RSV) then we need to keep him away from
other children.
 This kind of infection usually goes away within 2 weeks on its own.
 There's no medication to kill the virus that causes bronchiolitis. It’ll become better
without any treatment.
 We usually give paracetamol or ibuprofen to bring the fever down, but you are already
giving him that so just continue it till his fever goes down. Also because of this infection,
587
the fluids in the child’s body can decrease from the normal levels, so take care that you
give him enough fluids otherwise he can become dehydrated.
 If at any time you see that little Abdullah has difficulty in breathing (becomes blue), or is
not feeding well (dehydration), or becomes less active (drowsy), please bring him to the
hospital immediately.
Prevention:
1. wash your hands and your child's hands frequently
2. wash or wipe toys and surfaces regularly
3. keep infected children at home until their symptoms have improved
4. keep new-born babies away from people with colds or flu
5. prevent your child being exposed to tobacco smoke.
There are also a number of factors that can increase the risk of a child developing more
severe bronchiolitis like:
1. being under two months of age
2. having congenital heart disease
3. being born prematurely (before week 37 of pregnancy)
4. having chronic lung disease of prematurity (when injury to the lungs causes long-term
respiratory problems in premature babies)
Some signs of severe disease include:

1. poor feeding (less than half of usual fluid intake in preceding 24 hours)
2. significantly decreased activity
3. history of stopping breathing (Apnoea)
4. respiratory rate >70/min
5. presence of nasal flaring and/or grunting
6. severe chest wall recession (Hoover’s sign)
7. Bluish Skin.
Other investigation done in Atypical bronchiolitis:

1. CXR (When diagnosis is not certain)
2. FBC
3. U&Es (If child is dehydrated)
4. Blood and urine culture (If Fever >38.5)
5. ABG (Those who need mechanical ventilation)
DD:
1. Bronchiolitis
2. Cystic fibrosis
3. Asthma
4. Bronchitis
588
5. Foreign body.
6. Pneumonia
589
NIGHT TERRORS

Mrs. Jane Williams, 28 year old, has come to speak to a doctor about her child. She is
concerned about her daughter.
Please talk to the mother and address her concerns.
Daughter is not with the mother.

P: I am here to talk to you about my daughter. I am very concerned about her.
D: I am here to address all your concerns, but before that could you please confirm the
name and age of your child?
P: Her name is Jasmine and she is 5.
D: Could you please let me know what's your concern about Jasmine?
P: She has these episodes of screaming during the night time doctor.
D: Could you please tell me more about these episodes?
P: She has these episodes every night in her sleep.
D: May I know how many episodes does she have each night?
P: Around 1-3
D: What time does she usually go to bed and what time does she wake up?
P: She goes to bed at 8PM
D: What part of her sleep time does she get these episodes? Like the early part of her sleep
or late night or during the early mornings?
P: I think the early part of her sleep
D: Since how long is she having these episodes?
P: For 2-3 months
D: What exactly happens DURING these episodes?
P: She screams, shouts and gets panicked during these episodes.
P: Few minutes
D: Any Shaky/Jerky movements of her body during the episodes?
P: No
D: Any Faecal/Urinary incontinence?
P: No
D: Could you please tell me how is she just AFTER these episodes?
P: She is fine and goes back to her sleep
D: How is her rest of the sleep after the episodes?
P: Sometimes she has 2 or 3 episodes doctor but otherwise the rest of her sleep is good.
D: Is she able to remember these events after she wakes up?
P: No doctor
D: How is she just BEFORE she gets these episodes?
P: She is in her sleep.
590
D: Is her bed comfortable to sleep?
P: Yes
D: Any kind of disturbances to her sleep? Like dark or extra lighting, sound?
P: No
D: Does she watch TV I Listens to stories especially horror?
P: No
D: Is she having any Fever / Flu like symptoms recently?
P: No
D: Does she have any kind of pain anywhere?
P: No
P: No
P: No
D: Any allergy from any food or medications?
P: No
P: No
D: Any similar episodes in the family?
P: Her father had similar complaints as a child and went away with time
D: How was the birth of your child?
P: Normal delivery. No complications.
P: Yes
P: Yes
D: Has she recently received any jab?
P: No
D: Is she eating and drinking well?
P: Yes, no problems with that
D: Does she have any problem with her wee/poo?
P: No
D: Does she go to school?
P: Yes, she recently started a new school.
D: Is everything okay at school?
P: Yes
D: Any trouble or bullying at school?
P: No
D: Is she coping well with school or is she stressed or tired?
P: She is coping well.
D: Who looks after the child?
P: Me and my husband
591
D: Who all stay in the house?
P: Me, my husband and Jasmine
D: Is everything okay at home?
P: Everything is fine.
D: I would like to examine your child. Check her vitals, do general physical examination and
examine her neurological system.
D: I would like to do some initial blood tests to like FBC.
D: From my assessment, your child seems to have a condition called night terrors.
Have you heard about it before?
P: No
 D: Not to worry, this is not a serious problem. This is a common condition seen in
children of 3-8 years of age. It is usually seen in children who have a family history of
night terrors or sleep walking. Tiredness, fever, anxiety, sudden noises or full bladder can
also predispose this.
 In your child’s case, it might be because of her family history of her father having similar
complaints.
 This condition is not a serious one as I told and doesn’t need any medical treatment.
 We have to try to break the cycle of these episodes and regularise her sleep cycle. Try to
notice the exact time when these episodes happen after she falls asleep and try to wake
her up 15 mins prior to expected time for 7 days to stop night terrors. Stay calm and try
not to intervene or wake the child during the episode as this may make the child more
anxious. Try not to discuss about these episodes with your child as this may create more
anxiety.
 Try to find out if she has got any stress in life by talking to her and try to remove any
stress.
 Try to have a relaxing bedtime for her, sleep hygiene, comfortable bed and a nightlight to
avoid being dark. Empty bladder before going to bed.
 Please come back to us if this doesn’t get resolved by all these measures.
P: What are you going to do for her?
P: What should I do when she has the next episode?
592
CONSTIPATION CHILD
You are an F2 in GP
Mother of Daniel aged 2 Years has come to see you. Child was constipated. Daniel was
examined. All the examinations were normal.
She was given dietary advice and was asked to come back after 2 weeks. She has come back
after 1 week.
D: What brought you to the clinic today?

P: My child is having constipation doctor.
D: I am so sorry. I understand that you have come a week ago.
P: Yes. doctor. His constipation is still not resolved.
D: Don’t worry, I will ask you few questions to see what’s going on.
P: Ok Dr.
D: May I know what was told to you when you came last time'?
P: They gave me dietary' advice and asked me to give my child lots of fruits and vegetables and
plenty of water.
D: Were you giving him fibre diet?
P: Yes.
D: Could you please elaborate what do you give him throughout the day?
P: Normal food.
D: Is he drinking enough water?
P: I don’t think so dr. He doesn't have water at all.
D: How about his physical activity?
P: He is not that playful as before.
D: When was the last time he passed stool?
P: 10 days ago
D: Did he pass any wind?
P: Yes, this morning
D: Any overflow diarrhoea in between?
P: No
D: Did he soil his clothes anytime?
P: No
D: Does he know how to potty or are you training him now?
P: Yes/No
D: Does he try to go to the loo at all every day?
P: Yes Dr., he sits on the potty and cries sometimes.
D: Does he complain of any pain to defecate?
P: Yes/No
D: Does he complain of any tummy pain?
P: Yes/No
593
D: Did he have this problem in the past?
P: No
D: Has your child been diagnosed with any medical condition?
P: No
D: Is your child on any medication or is allergic to anything?
P: No
D: Does anyone in the family have any medical conditions?
P: No
D: How was the birth of your child?
P: Normal delivery.
P: Yes
D: Is he UpToDate with all his jabs?
P: Yes
D: Do you have any other children?
P: No. he is my first child.
P:
D: Does he go to school/nursery?
P: Yes/No
D: Does he have any stress or trouble going to school?
P: No
D: I would like to examine your child. Check his vitals, do head to toe examination and
tummy examination.
Ex: All examinations normal.
D: From my assessment, your child has constipation. As you told me that he cries sometimes
when he is on the potty, he might be having hard stools due to constipation.
D: Constipation is common in childhood, particularly when children are being potty trained
at around two to three years old. 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.
D: Your child may be constipated because they:
 aren't eating enough high-fibre foods like fruit and vegetables
 aren't drinking enough water
 are having problems with potty (or toilet) training
 are worried or anxious about something, such as moving to a new house, starting nursery
or the arrival of a new baby.
594
D: 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.
Laxative treatment may make your child have overflow soiling, before it gets better.
D: We will reassess your child after the constipation is resolved and if needed, we may have
to prescribe him laxatives for longer duration.
D: Try to stay calm as this can be stressful to both of you.
D: How to prevent constipation:
 Make sure your child has plenty to drink
 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.
 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.
D: Please come back to the hospital if your child develops any severe tummy pain, tummy
distension or vomiting.
P: Dr what’s going on?
P: Why is he still constipated?
P: What are you going to do?
P: Are you going to give him any medications?
P: I don’t want my child to have these medications for life long.
595
AUTISM
You are a F2 in GP. Mother of a 3-year-old child Jason is concerned about her son. Talk to
her and address her concerns.

P: I am very concerned about my son.
D: May I know what your concern is?
P: His health assessor is worried that Jason is not interacting well with other children at the
nursery.
D: I am so sorry, but could you please tell me what exactly you mean by not interacting?
P:
D: Did you notice that yourself?
P:
D: May I know, since when you started noticing this?
P:
D: Does he respond to his name?
P: Yes
D: Is he avoiding eye contact or not smiling when you smile at him?
P:
D: Does Jason have any kind of repetitive movements, such as flapping his hands, flicking his
fingers?
P:
D: Does he repeat the same phrases?
P:
D: Is he talking as much as other children?
P:
D: Is he walking and playing?
P: Yes, he plays with blocks.
D: Is there any trouble/stress at school?
P:
D: Are you happy with his red book?
P:
D: Did any incident take place after which Jason is not interacting well?
P:
D: How is his health recently?
P:
D: Did you or your partner/husband face any development delay?
D: What is your child's diet like?
D: Does your child eat food?
596
D: How is the wee and poo of your child?
D: Is he up to date with all the jabs?
P: Yes/No
P:
P:
P: Normal
P: Yes
P: No, it's my first baby.
P: Me
P:
D: I would like to talk to Jason and also examine him.
P: What's going on?
D: From my assessment, I suspect your son might be having Autism. I need to involve my
seniors and ask them to review Jason and confirm the diagnosis.
D: 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
45
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
P: What are you going to do for him?
D: An autistic spectrum disorder (ASD) is a lifelong condition. And unfortunately, there's no
"cure" for autism, but with the right support many autistic people live fulfilled and active
lives. As the severity can vary, it is difficult to predict the outcome for each child.
Some adults with ASD manage to work and get by with just a little support. In particular,
many people with Asperger's syndrome are able to manage well and live independently or
need little support when adult.
o The mainstay of treatment is special education support,
o Behavioural therapy.
o Medication may be considered to help with specific ASD-related symptoms. These
symptoms may be anxiety, depression or obsessive-compulsive disorder, outbursts of
excitement or aggression. Medication can also be used to help with sleep, epilepsy and
also with any repetitive behaviours.
P: Why did he get this?
597
D: 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 like lifestyle factors, such as diet and exercise, being born
prematurely, being exposed to alcohol or certain medicines, such as sodium
valproate in the womb.
P: Is this because of MMR vaccine?
D: No, this is not because of MMR vaccine. (Explain about MMR vaccine and autism study).
D: We have support services to support your child, family, carers and friends - National
Autistic Society.
D: 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 behavior 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 your child is
behaving in a challenging way and this is affecting family life, ask for help and support from
a GP or another healthcare professional.
598
8 WEEKS VACCINATION

Evana, 30-year-old female presented to your clinic with her 8 weeks old boy. She wants to
know about the vaccines that can be given to her baby.
Please talk to her, explain to her about the vaccines that can be given at 8 weeks of birth
and address her concerns.
Vaccine Side Effects

6 in 1 This vaccine is given as a single injection into your Redness,
baby's thigh. swelling at injection
This protects against 6 childhood diseases, such as site,
Diphtheria, Tetanus, Pertussis, Hepatitis B, Fever
Haemophilus Influenzae B and Polio
Pneumococcal Injection in your baby's arm or leg muscle Redness,
Protects against pneumococcus swelling at injection
site,
Fever
Rotavirus Oral vaccine against rotavirus infection. Irritable / Mild
Common cause of diarrhoea and sickness diarrhoea
Men-B Single injection into your baby's thigh to protect Redness,
against infection by meningococcal group B swelling at injection
site
Fever
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600
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PRIMARY ENURESIS
You are an FY2 in GP Surgery.

Rachel Williams, mother of 4-year-old David Williams, has brought him in to the clinic
because of Bed Wetting.

P: My child is not dry at night.
D: Tell me more about the it?
P: Dr he is 4 years old but still he wets the bed in the night.
D: Did you child use to be dry at night before?
P: my child has never been dry before.
D: Is it daily or off and on?
P: It is daily doctor.
D: Have you noticed any dry nights before or in between?
P: No
D: Did anything significant happen before the onset that led to this condition?
P: No
D: What is bathroom routine of child before going to bed.
D: Anything else?
P: No
D: Any fever?
P: Yes/No
D: Any daytime wetting?
P: Yes/No
D: Excessive crying?
P: Yes/No
D: Any burning while passing urine?
P: Yes/No
D: Any cloudy/smelly urine?
P: Yes/No
D: Any lethargy?
P: Yes/No
D: Loss of appetite?
P: Yes/No
D: Weight loss?
P: Yes/No
D: Any abnormal swellings in tummy?
P: Yes/No
P: No
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P: No
P: No
P: No
P: Yes.
P: Yes.
P: No
D: Does she have any problems with her wee and poo?
P: No.
P: It’s me.
D: Who else lives with the child
P: Me and my husband.
D: Any other child?
P: No
D: Is he going to school?
P: Yes.
D: Any problem at school?
P: No
I would like to check the vitals, general physical examination and abdominal examination.
Bedwetting is common in young children and children usually grow out of it. We can devise
a plan to help your child with this.
Plan:
Plenty of water during the day. It's best to avoid drinks for an hour before bedtime.
Avoid drinks that contain caffeine, such as cola, tea, coffee or hot chocolate, because they
increase the urge to wee.
Encourage your child to go to the toilet regularly during the day.
• If the child wakes up at night, encourage them to go to toilet.
• Make a habit of asking your child to go to toilet before going to bed.
Reward your child for having plenty of drinks during the day and remembering to have a
wee before bed
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We will be following your child up and if these measures did not help, or your child
developed daytime wetting, or your child did not outgrow of this after 5 years of age, then
we will further test your child.
Further plan of action:

• referral to enuresis clinic/ specialist.
• Urine test
• Alarm clock for encouraging the child to visit the loo
GP may suggest a medicine called desmopressin.
Please Come for the follow up and come back to the hospital with your child if he develops
fever, lethargy, tummy swelling, daytime symptoms and your child has suddenly started
wetting the bed after they've been dry at night for a while.
We will give you leaflet.
Note: if child is above 5 years, then you have to make referral, offer general advice same as
above and also include alarm clock and positive reward system. If child is of any age and has
daytime symptoms as well, make referral to enuresis clinic. If child was dry before and now
started wetting the bed, make referral.
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NEGATIVISM

Lisa James, aged 30, is concerned about her 4-year-old daughter.

P: My child doesn’t listen to me. She started her nursery 2 weeks ago.
P: She is always playing with her food. She is taking roughly 30 mins to go to bed.
D: Does she sleep alone.
P: Yes.
D: Since when has this been happening?
P: This has been going on for 3 months.
D: How often does this happen?
P:
D: Has it been regular since it started?
P:
D: How was she before that?
P: She was fine.
D: Anything else?
P: Like what?
D: Does she respond to sounds around her? (hearing loss)
P: Yes
D: Does she respond to her name? (autism)
P: Yes
D: Does she make eye contact while talking? (autism)
P: Yes
D: Does she engage in repetitive movements (autism)
P: No
D: Does she have tantrums often? (autism)
P: No
D: Is she unable to sit still? (ADHD)
P: No
D: Does she do excessive talking? (ADHD)
P: No
D: Is she unable to concentrate on tasks? (ADHD)
P: No
D: Is she constantly changing activities or tasks? (ADHD)
P: No
D: Any (tragic/traumatic) event occurred recently?
P: She started school 2 weeks go.
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D: How is she coping with it?
P:
D: Do you think she is getting tired/distressed with the school?
P: Yes/No
D: Have you spoken to your daughter about this?
P: Yes/No
D: Tell me more about Jasmine?
D: How has she been recently?
P: She has been fine
D: Has she got fever or flu like symptoms?
P: No
D: How is her sleep pattern?
P: Ok
D: Does she got to the toilet before going to sleep?
P: Yes/No
D: How much does she play on the smart devices?
P: Limited
D: Parental control on? (violent videos)
P: Yes
D: What time does she go to sleep?
P: Usual 8 pm
D: How is her diet?
P: Good
D: Is she up to date with her jabs?
P: Yes
P: Yes
D: How is her mood?
P:
D: Is she lethargic?
P: No
D: Is she on any medications?
P: No
D: Any allergies?
P: No
D: Anyone in your family with a similar problem?
P: No
D: How is the home condition?
P: Good
D: Who looks after Jasmine?
P: I’m her only carer, sometimes my friends look after her if I am busy
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D: Can you bring your child in to the hospital for assessment?
P: Yes
Patient Concerns:
1. Can you prescribe any medications?
2. Will this stay forever?
Conduct disorders are the most common type of mental and behavioural problems in
children and young people. They are characterised by repeated and persistent patterns of
antisocial, aggressive or defiant behaviour, much worse than would normally be expected in
a child of that age. Types of behaviour include stealing, fighting, vandalism, and harming
people or animals.
Conduct disorder is different from the occasional tantrum or “naughtiness” in a child.
Younger children often have a type of conduct disorder called “oppositional defiant
disorder”. In these children, the antisocial behaviour is less severe and often involves
arguing (“opposing”) and disobeying (“defying”) the adults who look after them.
In teenagers with conduct disorders, the pattern of behaviour can become more extreme
and include:
o Aggression towards people or animals
o Destruction of property
o Persistent lying and theft
o Serious violation of rules
What causes conduct disorders?

Possible environmental factors include:
o A “harsh” parenting style
o Parental mental health problems such as depression and substance misuse
o Parental history, such as the breakup of a marriage
o Poverty
o Individual factors, such as low achievement
o The presence of other mental health problems
How can conduct disorder be treated?

Several approaches have been developed for children at risk of, or diagnosed with, conduct
disorders. In particular, parenting programmes are run by health and social care
professionals to help parents improve their children’s behaviour. Treatment for the children
themselves includes psychological therapies and sometimes, medication.
Warning signs and symptoms:

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Younger children (aged under 11) may repeatedly argue with, disobey and defy those
looking after them.
Selective prevention
One of the key messages contained in the NICE guidelines is the importance and usefulness
of selective prevention. Selective prevention means identifying individual children with an
above average risk of developing a conduct disorder and then providing treatment to try
and prevent that from occurring. The rationale being that it is usually easier to prevent a
disease than to cure one.
NICE recommend that younger children aged three to seven years should be considered for
selective prevention if:
o They are growing up in a poor household
o They are underachieving at school
o There is a history of child abuse or parental conflict
o Their parents are separated or divorced
o One or both of the parents has a history of mental health problems and/or substance
abuse problems
o One or both parents have come into contact with the criminal justice system
Initial assessment should involve checking for the following complicating factors:
o A coexisting mental health problem (for example, depression or post-traumatic stress
disorder)
o A neurodevelopmental condition (in particular ADHD and autism)
o A learning disability or difficulty
o Substance misuse (in older children)
In younger children aged between 3 and 11 years, a type of treatment programme known as
group parent training programme is recommended. In some cases, drug treatments may
also be recommended.
Parent/foster parent/guardian training programmes

NICE recommend that this treatment should be offered for those whose children:
o Have been identified as being at high risk of developing oppositional defiant disorder
or conduct disorder
o Have oppositional defiant disorder or conduct disorder
o Are in contact with the criminal justice system because of antisocial behaviour
Parent/foster parent/guardian training programmes are based on the premise of helping

parents make the most of their parenting skills so they can help improve their child’s
behaviour. The programmes are run by specially trained health or social care professionals.
They cover communication skills, problem-solving techniques and how to encourage positive
behaviour in children.
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It is best if both parents, foster parents or guardians attend the programme if this is possible
and in the best interests of the child or young person.
The programmes are usually run on a group basis involving 10 to 12 parents, over the course
of 10-16 meetings, with each meeting lasting around 1-1/2 to 2 hours.
Medication
In a minority of cases, where a child or young person is finding it especially difficult to
control the anger, a medication called risperidone, which helps reduce aggressive
tendencies, may be recommended.
The most common side effects of risperidone include:

o Parkinson’s like symptoms such as muscle jerks and problems with body movements
o Headaches
o Insomnia
Autism Symptoms:
1. Not responding to their name
2. Avoiding eye contact
3. Not smiling when you are smiling at them.
4. Repeating same phrases and movements like flapping of hands
5. Not talking as much as other children
6. Developmental delay
7. Not socializing with others
ADHD Symptoms:
The main signs of inattentiveness are:
 Having a short attention span and being easily distracted
 Making careless mistakes – for example, in schoolwork
 Appearing forgetful or losing things
 Being unable to stick to tasks that are tedious or time-consuming
 Appearing to be unable to listen or carry out instructions
 Constantly changing activity or task
 Having difficulty organizing tasks
Hyperactivity and Impulsiveness

The main signs of hyperactivity and impulsiveness are:
 Being unable to sit still, especially in calm or quiet surroundings
 Constantly fidgeting
 Being unable to concentrate on tasks
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 Excessive talking
 Being unable to wait their turn.
 Acting without thinking
 Interrupting conversations
 Little or no sense of danger
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HAEMANGIOMA (BIRTH MARK)
You are FY2 in GP Surgery.

Mother of 10 days old baby is here with some concerns.
Talk to her , take a relevant history and address her concerns.
D: Hi I am Dr. Khalil one of the junior doctors working in this department

P: Hello doctor.
D: Can I confirm your name please?
P: Doctor my name is Matilda and i am the mother of Serena is 10 days old.
D: Okay, is Serena here with us today?
P: No doctor
D: Okay that’s fine , how can I help you today?
P: Doctor, my baby have a rash on her thigh .
D: Could you please elaborate it a bit more for me ?
P: Doctor I was changing my baby’s nappy and I saw some spot/ rash on her thigh I was very
curious to know how a 10 days’ old baby can have it, that’s why I came here to enquire about
this.
D: I am sorry to hear that , I know you are very anxious about it . can I ask a few more
questions about it so that I could understand it better?
P: Sure doctor.
FODPARA
D: Could you please tell me when it start?
P: I don’t know doctor but I saw it last night
D: What is the shape of the rash?
Any change in the shape of the rash?
P: Doctor I have a picture of it
D: What is the Size of the rash? Any change in the size?
P: Like a coin
D: What is the Color of the rash ? any change in the color?
P: Red in color
D: Any discharge from the rash?
P: No discharge
P: no
D: Who takes care of the baby ? (NAI)
P: me and my husband takes a good care of her .
D: Was it a planned pregnancy ? (NAI)
P: yes doctor
D: Do the baby cry after moving his neck ? (MENINGITIS)
P: no
D: Any problems with her wee?
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Any problems with her poo?
Is she feeding well?
BIRD QUESTIONS
D: how was the birth of the baby
P: NVD
D: Was she delivered at full term?
P: No doctor. She was delivered at 35 weeks
D: Did she have a low birth weight ?
P: Yes, she was low birth weight .
D: Was it multiple or twin pregnancies?
P: No
D: How’s the general health of the baby ?
D: Any congenital problem ?
P: No
D: Family history of any diseases?
P: No
D: Do you have any IDEA of what it is ?
P: No ( I will explain )
Thank you very much for the information regarding your baby Serena .
MANAGEMENT
I would like to have a look at the rash and would ideally examine your baby general health
as-well. ( she is not here )
Examiner may show you a picture of the rash
From what you have told me and from what I have assessed I suspect your baby have a
birthmark ( strawberry or hemangioma ).
D: Do you know what a birthmark is ? (concern)
P: No
Birthmarks are colored marks on the skin that are present at birth or soon afterwards. Most
are harmless and disappear without treatment, but some may need to be treated.
I would like to inform my seniors to have an expert opinion as-well .
P: Is it a serious condition ? (concern)
D: The good thing is that it is not a serious condition . the size may increase in the first few
months and then they usually disappear by the age of 6 to 7 years .
P: How are you going to treat him now ? ( concern )
D: Usually these birthmarks don’t need any treatment until unless if they are affecting your
vision, breathing, or feeding.
Treatment for birthmarks

Possible treatments for birthmarks include:
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• medicines – to reduce blood flow to the birthmark, which can slow down its growth and
make it lighter in color
• laser therapy – where heat and light are used to make the birthmark smaller and lighter
(it works best if started between 6 months and 1 year of age)
• surgery – to remove the birthmark (but it can leave scars)
A birthmark can be removed on the NHS if it's affecting a person's health. If you want a
birthmark removed for cosmetic reasons, you'll have to pay to have it done privately.
SEE YOUR GP if
• you're worried about a birthmark
• a birthmark is close to the eye, nose, or mouth
• a birthmark has got bigger, darker or lumpier
• a birthmark is sore or painful
• your child has 6 or more cafe-au-lait spots
• you or your child has a large congenital mole
The GP may ask you to check the birthmark for changes, or they may refer you to a skin
specialist (dermatologist).
The Birthmark Support Group has information about other type of birthmarks and getting
help and support.
RED FLAGS
Birthmark getting bigger
More darker and lumpier
Come back to us
Leaflets
Specific expectations
Wish him a good health
MORE INFORMATION ON DIFFERENT TYPES OF BIRTHMARKS
Types of birthmark
Flat, red or pink areas of skin (salmon patches or stork marks)
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Salmon patches:
• are red or pink patches, often on a baby's eyelids, head or neck
• are very common
• look red or pink on light and dark skin
• are easier to see when a baby cries
• usually fade by the age of 2 when on the forehead or eyelids
• can take longer to fade when on the back of the head or neck
Raised red lumps (strawberry marks or haemangiomas)
Strawberry marks:
• are blood vessels that form a raised red lump on the skin
• appear soon after birth
• usually look red on light and dark skin
• are more common in girls, premature babies (born before 37 weeks), low birth weight
babies, and multiple births, such as twins
• get bigger for the first 6 to 12 months, and then shrink and disappear by the age of 7
• sometimes appear under the skin, making it look blue or purple
• may need treatment if they affect vision, breathing, or feeding
Red, purple or dark marks (port wine stains)
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Cafe-au-lait spots:
• are light or dark brown patches that can be anywhere on the body
• are common, with many children often having 1 or 2
• look darker on dark skin
• can be different sizes and shapes
• may be a sign of neurofibromatosis type 1 if a child has 6 or more spots
Blue-grey spots
These birthmarks:
• can look blue-grey on the skin like a bruise
• are often on the lower back, bottom, arms or legs
• are there from birth
• are most common on babies with darker skin
• do not need treating and will usually go away by the age of 4
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• are not a sign of a health condition
If your baby is born with a blue-grey spot it should be recorded on their medical record.
Brown or black moles (congenital moles or congenital melanocytic naevi)
Congenital moles:
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• are brown or black moles caused by an overgrowth of pigment cells in the skin
• look darker on dark skin
• can become darker, raised and hairy, particularly during puberty
• may develop into skin cancer if they're large (the risk increases the larger they are)
• do not need to be treated unless there's a risk of skin cancer.
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CHILD DEVELOPMENTAL MILESTONES
You are FY2 in Paediatrics.

Hannah Williams mother of Jenny Williams aged 15 months comes to the hospital with a
concern that her child is not able to walk. The mother is very concerned.
Ask relative questions and address her concerns.

P: I’m worried my child can’t walk.
D: I can see that you care about your child.
P: Let me ask you few questions.
D: How old is your child?
P: 15 months.
D: Is your child able to stand independently?
P: No
D: Is your child able to stand by holding on to something?
P: No
D: Have you tried making your child stand up?
P: I tried but falls, so I didn't try. I can’t see my child falling and getting hurt.
D: Does your child sit with/without support?
P: Yes/No
D: Does your child crawl?
P: Yes
D: Does your child roll over?
P: Yes/No
D: Does your child hold a cup?
P: Yes/No
D: For how long? (if above answer is yes)
P:
D: How does your child hold the cup?
P:
D: How do you play with your child?
P:
D: Does she talk to you?
P: Yes, says Mama.
D: Does your child respond to you?
P: Yes. when I clap.
D: Does your child respond to their name?
P: Yes/No
D: Does your child call out your name?
P: Yes, says Mama.
D: Does your child show anxiety to a stronger?
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P: Yes/No
D: Does your child play peek-a-boo?
P: Yes/No
D: Does your child wave ‘bye bye’?
P: Yes/No
D: Is your child up to date with the jabs?
P: Yes/No
D: How has your child been recently?
P: Fine
P: Yes/No
D: Any bone disorders?
P: No'
P: Yes/No
D: Did you or your partner/husband face any development delay?
P: Yes/No
D: What is your child’s diet like?
P: Stopped taking breast milk at 12 months.
D: Have you started feeding your child with bottle milk?
P: Yes/No
P: Yes. baby food in puree form.
D: How is the wee and poo of your child?
P: Normal
P: No, it’s my first baby.
P:
D: Any stress at work/home?
P: Yes/No
I would like to assess your child.

We might refer your child to the specialist for further assessment if need be.
From the history it seems like your child at this moment in time doesn't not have any
development delay. However, we will keep monitoring the progress of your child.
I can see that you are worried about your child development, but let me reassure you that
we will together take care of her.
P: How can I help my baby to walk?
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 D: As your baby learns to stand, he may need some help working out how to get back
down again. If he gets stuck and cries for you, don't just pick him up and plop him down.
Instead, show him how to bend his knees so he can sit down without toppling over, and
let him give it a try himself.
 You can encourage your baby to walk by standing or kneeling in front of him, holding
both his hands as you help him walk towards you.
 You could also buy him a toddle truck or a similar toy that he can hold on to and push.
Look for toddle toys that are stable and have a wide base of support. Baby walkers can
cause accidents by tipping over, so it's best not to use them.
 As your baby learns to walk it's a good idea to keep his feet as free as possible. Let him
toddle barefoot if you can. Going barefoot helps him to improve his balance and
coordination. If cramped by tight shoes or socks, your baby's feet can't straighten out
and grow properly.
 As long as your baby is bearing weight on his legs and shows an interest in learning new
things, you don't have to be concerned. If your baby took a little longer than other babies
to learn to crawl, chances are he'll need a few more months for walking as well. Babies
develop skills differently, some more quickly than others.
 Remember that if your baby started to move around by bottom shuffling before he
learned to crawl, then he may walk later.
 The speed at which a baby learns a new skill is often inherited from his parents. If you or
your partner walked early or late, then there is a chance your baby will be the same.
6 Weeks
Gross motor - Limbs flexed. Head lag. Prone chin lifting.
Fine Motor - Follows person with moving eyes
Speech & Language - turns to sound
Social - smiles at mother, watches face
6 Months
Gross motor - Good head control, Roll over, Sit when held
Fine motor - Moves object hand-to-hand
Speech & Language - responsive to word “no” and changes in tone
Social - friendly to everyone, has likes and dislikes, talks to mirrors
12 Months
Gross motor - Sits unsupported. Lying -> Sitting. Pulls self up on furniture
Fine motor - Pincer Grip
Speech & Language -“dada” “mama”, knows the meaning of many words
Social -Stranger anxiety
15 Months
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Gross Motor - Sitting to standing alone. Walks (unstable). Crawl upstairs
Fine Motor - Point to what they want. Tower of 2 bricks
Speech & Language - listens, enjoys songs
Social - understands many phrases
18 Months
Gross Motor - Steady gait. Run short distance
Fine Motor - Scribbles with crayon. Turns 2/3 pages
Speech & Language - can point to 2/3 parts of body
2 Years
Gross Motor - Up & downstairs. Climb furniture. Throw & kick ball
Fine Motor - Tower of 6 bricks. Vertical line. Shapes in slots
Speech & Language - asks for food/drink. 2/3 word sentences
3 Years
Gross Motor - Walks up stairs with alternating feet. Stand on one foot. Tricycle
Fine Motor - Tower of 9 cubes
Speech & Language - knows nursery rhymes, count to 10, two colours
Social - can undress & dress, needs help with buttons and which shoe
4 Years
Gross Motor - Walks down stairs using alternating feet. Hop on foot
Speech & Language - gives 1st and 2nd name
Social - can attend all toilet needs
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SPEECH DELAY TWINS

Miss Diana Whales, mother of 15 months old boy and a girl came to the clinic because of
some concern.
Please talk to her and discuss your plan of management with her and address her concerns.
Children are not in the cubicle.
Reassurance to the mother

P: I’m worried my child can’t talk.
D: I can see that you care about your child. Let me ask you a few questions. How old is your
child?
P: 15 months.
D: Is your child able to stand independently?
P: Yes
D: Is your child able to stand by holding on to something?
P: Yes
D: Does your child sit with/without support?
P: Yes
D: Does your child crawl?
P: Yes
D: Does your child roll over?
P: Yes
D: Does your child hold a cup?
P: Yes
D: For how long? (if above answer is yes)
P:
D: How does your child hold the cup?
P:
D: How do you play with your child?
P:
D: Does he talk to you?
P: Yes, but he only speaks 2 words, dada and mama
D: Does your child respond to you?
P: Yes, when I clap
D: Does your child respond to their name?
P: Yes, says
D: Does your child call out your name?
P: Yes, says mama
D: Does your child show anxiety to a stranger?
P: Yes
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D: Does your child play peek-a-boo?
P: Yes
D:
P: Yes
D: Does your child wave ‘bye bye’?
P: Yes
D: Is your child up to date with the jabs?
P: Yes
D: How has your child been recently?
P: Fine
P: Yes/No
D: Any bone disorders?
P: No
P: Yes/No
D: Have you started feeding your child with bottled milk?
P: Yes/No
P: Yes, baby food in puree form
P: Yes, I have a twin daughter.
D: How is she doing?
P: She is doing well. In fact, she is saying many words compared to her brother.
D: Who looks after the children?
P: Me and my husband.
P:
D: Any stress at work/home?
P: Yes/No
I would like to assess your child. We might refer your child to the specialist for further
assessment if need be.
From the history it seems like your child at this moment in time doesn’t have any
developmental delay. However, we will keep monitoring the progress of your child.
I can see that you are worried about your child’s development but let me assure you that we
will together take care of her.
P: How can I help my baby to talk?

D:
12 to 18 months
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 If your child is trying to say a word but gets it wrong, say the word properly for example,
if they point to a cat and say “Cal” you should respond with, “Yes, it’s a cat”. Do not
criticize or tell off for getting the word wrong.
 Increase your child’s vocabulary by giving them choices, such as, “Do you want an apple
or a banana?”.
 Toys and books that make a noise will help your child’s listening skills.
 Enjoy singing nursery rhymes and songs together as your baby grows, especially those
with actions, such as “Pat-a-cake”, Row, row, row your boat” and “Wind the bobbin up”.
Doing the actions helps your child to remember the words.
The speed at which a baby learns a new skill is often inherited from his parents. If you or
your partner walked early or late, then there is a chance your baby will be the same.
6 Weeks
Gross motor - Limbs flexed. Head lag. Prone chin lifting.
Fine Motor - Follows person with moving eyes
Speech & Language - turns to sound
Social - smiles at mother, watches face
6 Months
Gross motor - Good head control, Roll over, Sit when held
Fine motor - Moves object hand-to-hand
Speech & Language - responsive to word “no” and changes in tone
Social - friendly to everyone, has likes and dislikes, talks to mirrors
12 Months
Gross motor - Sits unsupported. Lying -> Sitting. Pulls self up on furniture
Fine motor - Pincer Grip
Speech & Language -“dada” “mama”, knows the meaning of many words
Social -Stranger anxiety
15 Months
Gross Motor - Sitting to standing alone. Walks (unstable). Crawl upstairs
Fine Motor - Point to what they want. Tower of 2 bricks
Speech & Language - listens, enjoys songs
Social - understands many phrases
18 Months
Gross Motor - Steady gait. Run short distance
Fine Motor - Scribbles with crayon. Turns 2/3 pages
Speech & Language - can point to 2/3 parts of body
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2 Years
Gross Motor - Up & downstairs. Climb furniture. Throw & kick ball
Fine Motor - Tower of 6 bricks. Vertical line. Shapes in slots
Speech & Language - asks for food/drink. 2/3 word sentences
3 Years
Gross Motor - Walks up stairs with alternating feet. Stand on one foot. Tricycle
Fine Motor - Tower of 9 cubes
Speech & Language - knows nursery rhymes, count to 10, two colours
Social - can undress & dress, needs help with buttons and which shoe
4 Years
Gross Motor - Walks down stairs using alternating feet. Hop on foot
Speech & Language - gives 1st and 2nd name
Social - can attend all toilet needs
SCENARIO #2
A mother of 18 months child is inside she is concerned regarding her child development.
Take history assess him and address his concerns .
D: Hi I am Khalil one of the junior doctors working in this GP clinic .

P: Hello doctor
D: How may I help you today?
P: Doctor I am here for my son.
D: May I know his name and age please
P: Yes doctor his name is Edward and he is 18 months old
D: Is he with us today ?
P: No doctor
D: Ok, could you please tell me what happened ?
P: Doctor my son is not talking.
D: Could you please tell me more about it ?
P: Doctor he is 18 months old and still not able to talk , I am afraid that he is having some
problems with his ability to talk … ( WHY DO YOU THINK LIKE THAT ) she may say she has seen
other children talk at this age. If she does, ensure mother you are going to help her and will
come with a plan as well.
D: I am really sorry and I know you are quite anxious , we are here to help you out don’t
worry
P: Thank you doctor
D: I need to ask a few more questions for better understanding is that okay ?
P: Yes doctor sure
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D: How’s the general health of Edward?
P: He is fine doctor the only problem is his speech
D: Any long term history of having fever ?
P: No doctor
D: Is he able to say simple words like mama or dada ?
P: Yes doctor he can.
D: Is he responding to YES or NO ?
P: Yes doctor he can.
D: he recognizes your name ? ( 18TH MONTH MILESTONE )
P: No Dr. he doesn’t
D: Is he able to recognize the objects and body parts ? ( 18TH MONTH MILESTONE )
P: No Dr. he can’t
D: Do you give time to your son and talk to him?
P: Doctor I am a working lady, but I still try to talk to him and play with him when I am back to
home from work.
D: I am glad you are such a caring mother , and are trying your best for your child in every
aspect.
D: Is there any history of trauma to the head and face ?
P: No doctor
D: Have you noticed any problem with his tongue ?
P:No Doctor
D: Any problem with his lips ?
P:No doctor
D: Is there any weakness in other parts of the body ?
P: No doctor
D: Is he playful ( AUTISM)
P: Yes doctor he is
D: Does he go to a nursery yet?
If yeah- does he not talk at all the nursery as well or is it only home? (Selective Autism)
D: Do he maintain eye contact ?
P: Yes doctor
D: Have you observed any repetitive movements ? (AUTISM)
P: No doctor
D: What about his walking development ? Do he have any prob with walking.
P: That’s fine doctor ( CEREBRAL PALSY)
D: Who takes care of the child?
P: Me and my partner doctor (NAI)
D: Do Edward enjoy spending time with your partner
P: Yes doctor, they do.
D: Is he the biological father of your son ? (NAI)
P: Yes Doctor
D: How’s the relationship of you and your partner?
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P:Perfect doctor
BIRD HISTORY
D: How was the birth of the baby?
P: NVD
D: Is he up-to date with his jabs ?
P: Yes doctor
D: Are you happy with the red book ?
P: Yes doctor
D: How has the development of the baby been so far?
P: Normal development.
MAFTOSA
D: Any past medical history of any illness ?
P: No
D: Are you giving me any medications ?
P: No
D: Family history of any speech delay or developmental delays?
P: No
D: Do you and your partner use same language ? ( DIFFERENT LANGUAGE IS A RISK FACTOR)
P: Yes Doctor.
D: Thank you very much for the information . Do you have any idea what’s going on?
Examination
I would like to check the vitals , will examine the oral cavity and will do a GPE. And we will
also do routine blood investigations.
Management
From the information you have given me and from the assessment that we have done until
now I suspect your child has speech delay.
Every child develops at his or her own pace. But if your child doesn’t talk as much as most
children of the same age, the problem may be speech delay.
Treatment
Your child may not need treatment. Some children just take more time to start talking. But if
your child needs treatment, the type will depend on the cause of the speech delay. I would
like to inform my seniors who will reassess . He may refer you to a speech and language
pathologist. This person can show you how to help your child talk more and speak better,
and also can teach your child how to listen or how to lip read. Your doctor will tell you the
cause of your child’s issue and talk to you about treatment options.
Other specialists we may refer you include a psychologist (a specialist in behavior problems),
an occupational therapist (for help with daily activities), or a social worker (who can help
with family problems). Your doctor may also suggest programs in your area such as Early
Intervention.
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KEEP A DIARY
Keep a diary in which you need to notice the behavior of your child and note any
improvements , change in behavior, and any aggression .
SAFETY NETTING Sudden aggression come to the hospital If any difficulty in swallowing or
sleeping come to the GP.
FOLLOW UP Regular follow up is important
LEAFLETS EXPECTATIONS WISH YOU A GOOD HEALTH
MORE INFORMATION REGARDING SPEECH DELAY
CAUSES OF SPEECH DELAY
• hearing loss
• slow development
• intellectual disability
Other causes include:
• Psychosocial deprivation (the child doesn’t spend enough time talking with adults).
• Being a twin.
• Autism (a developmental disorder).
• Elective mutism (the child just doesn’t want to talk).
• Cerebral palsy (a movement disorder caused by brain damage).
Living in a bilingual home also may affect a child’s language and speech. The child’s brain
has to work harder to interpret and use 2 languages. So it may take longer for these children
to start using one or both languages they’re learning. It’s not unusual for a bilingual child to
use one language for a while.
Symptoms of a speech and language delay

Your child may have a speech delay if he or she isn’t able to do these things: Say simple
words (such as “mama” or “dada”) either clearly or unclearly by 12 to 15 months of age.
Understand simple words (such as “no” or “stop”) by 18 months of age. Talk in short
sentences by 3 years of age. Tell a simple story at 4 to 5 years of age
How is a speech and language delay diagnosed?

Your doctor can help you recognize a speech and language delay. He or she will ask you
what you have heard and can listen to your child’s speech and check your child’s mental
development.
Your doctor may refer you to other specialists to determine why your child isn’t speaking.
For example, if your doctor thinks your child may have trouble hearing, he or she may refer
your child to an audiologist for a hearing test. This is a licensed health care professional who
treats hearing problems.
Can a speech and language delay be prevented or avoided? Depending on the cause of your
child’s speech delay, you may not be able to prevent or avoid it.
Living with a speech and language delay If your child’s speech is delayed due to a hearing
loss, hearing aids or cochlear implants may help your child hear speech. Once your child has
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access to sound (and speech), he or she may be able to develop language and even catch up
to his or her hearing peers.
If your child hears and understands language, you can encourage him or her to speak by
talking as much as you can around them. Describe what you’re doing as you do everyday
activities. Keep talking. If your child speaks, confirm what he or she is saying. Always
provide positive feedback. Speech and language delays can be frustrating for parents and
children. Children who can’t express their thoughts and emotions are more likely to act out.
They anger easily. They may use unexpected behavior to get your attention. Try to
remember your child does want to communicate with you. Read to your child and talk as
much as you can. Encourage your child to speak. When he or she tries to speak, praise their
efforts.
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CHILD WITH TANTRUMS

A 30 year old mother wants to talk to you regarding her 3 year old child.
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?
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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.
• 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.
(OR)
From what you have told, it seems that your child is having temper tantrums. This is a battle
between freedom and frustration which can lead to tantrums. They want to express
themselves but find it difficult and frustration comes as tantrum.
As a parent, you should:

 Not panic
 Ignore the tantrum
 Be consistent with rules
 Pay attention to any good behaviour
Prevention of tantrums
Planning ahead.
Here are some examples:

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 Manage boredom when in a waiting room by taking their favourite books and toys to the
doctor’s surgery with you.
 Storing their favorite biscuits out of sight, rather than where they can see them.
 Manage a tired child by giving them an afternoon nap, instead of staying awake all day.
 Manage hunger by offering a snack after nursery at 3:30 pm, instead of having to wait
until 5.00 pm for tea.
 Distraction can help – you may be able to avoid a tantrum by diverting your child’s
attention.
Signs and Symptoms

Tantrums can also occur when a child is:
 Tired
 Hungry
 Feeling ignored
 Worried or anxious – a younger child may be unable to tell you that they are anxious and
they may cry, become clingy and have tantrums.
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
o 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.
o Children notice when you do not mean what you're saying.
• Do not give up
o 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
o 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
o This can be difficult. When your child does something annoying time after time,
your anger and frustration can build up.
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o 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.
o Find other ways to cope with your frustration, like talking to other parents.
• Talk to your child
o 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.
o 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.
o 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."
o 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.
o 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 much smaller.
• 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 go there.
• 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 being difficult.
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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.
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PAEDIATRIC EPILEPSY

Molly age 10 presented to hospital with fits and the diagnosis of Epilepsy has been made.
She has been medically managed and is fit for discharge. Neurology’ consultant has
prescribed her some medication.
Mother has some concerns. Please talk to the mother and address her concerns.
D: We are glad Molly is in good health now and fit to go home. I am here to talk to you
regarding some of the important things that needs to be done while she is at home, that are
important to all the patients of epilepsy.
P: OK doctor.
D: I suppose you understand that she has been diagnosed with epilepsy, would you like me
to explain you what exactly is it, so that we have a better understanding of how to deal with
it?
P: Yes sure
D: It is a condition that is associated with abnormality' in electrical activity of the brain. This
causes seizures in patients like the one your daughter experienced.
P: OK doctor
D: So now we know that what causes this, there are some medications that need to be given
to her at regular basis to prevent this happening in future. Has anyone talked to you
regarding this?
P: No doctor.
D: We have prescribed her a medication and it is very important to take the medication
regularly every' day, as we prescribed. This medication helps prevent attacks. This
medication is given every' day to maintain the level of medication in the body.
P: Ok
D: Has she been diagnosed with any medical condition?
P: No doctor
D: Does she take any medication including over the counter, herbal and supplements?
P: No doctor
D: Does she have any allergy?
P: No doctor
D: There are some triggers that I wish to discuss with you. It is very important to find out if
there are any, as this can help prevent any future attacks . We can work together on this, as
this is very important.
Spending a lot of time in front of TV or Computers and listening to loud music can trigger
fits. Does she watch a lot of TV or play with computers?
P: Yes she does
D: I can understand that considering her age. but we can always do that in small sessions
regarding being exposed to screens continuously for a longer period of time.
D: Lack of sleep can also trigger her condition. Please make sure that she have enough sleep.
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P: Ok doctor
D: There are a few more things like dehydration and skipping meals that can cause a fit. So
please make sure that she drinks plenty of water and does not skip meals. Excessive exercise
can also be a trigger. However, most sports and leisure activities are possible for people
with epilepsy, as long as necessary precautions are taken.
P: She goes for swimming and dance classes doctor.
D: Sports on or near water, or at heights, may need extra safety measures or supervision. If
you have seizures it's a good idea to swim with someone who knows about the condition
and type of seizures you have and how to help you if you have a seizure in the water. So it
would be great if you could accompany your child when she goes swimming.
 Please make sure that the swimming pool has a lifeguard who is aware of your daughters
condition. You can also tell the lifeguard how to help your daughter if she has an attack.
 Some people swim during quieter swimming sessions so it is easier for the lifeguard to
spot you.
 Some swimming pools have got a shallow area so it is advisable to swim in shallow
water.
As long as her dance classes are not so intensive and there is no loud music, you can take
her to dance class. It is important to inform her instructor about her condition.
D: Epilepsy medications usually have interaction with some medication. Please don’t give
your daughter any medication including OTC. Please always seek advice from her GP.
It is very important for her to be seen by GP regularly. Her GP will review your child’s
condition
and re-prescribe her medications. P: Sure Doctor
D: Some health problems such as vomiting and diarrhoea especially after having medication
will
decrease the efficiency of the medication. So, it is very important to seek medical advise in
such
a case.
P: Ok doctor thank you for letting me know.
D: Like any other medication, epilepsy medication has some side effects. Some side effects
are temporary and subside after some time. If she has any persistent side effect, please seek
advice from her GP. It is very important to not stop the medication. We try to tackle the SE.
if not possible we will review the medications. P: Sure doctor
D: Anything else I can help you with?
P: What should I do if she has another attack?
 D: It is important to put her in a safe position and stay with her while the convulsion is
happening. Lay her on her side with her head slightly tilted backwards (recovery
position). This will ensure that she will not swallow any sick (vomit) and the tongue does
not cause any obstruction, which helps to keep her airway clear.
 Remove any sharp objects if there are any around.
 Loosen any tight objects around her neck like a tie if any.
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 Don't put anything in her mouth. You child should be seen by a doctor after having fit. If
your child has a seizure that lasts more than 5 minutes, or if they do not regain
consciousness after a seizure, you need to call an ambulance.
P: Is it bad for the brain? Does it cause damage to the brain?
D: Fortunately in your child the duration of seizure was not that long so hopefully it does not
cause any damage to brain.
P: Will she be able to have a normal life?
D: Like I said it is very important to take the medication regularly and avoid the triggering
factors. Most of patients can have almost a normal life. Some patients after a while will be
symptom free and may not need any medication.
P: What precautions do I need to take?
D: Since a seizure can happen at any time it is important that your daughter is not in any
situation where she is in imminent danger or harm if she has a fit. For example a shower is
considered to be safer than a bath. Instead of locks on the door you can have “engaged”
sign.
These are just some examples of how she can be kept safe.
637
OB-GYNAE STATIONS
PRE-ECLAMPSIA
You are F2 in OBG.

Laila aged, 29 years old who is 36 week pregnant, has been referred to the hospital.
The mid-wife has seen the lady and made a note.
Vitals: BP 160/110, Urine protein - (+++). This must be reviewed by a doctor.
The patient’s BP in her first booking was 110/70.
Please talk to the patient, assess her condition, discuss you further management with
patient and
address her concerns.

P: I went for my check up and I was sent here by the midwife because of my blood pressure and
protein in my urine.
D: Could you confirm the age of your pregnancy?
P: 36/38 weeks
P: Yes
P: Pregnancy test at home.
P: No
P:
D: Could you feel the movements of your baby?
P: Yes doctor.
P: Normal.
P: No
D: Any medications during pregnancy? Iron or folic acid?
P: No
D: Have you attended all your antenatal check ups?
P: Yes
D: Do you know your blood pressure of your first visit?
P: 110/70
D: Have you got any scans done?
P: Yes
D: Do you twins in your pregnancy?
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P: No
P: Fine
No
P: No
D: Do you feel sick? Any vomiting? (hyperemesis gravidarum)
P: No
D: Any tummy pain?
P: No
D: Vaginal bleeding?
P: No
D: Any pain or burning sensation during urination? urinary frequency? (UTI)
P: No
D: Do you feel tired? (anaemia)
P: No
D: Any Headache/visual changes/swelling of feet, ankles or face?(pre-eclampsia) P: No
P: No
P: No
P: No
D: Any high blood pressure, diabetes or kidney problems?
P: No
D: Are you currently taking any regular medications, over-the-counter drugs or
supplements?
P: No
P: No
P: No
P: No
D: Did your mother or sister have any complications during their pregnancies?
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: No
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P: Office job
P: My partner
D: I would like to check your vitals including blood pressure and do Antenatal Examination.
test.
If the patient is 36weeks pregnant:

Examiner:
BP - 150/100 mmHg
Urine protein ++
ICE
 From my assessment you seem to have developed a condition called pre-eclampsia.

 Pre-eclampsia is a condition that affects some pregnant women, usually during the
second half of pregnancy (from around 20 weeks) or soon after their baby is delivered.
 Early signs of preeclampsia include having high blood pressure and protein in your urine.
 We checked your blood pressure and its high and your urine test shows there is protein
in your urine.
 Pre-eclampsia is thought to be caused by the placenta not developing properly due to a
problem with the blood vessels supplying it. The exact cause isn't fully understood.
 Some factors have been identified that could increase your chances of developing pre-
eclampsia.
 These include:
 having an existing medical problem - such as diabetes, kidney disease, high blood
pressure, lupus or antiphospholipid syndrome
 previously having pre-eclampsia
 it's your first pregnancy
 it's been at least 10 years since your last pregnancy
 you have a family history of the condition
 you're over the age of 40
 you were obese at the start of your pregnancy
 you're expecting multiple babies, such as twins or triplets
In your case it is most probably due to your first pregnancy.
 D: We will keep you in the hospital and monitor you and your baby closely.
 Your blood pressure will be checked regularly for any abnormal increases.
 Urine samples may be taken regularly to measure protein levels.
 Various blood tests - to check your kidney and liver health, for example.
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 You may have ultrasound scans to check blood flow through the placenta, measure
the growth of the baby, and observe the baby's breathing and movements.
 The baby's heart rate may be monitored electronically in a process called
cardiotocography, which can detect any stress or distress in the baby.
 We will give you medication to reduce your blood pressure(labetolol).
 We may have to give medication through your blood vessel(vein) (magnesium sulphate)
to prevent fits from happening.
 D: These medication are generally safe for you and your baby.
 D: We have to monitor you as this condition can cause some problems to you and your
baby.
 D: You can have a normal delivery if your blood pressure and the amount of protein in
your urine reduces. But we may have to induce your labour by giving you some
medication if needed. At any point of time if complications develop, we have to do a
caesarian section to deliver your baby.
 D: It is not advisable for you to have a pool delivery as we have to monitor you and your
baby continuously both during and after the delivery as some complications can happen
even after the delivery.
 D: This condition has some complications like you may develop fits(eclampsia), your liver,
kidney and lugs may get damaged, you may have clotting problems, your baby's growth
may be slow or you may even have a still birth.
 D: Please inform us if you have any tummy pain or you feel drowsy or confused
If the patient is 38 weeks pregnant:

Examiner:
BP - 150/100 mmHg
Urine protein ++
Fetal movement is normal.
Fetal heart rate is normal.
Head engaged.
D: We will have to deliver the baby within 24-48 hours. Your labour needs to be started
artificially by giving you some medication (known as induced labour) or you may need to
have a cesarean section, if things get complicated.
P: What’s going on doctor?
P: Why did I get this condition?
P: What are you going to do for me:
P: Can I go home with some medication?
D: May I know why do you want to go home?
P: I have work to do/my maternity leave starts in few days.
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P: How long should I stay in the hospital?
P: Are these medications going to affect my baby? (labetolol/nifedipine)
P: Can I give a natural birth?
P: Can I have pool delivery?
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PID RIF PAIN
You are F2 in A&E.

Mrs. Johnson, aged 28, presented to the hospital complaining of right lower abdominal pain
(RIF).
Please talk to the patient, take history, do relevant examination, discuss about initial
management with the patient and address her concerns.
Ask your examiner about the specific findings you are looking for. Your examiner will tell you
the results of those particular findings.

P: I have tummy pain.
HPC
Dr: May I know where is the pain exactly?
P: It’s here doctor. In my right lower tummy. (Patient shows her RIF)
SOCRATES:
P: It started 2-3 days ago.
P: I was sitting at home when it started doctor.
P: Doctor the pain is always there since it started.
P: No radiation.
P: It started at the same place.
P: No doctor, I took paracetamol but still I have pai
P: Just two tablets whenever I had pain doctor.
P: Nothing makes it worse.
P: Score is around 5.
Dr: Is there anything else thats bothering you?
P: I have discharge from my front passage.
D: When did the discharge start?
P: 2-3 days ago
D: What is the colour of discharge?
P: Green
D: Is there any blood in it?
P: No
D: Is there any smell?
P: Yes doctor, it smells bad
D: How much was the discharge?
P: Not too much
D: Is there anything else that’s bothering you
P: No
D: Did you have any fever or flu like symptoms?
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P: No/Yes I had some temperature
D: Were you feeling sick?
Yes from last 2-3 days
D: Did you vomit?
P: No
P: No
D: Have you got any of these symptoms anytime before?
P: No
P: 2/3 weeks ago
P: Yes
D: Any bleeding or spotting between your periods?
P: No
D: Any painful or heavy periods?
P: No
D: Have you been pregnant before?
P: No
P: Yes
P: Yesterday
P: Yes, I met my partner 2weeks ago
P: Yes, I had two other partners previously
D: What kind of sexual contact do you have? Genital? Anal? Oral?
P: Genital/Oral
D: Do you and your partner(s) use any contraception or protection against STIs?
P: Yes Dr. I have coil inserted.
D: Since when?
P: Since three years
D: Is it in place?
P: Yes
P: No
P: No, we enjoy our sex
P: 2 weeks back
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P: No
D: What other concerns or questions regarding your sexual health or sexual practices would
you like to discuss?
P: Nothing Dr.
D: Have you been diagnosed with any medical condition in the past
P: No
D: Did you have any cyst in your ovaries or any sexually transmitted infections before?
P: No
P: No
P: No
D: Any previous surgeries or procedures done around your private parts?
P: No
D: I would like to check your vitals and examine your abdomen, do bimanual and per
speculum examination.
test.
Examiner: Right adnexal tenderness and cervical excitation
 D: From our assessment, I suspect you have a condition called Pelvic Inflammatory
Disease in short
 PID. This is infection around your womb and surrounding structures including the ovaries
and the tubes connecting your ovaries to your womb. This is caused by some bugs
spreading from your front passage to your womb.
P: What are you going do doctor?
 D: We are going to run some tests to confirm the diagnosis. We are going to do some
blood and urine tests to see if there is any bug and also take swabs from your vagina and
send it to the lab to test for which bug is causing you these symptoms.
 We will do an ultrasound scan through your vagina to see off there is any abnormality in
your womb and surrounding structures.
 Examiner: USG is normal.
 We will prescribe you some pain killers for your pain and give you antibiotics for your
condition. A course of antibiotics for 14 days. You'll be given a mixture of antibiotics to
cover the most likely infections, and often an injection as well as tablets.
 We may change the antibiotics later depending upon your improvement and your test
results.
 It's important to complete the whole course and avoid having sexual intercourse during
this time to help ensure the infection clears.
 We may need to remove your coil if your symptoms doesn’t subside within a few days
645
 It is very important to complete the treatment by bringing in your partner and treating
him as well, if he has got the infection.
 If you are not able to bring your partner, we can contact him through Partner Initiation
Programme.
 Please make sure you come back for follow up after 3 days to see if there is any
improvement. We will test you after 14 days of treatment to see whether the infection
has cleared or not.
 It is advisable to practice safe sex all the time.
 It has many causes, the coil can be one of the causes, one of the commonest causes of
PID is sexually transmitted infections.
 It does not mean that your partner is cheating on you. these bacteria can stay in your
body for many months before causing any symptoms. You/He might have got this
infection from your/his previous relationships.
 This condition can lead to some complications in your pregnancy like pregnancy outside
your womb. This can also lead to infertility.
to have one?
P: Yes/No
back to us.
P: What are you going to do now'
P: Why do I have it?
P: Is my partner cheating on me?
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PID LOWER ABDOMINAL PAIN
You are F2 in A&E.

Mrs. Johnson, aged 40, presented to the hospital complaining of lower abdominal pain .
CS was done 15years hack She is taking desogestral 150 megdaily. She was diagnosed with
depression and is on sertraline for the same.
Please talk to the patient, take history, do relevant examination, discuss about initial
management with the patient and address her concerns.

P: I have tummy pain.
D: May I know where is the pain exactly?
P: It’s here doctor. In my right lower tummy. (Patient shows her suprapubic area.
P: It started 2-3 weeks ago.
P: I was sitting at home when it started doctor.
P: Doctor the pain is always there since it started.
P: No radiation.
P: It started at the same place.
P: No doctor, I took paracetamol but still I have pain.
P: Just two tablets whenever I had pain doctor.
P: Nothing makes it worse.
P: Score is around 5.
D: Is there anything else that is bothering you?
P: No
D: Any pain or burning sensation while passing
P: No
D: Did you have any fever or flu like symptom
P: No
D: Were you feeling sick?
P: No
D: Did you vomit?
P: No
D: When was your last menstrual period'
P: 5 years back
D: Any bleeding or spotting?
P: No
D: Any discharge?
P: I have discharge from my front passage.
D: When did the discharge start?
P: 2 weeks
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D: What is the color of discharge?
P: yellow.
D: Is there any blood in it?
P: No.
D: Is there any smell?
P: Yes doctor, it smells bad.
D: How much was the discharge?
P: Not too much.
P: Yes
P: Yes
P: 4 days ago
D: Do you have any other partner?
P: No ’
P: Normal.
D: Do you and your partner(s) use any contraception?
P: pills
P: No, we enjoy our sex.
P: No
P: Nothing Dr.
P: Depression, I am taking sertraline for that.
D: any other medical conditions?
P: No
D: Did you have any cyst in your ovaries or any sexually transmitted infections before?
P: No
P: No
P: No
D: Any previous surgeries or procedures done apart from CS?
P: No
D: I would like to check your vitals and examine your abdomen, do bimanual and per
speculum examination.
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test.
P: What is per speculum?

D: it is pelvic examination. I have to examine your front passage.
P: Can I come other time. I am not prepared for this right now.
D: What is the problem?
P: Nothing, actually I am not ready for it.
P: What is going on with me?
D: From our assessment. I suspect you have a condition called Ivie Inflammatory Disease in
short PID. This is infection around your womb and surrounding structures including the
ovaries and the tubes connecting your ovaries to your womb. This is caused by some bugs
spreading from your front passage to your womb.
P: What are you going do doctor?

 D: We are going to run some tests to confirm the diagnosis. We are going to do some
blood and urine tests to see if there is any bug and also take swabs from your vagina and
send it to the lab to test for which bug is causing you these symptoms.
 We will do an ultrasound scan through your vagina to see off there is any abnormality in
your womb and surrounding structures.
 We will prescribe you some pain killers for your pain and give you antibiotics for your
condition. A course of antibiotics for 14 days. You'll be given a mixture of antibiotics to
cover the most likely infections, and often an injection as well as tablets.
 We may change the antibiotics later depending upon your improvement and your test
results.
 It's important to complete the whole course and avoid having sexual intercourse during
this time to help ensure the infection clears.
Programme.
 Please make sure you come back for follow up after 3 days to see if there is any
improvement. We
 will test you after 14 days of treatment to see whether the infection has cleared or not.
 It is advisable to practice safe sex all the time.
 This condition can lead to some complications in your pregnancy like pregnancy outside
your womb. This can also lead to infertility.
to
have one?
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P: Yes/No
back to us.
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GONORRHOEA
You are F2 in GUM clinic.

Mrs. Juliet aged, 24 has come to the clinic for her investigation results.
Swab has been taken and the result shows gonorrhoea.
Please talk to patient, take sexual history, inform patient about the results, discuss about
further management and advise the patient.

P: I got a sexual check up done as I got to know about sexually transmitted infections and I am
here for my results.
D: Yes I have your results with me but before I disclose them to you I would like to ask you a
few questions in order to get a better overview.
P: Ok Dr.
D: Did you have any symptoms that made you have the check up done?
P: No Dr. Its just that I read it somewhere about STIs and thought L
D: That was really thoughtful.
D: Have you got any fever or flu like symptoms?
P: No
D: Do you have any bleeding or Discharge from your vagina?
P: No
D: Any pain or discomfort in your lower tummy or your private parts?
P: No
P: No
D: Cloudy or smelly urine. Frequency. Haematuria, Incontinence?
P: No
D: Any redness, hotness or swelling around your private parts or groin area?
P: No
D: Any eye problem or joint problem?
P: No
D: Have you got any of these symptoms anytime?
P: No
P: Yes
P: Yesterday
P: Yes
P: Yes, I had two other partners previously.
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P: Genital/Oral
P: Sometimes Dr.
P: No
P: No
P: Nothing Dr.
P: No
D: Did you have any sexually transmitted infections before?
P: No
P: No
P: No
P: No
 D: From our assessment and from your test results, it shows that you have a condition
called Sexually Transmitted Infection in short STI.
 STIs are caused by different type of organisms but in your case it is caused by a bacteria
called Gonorrhoea.
 This is a condition which is usually transmitted by having unprotected sex. And these
bacteria can stay in our body for months without causing any symptoms, that is the
reason why you are not having any symptoms. You might have got this condition from
your partner or from your previous relationships.
 This condition is not serious as we can treat this condition with antibiotics.
 We will give you a single antibiotic injection and a single antibiotic tablet.
 Ceftriaxone 500 mg intramuscular (IM) injection as a single dose, plus azithromycin 1 g
orally as a single dose
 You should attend a follow-up appointment a week or two after treatment, so another
test can be carried out to see if you're clear of infection.
 You should avoid having sex until you've been given the all-clear.
Programme.
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 It is advisable to practice safe sex all the time. Pills cannot protect you from sexually
transmitted infections. Using condoms is the only way to protect yourself from, getting
these infections.
 It does not mean that your partner is cheating on you, as I told you earlier these bacteria
can stay in your body for many months before causing any symptoms. You/He might
have got this infection from your/his previous relationships.
 The complications of this condition are Pelvic Inflammatory Disease (infection around
your womb and surrounding structures including the ovaries and the tubes connecting
your ovaries to your womb). This can also lead to some complications in your pregnancy
like pregnancy outside your womb. This can also lead to infertility.
to have one?
P: Yes/No
back to us.
PATIENT'S CONCERNS
P: Is Gonorrhoea a serious condition?
P: How are you going to treat me Dr.?
P: How did 1 get this condition?
P: Did I get it from my partner?
P: Is he cheating on me?
P: What are the complications of Gonorrhoea?
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ECTOPIC PREGNANCY
You are F2 in OBG Dept.

Janny aged, 18 presented to the hospital complaining of left iliac fossa pain.
Patient has come with six weeks of amenorrhea.
Pregnancy test has been done and is positive.
Please talk to the patient, take relevant history and discuss about different steps of

P: I have got pain here (Patient points at LIF).
D: Are you comfortable to talk?
P: Yes doctor.
SOCRATES:
P: It started last night.
P: It started suddenly.
P: I was not doing anything.
P: It is always there.
P: It is getting worse with time doctor.
P: It is a dull pain doctor.
D: Radiation?
P: No doctor.
P: No doctor, it is becoming worse on its
P: 1 tried paracetamol, but it didn't work.
D: When and how many tabs did you take?
P: 2 tabs few hours back
P: Score? Around 6-8.
D: Is there any thing else that’s bothering you?
P: I have got bleeding from my front passage.
P: Started around few hours back.
D: What is the colour of bleeding?
P: I didn’t notice doctor.
D: Was there any clots in it?
P: No
D: How many pads have you changed since the bleeding started?
P: Only one pad. It is more like spotting doctor.
D: Was there any discharge present?
P: No
D: Is there anything else that’s bothering you?
P: I have been feeling sick since last night.
D: Did you vomit?
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P: No doctor
D: Is there anything else that is bothering you?
P: No
P: 6 weeks ago.
P: Yes
P: No.
P: No
D: Are you pregnant by any chance?
P: Yes
D: Did you test it and confirm?
P: I did an over the counter pregnancy test and it was positive.
P: Yes
D: Did you use any type of contraception before?
P: Yes/No
D: Have you ever used IUCD or coil?
P: No
D: Have you had any fever or flu like symptoms?
P: No
D: Any breast tenderness?
P: No
D: Any pain around the tip of your shoulder?
P: No
D: Any bowel problems?
P: No
D: Any problem with your urination?
P: No
P: No
P: No
P: No, I broke up with my partner 2 weeks back.
P: 2 weeks back.
P: Yes, I had many partners.
D: What kind of sexual contact do you have? Genital? Oral?
655
P: Genital / Oral
D: Do you and your partners use any contraception or protection against STIs?
P: No
P: 2 weeks back
P: No
D: Any sexually transmitted infections or pelvic inflammatory disease?
P: Yes, I was diagnosed with Chlamydia.
D: When was that?
P: When I was 15
D: May I know how was it treated?
P: My GP gave me antibiotics.
P: No
P: No
D: Do you have any allergy to any food or drugs?
P: No
D: Any procedure or instrumentation through
P: No
D: Any previous hospital stay?
P: No
D: Has any member of your family ever been diagnosed with any medical condition
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
D: I would like to check your vitals and examine your tummy, do bimanual and speculum
examination.
test.
Examiner: Tenderness in LIF.

From my assessment, I suspect you have a condition called Ectopic Pregnancy. This means
the
pregnancy is outside the womb.
656
We need to do further investigations to confirm the diagnosis like we need to do special
blood test to check the amount of substance called Beta HCG produced by your pregnancy.
We will do an US scan tomorrow morning to confirm the diagnosis and also to find out the
location and size of the pregnancy.
For this we need to keep you in the hospital. We will give you pain killers for your pain.
P: I don't want to stay in the hospital doctor?
D: May I know if you have any concern?
P: 1 don't want my parents to know about this.
D: 1 do understand your concern, but it is very important for you to stay in the hospital and
undergo
all the investigations. And if the pregnancy is confirmed to be outside the womb, then we
have to
put you under observation.
P: I can come back for the tests tomorrow?
D: As I told you earlier, we need to observe you, as this condition may cause some severe
complications. The pregnancy may rupture and you may go into shock and collapse, which is
a
serious condition.
D: If this happens we need to treat you immediately, by giving you fluids through your blood
vessels and take you to operation theatre for emergency surgery to remove the ruptured
pregnancy.
D: If it is confirmed that you have ectopic pregnancy, we have few options to t
upon your blood results and the age, size and location of the pregnancy.
> We may have to wait and watch for the pregnancy to terminate by itself.
> We may have to give you some medication called Methotrexate to terminate the
pregnancy.
> We have an option of surgery also to remove the pregnancy
D: In the meanwhile if you get short of breath, dizzy or if you develop severe pain or
bleeding please inform us immediately.
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MISCARRIAGE
You are F2 in Antenatal Clinic.

Ema aged, 28 is referred by her GP for her first ANC check-up. She is 6 weeks pregnant.
Nurse has examined the patient. Urine test has been done. Vitals have been checked.
BP -130/80, Pulse-70, Urine Test Negative (infection <& protein)
Talk to the patient, take relevant history, do the initial assessment and address her
concerns.

P: My GP has sent me for my antenatal check-up
D: May I know why?
P: I am pregnant doctor.
D: Could you confirm the age of pregnancy?
P: 6 weeks doctor.
D: How has the pregnancy been so far?
P: It’s Okay Doctor.
D: Any complications so far?
P: No.
D: That’s great. Any symptoms?
D: Any bleeding, spotting or discharge from your front passage?
P: No
D: Feeling any tummy pain? (ectopic pregnancy)
P: No
D: Any pain in the breast?
P: No
P: No
D: Any pregnancies before?
P: Yes
D: How many pregnancies?
P: 2 Dr.
D: When was that?
P: 1st pregnancy was 3 years back and the 2nd was 1 year ago.
D: What was the outcome?
P: Ended in miscarriage.
D: I’m sorry (Sympathy). May I know at what age
P: One at 6 weeks and the other at 8 weeks.
D: How were they managed?
P: First time, I went to the hospital as I had some bleeding. They checked and confirmed
miscarriage. 1 was discharged and advised rest. Second time, I had bleeding again and went to
658
the hospital. They asked me to wait and watch. I came back some time later and they
confirmed the miscarriage.
D: Did you have any other symptom apart from the bleeding?
P: No
D: Any sort of pain anywhere?
P: No
D: Did they tell you why you had the miscarriage?
P: No, they did some test but they didn't give any reason for the miscarriage.
D: Any fever?
P: No
P: No
D: DM? HTN? Kidney problem? Thyroid problem? PCOS? Fibroids? STD/HIV?
P: No
D: Are you on any Medications? Allergies? Folic Acid?
P: No.
D: Any surgical procedures around your private part or womb?
P: No.
D: Any family members diagnosed with any medical conditions?
P: No.
D: How are your periods? Regular?
P:
D: Are they painful?
P:
D: How long does the bleeding last?
P:
D: Any bleeding between the periods?
P:
D: Any usage of contraception?
P: No.
D: Do you smoke?
P: I stopped when I planned for pregnancy. I have been smoking a pack of cigarettes per day
since I was a teen.
P: Yes. I stopped drinking when 1 knew I was pregnant.
D: How much do you drink? Were you drinking whilst you were pregnant?
P:
P: Good
D: Do you drink coffee or tea?
P: Yes/No
D: How is your physical activity?
659
P: I’m quite active.
D: Any usage of recreational drugs?
P: No.
P: Yes doctor, I am married.
P: Office job
P: With my husband.
D: I would like to do some examination:

Blood Pressure, Pulse. Temperature and Breathing Rate;
Measure height and weight;
GPE (general physical examination);
Tummy exam (Abdominal/Antenatal)
Ex: Everything normal
Investigation: Bloods for blood group/ sugar/ infections (rubella/syphilis/hepatitis/HIV)

US.
P: Why do I have these miscarriages?

D: There are many reasons why miscarriage may happen, although cause is not identified.
 If a miscarriage happens during the first trimester of pregnancy (the first three months),
it's usually caused by problems with the unborn baby (foetus).
 If a miscarriage happens during the second trimester of pregnancy (between weeks 14
and 26), it may be the result of an underlying health condition in the mother.
We will keep monitoring you and your baby. Hopefully everything will be fine.
P: Is there anything I should be doing?
D: In many cases, cause is not known. However, you can lower the risk of miscarriage by:
 Not smoking during pregnancy
 Not drinking alcohol or using illegal drugs during pregnancy eating a healthy, balanced
diet with at least five portions of fruit and vegetables a day.
 Making attempts to avoid certain infections during pregnancy, such as rubella.
 Avoiding certain foods during pregnancy, which could make you ill or harm your baby
being a healthy weight before getting pregnant.
P: Is it possible to have another miscarriage?
D: For most women, it’s a one-off event and they go on to have a successful pregnancy in
the future. Most women are able to have healthy pregnancy after a miscarriage, even in
cases of recurrent miscarriages.
FIRST TRIMESTER MISCARRIAGES
660
Most first trimester miscarriages are caused by problems with the chromosomes of the foetus.
Chromosome problems:
Sometimes something can go wrong at the point of conception and the foetus receives too
many or not enough chromosomes. The reasons for this are often unclear, but it means the
foetus won't be able to develop normally, resulting in a miscarriage
Placental problems:
The placenta is the organ linking the mother's blood supply to her baby's. If there's a problem
with the development of the placenta, it can also lead to a miscarriage.
Things that increase your risk
 An early miscarriage may happen by chance. But there are several things known to increase
your risk of problems happening.
 The age of the mother has an influence:
 in women under 30, 1 in 10 pregnancies will end in miscarriage
 in women aged 35-39, up to 2 in 10 pregnancies will end in miscarriage
 in women over 45, more than half of all pregnancies will end in miscarriage
 Other risk factors include: Obesity, Smoking, Drug misuse during pregnancy, Drinking more
than
 200mg Caffeine and drinking 2 units of alcohol a week.
SECOND TRIMESTER MISCARRIAGES

 Long-term health conditions like DM, HTN, Lupus, Kidney disease. Thyroid disease.
 Infections like Rubella. CMV, HIV, STIs, Malaria, Syphilis.
 Food poisoning: Listeriosis, Toxoplasmosis, Salmonella
 Medicines: Misoprostol. Retinoids and NSAIDs
 Womb structure
 Weakened cervix
 Polycystic ovary syndrome

 D: It would be good if you have life style modification.
 We may offer US.
 We will follow up regularly.
 If you have 3 miscarriages then we do further test to find out the underlying causes.
However, no cause is found in half of the cases.
P: Which tests?
 D: An ultrasound scan to check the structure of your womb for any abnormalities. Second
procedure maybe done with 3D US to study lower tummy and pelvis to get accurate
diagnoses.
 Scan also checks for weakened cervix. This can only have carried out if you are pregnant
again. In this case it is done between 10 and 12 weeks pregnant.
 Karyotyping for any genetic abnormality (chromosomes).
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 Blood tests to check for APS antibody levels and lupus anticoagulant. APS Antibodies are
known to increase blood clots and alter the way afterbirth attaches (aspirin/ heparin).
Please contact your GP, maternity team or early pregnancy unit at your local hospital in case
of
vaginal bleeding immediately.
662
PCOS

Ms. Kim aged 29, has come to GP Surgery with complaints of Acne and Amenorrhea. On her
first visit, pregnancy test was done and found to be negative. Her hormonal profile was
done.
Discuss these test results with her, take appropriate history, discuss management and
Hormonal Results:
LH -18 mlU/ml (1-12 mlU/ml)
FSH - 6 mlU/ml (1-9 mlU/ml)
BMI-32

P: I came here for my results today.
D: Yes. I have your results with me but please tell me why you had these tests done?
P: I did not get my periods and also my ACNE was troubling me.
D: You did a very good thing by having these tests. Let me ask you few questions first.
D: Since when have you not been getting your periods?
P: 3 months
D: Were they regular before 3 months?
P: Yes
D: Did anything happen before your periods stopped?
P: Yes/No
D: Do you have any pain around your pelvis?
P: Yes/No
D: Any pain in your breasts or discharge from your nipples?
P: Yes/No
D: Tell me about your ACNE?
D: Since when have you had ACNE?
P: 3 months
D: Have you done anything about it?
P: I am using emollients.
D: Has it improved?
P: Yes
P: No
D: Any fever/flu like symptoms?
P: No
D: Do you feel tired
P: Yes/No
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D: Any changes in your weight?
P: Yes, I gained weight
D: How much in how much time?
P: In last 3 months I gained 2 stones
D: Any bowel problem?
P: Yes/No
D: Do you feel cold when others are feeling normal?
P: Yes/No
D: Any excess hair anywhere?
P: Yes/No
P: Good/Bad
D: Have you ever been diagnosed with any medical conditions in the past?
P: No
D: Any Diabetes or Hypertension?
P: No
D: Are you taking any other medications including OTC or herbal medications?
P: No
D: Do you have any allergies from food or medicines?
P: No
D: Any previous surgery or hospitalizations?
P: No
D: Any surgeries around your womb or ovaries?
P: No
D: Has anyone in your family suffered from a similar condition in the past?
P: Yes. my sister had a similar problem. She is coping with it.
D: Do you smoke?
P: No
P: Wine on weekend
P: Yes/No
P: I love burgers and chips.
D: Any Stress?
Yes, at work sometimes.
P: I live with my partner
D: Do you have any children?
P: No, I am not keen on having children. I will think about it after I get married in a year’s time.
P: Yes
664
P: Yes/No
D: I would like to check your vitals and do GPE, BMI. Ex: All normal.
 From my assessment, I am suspecting you are having a condition called PCOS (Elaborate
and explain PCOS). You mentioned you have not had periods for the last 3 months and
also have acne which is getting better. Your BMI is also on the higher side which suggests
PCOS.
 We will be doing further investigation to confirm.
 We will do some more blood tests including cholesterol levels and thyroid function test.
 We will do US of your ovaries to see follicles (fluid filled sacs) in which egg develop.
 The main stay of PCOS treatment is lifestyle modification and reducing your weight.
 We will refer you to a dietician to help with a diet plan as the diet is not so good and BMI
is also on the higher side. (Counsel about lifestyle accordingly).
 We may also give you some medication to help with weight.
 We will refer you to a specialist for further management.
 We may have to give you medications to regularize your periods. These are usually
combined contraceptive pills. Sometimes, you may develop excess hair growth on your
face or chest. These OCPs also helps in that case.
 Usually prognosis is good with treatment.
 Complications include infertility and also developing DM.
 We will follow you up regularly with tests for hormone levels, blood pressure and
diabetes.
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CONTRACEPTION
You are F2 in GP.

29 years female patient presents to the hospital to get some advice about contraception.
Talk to the patient, take relevant history and discuss about different methods of
contraception.

P: I want to discuss about contraception.
D: I am here to talk to you about everything you want to discuss.
May I know, what do you want to talk about?
P: I just changed my partner and my new partner doesn’t like condoms.
D: Okay, we have many types of contraception which we can offer you. There are 15
different methods of contraception currently available in the UK. The type that works best
for you will depend on your health and circumstances. But before that, do you have any
particular type of contraception in mind that you want me to talk about.
P: I want to know about contraceptive pills.
D: No problem, before offering you any type of contraception I would like to ask you few
questions to see which type of contraception is better for you.
P: Ok Doctor
D: Did you use any kind of contraception before?
P: Yes doctor I used diaphragm before but I got pregnant.
P: 2 kids aged 2yrs and 5vrs.
D: Have you completed your family?
P: I am not sure. 1 just met my new partner.
P: I had blood clot in my legs after a long flight 2yrs ago.
D: May I know what was done for that?
P: I went to the hospital and I was given warfarin for 6 months.
P: No
D: Any Stroke, Heart or liver disease or any ovarian cyst?
P: No
D: Any STI or PID or pregnancy outside womb?
P: No
P: No
P: No
P: No
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D: Any procedure or instrumentation through your front passage?
P: No.
D: Any previous hospital stay?
P: No
P: No
D: Any problem with womb or pregnancy in the family?
P: No
P: I am on my periods now.
P: Yes.
P: No.
P: No
D: Any pain or bleeding during or after sex?
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
D: From my assessment you cannot have contraceptive pills as you have got blood clot in
your legs before. And taking these pills can cause you to have blood clot again. But don’t
worry we have many other types of contraception which we can offer you.
There is temporary, short term, long term and permanent methods of contraception.
There is tablet form, an injection, as a patch on your skin, as an implant under your skin, as a
device inserted into your womb and sterilisation which is permanent and irreversible.
Progestogen-only pill (mini pill):

Advantages:
 it's useful if you cannot take the hormone oestrogen, which is in the combined pill,
contraceptive patch and vaginal ring
 you can use it at any age - even if you smoke and are over 35
 it can reduce the symptoms of premenstrual syndrome (PMS) and painful periods.
Disadvantages:
 Your periods may be lighter, more frequent, or may stop altogether, and you may get
 spotting between periods
 It does not protect you against STIs
 You need to remember to take it at or around the same time every day
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 Medications, like certain types of antibiotic, can make it less effective.
Side effects:
 acne
 breast tenderness and breast enlargement
 an increased or decreased sex drive
 mood changes
 headache and migraine
 nausea or vomiting
 small fluid-filled sacs called cysts on your ovaries - these are usually harmless and
disappear without treatment
 weight gain
These side effects are most likely to occur during the first few months of taking the
progestogen only pill, but they generally improve over time and should stop within a few
months.
Contraceptive Injection (Depo-Provera)

There are three types of contraceptive injections in the UK: Depo-Provera, which lasts for 12
weeks, Sayana Press, which lasts for 13 weeks, and Noristerat, which lasts for eight weeks.
The most popular is Depo-Provera.
Advantages:
The main advantages of the contraceptive injection are:
 each injection lasts for either eight, 12 or 13 weeks
 the injection does not interrupt sex
 the injection is an option if you cannot use oestrogen-based contraception, such as the
combined pill, contraceptive patch or vaginal ring
 you do not have to remember to take a pill every day
 the injection is safe to use while you are breastfeeding
 the injection is not affected by other medicines
 the injection may reduce heavy, painful periods and help with premenstrual symptoms
for some women
 the injection offers some protection from pelvic inflammatory disease (the mucus from
the cervix may stop bacteria entering the womb) and may also give some protection
against cancer of the womb.
Disadvantages:
• Disrupted periods
• Weight gain
• Headaches
• Acne
• Tender breasts
• Changes in mood
• Loss of sex drive
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Risks:
There is a small risk of infection at the site of the injection. In very rare cases, some people
may have an allergic reaction to the injection.
Contraceptive Implant
Advantages:
 it works for three years
 the implant does not interrupt sex
 it is an option if you cannot use oestrogen-based contraception, such as the combined
contraceptive pill, contraceptive patch or vaginal ring.
 you do not have to remember to take a pill every day
 the implant is safe to use while you are breastfeeding
 your fertility should return to normal as soon as the implant is removed
 implants offer some protection against pelvic inflammatory disease (the mucus from the
cervix may stop bacteria entering the womb) and may also give some protection against
cancer of the womb.
 the implant may reduce heavy periods or painful periods after the first year of use
 after the contraceptive implant has been inserted, you should be able to carry out
normal activities
Disadvantages: Disrupted periods
Side effects:
 headaches
 acne
 nausea
 breast tenderness
 changes in mood
 loss of sex drive.
Side effects:
• headaches
• acne
• nausea
• breast tenderness
• changes in mood
• loss of sex drive.
Intrauterine Device:
Advantages of the IUD:
• Most women can use an IUD, including women who have never been pregnant.
• Once an IUD is fitted, it works straight away and lasts for up to 10 years or until it's
removed.
• It doesn't interrupt sex.
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• It can be used if you're breastfeeding.
• Your normal fertility returns as soon as the IUD is taken out
• It's not affected by other medicines.
There's no evidence that having an IUD fitted will increase the risk of cancer of the cervix,
endometrial cancer (cancer of the lining of the womb) or ovarian cancer. Some women
experience changes in mood and libido, but these changes are very small. There is no
evidence that the IUD affects weight.
Disadvantages of the IUD:
Your periods may become heavier, longer or more painful, though this may improve
after a few months.
 An IUD doesn't protect against STIs, so you may have to use condoms as well. If you get
an STI while you have an IUD, it could lead to a pelvic infection if not treated.
 The most common reasons that women stop using an IUD are vaginal bleeding and pain.
Risks of the IUD:
1) Damage to the womb
2) Pelvic infections
3) Rejection
4) Ectopic Pregnancy.
Intrauterine system(Mirena):
Advantages of the IUS:
 It works for five years (Mirena) or three years (Jaydess).
 It's one of the most effective forms of contraception available in the UK
 It doesn't interrupt sex.
 An IUS may be useful if you have heavy or painful periods because your periods usually
because much lighter and shorter, and sometimes less painful – they may stop
completely after the first year of use.
 It can be used safely if you're breastfeeding
 It's not affected by other medicines
 It may be a good option if you can't take the hormone oestrogen, which is used in the
combined contraceptive pill
 Your fertility will return to normal when the IUS is removed.
There's no evidence that an IUS will affect your weight or that having an IUS fitted will
increase the risk of cervical cancer, cancer of the uterus or ovarian cancer. Some women
experience changes in mood and libido, but these changes are small.
Disadvantages of the IUS:
 Some women won't be happy with the way that their periods may change. For example,
periods may become lighter and more irregular or, in some cases, stop completely. Your
periods are more likely to stop completely with Mirena than with Jaydess.
 Irregular bleeding and spotting are common in the first six months after having an IUS
fitted. This is not harmful and usually decreases with time.
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 Some women experience headaches, acne and breast tenderness after having the IUS
fitted. An uncommon side effect of the IUS is the appearance of small fluid-filled cysts on
the ovaries - these usually disappear without treatment.
 An IUS doesn't protect you against STIs, so you may also have to use condoms when
having sex. If you get an STI while you have an IUS fitted, it could lead to pelvic infection
if it's not treated.
 Most women who stop using an IUS do so because of vaginal bleeding and pain, although
this is uncommon. Hormonal problems can also occur, but these are even less common.
Risks of the IUS:
1) Damage to the womb
2) Pelvic infections
3) Rejection
4) Ectopic Pregnancy.
Female sterilisation:
Female sterilisation is usually carried out under general anaesthetic, but can be carried out
under local anaesthetic, depending on the method used. The surgery involves blocking or
sealing the fallopian tubes, which link the ovaries to the womb (uterus).
This prevents the woman’s eggs from reaching sperm and becoming fertilised. Eggs will still
be
released from the ovaries as normal, but they will be absorbed naturally into the woman's
body.
There are two main types of female sterilisation:
• when your fallopian tubes are blocked - for example, with clips or rings (tubal occlusion)
• when implants are used to block your fallopian tubes (hysteroscopic sterilisation, or HS).
Removing the tubes (salpingectomy):
If blocking the fallopian tubes has been unsuccessful, the tubes may be completely
removed. Removal of the tubes is called salpingectomy.
Advantages:
 female sterilisation can be more than 99% effective at preventing pregnancy
 tubal occlusion (blocking the fallopian tubes) and removal of the tubes (salpingectomy)
should be effective immediately - however, doctors strongly recommend that you
continue to use contraception until your next period
 hysteroscopic sterilisation is usually effective after around three months – research
collected by NICE found that the fallopian tubes were blocked after three months in 96%
of sterilised women
Other advantages of female sterilisation are that:
 there are rarely any long-term effects on your sexual health
 it will not affect your sex drive
 it will not affect the spontaneity of sexual intercourse or interfere with sex (as other
forms of contraception can)
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 it will not affect your hormone levels.
Disadvantages:
 female sterilisation does not protect you against STIs, so you should still use a condom if
you are unsure about your partner's sexual health
 it is very difficult to reverse a tubal occlusion - this involves removing the blocked part of
the fallopian tube and rejoining the ends, and reversal operations are rarely funded by
the NHS
 a 2015 US study found that around 1 in 50 women who had a hysteroscopic sterilisation
required further surgery due to complications such as persistent pain.
Risks:
 there is a very small risk of complications, including internal bleeding and infection or
damage to other organs
 it is possible for sterilisation to fail - the fallopian tubes can rejoin and make you fertile
again, although this is rare (about one in 200 women become pregnant in their lifetime
after being sterilised)
 if you do get pregnant after the operation, there is an increased risk that it will be an
ectopic pregnancy (when the fertilised egg grows outside the womb, usually in the
fallopian tubes)
If you miss a period, take a pregnancy test immediately. If the pregnancy test is positive, you
must
see your GP so that you can be referred for a scan to check if the pregnancy is inside or
outside your
womb.
Contraceptives that are more than 99% effective if used correctly:
 contraceptive implant (lasts up to three years)
 intrauterine system, or IUS (up to five years)
 intrauterine device, or IUD, also called the coil (up to five to 10 years)
 female sterilisation (permanent)
 male sterilisation or vasectomy (permanent)
Contraceptives that are more than 99% effective if always used correctly, but generally less
than 95% effective with typical use:
 contraceptive injection (renewed every eight weeks or every 12 weeks, depending on the
type)
 combined pill (taken every day for three weeks out of every month)
 progestogen-only pill (taken every day)
 contraceptive patch (renewed each week for three weeks in every month)
 vaginal ring (renewed once a month)
Contraceptives that are 99% effective if used according to teaching instructions.
symptothermal method of natural family planning (daily monitoring temperature and
cervical mucus)
Contraceptives that are 98% effective if used correctly:
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 male condom (every time you have sex)
Contraceptives that are 95% effective if used correctly:
• female condom (every time you have sex)
Contraceptives that are 92-96% effective if used correctly:
• diaphragm or cap with spermicide (every time
D: Can you make contraception part of your daily routine?

Methods that are used each time you have sex:
• male condoms and female condom:
• diaphragm or cap
Methods that are taken every' day:
• the pill (the combined pill
Methods that are replaced every week:
• contraceptive patch
Methods that are replaced every month:
• vaginal ring
Methods that are renewed every two to three months:
• contraceptive injection
Methods that are renewed up to every three years:
• contraceptive implant
Methods that are renewed up to every five to 10 years:
• intrauterine device (IUD)
• intrauterine system (IUS)
D: Would you prefer contraception that you don't have to remember every day?
Not all contraceptives have to be taken every day or each time you have sex.
You don't have to think about some contraceptives for months or years. These methods
need to be inserted by a health professional into your uterus (IUD or IUS) or arm (the
implant):
• intrauterine device (IUD) (lasts up to five to 10 years, depending on the type)
• intrauterine system (IUS) (lasts up to three to five years, depending on the type)
• contraceptive implant (lasts three years)
The contraceptive injection can be given one of two ways: either by an intramuscular
injection into the buttock, or as a subcutaneous injection into the thigh or abdomen. This is
given every eight weeks or every 12 weeks, depending on the type.
The subcutaneous injection can be given by a health professional, or you can be shown how
to inject it yourself.
Other contraceptives that need to be changed or replaced every month or week are:
• vaginal ring (worn for three weeks out of every four)
• contraceptive patch (a new patch is used each week for three weeks out of every four)
Other contraceptives used or inserted just before sex are:
• diaphragm or cap
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• male condom or female condom
P: May I know why I cannot use contraceptive pills doctor?
P: What are the advantages, disadvantages and failure rates of Mini pill. Injection, Implant.
Coil and IUCD?
D: Can you make contraception part of your daily routine?
D: Would you prefer contraception that you don't have to remember every day?
D: Remember, the only way to protect yourself against sexually transmitted infections (STIs)
is to use a condom every time you have sex. Other methods of contraception prevent
pregnancy, but they don't protect against STIs.
D: If you miss a period, take a pregnancy test immediately and see your GP.
P: Thank you Doctor. I will consult my partner and get back to you.
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PREGNANCY (HTN ON RAMIPRIL)
You are an FY2 in the GP Surgery.

Mrs Amy Travis, aged 42, has come to see you. She is on Ramipril for her hypertension.

P: I am trying to get pregnant.
D: Let me ask you few questions to make sure everything is fine.
P: Ok
P: No
D: Ask 4 P’s?
D: How long have you been trying to get pregnant?
P:
P: Yes, I have been diagnosed with hypertension for the last 5 years.
P: I’m on Ramipril
D: Are you taking it regularly as prescribed?
P: Yes
D: Have you been diagnosed with any other medical condition in the past like Diabetes,
Kidney Diseases and STI?
P: No
P: No
P: No
P: No.
P: No
D: Do you smoke?
P: No
P: No
P: Healthy
P: I try to be.
P: My partner
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D: How long have you been living with your partner?
P: 2 years
I would like to do a GPE, check the vitals including blood pressure.
 ACE inhibitors are not given in pregnancy, they should be stopped, and patient must be
started on some other medication. Ramipril should be stopped as she is pregnant. We
have to aim for blood pressure lower than 140/90 and always try to keep it 135/85.
 We may Consider giving Labetalol, Nifedipine, Methyldopa. ACEi can cause adverse effect
for the woman, fetus, and newborn infant. Give lifestyle advice to the patient.
 We may give you folic acid supplements and other medications. We may refer you to the
OBG department. They will run some blood tests and urine tests too.
 It's is important that you are monitored throughout your pregnancy to make sure your
high blood pressure is not affecting the growth of your baby (pre-eclampsia). Please
make sure you go to all your antenatal appointments.
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PREMENSTRUAL SYNDROME

A 32 year old lady wants to talk to you.
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: Thank you 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
Dr: Any body pains?
Pt: No
Dr: Any tummy bloating?
Pt: No
Dr: How is your mood nowadays? (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 nowadays?
Pt: It is low.
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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
Pt: No
Pt: No
Dr: Any allergies?
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 Depo-Provera .
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: Thank you.
Dr: How is your sleep?
Pt: It is fine/not fine.
Dr: Do you smoke?
Pt: Yes/No
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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:
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 (SSRIs)
• 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.
(OR)
I would like to do vitals, GPE, an examination of the tummy and neurological examination. I
would also like to do baseline investigations.
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From the history you have told me, it appears you have PMS. PMS (premenstrual
syndrome) is the name of the symptoms women can experience in the weeks before their
period. Most women have PMS at some point. Each woman’s symptoms are different and
can vary from month to month.
The most common symptoms of PMS include:

 Mood swings
 Feeling upset, anxious or irritable
 Tiredness or trouble sleeping
 Bloating or tummy pain
 Breast tenderness
 Headaches
 Spotty skin or greasy hair
 Changes in appetite and sex drive
Treating PMS (premenstrual syndrome)

As well as changes to your lifestyle, a GP can recommend treatments including:
 Hormonal medicine – such as the combined contraceptive pill
 Cognitive behavioural therapy – a talking therapy
 antidepressants
If you still get symptoms after trying these treatments, you may be referred to a specialist.
This could be a gynaecologist, psychiatrist or counsellor.
Do
Regular exercise
Eat a healthy, balanced diet
Get plenty of sleep – 7 to 8 hours is recommended
Try reducing your stress by doing yoga or meditation
Take painkillers such as ibuprofen or paracetamol to ease the pain
Keep a diary of your symptoms for at least 2 to 3 menstrual cycles – you can take this to a
GP appointment
Don’t
Do not smoke
Do not drink too much alcohol
Reference information:
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)
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III. Psychiatric causes
IV. Hormonal imbalances
V. Puberty
VI. Pregnancy
VII. Menopause
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MOOD SWINGS (DEPO-PROVERA)

Miss Katie Yale, aged 29, has come to you with some concerns. One week ago, investigations
were done in the GP and came back normal.

P: My husband thinks I am moody on a monthly basis.
P: Like what?
D Can you tell me since when?
P: Since the last 8 months.
P: Happens monthly during my periods
D: Anything else?
P: No
D: Do you feel sad, hopeless or irritable most of the time?
P: No
D: Do you have loss of interest in everyday activities?
P: No
P: No
D: Do you have episodes of feeling very happy, elated or overjoyed?
P: No
D: Do you sometimes feel full of great new ideas and important plants?
P: No
D: Do you make decisions or say things that are out of character and that others see as being
risky or harmful?
P: No
P: No
P: No
P: No
P: No
P: No
P: 2/3 weeks ago
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P: Yes
D: How long does your period last?
P: 5 days.
P: No
P: No
P: No
P: Yes
D: Do you and your partner(s) use any contraception or protection against STI’s?
P: I was on Depo-Provera 1 year ago, now we are using the natural family planning method for
contraception.
D: Were there any issues with the contraception used?
P: No
P: No, we enjoy our sex
P: It has been fine doctor
D: Could you please score your mood for me, with 1 being the lowest and 10 being the
highest?
P: It’s 7/8
D: Do you smoke?
P: No
P: No
P: Good/Bad
P: Yes/No
P: Lecturer
P: With my husband and 2 children
I would like to do vitals, GPE, an examination of the tummy and neurological examination. I
would also like to do some baseline investigations.
From the history you have told me, it appears you have PMS. PMS (premenstrual syndrome)
is the name for the symptoms women can experience in the weeks before their period.
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Most women have PMS at some point. Each woman’s symptoms are different and can vary
from month to month.
The most common symptoms of PMS include:

 Mood swings
 Feeling upset, anxious or irritable
 Tiredness or trouble sleeping
 Bloating or tummy pain
 Breast tenderness
 Headaches
 Spotty skin or greasy hair
 Changes in appetite and sex drive
Treating PMS (premenstrual syndrome)

As well as changes to your lifestyle, a GP can recommend treatments including:
 Hormonal medicine – such as the combined contraceptive pill
 Cognitive behavioural therapy – a talking therapy
 Antidepressants
If you still get symptoms after trying these treatments, you may be referred to a specialist.
This could be a gynecologist, psychiatrist or counsellor.
Do
Regular exercise
Eat a healthy, balanced diet
Get plenty of sleep – 7 to 8 hours is recommended
Try reducing your stress by doing yoga or meditation
Take painkillers such as ibuprofen or paracetamol to ease the pain
Keep a diary of your symptoms for at least 2 to 3 menstrual cycles – you can take this to a
GP appointment.
Don't
Do not smoke
Do not drink too much alcohol
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POST-PARTUM DEPRESSION (TELEPHONIC CONSULTATION)

Miss Amanda Lowe, aged 31, came to you with complaint of insomnia.

P: I have trouble sleeping/tiredness
D: Please tell me more about it?
D: When did this problem start?
P: It started 5 months ago.
D: Do you have trouble getting into sleep or do you wake up in the middle of the night?
P: I have trouble staying sleep.
D: What time do you go to bed?
P: I go to bed around 10
D: What time do you usually go to sleep?
P: I go to sleep around 10:30.
D: What time do you usually wake up?
P: I wake up around 7.
D: Do you wake up in between?
P: Yes
D: How often?
P: At least 3 to 4 times.
D: Are you able to fall asleep afterwards?
P: Yes/No
D: How was your sleep before this problem started?
P: It was fine.
D: Do you take any naps during the day?
P: Yes/No (Elaborate)
D: Anything else?
P: I also feel tired.
D: Did this start at the same time?
P: Yes
D: Can you think of anything which might be the cause of your problem?
P: I gave birth 5 months ago.
D: Tell me, what do you do before you go to bed?
P: I finish my chores.
D: How do you spend your time every day?
P: I look after my baby.
P: No
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P: No
P: No
P: No
P: No
P: It is low
D: Could you please score the mood on a scale of 1 to 10, 1 is low and 10 is highest.
P: It is 2/3
D: Have you had any thoughts of harming yourself?
P: No
D: Any thoughts of harming your baby?
P: No
D: Do you sometimes feel like you can hear voices?
P: No
D: Have you had difficulty bonding with your baby?
P: Yes/No
P: No
P: No
P: No
D: Do you smoke?
P: No
P: No
P: Good/Bad
P: Yes/No
P: I stay at home.
P: With my husband.
D: How is your relationship with him?
P: Good, he is supportive.
D: Do you have any relatives close by?
P: Yes, my mother.
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D: Have you talked to her about how you feel?
P: Yes. My mom thinks that it’s normal to be low.
D: How about any friends.
P: I don’t have any.
D: I would like to do vitals, GP examination. I would also like to do baseline investigations.
From the history you have given me, it seems that you may be having postnatal depression.
It is a type of depression that many parents experience after having a baby.
Postnatal depression can be lonely, distressing and frightening, but support and effective
treatments are available.
These include:
 Self-help – things you can try yourself include talking to your family and friends about
your feelings and what they can do to help, making time for yourself to do things you
enjoy, resting whenever you get the chance, getting as much sleep as you can at night,
exercising regularly, and eating healthy diet
 Psychological therapy – GP may be able to recommend a self-help course or may refer
you for a course of therapy, such as cognitive behavioural therapy (CBT)
Cognitive behavioural therapy (CBT) is a type of therapy based on the idea that unhelpful
and unrealistic thinking leads to negative behaviour.
CBT aims to break this cycle and find new ways of thinking that can help you behave in a
more positive way.
For example, some women have unrealistic expectations about what being a mum is like
and feel they should never make mistakes.
As part of CBT, you’ll be encouraged to see that these thoughts are unhelpful and discuss
ways to think more positively.
As part of CBT, you will be encouraged to see that these thoughts are unhelpful and discuss
ways to think more positively.
 Antidepressants – these may be recommended if your depression is more severe or other
treatments have not helped; your doctor can prescribe a medicine that’s safe to take
while breastfeeding.
Local and national organizations, such as the Association for Post Natal Illness (APNI) and
Pre and Postnatal Depression Advice and Support (PANDAS), can also be useful sources of
help and advice.
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Most women need to be treated in hospital. Ideally, this would be with your baby in a
specialist psychiatric unit called a mother and baby unit (MBU).
Medication
You may be prescribed one or more of the following.
 Antidepressants
 Antipsychotics
 Mood stabilisers (for example lithium)
 psychological therapy
Causes
1. Postpartum psychosis after a previous pregnancy or have a family history of mental
health illness, particularly postpartum psychosis (even if you have no history of mental
illness)
2. Already have a diagnosis of bipolar disorder or schizophrenia.
3. You have a traumatic birth or pregnancy.
Symptoms of postnatal depression

Many women feel a bit down, tearful or anxious in the first week after giving birth. This is
often called the “baby blues” and is so common that it’s considered normal. The “baby
blues” do not last for more than 2 weeks after giving birth.
If your symptoms last longer or start later, you could have postnatal depression. Postnatal
depression can start at any time in the first year after giving birth.
Signs that you or someone you know might be depressed include:

 A persistent feeling of sadness and low mood
 Lack of enjoyment and loss of interest in the wider world
 Lack of energy and feeling tired all the time.
 Trouble sleeping at night and feeling sleepy during the day.
 Difficulty bonding with your baby
 Withdrawing from contact with other people
 Problems concentrating and making decisions
 Frightening thoughts – for example, about hurting your baby.
Treatments for postnatal depression

Postnatal depression can be lonely, distressing and frightening, but support and effective
treatments are available.
These include:
 Self-help – things you can try yourself include talking to your family and friends about
your feelings and what they can do to help, making time for yourself to do things you
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enjoy, resting whenever you get the chance, getting as much sleep as you can at night,
exercising regularly and eating a healthy diet.
 Psychological therapy. CBT
 Antidepressants
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PREGNANCY (16 YO) VOMITING

Miss Leanne Bailey, aged 16, has booked an emergency appointment.
Talk to her, assess and manage her concerns.

P: I'm feeling sick, and I have vomited a few times.
P: Like what?
D: Since when did it start?
P: Since the last couple of days.
P: I wasn’t doing anything special.
D: Is it there all the time or does it come and go?
P: I have nausea from time to time
D: How often do you have nausea and vomiting?
P: I have had 4 episodes so far.
D: Is there anything which makes it better?
P: Not really
D: Is there anything which makes it worse?
P: No
D: Anything else?
P: No
D: Do you feel thirsty? (dehydration)
P: No
D: Is your urine dark yellow? (dehydration)
P: No
D: Do your mouth and lips feel dry? (dehydration)
P: No
P: No
D: Do you have fever?
P: No
D: Do you have loose stools?
P: No
D: Did you hurt yourself recently? (trauma)
P: No
D: Do you have headache?
P: No
P: No
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P: No
P: No
P: No
P: No
P: It’s late by 1 week, I haven’t gotten it.
D: Are they regular otherwise?
P: Yes
D: How long does your period last?
P: 5 days
P: No
P: No
P: No
P: Yes
D: Do you have a partner?
P: Yes, my boyfriend
D: How old is your partner?
P: He is 17 years old
P: We practice pulling out (coitus interruptus)
D: Do you smoke?
P: No
P: No
P: Good/Bad
P: Yes/No
P: I live with my mother.
D: How is your relationship with her?
P: We have a good relationship.
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I would like to check your vitals, GPE and urine pregnancy test
Ex: Vitals normal and UPT is positive
D: From the history you have given me, and the tests we have done, it appears that you are
currently pregnant. This is why you have not been feeling well and have vomiting and
nausea.
P: I don’t know, there is a lot to take in.
D: Finding out you’re pregnant when you’re a teenager can be daunting, especially if the
pregnancy wasn’t planned, but help and support is available.
As your pregnancy test is positive, it’s understandable to feel mixed emotions: excitement
about having a child, worry about telling your parents, and anxiety about pregnancy and
childbirth.
You may also be feeling worried or frightened if you’re not sure that you want to be
pregnant.
Make sure to talk through your options and think carefully before you make any decisions.
Try talking to a family member, friend or someone you trust. I would like to suggest you
discuss your pregnancy with your mother for support and understanding.
P: Don’t tell my mom I am pregnant.

D: Of course, as this conversation is confidential, we will not be discussing this with your
mother without your consent.
P: What are my options?
D: Your options are:
 Continuing with the pregnancy and keeping the baby
 Having an abortion
 Continuing with the pregnancy and having the baby adopted
If you decide to continue your pregnancy, the next step is to start your antenatal care. If you
decide not to continue with your pregnancy, you can talk to GP or visit a sexual health clinic
to discuss your options.
They can refer you for an assessment at a clinic or hospital if you choose to have an
abortion.
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BACTERIAL VAGINOSIS

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.
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 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
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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
Pt: No
Dr: Any allergies?
Pt: No
Dr: A bit of talk on your sex life is it okay?
Pt: Ok doctor
Pt: Yes
Dr: Are you in a stable relationship?
Pt: Yes
Dr: Is your partner having any symptoms?
Pt: No
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
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: Thank you
Examination:
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
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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.
Pt: Did I get it from my husband?
Dr: 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 bubble baths
II. Avoid douching
III. Avoid antiseptics and perfumed products
IV. Use showers instead of baths Are you following me?
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
develop any fever, tummy pains or increased discharge ,please let us know.
Pt: Ok doc.
Discharge Possible cause
Smells fishy bacterial vaginosis
Thick and white, like cottage cheese thrush
Green, yellow or frothy trichomoniasis
With pelvic pain or bleeding chlamydia or gonorrhoea
With blisters or sores genital herpes
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MISSED ABORTION
A 35 year old lady, Jenny Anderson is pregnant and got her antenatal scans done.
Transvaginal scan reveal-
Gestational age of foetus 7 weeks
No foetal heartbeat seen
Speak to Jenny about the reports and address her concerns.
D- Hi I am Dr Jane, one of the junior doctors in the department.

May I confirm your name and age please?
P: Hi. I am Jenny Anderson I am 35.
D- And How may I call you?
P: Jenny is fine.
D- Thank you Jenny.So may I help you today?
Patient will be a little awkward and quiet. That’s the clue to a breaking bad news because
the question did not say it’s a breaking bad news station at all.
P: Well I am pregnant and I have come for my reports.
D: That’s right. Jenny I do have your reports with me, but before we could discuss them I
just need to ask you few questions so that I can address your concerns better. Will that be
okay with you?
P: Yes.
D- Can you tell me why did you do the tests in the first place?
P: I had this brown discharge or she will say just a regular check up.
D- Okay. That great. I appreciate you are taking care of yourself and are proactive about
your health.
She does not answer.
D- Is this your first pregnancy jenny?
P: Yes
D-Was this a planned pregnancy?
P: Yes
D- Can you tell me how far are you with your pregnancy?
P: 7 weeks.
Okay. Can you appreciate any movements of the baby yet?
P: No
How has the pregnancy been so far?
P: Fine I think.
D- Do you a have any symptoms at all? (If she says regular check of the baby)
P: Like what?
D- Any discharge from your front passage ?
P: Yes brown coloured discharge.
D- When did it start?
P: A day ago
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D- How much discharge have you noticed?
P: Not much.
D- Any bleeding that you noticed beside the discharge?
P: No
D- Any tummy pain?
P: No
D-any nausea?
Any vomiting?
D- Any fever or flu like symptoms?
D- A few words about your gynaecological health if it’s okay with you/ or your periods if it’s
okay with you?
P: Yes
D- When was your last period?
P: 7 weeks ago
D- were they regular?
P: Yes
D- Any bleeding between the cycles or after sexual intercourse?
P: No
D- were you on any kind of contraceptions?
Pills or any devices or copper coil that you have ever used?
P: No
D- A few words about your sexual history if that okay with you-
P: Yes
D-Are you in a stable relationship? (asked because she was so quiet and awkward I also
thought it could be forced or in depression?)
P: Yes I am married for so many years.
D-That’s great. How is your relationship with your husband?
D-How has your mood been lately?
P: Fine
D-Can you please Rate your mood On a scale of 1-10?
P: 5 or 6
D-Have you ever been diagnosed with any medical conditions? HTN, DM2, PCOS, ANY
GYNECOLOGICAL PROBLEMS FROM BEFORE?
P: No
D-Do you take any medications including otc, vitamin supplements?
P: No
D-Anyone diagnosed with any other medical conditions in the family?
P: No
D-Are you allergic to any medications or food?
P: No
D-A few words about your lifestyle- yes
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D-How is your diet?
D-Do you smoke?
D-Do you drink alcohol?
D-Any kind of recreational drugs?
I would like to examine you, take your vitals(HR Bp SPO2 RR) and examine your tummy and
your front passage. I will ensure your privacy and have a chaperone with me.
D-Thank you for being so patient and answering my questions. I do have your reports Jenny.
Do you have any idea of what could be going on with you?
P: No
D-Well Jenny. From our discussion, examination and the investigations that I have I am
really sorry to say this I do not have a good news for you Jenny?
P: What is it?
Would you like me to call someone for you? Or is there someone you would like to be with
at the moment?
P-No. my husband is working so it’s fine.
D-Would you still want to know it’s?
P: Yes.
D- well jenny. As I said I don’t have a good news, you said that you were 7 weeks pregnant
and you have brown coloured discharge from your front passage. And from the reports here
it appears tour pregnancy is 6 weeks and the heart rate of your baby is not seen on this
scan. I am really sorry to tell you this but You might have gone through a miscarriage. Do
you know what that’s is? ( Pause )
P: Yes. You mean my baby is no more alive.
D-I can’t even imagine what you must be going through right now. I wish I had better news.
But unfortunately jenny I don’t and what you said is true.
(Patient is silent looking down on the floor and not answering.)
Jenny are you okay? (Silent)
Would you like a moment?(silent)
Can I call someone for you?( Still silent)
P-What are you going to do? (Pt will speak)
OR
D-Would you like to know what we are going to do for you ?(if patient doesn’t speak.)
D- I will just ant to double check with my seniors, if I might have missed onto something. In
the meantime we will have to keep you admitted, run certain tests for hormones (beta hcg)
depending on the values- we will decide wether we should wait for your pregnancy to
terminate and expel out on its own or wether you need an intervention where we will
remove it with a procedure.
P: Ok.
D- Do you have any specific concerns that I can answer for you Jenny?
P: No. Thank you.
Once you are ready to go home, we will speak to you about pregnancies in women more
than age of 30. Would you like that? I can also handover some leaflets to you in the
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meantime so that you can go through them. If you have any concerns my name is dr Jane
and you can just ask the nurse to call me.
If patient asks why did it happen?
Explain there are many possibilities to why this can happen. Ask her did anyone speak to her
about complications in pregnancy in women with age more than 35. Explain to her that can
be one of the causes, chromosomal disorders in the foetus are the most common reason for
pregnancies terminating in the first trimester.
(Please read all causes of miscarriages given in Dr Swamy’s notes.)
Later you can guide her for a check up at the fertility clinic, in case of repeated miscarriage’s
it will be required for her to go through a thorough check up to see if she is fit to be
pregnant in the future or not.
In case you think patient is too depressed you can advise her talking therapy as well.
The most common sign of miscarriage is vaginal bleeding.

This can vary from light spotting or brownish discharge to heavy bleeding and bright-red
blood or clots. The bleeding may come and go over several days.
Other symptoms of a miscarriage include:
• cramping and pain in your lower tummy
• a discharge of fluid from your vagina
• a discharge of tissue from your vagina
• no longer experiencing the symptoms of pregnancy, such as feeling sick and breast
tenderness
If you've had 3 or more miscarriages in a row (recurrent miscarriage) and are worried about
your current pregnancy, you can go straight to an early pregnancy unit for an assessment.
CAUSES-
First Trimester Miscarriages
First trimester miscarriages are often caused by problems with the chromosomes of the
foetus.
Chromosome problems
Chromosomes are blocks of DNA. They contain a detailed set of instructions that control a
wide range of factors, from how the cells of the body develop to what colour eyes a baby
will have.
Placental problems
The placenta is the organ linking the mother's blood supply to her baby's. If there's a
problem with the development of the placenta, it can also lead to a miscarriage.
Things that increase your risk
An early miscarriage may happen by chance. But there are several things known to increase
your risk of problems happening.
The age of the mother has an influence:
• in women under 30, 1 in 10 pregnancies will end in miscarriage
699
• in women aged 35 to 39, up to 2 in 10 pregnancies will end in miscarriage
• in women over 45, more than 5 in 10 pregnancies will end in miscarriage
A pregnancy may also be more likely to end in miscarriage if the mother:
• is obese
• smokes
• uses drugs
• has lots of caffeine
• drinks alcohol
Second Trimester Miscarriages
Long-term health conditions
Several long-term (chronic) health conditions can increase your risk of having a miscarriage
in the second trimester, especially if they’re not treated or well controlled.
These include:
Diabetes, (if it's poorly controlled) ,severe high BP ,lupus, kidney disease, over active or
under active thyroid, Antiphospholipid syndrome
Infections
The following infections may also increase your risk:
Rubella, CMV, Bacterial vaginitis, HIV, Chlamydia, Gonorrhoea, syphilis, Malaria
Food poisoning
• listeriosis – most commonly found in unpasteurised dairy products, such as blue cheese
• toxoplasmosis – which can be caught by eating raw or undercooked infected meat
• salmonella – most often caused by eating raw or partly cooked eggs
Read more about foods to avoid in pregnancy.
Medicines
Medicines that increase your risk include:
• misoprostol – used for conditions such as rheumatoid arthritis
• retinoids – used for eczema and acne
• methotrexate – used for conditions such as rheumatoid arthritis
• non-steroidal anti-inflammatory drugs (NSAIDs) – such as ibuprofen; these are used for
pain and inflammation
To be sure a medicine is safe in pregnancy, always check with your doctor, midwife or
pharmacist before taking it.
Read more about medicines during pregnancy.
Womb structure
Problems and abnormalities with your womb can also lead to second trimester miscarriages.
Possible problems include:
• non-cancerous growths in the womb called fibroids
• an abnormally shaped womb
Weakened cervix
In some cases, the muscles of the cervix (neck of the womb) are weaker than usual. This is
known as a weakened cervix or cervical incompetence.
Polycystic ovary syndrome (PCOS)
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PCOS is known to be a leading cause of infertility as it can lower the production of eggs.
There's some evidence to suggest it may also be linked to an increased risk of miscarriages
in fertile women.
Tests for miscarriage-
The first test used is usually an ultrasound scan to check the development of your baby and
look for a heartbeat. In most cases, this is usually carried out using a small probe inserted
into the vagina (transvaginal ultrasound). This can feel a little uncomfortable but is not
painful.
You may also be offered blood tests to measure hormones associated with pregnancy. You
usually need to have 2 blood tests 48 hours apart to see if your hormone levels go up or
down.
If you've had 3 or more miscarriages in a row (recurrent miscarriages), further tests are
often used to check for any underlying cause. However, no cause is found in about half of
cases. These further tests are outlined below.
If you've had a third miscarriage, it's recommended that the foetus is tested for
abnormalities in the chromosomes (blocks of DNA).If a genetic abnormality is found, you
and your partner can also be tested for abnormalities with your chromosomes that could be
causing the problem. This type of testing is known as karyotyping.If karyotyping detects
problems with your or your partner's chromosomes, you can be referred to a clinical
geneticist (gene expert).They'll be able to explain your chances of a successful pregnancy in
the future and whether there are any fertility treatments, such as in vitro fertilisation (IVF),
that you could try. This type of advice is known as genetic counselling.
USG scan- A transvaginal ultrasound can be used to check the structure of your womb for
any abnormalities. A second procedure may be used with a 3D ultrasound scanner to study
your lower tummy and pelvis to provide a more accurate diagnosis.The scan can also check
if you have a weakened cervix.
Blood tests- Your blood can be checked for high levels of the antiphospholipid (aPL)
antibody and lupus anticoagulant. This test should be done twice, a few weeks apart, when
you're not pregnant.These aPL antibodies are known to increase the chance of blood clots
and change the way the placenta attaches. These blood clots and changes can reduce the
blood supply to the foetus, which can cause a miscarriage.
Missed Miscarriage- Sometimes a miscarriage is diagnosed during a routine scan carried out
as part of your antenatal care. A scan may reveal your baby has no heartbeat or that your
baby is too small for the date of your pregnancy. This is called a missed or delayed
miscarriage.
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PREMATURE OVARIAN INSUFFICIENCY
You are FY2 in OB/GYN.

Sana, aged 26, presented with amenorrhea. She had blood tests done. Results are as
follows:
FSH and LH high estrogen low.
Diagnosis of premature ovarian insufficiency was made. Talk to her, explain the results and

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, reduced 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
Pt: No
Dr: Any allergies?
Pt: No
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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
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 (Donated eggs from other woman or using your eggs if you had stored)
o Surrogacy
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
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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 tuberculosis, 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
Radiotherapy and chemotherapy 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 anxiety
• reduced sex drive (libido)
• problems with memory and concentration
Women who go through early menopause also have an increased risk of osteoporosis and
cardiovascular disease because of their lowered oestrogen hormone levels.
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.
704
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 IVF and donated eggs from another woman,
or using your own eggs if you had some stored. Surrogacy and adoption may also be options
for you.
Counselling and support groups may be helpful. Here are some you may want to try:
• The Daisy Network – a support group for women with premature ovarian failure
• Healthtalk.org – provides information about early menopause, including women
talking about their own experiences
• Fertility friends – a support network for people with fertility problems
• Human Fertilisation and Embryology Authority (HFEA) – provides information on all
types of fertility treatment.
• Adoption UK – a charity for people who are adopting children
• Surrogacy UK – a charity that supports both surrogates and parents through the
process.
705
COMBINED PILL PRESCRIPTION
You are an FY2 in OB/GYN.

Avery Smith, aged 22 has come to you asking for 6 months' prescription of OCP.
She was not using condom for 5 months.
Starting the combined pill:

It is important to remember that you cannot put in repeat prescription requests for the Pill
or for HRT as you would for other medications. Once the doctor is satisfied that the
contraceptive pill or HRT you are on is the most suitable one for you, they will usually issue
a prescription for a six-month supply.
You should not take the pill if you:

 Are pregnant
 Smoke and are 35 years or older
 Stopped smoking less than a year ago and are 35 or older
 Are very overweight
 Take certain medicines (ask your GP or a health professional at a contraception clinic
about this)
You should also not take the pill if you have (or have had):
 Thrombosis (a blood clot) in a vein, for example in your leg or lungs
 Stroke or any other disease that narrows the arteries
 Anyone in your family having a blood clot under the age of 45
 A heart abnormality or heart disease, including high blood pressure
 Severe migraines, especially with aura (warning symptoms)
 Breast cancer
 Disease of the gallbladder or liver
 Diabetes with complications or diabetes for the past 20 years
You may need to use additional contraception during your first days on the pill – this
depends on when in your menstrual cycle you start taking it.
Starting on the first day of your period

If you start the combined pill on the first day of your period (day one of your menstrual
cycle) you will be protected from pregnancy straight away. You will not need additional
contraception.
Starting on the fifth day of your cycle or before
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If you start the pill on the fifth day of your period or before, you will still be protected from
pregnancy straight away, unless you have a short menstrual cycle (your period is every 23
days or less). If you have a short menstrual cycle, you will need additional contraception,
such as condoms, until you have taken the pill for seven days.
Starting after the fifth day of your cycle

You will not be protected from pregnancy straight away and will need additional
contraception until you have taken the pill for seven days.
If you start the pill after the fifth day of your cycle, make sure you have not put yourself at
risk of pregnancy since your last period. If you're worried you're pregnant when you start
the pill, take a pregnancy test three weeks after the last time you had unprotected sex.
You can get contraception free of charge, even if you're under 16, from:
 Contraception clinics
 Sexual health or GUM (genitourinary medicine) clinics
 Some GP surgeries
 Some young people's services
Pill checks
If you are taking the contraceptive pill then, for your safety, you will need check-ups every
6-12 months with the nurse, before your repeat prescriptions can be continued. The GP or
nurse will tell you how often you need a check. Please book your check-up well before you
will run out of your tablets.
If you do need a repeat prescription at the same time as your check-up, we can arrange this
for you, but you will need to call back to collect your prescription once the GP has signed it.
This may be after 5:30 pm the same day or another day. Alternatively, some pharmacies can
collect a prescription for you, if you arrange this with them.
Taking 2 packets of the combined pill back-to-back

If you take a combined contraceptive pill, you can delay your period by taking 2 packets
back-to-back.
How you do this will depend on which pill you take.
Examples are:
 Monophasic 21-day pills, such as Microgynon and Cilest – you take a combined pill for
21 days, followed by 7 days without pills, when you have a bleed (period). To delay
your period, start a new packet of pills straight after you finish the last pill and miss
out the 7-day break.
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 Everyday (ED) pills, such as Microgynon ED and Lorynon ED – you take a combined pill
every day. The first 21 pills are active pills and the next 7 pills are inactive or dummy
pills, when you have your period. To delay your period, miss out and throw away the
dummy pills, and start the active pills in a new packet straight away.
 Phasic 21-day pills, such as Binovium, Qlaira and Logynon – the mix of hormones in
each pill is different, depending on which phase you're in. You need to take these pills
in the correct order to have effective contraception. Ask your pharmacist, community
contraception clinic or GP for more information.
PATIENT'S CONCERNS
On the holiday, how can I avoid having period.
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ANTENATAL ASSESSMENT
You are FY2 in Antenatal clinic.

A 32 year old lady is coming for her antenatal assessment. She is 14 weeks pregnant.
Her lab results are:
Blood group: O Rhesus type: Rh -ve Rubella: Non immune
All other blood tests like LFT’s, RFTs and U and E’s normal.
USG: Singleton foetus
Dr: Hello, my name is Dr. XYZ. I am one of the junior doctors in antenatal clinic. How can I
help you?
Pt: I am here for my regular checkup.
Dr: Alright, I understand that we did some blood tests last time you visited us. I have the
results with me. Before that may I ask a few questions from you?
Pt: Ok
Dr: I understand that you are 14 weeks pregnant. So, how is your pregnancy so far?
Pt: Fine doc
Dr: Any vomiting?
Pt: No
Dr: Any bleeding through vagina?
Pt: No
Dr: Any tummy pains?
Pt: No
Dr: Is this your first pregnancy?
Pt: Yes
Dr :Any miscarriages before?
Pt: No
Dr: Any fever, rash (Rubella)
Pt: No
Dr: Do you have any health problems like increase blood pressure, blood sugar or clots in
lungs or legs?
Pt: No
Pt: No
Dr: Any allergies?
Pt: No
Pt: Yes
Dr: Are you in a stable relationship?
Pt: No
Dr: How many partners do you have in last 6 months?
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Pt: 2,3
Pt: No
Dr: Do you know the biological father of the baby?
Pt: No
Dr: Have you ever been diagnosed with any STI?
Pt: No
Pt: Nothing
Dr: Do you smoke?
Pt: Yes
Ask how much a day? From how long?
Dr: Do you consume alcohol?
Pt: Yes
Ask how much a day? From how long?
Dr: By any chance do you use any recreational drugs?
Pt: Yes
Dr: What do you use?
Pt: Heroin
Dr: How much a day? From how long? Do CAGE. Ask about needle exchange.
Examination
Now 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
Discuss test results

Dr: Everything is normal. However, your blood group is O-ve, it means that we have to be a
bit careful if baby is O+ve. For that, I will discuss with my seniors and we will discuss
regarding this in next visit ok?
Pt: Ok
Dr: Also ,your results are showing that you are not immune to rubella infection. Did you
have this infection earlier in your life?
Pt: No
Dr: For this, we will recommend you to avoid close contacts with people who have
symptoms like fever, sore throat or rash on body. Is it ok?
Pt: Ok
Dr: Fortunately, you have a single, healthy pregnancy as well.
Pt: Ok
Management:
• Advise her on smoking cessation
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o Offer support via replacement therapy, support groups and smoking cessation clinic.
• Advise her on alcohol cessation.
o Offer support via replacement medicines, CBT, support groups and alcohol cessation
clinic.
o Tell her that smoking and alcohol both can badly affect the development of baby.
• As she is a heroin abuser, advise her to stop using it as it can also affect her baby.
o Offer support via CBT and Narcotic anonymous support group.
• Advise her on safe sex.
Dr: We will also do your blood tests regarding any sexual transmitted infections(HIV,
Syphilis).Is it ok?
Pt: Ok
Dr: We will arrange your next follow up in a month. In the meantime, if you feel unwell in
anyway like fever, tummy pains or bleeding through vagina, please let us know.
Rubella
What are signs and symptoms of rubella?
About half of people with rubella have signs and symptoms, and half don’t. Rubella is
usually mild with flu-like symptoms followed by a rash. The rash often lasts about 3 days.
Flu-like symptoms include:
• Low-grade fever
• Headache
• Runny nose
• Red eyes
• Swollen glands
• Muscle or joint pain.
What causes rubella?
Rubella is caused by a virus (a tiny organism that can make you sick). It’s very contagious
and is spread through the air from an infected person’s cough or sneeze.
What problems can rubella cause during pregnancy?
Rubella can be a serious threat to your pregnancy, especially during the first and second
trimesters.
Having rubella during pregnancy increases the risk of:
• Congenital rubella syndrome (CRS) – This is a condition that happens when a mother
passes rubella to her baby during pregnancy. It may cause a baby to be born with one or
more birth defects, including heart problems, microcephaly, vision problems, hearing
problems, intellectual disability, bone problems, growth problems, and liver and spleen
damage.
• Miscarriage – This is when a baby dies in the womb before 20 weeks of pregnancy.
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• Stillbirth – This is when a baby dies in the womb after 20 weeks of pregnancy.
• Premature birth – This is birth that happens too early, before 37 weeks of pregnancy.
Can you pass rubella to your baby during pregnancy?

Yes. The best way to protect your baby is to make sure you’re immune to rubella. Immune
means being protected from an infection. If you're immune to an infection, it means you
can't get the infection.
Most likely you’re immune to rubella because you were vaccinated as a child or you had the
illness during childhood. A blood test can tell whether or not you’re immune to rubella. If
you’re thinking about getting pregnant and aren’t sure if you’re immune, talk to your health
care provider about getting a blood test.
If you’re not immune to rubella, here’s what you can do to help protect your baby:
Before pregnancy. Get the measles, m umps and rubella (MMR) vaccine. Wait 1 month
before trying to get pregnant after getting the shot.
During pregnancy. You can be tested at a prenatal visit to make sure you’re immune to
rubella. If you’re not immune, the MMR vaccine isn’t recommended during pregnancy. But
there are things you can do to help prevent getting infected with rubella:
• Stay away from anyone who has the infection.
After pregnancy. Get the MMR vaccination after you give birth. Being protected from the
infection means you can’t pass it to your baby before she gets her own MMR vaccination at
about 12 months. It also prevents you from passing rubella to your baby during a future
pregnancy.
What are the chances of passing rubella to your baby during pregnancy?
You’re more likely to pass rubella to your baby the earlier you become infected during
pregnancy. For example:
• If you get rubella in the first 12 weeks of pregnancy, your baby has about an 8 to 9 in
10 chance (85 percent) of getting infected.
• If you get rubella at 13 to 16 weeks of pregnancy, your baby has about a 1 in 2 chance
(50 percent) of being infected.
• If you get rubella at the end or your second trimester or later, your baby has about a 1
in 4 chance (25 percent) of getting infected.
If you have rubella during pregnancy, your baby’s provider carefully monitors your baby
after birth to catch any problems early.
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ANTENATAL CHECKUP (RUBELLA/RH NEGATIVE)
You are an FY2 in Antenatal Clinic.

Mrs. Chelsea Stokes, aged 30, is 14 weeks pregnant and has come to the hospital for the
reports. She came to antenatal clinic when she was 12 weeks pregnant for routine antenatal
clinic.
Report:
Rubella; nonimmune
Rh –ve or O Rhesus antibodies were negative.
Blood: Normal
Urine: Normal

P: I'm here for my results
D: Could you confirm the age of pregnancy?
P: 14 weeks doctor
D: How has the pregnancy been so far?
P: It’s okay doctor.
D: Any complications so far?
P: No
D: Any symptoms?
P: Like what Dr.?
D: Any bleeding, spotting or discharge from your front passage?
P: No
D: Feeling any tummy pain? (ectopic pregnancy)
P: No
D: Any pain in the breast?
P: No
P: No
D: Was this a planned pregnancy?
P: No
D: Any pregnancies before?
P: No
P: No
P: No
P: No
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P: No
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
D: Do you take recreational drugs?
P: Yes, I smoke cannabis.
P: Good/Bad
P: Yes/No
P: Manager
P: I live alone.
I would like to do vitals, GPE, and an examination of the tummy.
Measles:
I have your blood results with me, and I will discuss them with you. Your blood test shows
that you do not have immunisation for rubella. It is an infection that is very similar to
measles, and people are vaccinated for it in their childhood.
Rubella:
If the patient is pregnant and the blood test showed that the patient is not immune to
rubella, it means that children who missed out on their MMR vaccinations could spread
rubella to you, so you need to be aware of this risk. If any of your friends or their children
have a rash, it’s better to stay away from them until the rash has gone. After you’ve had
your baby, you should have the two vaccinations, so you’re protected next time you get
pregnant.
A baby born damaged by rubella is said to have Congenital Rubella Syndrome (CRS). Many
will have hearing loss, cataracts, other eye conditions, and heart problems that require
significant hospital treatment and affect the child throughout their life. A baby’s brain can
also be affected it can cause loss of the baby (miscarriage).
There’s no evidence that the vaccine causes harm to unborn babies, but if you need the
vaccine, you should have it after your baby is born. MMR immunisation during pregnancy is
not recommended.
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RhD
Secondly, your blood test shows that you are RhD negative. Red blood cells sometimes have
another antigen, a protein known as the RhD antigen. If this is present, your blood group is
RhD positive. If it’s absent, your blood group is RhD negative.
As you are RhD negative, you will be offered injections of anti-D immunoglobulin at certain
points in your pregnancy when you may be exposed to the baby’s red blood cells. This anti-D
immunoglobulin helps to remove the RhD foetal blood cells before they can cause
sensitization.
Rhesus disease can only occur in cases where all of the following happen:
 The mother has a rhesus negative (RhD negative) blood type
 The baby has a rhesus positive (RhD positive) blood type
 The mother has previously been exposed to RhD positive blood and has developed an
immune response to it (known as sensitization)
Rhesus disease is a condition where antibodies in a pregnant woman’s blood destroy her
baby’s blood cells. It’s also known as haemolytic disease of the foetus and newborn (HDFN).
Rhesus disease can largely be prevented by having an injection of a medication called anti-D
immunoglobulin.
This can help to avoid a process known as sensitization, which is when a woman with RhD
negative blood is exposed to RhD positive blood and develops an immune response to it.
Anti-D immunoglobulin
The anti-D immunoglobulin neutralizes any RhD positive antigens that may have entered the
mother's blood during pregnancy. If the antigens have been neutralized, the mother's blood
won't produce antibodies.
Alcohol:
Drinking in pregnancy can lead to long-term harm to the baby, with the more you drink, the
greater the risk. The safest approach is not to drink alcohol at all to keep risks to your baby
to a minimum.
When you drink, alcohol passes from your blood through the placenta and to your baby.
A baby’s liver is one of the last organs to develop and does not mature until the later stages
of pregnancy.
Your baby cannot process alcohol as well as you can, and too much exposure to alcohol can
seriously affect their development.
Drinking alcohol, especially in the first 3 months of pregnancy, increases the risk of
miscarriage, premature birth and your baby having a low birthweight.
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Drinking after the first 3 months of your pregnancy could affect your baby after they’re
born.
The risks are greater the more you drink. The effects include learning difficulties and
behavioural problems.
Drinking heavily throughout pregnancy can cause your baby to develop a serious condition
called foetal alcohol syndrome (FAS).
Smoking cigarettes and cannabis:

Protecting your baby from smoke is one of the best things you can do to give your child a
healthy start in life. It can be difficult to stop smoking, but it’s never too late to quit. Using
cannabis while pregnant may harm the unborn baby. Cannabis smoke contains many of the
same harmful chemicals found in cigarette smoke. Regularly smoking cannabis with tobacco
increases the risk of a baby being born small or premature.
Smoke can reduce your baby’s birth weight and increase the risk of sudden infant death
syndrome (SIDS), also known as “cot death”. Babies whose parents smoke are more likely to
be admitted to hospital for bronchitis and pneumonia during their first year.
The main reason that people smoke is because they are addicted to nicotine. We can offer
you nicotine replacement therapy. Nicotine replacement therapy is a medication that
provides you with a low level of nicotine poisonous chemicals present in tobacco smoke.
These can be given in the form of patch, spray or chewing gum.
It can help reduce unpleasant withdrawal effects such as bad mood and craving which may
happen when you stop smoking. You could also consider trying E cigarettes. Although the
yare not risk free, they are very much safer than cigarettes and can help people stop
smoking.
The NHS Smoke free helpline offers free help, support and advice on stopping smoking and
can give you details of local support services.
You can also sign up to receive ongoing advice and support at a time that suits you.
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CYCLICAL BREAST PAIN
You are F2 in GP.

Jenny aged 40 booked an urgent appointment to discuss her problem.
Talk to the patient, take history, assess her and discuss the plan of management and address
her concerns.

P: My breasts are lumpy and sore.
D: Could you please tell me more about the soreness?
P: I am having this soreness in both the breasts.
D: For how long you are having this soreness?
P: It was there from last few months.
D: Is it all the time or comes and goes?
P: It comes and goes.
D: how many episodes did you have till now.
P: I have this soreness whenever I am about to have my periods.
D: How often do you get this soreness?
P: I have this soreness few days before my cycle. When my period comes the pain goes away.
P: It is the same.
D: Is there anything make it better?
P: I tried paracetamol; it didn't help much.
P: When I touch my breast, it becomes more sore.
D: Tell me more about the lumps in your breast?
P: It is also same as the soreness. I feel it before the start of my periods. When my periods start
it gets resolved.
P: No
D: Any change in shape and size of the breast?
P: No
D: Any change in the skin of the breast
P: No
D: Any discharge from the nipples?
P: No
D: Any lumps and bumps in the body?
P: No
D: Any weight loss?
P: No
P: No
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D: Any SOB or tiredness
P: No
P: No
D: Tell me about your periods, when was your last menstrual period?
P: 2 weeks ago
D: Is it regular?
P: Yes
D: Any heavy periods or bleeding in between the periods?
P: No
D: Any pregnancy? If yes how many kids?
P:
D: Are you sexually active now?
P: Yes
D: Are you using any method of contraception?
P: Yes/No
P: No
P: No
D: Any breast problem in the past?
P: No
P: No
D: Any hormonal therapy?
P: No
P: Yes/No
Examination
Explain the procedure
Being gentle
Exposure
Chaperone
Consent
I am here to examine your breast, for the purpose of examination I want you to undress
above your waist, I have a chaperone with me to ensure your privacy. I will examine you in
sitting position, in lying down and in standing position. Is that alright? May I proceed?
Inspection: While sitting:
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1. Sit upright and put your hands on your thigh: Both the breast are symmetrical, nipples at
the same level. There is no redness, swelling, visible mass, bruises and scars for any
surgery.
There is no discharge, bleeding from the nipples. There is no peau d'orange.
2. Put your hands on your waist and bend forward: There is no visible mass on bending
forward.
3. Put your hands on the back of your head: There is no fullness in supraclavicular and
axillary area.
4. Lift your breast with two fingers: There is no fungal infection in infra-mammary area.
5. Squeeze your nipples with two fingers: There is no discharge or bleeding from the
nipples.
Palpation: While lying down at 45.

Temperature:
Compare All four quadrants of one breast with all the quadrants with the other breast.
(Upper inner, upper outer. Lower inner. Lower outer)
Superficial Palpation:
Go anti-clockwise and check for any tenderness.
Deep palpation:
Again go anti-clockwise and find the mass and comment on the mass.
(Size, shape, surface, regular or irregular, attached to underlying structures and attached to
overlying skin or not).
Periaerolar Palpation:
Go anti-clockwise and Use your thumb to find out the mass.
Lymph nodes: While standing check for axillary lymph nodes.

From the front check for Anterior, Medial and apical.
From the back check for Posterior and lateral.
Then check for supra clavicular lymph nodes:
Examination will be normal in this case.
From my assessment, you seems to have a condition called Cyclical breast pain This pain is
related to periods. Typically, it occurs in the second half of the monthly cycle, becoming
worse in the days just before a period.
It is thought that women with cyclical breast pain have breast tissue which is more sensitive
than usual to the normal hormonal changes that occur each month. It is not due to any
hormone disease or to any problem in the breast itself. It is not related to any other breast
conditions.
Although it is not serious, it can be a nuisance.
No treatment may be needed if the symptoms are mild. Many women are reassured by
knowing that cyclical breast pain is not a symptom of cancer or serious breast disease. The
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problem may settle by itself within few months. However, sometimes this pain may come
and go over the years.
Treatment options include the following:

1. Support your breasts with a well-supporting bra when you have pain.
2. Painkillers and anti-inflammatory medications (Oral and topical) like paracetamol or
ibuprofen can be taken on the days when the breasts are painful.
3. Medicines such as danazol, tamoxifen and goserelin injections can ease pain in most
cases. They are only prescribed by specialists only in severe condition.
4. Evening primrose oil might be helpful.
Follow up with your GP and if you feel worried or frightened about anything or if you want
to talk things through or have a question about breast health please come back. If you have
breast pain with a lump in your breast or under your arms, discharge from a lump or nipple,
swelling and redness in your breast any symptoms of pregnancy, such as a missed period
please see a Medicines may worsen cyclical breast pain:
1. The contraceptive pill or hormone replacement therapy (HRT)
2. Some antidepressants and some blood pressure medications
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ETHICAL STATIONS
BBN CEREBRAL BLEEDING
You are F2 in A&E.

Mr. Ali aged, 78, has collapsed and brought to the hospital with loss of consciousness by an
ambulance. The initial survey has been done. The CT Scan has been done and shows a
massive intra cerebral bleeding due to ruptured berry aneurysm. The neurology team has
seen the patient and reviewed his CT scan. They decided that surgery cannot be done.
He is now breathing independently/unassisted.
Patient is unconscious.
Please talk to his wife Mrs. Maria Ali, explain that her husband’s condition and address her
concerns.
Patient is in terminal condition and only palliative care is possible.
Patient’s wife does not know about her husband’s condition.
D: Hello Mrs. Ali I am John one of the junior doctor in the department. How are you doing?
P: I am okay. Could you please tell me how my husband is?
D: Yes I am here to talk to you about your husband's condition. Can you tell me what do you
understand about his condition?
P: Doctor my husband was absolutely fine. He was watching TV and suddenly he got a bad
headache and then he collapsed. I called the ambulance and we rushed to the hospital. Doctor,
how is he now?
D: Let me ask you a few questions about his general health. Has he been diagnosed with any
medical condition in the past?
P: He is having high blood pressure but he is taking medication for that.
D: Any other medical condition he is suffering from?
P: No
D: Any Diabetes or high cholesterol?
P: No
D: I'm so sorry to hear that. Do you have any idea what is going on?
P: No. doctor. Please tell me.
D: As you said earlier, you brought your husband to the hospital after he had a bad
headache and after he collapsed. We examined him and did a CT scan of his head. I am sorry
to say that I don't have a good news for you. PAUSE
Would you like anyone to be with you while I discuss your husband's condition?
P: Doctor I came to the hospital alone, please tell me what happened?
D: Unfortunately, your husband has had a bleeding in his brain. He is unconscious at the
moment, but he is breathing on his own.
P: But doctor, how could it be possible? He only had blood pressure (+/- and Diabetes), which
was well controlled. He always takes his medications.
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D: I understand but there are many factors that can cause bleeding in the brain. In his case,
bleeding happened because of a Ruptured Berry Aneurysm.
Have you ever heard of it before?
P: No
D: There are tubes that carry blood to the brain, which we call the blood vessels, when the
walls of these tubes becomes weak they become wider and forms a sac that looks like a
berry and when this sac ruptured, it causes bleeding in the brain. There are a number of
things that can increase the risk such as having diseases such as high blood pressure, family
history, smoking and age.
P: Doctor, what are you going to do now? Can you do an operation for him?
D: Unfortunately, we cannot do any operation. There is a massive bleeding in his brain with
his unconscious state and age, are also the reason. The team of expert neurosurgeons
believes that at this stage operation is not possible. PAUSE
I’m really sorry to say that his condition is terminal and we are not expecting him to get
better.
P: Doctor, does this mean that there is nothing you can do for him?
D: No. We will give your husband some supportive treatment. We will take some measures
to make sure your husband is as comfortable as he can be.
P: So what are you going to do for him?
D: We are going to keep your husband in the hospital.
1. We will provide him nutritional vitamins and supplements by passing a flexible tube into
his gut and gullet through his nose.
2. We may need to give him IV fluids and medication.
3. We will take all the necessary measures to prevent infections and we will provide mouth
care, maintaining good hygiene, to avoid any dryness or infections.
4. We move him regularly so that he doesn't develop bedsores and We will gently exercise
his joints to stop them from becoming stiff. This w ill also help prevent formation of
blood clots in his legs. We may also use some compression stockings for this purpose.
5. We will also help him in emptying his bladder by inserting a flexible tube through his
penis in to his bladder.
6. We will give him some medications to reduce the secretion in his mouth (anti-secretory
medicines) to prevent any breathing problems (aspiration). We may also give him
artificial tears to lubricate his eyes.
P: Doctor, are you going to shift him to ICU?
D: We will keep him in the ward. Your husband is able to breath normally by himself. All the
care that he needs can be given in the ward. And also shifting him to the ICU does not
change the prognosis of his condition.
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BBN TALK TO DAUGHTER
You are an F2 in Surgery.

Mr. David aged 65, had a Ischaemic Stroke last week which affected his left side. He was
recovering well and doing fine.
He developed another stroke yesterday and his GCS is 3 now. They did CT scan and it showed
massive clot in both the hemisphere. Only Analgesics and IV Fluids can be given to the
patient. If patient deteriorates then Do Not Resuscitate the patient. His daughter came to
you to discuss her father’s condition.
Please talk to the daughter, explain her father’s condition and address her concerns.
Daughter is pregnant. MDT has decided that surgery cannot be done and they have decided
only palliative care is possible.
D: Hello Miss Jane, my name is, How are you doing today?
P: I’m Ok Doctor, how is my father.
D: Yes, I’m here to talk to you about your father’s condition. What do you know about your
father’s condition?
P: He had a stroke but he was doing fine after that. He was recovering well.
D: I’m so sorry to hear that. You mentioned that he had a stroke a week back and he was
recovering.
However, later on his condition deteriorated. We examined him and did a CT scan of his
head.
Did anyone tell you about CT scan result?
P: No, tell me what happened?
D: I’m sorry to say that I don’t have good news for you (PAUSE)
Would you like anyone to be with you whilst I discuss your father’s condition?
P: No Dr. I came to the hospital alone, please tell me what has happened?
D: Unfortunately, you father had another stroke yesterday which has affected his both sides
of the brain and he is unconscious now.
D: Unfortunately, we cannot do operation as this massive stroke affected both sides of his
brain and a team of experts believes that at this stage operation is not possible (PAUSE)
I’m really sorry to say that his condition is terminal and we are not expecting him to get
better and we have decided that if his heart stops, we will not do chest compression (CPR).
P: Dr does this mean that you cannot do anything for him?
D: No, we will give your father supportive treatment. We will take measures to make sure
your father is as comfortable as he can be.
P: So, what are you going to do for him?
D: We will keep him in the hospital.
1) We will give him IV Fluids and pain medication so he will not be in pain.
2) We will take all the necessary measures to prevent bed sores;
723
3) We will provide mouth care whilst maintaining good hygiene to avoid any dryness or
infection in the mouth.
4) We will gently exercise his joints to stop them from becoming stiff and we may also use
compression stocking to prevent blood clot formation in his legs.
P: How much time does he have Dr?
D: It is very difficult to say how much time he has. I’m afraid to say that he can develop
complications such as infection which can be prevented. However, there are few
complications such as bleeding in his brain or another stroke that can happen at any time
and can be fatal.
P: Dr Can you put him on ventilator as I’m due for my delivery in the next 2 weeks
D: I wish I could say yes but unfortunately the condition is such that it is terminal and
expecting him to get better and as I have mentioned our team of doctors have decided not
to resuscitate him if his heart stops beating.
P: Can I see my dad?
D: Yes of course you can.
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EDH JOSHUA
You are F2 in Pediatric Emergency.

Joshua, aged 9 had a Road Traffic Accident an hour ago.
Initial survey has been done and there is a head injury. No other injury has been found. CT
Scan has been done and showed an extradural hemorrhage. You have not seen the patient.
A team of doctors is resuscitating the child and planning to take him to the theatre.
Please talk to the parents; Mr. and Mrs. Barnes and address their concerns.
D: Hello. I am Dr.X, let me just confirm are you parents of Joshua?

Mom: Doctor will he die?
Dad: How is my son?
D: I understand your concern. We are looking after your son. I am here to talk to you about
him. Can you tell me how much do you know about his condition? Has any one talked to
you about his situation.
Dad: We don't know; is he going to be ok?
D: I understand you are worried. I am here to answer your questions. I know it might be
difficult for you but could you please tell me what happened?
Mom: We were out for a picnic. Josh and I were waiting for his dad and his twin brothers
outside a restaurant. When Josh saw them he got excited and ran towards them. I heard a loud
noise and I ran to see what happened. I noticed a car had hit him and my Josh was on the
street.
Mom: It was my mistake that I was not holding Joshua’s hand.
D: I can imagine how difficult this must be for you, but please do not blame yourself. It
wasn't your fault. Can you tell me what happened after that?
Dad: We panicked and called the ambulance and brought him to the hospital.
Mom: Doctor, it took more than twenty minutes till the ambulance came.
D: Can you tell me how was Joshua just after the accident? Did you notice any blood or
injuries?
Dad: There was blood everywhere on the street.
D: Where was the blood coming from?
Dad: Doctor, we panicked and we didn't notice. I think from his head.
D: Was he conscious after the accident?
Dad:
A) Doctor, he was unconscious.
B) He was conscious.
Mom: Doctor, will he die?
D: let me reassure you that we are doing our best to help him: he is with a team of expert
doctors.
Dad: Will he be okay?
D: Let me tell you what we have done for him so far.
725
We examined him for external injuries and found an injury to his head.
We then examined this consciousness and if there was any weakness over his limbs. We also
checked the back of his eye to know if the pressure inside his head had increased.
We did necessary blood test. We did a CT Scan of his head. Has anyone talked to you about
the result of the CT Scan?
Dad: No doctor, please tell us.
D: I’m afraid to say that the Scan showed that your child had bleeding between the outside
of his brain covering and his skull. This happens because the injury causes damage to the
tubes that carry blood in the head and this results in blood to leak and collect between the
outside of brain covering and skull. We call this condition Extradural Hematoma.
Mom: Doctor, will he be ok?
D: We made sure he is breathing well. We took all necessary steps to make sure that his
blood pressure remain stable. We started giving him fluids through his tube in his arm as a
drip. He may need to receive some medication to decrease the pressure in his head.
Dad: Will he die?
D: He is in a critical condition and a team of doctors are looking after him and preparing him
for surgery.
Mom: Surgery! Which surgery?
D: I am not a surgeon but I will explain to you how much ever I know about this surgery. The
blood that has been collected in this head increases the pressure inside his head. The
purpose of this surgery is to remove the collected blood and lower the pressure. There are
different ways to do this. One of them is a procedure called “Burr-Hole Craniotomy”, in
which a small hole is made in the skull to suck out the blood through the hole. Stitches or
staples are then used to close the holes.
The other option is "Open Craniotomy”, tn which a portion of the skull is removed and the
brain exposed. It can relieve any raised pressure inside the skull. The blood clot, which has
formed, can easily be removed. The section of the skull that was removed is then replaced
and fixed back in place.
The surgeons will assess him and decide on the type of surgery' for this and this is done
keeping in mind the best interests of the patient.
Dad: Doctor, can we see him?
D: Of course you can but could you wait until his preparation for operation has been
completed as the surgical team is preparing him for surgery now.
Dad: No doctor, we want to see him now.
D: Don’t worry, I will go and talk to my senior and hopefully we are able to arrange for you
to see him now.
Mom: Are there any complications for this surgery?
D: Every surgery' has its own share of complications. He might develop infection over the
site of surgery or might develop clots in his legs but we will take adequate precautions to
avoid them. There is a chance of bleeding also that can happen.
Dad: Are there any long-term complications?
726
D: He may experience headache or dizziness, which can be temporary. He might also
develop fits or weakness of limbs but these can be controlled with medications/ physio.
Some chance of developing speech problems but it will be managed by speech therapist.
727
PELVIC FRACTURE
You are F2 in A&E.

Joshua aged 9 had a road traffic accident. He was brought to the hospital and initial survey
was done. He had an unstable pelvic injury. He has lost a lot of blood and he is hypotensive.
Initial management was done and patient has been resuscitated. He is being prepared to go
for a surgery. Parents are quite anxious.
Talk to the parents, discuss about further management and address concerns
D: Hello. I'm Dr. Y. let me just confirm are you parents of Joshua?
Mom: Doctor will he die?
Dad: How is my son?
D: I am here to talk to you about him. Before I start can you tell me what is your
understanding about your son's condition.
Dad: We don't know; is he going to be ok?
D: I am here to answer your questions. I know it might be difficult for you to go through this
again, but could you please tell me what happened?
Mom: We were out for a picnic. Josh and I were waiting for his dad and his twin brothers
outside a restaurant. When Josh saw them he got excited and ran towards them. I heard a loud
noise and I ran to see what happened. I noticed a car had hit him and my Josh was on the
street.
Mom: It was my mistake that I was not holding Joshua's hand.
D: I can imagine how difficult this must be for you, but please do not blame yourself. It was
not
your fault.
D: Can you tell me what happened after that?
Dad: We panicked and called the ambulance and brought him to the hospital.
Mom: Doctor, it took more than twenty minutes till the ambulance came.
D: Can you tell me how was Joshua just after the accident? Did you notice any blood or
injuries?
Dad: There was blood everywhere on the street.
D: Where was the blood coming from?
Dad: Doctor, we panicked and we didn't notice.
D: Was he conscious after the accident?
Dad:
A) Doctor, he was drowsy.
B) He was conscious.
D: Did he have any other problem?
Dad: Doctor, he was having some difficulty in breathing.
D: We are doing our best to help him; he is with a team of expert doctors.
728
D: Let me tell you what we have done for him so far. We did a full examination to check for
any external injuries. On examination we measured his blood pressure and it was low. This
type of injuries damage the tubes that supply blood around his hip and this can lead to
bleeding. This can explain why he had difficulty in breathing and low blood pressure. We
will do some imaging such as X-Ray, CT Scan and Ultrasound of his tummy and pelvis, to find
out the extent of injury
and detect any internal bleeding.
From the examination and investigation we have done, we found that he has an unstable
pelvic fracture that is the break in his hip bone.

D: We have started him on the best possible treatment. We gave him enough painkillers to
make sure he is pain free. We took all necessary' measures to make sure that he can breathe
properly and gave him oxygen. To compensate the blood loss, we gave him fluids through
the tube that supplies blood in his arm as a drip. We also took some blood sample to
monitor on-going blood loss. Since he may need to receive some blood transfusion, we sent
his blood sample to the lab to check which ty pe of blood group he needs to receive.
D: He is still in a critical condition and a team of doctors are looking after him. The initial aim
is to reduce the blood loss by stabilising his hip w ith the help of a pelvic binder which will
keep it in place and also reduce clot formation which will reduce bleeding.
Mom: Will he die?
D: As I mentioned he is being looked after by a team of expert doctors, which is preparing
him for surgery. As part of these preparations we will introduce a thin plastic tube into his
bladder.
Usually this tube is passed through the penis, but since there might be injury' in his private
part, we will be introducing it in a different way (suprapubic catheterisation) which will help
him pass urine. We may need to pass a plastic tube through his nose into his stomach if
necessary'. I understand all these must really scaring you but whatever we do is for the best
interest of Joshua.
Mom: Surgery! Which surgery?
D: There are still few scans that we w ill do before we proceed to surgery which w ill tell us
which exact surgery Joshua will need.
If you are okay with it I can explain to you about the possible surgeries that he can have, yet
again surgeons will be in a better place to explain to you again before the procedure. He
may need a procedure for stabilizing the fracture externally (External fixation). They may try
to stop the bleeding by a procedure called embolization, in which they try to block the blood
flow in the damaged tube that carries blood, which can control or prevent any possible
bleeding in the tummy (Interventional Radiology' Embolization). Sometimes, especially if
there is any tummy injury, the surgeon needs to open the tummy to find the site of bleeding
and take necessary action to stop it (Laparatomy and Pelvic Packing).
729
Dad: Doctor, can we see him?
D: Of course you can but could you wait till the surgery team prepares him for the surgery?
Dad: Doctor. I want to see him now.
D: Don’t worry, I will go and talk to my senior and hopefully we are able to arrange for you
to
see him now.
Mom: Are there any complications for this surgery?
D: Like any other surgery, this also has complications. He might develop infection at the site
of surgery or blood clots in his leg but we will take the best preventive measure to avoid it.
There is also a risk of continued bleeding from injuries to the surrounding structures. He is in
safe hands and everything will be done to make sure the surgery is uneventful.
Dad: Are there any long-term complications?
D: He might sometime develop persistent pain or difficulty to walk but with help of
physiotherapists we can control this. We are always around, in case you have any other
questions, feel free to contact me or anyone in our team.
730
POST MORTEM
You are F2 in Respiratory Dept.

Mr. Davis aged 60, was brought to the hospital because of cough, four days ago and was
diagnosed with chest infection.
He passed away yesterday. The most probable cause of death is respiratory failure due to
chest infection. Please talk to his wife, Mrs. Sarah and address her concerns.
Post mortem has been considered to determine the cause of death. Death certificate can be
issued.

P: My husband died yesterday and I am not quite sure why this has happened. I have got some
concerns about the death of my husband.
D: I am sorry to hear about that. Has anyone told you, what was the cause of his death?
P: Yes. but I didn’t quite understand.
D: Let me explain it to you. Your husband passed away because of respiratory failure.
P: What is it?
D: It is a life threatening condition in which our lungs cannot provide enough oxygen for our
body and that's why sometimes people die of this condition.
P: But he was fine and it was the first time he was admitted to any hospital. He has never even
smoked. How could he have respiratory' failure?
D: As you know your husband came to the hospital because of cough and he was admitted
with chest infection. Chest infection can sometimes lead to lung damage and then
respiratory failure.
P: He was absolutely fine and all this happened suddenly while he was here. I talked to my
friend who is a nurse and she told me that we can find out the exact cause of his death by
doing some procedure. 1 don’t know what l have to call that procedure?
D: Do you mean post-mortem
P: Yes.
D: Okay, we can arrange it for you.
P: Thank you so much doctor. How long does it take to be done?
D: The post mortem by itself takes just a few hours, but it usually takes a few days for the
entire procedure including paper work to be completed. Do you have any main concern?
P: I want to arrange for his funeral.
D: Ok. we need to make some necessary arrangements. Since this procedure will be carried
out in a special hospital (Human tissue authority (HTA) approved). This means you may be
able to arrange his funeral in the next few days.
P: Could you please tell me how are you going to do post-mortem?
 D:The post-mortem takes place in an examination room that looks similar to an
operating theatre. The examination room will be licensed and inspected by the HTA.
 There are two parts to the physical examination of the body: The external and the
internal examination.
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o In External examination, we will look at the body more closely. We may do some
imaging such as X-ray, CT scan or MRI.
o In internal examination the person's body is opened and the organs are 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 and we will stitch the body.
 Sometimes, we need to keep the organ in the laboratory for examination. In
this case, we will close the cut so you can take the body for the funeral. The
organs can be given to you later.
 Sometimes additional tests such as genetic testing may also be done.
P: Doctor, will the body be disfigured?
D: We cut the body gently with respect and then close it nicely with stitches. So the body
will not be disfigured. When you take the body for the funeral, it will be in a box, and will be
covered, so probably no one will notice that.
P: Okay doctor, that’s fine.
D: Before doing the procedure we need to take consent from you. We need to take consent
for two things,
One is to give us permission to do the procedure and other one in case we need to remove
any of his organs to send to the lab.
P: Ok
D: Would you like me to start arranging for the post-mortem?
P: Doctor. I need to think about it.
D: Ok. We would be grateful if you could inform us about your final decision soon.
D: I can imagine what you are going through. In this case talking and sharing your feelings
with
someone can also help. Some people find that relying on the support of family and friends is
the
best way to cope.
Your GP will be able to put you in touch with bereavement services in your area. You can
also
contact the national Cruse helpline.
When post-mortems are carried out?

A post-mortem examination will be carried out if it's been requested by:
1. A coroner - because the cause of death is unknown, or following a sudden, violent or
unexpected death
2. A hospital doctor - to find out more about an illness or the cause of death, or to further
medical research and understanding.
732
3. Sometimes, the partner or relative of the deceased person will request a hospital post-
mortem to find out more about the cause of death.
The post-mortem examination will be carried out as soon as possible and usually within 2-3
working days after the death. It may be possible to arrange it within 24 hours if necessary.
733
DOMESTIC VIOLENCE
You are F2 in OBG.

12 weeks pregnant, Alicia Peterson aged 28, presented to the hospital complaining of
vaginal bleeding. She is here for her antenatal check-up.
Your nurse colleague examined her and found no visible bleeding in her vagina. Ultrasound
shows viable 12-week pregnancy. Examination results were also normal. Your nurse
colleague noticed a fingerprint like bruise on her right wrist but she did not disclose it to the
patient.
Please talk to the patient, review the patient, do necessary management and address her
concerns.

P: I am worried for my baby.
D: I do have a good news for you. We did an examination and ultrasound and your baby is
fine and there is nothing to worry about.
P: Thank you so much.
D: Could you please tell me why you are so worried?
P: I noticed some bleeding from my front passage this morning and I got scared.
D: Let me ask you a few question about your pregnancy. Could you please confirm the age
of pregnancy?
P: I’m 12 weeks pregnant.
D: How has been your pregnancy so far?
P: It has been fine.
D: Did you have any complication?
P: No.
D: Any previous pregnancy?
P: I have a 3-year-old daughter
D: Do you have any medication conditions?
P: No
P: No doctor
D: Are you taking any blood thinners?
P: No
D: My nurse colleague who examined you told that there was no bleeding from your front
passage.
P: It was just a little (Patient remains silent at this point)
Keep Offering confidentiality, Go slow, Give pauses, Show sympathy. Ask general
questions.
D: Is there anything you would like to tell me?
Whatever you will say will remain confidential. It will remain between you and my team.
P:
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D: While examining you my nurse colleague noticed some bruises on your right wrist. What
happened to your wrist?
P: I banged my arm to the wall.
P: A few days ago.
D: May I have a look at your wrist?
Examination: When you look at the bruise, there is a thumb

Sometimes she will not show her hand.
D: This bruise doesn’t look like that you banged your hand into the wall. It looks like
someone have applied force as my nurse colleague noticed a fingerprint on your wrist.
PAUSE.
Please feel free to talk to me. I am here to help you and whatever you will remain
confidential.
D: Whom do you live?

P: My partner and my three-year old daughter.
P: For about 7 years doctor
D: Is everything alright at home?
P: Yes
D: How is your relationship with your partner?
P: I lied to you, there was no bleeding. The truth is that, my partner kicked me in my tummy
this morning and that's why I got worried and came to the hospital to see if my baby is fine.
D: This is completely illegal. You don't need to put up with this.
This is not your fault, please don’t blame yourself. (If she is blaming herself)
HARK: Ask if she is not talking at all.

Humiliation: Does your partner make you feel bad about yourself?
Afraid: Are you afraid of your partner?
Rape: Did your partner force you to make sexual relation w ith you when you don’t want?
Kick: Have you been physically hurt by your partner?
D: Has it happened before as well?

P: Yes doctor, it is not the first time it happened before as well.
D: Does he have any mental health problems?
P: No
D: Was he under the influence of alcohol or drugs when he hit you?
P: No
735
D: Does he have any criminal record?
P: No
D: Is your partner is the biological father of your daughter.
P: Yes.
D: Has your partner ever hurt your daughter?
P: He loves Janny.
D: Has he ever hit you in front of your daughter?
P: No.
D: Have you ever done anything for this problem
P: No
D: Do you have any other family member li
P: My mom lives nearby.
D: How is your relationship with your mom?
P: It is OK. We don't talk that much.
P: I am a housewife.
P: Not really
D: As you told me, you have been kicked by your partner a few times. You are pregnant and
you have a daughter living with you. Don’t you think it is not a safe living with him? There
are some ways that we can help and support you. There is a designated person in the
hospital who deals with these issues. We can arrange a meeting with that person. He will
explain about the sendee
available to support you and your children.
Don’t worry. My colleague will refer you to an organization(MARAC) (A Multi Agency Risk
Assessment Conference) and they will support you financially, deal with your housing
problem, they can provide you and your children a safety plan. The police will be involved if
necessary.
No one will separate the child. They will look after you and your baby. They will make sure
that you and your child are safe.
If patient still says I want to go home:
D: You can take decision for yourself but as you pregnant, we have got some duties
towards your unborn child. I have to talk to my senior regarding your case.
736
INSOMNIA DOMESTIC VIOLENCE
You are an F2 in medicine.

Eleena aged, 32 came to the hospital with insomnia.
Talk to the patient and address her concern.

P: I have trouble sleeping.
D: Please tell me more about it
P: What do you want to know.
P: It started few months ago.
P: I have trouble in going to sleep.
D: What time you go to bed?
P: I go to bed around 10.
D: What time you usually go to sleep?
P: I go to sleep around 2 am. Sometimes I don’ t sleep whole night.
P: No
P: It was fine.
P: No
D: Anything else?
P: No
P: No
D: Tell me what do you do before you go to the bed?
P:
Patient is anxious and shaking too much in the station. We need to make her comfortable.
After that she will open up
D: Are you comfortable? Or anything bothering you?
P: Is this conversation confidential?
D: Yes, it is confidential.
P: I am having problem with my husband.
P: He got violent with me.
P: It happened few days ago.
737
P: No. this has happened many times.
P:
D: Does he have any mental health problems?
P: No
P: No
P: No
D: Is there anyone else in the family?
P: No
D: Any relative nearby?
P: No
P: It is okay
D: Could you please score the mood on a scale of 1 to 10, where 1 is lowest and 10 being the
highest.
P: It is average dr.
P: I work in landscape.
P: I have few friends around.
D: Did you discuss it with them?
P: No
Ask about
Tea, coffee? How much? When you take last cup?
Smoking. Alcohol. Recreational drug, stress. Watching TV etc.
Noisy environment
D: Do you think your sleeping problems are because of this ongoing issue with your
husband?
P: Yes. I think so.
D: The incident you told me is completely illegal. You don’t need to put up with this. There
are some ways that we can help and support you. There is a designated person in the
hospital who deals with these issues. We can arrange a meeting with that person. He will
explain about the service available.
Don’t worry. My colleague will refer you to an organization (MARAC) (A Multi Agency Risk
Assessment Conference) and they will support you.
P: I am afraid to go home.
D: The police will be involved, you don’t have to worry about anything.
738
DOMESTIC VIOLENCE (BURN) – SEX TRAFFICKING

Emma, 20-year-old girl came because of scaled burn on her tummy.
Wound has been managed by the nurse.
History:
(In this situation, patient will be anxious and worried. She won't open up easily as well so
keep convincing and supporting her, acknowledge nonverbal cues)
D: Hello how can I help you?

P: I am burnt
D: I am sorry to hear about that, nurse has checked on your wound. How are you feeling
now?
P: Ok
D: How did you get the burn?
P: Kettle dropped on me.
D: How?
P: It was an accident.
D: Is it the first time it happened?
P: Yes
D: I can see that something is bothering you. I want to assure you are in the right and safe
place Emma. If there is anything you want to talk about, I am here to listen and help you as
much as I can.
P: No.
D: Emma, I can see you are quite worried. If you tell me what is bothering you, maybe I will
be able to help you out and ease your worry.
P: No doctor, it's nothing.
D: Emma if you want to talk to me about anything, I assure you it will be a conversation that
stays between you and our medical team until your safety is concerned.
P: Doctor, I don't know how to tell you this.
D: It's okay Emma, sometimes it can be difficult to talk about certain things, take your time, I
am here with you.
P: Doctor it was not the kettle, it was this man who is not good to me, he did this to me.
D: I can't even imagine Emma what you must be going through at the moment, but I am
really glad that you opened up to me and let me tell you, you are very brave Emma. Can you
tell me a bit more of what happened, so that I can understand your position better Emma.
P: I don't know doctor where to start but I don't want to go back with that man.
D: That's okay Emma, you are in the hospital with us and we will not let you go back with
him again if you are not comfortable with it. Can you tell me a bit more about this man.
P: I don't know his name, but he has me and few other girls in the apartment.
739
D: Alright, I see Emma this must have been so scary for you. Can you tell me where are you
living?
P: In a house with 2 girls
D: How are those girls?
P: Fine
D: Since when you are living with him and do you remember how this started?
Do you remember the address where you are living Emma?
Has he ever hurt you physically before this?
Has he ever forced you into sexual activity Emma?
Have you ever tried to take help before or to escape?
P: No
D: Do you have any family in town?
D: I need to ask you certain questions about your health now, will that be okay?
D: Do you have any health problems?
P: No
D: Are you using any medications?
P: No
P: Nothing.
D: Whatever has happened Emma, to my understanding from what you have told me is
absolutely wrong. And you have been very brave by telling me this Emma. I assure you I will
not let you go with this man again. This should never happen to anyone, and I am going to
help you get out of this situation.
However, to do so we have to involve the police, so that we can not only save you but also
save the other girls that have been captured by him.
P: Doctor, I am scared of the police.
D: Why is that?
P: What if the police fail, he will kill me or take me back.
D: Emma I assure you the police will handle this situation correctly and we will make sure
you live a safe and healthy life now onwards.
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

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?
740
 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.
SCENARIO 2
Miss Ella Jackson, 18-year-old, came in because of scalded injury on her tummy. Nurse has
seen the patient and have done the dressing.
Talk to her and manage her condition and address her concerns.

P: I am burnt
P: Like what?
D: Where have you gotten burnt?
P: I don’t know/burnt my tummy
D: Is there anything you would like to tell me?
P: What would like to know?
P: In the morning.
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P: No, my landlord was there.
D: What did you get burnt with?
P: Hot water
D: Did you try treating it yourself before you came here?
P: I ran it under cold water
P: My landlord
D: Where do you live?
P: I live in a hostel with other girls.
P: No
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: I live with other girls in the apartment.
D: Do you work currently?
P: Yes, I am a waitress.
HARK: Ask if she is not talking at all.
Humiliation: Does your landlord make you feel bad about yourself?
Afraid: Are you afraid of your landlord?
Rape: Did your landlord force you to make sexual relation with you when you don’t want?
Kick: Have you been physically hurt by your landlord?
D: Did he try to hurt you?
P: Yes
D: This is completely illegal. You don’t need to put up with this.
Has an episode like this happened before as well?
P: Yes
D: Does your landlord have any mental health problems?
P: I don’t know
P: I don’t know
742
P: No
D: Has your landlord ever hurt other girls?
P: Yes
D: Has he ever hit you in front of other girls?
P: Yes
D: Have you ever done anything for this problem?
P: No
D: Do you have any other family members living nearby?
P: No
P: Not really
P: I don’t want to go with him, with this man who is taking care of us.
You have mentioned your landlord has been physically abusive towards you and your
flatmates. I believe it is not safe living with him. There are some ways that we can help and
support you. There is a designated person in the hospital who deals with these issues.
We can arrange a meeting with that person. He will explain about the service available.
Don’t worry.
My colleague will refer you to an organization (MARAC) (A Multi Agency Risk Assessment
Conference) and they will support you financially, deal with your housing problem. The
police will be involved if necessary.
743
CANCER WITHHOLD
You are an F2 in Surgery Dept.

Mrs. Maria Ali aged, 78 presented to the hospital with confusion due to chest infection.
Investigations including CT scan has been done and the diagnosis of bowel cancer has been
made. Your consultant decided to talk to her daughter instead, to explain her mother’s
condition since the patient was confused. Her son, Mr. Mohammed Ali was not present at
that time. He has come to the hospital to talk to the consultant urgently. The consultant is
not available. He told the nurse that he doesn't want anyone to talk to his mother about her
cancer.
Please talk to Mr. Mohammed Ali and address his concerns.
Consent has been taken from Mrs. Maria to talk to her son. Diagnosis hasn 't been disclosed
to the patient yet. Patient has been assessed and has full mental capacity now.
Doctor: How may I help you?

Muhammad Ali: Doctor your consultant spoke to my sister and told her that my mom has got
cancer. Please don’t tell her that she has cancer.
Doctor: I am so sorry to know about the diagnosis of your mother. I can understand it is very
tough time for you and for your family, but may I know why don’t you want us to tell her?
Muhammad Ali: It will be very devastating for her if she came to know about her condition.
Doctor: I totally understand your concern. But as you know it is your mother s right to know
about her condition. Recently she was diagnosed with cancer so we need to do further
investigations and then we have come up with a treatment plan for her. She w ill ask us why
we are doing all these tests then we have to explain it to her.
Muhammad Ali: Doctor She is old and weak. She won’t be able to digest the news that she has
got cancer.
Doctor: I can imagine what you are going through. We will handle this conversation in a
sensitive manner. We will break the news in layers. First of all we will ask her if she w ants
to know about her condition or not. if she wants to know then how much she wants to
know. We will give her some time so that she can absorb the news.
Muhammad Ali: Doctor. I'm her son/I know her better than anyone. Please don’t tell her I am
the head of the family. I take all the decisions for her.
D: Muhammad Ali is there any particular reason that you don’t want us to tell her about her
condition?
Muhammad Ali: Dr. my dad had cancer and he died because of cancer 3 years ago and my
mom was the one looking after him. She has seen all the sufferings that my father had. That's
why I am telling you please don’t tell her about her condition.
D: I am so sorry for your loss. My deepest condolence is with you. As you told me that your
dad had cancer and she was the one looking after him. Don’t you think sooner or later she
will come to know about her illness. At that time she will not trust anyone. She will not trust
you she will not trust us and no treatment will be effective on her.
744
Muhammad Ali: Dr. she is very simple lady, tell her that she has infection and treat her for the
cancer.
Dr: Muhammad Ali the treatment for the cancer and infections are different. Soon she will
come to know that she is suffering from cancer as she knows about the symptoms of cancer
because she was taking care of your father.
Muhammad Ali: Ok dr. Just don't use the word cancer in front of her as I mentioned she knows
about this word.
D: What we can use instead of cancer. There are words like tumour or growth but these are
medical words and she may not understand these words. It can be misleading to her if we
will use these words. She has got full mental capacity, we have to tell her that she has got
cancer so that we can discuss further plan of management with her.
Muhammad Ali: Dr. she doesn't understand English.
D: Don’t worry we will arrange an interpreter for your mom. so that is not an issue.
Muhammad Ali: Can I be an interpreter?
D: Muhammad Ali we have specialist in this field those who know how to tell the
information to our patient. I am so sorry you cannot be our interpreter
Muhammad Ali: Can I be there while you are talking to my mom?
D: Yes of course you can be with us when we will be talking to your mom. if she wants. As
long as she is happy we don't have any problem to have you on her side.
Muhammad Ali: Doctor. Can I interrupt you while you are talking to my mom about her
condition?
Doctor: May I know why do you want to interrupt us. as it won't be appropriate?
Muhammad Ali: Because I know my mom. may be you tell her something that will hurt her
sentiments.
Doctor: I know you know your mom better than anyone and I would say it would be helpful
if you can talk to us now regarding anything which might be useful for us. But I don't think
so it would be appropriate to interrupt us while we are talking to your mom and discussing
her condition.
Muhammad Ali: Okay Doctor, thank you!
745
END OF LIFE CARE…DNAR
You are F2 in Genera! Medicine

Mr. Arthur aged, 75 presented to the hospital with symptoms of severe pneumonia
yesterday.
The consultant advised to take IV antibiotics and he has been receiving it since admission.
Patient had triple bypass graft (CABG). Patient health has been declining last 2years since he
has developed heart failure 2 years ago for which he has been taking medications
Please talk to the patient. Explore the patient’s thoughts and assess whether the patient
knows the implications of his decisions.
Patient is sitting on a couch with an IV cannula in his hand and looks calm

P: I had a chest infection and I was admitted to the hospital and was given IV antibiotics. This
is the 4th time I am here because of this chest infection. I am also taking so my heart and I
don’t want to continue with those medications
D: Which medication you are talking about?
He will give you a slip of paper:
Aspirin, Bisoprolol, Atorvastatin, Ramipril, Clopidogrel
D: Why are you taking these medications?
P: I had a heart operation 15 years ago but in the last two years, I developed heart failure and
my health has deteriorated.
D: Why don’t you want to take this medication?
P: I am taking all of it regularly but I have many symptoms. I can’t do any activity. After
walking a few steps I get tired and I can’t sleep these days.
D: Since when you have been like this?
P: It started recently.
D: So. most probably it is not because of the medication and we can review your
medications. If
you don't take the medication you might become worse.
P: I don’t want to take it.
D: Do you know the implications of not using the medication?
P: Yes/No then explain.
Aspirin ( It helps to prevent complications like stroke and heart attack).
Bisoprolol (It will reduce the strain on your heart).
Atorvastatin (it will prevent the bad fat in your body ).
Ramipril (It will prevent your heart from changes its shape (remodeling).
Clopidogrel (It helps to prevent complications like stroke and heart attack)
P: I believe you but I don't want to take the medication. I have made up my mind/ Sometimes
patient says I will think about it.
D: Why?
746
P: Dr. I am tired. I am fed up. I don’t want to take it because it doesn't work and I know what is
going on. I think my time has come and people with my condition don't live for very long. I
can’t go out because I get tired. I have to stay at the home all the time.
D: I can tell my colleagues occupational therapist’s, they can come and assess you at your
home. May be they can make some arrangements for you.
P: No. dr. All I am doing is watching TV and solving crosswords. Is this life?
My wife passed away and so did my friend who I played cards with. I feel lonely. My daughter
lives nearby and she has RA which has made her cripple so she can’t visit me. I can't enjoy
being with her because I feel tired and sleepy. I have already enjoyed my life, I am old and I am
ready to go.
D: I can imagine what you been through. Ageing is not an illness, but it is challenging
sometimes. A lot of person of your age are living a healthy life. We have many organizations
like Age UK where we provide services and support.
P: No dr I have made my mind.
P: yes. I want to sign a legal form and if my is 1 don't want you to get me back to life.
D: Why?
P: I am not happy about the quality' of my life. I want to die normally. I don't want an artificial
life. I saw how they do it. it looks painful and I want to die with dignity
D: I totally understand your situation but do you know the implication of the decision?
P: I will die peacefully.
D: This is a very big decision, do you want to discuss it anyone in your family. You mentioned
about your daughter?
P: No. I make my own decisions. I will tell her after signing the form else she will ask me not to
do it. I don't want to change my mind in this way.
P: My mood has been fine. I am not suicidal. I am making an informed decision.
D: Okay, I will talk to my senior and I will make arrangements for your request to be
fulfilled. But at any point of time if you want to change your decision, you can do that just
let us know.
Sympathy and empathy to the patient. This patient will talk a lot so please don’t interrupt
him, let him talk.
Don’t forget to take social history in this station if he doesn’t tell you.
Age UK offers two different types of befriending services:

• Face-to-face befriending: where a volunteer befriender visits an older person in their
home, perhaps for a cup of tea and a chat, or accompanies them to an activity (such as a
trip to a cafe or the theatre). In some cases, a volunteer may accompany the older person
to occasional hospital or doctor's appointments.
• Telephone befriending: where a volunteer befriender will phone an older person at an
agreed time for a chat.
747
MS (DNAR)
You are F2 in General Medicine

Mrs. Pattinson aged 75 has been diagnosed with multiple sclerosis 10 years ago.
Her condition is deteriorating and she is in terminal stage now. Only palliative care is
possible. Patient wants to sign a DNAR form.
Talk to the patient, assess her condition, and do the necessary documentation.

P: I am suffering from multiple sclerosis and I am in terminal stage of it. I was told by the nurse
that you want to talk to me.
D: Could you please tell me for how long you are suffering from this illness?
P: It has been years I am having this disease and now I am having frequent attacks of it.
D: How has it been managed?
P: I am in terminal stage of multiple sclerosis and I am receiving palliative care for that. I am
not happy about the quality of my life. I want to sign a legal form and if my heart stops, I don't
want you to get me back to life. I have discussed it with your nurse colleague and she said that
I have to talk to you regarding do not resuscitate form.
D: I can't even imagine what you been through. May I know why you want to sign that
form?
P: I am fed up because I have to come to the hospital every now and then. I want to die
normally. I don't want an artificial life, I don’t want anyone doing chest compression if my
heart stops.
D: Do you know the implication of the decision?
P: Yes, I will die peacefully. I don't want to live this kind of life.
D: Have you discussed about this decision with your husband as it is a big decision?
P: Yes, I have discussed with him and he understands my situation.
D: Is there anything else that we can do for you?
P: I want to sign the form doctor.
fulfilled. But at any point of time if you want to change your decision, let us know. We can
assess you again.
P: OK Doctor.
Does the Patient have 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
DNA CPR.
748
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).
749
TREATMENT REFUSAL (SCLC)
You are F2 in Oncology.

Mr. Arthur aged 75 has been presented to the hospital with Chest Infection yesterday. The
consultant advised to take IV Antibiotics. The treatment is going well & the consultant is
happy with the results. Patient was receiving chemotherapy for the last 3 years for lung
cancer (small cell lung carcinoma).
Please talk to the patient. Explore the patient’s thoughts and assess whether the patient
knows the implications of his decisions.
Patient is sitting on a couch with an IV cannula in his hand and looks calm.

P: I had a chest infection and I was admitted to the hospital and was given IV antibiotics. This is
the 3rd time I'm here because of this chest infection. I’m also having chemotherapy. I don’t
want to continue with the treatment anymore.
D: May I know why you are having chemotherapy?
P: I am having it for my lung cancer for a few months now.
D: Why do you not want to continue with your chemotherapy?
P: Because of this chemotherapy I have this repeated chest infection and I have to get
admitted regularly. After each session of chemotherapy. I have to get admitted to hospital. Is
this life?
D: We can review your chemotherapy medication. If you don't take the medication, you
might become worse.
P: I don't want to take it.
D: Do you know the implications for not taking chemotherapy?
P: I believe you but I don’t want to take chemotherapy. I have made my mind up.
D: Why?
P: I’m just fed up. I don’t want to continue because the chemotherapy makes me ill. I think my
time has come and people with my condition don't live for very long. I have already enjoyed my
life. I'm old and I’m ready to go. I live alone and my daughter lives nearby and she has RA
which has made her a cripple and she can't visit me.
D: Do you have anyone else in your family?
P: My wife passed away last year. I'm living alone.
D: I can imagine what you been through. Ageing is not an illness and it is challenging
sometimes. A lot of people of your age are living a healthy life. We have many organization
like Age UK where we provide services and support.
P: No Doctor. I have made my mind up.
D: Do you have any other concern?
P: I want to sign the legal form.
P: Yes. I want to sign a legal form and if my heart stops I don't want you to get me back to life.
750
D: Why?
P: I am not happy about the quality of my life. I want to die normally. I don't want an artificial
life. I saw how they do it, it looks painful and I want to die with dignity.
D: I totally understand your situation but do you know the implication of the decision?
P: I will die peacefully.
D: This is a very big decision. Do you want to discuss it with anyone in your family. You
mentioned about your daughter?
P: No. I make my own decisions. I will tell her after signing the form else she will ask me not to
do it. I don’t want to change my mind in this way.
let us know.
Sympathy and empathy to the patient. This patient will talk a lot so please don’t interrupt
him, let him talk.
Don’t forget to take social history in this station if he doesn’t tell you.
Age UK offers two different types of befriending services:

Face-to-face befriending: where a volunteer befriender visits an older person in their home,
perhaps for a cup of tea and a chat, or accompanies them to an activity (such as a trip to a
cafe or the theatre). In some cases, a volunteer may accompany the older person to
occasional hospital or doctor's appointments.
Telephone befriending: where a volunteer befriender will phone an older person at an
agreed
time for a chat.
751
REFUSAL OF BREAST CANCER TREATMENT (TELEPHONIC CONVERSATION)
You are F2 in GP.

Mrs. Samantha May, aged 40, was diagnosed with breast cancer 2 weeks ago. The
multidisciplinary team has discussed the treatment plan with her.
D: How can I help?

P: I don’t want to take the treatment for breast cancer.
D: Could you please tell me when you were diagnosed?
P: 2 weeks ago.
D: How are you feeling?
P: I’m fine.
D: Has any of your symptoms got worse?
P: Yes/No
D: Do you know what stage of breast cancer you have?
P: Early stage
D: Are you on treatment at the moment?
P: They have decided to do the surgery followed by chemotherapy.
P: My husband.
D: Is he supportive?
P: Yes
D: Any other family or friends nearby?
P: Yes/No
D: Why don’t you want to take this treatment?
P: I have read some blogs where patients were mentioning that treatment for breast cancer
has ruined their lives. I am going to die any way.
D: The internet and blogs in particular have tendency to have unauthentic information. We
do extensive research and then treatment guidelines are made by keeping patient’s interest
in mind. In the MDT meeting, all the doctors, nurses and other medical personnel’s including
occupational therapist have discussed your case and thereafter they have decided to treat
you in a particular manner.
P: Okay
D: Do you know the implications of not using the treatment?
D: Breast cancer, if left untreated has the potential to spread to other parts of your body.
You may experience pain, tiredness, and weakness as it progresses if you do not get treated.
Getting treated early on helps control the spread of breast cancer, and it may be difficult to
treat in the later stages.
P: I have heard that I will lose my hair after chemotherapy.
752
D: This is just temporary, after the treatment usually the hair grows back and it will be like
before.
P: Okay. I was told that the doctors will remove my breast. I will feel embarrassed.
D: There is a surgery for reconstruction of breast. If you want, I can book an appointment for
you with the specialist who will discuss in detail about this surgery.
P: I don’t want to take the treatment. I have made up my mind. I am tired. I am fed up. I don’t
want to take it because it doesn’t work, and I know what is going on. I think my time has come
and people with breast cancer don’t live for very long.
D: This is a very big decision, do you want to discuss it with anyone in your family?
P: No, I can take my own decisions.
D: It’s advisable to discuss with family members.
P: I don’t want them to change my mind. I don’t want to suffer through the treatment.
D: I can imagine what you been through. Cancer is a challenging diagnosis, but a lot of
people with breast cancer recover and are living a healthy life. We have many organizations
like Breast Cancer Now and many more where we provide services and support.
P: No Doctor. I have made my mind up.
P: My mood has been fine. I am making an informed decision.
P: No
let us know.
753
INFECTIVE ENDOCARDITIS-DRUG ADDICT
You are F2 in general medical ward.

Mrs. Sally Robins, aged 27, was admitted to the hospital a week ago and the diagnosis of
infective endocarditis has been made. The patient has received her IV antibiotic treatment in
the last 5 days. She needs to receive further antibiotics for a few weeks. She is required to
stay in the hospital in order to receive her IV antibiotics for a few more days. The patient
wants to be self-discharged. Patient has already talked to the nurse and wants to talk to a
doctor. She is an IV drug abuser.
Please talk to the patient, assess the reasons for discharge and address her concerns.
D: Hello there. How can I help you?

P: Finally you are here! Doctor, I just want to go home. I'm feeling much better.
D: I am so glad to hear that. I'm going to ask you some questions and possibly carry out a
quick examination to assess if you are fit to go home.
P: Okay doctor.
D: Firstly, may I know why you came to the hospital?
P: A week ago, I had shortness of breath and chest pain. I decided to come to the hospital.
Later, they looked at me and told me that I have to statin the hospital.
D: Tell me more about your chest pain?
P: I was experiencing this sharp pain here (patient points to left side of her chest).
D: You also mentioned you had some difficulty' breathing. Tell me more about that?
P: It is worse when I'm walking
D: Did you experience any other types of symptoms?
P: Yes. I also had a fever when I checked 2 days ago.
D: Anything else?
P: No.
D: How about now?
P: I'm fine
D: Any chest pain?
P: No
P: No
D: Are you still feeling feverish?
P: Just a little bit
P: No
D: Are you experiencing any shivers?
P: No
P: No
D: Are you taking any medications for anything except this?
754
P: No
D: Has anyone discussed the diagnosis with you?
P: Yes, they told me I have some infection in my heart.
D: May I know what has been done for you so far in the hospital?
P: They did many tests and then gave me antibiotics. They are still giving am already feeling
better.
D: Has anyone mentioned to you for how long you should receive antibiotics?
P: They said for a few weeks. But, I'm already feeling much better now.
D: Like you mentioned, we ran some investigations on you and found that you have a
condition called infective endocarditis. It is an infection of the inner surface of the heart. In
your case, we confirmed that the cause is a bacteria and that is why we have administered
antibiotics to help fight against the bacteria. These antibiotics are most effective when given
directly into a blood vessel and that's why we require you to stay here with us for a little
while longer. Your condition may not improve if you do not receive the full course of
antibiotics. It may also lead to some fatal complications including heart and kidney failure.
P: I can't stay here any longer.
D: Is there any particular reason?
P: I need to smoke a cigarette. The nurses don't allow me to smoke, even in the smoking zone
outside.
D: I do understand your frustration. My colleagues are advising that for your own health and
benefit. Stopping smoking will help develop your immunity and speed up your recovery. At
the same time, we can offer you some help in regards to cutting down and quitting smoking.
We can offer some medication to help reduce your cravings.
P: I don't want any help with that. I just want to be able to smoke.
D: Do you understand what may happen if you continue to smoke?
P: It may delay my recovery. (Retention of information) Are you going to stop me?
D: I strongly recommend not smoking but nobody is going to force you not to smoke.
P: I don't want to stay here any longer because of these nurses.
P: They are rude to me and talking bad things about me. They are behaving strangely.
D: I apologize for that. I will personally look into this matter. I'll have a word with them
immediately to find out what the matter is. If they've done something wrong they will
surely come and apologize to you. Does that sound fine?
P: No. doctor. I still want to leave.
D: Do you understand why we require you to stay in the hospital?
P: To receive my antibiotics. (Retention of information)
D: Do you understand why it's important to receive antibiotics?
P: To help fight against my infection. (Retention of information)
D: Do you understand what will happen if you don't complete the course of antibiotics?
P: My condition may not improve and it may lead to complications.
P: Can I take the antibiotics by mouth instead? That way I will be able to take them at home
D: Unfortunately, the antibiotics may not be able to reach the bacteria if taken this way.
755
Furthermore, we are required to take regular blood samples to monitor how well the
treatment is working. Once we are satisfied with the treatment, you may be able to leave
the hospital and continue some treatment at home.
P: Are you going to stop me from leaving the hospital?
D: I strongly recommend that you stay here while we deliver the best healthcare possible.
We want to see you till you are fit and healthy. However, we will not keep you here against
your own will.
P: I'm a heroin user. I need to take my heroin, (you can ask in PMH if she is taking any
recreational drug as it is given in the question she is an IV drug abuser)
D: May I know how much you take?
P: Usually 2-3 times a day. But since I came to the hospital I've not had it once.
D: For how long have you been taking it?
P: For 5 years now.
D: How do you usually take it?
P: Needle
D: Do you take any other recreational drugs?
P: Currently. I only take heroin.
D: Have you experienced any symptoms due to not having heroin?
P: Like what?
D: Have you experienced symptoms such as agitation, hand shaking, diarrhea, tummy pain?
P: Yes, I feel very anxious and have a tummy ache.
D: I'm sorry for what you are experiencing. We may be able to offer you a substance known
as methadone. This will help you to give up heroin while avoiding these unpleasant
symptoms that you are experiencing.
Sometimes patient is already on Methadone and she doesn’t have these symptoms.
Sometimes patient is already on Methadone and she has these symptoms then we can tell
the
patient that we can increase the dose of Methadone.
D: Are you happy to stay with us in the hospital?
P: I will think about it.
756
WARFARIN-RAT POISON

Mr. Simon Payne aged, 55 has been admitted in the hospital because of shortness of breath
and palpitations. He has been diagnosed with atrial fibrillation. He was commenced on
digoxin and his condition has improved.
He is now supposed to receive warfarin. Your colleague has already talked to the patient
about warfarin. Patient is concerned about warfarin and is not willing to take it. Your
colleague has already assessed patient’s mental capacity. Patient has history of two strokes
in the past.

P: I don't want to take this rat poison. I have been prescribed warfarin and I don't want to take
it.
D: Why you don't want to take warfarin?
P: Doctor. My dad had a heart condition and he was given warfarin. One day, he hit his head,
started bleeding in his brain and died.
D: I’m so sorry about your dad. Could you please tell me what brought you to the hospital?
P: Doctor, I was having shortness of breath and heart racing So I came to the hospital.
D: When did you come to the hospital?
P: A week ago.
D: Have you been told about your condition?
P: They told me 1 have irregular heartbeat, what you call AF.
D: How has your condition been managed?
P: They gave me some med called digo... .digo....
D: Digoxin.
P: Yes doctor.
D: Have you been prescribed any other medication?
P: Yes doctor, I was given warfarin but as I said I don't want to take it.
P: I’m perfectly okay.
D: Do you have any symptoms?
P: No.
D: By any chance any heart racing? Any dizziness? Any shortness of breath? Any chest
tightness?
P: No.
P: I have high blood pressure and 2 strokes in the past.
P: Doctor, they gave me some medications.
D: May I know which medications?
757
P: Patient will give you a piece of paper.
Statin. Aspirin. Amlodipine. Ramipril.
D: How stroke has affected your life?
P:
D: Do you know what warfarin is?
P: Yes. it's a blood thinner.
D: Do you know why you should take it?
P: Like I said. I had two episodes of stroke in the past. They said I need warfarin to prevent any
further stroke.
D: Yes, you are right. Warfarin prevents formation of blood clot and can protect you from
any
further stroke. Do you know what happens if
P: Yes. I may have another stroke.
D: You are highly at risk of having another stroke as you already had 2 episodes of stroke,
you also have high blood pressure. You have been also diagnosed with irregular heartbeat.
Having these condition increases the risk of a stroke. Warfarin prevents formation of blood
clots by reducing the thickness of the blood to prevent strokes from happening again.
P: But I am already taking aspirin. That’s a blood thinner, isn't it? Don't you think if I start
taking warfarin I will start bleeding and die like my father?
D: One of the side effects of warfarin is an increased risk of bleeding. But we will be doing
regular blood tests and prescribe warfarin accordingly. So your blood won't become too thin
to increase the risk of bleeding in your brain.
P: But I don’t want what happened to my dad. happens to me!
D: I can imagine where you are coming from. But, you might have another stroke if you
don’t receive appropriate treatment The injury to the brain caused by stroke can lead to
long lasting problems, people who have stroke need long-term support and many never
fully recover and need support lifelong. I am sure you don’t want this happen to you.
P: But doctor, what if I have a fall?
D: You need to come to the emergency department if you had a fall and had a head trauma,
or if you were involved in any major trauma or if you experienced an unusual headache. If
any of these happens we will do a CT scan of your brain in order to give you the best
treatment if needed.
P: Okay, but what about my digoxin? Can that have any side effect if given with warfarin?
D: Don't worry, that combination is safe to give.
It is very important to take this medicine regularly everyday if you will not take it regularly
then your blood can become thick and can cause more strokes. You have to take this
medicine daily on the same time.
If patient is not convinced then say I will talk to my senior.
Patient has the right to refuse the medication.
758
HERBAL MEDICATION
You are F2 in Paediatrics.

Jazllyn aged 15 months diagnosed with neuroblastoma abdomen has been admitted to the
hospital with neutropenic sepsis. Few nurse colleagues noticed that mother Mrs. Devoine is
feeding green fluid to the child and they want you to speak to the mother.
Talk to the mother and address her concerns.

P: Your nurse colleague told me that you are going to talk to me.
D: Yes, I am here to talk to you about your child’ s health. Let me ask you a few questions.
P: Ok
D: Why have you brought your child to the hospital?
P: She was diagnosed with neuroblastoma and recently she developed fever. So I brought her
to the hospital.
D: How is she now?
P: She is fine now.
D: Any fever, flu or cough?
P: No
D: Any rash?
P: No
D: What treatment is she getting in the hospital?
P: She is being treated with antibiotics.
P: Normal vaginal delivery.
D: Are you happy with red book?
P: Yes
P: Yes
P: Yes
D: Does she have any problem with her wee and poo?
P: No
D: Has she been diagnosed with any other medical conditions in the past?
P: No
D: Is she taking any other medication’ s including OTC or supplements?
P: I' m giving herbal medication
D: May I know why are you giving to her?
P: This is very good medicine and one of my friends who had breast cancer got better by using
this.
D: May I know for how long you have been giving this medication to your child?
P: I am giving her for last 3 months.
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D: How many times you are giving this medication to your child?
P: 3 times a day
D: May I know from where you got that medicine?
P: My friend gave it to me.
D: Do you know what is there in it?
P: I don’ t know. But I know my friend got better after using it.
D: Are you aware of what chemicals are there in the medication?
P: No Doctor, but I know all herbal medications are safe.
D: I can see that you are so much concerned about your child. But. this medication can have
interaction with the medication we are giving to your child in the hospital and can have
some bad effects to her body.
P: Like what?
D: It can have bad effects on the organs of our body. It can affect mainly her liver.
P: I am not happy with the modern medication and herbal medications are natural so there will
not be any interaction.
D: Herbal medications do have chemicals in it which can have interaction w ith the
medication we are giving to your child. Our all the protocols are based on regulated
medications, so we use only those medicine on which our protocols are been made.
P: but I have to give her this herbal medication.
D: I understand your concern. As I have already mentioned, This can affect her badly, so it is
advisable not to use any of the medications which are not regulated. A team of doctors are
looking after the child. It is advisable to always consult with the doctor regarding additional
medication.
P: But I am thinking it is helping her.
D: Her condition is improving slowly. All the medicines take some time to show its effect. It
is advisable to always consult with the doctor regarding additional medication
P: I didn’t know about all this otherwise I wouldn’t have given her the medications.
D: Ok don’ t worry we are looking after you child and we are giving her the best possible
care in the hospital. If you have any doubt about the medications you can always come and
speak to us.
P: I wanted to help my child that is why I was giving this medication to my child.
D: I understand your concern, we also want to give the best treatment for your daughter. I
will talk to my ward manager and senior, they will come and speak to you and we can
arrange some blood test or some other tests to check interactions of the herbal medication
with the treatment we are giving in the hospital.
P: Ok
D: If you have any concern please let us know, we are here to help you I can imagine you are
going through rough time, but we are doing our best to do the best for your child.
Some possible drug interactions:

1. Ginkgo can interact with Omeprazole and Blood thinners.
2. Garlic can interact with blood thinner like aspirin.
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3. Green tea contains vitamin K can interact with blood thinners.
4. Kava can interact with of buprenorphine.
5. St. John’s wort can interact
761
DEMENTIA
You are F2 working in Neurology.

Mrs. Parker aged, 78 has been admitted to hospital because of weight loss.
She has been suffering from dementia in the last 3 years and she has not been taking any
food properly, recently. All the investigations including blood test, ECG, X-ray, ultrasound,
and CT scan of abdomen are normal. Patient has been given some fluid and she is able to
tolerate a hit now. It has been decided that invasive and aggressive management is not
appropriate.
Palliative care has been decided by the consultant. She was very weak on admission but she
has been medically managed.
Please talk to her daughter, Mrs. Parker, take relevant history, assess her condition, explain
her mother’s present health status, discuss about further plan of management and address
her concerns.
Patient is not available to talk. Consent was taken from patient to talk to the daughter. The
weight loss is only due to dementia.
Dementia:
Dementia is a condition associated with an on-going decline of brain and its ability. It is
caused by gradual change and damage to the brain
D: Hello lam ... .How are you?

P: lam fine I want to know how is my mother?
D: I am here to talk to you about your mother’s condition. Tell me how much do you
understand about your mother condition?
P: She has been diagnosed with dementia. Her condition is becoming worse now. Initially she
was eating and drinking, but now she is not eating or drinking anything. Now she is losing
weight as well.
D: As you told me your mother was admitted in the hospital because of weight loss and she
was not eating or drinking properly. We did some investigations such as blood test. X-ray.
Ultrasound and CT scan to see if the is any abnormality inside of her body, and fortunately
all the test results came back normal. This means that she has not got any other medical
problem presently causing her weight loss. The cause of her weight loss is only Dementia
which we already know about.
P: But why she is not eating?
D: Dementia can present with various symptoms. Some of them are memory problem,
eating problem and weight loss. This is just a progression of her Dementia to a stage where
we cannot do anything about it. Our goals of treatment have changed from treating her
actively to keeping her comfortable now.
The person should be supported to eat and drink for as long as they show an interest and
can do so safely.
Our nurse colleague tried to give her some liquids and she was tolerating that.
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P: Are you going to keep her in the hospital or ITU?
D: She is medically fit at the moment. People with dementia during the later stages are less
likely to get benefits from hospital. In the hospital, they become more prone for some
infections.
Do you still think that she should stay here?
P: Doctor. Are you going to give her NG feeding?
D: Yes we can give her food through the tube but our team of doctors assessed her and
decided not to give any aggressive treatment to her. As NG tube is only a short term
solution and it has got own risks. Patients usually feel uncomfortable and they try to pull out
the tube which can lead to further injuries. This also increases the risk of choking and
increases the chances of food or saliva going down the windpipe which can cause infection.
P: How will I be able to feed her at home?
D: We can make an appointment for you with a dietitian or speech and language therapist
professional which can be helpful in such cases. We can involve the palliative care team who
can help her stay comfortable. We can provide you with support at home so that you can
take care of your mother. Also Dementia nurses can come to your house who know about
the condition and it's symptoms, to help you and your mother
From your side what you can do is give her plenty of time to eat and remind her to chew and
swallow carefully. Eat with her as research suggests that people eat better when they are in
the company of others. Give her small and frequent meals. Sen e meals in quiet
surroundings, away from the television and other distractions. You can always put the drink
in their hand if they are struggling to see it and also changing the consistency of food and
drinks can be helpful, (for example serving it in liquid or puree form).
Always take care of oral health as it will have an impact on the ability to eat and
communicate. If the person has poor oral health it can lead to pain, which could mean they
don’t want to eat or they may behave out of character.
D: May I know who looks after her?
P: lam the main carer.
P: I have left my job, I am taking care of my mother.
D: Do you get any support for her dementia?
P: No.
D: Has she made her wishes known regarding care in their later stages?
P:
D: We are here to help you and w e have got a lot of options for your mom. A care plan will
be prepared by the medical team for your mother.
D: If you want to know the options, I am more than happy to explain them to you. If the
daughter says Yes, then explain the options.
1) Provide all necessary' care at home, e.g. if patients needs any help like carers, we can
provide them that can help you in looking after your mother. There are some community
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services which we can offer such as dementia specialist nurses that can come home and help
you and your mother in taking care of her.
2) There is an option of sending patients out of the home to meet all the needs such as day
care center (where you can send your mum where she can get the necessary care and you
can get her back home in the evening).
3) There is another option of sending patients out of the home to meet all the needs such as
a care home.
764
DEMENTIA MOTHER

Mrs. Elena Petrovitch, 80 years old, was diagnosed with dementia 3 years ago. Patient is a
diagnosed case of hypothyroidism taking thyroxine. Patient is taking Amlodipine for the
high blood pressure. Daughter is concerned about the deteriorating health of the mother. All
the blood tests are done and are normal.
Talk to the daughter and address her concerns.

P: I was expecting your call.
D: May I know what exactly happened?
P: It is about my mother, when I came home, I saw her faeces in the room.
P: Like what?
D: Is this the first time it has happened?
P: Yes
D: Has she complained of incontinence?
P: No
D: Has she had trouble with her wee?
P: No
P: She keeps on talking about her childhood.
D: When did this start?
P: Couple of months ago.
D: Has she been doing this continuously or do these episodes come and go?
P: Continuous
P: No
D: Does she have anything else associated with this?
P: Sometimes she thinks I am her mom.
D: Did this start at the same time as well?
P: Yes
D: Does she have trouble maintaining conversations?
P: Yes
D: Is she able to remember things?
P: No
D: Is she more anxious or scared?
P: Yes/No
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P: Yes, dementia, hypothyroidism and high blood pressure
D: How are they managed?
P: She takes thyroxine and amlodipine
D: Is she taking it regularly?
P: Yes
D: Is she taking any other medications including OTC or supplements?
P: No
P: No
P: No
P: No
D: Does she smoke?
P: No
P: Occasionally
D: Tell me about her diet?
P: She eats a healthy diet
D: Does she have any bowel/urinary problems?
P: No
D: Is she physically active?
P: Yes
D: Is she able to do her daily chores?
P: Yes
I would like to check her vitals, do a GPE and perform a neurological examination.
From our assessment, it seems that unfortunately, your mother seems to have developed
more concerning symptoms of dementia. The symptoms of dementia usually become worse
over time. In the late stage of dementia, people will not be able to take care of themselves
and may lose their ability to communicate.
As symptoms get worse, the person may feel anxious, stressed and scared at not being able
to remember things, follow conversations or concentrate.
It’s important to support the person to maintain skills, abilities and an active social life. This
can also help how they feel about themselves.
As you mentioned there was faeces in her room, people with dementia may often
experience problems with going to the toilet.
Both urinary incontinence and bowel incontinence can be difficult to deal with. It can also
be very upsetting for the person you care for and for you.
Problems can b e caused by:
766
 Urinary tract infections (UTIs)
 Constipation, which can cause added pressure on the bladder
 Some medicines
Sometimes the person with dementia may simply forget they need the toilet or where the
toilet is.
Although it may be hard, it’s important to be understanding about toilet problems. Try to
remember it’s not the person’s fault.
You may also want to try these tips:
 Put a sign on the toilet door – pictures and words work well
 Keep the toilet door open and keep a light on at night, or consider sensor lights
 Look for signs that the person may need the toilet, such as fidgeting or standing up or
down
 Try to keep the person active – a daily walk helps with regular bowel movements
 Try to make going to the toilet part of a regular daily routine
Dementia Nurses: Admiral nurses are registered nurses and experts in dementia care. They
give practical, clinical and emotional support to families living with dementia to improve their
quality of life and help them cope.
Social services:
Carer at home
Day care: Some Age UKs offer specialised dementia day care through our dementia services.
Care homes: As the symptoms of dementia will get worse over time, many people eventually
require3 support in a care home. Depending on their needs, this could be a residential care
home or a nursing home that offers services for people with dementia.
767
ELDERLY ABUSE
You are F2 in A&E.

Mrs. Blake aged, 85 was brought to the hospital by her daughter after having a fall. On
examination there are multiple bruises of different ages on her body.
She has tenderness in her chest.
Please talk to her daughter, Ms. Angela and discuss about your further management plans
with her.
Patient is not available to talk. She has been sent for X-ray. Consent has been taken from the
patient to talk to her daughter.

P: Dr. my mother fell down and I brought her to the hospital. I want to ki
D: You did a right thing that you brought her to the hospital. We have given her pain killer
she is not in the pain at the moment. We have sent her for the X-ray and we are waiting for
the results. Tell me how did she fell?
P: Dr. after changing her clothes I was getting ready for work. Then I heard a bang when I went
there to see what happened. I saw she fell down on the radiator. She told me that she has
some chest soreness I got so worried and I rushed to the hospital immediately.
D: May I know when did this happen?
P: 2 hours ago.
D: Did you notice any other injuries?
P: No
D: We also examined her and we found many bruises on her body. Have you noticed any?
P: She use to fall quite often as she is old and she has dementia. But this time when she told me
that she has some chest soreness I got so worried and I brought her here.
D: Since when she has dementia?
P: 2-3 years ago.
D: How dementia has affected her life?
P: She has become forgetful. She is able to eat properly. Her condition is getting worse.
D: Are you going to her GP regularly?
P: Yes
D: Does she get any dementia related services?
P: No
D: May I know who looks after her?
P: I take care dr.
D: Anyone else in the family?
P: Yes my 2 children.
D: May I know how you cope up with her condition?
P: Doctor, when I am going to work, I leave some food for her. But mostly she doesn’t eat
because of her dementia.
D: Do you work full time?
768
P: Yes dr. I work in an office full time after my husband passed away.
D: what about your kids? Do they help in taking care of her?
P: Not really.
D: How old are they?
P: They are in 20s.
Find other causes of fall:
P: No
P: No.
D: You told me she has dementia. Apart from that any other medical condition?
P: No
D: Any high blood pressure, diabetes, heart disease?
P: No doctor.
D: Any joint or eye problem?
P: No Doctor.
D: any medication including OTC or herbal remedies?
P: No
P: No
D: Any slippery floors?
P: No
D: Does the house has enough light?
P: Yes
D: I would like to check her vitals and examine her chest, heart, tummy.
D: I would like to send for some initial investigations including routine blood test, urine dip
and ECG.
As I have already mentioned that we have already done general physical examination and
we found she has multiple bruises and she had some chest soreness for that we have given
her painkiller and sent her for an X-ray.
I will ask my seniors to come and review your mom and they can do some further tests like
skeletal survey.
You told me you are not receiving any support regarding her dementia.
She needs to be assessed by social sen ices and occupational therapist before you take her
home.
Her future health and social care needs will need to be assessed, and then a care plan will be
created for her. Your local authority can provide social care services for the home so you can
contact them.
Admiral Nurses are NHS specialist dementia nurses who will visit you to give you practical
guidance on accessing services as well as offering emotional support.
Sometimes daughter will say I pushed my mom so we have to involve the social services.
769
Also the presence of multiple bruises on her body points towards elderly abuse.
770
ELDERLY WRIST FRACTURE
You are F2 in surgery.

Mrs. Maria, aged 82, had a wrist fracture on her non-dominant hand after having a fall
three weeks ago. The cast has been placed. She was given a walking aid to help her to be
mobile.
Patient has been assessed and is able to use the walking aid. Patient is lucid. Patient is
willing to be discharged.
All the investigations including all blood tests, urine test, ECG, X-ray and USG are normal.
MDT including physiotherapist, occupational therapist, social services, nurse and doctor are
satisfied that the patient is fit for discharge. She has been planned to come to the fracture
clinic twice per week. “Home to hospital services scheme” has been arranged to visit the
patient twice per week. Her son has got some concerns and wants to talk to you regarding
his mother.
Please talk to the son, Mr. Jackson, and address his concerns.
Mother has given consent to talk to her son.
D: Hello there. What brought you to the hospital?

P: Doctor, my mother had a fall a few weeks ago and you are discharging her now, but I don’t
think it’s the right decision.
D: Firstly. I'm sorry about what happened to your mum. If I may ask, why do you think it’s
not the right decision?
P: She is not fit to leave the hospital. I don't think you have checked her properly.
D: I can assure you that we haven't missed anything. In fact, the healthcare team and myself
have assessed her by carrying out multiple tests and everything came back normal. We are
satisfied with her condition and are confident that she is fit for discharge. I can add that
your mother is also willing to be discharged. I'd be more than glad to explain the
investigations that we have carried out for her.
P: Yes. doctor.
D: Firstly, we carried out the following investigations to identify an underlying medical
cause. We checked her lying and standing blood pressure which came back normal. We took
a full blood count to rule out any anaemia or infection. We also did an X-ray to further rule
out any source of infection. We did an ECG to exclude any type of abnormal heart rhythm.
Fortunately, all the test results have come back normal.
P: So. why did my mother fall?
D: Apart from medical causes, there may be some environmental factors that can cause this
problem. For example, slippery floors, inadequate lighting, unsecured mats and mgs. lack of
non-skid surfaces in bathtubs, among many others. Our occupational therapists have
completed a home hazards assessment and have assisted your mother in recognizing and
addressing certain risks for falls. Our physiotherapists have also helped to improve your
mother's physical abilities so that she can safely perform daily tasks.
P: But what if she falls again?
771
D: I understand your concern. Unfortunately, having a fall at this age is not unusual. Those
over 65 have the highest risk of falling. At this age, muscles and bones simply become weak
and may not be able to support the body weight properly. We've given your mother a
walking-aid to help keep her mobile and she seems to be using it very well.
P: Doctor, she is very old and weak. I think you should keep her in the hospital so you can take
care of her better.
D: I definitely understand your concern, but as I explained earlier, we haven't identified any
medical cause for her fall. Being in the hospital has its own risks such as infection which can
be fatal in elderly patients. We do not advise keeping any patient in the hospital
unnecessarily. We have also identified and addressed all of the environmental factors.
P: What will happen if she falls again?
D: We have taken all necessary precautions to prevent something like this from happening
again. At the same time, our team will continue to keep a regular eye on your mother. We
have arranged for her to follow-up in the fracture clinic twice a week. We have also
arranged for someone to visit her regularly at home to keep her company and also help her
with some errands such as fetching shopping or prescriptions, going to the bank or post
office, accompanying her to social activities, sorting out bills and other paperwork that may
have gathered while your mother was in the hospital.
P: Okay, doctor.
P: Doctor. I am not sure if she can look after herself. Can you talk to my mum and convince her
to go to a care home?
D: May I ask why you feel this way?
P: She is very old and I’m worried about her. I live very far away from her and I can't look after
her. It’s better for her to stay in a care home. She will always have help.
D: I do understand your concern. Have you ever discussed this matter with her?
P: Yes doctor. She is not willing to live in a care home but if you talk to her, she may be
convinced.
D: I understand your concern as a caring son. However, this is a very sensitive matter to be
discussed with an elderly person. For elderly people, moving to a care home is a big decision
to make and sometimes could be heart breaking. It's better not to push them, rather they
should come to such a conclusion by themselves. Also, falls can have a profoundly negative
impact on a person's confidence. They may feel as if they have lost their independence.
That’s why it is not appropriate to offer such an option to your mother at this moment. It
may be better to talk to her regarding this matter in a different setting and time. In the
future, if both of you do come to the conclusion of settling her in a care home, her GP will be
able to offer her all the information and make necessary arrangements.
772
CONCERNED MOTHER OCP
You are F2 in GP.

Mrs. Jordan has arranged an urgent appointment with you to talk about her daughter. Her
daughter Katie is 15 years old. She wants to talk to you since she has some concerns about
her daughter. Husband, mother and daughter have been registered in this clinic for 15 years.
This is the first time you are seeing anyone from the family.
D: Hello Mrs. Xyz, How are you doing?

P: I am fine Dr. I need to talk to you about my daughter.
D: That is fine Mrs. Xyz. I am here to answer all your concerns. Could you please me what is
it?
P: Could you tell me whether you prescribed contraceptive pills to my daughter.
D: May I know what made you think in that way?
P: I found Pills in her room.
D: Okay. Did you talk to her about this?
P: Yes, but she told me that these are her friend s pills and she got angry and left.
D: Is there any tiling that is bothering you?
P: Yes Dr. I want to know if she is having sex or taking the pills at this age. She is just 15.
D: I do understand your concern Mrs. Xyz, but unfortunately we cannot discuss this
information with you. This information is confidential.
P: What do mean by confidentiality?
D: We need to offer confidentiality to young people when we deal with them because it
helps them to come to us and get advice on sexual health. If we don’t offer confidentiality it
may deter them from getting advice and may start having sex without proper knowledge
about it.
P: She is just 15 and is it legal for her to have sex?
D: The legal age to give consent for sex in UK is 16. We also inform young people about the
law for having sex in the UK. Even though they are legally not allowed to have sex, we can
give them advice on sexual health and prescribe them with contraceptive pills because
young people are more likely to begin or continue having sex with or without proper advice.
P: Are you allowed to prescribe contraceptive pills to young people of this age?
D: We are able to give them advice on contraception and sexual health if we feel that they
are competent enough to understand, retain and use the information in order to make a
decision about their care and give consent for their treatment.
P: What if she gets an STI?
D: We deal with the young patients who come to us with carefully. We do assess the
situation by informing them about the risk of sexual activity like STIs, HIV and getting
pregnant.
P: What if she is having sex with an older person?
773
D: We also discuss about their partners to see if there is any age difference between them or
if there is any force, power, money, alcohol or drugs involved.
P: We are religious Catholics and we are not supposed to have sex like this.
D: I do understand your concern as a mom and respect your religious beliefs, but don’t you
think your daughter can make her own way.
P: I failed to raise her as a mom.
D: Please don't blame yourself and I am sure you are a good mom.
P: I just want to know whether she has come here to take the pills or not?
D: I can understand your concern but as I told you that this is a confidential information and
I cannot tell you this. Even if she would have come here I can reassure that our doctors
would have assessed the situation told her the law in relation to the sexual activity , given
advice on sexual health and contraception. They would have also told her about the risks
associated with having sex like STIs. HIV and pregnancy.
We will always encourage our young patients to discuss these matters with their
family/parents. However, we cannot force them to tell their parents or discuss with their
parents without their knowledge.
D: How is her relationship with you?
P: It is fine doctor, but after today. I don't know how things will be.
D: I am sure you know your daughter better than anybody, you can try talking to her
peacefully on another day. she might open up and tell you everything.
Maintaining a young patients confidentiality is very important, however, where there may
be a risk to health, safety or welfare of young person or others, doctor should follow child
protection procedure and the young patients, family should be involved.
If doctors realize that a young patient is in an abusive relationship he can breach the
confidentiality.
The following factors may suggest an abusive relationship:
1. A young person is too immature to understand or give consent.
2. Big differences in the age, maturity or power between sexual partners.
3. A young patients sexual partner has a position of trust.
4. Force, emotional or psychological pressure to engage in sexual activity.
5. Drug or alcohol to influence young patient to engage in sexual activity.
6. If young patients sexual partner is known to the police or children protection agency as
having abusive relationship with children or young people.
774
EMERGENCY CONTRACEPTION
You are F2 in GP.

14 years old Julia came to the clinic. She had unprotected sex and she has some concern.
Please talk to the patient, assess the situation and address her concerns.
D: May I know what brought you to the clinic today?

P: I am here for morning after pill/ emergency contraception.
D: I will talk to you about your health and give you contraception.
P: Ok Dr
D: Could you please tell me the reason for you to ask for emergency coni
P: I had unprotected sex with my boyfriend last night.
D: May I know what’s bothering you?
P: I scared of getting pregnant.
D: Don’t worry I will prescribe you contraception after a few questions
P: Ok Dr
Offer confidentiality when patient is not comfortable and she is not answering
D: May I know since when are you sexually active?
P: Since few weeks
D: Do you use any type of contraception
P: Yes Dr we always use condom.
D: What happened last night?
P: We forgot Dr.
D: Has this ever happened before or did you use emergency contraction before?
P: No
D: Could you tell me about your boyfriend?
P: He is my schoolmate.
D: May I know his age?
P: 15
D: Since when are you in relationship with him?
P: Few weeks
D: How is your relationship?
P: Fine
D: Any other sexual partners?
P: No
P: 2 weeks ago.
P: Yes
D: Any bleeding or discharge between periods?
P: No
D: Any pain or bleeding during or after sex?
775
P: No
D: Do you know the legal age to have sex in UK?
P: Yes/No. 16 years
D: Any idea about the implication of unprotected sexual activity?
P: Yes/No
D: Could you tell me?
P: Pregnancy.
D: You are absolutely right. Do you know you are at risk of sexually transmitted infection,
HIV, physical and emotional stress?
P: Yes
D: Any idea about emergency contraception morning after pill?
P: Yes. It prevents pregnancy after unprotected sex.
D: Yes you are right. How did you come to know about morning after pill?
P: Magazine, newspaper, internet.
P: My parents
D: How is your relationship with them?
P: Fine
D: Do they know this?
P: No
D: May I know why?
P: I don't want them to know.
D: That is okay don't worry about that. What ever we discuss here is confidential, but we do
advice you to discuss this with your parents as you can get some support from them.
P: That is ok Dr. I don't want them to know.
P: No
D: Any sexually transmitted infections or pelvic inflammatory disease?
P: No
P: No
P: No
P: No
D: Do you smoke?
P: No '
P: No '
D: Any recreational drug use?
P: No
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D: Thank you very much for coming to us and answering all my questions. You did the right
thing by coming here. I will prescribe you morning after pill. There are two types of
emergency contraception. Morning after pill and Intrauterine device/ coil which will be
inserted into your uterus. These can be given within 72hrs and 120hrs after having
unprotected sex. Which one would you like me to prescribe for you?
P: Morning after pill Dr.
D: Please make sure you take this pill before 72hrs.
P: Ok Dr.
D: There are different types of contraception available for you if you are having sex
regularly. Do you want me to discuss them with you.
P: No Dr. that’s okay
D: I sincerely advice you to practice safe sex, especially with condoms because other type of
contraception cannot protect you from STIs and HIV. Please discuss with your parents, may
be your mom as they can give you support.
P: Ok thank you.
 D: You might have some side effects like Nausea or vomiting. Dizziness, Fatigue.
Headache, Breast tenderness, Bleeding between periods or heavier menstrual bleeding.
Lower abdominal pain or cramps.
 D: This is an emergency contraceptive pill and should only be taken after you have had
unprotected sex or if the condom broke. It is not a regular contraceptive pill so will not
protect you against future acts of sexual intercourse.
 If you want to have sex, make sure you’re protected. Use a reliable barrier contraceptive
method such as condoms until your next period, even if you use a regular contraceptive
pill.
 D: If you are sick (vomit) within three hours of taking morning after pill tablet, come back
to us we may have to give another tablet to take.
 D: If you miss your next period or you feel that you might be pregnant, please do a
pregnancy test and come back to us.
 If you develop any lower tummy pain, burning sensation during passing urine, any
discharge or
 any lump or swelling around your private parts please come back to us.
Confidentiality:
Before prescribing:
1. Establish a good rapport with the patient and support them as much as possible.
2. Establish the nature of the sexual relationship. Be alert for indications of an abusive
relationship.
3. Explain the physical implications of sexual activity, including pregnancy and sexually
transmitted diseases.
4. Encourage the patient to tell their parents or a trusted adult
Gillick competency:
777
Lord Fraser stated that a doctor could proceed to give advice and treatment:
"provided he is satisfied in the following criteria:
 that the girl (although under the age of 16 years of age) will understand his advice;
 that he cannot persuade her to inform her parents or to allow him to inform the parents
 that she is seeking contraceptive advice;
 that she is very likely to continue having sexual intercourse with or without
contraceptive treatment;
 that unless she receives contraceptive advice or treatment her physical or mental health
or both are likely to suffer;
 that her best interests require him to give her contraceptive advice, treatment or both
without the parental consent.
What are the implications for child protection?

1. Professionals working with children need to consider how to balance children’s rights
and wishes with their responsibility to keep children safe from harm.
2. Underage sexual activity should always be seen as a possible indicator of child sexual
exploitation.
3. Sexual activity with a child under 13 is a criminal offence and should always result in a
child protection referral.
778
CEREBRAL PALSY
You are F2 in A&E.

Mr. Colum, aged 22, who is suffering from cerebral palsy, presented to the hospital with a
bruise on his ankle after having a fall from his wheelchair a few days ago. He was assessed
by the medical team. Examination was done and showed no bony/point tenderness. Your
colleagues decided that there was no clinical indication for an X-ray as it would not have
changed the management plan. He was then discharged with painkillers.
Colum’s father, has now presented to the hospital with some concerns. He is not satisfied
with his son’s treatment.
Please talk to the father, discuss the situation, and address his concerns.
D: Hello there. How can I help you?

P: Doctor. I brought my son to the hospital a few days ago and
D: I'm sorry you feel that way. If you don't mind I'll ask you a few questions first, so I will be
in a better position to address your concern?
P: Okay.
D: May I know why you brought your son to the hospital?
P: Actually my son has cerebral palsy. Two days ago. he fell from his wheelchair and injured his
ankle. I noticed a bruise so I brought him to the hospital.
D: I am so sorry to hear that. How exactly did he fall?
P: He was trying to reach out for something. His wheelchair tripped over and he fell down.
D: That’s terrible. Was he in a lot of pain?
P: Yes, doctor.
D: Did you notice any visible deformity in the ankle?
P: No doctor.
D: When did you bring him to the hospital?
P: Immediately after the fall.
D: Okay, may I ask what was done for your son at the hospital?
P: The doctor had a look at the ankle and decided not to do an X-ray. Instead, he just gave
some painkillers and sent us away.
D: Did the doctor discuss the diagnosis with you?
P: He said something about a soft tissue injury'. That's all.
D: How is your son doing now? Any pain?
P: He is better now.
D: That's great to hear. Is he taking the painkillers regularly, as prescribed?
P: Yes doctor, I make sure of it.
D: Good job. How about the swelling?
P: I think it's less than before.
D: How about the bruise. Is it still there?
P: Yes doctor. It hasn't changed.
D: Is he able to move his ankle/foot?
779
P: Yes
D: Okay. Apart from this injury, how has his general health been?
P: It’s been fine doctor.
D: You mentioned cerebral palsy. Apart from that, does he have an
P: No doctor.
D: How about any blood disorders?
P: No.
D: Is he taking any regular medications?
P: No.
P: No doctor.
D: Any blood disorders in the family?
P: No doctor.
D: Any family history of any me
P: No.
D: May I know who takes care of your son?
P: I do.
D: Is there anyone else to help you with that?
P: I'm the only one who takes care of him. My wife passed away.
D: I am sorry to hear that. I can imagine what you must be going through. By any chance,
does anyone live with you?
P: No.
P: I'm a banker. I work part-time.
D: How do you manage to look after him while you are at work?
P: I send him to the day care facility while I am working.
D: I would like to have a quick look at your son's ankle and perform a musculoskeletal
examination.
Ex: The swelling has gone down. The bruise is still there. All the examinations and results are
the same as what you have in the task.
D: May I know why you aren’t happy with your son's treatment?
P: Your colleague was very quick to send us home. He didn't even tell me how long my son
should take the painkillers for.
D: I am extremely sorry for your experience. I will definitely have a word with my colleague.
We usually advice patients to take painkillers regularly for the first few days, then as
required.
But the good news is that his pain is controlled now. I will confirm with you how much
longer he should take the painkillers for and soon we can stop them completely.
P: I think he treated my son differently because he is disabled.
D: I can reassure you that we treat all our patients equally, regardless of their
circumstances. But may I know why you think so?
780
P: Because in such situations they always do an X-ray. But this doctor didn't even bother to do
one for my child.
D: I understand your concern. We would have carried out an X-ray if there was a strong
suspicion of a fracture. My colleague carried out a complete assessment and examined your
son's ankle and it showed no signs of having a fracture. Unless it's for a real emergency
situation. X-rays should be avoided because their harmful side effects may pose a great
health risk. I can assure you that an X-ray would not have changed our management plan for
your son.
P: So if it's not a fracture, what could it be?
D: As I mentioned, it seems to be a soft tissue injury or more commonly known as an ankle
sprain. It occurs due to stretching or tearing of the ligaments of the ankle. It commonly
occurs when the foot rolls underneath the ankle or leg. much like when your son fell from
his wheelchair.
781
INSOMNIA
You are F2 in GP.

Mrs. Ashley Adams, aged 65, presented to the clinic for assessment. Patient has been
diagnosed with Rheumatoid Arthritis. Patient is on the following medications: Methotrexate
PO 7.5 mg per week, Paracetamol PO up to 8 tablets, Folic acid PO. Her arthritis is under
control and blood levels for methotrexate is normal.
Please talk to patient, take history, do examination, discuss about management with the
patient and address her concern.

P: I have trouble sleeping.
D: please tell me more about it?
P: What do you want to know.
P: I have trouble in going to sleep.
D: What time you go to bed?
P: I go to bed around 10.
D: What time you usually go to sleep?
P: I go to sleep around 2 am. Sometimes I don’t sleep whole night.
P:No
P: It was fine.
P: No (If yes, How many? How long?)
D: Anything else?
P: No
P: My husband passed away 6 months back. But I am managing, he use to encourage me
always.
D: How did he die?
P: He died because of heart attack.
D: Tell me what do you do before you go to the bed?
P: I drink brandy with milk before going to bed.
D: Is it a new habit or old?
P: I am doing it for so long but now it is not helping me.
D: How do you spend your time every day?
782
P: I have recently found a reading club in our local library. I go there every
D: Do you have friends there?
P: No '
D: Do you interact with people there?
P: No
P: I live alone.
D: Do you have any relatives?
P: No (IF yes D: How often do you see them? How is your relationship?
D: How about any friends?
P: I don't have any.
P: It is ok.
D: Could you please score the mood on a scale of 1 to 10. where 1 is lowest and 10 being the
highest.
P: It is average dr.
P: No
P: No
D: How is your joint problem? Are you in pain at the moment?
P: No
D: Are you taking any medications for your joint problem?
P: Yes I am taking.
D: Are you taking it regularly?
P: Yes ’
D: Have you been diagnosed with any other medical condition in the past?
P: No
D: Any asthma?
P: No
P: No
Ask about
Tea, coffee? How much? When you take last cup?
Smoking, Alcohol, Recreational drug, stress, Watching TV etc
Noisy environment
D: I would like to check your vitals and examine your chest and joints.
Do:
• go to bed and wake up at the same time every day - only go to bed when you feel tired
783
• relax at least 1 hour before bed - for example take a bath or read a book
• make sure your bedroom is dark and quiet – for example use thick curtains, blinds, an
eye mask, ear plugs
• regular exercise during the day
• make sure your mattress, pillows and c
Don't
• smoke, drink alcohol, tea or coffee at least 6 hours before going to bed
• eat a big meal late at night
• exercise at least 4 hours before bed
• watch television or use devices right before going to bed - the bright light makes you
more awake
• nap during the day
• drive when you feel sleepy
• Avoid watching clock as it will make you anxious.
Write a list of your worries and any ideas to solve them before going to bed. This may help
you forget about them until the morning.
Keep yourself busy and try to engage in social activities.
If changing your sleeping habits doesn't help, we may be able to refer you for a type of
cognitive behaviour therapy that's specifically designed for people with insomnia.
The aim of CBT is to change unhelpful thoughts and behaviors that may be contributing to
your insomnia. It's an effective treatment for many people and can have long-lasting results.
P: Can you give me sleeping pills?
D: It would be better if you try the lifestyle modification that we have just discussed.
Hopefully your sleeping pattern will be regulated and you wont have any problems. But if
your sleeping problem persists, I will discuss it with my senior and we may consider giving
you sleeping pills.
784
INSOMNIA (CANNABIS USER)
You are an F2 in GP Clinic.

A 40-year-old man came in with sleep disturbance. He is concerned about it and he is
requesting for sleeping pills.

P: Dr. I have problems sleeping.
D: Could you please elaborate what exactly is your problem?
P: I am not able to get to sleep these days
D: I am so sorry to hear. Could you please tell me since when?
P:
D: Is there anything in specific that's disturbing your sleep?
P:
D: Are you having trouble getting to bed or waking up in the middle of your sleep or waking
up early in the morning?
P: Getting to bed
D: What time do you go to bed usually?
P: Around 3-4 am.
D: What time do you wake up?
P: Noon time.
D: What do you do before you go to bed?
P: I play video games
D: Any naps during the day time?
P: No
D: Where do you live?
P:
D: Any airports or train stations nearby?
P:
D: Any kids in the house or any noisy neighbours?
P:
P:
P: Its fine
D: Score 1-10?
P: No
P: No
P: No
785
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: I smoke marijuana (cannabis)
D: Any other drugs?
P: No
D: Any tea/coffee?
P: No
P: I eat everything
D: Do you have any kind of stress or anxiety?
P: I have anxiety Dr.
D: Can you please tell what are you anxious about?
P: I don't know
P:
D: I would like to check your vitals and examine you fully.
I would like to send for some routine investigations.

D: Thank you for answering all my questions, do you have any particular concern before I
proceed.
P: Dr. could you please give me sleeping pills.
(Pt repeatedly asks for sleeping pills).
D: I understand your concern but let me tell you what I found from your history and how to
deal with them.
P: Ok dr.
D: There are few things which we can do together to help with your problem.
D: Firstly, regulating your sleep cycle - Sleeping and waking up at odd times can cause a lot
of disturbance to your sleep. It is very important that you go to bed early and wake up early
to regulate your sleep cycle. It is better you set a time to go to bed and to wake up in the
morning. You said you are playing video games till early morning; it is advisable to stop
786
playing video games till late night and not to do anything just before you go to bed. You can
maintain a sleep diary.
D: Secondly, you said you are anxious, and you are smoking marijuana. Marijuana can have
many ill effects on your health. It can make you anxious and it can disturb your sleep. It is
advisable for you to stop smoking marijuana. We have many services to offer you – Support
groups/Narcotics anonymous group.
P: Can you please give me some sleeping pills?
D: Sleeping pills have their own side effects and can develop dependence. More
importantly, sleeping pills may not work without lifestyle modification. As I mentioned you
earlier, we will try with these simple measures first and then in future if you still need
sleeping pills I will discuss with my seniors and hopefully we can prescribe you.
787
ANKLE SPRAIN
You are F2 in A&E.

Mrs. Price aged, 28 has come to the hospital for her Ankle X-ray result.
She presented to the A & E yesterday because of pain and swelling in her ankle. You talked
to the patient, examined the patient and ordered an X-Ray for the patient yesterday.
Please talk to the patient, explain the X-ray findings, discuss about management and
You can find the X-Ray of ankle in the cubicle. The record of A&E from yesterday is beside
you and in the cubicle.
Ligament (It is strong bands of tissues around joints that connect bones to one another)
D: Hello Mrs. Price. How are you?

P: As you know I fell down and twisted my ankle yesterday. Today I came for my X-ray results.
D: Yes, I have your X-ray results with me. First tell me how you feeling now?
P: I am feeling better.
D: Any pain?
P: Yes
D: Any swelling?
P: Yes
D: Are you able to bear weight?
P: Yes.
D: Are you able to walk?
P: Yes
D: Let me have a quick look at your X-ray.
(Explain both lateral and view) If there is any fracture in the bone, we can see it as a black
line. There is no black line in your X-ray, it means that your X-ray is normal and there is no
fracture in your ankle.
P: What can it be then?
D: From my assessment you have ankle sprain.
P: What is that doctor?
D: A sprained ankle is an injury that occurs when you roll, twist or turn your ankle in an
awkward way. This can stretch or tear the tough bands of tissue (ligaments) that help hold
your ankle bones together. Ligaments help stabilize joints, preventing excessive movement.
Do PRICE and Avoid HARM
P: What are you going to do for me doctor?
P - Painkiller, Protection
R - Rest
I - Ice
C - Compression
E - Elevation
788
H - Heat
A - Alcohol
R - Running
M - Massage
Mostly patient will not allow you to explain PRICE HARM she will interrupt you in between.
P: When can I walk properly?

D: It depends on person to person. It depends on the healing power and the extent of the
injury. Generally, after an ankle sprain you'll probably be able to walk a week or two after
the injury. You may be able to use your ankle fully after six to eight weeks, and you'll
probably be able to return to sporting activities after 8 to 12 weeks.
P: Doctor, I cannot remember what was written in my note. Can you tell me?
D: Yes. it is written that you slipped on the grass while you were going back home.
A and E Note:
A 28-year old Mrs. Price presented to the A & E.
She slipped on grass while walking home and twisted her ankle and fell down.
On examination there was swelling and tenderness on lateral malleolus of her Left Ankle.
She was not able to touch her feet to the ground and she could not bear w eight on her
ankle.
She was also unable to walk.
However, after giving painkiller she could stand and walk but it was painful and she was
limping.
X-Ray has been advised.
P: Doctor, yesterday I was in pain and I was confused. Actually, I twisted my ankle at work. Can
you change the medical note for me doctor?
D: May I know why do you want me to change the notes?
P: I am a single mother, I have 3 children and I am working part time in a school as a cleaner. If
you will change it, then I can get compensation from work.
D: I can’t change because it is illegal.
P: But I was in pain that time and now I am telling you the truth.
D: Ok but as I said I can’t change the notes what I can do is to document what you are telling
me now in your file.
P: Don’t you have kids? I thought it could be just between you and me. I am doing it for my
kids.
D: We cannot change the note. You can see your GP and he can provide you with a medical
certificate. Then you can get sick leave from your employer and you will be paid till the time
you start working.
P: Doctor, I am on zero-contract and I won’t get paid if I will not work.
789
D: If you're on a zero hours contract, you can still get sick pay - you should ask your
employer for it. If they say no, ask them to explain why or you can contact your nearest
Citizens Advice Bureau if you're not happy with their explanation. You can get financial
benefits from the government as well. Your GP will be able to provide you with a medical
certificate and you will be able to apply for benefits.
If you are on permanent contract, you may be able to get sick leave. This means you will be
paid for a certain number of days during a year while you are sick and cannot work. You may
not need to provide any document to your employer for the first few days but if it takes
longer your GP can provide you with a medical certificate.
If you are a resident of the UK and you have a national insurance number, you are entitled
to receive financial help from the government during the time that you are unemployed (Job
Seeker Allowance) and during the period where you are not physically fit to work
(Employment Support Allowance).
This medical certificate issued by GP is called a ‘statement of fitness for social security for
sick pay’.
Employment rights. Everyone employed on a zero hours contract is entitled to statutory

employment rights. There are no exceptions.... Any individual on a zero hours contract who
is a 'worker' will be entitled to at least the National Minimum Wage, paid annual leave, rest
breaks and protection from discrimination.
790
ANGRY PATIENT – CHANGE IV CANNULA
You are F2 in A&E.

Mrs. Sarah River, aged 50, presented to the hospital because of insect bite that happened 48
hours ago. Patient has been diagnosed with cellulitis. Your consultant has seen the patient
and decided to give her IV antibiotics for 24 hours. Patient is upset and wants to talk to you.
Please talk to patient and address her concerns. Doctor Wilson is the FYI who has started her
training recently.
It is important to be a good listener, and show empathy with the individual’s situation.
P: Dr. I was supposed to receive my antibiotics 2 hours ago. but I couldn’t get because my
cannula is blocked. (She will points towards the blocked cannula.)
D: I am really sorry' to hear about that. It should not have happened. I am going to change
your IV Cannula now and will give you your antibiotics. May I know how do you feel now?
P: I am fine now.
D: Any pain at your cannula site?
P: No
D: Do you have pain anywhere else?
P: I don't have any pain. But 1 want to know why this happened to me.
D: I know this is upsetting for you and it wou Id be for anyone. But may I know did you talk
to anyone regarding this?
P: I talked to your nurse colleague and she tried to fix it but she couldn't fix it. She called Dr.
Wilson and dr. Wilson saw my cannula and told me that she was busy with handover at the
moment. She will come and change my cannula. But it is now 2 hours dr. no one turned up.
D: I am really sorry' for what you have been through. Please accept my apology on behalf of
my team. I know it should not have happened. I am glad to know that you are fine now. I
will definitely talk to her to find out what exactly happened and will tell her to come to you
and explain you the whole situation and apologize to you.
P: Dr. I want to know. Is it usual in the hospital that every patient has to suffer like this?
D: I am sorry' for what had happened. I am so sorry for your experience. I would be asking
the same questions as you are asking. Dr. Wilson has just started her training and may be it
was difficult for her to cope up with the workload in the hospital. I am sure it would be
there on her list but she must have got something urgent.
P: But this is not my responsibility Dr. if she is junior?
D: I understand your concern. In the hospital all the junior doctors take help from their
seniors in case they are facing any issues. I will talk to Dr. Wilson to find out what exactly
happened.
P: OK dr. but what do you think if my mom was in my place, she would have suffered.
D: I do understand your concern. I do appreciate your concern for other people. We have a
system in our hospital in such situations, I will document about this incident in your notes, I
will
791
inform my consultant and I will fill an adverse report form (incident form) to let the hospital
authorities know about the incident. In this way the hospital authorities can act promptly to
reduce the risk of further incidents and improve the service we provide in the NHS. These
incidents are reported nationally as well in order prevent them happening elsewhere.
P: Can I have a copy of that form?
D: It is a confidential document and it is entirely for our office purpose. I am afraid we won't
be able to provide you a copy of the form.
P: Doctor, I am supposed to receive my last dose at 8 AM tomorrow. I have to be at my job at
10. But it seems like you are going to give the last dose of my medication at 10 as this dose is
already 2 hours late. But I have to be in my office on time.
D: I am so sorry you have to go through all this. It will be good for your health if you can stay
for 2 hours and we will provide you with a medical certificate so you can show it to your
employer.
P: No dr. medical certificate will not work. 1 have to be there at 10.
D: I will discuss this with my senior and we will be able to give you your last dose of
antibiotics a bit earlier.
D: Is there anything else that I can help you with?
P: I can't accept it dr. how it is possible?
D: The other thing I can do is I can get you in touch with PALS service and it is a service
where you can make formal complains if you strongly feel that your care is compromised.
They will look into detail of it.
I will make sure you get the best possible treatment and nothing like this happen in the
future.
P: Ok. dr.
Sometimes patient will tell you that why you are saying sorry you haven’t done anything
wrong. In his case tell her that we work as a team.
792
IV CANNULA TALK TO DR. WILSON
You are F2 A&E.

Mrs. River, aged 50, has been diagnosed with cellulitis. She was supposed to receive
antibiotics but her IV cannula was blocked so she didn’t receive her medication.
Mrs. River asked Dr. Wilson to change her blocked IV cannula one hour ago, but she didn’t
show up. Patient is very angry and wants to complain.
Please talk to your colleague Dr. Wilson about the incident and discuss about further plan.
Your colleague, Wilson is the FYI doctor who has just started her training in your hospital.
Cannula has not been changed yet.
D: Hello. Dr. Wilson. I am Dr XYZ, one of your FY2 colleagues in the department. How are
you?
Wilson: I am fine.
D: How is your shift so far going?
Wilson: It is busy as usual, but I could manage.
D: Yes I understand that shifts are usually busy. Thank you for giving me some time. Do you
have any idea what I am going to talk to you about.
Wilson: No Dr.
D: I’m here to talk about one of our patients Mrs. River? Do you remember her?
Wilson: Yes I know. What happened to Mrs. River?
D: As you know she was admitted due to cellulitis and was prescribed IV antibiotics.
Unfortunately her IV cannula was blocked. If I am not wrong you told her that you will
change her cannula.
P: Yes I know, she is in my list. I told her that I will change her cannula. She was fine with it.
D: Did you manage to change her cannula?
Wilson: No dr. Have you changed the cannula dr?
D: No I have not. I think we should go and change her cannula?
Wilson: Yes Dr. I will go and change it.
D: That’s great. May 1 know why you did not change the cannula?
Wilson: I know I should have changed it but you know how busy A&E was today. I had a
patient who needed an immediate X-Ray. there was no porter, so I had to take the patient
by myself to the X-ray room. Then I had a patient of cardiac arrest so I was busy there.
D: I am so glad Wilson that you recognised the emergencies and you prioritised your tasks.
But don’t you think you should have asked one of us to change the IV cannula for you as you
know all of us here work as a team.
Wilson: Yes, I could have done that. I will make sure it next time.
D: Well done. I know you have joined the work recently and this environment is new for
you. Sometimes we have to see many patients at the same time and it becomes difficult to
cope with the workload. That is why we work as a team so that we can help each other and
patient get the best possible care in the hospital. So please don’t hesitate to ask for a
favour.
793
Wilson: Yes Dr., I will do that. Thank you for this.
D: Mrs. River is a bit angry now, but I am sure if you will explain your situation and apologise
to her, she will understand.
Wilson: Ok Dr., I will talk to her and I will change her cannula.
D: That would be great Dr. Wilson. But do you know We have a system in our hospital in
such situations, we have to document about this incident in her notes, we have to inform
the consultant and we have to fill an adverse report form (Incident form)
Wilson: Do we have to inform the consultant and fill the adverse report form here as well. But I
mentioned I was busy with some other serious patients. Otherwise I would have changed the
cannula. This will be the first complain against me dr.
D: I understand that you were busy with other patients and you prioritized your task. This is
nothing against you Wilson. Don’t take it personally, it is an hospital protocol that we have
to inform our consultant and fill this form. In this way the hospital authorities can act
promptly to reduce the risk of further incidents and improve the service we provide in the
NHS.
Also our consultant can take some steps to prevent these incidents happening in the future.
As you mentioned that we were short of staff so in this case he can contact HR manager and
solve this problem by appointing more people.
Wilson: Ok dr. that is fine.
D: Wilson. Whatever we are doing is to improve the services of our hospital and NHS. If you
have any suggestions in it then please share with us. Our aim is to work as a team and give
the best services to our patients so that we can case their stay in the hospital.
Wilson: Yes Dr. I understand what you are saying I will take care of these things in the future.
D: Is there anything that I can help you with dr. Wilson.
Wilson: No thank you.
D: If you want any help, you can contact me anytime. It was nice talking to you Wilson.
Wilson: Same here
794
COLLEAGUE DELAY PT DISCHARGE
You are the F2 in Acute Medicine.

Dr Gupta is an Fl working in your department. Mrs. Stream is about to be discharged & Dr.
Gupta has to write the discharge notes & discharge the patient. She asked Dr Gupta 2-3
times to get discharge typed up. He didn’t do that & now she wants to complain. She asked
the nurse colleague to contact the Doctor.
The ward manager came to the ward saying that the beds are not empty & that patients are
waiting in the A&E to get the bed.
Talk to Dr Gupta & manage the situation.
One F1 is sick & is on sick leave
D: Hello Dr Gupta, I am Dr ■ • ■ One of your colleague in the department

Gupta: I am fine.
D: How is your shift going so far?
Gupta: It is busy as usual, but I am managing.
D: Yes. I understand shifts are usually busy. Thank you for giving me some time. Do you have
any idea what I am going to talk about?
Gupta: No
D: I am here to talk about one of our patient Mrs. Stream. Do you remember her?
Gupta: Yes. I know, I saw her earlier and the plan was to discharge her.
D: Did you manage to discharge her?
Gupta: No. it’ s been a stressful day. I have got too much on my hands all of a sudden. I’ve to
go to the x-ray. take bloods, manage emergencies, all of it. It s just too much.
D: Oh. I ’ m so sorry that so much work has piled up on you all of a sudden. I think we should
go and discharge her first.
G: Yes, I will do that.
D: Is there no other colleague to help you out?
Gupta: We are only 2 FYIs & the other one is on leave, so all the work is on me now.
D: I can understand that it must be hard for you to manage it all alone. It gets really busy
here at times, seems this is one of those times.
Gupta: Yes, it is
D: Right. Did you get a message from the nurse that Mrs. Stream was asking for you to
discharge her?
Gupta: Yeah. I did. But I had these tasks in hand. I thought that I will get done with these
quickly as many patients are waiting. As there is no one else, I have to do all this too.
D: I can see that you have lots of work & I must say that it’ s really admirable that you' re
trying to manage it all on your own.
Gupta: Thank you
D: But Gupta, sometimes the workload becomes too much for one person to handle. You
could’ve asked me or someone else to help you out.
Gupta: Yeah. I should have asked.
795
D: Gupta, did you tell anyone that your colleague was not on work today & that it was
becoming difficult for you to manage it all alone?
Gupta: No, I haven’t had the time. Anyways I thought that they might know it already.
D: Gupta, it is understandable that it can become difficult to cope with the workload at
times. That is why we work as a team so that we can help each other and patient gets the
best possible care in the hospital. So please don't hesitate to ask for a favor whenever you
need it.
Gupta: Yes, I will do that. Thank you for this.
D: About Mrs. Stream, you know that you were going to discharge her some time ago & she
has been waiting since then for you. Because of the wait, she got upset as she wanted to go
from the hospital as soon as possible. She even asked the nurse for you but was not able to
reach you. She became really angry & wants to complain about it.
D: Mrs. Stream is a bit angry now, but I am sure if you will explain your situation and
apologize to her, she will understand.
G: Ok. I will talk to her and I will make her discharge immediately.
D: The ward manager came to the ward saying the beds are not empty and the patients are
waiting in the A&E to get the bed.
Gupta: Yes, I understand. I am working on it.
D: That would be great Gupta, but do you know we have a system in our hospital in such
situations, we have to document about this incident in her notes, we have to inform the
consultant and we have to fill an adverse report form (Incident form).
G: Do we have to inform the consultant and fill the adverse report form here as well? I
mentioned that I was busy with some other important tasks for other patients & I’ m the only
one to do everything today. Otherwise I would have discharged her immediately. This will be
the first complaint against me doctor. People will start talking bad about me. The nurses were
already talking amongst themselves earlier that I'm inefficient. I'm really trying my best here.
D: I understand you are busy with other patients, and you are the only one in the ward
today. I am sorry' that you are feeling this way. This is nothing against you Dr Gupta. Don’ t
take it personally. It is a hospital protocol that we have to inform our consultant and fill this
form. In this way, the hospital authorities can act promptly and reduce the risk of incidents
and improve the services that we provide in the NHS. Also, our consultant can take some
steps to prevent these incidents happening in the future. As you mentioned that we were
short of staff, so in this case, consultant can contact the HR manager to solve this problem
by appointing more staff.
Gupta: Ok Doctor that is fine.
D: Also, Gupta, when you go & talk to Mrs. Stream, I’ m sure she will understand when she
gets to know the reason behind it. If she wants to complain, do you know how to guide her?
Gupta: No Doctor.
D: Please get her in touch with the PALS service. They will guide her.
G: Okay
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D: Gupta, whatever we are doing is to improve our services. If you have any suggestion in it,
please share it with us. Our aim is to work as a team and give the best care to our patients
so that we can ease their stay in the hospital.
Gupta: Yes, I understand what you are saying and I will take care of these things in the future.
D: Great. Please do let me know if you need any help with finishing yo , I would love to help
you. I have some free time now.
G: Thank you. that is very kind of you.
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LUNG CANCER MISSED X-RAY BY GP
A 70 year old diagnosed with Lung cancer. She was referred by the GP to the hospital where
an X-ray detected the cancer.
Son, Mr. Adam wants to talk to you about her. Address his concerns.
Grips –
D- Hi I am Dr Jane one of the junior doctors in the Medicine unit. May I confirm your name
please.
S: Hi. I am Adam.
D- Thank you, how may I help you Adam?
S: Well doctor my mother is admitted in the ward, I wanted to talk regarding her condition.
D- Well, of course. Before we proceed can you confirm your mother’s full name and age for
me please.
S: Yes it’s Sarah Thompson and she is 70.
D- Thank for that Adam, please tell me how may I help you today?
S: Doctor my mother is diagnosed with Lung cancer as you already know. I just want to know
why was this not diagnosed before?
D- I am so sorry to hear that Adam. I understand how distressing this must be to see your
mother like this. But I am here and I will help you as much as I can. Can you tell me what do
you mean by not diagnosed before?
S: Doctor we went to the GP when she was unwell, the GP gave her certain antibiotics and sent
her home. She took the medications but she wasn’t better.
And we brought her here you guys did the X-ray and found out that she was having cancer
Angry tone- why wasn’t it diagnosed before then, why didn’t the GP do the X-ray before.
D- Well Adam I can see why you are concerned. But can you tell me what symptoms Did she
have back then so I can address your concerns better?
S: She had this cough for a few days.
D- Was it Dry cough or wet cough? Or any phlegm with it?
D- If yes what was the colour?
D- How much amount of sputum in a day did she have?
D- Was there any blood in it?
D- Any breathing difficulty?
D- Did she have a fever?
D- Did she have any lumps and bumps anywhere in the body?
D- How was her appetite?
D- Did she lose weight recently?
D- Was she diagnosed with any medical conditions? Lung (COPD Asthma), Heart(MI), DM2
She had COPD and was taking her medications regularly.
D- Any other medications that she took, OTC, Vitamin supplements?
D- Any medical conditions in the family?
D- Did she travel anywhere recently?
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D- Does she smoke?
S: Yes she used to smoke.
D- How much and what did she smoke?
D- I believe she is retired now, was she ever exposed to any paint, rubber or dye industries
before?
S: No. You are asking too many questions, can you answer me tell why the GP did not do an X-
ray before. (Really Angry son)
D- I am really sorry if this has annoyed but it was important for me to ask certain questions
to understand why the GP did not do an X-ray before. From our discussion as you
mentioned she had COPD and the symptoms you told me, firstly any doctor would consider
it as a lung infection that we call is pneumonia. As it is common condition in patients with
COPD and elderly. Hence the GP prescribed the antibiotics. I am really sorry that this was
not diagnosed before.
S: He could have done the X-ray and we would have known earlier.
D- I understand where you are coming from. But as you know X-ray radiations can itself
cause cancer and hence they are avoided until they are very necessary.
S: But she did have cancer already and we could have known that it was cancer before.
D- I am really sorry Adam. What I can do is I can raise an incident for as well, which will help
not only the GP but will make all healthcare professionals in the NHS aware of such
incidents so that it should never be repeated again.
D- You are sorry that means this happens a lot and the GP did wrong. He did not diagnose
my mother in the right time.
D- Well I am really sorry for what you are going through at the moment, all your queries are
absolutely valid. What I can do is speak to the GP myself and find out what exactly
happened and then we can discuss this in detail, how would you like that?
S: I want to complain doctor!
D- You have all the right to complaint Adam if you think your mothers care has been
compromised. But if you want to complaint, I can guide you towards PALS(Patient Advisory
Liason Services), they take such matter very seriously and will keep you posted on the
matter. I would like you to know but here I am not trying to defend the GP or any other
doctor- cancer is something that starts off In an Early stage and gives symptoms later in life.
Also if the X-ray would have been done by the GP, it wouldn’t have changed the prognosis
of your mothers condition. I am really sorry to say that.
S: I will think about that. Thank you.
D: Do you any other concerns that I can answer for you Adam?
S: Can I see my mother?
D: Yes of course you can. We do have certain visitors policies in place due to the ongoing
COVID situation but you can meet her in the visiting hours.
Anything else I can help you with.
S: No thank you doctor.
D: Thank you Adam. I wish your mom a good health.
S: Thank you doctor.
799
SCENARIO #2

Mrs. Daniella White, aged 67, had presented to the hospital with breathlessness and was
diagnosed with lung cancer. She visited the hospital previously with cough and was treated
for lung infection. Son is angry as he things the diagnoses was made late.
Talk to him and manage the situation.

S: Doctor, I am extremely upset as the GP missed lung cancer in my mother.
D: If you don’t mind, I’ll ask you a few questions first, so I will be in a better position to
address your concern.
S: Okay
D: May I know why your mother came to the GP?
S: She came to the clinic with cough with phlegm and was give antibiotics. She didn’t improve
even after continuing the medications. Then she developed breathlessness and was diagnosed
with lung cancer.
D: How is she now?
S: She was fine before, now she is getting worse.
D: Were there any investigations done?
S: My mother has been to the clinic previously and x-ray was not done. Only some blood tests
were done. Now she has been diagnosed with cancer and nothing can be done.
D: Have the doctors discussed the treatment plan for your mother?
S: Yes/No
D: Since when she’s been having a cough?
S: Few weeks
D: Did you notice weight loss?
S: No
D: Did she complain of any lumps or bumps around her body?
S: No
D: Did she mention nay blood in her sputum?
S: No
D: Does she have any medical conditions?
S: No
D: Any family history of any medical conditions?
S: No
D: Does your mother smoke?
S: No
D: May I know who takes care of your mother?
S: I do
D: How are you coping with all this?
800
S: It is a lot to handle.
D: Do you need any help for your mother?
S: No
D: Is there anyone else to help you out with that?
S: I’m the only one who takes care of her.
D: As you mentioned, your mother had a cough when she initially visited the GP and had
blood tests done and she was treated for chest infection. Cough is a common symptom of a
chest infection which is why the GP did not plan an x-ray and there were no alarming signs
like weight loss and blood in cough. As your mother developed breathlessness later on, x-
ray was done, and her cancer was diagnosed.
S: Okay
D: Did you mention to the GP that her cough isn’t getting better despite the medicines?
S: My mother took antibiotics which was prescribed to her for her chest infection and there
was no improvement in her health. Then she visited again to the GP and was referred to the
specialist for further management.
D: I understand an early x-ray chest could have identified the cancer. However, the
symptoms your mother presented with initially pointed more towards the infection.
S: Okay
S: I am still not happy with the way the GP handled everything related to my mother. If she was
your mother how would you feel?
D: We will look into the whole situation as I was not there at that time. We will talk to your
mom’s GP and find out exactly what happened. If you wish, we can arrange an appointment
for you with the GP to discuss this. We can also discuss this with the practice manager at
your GP surgery. I will also escalate this matter to our seniors.
S: I want to make a complaint.
D: No problem at all. That’s your right to make a complaint if you wish to. What I can do is I
can get you in touch with PALS service and it is a service where you can make formal
complaints if you strongly feel that your mother’s care is compromised. They will look into
detail of it.
801
PREMATURE CHILD BIRTH-CONCERNED MOTHER
You are F2 in Paediatrics

Mother of 9 month old baby, came to see her child, who has been admitted to the hospital
since birth as she was born at 26 weeks of gestation.
She is angry and has some concerns.
Please talk to the mother and address her concerns

P: I came to see my child and I am worried about the care she is receiving in the hospital.
D: Could you tell me more about what happened?
P: She was covered in poo when I went to see her and she was smelling bad that’s because no
one is looking after her. Every time I come I see new nurses they know nothing about my
daughter condition and some time they don't even talk to me much.
D: I am extremely sorry for your experience. We are here to help you and your child. I will go
and talk to the nurse about this matter. But let me re assure you that we always take good
care of our patients. I will address all your concern, let me ask you a few questions regarding
her health.
D: May I know how is she now?
P: She is doing fine.
P: Yes. they corrected the age of my child.
P: Yes.
P: No
P:
D: Does she have any problems with her wee and poo?
P:
D: May I know what is bothering you the most?
P: My main concern is whenever I talk to any nurse about my child condition they just give me
a vague answer. This wasn't the case when she was in another ward a while back where
everyone was cooperative and they knew every details about my child.
D: I am sorry about your experience. I apologise on the behalf of my colleagues. It should
not have happened. I will talk to them and find out what exactly happened. I will tell them
to come and speak to you.
P: There are no regular nurses. Nurses are temporary so no one knows properly about the
child.
802
D: I understand your concern. I can see that you are concerned about your child. All the staff
including nurses work in shifts. We always try to have regular staff in the hospital. But
sometimes due to the shortage we have to appoint temporary staff as well. But I can
reassure you that all the staff is well qualified and competent.
P: I want a senior nurse to take care of my baby all the time.
D: I can tell one of the senior nurses to supervise the care of your baby. But it is not possible
for one person to take care of any patient for the whole day as we work in shifts.
P: I think I will get better service in the private setup.
D: I am really very sorry that you are not happy with the treatment of your child here. We
will definitely try our best to care for your child. It is up to you to decide whether you want
to take the child to the private hospital.
P: Ok
D: I will also inform the ward manager so that they can also look into this matter. I will also
escalate this matter to our seniors.
P: I want to talk to your seniors?
D: Yes, you can talk to the seniors. I will arrange a meeting with the seniors. I will also
inform the ward manager so that they can also look into this matter. In the meanwhile, is
there anything that I can help you with?
P: No
D: I will talk to the nurses if something has happened they will definitely come and speak to
you. I will take this matter to my seniors and I am sure they will look into this and do
something about this problem. I will also inform the ward manager so that they can also
look into this matter.
If pt. wants to make complaint.
P: I can t accept it. I want to complain?
D: Ok, The other thing I can do is I can get you in touch with PALS service and it is a service
They
will look into detail of it.
803
TALK TO CONSULTANT SON ABOUT HIS MOTHER

Maria aged, 80 referred from nursing home as she was losing weight. She had CT scan of
abdomen that showed suspected malignancy in the ascending colon. You haven’t spoken to
the patient.
Talk to son and address his concern.
Son: I am a surgical Consultant. 1 want to discuss about the test results and further plans for
my mom.
D: I can see that you are very much concerned. Let me ask you some questions about her
general health. How is her health recently?
Son: I don’t have much idea about her condition. 1 don’t live with her. She lives in a care home.
D: Has she been diagnosed with any medical conditions?
Son: No
D: Is she taking any medications?
Son: No
D: Any previous surgery or hospital stay?
Son: No
D: May I know how much you know about your mother’s condition? Why she was referred
to the hospital from the care home?
Son: No
D: Did you speak to care home staff about her health?
Son: Yes, they told that she was losing weight and they referred her to the hospital.
D: Ok, but we cannot discuss about your mother condition with you at the moment because
we have not spoken to her yet. As you know we cannot disclose patient information to
anyone else unless we have consent from the patient.
Son: I am consultant here and I can help you in her treatment plan if something is wrong with
her.
D: We will talk to your mother soon and ask for consent to talk to you. If she gives consent
we will surely come back immediately and talk to you about it.
Son: Can I be there when you talk to my mom?
D: Of course, you can be there if she wants. So, let me talk to her first about this. I am sure
she will be well supported if you are there.
Son: Does she know about the result?
D: I can see that you are worried about your mom. We haven’t spoken to her till now, we
are going to discuss the results with her.
Son: Can you just tell me if it is bad news?
D: 1 am sorry 1 cannot discuss anything about the results now. First of all we have to speak
to her and after she gives the consent then we can discuss the result with you.
Ex: What you will do now?
804
D: I will talk to my senior about the test result and ask for further plans for the patient and 1
will inform the patient about the test result and discuss further investigations and
management plan with the patient. I will also inform my senior about her son is a surgical
consultant and wants to know about his mother and discuss further management with the
team. I will also ask the patient if she wants her son by her side while we are disclosing the
results to her.
D: Do you have any other concern? Is there anything I can help you with?
Son: No
805
MEDICAL ERROR MI
You are F2 working in CCU.

Mr. Andrew, aged, 40 presented to the hospital 48 hours ago with chest pain and has been
admitted to the hospital. Patient attended theA&E department complaining of chest pain,
three days before his admission. In the A&E department ECG was done, but the diagnosis
was not picked up. Patient was sent home with the diagnosis of musculoskeletal pain,
before getting the Troponin results. Troponin result came back positive while patient had
already been discharged. When he came the second time, cardiologist consultant reviewed
his ECG, which was done in his first attendance to the hospital. T-wave inversion has been
found and diagnosis of inferior wall MI has been made. Patient was admitted to the CCU. He
has been medically managed and will be shifted to the medical ward.
Please talk to the patient, assess his condition, explain the medical error, explain the next
steps of management and address his concerns.
How to approach:
1. Patient safety- a pt. safety incident occurs.
2. Documentation- document the incident in the pt. record.
3. Being open- inform the pt and their family and carers and apologise.
4. Reporting - Report the incident by your local reporting system.
5. Learning- How will my report inform local and national learning.
6. Complaint- What if pt. wants to make a complain
D: Hello I am Dr. XYZ. I understand that you came to the hospital 2 days ago. Am I right?
P: Yes dr.
D: Have you been told about the reason why you are in the hospital?
P: Yes I came to the hospital with chest pain and they did some investigations. I was told that I
had an heart attack.
D: Yes you are right you came to the hospital and diagnosed with heart attack. How are you
feeling now?
P: I am feeling fine now.
D: I am glad to know that you are fine now and you are being shifted to ward.
P: Okay Dr.
D: Do you have any symptoms? Chest pain? Breathlessness? Heart racing? Swelling in the
legs? Cough?
P: No
P: No
P: No ’
Examination: D: I would like to check your vitals and examine your chest.
806
D: Do you have any idea what treatment did you get in the hospital?
P:
D: If I‘m not wrong, you came to the hospital a few days ago as well. May I know why?
P: Yes. I had this chest pain 5 days ago. I came to the hospital doctors did some tests and told
me that it is just a muscle pain, they gave me some painkillers and sent me home.
D: OK I am here to talk to you about an error which has happened in your treatment. Has
anyone mentioned it to you already?
P: No. What do you mean?
D: It is important that being a doctor we are open in these things if any error happened. We
need to explain you everything. Let me explain it to you, Unfortunately, First time, when
you came to the hospital you actually had a heart attack which was not diagnosed in the
A&E. Our colleagues in the A&E couldn’t pick the abnormality in your ECG and before the
blood results came back, they sent you home and unfortunately your result was positive for
heart attack.
P: How can it even be possible?
D: We will look at everything what went wrong in this case in terms of not waiting for the
blood results and not reading your ECG properly. I am really sorry for what has happened,
this really should not have happened. Please accept my apology on behalf of my colleague
and my team. I am glad that you are fine now and we are monitoring you in the hospital.
P: Do you think I would have had another heart attack if I was diagnosed the first time?
D: If you were diagnosed the first time we would have started you on medications and
wouldn’t have had the heart attack again. But we will make sure that it doesn’t happen
again.
P: How will you make sure?
D: We have a system in our hospital in such situations, I will document about this incident in
your notes, I will inform my consultant and I will fill an adverse report form (Incident fonn)
to let the hospital authorities know about the incident. In this way the hospital authorities
can act promptly to reduce the risk of further incidents and improve the service we provide
in the NHS. These incidents are reported nationally as well in order prevent them
happening elsewhere.
future.
P: OK dr.
D: Do you understand what we were talking about.
P: Yes dr.
D: So I will tell my consultant to come and speak to you. We are going to have a closer look
at you. We will take all necessary actions to prevent any further heart attacks.
807
We will do some further investigations to make sure everything is fine
ECG (tracing of heart)
ECHO (Ultrasound of your heart)
Angiography if needed, (to assess the narrowing of the vessels supplying to the heart)
We will give you some medications to improve the function of your heart and to prevent
this from happening again. (Aspirin, Clopidogrel, ACE inhibitor. Beta blocker. Statins)
You may need to make some necessary changes in your life-style. (Ask and address
accordingly)
808
MISDIAGNOSED PNEUMONIA

Andy Parker aged, 52 has presented to the clinic for Review. Patient presented to the
hospital 4 weeks ago with Cough and Shortness of Breath. Investigations including blood
test and X-Ray were done. Patient has been diagnosed with Pneumonia. Patient was
admitted in the Acute Medical Unit and then shifted to the ward. Patient has been
prescribed Amoxicillin.
One of the doctors read another patients X-Ray by mistake and the diagnosis of Pneumonia
was made based on that. Patient’s formal X-Ray report came back a few days later and it
was normal.
Please talk to the patient, assess his current condition, explain the error and address
patient's concerns.
How to approach:
D: Hello. I am Dr…. I understand that you were diagnosed with pneumonia 4 weeks ago and
you have come for your review.
P: Yes Dr.
P: I am fine.
D: Do you have symptoms? Any fever or flu like symptoms? Any cough or shortness of
breath? Any chest pain?
P: No
P: No ’
P: No
Examination: D: I would like to check your vitals and examine your chest.
D:I am glad that you are fine now. May I know what was done for your pneumonia?
P: They gave me antibiotics (amoxicillin) for seven days.
D: Did you finish the course of antibiotics?
P: Yes Dr. but I experienced some side effects.
D: May I know what side effects did you get?
P: I got tummy pain and diarrhoea.
809
D: When exactly did you get them?
P: After 2-3 days of taking antibiotics.
D: I am so sorry to hear that. What did you do for that?
P: I went to my GP and he told me that they will get better on their own and these are the side
effects of antibiotics.
D: Do you still have those side effects?
P: No '
D: OK I am here to talk to you about an error which has happened in your treatment 4
weeks ago. Has anyone mentioned it to you already?
need to explain you everything. Let me explain it to you. Unfortunately, When you were
admitted in the hospital last time you didn’t actually have pneumonia. I am really sorry to
tell you that you were misdiagnosed at that time and you should not be given those
antibiotics.
P: How it can even be possible?
D: We will look at everything what went wrong. One of my colleagues mistakenly read
another patient's X ray and diagnosed you with pneumonia. I am really sorry for what has
happened, this really should not have happened. Please accept my apology on behalf of my
colleague and my team.
I am glad that you are fine now.
P: How can such a thing happen in the hospital, aren’t the X rays labelled?
D: I completely understand your concern and as I told you this shouldn’t have happened. I
am really sorry for that. Fortunately you are fine now. We are going to take necessary steps
in order to prevent such incidents to happen in the future.
P: What are you going to do doctor?
your notes. I will inform my consultant and I will fill an adverse report form (incident form)
in the NHS.
These incidents are reported nationally as well in order prevent them happening else where.
P: This means that I shouldn’t have had those antibiotics and I have got side effects because of
that?
D: I am really sorry and we will make sure that it doesn’t happen again.
P: Are there any long term side effects of these antibiotics?
D: Antibiotic resistance.
810
HAIRLINE FRACTURE
You are F2 in A&E.

Mr. Jonathan had brought his 4-year old son Carl to the hospital 2 days ago after having fall
while playing. He had swelling on his right hand. Doctor on duty saw hint. The X-ray was
done .He was treated as a soft tissue injury. Patient has been discharged with analgesia.
Radiologist reviewed the lateral view of X-ray and found minor hairline fracture of radius.
Orthopedic specialist review the X-ray and planned for cast and review the patient after 2
weeks.
He has been called by the nurse to bring back his son again to the hospital for review. Please
talk to the father, explain the error, discuss about the management which has been decided
and address his concerns.
Father is very angry. There is no evidence suggestive of NAI and it has already been ruled
out.
How to approach:
6. Complaint- What if pt. wants to make a complain.
D: Hello I am Dr… I understand that you have been called by the nurse to bring back your
son again to the hospital for review. Am I right?
P: Yes Dr.
D: Ok Thank you for coming. If I am not mistaken your child was brought to the hospital two
days ago. Could you please give me a recap of what happened 2 days ago?
P: My son, Carl fell from the bed and had an injury to his wrist. He had a swelling on his right
hand. I brought him to the A&E. they did an X-ray and told us it is an soft tissue injury. We
were sent home after giving some painkillers.
D: How is he now? Did you give him the painkillers? Did the painkiller help at all? Has the
pain
changed? Do you think he is still in pain? Any swelling now?
D: Like you said, you brought your little one to the A&E after a fall two days ago. We did the
XRay
and you were told that it was soft tissue injury. I am here to talk to you about an error
which
has happened in your treatment. Has anyone mentioned it to you already?
P: No doctor, please tell me what happened.
need to explain you everything. Let me explain it to you. Unfortunately, first time When you
811
came and the X-ray was done, my colleague had a look at the X-Ray and found only soft
tissue injury.
Later, the X-Ray was reviewed by the radiologist, and he found that your little one has a
minor
hairline fracture in his hand.
P: You mean my child have a broken bone? How it can even be possible?
D: We will look at everything what went wrong in this case. I am really sorry for what has
happened, this really should not have happened. Please accept my apology on behalf of my
colleague and my team. I am glad that he is fine now. But let me tell you that this is a
hairline fracture, which is a minor fracture or crack in the bone. Our orthopaedic specialist
have reviewed the X-ray and they have already planned for cast for 2 weeks.
P: How can such a thing happen in the hospital? My little one has broken bone for the last two
days, why do you keep such unprofessional and inexperienced people in the hospital? Why a
senior didn't see the x-ray on the first time?
D: I completely understand your concern and as I told you this shouldn't have happened. I
am really sorry for that. I will definitely talk to my colleague to find out why this happened. I
will also ask my colleague to come to you. explain himself and apologise to you. However,
my colleague should have waited for the X-Ray report from them Radiologist before sending
you home. Fortunately, your child is doing fine now. We are going to take necessary steps in
order to prevent such incidents to happen in the future.
D: We have a system in our hospital in such situations, I will document about this incident. I
will inform my consultant and I will fill an adverse report form (incident form) to let the
hospital authorities know about the incident.
In this way the hospital authorities can act promptly to reduce the risk of further incidents
and improve the service we provide in the NHS. These incidents are reported nationally as
well in order prevent them happening elsewhere.
future.
P: OK dr.
D: Do you understand what we were talking about. P: Yes dr.
at your child. We will take all necessary actions to prevent any further incidents.
Patient might ask:
P: Doctor, will he be fine? What are you going to do?
D: We will give him pain killer to make him pain free. Our bone specialist will come and
review your child. They have reviewed the X-ray and they have already planned for cast for
2 weeks and then review after that.
812
P: How is it going to affect the healing? Will there be any complications?
D: As long as the cast is applied and the bone is kept stable, the healing should continue as
normal. Fortunately your child is fine now. There can be some temporary complications such
as numbness and some residual weakness of the arm, which improve by themselves.
P: Will this delay of 2 days make it more difficult to apply the cast?
D: I can imagine how worried you are, but like I said, it is a minor fracture and there should
not be any problem.
P: Doctor, when can you do this cast?
D: Like I said, the bone specialist will review your child and will apply the cast right away. If
you wish, we can ask them to talk to you, explain more about the fracture, the treatment
your little one will receive, and answer any further questions you may have.
813
AMOXICILLIN RASH
You are F2 in A&E

The child was brought to the A&E by her mother yesterday. Your colleague saw the child,
and diagnosis of respiratory infection was made. Child was prescribed Amoxicillin.
The child was given antibiotic by the mother. Mother noticed a rash and is concerned about
it.
She has come to the A&E now to talk to a doctor.
Please talk to the mother, discuss about plan of management and address her concerns.
The image of rash is inside the cubicle. The mother is very worried. The child is not in the
cubicle.
How to approach:
3. Being open- inform the pt and their family and carers and apologis

P: I have come here to speak to you because I brought in my daughter yesterday. She was
prescribed some medication. I gave it to her and she developed a rash.
D: Could you please give me a recap of why you brought her to the hospital?
P: She had a sore throat and flu from last few days. That is why I brought her to the hospital.
D: Which drug she was given?
P: Amoxicillin
D: Did she have any other symptoms apart from sore throat and flu?
P: She had temperature with the sore throat
D: Any other symptom?
P: No
D: Any runny nose?
P: No
D: Any cough or phlegm?
P: No
D: Any difficulty in breathing?
P: No
D: Tell me more about the rash.
P: She has a rash all over her body. (She will show a picture of the rash)
P: This morning.
D: What was the color?
814
P: Red.
D: Is it itchy?
P: Yes. it is.
D: Is it raised?
P: I don’t know
D: Any swollen glands in the neck? (Infectious Mononucleosis)
P: No.
D: Did she have any difficulty in breathing?
P: No.
D: Any SOB?
P: No
D: Any wheezing?
P: No
D: Any swelling in lips or face (anaphylaxis)
P: No
D: Is the light bothering her?
P: No
D: Any neck stiffness? (Meningitis)
P: No doctor.
D: How is she now?
P: She is the same as before.
D: Has this kind of rashes happened before?
P: Yes. once before when she was prescribed Amoxicillin in the A&E 3 years ago.
D: Why she was prescribed the medicine?
P: Because of an ear infection.
D: What did you do then?
P: I took her to the GP. He told me she is allergic to Amoxicillin and changed it to something
else.
D: Did the doctor ask you about allergies this time?
P: No.
D: I’m so sorry about what happened. This should have been asked by my colleague.
I am sorry about what happened. It should not have happened. Please accept my apologies
on behalf of my colleagues. Fortunately your daughter is fine and the antibiotic has been
stopped.
D: I would like to check her vitals, chest, ear, nose and throat and lumps and bumps in his
body.
EX: T: Afebrile. 02 Stats: >96%. RR: 16. HR: 90. BP: 120/70 mmHg.
Rash picture.
Other examinations are normal.
815
D: From our assessment, it seems your daughter has allergy to penicillin.
We did physical examination and she is fine. We will change her medication and give her
different antibiotic. (Erythromycin). I will document your daughter has allergy in the hospital
notes so that if she comes to the hospital next time, we will be aware of that.
Usually such rashes disappear soon after stopping the antibiotic. However, since it is itchy
we can prescribe some medication called anti-histamines (Benadryl).
Hopefully she will be fine, but if by any chance the rash does not go away, we may refer her
to skin specialist.
Please make sure she drinks plenty of fluids, especially water, which will help her body clear
the toxins causing the rash.
Please dress her lightly and maintain a cool, well-ventilated environment.
P: Does this happen quite often? How will you make sure it will not happen in future?
D: We have a system in our hospital in such situations. I will document about this incident in
her notes. I will inform my consultant and I will fill an adverse report (Incident form) form to
let the hospital authorities know about the incident. In this way the hospital authorities can
act promptly to reduce the risk of further incidents and improve the service we provide in
the NHS. These incidents are reported nationally as well in order prevent them happening
elsewhere.
future.
P: OK dr.
P: Yes dr.
If at any point the rash becomes worse, please come back to see us.
Allergic reactions to penicillin:

A raised, itchy skin rash (urticaria, or hives), Coughing, wheezing and tightness of the
throat, which can cause breathing difficulties
816
FOREIGN BODY
You are F2 in A&E

3 years old Amy, daughter of Jane was brought to the A&E this morning after the mother
noticed the child was choking. You assessed the child. X-Ray was done. You reassured her
and discharged the child. As soon as the child was sent home, you received the report from
the Radiology Department, which shows that there was a button in the Oesophagus.
Call Amy’s mother, explain what happened and ask her to bring Amy to the A&E for further
assessment. X-Ray is inside the cubicle.
D: Hello, am I talking to Amy’s mother?

P: Yes. who is talking?
D: Hello I'm Dr…. calling from the A&E department who saw your daughter earlier. Could
you please confirm Amy 's DOB and your home address.
P: Yes. It is....
D: Is it ok to talk for a few minutes?
P: Yes.
D: I understand that you came here because Amy was choking. Could you please give me a
recap of what exactly happened with Amy?
P: Amy was playing with her little brother this morning and I was in the other room when
suddenly I heard her choking. I went to Amy and I saw that she was breathless. I patted her on
the back as I thought it could be a food particle.
D: How was she after that?
P: She was fine but she looked pale. I thought I should get it checked and that's why I brought
her to the hospital. She was assessed. The X-Ray was done and I was told everything is normal
and we can go home.
D: How is Amy right now?
P: She is fine.
D: Any breathing problem?
P: No
D: Any coughing?
P: No
D: Any blue discoloration of face?
P: No
D: Any tummy pain?
P: No
D: Any vomiting?
P: No doctor.
D: Is she able to eat or drink?
P: Yes
D: Did she pass any stool?
P: No.
817
D: Yes, you have been told that everything is normal and you have been sent home. I want
to talk to you about an error which has happened in her treatment.
P: What do you mean doctor?
D: Has anyone mentioned it to you already?
P: No
need to explain you everything. Let me explain it to you, After we sent you home we
received the report from the Radiology Department. They realized there is a button in her
food pipe and that's why I'm calling you now.
P: How it can even be possible?
D: We will look at everything what went wrong. I am really sorry for what has happened,
this really should not have happened. Please accept my apology and I am glad that she is
fine now. Actually, the button was not clear enough for me to spot on the X-Ray. Radiology
doctors, who are experts in this field, reviewed and reported the X-Ray. Fortunately, they
were able to spot the button in your baby’s food pipe that I had missed. We would like you
to bring her back to the hospital.
P: Now I have to get back to work. I took leave earlier.
D: I understand your circumstances but you can talk to your employer and explain the
situation and I am sure they will understand.
P: Doctor, I have to go to work. I am on zero contracts; I won't get paid if I don’t go to work.
D: I am wondering who else looks after Amy so if it is possible, you can ask the person to
bring her to the hospital.
P: I am single mom. My sister looks after my babies. It’s difficult for her to come to the hospital
with two babies.
D: I can understand your situation but we need to reassess Amy to see if everything is fine. It
must be a bit inconvenient but it would be great if you could bring her. It is very important
for Amy’s health. I can arrange transport for you.
P: Ok doctor
D: Could you remember what was around Amy while she was choking?
P: I didn't notice anything.
D: The radiologist found a button in her food pipe. Do you think it can be a button battery?
P: No doctor.
D: Ok
D: Has she been diagnosed with any medical condition?
P: No
818
SAMPLE NOT LABELLED
You are F2 in Trauma.

Mr. Peter aged, 40 had pre-operative assessment yesterday.
As a part of pre opertive assessment you took some blood yesterday front him and from
other patients as well. Everything about the surgery and post-operative management has
been explained to the patient. Today you called the lab for the result. They said you need to
take the sample again because samples were not labelled.
Please talk to the patient on phone and explain the error. Tell him that you have to the
hospital for the bloods again.
How to approach:
3. Being open- inform the pt and their family and carers and ap
D: Hello. Am I talking to Peter?

P: Yes, who is talking?
D: Hello I'm Dr ________ calling who saw you yesterday. Could you please confirm your age
and your home address.
P: Yes. It is....
D: Is it okay to talk for a few minutes?
P: Yes, actually I was also expecting a call from you.
P: I am fine
D: Any pain.
P: Yes, my ankle pain is acting up, it is becoming really difficult for me to go to my work.
D: Do you have any idea why I am calling you now?
P: Yes, you want to tell me my blood results
D: As you know that we did your Pre-operative assessment yesterday and we took some
blood from you. I am here to talk to you about an error which has happened in your
treatment. Has anyone mentioned it to you already?
need to explain you everything. Let me explain it to you, Unfortunately, when I took the
blood sample from you then I forgot to label the sample. So now we don't have any result.
Can you back to the hospital so that we can take blood sample again.
P: Is it my mistake? I can't come back and also my sick leave is going to start in a few days.
819
D: I am so sorry what have happened. If you will explain it to your employer then I am sure
he will understand your situation.
P: When can you arrange the next appointment for me?
D: I will speak to my senior and we will try to give you appointment as soon as possible.
P: How can I come doctor Do you know it takes 2 hours to come to the hospital.
D: I can arrange the transport for you if you want. It is for your good health. We have to
have your blood sample so that we can do your surgery.
P: How it can be possible? Does this happen a lot in the hospital?
D: I am really sorry for what has happened, this really should not have happened. Please
accept my apology on my behalf. I am glad that you are fine now. We will make sure that
these kinds of incidents should not happen in the future.
your notes, I will inform my consultant and I will fill an adverse report form (Incident form)
will learn lesson from these events, draw possible solutions and act promptly to reduce the
risk of further incidents and improve the service we provide in the NHS. These incidents are
reported nationally as well in order prevent them happening elsewhere.
P: I can't accept it Dr. how it is possible?
future.
P: OK dr.
P: Yes dr.
820
KIDNEY SAMPLE LOST
You are an F2 in Urology Dept.

Mr. Ashley aged, 27 has been referred by the GP. The diagnosis of Poststreptococcal
Glomerulonephritis has been made. It has been decided by the nephrologist to do a kidney
biopsy. Renal biopsy has been done and the specimen has been taken 2 days ago. The
patient is now here for the results.
You called the laboratory to trace the specimen and enquire about the renal biopsy report.
The laboratory informed you that the specimen was never received. Hospital has been
searched intensively but the specimen hasn’t been found. No valid reason found for not
getting the sample.
Please talk to the patient, disclose the situation and address his concerns.
How to approach:
1. Patient safety- a pt. safety' incident occurs.
3. Being open- inform the pt and their family and carers and apologize
4. Reporting - Report the incident by your local reporting
5. Learning- How will my report inform local and national learning
Dr: I understand that you have been referred by your GP and you came for your results.
Could you please give me a recap of what happened why did you go to GP?
P: Doctor, I was having this sore throat in the last few weeks and I noticed some blood in my
urine that is why I went to my GP. My GP did some urine test and told me there is something
wrong with my kidneys.
Dr: Yes, you have been diagnosed with a condition called Post-streptococcal
glomerulonephritis (It is a kidney disease that develops 10 to 14 days after a skin or throat
infection, it is not caused by the bacteria itself, but by the body's infection fighting (immune)
system, the main symptoms are blood in your urine and swollen ankles or puffy eyes) and a
biopsy is taken from your kidneys.
P: Yes.
P: I am fine.
D: Any fever?
P: No.
P: No.
D: Any swelling in your feet and face?
P: No.
D: Pain in joints?
P: No.
821
P: No.
D: Any rash on your body?
P: No.
P: No.
P: No.
D: Ok I am here to talk to you about a problem which has happened in your biopsy sample.
Has anyone mentioned it to you already?
need to explain to you everything. Let me explain it to you, Unfortunately, we have been
informed by the lab, that they have never received your sample.
P: How it can even be possible? Where is my result?
D: I understand your frustration. We will look at everything what went wrong in this case in
terms of your sample. I am really sorry for what has happened, this really should not have
happened. Please accept my apology on behalf of my colleague and my team. We have tried
our best to search it but nobody was able to find. But, I am glad to know that you are fine
now.
P: You are telling me after two days, why you didn’t tell me before?
D: It takes few days to get the biopsy results. We called the lab to find out the result of the
biopsy then we came to know when they told us that they have never received the sample. I
will talk to my colleague who took your sample to the lab to get more information about
what happened. I will definitely get back to you. I can also ask my colleague to come to you
to explain himself and apologise in person.
D: We need to take another sample to give you the best treatment.
P: I don’t want to do another biopsy? Last time I was in so much pain when you took the
sample.
D: This time, we will make sure you are pain free while we do the procedure. If you want,
we can give you some mild sleep medication so you don't experience any pain.
P: How are you going to treat me now?
D: This is a self-limiting condition and usually goes away by itself after several weeks to
months. We have to treat your symptoms. We will check your vitals. We may need to repeat
your urine test to see if there is any bug. blood or protein in your urine.
P: How will you make sure it doesn't happen in future?
your notes. I will inform my consultant and I will fill an adverse report form (Incident form)
822
in the NHS. These incidents are reported nationally as well in order to prevent them from
happening elsewhere.
future.
P: OK dr.
P: Yes dr.
at you. We will take all necessary actions to prevent any further incidents.
Patient may ask these questions:

P: Why is it necessary to do this biopsy
Dr: We usually recommend a kidney biopsy if the condition is affecting the kidneys. A kidney
biopsy may be necessary if there are signs that the kidneys are getting worse, then we can
give you treatment to reduce the inflammation in the kidneys.
P: Yes Dr.
P: I can't accept it Dr. how it is possible?
where you can make formal complaints if you strongly feel that your care is compromised.
I will make sure you get the best possible treatment and nothing like this happens in the
future.
P: Ok Dr.
P: What you can see in the biopsy?
D: After a kidney biopsy is done, the tissue is looked at under a microscope. In this
condition, the kidney filters appear large with obvious increases in the number of
inflammatory cells. In some cases it is possible to see well-defined rounded deposits outside
of small blood vessels, which look like humps. The presence of these humps may be a sign of
post-infectious glomerulonephritis.
P: How long will it take to do another procedure?
D: I will discuss this with my senior and I reassure you to put you first in our list. Hopefully, it
won’t take more than a few' days.
General Advice:
You should try and reduce the amount of salt in your diet.
You need to drink less fluid during this time.
823
CHANGING COUNSELLOR
You are F2 in GP.

Patient aged 30 is going for counselling sessions for depression and she is taking sertraline
for that. She is requesting to change her counsellor.

P: I want to change my counsellor.
D: Let me ask you a few questions to get better understanding of your problem. Could you
please tell me why are going to the counsellor?
P: When I was pregnant my husband left me for someone else and I had to abort the baby. I
was in depression and I am taking medications also. I was seeing him for that purpose.
D: Could you please tell me when did you start taking medications for the depression?
P: I started taking medication 2 years back.
D: How are you now?
P: I am fine.
D: Do you eat well?
P: Yes
D: Do you have any problem with the sleep?
P: No
D: How long have you been taking counselling sessions?
P: I was taking the counselling sessions from last one year.
D: You were going to the same counsellor or did you change in between?
P: I was going to the same counsellor.
D: Could you please tell me why do you want to change your counsellor?
P: I prefer a female counsellor.
D: May I know is there any particular reason that you want a female counsellor.
P: Sometimes he touches and hugs me. There was some intimacy between me and my
counsellor.
D: I am sorry to hear that. Is this happening against your will?
P: No, it was Consensual from my side as well. This is not his fault, I use to encourage him and
we went out for few dates. But then I came to know he has a girlfriend. I have no complaints
against him. I just want a female counsellor. Please change my counsellor.
D: I will talk to my seniors and we can arrange another counsellor for you.
Thank you so much for letting us know about this. I am glad that you have opened up to me.
However, I will tell this to my seniors because we do not encourage this as it is against our
professional ethics. It is unethical for a doctor to have relationship with a patient.
P: I don’t have any problems against my previous counsellor. I don’t want him to get into
trouble, he is a nice man.
D: I understand your concern. You are our patient and as you mentioned you have
depression that makes you more vulnerable and our profession doesn’t encourage it. I have
824
to escalate it to my senior. And also I will discuss about your wish to change the counsellor
with my senior.
If she wants to complain, offer PALS in those cases
825
GENDER SELECTION PRE-CONCEPTION
You are in GP.

Isabelle aged 35 came to the clinic to see you. She has 3 daughters, 7, 4 and 1 year old. She is
taking contraceptives pills.
Talk to her and address her concern.
D. How can I help you?

P. Doctor I want to make sure my next baby is male. Can you do anything for that?
D: May I know why you want a male baby?
P: I have 3 girls and my husband wants the family name to carry on and that is only possible
with a male child.
D: Let me ask you few questions first. Could you please tell me about your previous
pregnancies?
P: My 3 girls are 7, 4 & 1.
P: No
D: Are you currently taking any regular medications, over-the-counter drugs or
supplements?
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: No
D: How was the delivery of your children?
P: It was normal delivery.
D: Was there any complications during delivery?
P: No
D: Any congenital problem in your daughters.
P: No
P: 1 week ago.
P: Yes
826
D: Any discharge or spotting in between the cycles?
P: No
P: Yes. OCP.
P: What can we do to determine the sex of the baby?
D: We can do an ultrasound to find out the sex of the baby.
P: When can we determine the sex of the child?
D: It can be done between 18 and 21 weeks through ultrasound scan. If you want to know
the sex you can ask the sonographer and he will be able to help you out. But it is not true all
the times means sometimes we will not be 100% certain about your baby's sex due to
awkward presentation of the baby in the womb.
P: If it’s a girl, can I terminate the pregnancy?
D: Abortion solely on the basis of reference of gender, where there are no health
implications for the baby or for the woman are unlawful. You cannot terminate pregnancy
due to sex selection in UK.
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.
P: My aunt has breast cancer. So there are some chances that it may transmit to my daughter.
Can I give this as a reason to abort my child?
D: If a foetus has sex-related genetic defects then it can be considered as medical criterion
for the termination of pregnancy. However, breast cancer is not linked to any sex-related
genetic defects.
UK law
D: You mentioned that you want a male child. In Britain, sex or gender selection has been
banned.
At the moment, such treatment is only permissible in cases where there is a genuine
medical reason for the procedure, for example in cases of sex-related genetic defects. It can
be used to avoid sex linked genetic disorder.
You can have gender selection for medical reasons at many private clinics throughout the
UK.
Preimplantation Genetic Diagnosis (PGD) is available at a number of fertility centres in
England, Wales, Scotland and Northern Ireland. PGD can help identify genetic defects and
improve the chances of conceiving a healthy baby. But once again, any form of sex selection
during this process will only be allowed for the medical reasons. PGD costs in the region of
£1000 to £2000 in the UK. For combined PGD and IVF, expect to pay anything from £6000 to
£9000.
827
GENDER DYSPHORIA

Mr. Michael Lewis, aged 16, wants to talk to you about some problem he is facing.

P: I feel embarrassed doctor.
D: You don’t have to be embarrassed about anything. Whatever you want to discuss, I am
here to help.
P: I feel weird.
D: What do you mean by weird?
P: I feel like I want to be a woman.
D: When did you first notice this?
P: I have always felt his way, but I have been scared to talk about it.
D: I understand this can be difficult for you, but you don’t need to be scared. This is a safe
space, and I will try to help you.
P:
D: What problem are you facing?
P: I feel anxious, I feel like I don’t belong to my gender.
D: Since when have you been feeling this way?
P: I have always felt this way
D: Have you discussed it with anyone?
P: No doctor
D: Have you ever sought help for anxiety?
P: No doctor
D: How is your mood these days? (depression)
P: Its fine doctor
D: Can you rate it for me, 1 being the lowest and 10 being the highest.
P: Its around 6.
D: Have you ever tried to harm yourself? (suicide)
P: No doctor
D: Do you think you have low self-esteem? (low self esteem)
P: Yes/No
D: Do you feel like you have been bullied? (bullying)
P: Yes/No
D: Are there any other problems?
P: No doctor
D: Is there anything that is bothering you?
P: I don’t want to feel this way anymore.
P: No
828
P: No
P: No
P: No
P: No
D: Do you smoke?
P: No
P: No
D: Do you do any recreational drugs?
P: No
P: Yes
P: No
D: What do you do?
P: Student
P: My parents and sister
D: Do you have friends?
P: Yes/No
D: Have you spoken to them about this?
P: No
D: Have you ever been able to have a relationship?
P:
D: What made you talk to me today?
P:
D: Do you think your family and friends can support you?
P: No doctor, my parents are strict. They will not understand. I don’t have many friends.
Thank you for coming. It must have taken a lot of courage for you to do so.
I would like to do GPE and vitals. I would also like to run some routine blood tests like
kidney and liver function tests and thyroid function tests.
From my assessment, I suspect that you may have a condition known as gender dysphoria.
Gender dysphoria is the feeling of discomfort or distress that might occur in people whose
829
gender identity differs from their sex assigned at birth or sex-related physical
characteristics.
What kind of help do you think you need?
Adolescence
Age under 18 and may have gender dysphoria, they’ll usually be referred to the Gender
Identity Development Service (GIDS). GIDS has 2 main clinics in London and Leeds.
Your child or teenager will be seen by a multidisciplinary team at GIDS including a

 Clinical psychologist
 Child psychotherapist
 Child and adolescent psychiatrist
 Family therapist
 Social worker
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):
o Below 16: Mandatory Court Permission for Hormonal Therapy
o Age 16, 17: Optional Court Permission for Hormonal Therapy depending on their
understanding.
o Young people aged 17 or older may be seen in adult gender identity clinic or be
referred to one from GIDS. By this age, the teenager and the clinical team may be
more confident about confirming the diagnosis of gender dysphoria.
Adults
Adults who think they may have gender dysphoria should be referred to a gender dysphoria
clinic (GDC).
GDCs have a multidisciplinary team of healthcare professionals, who offer ongoing
assessments, treatments, support and advice, including:
 Psychological support, such as counselling
 Cross-sex hormone therapy
830
 Speech and language therapy (voice therapy) to help you sound more typical of your
gender identity
 Surgical treatment
 Gamete storage
 Lifestyle
Once they have assessed you, they will be able to offer you different treatment options
including surgeries and hormonal therapy. You may be assessed by a hormone specialist
who will assess the need of hormone blockers to pause the physical changes of puberty,
such as facial hair or cross sex hormones.
In case you feel the need to talk to someone we can arrange that for you. You can also go
for family therapy once you feel you are ready. In case you have any other problem, please
come back to us.
Whilst you are waiting for the appointment for the GDS:
- Do not smoke
- Do not take cross sex hormone (oestrogen/testosterone)
- Maintain healthy BMI (<25)
Surgery for Transmen

- Removal of both breasts and associated chest re-construction
- Nipple repositioning
- Dermal implant and tattoo
- Construction of penis
- Construction of scrotum and testicular implants
- Ap penile implant
- Hysterectomy with salpingo-oophorectomy may also be considered
Surgery for Transwomen

- Removal of testis
- Removal of penis
- Construction of vagina
- Construction of vulva
- Construction of clitoris
Life after transition

1. You will need lifelong monitoring of hormone levels by your GP.
2. You will still need contraception if you are sexually active and have not yet had any gender
surgery.
3. You will need to tell your optician and dentist if you are on hormonal therapy.
831
4. You may not be called for screening test as you have changed your name on medical
records. Ask your GP to notify you for cervical and breast screening if you are a transmen with
the cervix or breast tissue.
5. Transfeminine people with breast (registered with GP as females) are routinely invited for
breast screening from the age of 50 up to 71.
Most common risk/side effects of Hormonal Therapy:

1. Blood clots
2. Gallstones
3. Weight gain
4. Acne
5. Dyslipidaemia
6. Elevated Liver Enzymes
7. High concentration of RBCs
8. Androgenic alopecia
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CONFUSION 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.
D: 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?
P: Yes, I am Tom Cooper and I am 15 years old.
D: It’s nice to meet you Tom. How can we help you today?
P: Doctor, I had something to say but can you promise me first that you are not going to tell
my parents about this.
D: 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
your parents. But of course, we are also going to make sure that there is no risk to your
safety, okay?
P: Okay.
D: So, what did you want to talk about today, Tom?
P: Doctor, it’s kind of embarrassing…
D: 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.
P: Well, there is boy in my class at school who is gay and everyone bullies him for it.
D: I see. Please go on, Tom.
P: Well, I think that might have feelings for him.
D: It’s natural to start having feelings of attraction to other people at your age, Tom. Has
something been bothering you?
P: Doctor, I think I might be gay.
D: When did you first realize this?
P: A couple of months ago.
D: What has been going through your mind since then?
P: I am confused and worried about being treated differently if I tell someone.
D: I see, that must have been tough. Have you discussed your feelings with anyone?
P: No, nobody.
D: Have you talked about this to the boy you like, Tom?
P: No.
D: Do you have some friends you can trust, Tom?
P: I have friends but they won’t understand and I might lose them.
D: And have you considered talking to a family member?
P: They are very traditional. They won’t accept it.
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P: My parents and my older sister.
D: Have you thought about opening up to your sister?
P: No. She is traditional like my parents.
D: How is everything at home apart from this?
P: It’s fine.
D: 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?
P: Okay, thank you.
D: Tom, when someone goes through a tough time it can sometimes affect his or her mood.
How has your mood been lately Tom?
P: My mood is fine.
D: How is school going?
P: School is great. I have friends. I do well in studies and sports.
D: That’s good to hear, Tom. Have you ever been bullied at school?
P: No, I am pretty popular but I am afraid I might be bullied if tell someone I like another boy.
D: I see, Tom.
D: Are you feeling more anxious or worried than usual?
P: No, not really.
D: Have you ever been diagnosed with any medical conditions or any mental health
conditions?
P: No.
D: Do you take any medications currently?
P: No.
D: Can I ask if you smoke?
P: No.
P: No.
D: Have you ever used any recreational drugs?
P: No.
D: Tom, have you had a relationship before?
P: Only one. I had a girlfriend for a couple of months last year.
D: I see. May I ask if you have been sexually active?
P: No, never.
D: Have you felt attracted towards the opposite gender as well?
P: I don’t know. I feel confused.
D: 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.
834
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?
P: Yes.
D: Have you had classes on sex education and sexuality at school?
D: Is there a counselor at school that you can talk to about this?
P: No.
D: Does your school have any LGBTQ support groups or Gay-Straight alliance groups?
P: No.
D: 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?
P: I don’t know.
D: 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?
P: I can try.
D: 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.
I am going to print out some information for regarding these support groups as well as local
LGBT support groups for you, okay?
P: Okay.
D: 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?
P: That’s good, I guess.
D: 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?
P: Yes, please.
835
D: 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?
P: No, I don’t want them to know.
D: 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?
P: Okay.
D: 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
friend 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?
P: Yeah.
D: 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?
P: Okay.
D: Is there anything else you wanted to talk about today?
P: No.
D: Do you have any questions?
P: I can’t think of any.
D: How are you feeling now, Tom? Do you think this talk had helped a little?
P: Yes, thank you.
D: 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?
P: Okay.
D: 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?
P: Thank you.
836
DUCTAL CA IN SITU
You are an F2 in surgery.

Sarah aged 60 has presented to the outdoor clinic to receive results of FNAC done as part of
breast screening a few days back. FNAC shows low grade Ductal Carcinoma In Situ (DCIS).
Talk to her & address her concerns.
Do not examine the patient.
D: Hello, how are you doing today?

P: I am here for my results. PM really worried about the results.
D: May I know why?
P: When I came for routine breast screening, they took samples from my breast. Before that
they only used to do an x-ray. Now I received a letter saying that reports are ready. I'm really
worried about the results.
D: I have the test results with me. Can I ask a few questions before I tell you the results?
That way I’ll be able to explain the results better.
P: No
D: Can you please tell me what brought you to the hospital?
P: Yes, I came for routine breast screening.
D: Have you ever had the screening before?
P: Yes, 3 years ago
D: Was it normal?
P: Yes
D: Did you notice anything in your breast?
P: I’ve been examining myself regularly for any lump in my breast, but I haven’t found any.
D: Have you noticed any discharge or bleeding from the breast?
P: No
D: Have you noticed any discharge or bleeding from the nipples?
P: No
D: Have you felt any pain anywhere in the breast recently?
P: No
D: Have you noticed any change in the skin of the breast?
P: No
D: Have you noticed any change in the size and shape of the breast?
P: No
D: Have you felt any lumps or bumps in your breast?
P: No
D: Have you felt any lumps or bumps elsewhere in the body?
P: No
P: It’s alright
D: Have you noticed any decrease in weight?
837
P: No
D: Any SOB or heart racing?
P: No
P: No
D: When did you have your first period?
P: No
P: No
D: Have you used any contraception in the past?
P: No
P: No
D: Any lumps in the past?
P: No
P: No
P: No
D: Have you ever taken hormone replacement therapy?
P: No
P: No
P: No
P: Yes/No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: Yes/No.
P: No dr.
D: I have the results of the biopsy. Is there anything specific that you're worried about?
P: I'm just afraid that it might be cancer.
D: The results show that you have low grade Ductal Carcinoma In Situ, a less serious type of
breast cancer. You actually have a non-invasive form of breast cancer. The breast tissue is
838
made of a lot of small ducts which form an internal duct system within the breast. In this
type of cancer, the cancer remains in the ducts only & does not spread anywhere else & can
be fully treated. In invasive type of cancer it can spread to other areas of the breast as well
as the body even after treatment.
The type of cancer you have is an early type of cancer. There’s usually no lump initially. It is
mostly found on routine breast screening & is confirmed with a biopsy.
Treatment
D: The only treatment for this kind of breast cancer is surgery. You might need a surgery to
remove an area of the breast (Wide local excision), or to remove the whole breast,
surgically. We will remove the affected breast tissue during surgery. After the surgery you
might need to take radiotherapy to kill any abnormal cells still left in the breast tissue.
However, Mastectomy might be done if the area involved in DCIS is large or there are
several different areas of DCIS. In case of mastectomy we can offer you breast
reconstruction.
This is a non-invasive type of cancer so it doesn't spread to other areas. Surgery treats it
completely. The chances for this type of cancer to recur are also extremely low.
Lumpectomy/Mastectomy:
In lumpectomy only a small lump is removed. It is done in cases where there are small lumps.
In mastectomy the whole of the breast tissue is removed. It is done in cases when the area
affected is larger.
-You’ll also be assigned a breast care nurse who will help you & guide you along each step.
-Nowadays the patient knows that its cancer, so counselling is important.
-If she has a sister who is in 30's so can offer her as well screening.
839
PRE-CONCEPTION COUNSELLING

Lucy, 36 year old female presented to your clinic. She wants to become pregnant and is here
for advice regarding that.
1. Discuss about the potential impact of maternal age on fertility and birth outcomes.
Women over 35 have an increased risk of miscarriage, chromosomal abnormalities
2. and obstetric complication compared with younger women.
3. Discuss interpregnancy interval (ideally 18-59 months)
4. Advise that sexual intercourse every 2-3 days optimizes the chance of pregnancy
5. Advise women who are risk for NTD to take folic acid daily
6. Eat healthy and balanced diet and maintain a healthy weight
7. Stop smoking, avoid drinking alcohol and avoid taking any recreational drugs
840
SICK NOTE
You are FY2 in A & E.

Mandy Hills aged 29 presented to the hospital 2 weeks ago after an accident.
Record in the Emergency Unit shows that she had no injuries and was certified fit.
She has come in now for a Sick Note.
(Sometimes states Patient had a Road Traffic Accident 2 weeks ago and had minor injuries.
She has recovered now and has come for a review).

P: I need a sick note for my job.
D: Why do you need a sick note?
P: I had an accident 2 weeks ago and I want time to recover.
D: Can you tell me more about the accident?
P: I was drunk and was driving my car when I had the accident.
D: What did you do after the accident?
P: I took 2 weeks off from work to recover. But now I want to take few more days off to
recover. That's why I need a sick note from the hospital.
P: Like what?
D: Do you have pain?
P: Yes/No
D: Any breathing problems?
P: No
D: Any swellings?
P: Yes/No
P: Good/Bad
D: Do you sleep fine?
P: Yes/No
P: Yes/No
D: Can you tell me about your work?
P:
P: No
P: No
D: any DM, HTN or Heart disease?
P: No
841
P: No ’
P: No'
P: No
D: Do you smoke?
P: Yes/No
D: How often do you drink alcohol? (CAGE)
P:
D: Tell me about your diet? • AL
P: No Dr.
D: I will check the records.
P: Ok
D: The records state that you were certified fit and you had no injuries at that time.
P: Can you please change the notes and give me a sick note which says 1 had injuries and need
to rest for few more days?
D: Why do you want to do that?
P: I will lose my job if you don't give me a sick note. I don’t have any support.
D: I am sorry, unfortunately we cannot give you a sick note with changed findings.
P: Doctor you don't understand. The police took away my car and I don’t have any way to get
to work. So please give me a sick note.
D: I can imagine things are difficult for you. Is there any other way you can arrange
transport? Could you ask your colleagues to pick you up and drop you off?
P: I can try
D: I can arrange a meeting with Citizens Advice Bureau or the Job Centre to help you.
P: Ok
D: Is there anything else I can help you with?
P: No
842
ELDERLY WOMAN MED REVIEW

An elderly woman is coming for follow-up of her test results.
Test results:
TSH low,T3,T4 high. Blood pressure:160/95
Cholesterol in normal range. Her meds:
Levothyroxine 125 microgram/litre once daily. Statin 20mg once daily.
Amlodipine 5mg once daily.
Discuss test results with her, review her medications and discuss further management.
Dr: Hello, my name is Dr. XYZ. I am one of the junior doctor. I understand that you are here
for your follow up.
Pt: Yes doc.
Dr: Alright, I have test results with me. Before explaining your results, is it ok if I can discuss
somethings with you to have a better understanding of your health?
Pt: Ok doc
Dr: Why did you come in the first place to GP clinic?
Pt: For regular check up
Dr: Okay, how is your health overall?
Pt: I am fine doc
Dr: Any visual disturbances? (Hyperthyroidism symptoms)
Pt: No
Dr: Any chest pain?
Pt: No
Dr: Any change in bowel habit?
Pt: No
Dr: Any heat intolerance?
Pt: No
Dr: Any tummy pains (hypertension symptoms)
Pt: No
Dr: Any headaches?
Pt: No
Pt: I have hypothyroidism.
Dr: From how long?
Pt: From last 10 years
Dr: So how are you managing it?
Pt: I am taking levothyroxine 125microgram/litre daily.
Dr: Are you taking it as prescribed?
Pt: Yes
Dr: Any other health problems?
843
Pt: I have hypertension and high cholesterol.
Dr: Are you taking medicines for them?
Pt: I am taking statin 20mg daily but not taking blood pressure med.
Dr: May I know why?
Pt: I have run out the medication.
Dr: From how long you are out of it?
Pt: From last 3 months.
Dr: Any other medication?
Pt: No
Dr: Any allergies?
Pt: No
Pt: With my daughter
Dr: Do you smoke or drink?
Pt: No
Examination
Dr: Ok now, I would like to check your vitals i.e. your blood pressure, pulse, respiratory rate
and temperature. Also your thyroid gland and general examination of your body.is it ok?
Pt: Ok
Discuss results
Dr: From your results, we can see that unfortunately your thyroid is working more than
normal. Also your blood pressure is quite high. Your cholesterol levels are gladly normal.
Pt: So what are you going to do for me?
Dr: As your thyroid is working more, we have to reduce its dose to 100 microgram/litre.
What do you think?
Pt:(patient will become angry at this point and doesn’t want this change in dose.) No doc, I am
feeling better. I don’t want this change in my dose.
Dr: I can understand that but its important to reduce the med dose because extra thyroid
hormones can do harm to your body I am afraid.
Pt: How by just looking at my blood results, you can say that you want to reduce the dose?
Dr: These results are showing that thyroid levels are more in your blood than normal that’s
why we are concerned.
Pt:(patient will keep complaining )
Keep convincing her and involve seniors
Dr: Also, we can see that your blood pressure is high. And you have runout of the med.
Pt: Yes doc, I think that blood pressure is short term and it will go away .
Dr: I am sorry but blood pressure is long term condition and if you will not take your med
then it can cause serious side effects.
Pt: I will think about it
Dr: We will also refer you to a specialist doctor(endocrinologist).is it ok?
Pt: ok
844
Dr: We will arrange your follow up in a month. In the meantime, if you feel blurry vision,
chest pain, change in bowel habit or headaches please let us know.
845
LEVOTHYROXINE DOSE ADJUSTMENT-DAUGHTER CONCERNED

Mrs. Michelle Armstrong, daughter of a 65-year-old lady living in care home presented to
you to know why she has not been informed about the dose reduction of her mother's
thyroid medication. Daughter has the power of attorney and her mother doesn’t have the
capacity. Thyroid function tests were normal and thyroid function tests will be done again
after 6 weeks to check her mother's thyroid hormone levels.

Dr. I am Michelle. I am the daughter of your patient, Mrs. Smith. I am here to talk about her
Dr: Can you tell me what exactly happened?
P: Dr. I went to the nursing home and I came to know your colleague has changed my mother's
thyroid medication without informing me.
D: Can I ask you a few questions to have a better understanding of your mother’s health?
P: Yes.
D: How often you come to the care home to see her.
P: I come here once a week.
D: Can you please tell me about your mother's thyroid problem?
P: Dr. she is doing fine. She has been taking the thyroid medication for 6 years now. She
doesn't have any symptoms of thyroid now.
D: Has she been diagnosed with any other medical condition in the past?
P: Yes, she has dementia for the last 10 years.
D: Is she on any other kind of medication except the thyroid one?
P: No.
D: How is she coping up with her dementia?
P: Dr. it was getting difficult for me to take care of her alone as I am working full time. So, I
decided to send her to care home. She has been there for 8 years now. They keep me updated
about my mother's health time to time. And the doctors always inform me about my mother's
health and medications. But I don't know what happened this time.
D: We always do thyroid function test regularly and make the changes in the medications
depending on the blood results. This time when we did the test, there was a little bit
improvement, so we reduced the dose of levothyroxine.
P: Why I was not informed regarding the dose reduction of levothyroxine, I have got power of
attorney as well.
D: I can see you are upset regarding this matter. We take good care of all the patients. If
there are any changes in the treatment, we are doing it for the betterment of our patients. I
know you are having power of attorney so you have rights to discuss about your mother’s
treatment with the doctors and you can also give your opinion regarding what kind of
treatment is not suitable for your mother. I can reassure you all the treatment we are giving
is for the benefit of your mother only.
846
P: I want to speak to your senior?
B: We will document everything. We will escalate this issue to the consultant and seniors. If
you want to speak to our consultant, we will make an appointment for you.
P: But I don't know why her medication has been reduced.
D: Let me explain it to you further. Your mother was having a condition what we call
hypothyroidism that means her thyroid gland was underactive and was not secreting
enough hormone. So, we gave hormone replacement medication to make up for it. Now her
hormones have come back to normal. If we continue giving the medication at the same dose
there is a chance of overactivity of hormones. That's why we had to reduce the dose of the
medication.
P: Ok.
D: We will be checking your mother's thyroid hormone levels after 6 weeks. And decide how
the treatment will progress. We will update you as soon as we get the results.
P: Ok. Thank you.
P: I want to make the complaint.

D: We have a service in the hospital to deal with patient’s complaints (Patient Advisory
Liaison Service). We can arrange an appointment for you with them.
847
EUTHANASIA
You are FY2 in Medicine ward.

A 70 years old female named Mrs. Smith had stroke and now she is in the care home . Only
palliative care can be given to the patient. She is conscious.
Talk to the son and discuss the situation of the mother with him.
D: Hi, I am James one of the junior doctors working in this department

D: Can I confirm your name please
P: Yes Dr., my name is Patrick and I am the son of Mrs. Smith.
P: I want to talk about my mother
D: Okay Patrick we are here to help you out but could you please tell me how much do you
know about your mother.
P: Yes Dr. I know my mother had a stroke and now doctors have decided that no aggressive
treatment can be given and that she can be given palliative care treatment only.
D: Exactly Patrick I am glad to know that you care about your mother and you are concerned
about her .
P: Doctor I need to discuss about. Is there anything by which she can die with dignity. She has
suffered a lot and still suffering.
D: Why do you think like that?
P: Doctor she is suffering since long and I can’t see her in pain anymore I want her to die with
dignity . Is there anything you can do for her?
D: we are providing her the best possible care and now we have planned to provide her with
palliative care .
P: Doctor I want her to die with dignity as she is suffering and these treatments would make
her suffer more .
P: Doctor I want to talk to you about EUTHANASIA
D: What do you know about euthanasia ?
P: Yes I know that doctors give some medications to the patients to end their life and
decreasing their sufferings.
D: Patrick do you know that euthanasia in England is ILLEGAL ?
P: But doctor euthanasia is legal in the Sweden .
D: But here in England it is totally illegal to do it . Because it is like killing someone else or
ending up their life. It is against the good medical practice.
D: we are providing with the best possible care to your mother.
D: Are you with me?
P: Yes Dr.
D: I know it must be very hard time for you but we have many other options for you as well.
Okay let me explain it to you in more detail.
Euthanasia is the act of deliberately ending a person's life to relieve suffering.
848
For example, it could be considered euthanasia if a doctor deliberately gave a patient with a
terminal illness a drug they do not otherwise need, such as an overdose of sedatives or
muscle relaxant, with the sole aim of ending their life.
Assisted suicide is the act of deliberately assisting another person to kill themselves. If a
relative of a person with a terminal illness obtained strong sedatives, knowing the person
intended to use them to kill themselves, the relative may be considered to be assisting
suicide.
The law
Both euthanasia and assisted suicide are illegal under English law.
Assisted suicide
Assisted suicide is illegal under the terms of the Suicide Act (1961) and is punishable by up
to 14 years' imprisonment. Trying to kill yourself is not a criminal act.
Euthanasia
Depending on the circumstances, euthanasia is regarded as either manslaughter or murder.
The maximum penalty is life imprisonment.
Types of euthanasia
Euthanasia can be classified as:
• voluntary euthanasia – where a person makes a conscious decision to die and asks for help
to do so
• non-voluntary euthanasia – where a person is unable to give their consent (for example,
because they're in a coma) and another person takes the decision on their behalf, perhaps
because the ill person previously expressed a wish for their life to be ended in such
circumstances
DIVERT HIS ATTENTION TO END OF LIFE CARE INSTEAD

End of life care
When you're approaching the last stage of your life, you have a right to high quality,
personalised end of life care that helps you live as well as possible until you die.
Find out more about:
1. where you can receive your care, If you are approaching the end of life, you may be
offered care in a variety of settings. The palliative care team will organise for you to be
cared for according to your wishes. You can receive end of life care: • at home • in a care
home • in a hospital • in a hospice
2. coping with a terminal diagnosis
3. ways to start talking about the fact you're dying
4. managing pain and other symptoms
Pain
Not everyone approaching the end of life has pain. If you do, your doctor or nurse will assess
the pain and decide on a suitable medicine and the correct dose to manage it.
They'll ask you (or your family or carers if you're not able to communicate) questions about
the pain.
849
These might include:
• where the pain is
• when it started
• the effect it's having on you – for example, whether it's stopping you sleeping
The doctor or nurse will sometimes ask the palliative care team to advise them. Pain-
relieving medicine is available at home and in hospitals, hospices and care homes.
Your doctor or nurse will use the weakest painkiller available that keeps you free from pain.
In order of strength (starting with the weakest) there are:
• non-opioid painkillers, such as paracetamol
• mild opioids, such as codeine
• strong opioids, such as morphine
An opioid is a chemical that works by binding to opioid receptors in the body (found mostly
in the central nervous system and gut), which reduces the pain we feel.
How are medicines given?

You'll usually be given medicines in the least invasive way possible. This means they'll be
given in a way that causes the least amount of discomfort, pain or distress.
The first step is to take them by mouth (orally).If taking medicine by mouth is not possible,
for example if you're being sick or cannot swallow, you can have painkillers:
• through an injection under the skin (subcutaneous)
• through an injection into the muscle (intramuscular)
• directly into a vein (intravenous)
Sometimes a small battery-operated pump called a syringe driver is used to give medicine
continuously under the skin for a period of time, such as 24 hours.
You might be offered a syringe driver if you cannot take medicine by mouth – for example, if
you're being sick or have difficulty swallowing.
There are also some strong painkillers that can be given through a patch on the skin.
Sometimes supplementary (adjuvant) painkillers are used alongside non-opioid and opioid
painkillers.
Adjuvants include medicines designed for other conditions, such as epilepsy, but work well
with certain types of pain, such as nerve pain.
Coping financially and benefits entitlement

Money can be a worry if you or a family member need to take time off work as a result of
illness or to care for someone with a terminal illness. But there is support available. Ask a
GP, hospital doctor or nurse to refer you to a hospital social worker or community social
worker. They can assess your financial situation and give you advice on benefits. They can
also tell you about any special funds you might qualify for.
Making a legally binding advance decision to refuse treatment You make the advance
decision, as long as you have the mental capacity to make such decisions. You may want to
make an advance decision with the support of a clinician. If you decide to refuse life-
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sustaining treatment in the future, your advance decision needs to be: • written down •
signed by you • signed by a witness If you wish to refuse life-sustaining treatments in
circumstances where you might die as a result, you need to state this clearly in your advance
decision. Life-sustaining treatment is sometimes called life-saving treatment. You may find it
helpful to talk to a doctor or nurse about the kinds of treatments you might be offered in
the future, and what it might mean if you choose not to have them.
Creating a lasting power of attorney so someone you trust can make decisions for you if you
cannot make them in the future If you become unable to make decisions for yourself in the
future, someone will need to make decisions for you. Who does this will depend on the
situation. Generally, professionals will make decisions about your health and social care,
and your family or carers will decide on day-to-day matters. If you wish, you can officially
appoint someone you trust to make decisions for you.
This is called making a lasting power of attorney (LPA), and enables you to give another
person the right to make decisions about your care and welfare. You can also appoint an
attorney to decide on financial and property matters.
Is euthanasia legal in the UK?

Euthanasia is a crime under English law, carrying a maximum penalty of life in jail, and
assisted suicide 14 years. The only exception is "passive euthanasia", which is where
treatment that might extend someone's life is withdrawn - such as a life machine being
turned off. For terminally ill patients in the UK, the only alternatives are hospice care or
refusing treatment, which mentally capable patients have the right to do. As a result, some
terminally ill people decide to travel abroad to die.
851
NAI (SEXUAL HARASSMENT)

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.
(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)

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)
Pt: No
Pt: No
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
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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

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.
853
COUNSELLING STATIONS
FIRST SEIZURE
You are FY2 in medicine.

Mr. Mike Taylor, aged 10, has been brought in by his mother because of having a fit.
D: How can I help?

P: My son had a fit.
P: 2 hours ago
P: Like what?
D: How was he earlier, before the fit?
P: He was fine.
D: What was he doing when he had the fit?
P: He was in his room.
D: What happened when you found him?
P: He was on the floor.
D: Did he have up-rolling of the eyes?
P: Yes/No
D: Did he have jerky movements?
P: Yes/No
D: Did he have frothing from his mouth?
P: Yes/No
D: Did he hurt himself during the fit?
P: No
D: Was he unconscious?
P: Yes
D: How long did this episode last for?
P: 2-3 minutes
D: Was he drowsy when he woke up?
P: Yes
D: Did he have any fever?
P: No
P: No
D: Any headaches?
P: No
D: Did he miss any meals?
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P: No
P: No
P: No
P: No
P: No
P: No
D: Anyone in the family have epilepsy?
P: No
P: Good
D: Does he do physical exercise?
P: Swimming
D: Does he do well in school?
P: No
D: Who else takes care of your son?
P: My husband
I would like to check his vitals and do the GPE. I would also like to do some baseline
investigations including routine blood tests, glucose, electrolytes, calcium, renal function,
liver function and urine test. We may also plan an EEG and an MRI or CT scan.
From our assessment, it seems that your son had an episode of a fit. It occurs when there is
a sudden burst of electrical activity in the brain temporarily interfering with the normal
messaging processes. It can happen due to many reasons, such as low blood sugar,
infections or trauma.
Treatment:
We will keep him under observation at the hospital and will arrange a specialist review once
the investigations are back. Children and adults who have had a suspected first seizure should
be referred urgently within 2 weeks’ time to an epilepsy specialist (children do not routinely
require referral following a febrile convulsion).
Until then, I’ll discuss what precautions you can take if he has another fit.
If you’re with someone having a fit:

- only move them if they’re in danger, such as near a busy road or hot cooker
- cushion their head if they’re on the ground.
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- Loosen any tight clothing around their neck, such as a collar or tie, to aid breathing
- turn them on to their side after their convulsions stop (recovery position)
- stay with them and talk to them calmly until they recover
- note the time the seizure starts and finishes
Call 999 and ask for an ambulance if:

- it’s the first time someone has had a seizure
- the seizure lasts more than 5 minutes
- the person does not regain full consciousness, or has several seizures without regaining
consciousness.
- the person is seriously injured during the seizure
Most people with epilepsy can take part in sports and other leisure activities. There are some
precautions you might need to take if your seizures are not well controlled.
For example you may need to:
- avoid swimming or doing water sports on your own
- wear a helmet while cycling or horse riding
- avoid using certain types of gym equipment – ask staff at the gym for advice
Differential Diagnosis
Syncope
Transient ischaemic attack
Metabolic encephalopathy
Sleepwalking
Night terrors
Complex migraines
Cardiac arrhythmias
Psychogenic non-epileptic seizures
856
EPILEPSY DISCHARGE

Mr. Sarjeet Singh, aged 27, presented to the hospital for his follow up.
He was admitted to the hospital four weeks ago after having fits. Diagnosis of epilepsy has
been made. He got discharged and now is on medication.
Please talk to the patient, take relevant history and address his concerns.
You have the discharge summary beside you and in the cubicle.

P: I came for my review.
D: I understand that you were admitted and diagnosed with epilepsy four weeks ago. How
are you now?
P: I had two attacks afterwards. I came here today for my review.
D: Tell me more about it? When did it happen?
D: Any change in the attacks?
D: You have given a medication for epilepsy. Were you taking it regularly?
P: I was prescribed Sodium Valproate after I got discharged. I was taking my medication
regularly, once a day. But after that I had an attack and I started taking it only when I had the
feeling that I would have an attack.
D: Did anyone tell you how you should take your medications at discharge?
P: When I got discharged someone talked to me about my medication but I was not paying
attention. I didn’t know how I should take it.
D: It is very important to take your medication regularly as prescribed. You should take your
medication twice but you took it once a day. It takes time for the medication to build up its
maximum effect in your body so it is important to take it regularly even after you have had a
fit. So please make sure you take it twice a day.
D: Did you experience any side effects of the medication?
P: Yes I was having headache.
D: Please don’t worry this headache will go after some time or we can give you some
painkillers, but if still persists we can review your medications. But you have to take the
medication as prescribed.
D: Did you have any infection? Fever or flu like symptoms?
P: No.
D: What were you doing when you had the attacks?
P: Doctor, when I had my first attack I was at my friend’s place for a party and I had a few cans
of beer, then I had an attack. My friend took me home.
D: Did you have enough sleep? Were there flashing of lights or loud music? Any recreational
drug? Do you eat regularly, any skipped meals? Do you drink enough water? Any strenuous
exercise? Any stress in your life?
D: What you do? Do you have to sit in front of computer for long hours?
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D: How about the second time?
P: The same happened the second time.
D: Let me tell you that alcohol, lack of sleep, skipping meals, flashing lights can be the trigger
for your epilepsy attacks. Please try to avoid all these things. Dehydration and excessive
exercise can also trigger epilepsy. Try to relieve your stress by doing yoga or meditation. If
you need any support, we are here for you.
Spending too much of time in front of the computer can trigger your condition.
It would be great if you could spend less time in front of the computer. Try to give yourself
breaks in between. You may try' to use special screens on your computer.
D: whom do you live with?

P: I live with my parent’s doctor.
People can drive after a year when they are symptom free. GP can discuss in detail.
People who drive and get diagnosed with epilepsy, should stop driving and they have to
inform the DVLA.
General advice:
1. Use guards on heaters and radiators to stop you falling directly on to them.
2. Install smoke detectors to let you know' that food is burning if you sometimes forget
what you're doing or have seizures that cause you to lose awareness
3. Cover any furniture edges or corners that are sharp or stick out
4. Have a shower instead of a bath and don't lock the bathroom door
5. Place saucepans on the back burners and with the handles turned away from the edge of
the cooker
6. You can also wear a bracelet that can inform other people about the condition in case of
any emergency.
Side effects of Sodium valproate:

Nausea. Gastric irritation. Diarrhoea. Weight gain. Hyperammonaemia (you have too much
ammonia in your blood). Thrombocytopenia (low levels of platelets in your blood, which
may mean you bruise easily). Transient hair loss (regrowth may be curly). Increased
alertness.
858
BP MANAGEMENT
You are an F2 in working in GP clinic.

Mr. Pat Murphy aged, 55 presented to you for his first follow-up.
Patient has diabetes mellitus. Patient has been admitted to the hospital due to cellulitis four
weeks ago and was treated for it with antibiotics. During the admission, patient was newly
diagnosed with hypertension. On discharge, patient was prescribed with some medications.
Please talk to the patient, take focused history, check his/her blood pressure and discuss
about further management with the patient. This is patient’s first review after being
diagnosed with high blood pressure.

P: Four weeks ago. I was diagnosed with cellulitis and I was admitted in the hospital and
treated with antibiotics. During that period I was diagnosed with high blood pressure and I
came here for my review today.
D: How is your leg now?
P: It’s perfectly fine doctor.
D: If I am not wrong you have been prescribed some medication for your high blood
pressure?
P: Yes (points towards Enalapril)
D: Are you taking your medication? P: I stopped taking my blood pressure medication 3
weeks ago
D: Why?
P: This blood pressure medication gave me this cough.
D: Why do you think that way?
P: I am taking these (point towards Aspirin and Statin) for a long time and I never had any
problems. 1 am sure it is because of my blood pressure medication. I don't want to take this
medication.
D: Any fever, flu like symptoms or phlegm during the time you were coughing?
P: No.
D: Any symptoms after you stopped taking your blood pressure medication?
P: No.
D: Any headache? Any dizziness? Any visual problem? Any chest pain. SOB or heart racing?
P: No
D: Have you been diagnosed with any other medical condition other then high blood
pressure.?
P: I have Diabetes.
D: For how long?
P: 10 Years.
P: My diabetes is controlled on diet.
D: Are you taking any medications for it?
859
P: No doctor.
P: Yes.
D: Any complications of diabetes?
P: No doctor.
P: Yes I frequently go to my GP and he said my diabetes is well-controlled.
D: Do you go for your annual check ups?
P: Yes doctor
D: Do you have any other medical conditions?
P: No doctor.
D: Any kidney disease, heart problem?
P: No doctor
D: Since when have you been taking these Aspirin and statin?
P: 10 years.
P: Yes doctor.
D: Do you take any other medications?
P: No
D: Do you smoke?
P: Yes/no
P: Yes/no
P: Not good
P: Not active
GIVE LIFESTYLE ADVICES ACCORDINGLY
D: I am going to check your blood pressure now.

EX: 170/100.
 D: Your blood pressure is high and it is because you haven't taken your blood pressure
medication in last few days. The medication you were prescribed causes persistent dry
cough.
 You were experiencing this side effect.
 I will discuss this with my seniors. We will change your medication to another one and
hopefully you can take it this time without any problems.
 We will change your medication to another group of medication (ARBs).
 We have different options, one of them is called Losartan (50-100 mg OD) and the other
one is called Telmisartan (20-80mg OD). I will confirm with my book as well.
860
 Take your medications regularly as we prescribed, otherwise you may face many
problems in the future. If you develop any side effects, please feel free to come back to
us.
S/E of ARBs
Dizziness, headache, drowsiness, nausea, vomiting, diarrhoea, elevated potassium levels.
NOTE:
Sometimes in this station patient is on Amlodipine and he complains of Ankle edema
(Common
side-effects of CCB's). Then we can change to other drug and I will confirm with my book.
If patient is insisting which one then we can say ACE inhibitors (Ramipril)
861
CDAD
You are F2 in Genera! Medicine.

James Henry aged, 75 year presented to the hospital 10 days ago. The diagnosis of
pneumonia has been made. Patient has been admitted in the hospital and treated with
antibiotics and recovered from pneumonia.
Patient developed diarrhoea 2 days ago before getting discharged.
Investigation has been done. On stool sample the diagnosis of Clostridium Difficile
Associated Diarrhoea has been made. Patient has been moved to another ward with
patients with similar conditions. Patient is now receiving IV fluids and antibiotics.
Please talk to the patient’s son and address his concern.
His son is really concerned about his father’s condition and wants to talk with you. Consent
has been taken from the father to talk to the son.

P: My father was unwell 10 days ago, we brought him to the hospital and he was admitted. He
has been recovering but he developed diarrhoea two days ago. Why has he been shifted to
different ward.
D: Why did you bring your dad to the hospital?
P: We brought him to the hospital because he had shortness of breath and cough for a few
days.
D: Yes he was diagnosed with pneumonia and we treated tibiotics. He was treated with
antibiotics and recovered well, but like I said he developed diarrhoea two days ago. He has
been moved to the ward with other people.
P: So why did he get diarrhoea now?
D: As you know your dad has been diagnosed with pneumonia and treated with antibiotic.
One of the possible side effects of antibiotic is diarrhoea due to inflammation of the bowel.
P: How it is possible?
D: There are good bugs in the normal flora of the bow el that help to digest the food. When
this gets altered then the problem like diarrhoea can happen. We checked your dads stool
and the result shows a bug called Clostridium Difficile. When this overgrows it can cause
inflammation of the bowel and diarrhoea. This condition is called Clostridium Difficile
Associated Diarrhoea or Pseudomembranous Colitis.
P: This means it is not a food poisoning?
D: In your dad’s condition the most likely cause of diarrhoea is antibiotic that can lead to
this condition.
P: Doctor, he must have gotten it from the hospital. Can you get it from other people?
D: This condition can also pass from person to person, however, in the hospital we take all
the necessary precautions to prevent this from happening. So this is very unlikely to be the
cause.
Here it is one of the complications of the medication that he has been receiving for his chest
infection.
862
It is important to point out that this infection is more common in older people in over 65
years.
P: Doctor, did you give him the wrong medication?
D: I do understand your concern but your dad had chest infection and treatment is
antibiotics.
We did not give him any wrong antibiotic this is one of the side effect of the medication that
your dad need to take.
P: But doctor why is he in the ward with other patients with food poisoning?
D: As you possibly know that the bug that cause diarrhoea can easily pass from person to
person that's why when we have any patient with diarrhoea in the main ward we will shift
them to a separate room or another ward to look at our patients more closely and to
prevent this bug from spreading.
P: What are you going to do for my dad?
D: We checked your fathers stool to find which bug caused diarrhoea.
We will do some further investigations like routine blood to see the amount of blood cells
which fight against bugs in our body. We may need to have a look at your father's bowel by
doing a procedure called colonoscopy. We may need to take some sample.
We may also need to do some imaging such as X-Ray or CT Scan.
P: Doctor how are you going to treat my dad?
D: First we stop the medication that caused this condition. Since your dad has diarrhoea and
he has lost fluid we are giving him IV fluids.
We have prescribed him strong antibiotic. Symptoms usually improve within a few days.
(Vancomycin or Metronidazole for 10-14 days).
We will give your dad some protein supplements and minerals to compensate this loss.
P: Doctor, are you giving him antibiotics again?
D: Yes we must prescribe antibiotic. If this condition is left untreated it may cause some
complication such as bowel perforation, which needs surgery. We don't want this to happen
to your dad.
GENERAL ADVICES:
1. Wash your hands regularly with soap and water, particularly after going to the toilet and
before eating - use liquid rather than bar soap and don't use flannels or nail brushes
2. Visitors to wear disposable gloves and gown and wash their hands with soap and water
as they enter and leave the room.
3. Clean contaminated surfaces - such as the toilet, flush handle, light switches and door
handles with a bleach-based cleaner after each use
4. Don't share towels and flannels.
5. Wash contaminated clothes and sheets separately from other washing at the highest
possible temperature.
6. When visiting someone in hospital, observe any visiting guidelines, avoid taking any
children under the age of 12, and wash your hands with liquid soap and water when
863
entering and leaving ward areas - don't rely on alcohol hand gels, as they're not effective
against C. difficile
Avoid visiting hospital if you're feeling unwell or have recently had diarrhoea
864
MRSA
You are an F2 in Respiratory Dept.

Mr. Smith Brown aged, 65 was admitted to the hospital few days ago. Patient has been
diagnosed with COPD. Nasal swab has been taken. The result shows MRSA. Patient has been
isolated and all necessary precautions have been taken. Please talk to the wife and address
her concern. Consent from husband has been taken.

P: My husband was doing well, but I don't know why he was shifted to a separate room.
Doctors are wearing some different cloth and mask. I'm not being allowed to go inside.
D: Let me ask you a couple of questions.
P: OK.
D: Why you brought him to the hospital?
P: He has smoker’s cough and suddenly 2 days before he became breathless so I brought him
to the hospital and he was admitted.
D: How is he now?
P: They gave him antibiotics and he was improving.
D: Any cough?
P: No. he is better now.
D: You told me he has COPD, when was he diagnosed with COPD?
P: It's more than 10 years.
P: He is taking blue and brown inhalers.
D: Is his condition well controlled?
P: Yes doctor.
D: Has he been diagnosed with any other medical condition?
P: No
D: Does he take any other regular medication, herbal remedy, supplements or OTC drugs?
P: No
D: Does he have any allergy?
P: No
D: Does he smoke?
P: Yes, elaborate.
P: Occasionally.
D: Tell me about his physical activity?
P: He is not quite active.
D: How about his diet?
P: We try to eat healthy.
P: Doctor, what is going on with him?
865
D: You told me your husband has COPD and was admitted because of chest infection. We
took some swab from his nose.
D: Has anyone told you about the result?
P: No.
D: The result of the swab shows you have MRSA.
Do you know what MRSA is?
P: I saw about it on TV. It is a superbug with no treatment and it is very dangerous.
D: MRSA is a type of bug that doesn’t respond to normal antibiotic BUT we have many
strong antibiotic that can fight against this bug. MRSA stands for Methicillin Resistant
Staphylococcus Aureus.
This bug is not more aggressive or infectious than other subtypes of Staph. Aureus.
However, many antibiotics don’t work against MRSA. But we have many good and strong
antibiotics that can work against MRSA.
P: What are you going to do for my husband?
D: He has already been shifted to a separate room and we will treat your husband with
medication. We don’t want your husband to catch any other bug as he is weak and this can
be dangerous for him and we don't want this bug to spread in the hospital.
P: I heard it spreads due to dirty hands because people don't wash hands properly. Is that
correct?
D: MRSA spreads from person to person, usually through direct skin-to-skin contact. If a
person is healthy. MRSA usually won’t cause infection. We call this person MRSA carrier,
when we have poor immune system this bug can be infective. That's why when we admit
our patient we check by taking swab and if they have MRSA we can look after them better.
P: How are you going to treat my husband?
 D: When a person is an MRSA carrier, we will consider decolonization, which involves
using antibacterial body wash or powder, cream and shampoo.
 Antibacterial products such as body wash to remove MRSA from the skin. This must be
used daily for 5 days. (Chlorhexidine). This must be used like a shower gel. You have
apply a small amount to whole body including groin and armpit.
 An antibacterial cream can be used to remove MRSA from inside your nose. This should
be used three times daily for 5 days. (Mupirocin Nasal ointment 2%).
 An antibacterial shampoo can be used to remove this bug from your scalp. This should be
used daily for 5 days.
 During decolonization process, you should wash every day, ideally using a fresh towel to
dry yourself each time. You should also wear a new set of clothes each day. The bedding
will also be changed on a daily basis.
 After completing 5 days course you must be rescreened. We rescreen 48 hours after
completing the course and at 48 hours interval until 3 sets have been sent. If you still
have MRSA positive, then course of decolonization should be completed up to two times
after the course.
P: I heard MRSA kills many of our people?
866
D: From what you told me and what we did it seems your husband hasn’t developed any
MRSA infection. He is only MRSA Carrier and hopefully we can clear the bug from his body
with the help of medication which I already mentioned. However, even if he develops MRSA
infection we have many good antibiotic that can fight against MRSA and most patients
respond to this Antibiotic. These antibiotics are usually given through blood vessel as a drip.
Swabs may be taken from several places, such as your nose, throat, armpits, groin, and any
damaged skin. This is painless and it takes just a few seconds. The result will be available
within few days.
867
POST MI LIFESTYLE
You are an F2 in Medicine.

Mr. Ashley Brown aged 55 had MI 4 days ago. He was admitted to the hospital. He has been
medically managed. He is going to be discharged.
Patient has been prescribed the following medication:
Aspirin, Bisoprolol, Simvastatin, Clopidogerol, and Ramipril.
Please talk to the patient, discuss about lifestyle modification and address patients concern

P: I am going to be discharged and I was told someone is going to talk to me.
D: I am glad that you are fine and you are going home. Could you please give me a quick
recap of what exactly happened to you?
P: I had chest tightness 4 days ago. I came to the hospital and they told me I had a heart
attack. I was given some medication. I am good to go home now.
D: How do you feel now? Any chest pain? Any chest tightness? Any SOB? Any heart racing?
Any ankle swelling?
P: No
D: Have you been diagnosed with any medical condition in the past? DM? HTN? High
cholesterol?
P: No
D: Do you know about your medications we have prescribed? Do you know how to take
those medications?
P: Yes
P: No
D: Do you smoke?
P: Yes'
P: Yes
P: Bad diet
P: Not active
P: Yes'
Smoking:
D: Smoking can damage the inside of wall of blood vessel and narrows them. I know it is not
easy to stop smoking but we are here to help you. We can refer you to the smoking
cessation clinic, they will do their best to help you to stop smoking by using different
868
methods. There are nicotine replacement products - including patches, gum. lozenges and
mouth and nasal sprays.
We can also provide with some tablets (varenicline and (bupropion).
DIET:
I understand that you have a busy life but it is very important to have a sensible diet. Having
a healthy diet will help in controlling your weight and reduces the risk of further
complications. Eating out is not healthy as they use a lot of salt, sugar and fat to make it
tastier. I understand it may be difficult to cook every day but you can cook once or twice
per week and use it for the whole week. So you don’t have to eat outside every day.
Using olive oil or rapeseed oil for spreads, salad dressings, cooking, baking and other food
preparation rather than animal-based fats such as butter.
Please try to have plenty of fruits and vegetables in your diet. Fruit and vegetables are a
vital source of vitamins and minerals. Eat at least five portions of fruit and vegetables per
day.
Please cut down the amount of red meat and processed meat such as sausages and bacon
and try to have white meat such as chicken and fish instead. Eat at least two portions of fish
per week, including a portion of oily fish
It is also better to have grilled, steamed or boiled food rather than fried food.
Eat at least 4 to 5 portions per week of a mixture of unsalted nuts and seeds.
Keep salt intake low (less than 6 g per day). Therefore, not to add salt at the table, and to
keep processed foods to a minimum.
Minimizing intake of foods containing refined sugars.
We can also refer you to a dietician who can help you better.
Physical activity:
It is advisable to have at least thirty minutes of physical activity every day five times a week.
(150 mins per week) You don’t necessarily have to go to the gym. It shouldn’t be in one
session, it could be split into two sessions of fifteen minutes or three sessions of ten
minutes. For example if you use public transport, you can get off one to two stops before
reaching home and you can walk instead. If you drive, please walk when you going to buy
something from your local shop. If you live in a flat, you can climb the stairs instead of using
the lift. Moderate intensity activities include those that can be incorporated into everyday
life such as brisk walking, using stairs, and cycling.
start at a level that is comfortable, and increase the duration and intensity of activity as
your fitness improves and hopefully you will be able to achieve it in next 6-8 weeks.
Stress: Stress could worsen your condition. So it is important to relieve your stress. You may
try doing some physical activities such as walkingjogging or swimming. In this way you can
relive your stress and relax yourself. You may also try taking yoga classes.
869
Alcohol: It is always advisable to cut down the amount of alcohol you take. The
recommended daily amount of alcohol is 2 units per day. I know it is not easy to cut down
but we are here to help you. We can refer you to our colleagues, they will do their best to
help you to cut down your alcohol.
DVLA recommends that all patients should stop driving for at least 4 weeks after a heart
attack.
DVLA recommends that patients who drives bus, coach should stop driving for at least 6
weeks after a heart attack.
Patients are usually able to have sex again once they feel well, usually in 4 to 6 weeks after
heart attack. (As long as you can walk without any discomfort such as shortness of breath.)
870
VASCULAR DEMENTIA (LIFESTYLE)

Mrs. Kathie aged 55 is diagnosed with psoriasis and is using skin emollients. Her psoriasis is
well controlled.
Her BMI is 32.
Talk to the patient and address her concerns.

P: Doctor can you tell me what is dementia?
D: Yes, but may I know why do you want to know about dementia?
P: Because my colleagues and my sister has got vascular dementia that is why 1 am worried
about it.
D: Could you please tell me how old was your sister when she was diagnosed with
dementia?
P: At the age of 65.
D: Let me ask a few questions to have better insight into your problem. What do you know
about dementia?
P: I know about dementia but I am just worried if I would get it.
D: Do you forget things these days?
P: No
D: Do you feel it is difficult to concentrate on your work?
P: No
D: Do you find it hard to carry out your daily tasks?
P: No
D: Do you feel confused about the time and place?
P: No
D: Do you often struggle to find the right word in the conversation?
P: No
D: How is your mood? Any mood changes?
P: No
P: It is fine
P: No
D: Have you ever been diagnosed with any medical condition in the past?
P: Yes, I have psoriasis.
D: How you are managing it?
P: I am using emollients for that.
D: Is it under control?
P: Yes
871
P: No
D: Any DM. HTN. high cholesterol, stroke or mini-stroke?
P: No
D: Are you taking any other medications including OTC or supplement;
P: No
D: Any steroids?
P: No
D: Has anyone in the family ever been diagnosed with any medical condition apart from
dementia that your sister has?
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: I eat everything like burger, chips, I mostly eat outside because I don’t have time to cook.
P: I don’t do much of it.
P: I live with my husband. He takes care of me, but I take care of him more.
I would like to check your vitals and do general physical examination.

We will do some routine blood investigations including liver function, kidney function,
cholesterol level check and Q-risk scoring as well to see your risks of having any stroke or
ministroke in the future.
We have done your examination and your BMI is in higher side. Your BMI is 32 which is a bit
higher which can lead to many problems like dementia mainly vascular dementia which is a
type of dementia.
 From our assessment there are some risk factors that you have for dementia, like your
age and family history, which we can’ t do anything about. Let me tell you the factors
where we can work on to decrease the risk of developing dementia.
 You need to make some change in your lifestyle.
 Smoking, alcohol, poor diet, lack of physical exercise and stress are the main cause of
which can lead to many problems in the future, like stroke and that can lead to
dementia.
Smoking:
 Smoking can damage the inside of wall of blood vessel and narrows them: this can
increase the risk of vascular dementia. I know it is not easy to stop smoking but we are
872
here to help you. We can refer you to the smoking cessation clinic: they will do their best
to help you to stop smoking by using different methods. There are nicotine replacement
products - including patches, gum. lozenges and mouth and nasal sprays. We can also
provide with some tablets (varenicline and bupropion).
Diet
 I understand that you have a busy life but it is very important to have a balanced diet.
Diabetes, high blood pressure, high cholesterol and heart disease can raise the risk of
having dementia. Having a healthy diet will help in controlling your weight and reduces
the risk by controlling these diseases. Eating out is not healthy as they use a lot of salt,
sugar and fat to make it tastier. I understand it may be difficult to cook every day but you
can cook once or twice per week and use it for the whole week, so you don’ t have to eat
outside every day.
 Please try to have plenty of fruits and vegetables in your diet. Fruit and vegetables are a
vital source of vitamins and minerals and should make up just over a third of the food we
eat each day. There's evidence that people who eat enough fruits and vegetables have a
lower risk of heart disease.
 Please cut down the amount of red meat and processed meat, such as sausages and
bacon and try to have white meat such as chicken and fish instead.
 It is also better to have grilled, steamed or boiled food rather than fried food.
 We can also refer you to a dietician who can help you better.
P: Can I eat fish?

D: Fish is a good source of protein and contains many vitamins and minerals. Aim to eat at
least two portions of fish a week, including at least one portion of oily fish. Oily fish contains
omega-3 fats, which may help to prevent heart disease.
Oily fish include mainly includes salmon, mackerel, trout and sardines.
Physical activity:
You don’ t necessarily have to go to the gym. It shouldn’t be in one session, it could be split
into two sessions of fifteen minutes or three sessions of ten minutes. For example if you use
public transport, you can get off one to two stops before reaching home and you can walk
instead. If you drive, please walk when you going to buy something from your local shop. If
you live in a flat, you can climb the stairs instead of using the lift.
Stress:
D: Stress could increase the risk of heart disease, high blood pressure and even stroke. So, it
is important to relieve your stress. You may try doing some physical activities such as
873
walking, jogging or swimming. In this way, you can relieve your stress and relax yourself.
You may also try taking yoga classes.
Alcohol:
It is always advisable to cut down the amount of alcohol you take. I know it is not easy to
cut down but we are here to help you. We can refer you to our colleagues; they will do their
best to help you to cut down your alcohol.
For most adults, a BMI of:

18.5 to 24.9 means you're a healthy weight
25 to 29.9 means you're overweight
30 to 39.9 means you're obese
40 or above means you're severely obese.
Things that can increase your chances of getting vascular dementia in later life include:
- high blood pressure (hypertension)
- smoking
- an unhealthy diet
- high blood cholesterol
- lack of exercise
- being overweight or obese
- diabetes
- excessive alcohol consumption
- atrial fibrillation (a type of irregular heartbeat) and other types of heart disease
These problems increase the risk of damage to the blood vessels in and around the brain, or
cause blood clots to develop inside them.
874
OSTEOPOROSIS
You are F2 in GP.

Peter Smith aged, 62 presented to clinic. She had a wrist fracture 3 months ago, which was
managed. DEXA Scan has been done 2 weeks ago, which showed Osteoporosis. She is here
for her results.
Please talk to the patient, discuss the result and plan of management.

P: I am here for my test results.
D: May I know why you had the test?
P: I had the test because I had a fracture in my wrist 3 months ago. I was moving
house and there was a loose carpet and I tripped.
P: I went to the hospital. They did X-Ray of my hand and they applied some cast.
D: How is your wrist now?
P: It's fine doctor.
D: Any pain?
P: No
D: Any problems with movement?
P: No
D: Has anyone told you about the results?
P: No
D: The result shows you have a condition called Osteoporosis.
It means porous bones, it is a disease in which the density and quality of bone are reduced.
As bones become more porous and fragile, the risk of fracture is greatly increased. The loss
of bone occurs silently and progressively.
P: Ok
P: Why do I have osteoporosis?
D: Let me ask you a few questions so I will be in a better position to answer to your concern.
P: Ok
P: No
P: HTN.'
D: Since when?
P: From last few years.
D: Do you take any medication for it?
P: I am taking Amlodipine
P: Yes
D: Any other medical illness? Kidney diseases, IBD, Coeliac disease
875
P: No
D: Are you taking any medications including OTC or supplements? Steroids, vitamin D,
Calcium
P: No
P: No
P: When I was 35 I had a surgery to remove my ovary and womb
D: Any bone disease. Osteoporosis or fractures in the family?
P: My mother and grandmother fractured their hips
P: Yes I have 2 children when I was 25 and 29
D: What was the mode of delivery?
P: Normal vaginal delivery
D: May I know when did you have you Last Menstrual Period?
P: when I was 35 my womb and ovary were removed. (Early menopause)
D: Have you received any Hormone Replacement Therapy after your menopause?
P: I was offered but I didn't take it.
D: Do you smoke?
P: Yes/no
P: Yes/no
P: Good diet
D: Do you take enough Dairy products like milk, curd or fish?
P: No ’
P: Quite active
 In your case there are some risk factors about which there is nothing can be done which
include the family history of osteoporosis and the operation that you had for your womb
and ovaries removal. There are some areas which we can work on in order to minimise
the risk of any further fracture.
 You need to make some necessary changes in your lifestyle.
 Smoking is one of the Risk Factors for Osteoporosis. I know it is not easy but it would
great if you could stop smoking. We can support you by sending you to the Smoking
Cessation Clinic.
 They help you to stop smoking through different ways.
876
 Excessive amount of alcohol intake can weaken the bones. It may be difficult, but it
would great if you can drink in moderation. We can support you in different ways if you
need any help.
 Please include dairy products, oily fish and nuts in your diet.
 Weight bearing exercise and resistant training can help to strengthen the bone. You can
strengthen your bones by doing weight bearing exercise such as walking, jogging, and
simple activity such as climbing stairs or sitting and standing. Resistant training such as
using cable machines in the gym can be helpful so we may be able to refer you to the gy
m instructor to have such training under their supervision.
 We will give you Vitamin D and Calcium supplements.
 We will prescribe you a medicine, called Bisphosphonate, which can help to strengthen
your bones.
 It should be taken first thing in the morning before eating or drinking and You need to
swallow with a full glass of water and sit upright for 30 mins.
 You must tell your dentist if you are taking Bisphosphonate and you will need regular
dental check ups. This is because there is a very small chance this medication can cause
some problem with your jawbone(osteonecrosis)
S/E of bisphosphonates: : Being sick, Indigestion, Heartburn, Tummy pain, Diarrhoea and
Constipation.
877
STROKE ASSESSMENT
You are FY2 in GP

Mr. Henry aged, 60, has presented to the clinic. He has some concerns about stroke. Your
nurse colleague checked his blood pressure and it was 150/100 mmHg.
Please talk to the patient, take history, and address any issues that may arise with the
patient. Please do not examine this patient.

P: Dr. I am worried about stroke. My dad also passed away due to stroke.
D: May I know at which age your dad passed away?
P: 65 years.
D: Do you have any medical condition?
P: No
D: My nurse has examined you and she found that your blood pressure was on a high side.
But don't worry we will take care of that.
P: Ok Dr.
D: Any diabetes, high cholesterol, heart and kidney disease?
P: No
D: Have you had any headache, dizziness, visual problem, heart racing or chest pain?
P:No
D: Any numbness or tingling sensation? (TIA)
P:No
P: No
P:No
D: Do you smoke?
P: Yes
P: Occasionally
P: Mainly burger chips
P: I don’t have time to do.
P: Every job is stressful.
From our assessment, there are many risk factors that you have got for stroke, there are
some like your age and male sex which are the risk factor but we can't do anything. Let me
tell you the factors where we can work on to decrease the risk of developing stroke.
You need to make some change in your lifestyle.
878
Smoking, alcohol, poor diet, lack of physical exercise and stress are the main cause of which
can lead to many problems in the future like stroke.
Smoking:
D: Smoking can damage the inside of wall of blood vessel and narrows them, this can
increase the risk of stroke. I know it is not easy to stop smoking but we are here to help you.
We can refer you to the smoking cessation clinic, they will do their best to help you to stop
smoking by using different methods. There are nicotine replacement products - including
patches, gum. Lozenges and mouth and nasal sprays. We can also provide with some tablets
(varenicline and (bupropion).
DIET:
I understand that you have a busy life but it is very- important to have a sensible diet.
Diabetes, high blood pressure, high cholesterol and heart disease can raise the risk of having
stroke. Having a healthy diet will help in controlling your weight and reduces the risk of
stroke by controlling these diseases. Eating out is not healthy as they use a lot of salt, sugar
and fat to make it tastier. I understand it may be difficult to cook every day but you can cook
once or twice per week and use it for the whole week. So you don't have to eat outside
every day.
eat each day. There's evidence that people who eat enough fruits and vegetables have a
lower risk of heart disease, stroke and some cancers.
and try to have white meat such as chicken and fish instead.
Physical activity:
You don't necessarily have to go to the gym. It shouldn't be in one session, it could be split
Stress
D: Stress could increase the risk of heart disease, high blood pressure and even stroke. So it
is important to relieve your stress. You may try doing some physical activities such as
walking, jogging or swimming. In this way you can relive your stress and relax yourself. You
may also try taking yoga classes.
Alcohol:
879
cut down but we are here to help you. We can refer you to our colleagues, they will do their
As you know my nurse colleague checked your blood pressure and it was high. We will check
your blood pressure again. We may need to prescribe you some medications to control your
blood pressure.
We will do routine blood test to check cholesterol level, sugar level and kidney and liver
function.
We will also do urine test. Depending on the results we will give you medications.
We may also consider giving you mini-aspirin, which is a blood thinner to decrease the risk
of stroke.
We may refer you to the stroke clinic if needed.
You also need to come for regular follow-ups for regular blood pressure measurements and
routine blood tests.
If you develop any;

F: facial drooping
A: arm weakness
S: slurred speech
T: telephone, call the ambulance.
880
OBESITY COUNSELLING
You are F2 in GP
Carla aged, 52 presented to the clinic with complaints of overweight.

P: I am obese I want lose weight.
D: Since when are you gaining weight?
P: My problem of gaining weight is getting worse after the pregnancy.
D: Do you get breathless while sleeping?
P: Yes/ No
D: Do you feel cold when others are feeling fine?
P: No '
D: Any constipation in the recent times?
P: No
P: Yes
D: Have you been diagnosed with any
P: No
D: Any Diabetes, high blood pre
P: No
P: No
D: Any long term steroid use?
P: No
D: Any allergies from food or medication?
P: No
P: No
P: My father and mother died of heart attack. They were also obese.
D: Any other medical condition in the family?
P: No
D: Do you smoke?
P: Yes/ No
P: Yes/No
P: Eat everything, sweets, pastries.
P: Yes/ No
881
P: Yes/No
P: No
I would like to examine you. Check you vitals, do a general physical examination and Check
your height and weight.
I would like to send for some blood tests for routine tests, to check how the function of you
liver
and kidneys and to check the level of cholesterol in you blood.
EX: Everything is normal. BMI is 40.
It's very important to take steps to tackle obesity because, as well as causing obvious
physical changes, it can lead to a number of serious and potentially life-threatening
conditions, such as:
type 2 diabetes, coronary' heart disease, some types of cancer, such as breast cancer and
bowel cancer, stroke. Obesity can also affect your quality of life and lead to psychological
problems,
such as depression and low self-esteem.
D:
DIET:
The best way to treat obesity is to eat a healthy, well balanced, reduced-calorie diet and
exercise regularly. Your diet should consist of plenty of fruits and vegetables with some milk
and dairy foods, some meat. fish, eggs, beans and other non-dairy sources of protein. Try to
avoid foods containing high levels of salt because they can raise your blood pressure, which
can be dangerous for obese people. Eat slowly and avoid situations where you know you
could be tempted to overeat. We can refer you to dietitian who can advise you on that.
EXERCISE:
Normally It is advisable to have at least thirty minutes of physical activity every day five
times a week. You don’t necessarily have to go to the gy m. It shouldn't be in one session, it
could be split into two sessions of fifteen minutes or three sessions of ten minutes. You may
need to exercise for longer each day. To avoid regaining weight after being obese, you may
need to do 60-90 minutes of activity each day. You can also try doing moderate intensity
activity brisk walking, cycling, recreational swimming, dancing. Alternatively, you can try 75
minutes (one hour, fifteen minutes) of vigorous-intensity activity a week, or a combination
of moderate and vigorous activity, running, most competitive sports, circuit training. You
should also do strength exercises and balance training two days a week. This could be in the
form of a gym workout. It's also critical that you break up sitting (sedentary) time by getting
up and moving around. Join a local weight loss group. There are other useful services, such
882
as local weight loss groups and these could be provided by your local authority', the NHS. or
commercial services. We can refer you to a local active health team for a number of sessions
under the supervision of a qualified trainer. You can try' activities such as fast walking,
jogging, swimming or tennis.
It's also important to find activities you enjoy and want to keep doing. Activities with a
social element or exercising with friends or family can help keep you motivated. Make a
start today - it's never too late. Your GP. weight loss adviser or staff at your local sports
center can help you create a plan suited to your own personal needs and circumstances,
with achievable and motivating goals. Start small and build up gradually. We can refer you
to Psychologists who can help you change the way you think about food and eating.
MEDICATIONS:
If lifestyle changes alone don't help you lose weight, we can prescribe a medication called
Orlistat. This medication works by reducing the amount of fat you absorb during digestion.
Orlistat must be combined with a balanced low-fat diet and other weight loss strategies,
such as doing more exercise. It's important that the diet is nutritionally balanced. Even then,
orlistat is only prescribed if you have a body mass index (BMI) of 28 or more, and other
weight-related conditions, such as high blood pressure or type 2 diabetes or BMI of 30 or
more.
Since your BMI is 40 which is very' high we may be able to do surgery to reduce your weight.
Weight loss surgery, also called bariatric or metabolic surgery, is sometimes used as a
treatment for people who are very' obese.
Types of weight loss surgery:

 There are several types of weight loss surgery.
 Gastric band - a band is placed around the stomach, so you don't need to eat as much to
feel full.
 Gastric bypass - the top part of the stomach is joined to the small intestine, so you feel fuller
sooner and don't absorb as many calories from food.
 Sleeve gastrectomy - some of the stomach is removed, so you can't eat as much as you
could before and you'll feel full sooner.
For most adults, a BMI of:

 18.5 to 24.9 means you're a healthy weight
 25 to 29.9 means you're overweight
 30 to 39.9 means you're obese
 40 or above means you're severely obese.
DD’s:
Hypothyroidism
883
Long term usage of steroids (Cushing’s Syndrome)
Diet
Physical activity
Family history
884
STATIN
You are F2 in GP.

Mrs. Emma aged, 55 came to the clinic for health checkup.
All the blood test including blood sugar, LFTs and U&Es came back normal.
Only cholesterol was found high and her ORISK score is 14%. She should be on statins.
Please talk to the patient discuss your initial plan of management with the patient and
address her concern.

P: I want to know about my blood results.
D: Yes I will discuss your blood tests but before that let me ask you a few questions?
P: Ok
D: Could you please tell me why you did those blood tests?
P: One of my friend had TIA and I was worried that is why I had these blood tests.
P: No
D: Have you been diagnosed with any medical condition in the pas
P: No.
D: Any high blood pressure or Diabetes?
P: No.'
D: Any heart disease or kidney disease?
P: No.'
P: No
P: No
P: No
P: No
D: Do you smoke?
P: No/Yes
P: No '
P: I eat everything; I love fast foods and pastries.
P: Not much dr.
P: No '
885
We have checked you r bloods and all are normal except cholesterol.
Cholesterol is a fatty substance known as a lipid and is essential for the normal functioning
of the
body.
P: How you are going to treat me?
D: We are going to start you on a medication called statins.
P: Why should I take the medications?
D: Evidence strongly indicates that high cholesterol can increase the risk of narrowing of the
arteries (atherosclerosis), heart attack, stroke, transient ischaemic attack (TIA) and
peripheral arterial disease (PAD).
This is because cholesterol can build up in the artery wall, restricting the blood flow to your
heart, brain and the rest of your body. It also increases the risk of a blood clot developing
somewhere in your body. Your risk of developing heart disease also rises as your blood's
cholesterol level increases. This can cause pain in your chest or arm during stress or physical
activity (angina).
P: Is there any side-effects of Statins?

 D: One of the side-effects is increase in blood sugar Having well balanced diet, physical
activity and checking blood sugar regularly can control your blood sugar, if needed we
will give you some medication.
 It can lead to problems with the digestive tract like constipation, diarrhoea and
flatulence but it can be managed easily by making some changes in the diet. For e.g.
Sticking to the simple food. Avoid spicy and oily food.
 One of the side effect is muscle pain or joint pain, if it happens please contact your GP.
 It is very important to have a sensible diet. Having a healthy diet will help in controlling
your cholesterol level. Please try to have plenty of fruits and vegetables in your diet. Fruit
and vegetables are a vital source of vitamins and minerals and should make up just over
a third of the food we eat each day. Please cut down the amount of red meat and
processed meat such as sausages and bacon and try to have white meat such as chicken
and fish instead. It is also better to have grilled, steamed or boiled food rather than fried
food. We can also refer you to a dietician who can help you better.
 Smoking can damage the inside of wall of blood vessel and narrows them. I know it is not
methods. There are nicotine replacement products - including patches, gum. lozenges
and mouth and nasal sprays. We can also provide with some tablets (varenicline and
(bupropion).
 The recommended daily amount of alcohol is 2 units per day.
o One large glass (250ml) of wine approximately contains 3 units of alcohol. A bottle
of wine (750ml) contains approximately 9 units of alcohol.
o One pint (585ml) of beer or lager contains approximately 2 units of alcohol.
886
o One shot (25ml) of spirits (example Vodka. Whiskey, Bourbon. Gin. Tequila.
Cognac) contains approximately 1 unit. One bottle (750ml) of spirit contains 30
units of alcohol.
o It is always advisable to cut down the amount of alcohol you take. I know it is not
easy to cut down but we are here to help you. We can refer you to our colleagues,
they will do their best to help you to cut down your alcohol. If patient develops
any symptoms because of alcohol then tell the patient to stop.
 It is advisable to have at least thirty minutes of physical activity every day five times a
week. You don’t necessarily have to go to the gym. It shouldn’t be in one session, it could
be split into two sessions of fifteen minutes or three sessions of ten minutes. For
example if you use public transport, you can get off one to two stops before reaching
home and you can walk instead. If you drive, please walk when you going to buy
something from your local shop. If you live in a flat, you can climb the stairs instead of
using the lift.
887
DIABETIC RETINOPATHY
You are F2 in GP Surgery.

Mr. Sam Roberts, age 48, came to the clinic with a new problem. He is diagnosed with
noninsulin dependent diabetes mellitus, which is controlled with diet. Please talk to the
patient and discuss plan of management with the patient.
Please do not examine this patient.

P: Doctor I went to optician to check my eyes. He gave me this note.
Letter:
We examined the eyes of 48 years old gentleman.
Patient has been diagnosed with Diabetes.
Patient visual acuity is normal and On examination there i
retina.
Carry this letter when you see your GP.
Follow up is required.
D: Why did you go to optician?

P: I just went to check my eyes to see if I need glasses, I am a painter and I'm having trouble
seeing fine lines while working.
P: A few days ago.
D: Has anyone told you what is going on?
P: No doctor, optician gave me this letter and asked me to see you.
D: How long have you been diagnosed with diabetes?
P: 2 years.
D: How has your Diabetes been managed?
P: My condition is controlled by diet.
D: Do you take any medications?
P: No
D: Is your diabetes well controlled?
P: I think so
D: Do you check your blood sugars regularly?
P: No
D: When did you check your blood sugar last time?
P: 2 years ago.
D: Do you visit your GP regularly?
P: No. I don’t have any symptoms to go to the GP.
D: Do you go for your annual check-up?
P: No. I missed.
888
D: Have you been diagnosed with any other medical condition in the past? HTN. Heart and
kidney diseases?
P: No
D: Are you taking any medications
P: No
D: Do you smoke?
P: Yes/no
P: Yes/no
P: I don't give much time.
P: Yes. I am self employed.
D: From the assessment done by the optician, you have a condition called diabetic
retinopathy. It is one of the complication of diabetes. Diabetes can cause damage to small
or large blood
vessels. Damage to large blood vessels will cause heart disease, kidney disease and stroke.
Damage to small blood vessels at the back of the eye causes retinopathy.
SMOKING:
cessation
clinic, they will do their best to help you to stop smoking by using different methods. There
are
nicotine replacement products - including patches, gum. lozenges and mouth and nasal
sprays.
DIET:
a
healthy diet will help in controlling your weight and reduces the risk of further
complications.
Eating out is not healthy as they use a lot of salt, sugar and fat to make it tastier. I
understand it
may be difficult to cook every day but you can cook once or twice per week and use it for
the
whole week. So you don’t have to eat outside every day.
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vital
source of vitamins and minerals and should make up just over a third of the food we eat
each
day.
and try
to have white meat such as chicken and fish instead.
PHYSICAL ACTIVITY:
into
two sessions of fifteen minutes or three sessions of ten minutes. For example if you use
public
transport, you can get off one to two stops before reaching home and you can walk instead.
If
you drive, please walk when you going to buy something from your local shop. If you live in
a
flat, you can climb the stairs instead of using the lift.
Stress
D: Stress could worsen your condition. So it is important to relieve your stress. You may try
doing some physical activities such as walking, jogging or swimming. In this way you can
relieve your stress and relax yourself. You may also try taking yoga classes.
Alcohol:
cut down but we are here to help you. We will refer you to our colleagues, they will do their
Let me tell you what we can do for you:
We need to see your blood pressure regularly.
We will do routine blood test to check cholesterol level, sugar level and kidney and liver
function. We will also do special blood test to know the level in last 3 months.
We will also do urine test. Depending on the results we will give you medications. We may
consider giving you some medications (Metformin. ACE inhibitors .Aspirin and Statins).
We will check your eyes regularly. We need to take a digital photograph from back of your
eye.
If needed, the specialist may do further investigation to see if there is any swelling, leaking
or abnormality in the blood vessels at the back of your eye (Fluroscein angiogram)
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They inject a dye into one of the veins in your arm. Dye goes to the blood vessels of your
eye. A camera can show any swelling, leaking or abnormality in your blood vessels.
If specialist notices there are new blood vessels at the back of your eye you may need to
have a procedure, which can be done by laser.
By doing this procedure, the laser can seal leaks from blood vessels
P: Is this condition reversible?

D: There are many ways to stop or slower the progression of your disease. But. this
condition is
not reversible.
P: Doctor, will I go blind?
D: We should take all the necessary measures to stop or slower the progression of your
disease.
In order to do it we should control your blood sugar. We should regularly come for the
follow
up.
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DIABETIC REVIEW
You are F2 in GP Surgery.

Jack aged, 52years diagnosed with type I DM. He is on insulin. Examination has been done
by nurse. He has loss of fine sensation and pain below ankle bilaterally. Urine test has been
done and shows ++ glucose and + protein. The patient has been seen by an optician.
Fundoscopy has been done and showed dots and blots. The plan is to refer the patient to
ophthalmologist. His prescription was one month old.
Talk to the patient about diabetes control and discuss initial management with the patient.
Please don’t examine the patient.

P: It is about time that I have to look after myself and control my DM.
D: Since how long have you been diagnosed with DM?
P: Since I was teen.
D: How you are managing it?
P: Insulin.
D: Which insulin?
P: I am using glargine once a day.
P: I think so.
D: Any symptoms of DM?
P: No
D: Feeling thirsty?
P: No
D: Going to loo more often?
P: No.
D: Do you check your blood sugar regularly?
P: No.
D: Any complications of DM?
P: Like what.
D: Any problem with foot?
P: I am having sore foot and burning sensation in them.
D: For how long?
D: Has it changed?
D: Any problem with vision?
P: I am having some blurry vision from last 2 months that is why I went to my optician and he
sent me here.
P: No I don't get time.
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D: Do you go for your annual check up?
P: I missed it last year.
D: Have you been diagnosed with any medical other medical condition a
P: I have high blood pressure for the last 5 years.
P: I take Amlodipine once a day.
P: Yes
D: By any chance any headache, dizziness, chest pain?
P: No
D: Any problem with kidney, high cholesterol, or any blood disease?
P: No
D: Do you smoke?
P: Yes/no
P: Good/bad
P: Good/bad
D: Is it stressful?
P: Yes/No
From our assessment, your DM is not well controlled.

We examined your leg and there is loss of sensation below ankle in both the legs. While we
were examining your eyes we found there was some abnormalities at the back of your eyes.
Your urine and shows there might be some problem with your kidneys.
P: Why diabetes causes these problems?
D: DM can cause damage to large blood vessels and can cause kidney problem, heart disease
and high blood pressure.
DM can cause damage to a small blood vessel at the back of your eye can cause vision
problems, nerves of your feet.
P: what are you going to do for me?
D: It is very important to take your insulin regularly as we prescribed. If you do not take it
regularly as prescribed, your blood sugar cannot be controlled. So please make sure you are
not missing any dose.
Smoking:
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mouth and nasal sprays. We can also provide with some tablets (varenicline and
(bupropion).
DIET:
complications.
Eating out is not healthy as they use a lot of salt, sugar and fat to make it tastier. I
understand it may be difficult to cook every day but you can cook once or twice per week
and use it for the whole week. So you don't have to eat outside every day.
eat each day.
Physical activity:
Stress
D: Stress could worsen your condition. So it is important to relieve your stress. You may try
doing some physical activities such as walking, jogging or swimming. In this way you can
894
DIABETIC FOOT
You are F2 working in diabetic clinic.

John aged, 45 presents to the clinic for his diabetic annual review. Patient has been
diagnosed with diabetes 5years ago. He is not on any medication. His condition has been
controlled on diet.
Please talk to the patient, take focused history, do relevant examination and discuss about
D: I understand you have diabetes and you came for your annual review.
P: Yes dr.
D: Since when you have diabetes?
P: From last 5 years.
P: Yes, it is well controlled.
P: I am managing it with my diet.
P: Yes, I check it regularly
D: When was the last time you checked it?
P: I checked it yesterday
D: How much was it?
P: It was 6.
D: Was it before or after the meal?
P: It was before meal.
D: Are you going for your regular check-ups?
P: Yes. I am going.
D: Do you have any complication of diabetes?
P: No
D: Any heart, kidney, eye, foot problem?
P: No
P: No
D: Any medication
P: No
D: Tell me about your diet.
P: I eat everything. 1 was living with my wife initially for 4 years then she left me and now I am
eating everything whatever I find. Mainly I eat burgers and chips.
D: Do you smoke?
P: Yes/No
P: Yes/No
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P: I live alone.
Examination:
I will check your blood pressure, back of your eyes, height and weight to check if you are
under or overweight.
I would like to check your glucose readings.
EX: BMI-30, BP-120/70
I will do foot examination.

Examination:
a. Exposure
b. Chaperone
c. Being gentle
d. Consent
e. Position patient on an examination couch at 45°

I am here to examine your feet 1 will be as gentle and as quick as possible. At any point of
time
you feel uncomfortable and want me to stop please let me know I will stop my examination.
I
have a chaperone throughout my examination to ensure your privacy. May I proceed.
2. Inspection:
a. Front of legs: We are looking for redness, swelling. Shiny skin. Pigmentation, dryness,
ulcers, hair loss.
b. Dorsum of the foot: We are looking for hard com. thick skin.
c. Toes: We are looking for Pallor, Discoloration. Amputation, in growing
d. Web-spaces: We are looking for fungal infection, ulcers and cracks.
e. Sole: we are looking for Callus, dry scaly skin and ulcers.
f. Heel: We are looking for pressure sores
g. Back of the legs: We are looking for redness, swelling. Shiny skin, pigmentation ulcers,
hair loss.
> I am going to have a look on your legs:

Verbalize: On inspection there is no redness, swelling. Shiny skin, Pigmentation, dryness,
ulcers, hair loss in the front of the legs. On dorsum of the foot there is no thick skin and hard
corn. There is no Pallor, Discoloration, Amputation, in growing toe nails.
> I am going to touch your finger:
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Verbalize: There is no fungal infection, ulcers and cracks. There is no callus, dry scaly skin
and cracks on the sole.
> Could you please lift your right leg and then left leg.
Verbalize: There are no pressure sores on the heels.
> Could you please bend your both the legs.
Verbalize: There is no redness, swelling. Shiny skin. Pigmentation, dryness, ulcers, hair loss
at the back of the legs
897
HYPOGLYCAEMIA
You are F2 in GP
Tariq Ahmed 35 had an episode of hypoglycemia 2 weeks back. Now he came for the
diabetic review. His HbAlc is 61. Talk to him and address his concern.
D: What brings you to the hospital?

P: I came for review of my Diabetes.
D: Great. May I know when were you diagnosed with diabetes?
P: 15 years ago
D: May I know how was it managed?
P: I used to take Metformin and Glimipride initially. 6 months back I started taking insulin.
D: May I know how do you take insulin?
P: I take 10 units in the morning and 10 units in the evening (doesn't know the name of the
insulin).
D: Are you taking your insulin regularly?
P: Yes ’
D: Do you check your sugar levels regularly?1
P: I have a glucometer but I don't use
P: Yes but. a few days back I was at a friend's party at night. 1 ate a lot in the dinner, then I got
a call from my job and I took my car and went. I took extra dose of insulin. I was sweating and
feeling dizzy. I always carry chocolates with me then I ate it and called my sister. She is a nurse.
She told me it might be hypoglycemia attack.
D: Do you have any symptoms of DM?
P: No '
D: Polyuria, Polydipsia?
P: No
D: Any complication of DM?
P: No
D: Any problem with your vision, foot or kidney problems?
P: No
D: Have you had similar kind of episode in the past?
P: No
D: Have you been diagnosed with any other medical condition?
P: No
D: Any high blood pressure, heart or kidney condition?
P: No
P: No
P: No
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P: No
P: No
P: I eat everything, I love Jalebi. Rasgulla and all the sweets
D: Physical exercise?
P: Not having time to do physical activity
D: Smoking?
P: Yes/No
D: Alcohol
P: Yes/No
P: I am a taxi driver
 D: A low blood sugar, also called hypoglycaemia is where the level of sugar in your blood
drops too low. It mainly affects people with diabetes, especially if you take insulin. A low
blood sugar can be dangerous if it's not treated promptly, but you can usually treat it
easily yourself.
 We have checked your blood sugar level special blood test what we call as HbAlc which
tells us how was your sugar level in your blood in the last 2 to 3 months. Normally it
should be about 48 mmol/mol (6.5%) for diabetic patients. In your case it is 61mmol/mol
which is very high. This means your sugar level was very high in the last few months. It
can cause many problems in your heart, eyes, kidneys and nerves in the legs.
 It is very dangerous to have low sugar - it can cause sudden death if the sugar in the body
becomes very low. So please do not inject large doses of Insulin even if you eat lot of
sugar.
 As you mentioned you ate sweets in the party, these are harmful in a patient who is
diabetic. It is advisable to make some changes in your lifestyle. Give lifestyle advices.
 Please take your insulin regularly as prescribed.
 Since you are a Taxi driver though you are not banned from driving. You need to inform
the Driver and Vehicle Licensing Agency (DVLA) and your car insurance company about
your condition.
 Signs of hypoglycaemia: Shakiness, Dizziness, Sweating. Hunger, irritability or moodiness.
 Anxiety or nervousness, Headache. If any such symptoms eat chocolate, sugary drinks.
Keep sweets at all times with you.
 Please wear your diabetic bracelet at all times.
Treatment for low blood sugar:

Follow these steps if your blood sugar is less than 4mmol/L or you have hypo symptoms:
1. Have a sugary drink or snack - try something like a small glass of non-diet fizzy drink or
fruit juice, a small handful of sweets, or four or five dextrose tablets.
899
2. Test your blood sugar after 10-15 minutes - if it's 4mmol or above and you feel better,
move on to step 3. If it's still below 4mmCit, treat again with a sugary drink or snack and
take another reading in 10-15 minutes.
3. Eat your main meal (containing carbohydrate) if you're about to have it or have a
carbohydrate-containing snack - this could be a slice of toast with spread, a couple of
biscuits or a glass of milk.
You don't usually need to get medical help once you're feeling better if you only have a few
hypos, but tell your diabetes team if you keep having them or if you stop having symptoms
when
your blood sugar goes low.
900
HYPOGLYCAEMIA FITS

John aged 22, known case of type 1 DM is on insulin brought to the A&E by the ambulance
after he was found collapsed.
Vitals:
B.P. 100/60, P.R. 105, R.R. 20, Sats. 95%, Blood sugar 2.1
Please talk to the patient, take history, convince him to get admitted and discuss your initial
plan of management with the patient.
Patient doesn’t want to stay in the hospital.

P: I want to go home.
D: May I know if there is any particular reason?
P: I have many things to do at home that is why I want to go home.
D: Let me ask you few questions and assess your condition. Why did you come to the
hospital?
P: I don’ t know, I collapsed at home then I woke up here.
D: Do you remember what happened before you collapsed?
P: No
P: No
D: Any difficulty or pain moving his head and neck?
P: No.
D: Did you have any sore throat or runny nose?
P: No
D: Anything you remember during the collapse?
P: No
P: I don’t know.
D: Did you lose his consciousness?
P: Yes/No.
D: Was their anyone around when this happened?
P: Yes/No
P: I don’t know who called the ambulance.
D: Could you tell me. what happened after the fit?
P: I don’t know, the next thing I know that I was here.
D: Any head injury?
P: No
D: Did you vomit?
P: No
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P: I am fine
P: No
P: Yes I have DM
D: Since how long have you been diagnosed with DM
P: Since I was 11
D: How you are managing?
P: I am taking insulin
D: Which insulin?
P: I am using two times a day. Don't know the name.
D: How many units?
P: 16 in morning and 16 in evening
P: I think so.
D: What happened today?
P: I was busy and skipped mv breakfast and I took my insulin.
D: Any symptoms like sweating, feeling tired, palpitations?
P: No
P: Yes
P: No
D: Any problem with foot?
P: No
D: Any problem with vision?
P: No
P: Yes
D: Do you go for your annual checkup?
P: Yes.
D: Have you been diagnosed with any other medical condition like kidney disease, heart
disease or high cholesterol?
P: No
D: Any other medications apart from insulin?
P: No
D: Any allergy to medication/food?
P: No
D: Any previous hospital stay or surgery?
P: No
902
P: No
D: Do you smoke?
P: Yes/no
P: Yes/no
P: Good/bad
D: Do you do physical exercise
P: Good/bad
P: I live alone
D: what do you do for a living
D: Is it stressful?
P: Yes/no
D: I would like to check your vitals. GPE.
I would like to send some routine blood investigations and ECG.

We have examined you and we found your blood pressure is 100/50, your heart rate is on
higher side 105. Respiratory rate is 20. Blood sugar was very low which is 2.1.
From our assessment you have a condition called Hypoglycaemia or low sugar level. We will
keep you in the hospital. We will do further investigation, including HbAlc.
P: I am already on leave, I am getting married next week.
D: Your health comes first, so it is advisable to stay in the hospital in this situation. I will also
talk to my senior and they will also come and assess you.
Follow these steps if your blood sugar is less than 4mmol/L or you have hypo symptoms:
 Have a sugary drink or snack - try something like a small glass of non-dict fizzy drink or
fruit juice, a small handful of sweets, or four or five dextrose tablets.
 Test your blood sugar after 10-15 minutes - if it's 4mmol or above and you feel better,
move on to step 3. If it's still below 4mmol. treat again with a sugary' drink or snack and
take another reading in 10-15 minutes.
 Eat your main meal (containing carbohydrate) if you're about to have it or have a
carbohydrate-containing snack - this could be a slice of toast with spread, a couple of
biscuits
 or a glass of milk.
Please inform the DVLA (if he drives).
Preventing low blood sugar

If you have diabetes, these tips can help reduce your chances of getting low blood sugar:
1. Check your blood sugar regularly and be aware of the symptoms of a low blood sugar so
you can treat them quickly.
903
2. Always carry' a sugary snack or drink with you. such as dextrose tablets, a carton of fruit
juice or some sweets. If you have a glucagon injection kit. keep it with you at all times.
3. Don't skip meals.
4. Be careful when drinking alcohol. Don't drink large amounts in a short space of time, and
avoid drinking on an empty stomach
5. Take care when exercising. Eating a carbohydrate-containing snack before exercise can
help reduce the risk of a hypo. If you take insulin, you may be advised to take a lower
dose before or after doing strenuous exercise.
6. Have a carbohydrate-containing snack, such as biscuits or toast, before going to bed to
stop our blood sugar level dipping too low while you sleep.
7. If you keep getting low blood sugar, talk to our diabetes team about things you can do to
help prevent it.
Give lifestyle advices accordingly.
904
DKA
You are F2 in A&E.

Mrs. Margret aged, 25 was brought to the hospital by the ambulance. She has been
diagnosed with Type 1 diabetes. She is Insulin dependent. The blood test has been done and
she has been diagnosed with DKA. She is not willing to stay in the hospital
Vitals:- BP: 90/60 mmHg, Pulse: 110,02 Sat: 95, RR: 17, TEMP: 37
Please talk to the patient and address her concerns.

P: I just want to go home.
D: Let me first ask you some questions and if everything is fine, you can go home. Tell me
what brought you to the hospital?
P: I was feeling sick and I had tummy pain.
Elaborate pain and sickness briefly as it is already diagnosed:
D: Tell me more about your pain??
P: I have got pain all over my tummy, (points towards her abdomen) from last few hours and it
is getting worse.
D: Tell me more about your sickness?
P: It started at the same time with my belly di,
D: Any vomiting?
P: No
D: Have you had anything else apart from these?
P: No
D: Have you been going to the loo more often?
P: Yes/No
D: Have you been feeling excessively thirsty?
P: Yes/No.
D: Have you noticed any fruity smelling breathe?
P: No.
D: Have you been breathing faster or deeper than usual?
P: No.
D: Is your mouth dry?
P: No.
D: Do you feel tired or sleepy?
P: No.
D: Have you been confused?
P: No.
D: Did you pass out by any chance?
P: No. ’
D: Any fever, flu-like symptoms recently? (Viral infection)
P: No.’
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P: No
D: Tell me about your diabetes?
P: I have diabetes from last 10 years since I was a teenager.
D: May I know which Insulin?
P: I take Actrapid and some another one.
D: How many times a day are you taking it?
P: I take it once at night and 2-3 times during
P: Usually I do. But I didn't take it for the past 5 days
D: why?
P: There is a marriage in 4 weeks time and I want to look beautiful in the dress 1 bought and I
am trying to lose some weight so I can fit into my dress. I didn't eat much in the last 5 days so I
did not take my insulin. I will start eating and taking the medication regularly. Please let me go
home. I feel fine.
D: I understand. I just want to ask a few more questions to assess if it’s safe to send you
home.
P: Okay.
D: Have you ever skipped your dose of Insulin before?
P: Yes. I have done it when I was 16 and there was no problem.
P: Not really
P: When I came to the hospital.
D: How much was it?
P: 22.
D: Do you go to your GP regularly?
P: Yes'
D: When was the last time you went to the GP?
P: A year ago.
D: Do you have any complications of diabetes?
P: No.
D: Any foot or eye problems?
P: No I feel fine.
D: Do you attend your annual review regularly?
P: I missed the last one.
D: Have you been diagnosed with any other medical conditions?
P: No.
P: I’m a social drinker.
D: Tell me about your diet generally?
P: I have a good diet.
906
I would like to check your vitals and examine your
I would like to send for some initial investigations including routine blood test.
EX: All the investigations are on the table.
NOTE: On the table there are 2 sheets of paper with results of investigations. ABG in one
page and the rest of them are written in another page.
Abnormal results are indicated on all the 2 sheets by a “ *
1. ABG: pH - 7.14* (7.35-7.45). HCO3 - 14* (22-28). PCO2 49* (38-42)
2. U&E: K-4.5 (3.5-5). Na - 1.29* (1.35-1.45)
3. FBC: WBC - 19000* (4000-11000). Hb - 12.3 (12-16), Platelets - 315 (150-450)
WBC Breakdown: Neutrophils and lymphocytes were high and the rest were normal.
4. Urine:
Urinary ketones (+++).
Leucocytes and nitrates negative
 From my assessment you have a condition called diabetic ketoacidosis.

 It is a common complication of diabetes. It happens when our body is unable to use
blood sugar, because there is not enough insulin to push glucose from blood into the
cells. Therefore the body breaks down fat as an alternative source of fuel. This causes
build up of a by-product called ketones.
 Missing insulin dose is one of the most common causes of DKA because in this situation
the body cannot use blood glucose without insulin.
 We checked your blood which is acidic. There was increased in the amount of white
blood cells which usually rise during infection to fight against bugs. We checked your
urine and it contained ketones.
 So we need to keep you in the hospital to give you necessary treatment.
 The main aim is to remove ketones from your body. We need to give you fluids, if we
don't give you fluids. We need to give you Insulin through your blood vessel. We may
need a replacement of minerals such as Potassium.
 You need to be monitored in the hospital. We need to check your blood sugar regularly,
level of potassium. We need to check the acidity of your blood regularly. We need to
check your urine regularly to monitor the amount of ketones and urine output,
(catheterization)
 We need to do an ECG to check the rhythm of your heart.
 So monitoring of insulin and fluids can be done in the hospital.
 This is an emergency and should be treated immediately. This is fatal condition if not
treated properly. If you don’t receive this treatment, you may end up in a coma.
907
DIABETIC POST DKA WITH LEARNING DIFFICULTIES

Mr. James Atkinson, aged 24, was diagnosed with Type 1 diabetes two months ago after he
had an episode of DKA. He was admitted and managed in the hospital. He was put on a
short-acting insulin three times with meal and long-acting insulin before going to the bed.
The diabetic nurse has been going to his house to check the blood glucose and on 2
occasions they were on the higher side.
Note: The patient has a learning disability.
D: What brings you in?

P: I am here for my diabetic review.
D: Since how long have you been diagnosed with DM?
P: For 2 months.
D: How are you managing it?
P: Insulin.
D: Are you taking them as prescribed?
P: No, I take it when I have sugary meal.
D: May I know why?
P: This is what I understood the last time I saw the doctor.
D: Any symptoms of DM?
P: Like what?
D: Feeling thirsty?
P: Yes
D: Going to the loo more often?
P: Yes
P: No
P: Like what?
D: Any problem with the foot?
P: No
D: Any problem with the vision?
P: No
D: Any chest pain?
P: No
P: Yes
P: No
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P: No
D: Any allergies from any food or surgeries?
P: No
P: No
D: Has anyone in family been diagnosed with any medical condition?
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: Good/Bad
P: Good/Bad
P: I work from home
P: Alone
D: Any family nearby?
P: Yes my parents.
D: Is it stressful?
P: Yes/No
I would like to check your vitals and do the GPE.

I would like to send for some initial investigations including routine blood tests, U&E, LFT's,
blood sugar and HbA1c.
Examiner: Examination Normal.
From our assessment, your DM is not well controlled as you are drinking water more than
usual and going to the loo more often. You are also not taking the insulin as prescribed.
We will do a routine blood test to check cholesterol level, sugar level and kidney and liver
function. We will also do a special blood test to know the level in the last 3 months. We will
also do a urine test.
It is very important to take your insulin regularly as we prescribed. If you do not take it
regularly as prescribed, your blood sugar cannot be controlled. You have to take the insulin
3 times a day, before breakfast, before lunch and before dinner. You have to take one
909
insulin before going to sleep. Please make sure that you do not miss any of your meals and
also do not forget to take the insulins.
If you do not follow this, DM can cause damage to large blood vessels and can cause kidney
problems, heart disease and high blood pressure. DM can cause damage to small blood
vessels at the back of your eyes and can cause vision problems. It also affects the nerves of
your feet. Missing insulin dose is one of the most common causes of DKA which you had in
the first place.
Smoking:
Smoking can damage the inside of the walls of blood vessels and narrow them. I know it is
not easy to stop smoking but we are here to help you. We can refer you to the smoking
mouth and nasal sprays.
Diet:
complications. Eating out is not healthy as they use a lot of salt, sugar and fat to make it
tastier. I understand it may be difficult to cook every day but you can cook once or twice
per week and use it for the whole week. So you don’t have to eat outside every day.
Physical activity:
You don’t necessarily have to go to the gym. It shouldn’t be in one session, it could be split
Stress: Stress could worsen your condition. So it is important to relieve your stress. You may
try doing some physical activities such as walking, jogging or swimming. In this way you can
Alcohol: It is always advisable to cut down the amount of alcohol you take. The
recommended daily amount of alcohol is 2 units per day. I know it is not easy to cut down
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but we are here to help you. We can refer you to our colleagues, they will do their best to
help you to cut down your alcohol.
911
WARFARIN

Mrs. Diana Smith aged, 35 presented to the hospital with leg pain. She has been diagnosed
with deep vein thrombosis (DVT). She has been prescribed warfarin and is about to get
discharged.
Please talk to the patient, explain about her medication and address her concerns.
Anticoagulant Folder contains a booklet or leaflet, Record book and an Alert Card

P: I came to the hospital because of my calf pain. I was told someone is going to talk to me
about my tablets and discharge, (pointing towards medications).
D: let me ask you a couple of questions.
P: Okay Dr.
D: How is your leg pain?
P: It is much better.
D: When were you admitted to the hospital?
P: Yesterday.
D: Have you started taking this medication?
P: No.
D: Have you been diagnosed with any medic
P: No
D: Any high blood pressure, liver disease or
P: No
D: Are you taking any medications including OTC or supplements? Any painkillers?
P: No
D: Any allergies from anv food or medications?
P: No
D: Do you smoke?
P: Yes/No
P: Yes
D: Do you have any idea why did you have calf pain?
P:No.'
D: You had a blood clot in your leg.
P: What is a blood clot?
D: A blood clot is formed when your blood becomes thick and solid.
D: You have been prescribed a medicine for your clot and I will discuss about this medicine
with you. You have been given this medicine called Warfarin
912
This medication is a blood thinner and prevents harmful blood clots from forming in your
blood vessels. It works by making your blood take longer to clot.
 D: Please take your Warfarin at about the same time every day (6 pm) with a full glass of
water.
 You need to start with one tablet from today.
 You need to see your doctor regularly. They will check your blood to see how long it
takes to clot and then they will tell you how many tablets you should take even' day.
Your blood test will be done daily for first few days, and then every week.
P: How long I should take it?
D: People with blood clot in their leg usually take Warfarin for 3-6 months. Your doctor will
tell you how long you should continue this medication.
1. This is a booklet/leaflet containing all the information that we are discussing. Please
make sure you read it and keep it at home in case your forget something.
2. This is an alert card. This shows that you take Warfarin. This is important in an
emergency and to inform healthcare professionals like your dentist or any specialist,
before receiving another treatment. (You have patient details, drug name, reason for the
treatment, target INR, date treatment started, the name of warfarin clinic and telephone
number of warfarin clinic). This card is small like a credit card and can easily be carried in
your wallet.
3. This is a record book, which indicates your treatment record, dose of your medication
and date of your blood tests.
Your doctor or nurse will record the necessary information in it so please just have this
booklet with you go for blood tests.
Warfarin side effects

1. Nausea, vomiting and Diarrhoea.
2. Bleeding: you need to see your doctor if you experience Prolonged nose bleeding (more
than 10 mins), blood in'vomit, blood in phlegm, blood in your urine or stool, severe
bruising, unusual headache.
3. Please come to A&E if you are involved in major trauma and you are unable to stop the
bleeding
General a
1. Please take your medication regularly and if you miss a dose, or took the wrong dose,
please make a note in your booklet and take the normal dose on the next day. Moreover,
If the dose you took in error greatly exceeded your normal dose please contact your GP
or warfarin clinic.
2. Tell the pharmacist that you are taking Warfarin and show them your alert card
whenever you go there to buy any other medications like pain killers.
3. Do not make any major changes in your diet as your diet can lead to changes in your
blood results.
Foods containing large amounts of vitamin K include:
913
a. green leafy vegetables, such as broccoli and spinach
b. vegetable oils
c. cereal grains.
4. Please drink in moderation and avoid binge drink while taking this drug.
5. Contact sports should be avoided like football, rugby, martial arts and kickboxing must
be avoided
You can continue to take part in non-contact sports, such as running, athletics, cycling and
racquet sports. However, make sure you wear protective clothing, such as a cycle helmet.
NOTE: Usually for Day 1 and Day 2 we introduce 5mg and from Day 3, dosage depends on
the INR.
P: Doctor, if I have headache what should I do?
D: if you have a mild and simple headache, you can have Paracetamol. Please do not take
medicine such as Ibuprofen or Diclofenac. But if you have any unusual headache, you need
to see a doctor.
P: If I cut myself then?

D: Apply firm pressure to the site for at least five minutes using a dry and clean dressing. If
blood doesn’t stop then please come to the hospital.
914
NSI NURSE
You are F2 in A&E.

Your nurse colleague Mrs. Jasmine Allen, aged 25, pricked herself while taking blood from
her patient.
Please talk to the patient, take relevant history, discuss about your plan of management
with your patient and address her concerns. She is very worried. You are the first person
seeing her.
After needle stick injury:

1. Dispose the needle in sharps bin.
2. Wash the hand under running water with soap.
3. Inform senior
4. Go to the occupational health to seek medical advice, if the time is be hour go to A/E).
5. Fill the incident form.

P: I was taking blood from patient. He moved his hand and I pricked my finger accidently.
P: An hour ago doctor.
D: Were you gloved?
P: Yes
D: Was the injury superficial or deep?
P: It was superficial.
D: What kind of needle it was?
P: It was just normal needle we use for taking blood.
D: Any visible blood on the needle?
P: I don’t know.
D: Did you dispose the needle into the sharps bin?
P: Yes.
D: Did you tell someone else to take the blood from the patient?
P: Yes.
D: What did you do after you pricked yourself?
P: I washed it under tap water and then I squeeze my finger.
D: Did you wash it with soap?
P: I washed it with plenty of soap.
D: Tell me about your patient?
P: He is 20 years old suspected case of meningitis.
D: How is he now?
P: He was unconscious doctor.
P: I am worried about infections.
915
D: Okay. May I know which infection is your concern?
P: Meningitis.
D: You told me that you were gloved. Did you take universal precautions (Gloves or gown)?
P: Yes.
D: Meningitis is not a blood borne disease, it is air borne and you had your mask, gloves and
gown. The blood test from your patient will be tested to see if he has meningitis or not. We
will also seek advice from our microbiology team or occupational health to see if you need
any specific antibiotics.
P: HIV.
D: The risk of catching HIV is low Because in order to get HIV, our patient should be HIV
positive and all the patients in the hospital are not HIV positive.
You told me that you were gloved and the injury was superficial and you washed your finger
with soap which was great, so you should not be that worried.
P: Can we get blood from my patient to know if he is HIV positive or not?
D: We need to take his consent but as you told me he was unconscious. So we may not be
able to take consent from your patient at this moment. But we will talk to him once he is
conscious to get his permission. Meanwhile, we can check his medical records to find out if
he has been diagnosed with it or not.
We can offer you post-exposure prophylaxis medications (PEP). This includes two
medications which should be taken for 28 days. These medications have side effects such as
nausea and vomiting but it is very important to complete the course of medications when
you start them.
These medications should be prescribed up to 72 hours after exposure but the golden time
within one hour after the exposure. Before starting this medication we need to know about
your general health and we may do some blood tests including your liver and kidney
function test. We will also check your HIV status three months later. A blood sample from
you will be sent to our virology or microbiology laboratory' for serum to be saved and
stored. There is no point in testing this sample for blood-borne viruses at this stage. We just
do this for medico legal purpose. It is advisable to practice safe sex for a period of three
months. Please do not donate blood until all your screening tests are clear.
P: Hepatitis?
D: Which hepatitis B or C?
P: Doctor, I am worried about hepatitis B.
D: The chances of catching hepatitis are also very low.
I. It is low because in order to get hepatitis your patient should be hepatitis B positive and
all the patients in the hospital are not hepatitis B positive.
You told me that you were gloved and the injury was superficial and you washed your finger
with soap which was great, so you should not be that worried.
D: I’m sure you have been vaccinated against hepatitis?
P: Yes I am vaccinated.
D: When did you receive your last dose?
P: 2 years ago
916
D: Have you received anv booster?
P: No
We will check your hepatitis B antibody levels (HBsAb) to see how effective the vaccine was.
But. we can offer you the hepatitis vaccine for now before getting the results of titration.
We will take a sample of your blood now, in the next three and six months, to see your liver
function.
We will also take samples of your blood in the next three and six months for hepatitis
serology. If by any chance you noticed tummy pain, yellowish discoloration of your skin and
eyes, nausea or fever, please come back to us.
Wound Infection:
P: Are you going to prescribe me antibiotics?
D: The risk of catching infection is low. however, we will assess your wound and check it for
any redness, swelling, hotness, tenderness, pus or any discharge. If needed, we will give you
antibiotics after ruling out allergies and contraindications.
D: Did you inform your senior?
P: Yes doctor.
D: Have you filled the incident form?
P: Yes doctor.
Hepatitis C is usually diagnosed using two blood test, the antibody test and the PCR test. The
results usually come back within two weeks. The antibody blood test determines whether
you have ever been exposed to the hepatitis C virus by testing for the presence of
antibodies to the virus. Antibodies are produced by your immune system to fight germs.
The test will not show a positive reaction for some months after infection because your
body takes time to make these antibodies. If the test is negative, but you have symptoms or
you may have been exposed to hepatitis C, you may be advised to have the test again. A
positive test indicates that you have been infected at some stage. It doesn't necessarily
mean you are currently infected, as you may have since cleared the virus from your body.
The only way to tell if you are currently infected is to have a second blood test, called a PCR
test. The PCR blood test checks if the virus is still present by detecting whether it is
reproducing inside your body. A positive test means your body has not fought off the virus
and the infection has progressed to a long-term (chronic) stage.
917
NSI CHILD
You are F2 in A&E.

3-year-old Carla was brought to the hospital by her nanny. She had a needle stick injury.
Talk to the nanny, take history and address her concerns. The child is in the next room, your
nurse colleague is looking after her.

P:I am worried about Carla.
D: She is in the next room with my nurse colleague. Tell me what happened?
P: She was playing in the park. She was going down the slide I heard her scream. I went there
to find out what had happened. I saw a needle stuck in her hand and she was crying.
D: Did you tell her parents?
P: Yes, her mother is on the way.
P: 2 hours ago.
P: Carla s was bleeding so I washed and squeezed her hand and then called the ambulance.
D: What kind of needle was it?
P: It was hollow-bore.
D: Was it attached to a syringe?
P: Yes doctor.
D: Any blood in the needle.
P: No
D: Was the needle rusty?
P: I don’t know.
D: How deep was the injury?
P: It was not that deep.
NOTE: When you start asking some questions, the nanny will tell you, “I’m going to write
down what you are asking me and telling me to show it to Carla's mom."
She looks very worried. Please reassure her and tell her. "Don’t worry, you can write down
points from what we discuss, but let me reassure you we will talk to Carla's mom and
explain everything to her if she wishes.”
D: Who takes care of the baby?
P: I am her nanny for the last 3 months. During the day, I am taking care of her and during the
night her parents take care of her.
D: Is she up to date with her jabs?
P: I don't know.
D: When did she receive her tetanus jabs?
P: I don't know.
D: Has she received hepatitis jabs?
918
P: I don’t know.
I would like to check her vitals and look at the hand.
D: Do you have any specific concerns?

P: I am worried about some nasty infections from this needle.
D: We will take all necessary action to prevent any possible infection. You told that you
washed her finger. This reduces the chances of infection.
Needle-stick Injury can sometimes cause infections such as wound infection, tetanus,
hepatitis and HIV. Which one would you like me to talk?
P: Tell me about all of them.
Wound Infection:
We only prescribe antibiotics if the patient developed infection. If she develops any signs of
wound infection such as pain, discharge, redness, hotness or swelling, then we will consider
prescribing her some antibiotics.
Tetanus
There is a possibility of catching the tetanus bug, especially if the needle is rusty. I will talk
to my senior and we might give Carla a tetanus jab.
We give tetanus jabs at 2, 3 and 4 months of age. We then give one jab before going to
school and another one post-school usually around the age of 16.
P: Okay doctor, how about Hepatitis?
Hepatitis (B or C)
Usually this bug cannot survive outside the body that is why it is very unlikely that transition
of this virus will occur through an injury' from a discarded needle.
She will be given a Hepatitis jab today and two more - one at 4 weeks and other at 8 weeks’
time.
We are also going to take a blood sample to see how her liver is working. The blood test will
be repeated in the next 3 and 6 months to make sure everything is fine.
HIV
The chances of getting HIV through a discarded needle are relatively rare because this bug
cannot survive outside the body. You told me her finger was washed immediately after the
injury.
However, we can arrange for a reliable test at 3 months from the incident.
We have prophylaxis medication for needle stick injuries but as it happened outside of
hospital, there is no need to take it because the risk of catching HIV is very low and the
medications used for the prophylaxis are very strong with lot of side effects.
919
Hepatitis C is usually diagnosed using two blood test, the antibody test and the PCR test. The
results usually come back within two weeks. The antibody blood test determines whether
you have ever been exposed to the hepatitis C virus by testing for the presence of
antibodies to the virus. Antibodies are produced by your immune system to fight germs.
The test will not show a positive reaction for some months after infection because your
body takes time to make these antibodies. If the test is negative, but you have symptoms or
you may have been exposed to hepatitis C, you may be advised to have the test again. A
positive test indicates that you have been infected at some stage. It doesn't necessarily
mean you are currently infected, as you may have since cleared the virus from your body.
The only way to tell if you are currently infected is to have a second blood test, called a PCR
test. The PCR blood test checks if the virus is still present by detecting whether it is
reproducing inside your body. A positive test means your body has not fought off the virus
and the infection has progressed to a long-term (chronic) stage.
920
COPD SMOKING CESSATION

Mr. Zimmerman aged, 65 has come for annual check-up. He was diagnosed with COPD and
is taking inhalers. From time to time he is taking antibiotics for his recurrent chest infection.
The nurse colleague examined him.
Please talk to him, take focused history and discuss management

P: The nurse colleague said you are going to talk to me.
D: You have been diagnosed with COPD and you are here for your annual check- up. Let me
ask you some questions.
COPD: Chronic obstructive pulmonary disease describes a group of lung conditions that
make it difficult to empty air out of the lungs because the airways have narrowed.
D: When was your diagnosed?
P: 10 years ago
D: Do you take any medication?
P: I am using Blue and brown inhalers.
P: Yes
D: How do you take the blue inhaler?
P: Whenever I’m having SOB
D: How often do you use your blue inhaler?
P: 3-4 times
D: How long have you been using it like this?
P: A few months now
D: Do you experience any symptoms?
P: I have shortness of breath. I cannot climb the stairs.
D: How long you have this symptom?
P: Few weeks doctor.
D: Has it changed?
P: I also have cough and phlegm
P: when I get infection I cough more and have yellowish phlegm.
D: How much is the amount of phlegm?
P: Patient shows handful.
D: Any blood in your phlegm?
P: No
P: No
921
D: Any wheeze?
P: No
D: How often you have chest infection?
P: I had 5 times last year.
P: I go to my GP and he gives me antibiotics.
P: No
P: No
D: Any allergies from any food or medicines?
P: No
D: Do you smoke?
P: Yes 20 cigarettes since I was young.
P: Yes occasionally
P: It is good
P: I can t do much because of SOB.
P: I am an NHS Manager.
P: I live with my wife and my two children.
D: I would like to check your vitals and examine your chest.
D: From my assessment, it seems like your COPD is not controlled because of smoking.
P: I know that. Everyone is telling me to stop.
D: Have you thought of quitting?
P: No. I enjoy smoking. It makes me relaxed.
D: I am sure it’s not easy to stop. You can find many ways to relive your stress for example
you can go for yoga or meditation.
Many claim that it relaxes them and relieve their stress. The nicotine withdrawal can
increase the feeling of stress. As the stress of withdrawal feels the same as other stresses.
So it can seem like smoking is reducing other stresses whereas this is not the case. Studies
show stress levels are lower after they have stopped smoking.
Being a smoker increases the risk of damage to your blood vessel supplying blood to your
heart.
This can increase the risk of having further complications.
D: I understand that it’s not easy! But we are going to help and support you. We can refer
you to a smoking cessation clinic. They have different ways to help you quit. You have
already cut it down so you may be able to stop.
922
There are medical and non-medical ways to help you stop smoking.
Non-medical approach:
You can have one to one session from local stop smoking clinic and You are able to meet
people who have stopped smoking. They can share their experience with you and motivate
you. In your first meeting with an adviser, you'll talk about why you smoke and why you
want to quit. If you do decide to quit, the adviser can help you form an action plan and set a
quit date,
There are some helplines which can help you and advise you how to deal with your cravings.
You can find much online support such as NHS Smoke free Website, which can boost your
chance of success in stopping smoking. You can call the free Smokefree National Helpline.
If you do relapse, we won’t judge or nag you or take it personally. We’re a friendly face that
understands how difficult it is to quit, and we’ll help you get back on track to becoming a
nonsmoker.
Medical Management:
The main reason that people smoke is because they are addicted to nicotine. We can offer
you nicotine replacement therapy. Nicotine replacement therapy is a medication that
provides you with low level of nicotine poisonous chemicals present in tobacco smoke.
These can be given in the form of patch, spray or chewing gum.
It can help reduce unpleasant withdrawal effects such as bad mood and craving which may
happen when you stop smoking. You could also consider trying E cigarette. Although they
are not risk free, they are very much safer than cigarettes and can help people stop smoking.
There are stop smoking tablets Champix (varenicline) and Zyban (bupropion). We can
prescribe those as well.
923
SMOKING CESSATION
You are F2 in Genera! Medicine.

Mrs. Neena Parker aged 50 presented to the hospital. She has been diagnosed with unstable
angina and has been planned to have an angioplasty. Patient has high cholesterol and she is
on statin and aspirin. Her condition is well controlled. Patient has smoked 20 cigarettes per
day in the last 35 years. She is not willing to quit smoking.
Please talk to the patient about vascular risk, lifestyle modification and smoking cessation.

P: I am getting chest pain. They told me. that someone is going to talk to me.
D: Do you know why you are having this problem?
P: No doctor.
D: You have chest pain because of a condition called Angina.
Like any organ in our body, the heart needs a constant supply of blood vessels that supply
blood to the heart become narrow, the blood flow to the heart will be reduced and this
leads to chest pain which is called angina. Angina can be treated with medications.
However, sometimes we need to perform a procedure called angioplasty.
Angioplasty is a procedure in which we try to widen the vessel supplying blood in your
heart, which became narrowed. In this procedure we are putting a short wire mesh tube in
there.
Therefore, the blood can flow through the vessels and the pain is relieved.
P: OK
D: Let me ask you a few questions to assess you better. Tell me more about your chest pain?
P: Sometimes I get chest pain. Previously I had pain while I was doing physical activity but now
sometimes even at rest I have this pain.
P: Sometimes I have difficulty in breathing.
P:No
D: How long you had high cholesterol?
P: Since the past few years.
D: Are you taking any medications for it?
P: I’m taking aspirin and statin.
P: Yes. I never miss any medicine.
P: Yes
D: Any other medical conditions? DM or HTN?
P: No
P: No
924
P: occasionally.
P: good
P: Everyone has stress in their life.
D: Do you smoke?
P: Yes I smoke around 10 cigarettes per day since I was young.
You have high cholesterol, which can be one of the causes of your angina, you are taking
your medications regularly.
Smoking can be one of the cause of your chest pain. What do you think?
P: My father is also a smoker. He has been smoking 40 cigarettes in the last 60 years and he
hasn't got any health problems.
D: This is not always the case. It is good that your father is fine.
P: If smoking is bad. why do all the doctors smoke?
D: What doctors do is not always the right thing to do.
D: Don't you think you need to stop smoking?
P: I have already cut down smoking. I used to smoke 20 cigarettes a day but now I smoke only
10.
D: Why can’t you stop as you know' it is not good for the health?
P: Doctor, I enjoy smoking! .it makes me relaxed! It relieves my stress.
D: I am sure it’s not easy to stop. You can find many ways to relive your stress for example you
can go for yoga or meditation!
 Many claim that it relaxes them and relieve their stress. The nicotine withdrawal can
increase the feeling of stress. As the stress of withdrawal feels the same as other
stresses. So it can seem like smoking is reducing other stresses whereas this is not the
case. Studies show stress levels are lower after they have stopped smoking.
 Smoking can cause damage in the wall of blood vessel and make them narrowed so they
cannot supply enough oxygen to your heart muscle so you get chest pain and that's why
you get chest pain time to time.
 Being a smoker and having high cholesterol increases the risk of damage to your blood
vessel supplying blood to your heart. This can increase the risk of having heart attack and
stroke.
 D: I understand that it's not easy! But we are going to help and support you. We can refer
you to a smoking cessation clinic. They have different ways to help you quit. You have
already cut it down so you may be able to stop.
There are medical and non-medical ways to help you stop smoking.
925
Non-medical approach:
 You can have one to one session from local stop smoking clinic and you are able to meet
people who have stopped smoking. They can share their experience with you and
motivate you. In your first meeting with an adviser, you'll talk about why you smoke and
why you want to quit. If you do decide to quit, the adviser can help you form an action
plan and set a quit date.
 There are some helplines which can help you and advise you how to deal with your
cravings.
 You can find much online support such as NHS Smoke free Website, which can boost your
chance of success in stopping smoking. You can call the free Smokefree National
Helpline.
 If you do relapse, we won’t judge or nag you or take it personally. We’re a friendly face
that understands how difficult it is to quit, and we’ll help you get back on track to
becoming a nonsmoker.
Medical Management:
 The main reason that people smoke is because they are addicted to nicotine. We can
offer you nicotine replacement therapy. Nicotine replacement therapy is a medication
that provides you with low level of nicotine poisonous chemicals present in tobacco
smoke.
 These can be given in the form of patch, spray or chewing gum.
 It can help reduce unpleasant withdrawal effects such as bad mood and craving which
may happen when you stop smoking. You could also consider trying E cigarette. Although
they are not risk free, they are very much safer than cigarettes and can help people stop
smoking.
 There are stop smoking tablets Champix (varenicline) and Zyban (bupropion). We can
prescribe these as well.
926
URTI
You are F2 in GP.

Olivia aged, 27presented to the clinic because of problem that she had before.
Patient came to the clinic 2 days ago because of runny nose, sore throat, sneezing and
cough.
Patient has been seen by nurse practitioner. Swab was taken and no bacterial growth has
been found. She was diagnosed with viral URTI. Mild analgesics were prescribed. Steam
inhalation has been advised.
Talk to the patient, assess her and address her concern.

P: I came to the clinic 2 days ago because of my problem. I am still hav e same problem. Please
give me antibiotics
D: Please tell me what brought you to the hospital 2 days ago?
P: I had sore throat and cough.
D: Since when?
P: 3-4 days ago
D: Did they tell you what was wrong with you?
P: Your nurse colleague saw me and I were told that I had a cold/flu.
D: What they did for you?
P: I was told it is flu and they advised me steam inhalation. Also I was given Paracetamol.
D: Did you take PCM and steam inhalation?
P: Yes. I took 2 tablets only and I took steam only once. It wasn't working that is why I came for
antibiotics.
D: How do you feel now?
P: It is same, I am still having sore throat and cough.
D: Anything else?
P: No
D: Any fever or flu like symptoms. Any runny nose. Any headache or bodyache, Any
tiredness?
P: No
D: Any rash, neck stiffness? (Meningitis)
P: No
D: Any swollen gland in your neck or armpits? (Inf. Mononucleosis)
P: No
D: Any ear problem? Any ear pain? Any hearing problem?
P: No
P: Yes few months ago.
D: what was done for that?
P: I was given antibiotics that time.
927
P: No
P: No
P: No'
P: No
D: Do you smoke'?
P: Yes/No
P: Yes doctor, I live with my girlfriend
D: Do you practise safe sex?
P: Yes
D: I would like to check
EX: T-38C
D: Why you want antibiotics?

P: I am going to a party this weekend. I am coughing. I told you I had the same problem last
time and I was prescribed antibiotic. It worked.
From our assessment, you have a condition called URTI or common cold. It is infection of
nose, throat and other part of your upper wind pipe. It is caused by viruses and wc have
taken swab and no bacterial growth was found.
Antibiotics work against bacteria. Your condition is caused by virus. If we will give antibiotics
now you can develop antibiotic resistance. This means when your body needs antibiotics for
some bacterial infections, they won’t work.
This infection will settle down on its own. It may take up to 1-2 weeks.
We will give you PCM to reduce your temperature.
Take steam inhalation to lose mucous so that you can breathe properly. Drink plenty of
fluids; you can also take warm water with honey and lemon. Salt gargles and lozenges are
also helpful.
It is advisable to wash your hands often with soap and water. Please don't get too close to
others like hugging. Avoid sharing towels because You can easily pass this bug to other
people If you develop headache, rash, ear pain or discharge, rusty coloured phlegm, or your
symptoms doesn't subside in 2 weeks come back to us.
PATIENT CONCERNS:
When are you going to give me antibiotics?
What are you going to do for me?
If it turns into bacterial infection?
928
DD:
Infectious Mononucleosis
Meningitis
Otitis media
Pneumonia
Asthma
929
COELIAC DISEASE
You are an F2 in Medicine.

Patient aged 47, came to the hospital because of tiredness. She was prescribed Iron tablets
by her GP for Iron Deficiency Anaemia. She had undergone some test and she was found to
have tissue transglutaminase 2 antibody test (tTGA2) positive. She was diagnosed with
Coeliac Disease. She was planned for the Endoscopy and Duodenal Biopsy.
Please talk to the patient, assess her, and address his concerns.
Coeliac disease is an autoimmune condition affecting mainly the small intestine because of
dietary- protein gluten. Classic symptoms include gastrointestinal problems such as
chronic diarrhoea, abdominal distention, malabsorption.

P: I was told I have Iron Deficiency Anaemia and my GP sent me here for Endoscopy.
D: May I know why did you go to your GP?
P: I was feeling tired from last few weeks and I have tummy discomfort.
P: I feel tired from last few weeks, I went to my GP. he told me I have Iron Deficiency Anaemia,
and he gave me Iron Tablets.
D: Did you take those tablets regularly?
P: Yes.
D: Tell me more about your tummy discomfort?
P: I have diarrhoea since last few weeks.
D: Has it changed?
D: How frequently do you have to go?
P: 3 to 4 times a day.
D: How was your bowel habits before?
P: I use to go once in a day.
D: What is the consistency?
P: It is watery.
D: Any blood or mucus?
P: No’
P: I was told I have Iron Deficiency Anaemia and my GP sent me here for Endoscopy.
D: Any alternate bowel habits?
P: No
P: No
D: Any decrease in urine output?
P: No
930
D: Anything else?
P: No
D: Any tummy pain or bloating?
P: No
D: Any Nausea or Vomiting?
P: No
D: Any Fever or Flu like symptoms?
P: No
D: Any tingling or numbness in your hands and feet? (Peripheral Neuropathy)
P: No
P: Yes. I lost half a stone in the last few weeks.
P: No
P: No
D: Any problem with your balance
P: No
P: No
P: No
D: Any DM, Thyroid. Epilepsy or any skin problem?
P: No’
D: Are you taking any other medications apart from Iron Tablets you told me including OTC
or supplements?
P: No
P: No
P: No
P: Yes/No
D: Do you smoke?
P: Yes/No
P: Occasionally
P: Good/Bad
P: Yes
931
P: Yes'
I would like to do GPE. Vitals, and abdominal examination.
 Iron deficiency anaemia is one of the common finding of Coeliac disease.

 We have done blood tests for the antibodies which was found to be positive. However,
we need to confirm the diagnosis by doing endoscopy and by taking a biopsy that is why
your GP sent you here.
 In endoscopy, we will pass a thin, flexible tube with a light and camera attached into
your mouth and gently passed down to your small intestine. Then we will take a sample
then that is examined under a microscope for signs of coeliac disease.
 Before the procedure, you'll be given a local anaesthetic to numb your throat or a
sedative to help.
 While being tested for coeliac disease, you will need to eat foods containing gluten to
ensure the tests are accurate. You should also not start a gluten free diet until the
diagnosis is confirmed by a specialist, even if the results of blood tests are positive.
 We may do some further blood tests to check the levels of other vitamins and minerals in
your blood. We may consider doing an DEXA scan in some cases of coeliac disease if your
GP thinks your condition may have started to thin your bones. It is a type of X-ray that
measures bone density. It may be necessary in coeliac disease, a lack of nutrients caused
by poor digestion can make bones weak and brittle.
D: Why you think it is cancer?
P: I am worried because I am losing weight and feeling tired.
D: Your blood test shows that it is coeliac disease and all these symptoms that you are
having explains it. But as I have already mentioned that we have to do endoscopy to confirm
the diagnosis.
Treatment:
 Coeliac disease is usually treated by simply excluding foods that contain gluten from your
diet.
 This prevents damage to the lining of your gut and the associated symptoms, such as
diarrhoea and stomach pain.
 If you have coeliac disease, you must give up all sources of gluten for life. Your symptoms
will return if you eat foods containing gluten, and it will cause long-term damage to your
health.
 Your symptoms should improve considerably within weeks of starting a gluten-free diet.
 However, it may take up to two years for your digestive system to heal completely.
932
 When you're first diagnosed with coeliac disease, you'll be referred to a dietitian to help
you adjust to your new diet without gluten. They can also ensure your diet is balanced
and contains all the nutrients you need.
 Your GP will offer you an annual review.
DD:
Coeliac Disease
Colon Cancer
Anaemia
Hypothyroid
HIV
933
POST-OP HEMIARTHROPLASTY
You are F2 in Ortho.

Mrs. Bond, aged 78, presented to the hospital due to the fracture of neck of femur. She has
been planned to have a hemiarthroplasty.
Please talk to the patient, discuss about post-operative management and complications.
Discuss about management once patient has got discharged and address her concerns.
Anaesthetist has explained pain management. The consultant has explained the procedure.
D: Hello I am Dr xyz one of the junior doctors here. How are you doing today?
P: I am ok.
D: I am so sorry for what has happened to you. But don't worry we are here to give you the
best we can.
P: Thank you.
P: I am fine.
D: Has any one told you what has happened to you and what we are going to do for that?
P: Yes they told me that I have a broken bone in my hip and you are going to do an operation
to fix it.
D: You are right. And I believe my consultant/colleaguc has explained to you about the
procedure of surgery and the pain management after surgery.
P: Yes Dr.
D: Have you got any concerns that needs to be addressed before the surgery?
P: Yes Dr.
D: Don’t worry my dear I am here talk to you and address all your questions.
P: Can you tell me what happens after the surgery?
D: After the surgery you will be shifted to recovery room, where you will be observed and
monitored for a while.
P: When will I be able to walk?
D: We will try to make you mobile as quickly as possible after the operation. We encourage
our patients to walk the day after the surgery, however sometimes you will be made to walk
on the same day of the operation. But you will be needing some walking aids like crutches
to walk in the beginning. We do this to avoid any complications.
P: What are the complications of this surgery?
D: There can be some complications like:
 Infection or bleeding at the site of the surgery
 Hip dislocation
 Injuries to the blood vessels or nerves
 Differences in leg length
 Blood clot in the legs
If any of these things happen we will manage them accordingly.
934
P: Dr one of my friends underwent the same operation and she had this blood clot in her legs
and her condition became very serious. I am very concerned about that?
D: I totally understand your concern about that. First of all let me ask you few questions to
assess your risk of getting this condition.
P: No.
P: No
D: Are you currently taking any medications, OTC or supplem
P: No
P: No
P: No.
D: Any blood disorders or blood clots in the family?
P: No
D: You don't have any risk factors for developing this condition but we will take all the
necessary precautions to prevent this.
P: What precautions are you going to take?
D: As I told you earlier, we are going to make you mobile as quickly as possible after the
surgery because lying down in the bed can sometimes lead to this condition.
We may have to give you blood thinners which prevent clotting of blood.
We may also consider giving you some special stockings (TED stockings) if needed.
P: When will I be able to start my normal daily activities?
D: For the first four to six weeks after the operation you’ll need a walking aid. such as
crutches, to help support you.
You may also be enrolled on an exercise programme that’s designed by physiotherapist to
help you regain and then improve the use of your new hip joint.
Most people are able to resume normal activities within two to three months but it can take
up to a year before you experience the full benefits of your new hip.
D: Have you got any other concerns?
P: How will I get around in my home?
D: May I know about your home, whether it is a flat or a house?
P: I live in a house dr.
D: Do you have all the facilities on one floor?
P: No dr. my bathroom is upstairs.
D: Don't worry this is one of the areas we look into before discharging you because climbing
stairs can lead to fall and cause dislocation, one of the complications.
Our Occupational health therapist will assess your home condition and do all the necessary
adjustments before you get discharged. They make sure all the facilities are on one floor or
they may fix an electric chair to carry you up and downstairs. They will also change any low
toilet seats to high seats.
935
P: What about shower?
D: Bathroom can be slippery and pose risk of fall but don't worry about it, an electrical chair
can be fixed in the shower and also hand railings can be arranged.
P: When can I have food and drinks after the operation?
D: You may be allowed to have a drink about an hour after you have been to the ward and
depending on your condition, you may be allowed to have something to eat.
P: When will you discharge me?
D: Do you have anyone to look after you at horn
P: No Dr, that's one of the reasons why I am won
D: I can understand your concern, but don’t worry about it we can sort that out for you by
involving social services and arranging someone to take care of you or a carer.
D: You'll usually be in hospital for around three to five days, depending on the progress you
make. If your recovery is really good we may be able to discharge in 1-3 days.
 But before we discharge you we need to make sure everything is going well with you.
 Our surgeon and physiotherapist should be happy to discharge you.
 Our occupational health team and social services have assessed your home condition and
do the necessary arrangements for you to stay safe and comfortable.
 Contact your GP if you notice redness, fluid or an increase in pain in the new joint.
 If you develop any sudden chest pain or redness, hotness, swelling or pain over calf area
come back to us immediately.
 You'll be given an outpatient appointment to check on your progress, usually six to 12
weeks after your hip replacement.
 You'll need to be extra careful to avoid falls in the first few weeks after surgery as this
could damage your hip. meaning you may require more surgery.
 Continue the exercise plan given by the physiotherapist.
 Use any walking aid. such as crutches, a cane or a walker as directed.
 Take extra care on the stairs and in the kitchen and bathroom as these are all common
places where people can have accidental falls.
Please:
 Avoid bending your hip more than 90° (a right angle) during any activity.
 Avoid twisting your hip.
 Don't swivel on the ball of your foot.
 When you turn around, take small steps.
 Don't apply pressure to the wound in the early stages (so try to avoid lying on your side).
 Don't cross your legs over each other.
 Don't force the hip or do anything that makes your hip feel uncomfortable.
 Avoid low chairs and toilet seats (raised toilet seats are available).
936
PRE-OP ASSESSMENT-ANKLE PIN REMOVAL

Mr. Peter Murphy, aged 48, presented to the hospital for his pre-operative assessment. He
has been arranged to have an operation under general anaesthesia for the removal of screw
in his ankle. His operation will be done in two weeks time. He had an ankle fracture twelve
months ago and underwent a surgery because of it.
Please talk to the patient, assess his pre-operation fitness for day care surgery and address
his concerns.

P: I have come for my check-up. I had a fracture in my ankle last year and I had an operation
for it and now I have a day care surgery for pin removal from my ankle.
D: We are going to remove the pin that we put in your ankle in your previous operation. For
that we need to put you to sleep. First let me ask you some questions.
D: How are you these days?
P: lam fine.
D: Any cough, fever or flu like symptoms?
P: No
D: Have you been diagnosed with any medication
P: I am diabetic.
D: For how long?
P: 20 years ago
P: I am taking insulin for it.
D: Which insulin you take?
P: I am taking Lantus and Novarapid.
D: how do you take it?
P: I am taking Lantus once before going to bed. I am also taking Novarapid 3 few times.
D: Do you take your Insulin regularly as prescribed?
P: Oh yes doctor.
D: Is your diabetes well controlled?
P: Yes doctor.
D: Do you have any symptoms such as feeling thirsty or going to loo more often?
P: No doctor.
D: Have you developed any complications of diabetes?
P: No doctor.
D: By any chance any problems in your feet or eyes?
P: No
P: Yes, I check it regularly.
937
P: I checked it this morning.
D: What was the reading?
P: 6
D: Was it before meal or after meal?
P: I checked before having my breakfast.
P: Yes
D: Are you going for annual diabetic checkup?
P: Yes
D: Have you been diagnosed with any other medical conditions?
P: No.
D: Any high blood pressure or heart or kidney problem? Any lung problems like Asthma or
COPD? Any epilepsy? Blood disorders? Any loose dentures? Any problem with the neck?
P: No
P: No
P: No
D: Tell me about your experience in previous operation?
P: It was ok.
D: Were you put to sleep?
P: Yes.
D: Did you stay in the hospital last time?
P: Yes.
D: Any complications last time?
P: I vomited a lot last time. Doctor, will it be the same this time.
D: That was possibly because of the medication we gave you to put you to sleep and also the
medication we gave you to control your pain. This time we ” prescribe you an anti-sickness
medication to prevent it.
D: Do you smoke?
P: No
P: No
D: I would like to check your weight and height and vitals.

I would like to examine your heart, lung and tummy.
I will examine your skin for any infection/bug (MRSA Screening).
I will also check your airway and your neck movements.
 We need to run some tests to make sure you are fit enough for the surgery.
938
 I would like to send for some investigations including routine blood test to check for
anaemia, your blood group and your liver, kidney function. We will check your blood
sugar and bleeding and clotting time.
 We will do a urine test for any bugs and an ECG to check your heart rhythm.
 Hopefully, all the examination and investigation will be normal and you will be able to
have your operation.
 Let me tell you what you need to take in consideration. You need to stop eating and
drinking 8 hours before the operation. You need an empty stomach during the surgery so
you don’t vomit while we put you to sleep.
 As you are taking insulin and you should avoid eating or drinking before the operation,
please skip your morning dose, but you can take your night dose as it is.
P: Doctor, I live alone.
D: Do you have anyone to look after you for 24 hours after the operation?
P: But why?
D: Any operation has some complications. We make sure that you are fine and able to drink
and eat before you go home, if you develop any other complications, you need someone to
be around you to look after you.
P: I can ask my friend to come and look after me.
D: Ok that would be great. You will be seen by your GP in the next two weeks. You will be
also seen by us in six weeks to check if everything is fine.
If you develop any Severe pain. Bleeding. Shortness of breat chest pain. pain, hotness,
redness or swelling in your calf Please come back to us.
939
PRE-OPERATIVE CARE

Ms. Sally Armstrong, aged 25, has come to the hospital with a pre-operative assessment.
Talk to her, check her fitness for surgery and take verbal consent for surgery.

P: I have been told to come to the hospital for a check-up before my surgery for the gallbladder
removal.
D: We have planned a gallbladder removal operation, and for that we need to put you to
sleep. First let me ask you some questions.
D: How are you these days?
P: lam fine.
D: Any cough, fever or flu like symptoms?
P: No
P: Migraine.
D: For how long?
P:
P: I am taking sumatriptan.
D: Do you take your medicine regularly as prescribed?
P: Oh yes.
D: Is your migraine well managed?
P: Yes doctor.
P: Acute cholecystitis
D: Have you been hospitalized?
P: Yes, for acute cholecystitis
D: Have you had any blood transfusions?
P: No
P: No
P: No
D: Do you smoke?
P: No
P: No
P: Doctor, I live alone
D: Do you have anyone to look after you for 24 hours after the operation?
940
P: But why?
D: Any operation has some complications. We make sure that you are fine and able to drink
and eat before you go home. If you develop any other complications, you need someone to
be around you to look after you.
P: I can ask my friend to come and look after me.
D: I would like to check your weight and height and vitals.

I would like to examine your heart, lung and tummy.
I will examine your skin for any infection/bug (MRSA Screening).
I will also check your airway and your neck movements.
 We need to run some tests to make sure you are fit enough for the surgery.
 I would like to send for some investigations including routine blood test to check for
anaemia, your blood group and your liver, kidney function. We will check your blood
sugar and bleeding and clotting time.
 We will do a urine test for any bugs and an ECG to check your heart rhythm.
 Hopefully, all the examination and investigation will be normal and you will be able to
have your operation.
 There are two types of gallbladder removal surgeries, a laparoscopic (keyhole) surgery or
an open surgery.
 An open procedure may be recommended if you can’t have keyhole surgery – for
example because you have a lot of scar tissue from previous surgery on your tummy.
 It is also sometimes necessary to turn a keyhole procedure into an open one during the
operation if your surgeon is unable to see your gallbladder clearly or remove it safely.
 Let me tell you what you need to take in consideration. You need to stop eating and
drinking 8 hours before the operation. You need an empty stomach during the surgery so
you don’t vomit while we put you to sleep.
 As you are taking sumatriptan, I would advise you to stop taking this medicine 24 hours
before the surgery.
Removal of the gallbladder (cholecystectomy) is considered a relatively safe procedure, but

like all operations, there is a small risk of complications. These can include infections,
bleeding, bile leakage, injury to the surrounding organs, etc. You may also experience some
side effects and complications from the general anaesthesia. I will provide a leaflet for
detailed information on all of this.
Once you have had your surgery, you will be on your way to recovery, and will be seen by
your GP in the next two weeks. You will also be seen by us in six weeks to check if
everything is fine.
If you develop any fever, severe pain in the tummy, bleeding, shortness of breath and chest
pain, hotness, redness or swelling in your calf, please come back to us.
941
Please confirm that you are willing to undergo the procedure of gallbladder removal?
1. How big will be the surgical incision and will it leave a scar
2. Will I be losing much blood?
3. I don’t want a transfusion as I am Jehovah
4. Can it be an open surgery?
Ask:
Is it okay to transfuse your own blood?
Is it okay to transfuse any blood products like platelets & RBCs?
942
HERNIORRHAPHY

Mr. James Anderson aged, 40 has been planned to have a right inguinal hernia repair.
Anaesthetist have done the assessment.
Your nurse colleague measured his blood pressure as 152/88 mmHg.
Please explain the procedure and address his concerns.
The consultant will come later to take consent.

P: I have been planned for a surgery for my hernia and I have got some concerns doctor
regarding the surgery.
D: Okay. I am here to talk to you. explain to you everything and address to all your concerns.
But before that let ask you few questions.
P: Ok
D: Do you know what exactly is hernia?
P: No '
D: A hernia occurs when an internal part of the body pushes through a weakness in the
muscle or surrounding tissue wall. An inguinal hernia is the most common type of hernia
and it mainly affects men.
P: Ok
D: Has your pre-operative assessment been done
P: Yes/No (Then do pre-assessment)
D: Has any one examined you?
P: Yes.
D: Has anyone taken any blood from you?
P: Oh yes doctor. It has been done.
D: Could you please tell me since when are you having this problem?
P: Few months.
D: Which side do you have it?
P: Right side.
D: How did you notice it first?
P: I just noticed some swelling in my groin area.
D: Do you have any pain there?
P: Yes/No
D: Do you have any persistent or heavy cough?
P: No ’
D: How are your bowel habits?
P: Fine
D: Any constipation by any chance?
P: No.
943
P: No
P: No.
D: Any high blood pressure, diabetes, bowel problems?
P: No
D: Any heart or kidney problems?
P: No
D: Are you currently taking any medications, over-the-counter <
P: No
D: Any allergies from any food or medications9
P: No
P: No
P: Yes. my father also had this problem when he was 60.
D: I’m so sorry to hear that. Did your father have an operation for his hernia?
No, He use to wear a truss.
D: Do you smoke?
P: Yes/ No
P: Yes/No
P: I am quite active at work
D: May I know what do you do for a living?
P: I work in a warehouse.
D: Does it involve lifting heavy weights?
P: Yes Dr.
D: I would like to check your vitals and examine your whole body including your heart,
lungs, tummy, nervous system and also your hernia.
I would like to send for some initial investigations including routine blood tests to see if you
have any anemia, check the function of your liver and kidneys and also check how well your
blood clots.
D: We checked your blood pressure and it is on the higher side. This necessarily doesn’t
mean that you are diagnosed high blood pressure. We need to check at different times for
us to come to a conclusion.
P: Ok Dr.
944
D: Let me explain it to you that we do two types of operation for hernia, key hole surgery
under general anaesthesia and open surgery under local (Spinal) anesthesia. But as your
blood pressure is high, we will be doing an open surgery under local (Spinal) anaesthesia. As
local anaesthesia needs less fitness than general anaesthesia or else we have another option
for you which is, to wait and postpone your surgery for few days while we control your
blood pressure.
Does the hernia bother you much?
P: it is very uncomfortable.
D: Do you think you can wait until assessment for your blood pressure will be done?
P: Doctor, I can think about it? But tell me how you are going to do the surgery.
D: Did anyone explain you the procedure how we do this surgery?
P: No
D: Don’t worry I will explain it to you, in an open surgery, the surgery is carried out under
local anaesthesia injected into your spine. You will be awake during the procedure, but the
area being operated on will be numbed so you won't experience any pain. Once the
anaesthetic has taken effect, the surgeon makes a single cut (incision), over the hernia. The
surgeon then places the lump of fatty tissue or loop of bowel back into your tummy. A mesh
is then placed in your tummy wall, over the hole at the weak spot where the hernia came
through, to strengthen it.
When the repair is complete, your skin will be sealed with fine stitches. These usually
dissolve on their own over the course of a few days after the operation.
P: How long the surgery will last?
D: It usually takes between 30 minutes and 60 minutes, however sometimes it takes longer
depending on the person to person.
P: For how long i have to stay in the hospital?
D: This operation can be done as a day care surgery meaning if everything goes smoothly,
after you are able to take fluids and pass urine you will be able to go home at the same day
of the operation. Sometimes it may be difficult to pass urine immediately after the
operation and you may have to stay in the hospital overnight.
P: Are there any complications of the surgery?
D: Like any other operations, this may have some complications.
You may have some pain after the operation, however, we will give you adequate painkiller
to relieve your pain. Infection can occur after the operation. Fortunately, this is uncommon
but if this happens, we can prescribe you antibiotics. Sometimes we give a single dose of an
appropriate antibiotic to minimize any chance of infection. Bleeding and damage to
surrounding structures is also possible. Don’t worry this is also rare and if it happens we will
manage it accordingly.
Sometimes, blood or fluid may build up in the space left by the hernia, however, this usually
gets better without treatment. You may experience hematoma. This is the bruise that can
occur in the groin or scrotum. Formation of blood clot in the legs or lungs is also possible.
Try to have gentle physical activity to improve the circulation of blood in your legs. If you
945
are at risk you will be given special compression stockings and possibly blood thinning
injection to reduce the risk.
P: Is there any long term complications?
D: In some patients, the hernia may come back. Patients may experience mesh infection
usually
from bug on the patient s skin. If this does occur the mesh will normally have to be removed
with another operation.
P: How should I take care of my wound?
D: Make sure you follow the instruct our nurse gave you about caring for your wound,
hygiene. A see-through plastic dressing will cox er the wound and can be peeled off after 3-7
days. Do not change the dressings unless they have become very blood stained. Wounds
should appear clean, dry and healing. If you are in doubt seek advice from your GPs practice
nurse.
P: Will I be able to take shower?
D: Yes, you can take shower rather than bath for the first 10 days. But make sure dressing
should be waterproof.
P: When can I drive after the surgery?
D: It is usually advisable to avoid driving until you are able to perform an emergency brake
without feeling any pain or discomfort. It will usually take one or two weeks before you
reach this point after having a keyhole surgery, however, in your case it may take longer
since you have an open surgery.
P: When can I resume my sexual activity?
D: You may find sex painful or uncomfortable at first, but it's usually fine to have sex after 2
weeks or when you feel.
P: When can I go to my work?
D: As you mentioned your job involves heavy lifting or manual labour it may take up to take
six weeks before you can return to work.
P: Do I have to wear a truss/belt/jockstrap like my dad used to wear?
D: Wearing a truss to stop the lump coming out of the hole is not ideal. This was used in the
past when surgery was complex, dangerous and had a universally poor success rate. It is
now thought to have no or limited benefit and are also fairly uncomfortable. It is generally
no longer recommended.
If you have Sudden, severe pain, Vomiting, Calf pain or increasing breathlessness. Excessive
bleeding. Difficult} passing stools or wind (Obstructive or strangulated hernia). Please come
to the hospital.
General Advice:
It is advisable to have plenty of water for two days before the operation. It is also important
to eat plenty of fruits and vegetables during this period as this helps avoid constipation and
pain after operation.
It is advisable to continue such diet after the operation.
946
You may take some medication (laxatives such as Senna or lactulose) for the first two days
after the operation if needed. This also helps reduce pain and constipation.
Indications of keyhole laparoscopic repair:

Recurrent Hernias, failed open repair, Bilateral Hernias, incisional hernias. Hernias in women
(there is some evidence that women have a higher chance of another undiagnosed hernia
that is not easily seen during open surgery. In patients whose predominant symptom is
pain}.
947
DERMOID CYST

Yulia aged 24 presents to the hospital with Abdominal pain. Ultrasound has been done and
shows Dermoid Cyst in the right ovary. Consultant has decided to do Open Ovarian
Cystectomy with an incision of 8.5 cm. Consultant has decided to keep the patient in the
hospital after the surgery for 2 days.
Talk to the patient and address her concerns.

P: I came to the hospital because of pain in my tummy. I have been planned for a surgery and I
have some concerns regarding the surgery.
D: Yes, that’s correct. I’m here to talk to you and I will address your concerns. Before that,
let me ask you few questions.
P: Ok Doctor.
D: Tell me more about your tummy pain?
P: I have had this pain for the last few days.
P: On the right side of my tummy
P: No Doctor.
D: Any HTN/DM/Bowel proble
P: No
D: Are you on any medications including OTC or supplements?
P: No
D: Any Allergies from food or medication?
P: No
D: Any previous hospitalisations or surgeries in the past?
P: No
D: Has anyone been diagnosed with any medical conditions in the family?
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: Yes. I’m quite active.
D: What do you for living?
P: I'm an accountant.
D: Thank you for answering these questions. As you told me, you came to the hospital with
pain, we did US scan of your tummy and we found fluid-filled sac in your ovary which we call
Ovarian Cyst.
948
P: So. what are you going to do now?
D: Our consultant has decided to do an operation to remove this cyst
P: Is it serious?
D: Ovarian Cyst are common and they usually do not cause symptoms. However, if the size
of the cyst is large and the cyst is causing problems then we have to do surgery.
P: Is it compulsory to undergo this surgery?
D: Yes, in your case we have to do this operation for removing the cyst as you are having
pain. If we do not remove this cyst now, it may rupture and bleed in the future. In that case
we have to do emergency operation. To avoid such situation, it is best if we remove it now.
P: Ok Doctor. So how are you going to do the surgery?
D: Our consultant has decided to do an Open Surgery. In this we will put you to sleep and an
incision will be made on your bikini line (Pfannenstiel incision or Bikini line incision). Then
we will remove your Ovarian Cyst. In most of the cases we will remove only the cyst but in
few cases during the procedure we have to remove the ovary as well.
P: How long will the surgery' last?
D: Usually takes 30 to 60 mins however sometimes it takes longer depending on person to
person.
P: For how long do I have to stay in the hospital?
D: Our consultant has decided to keep you in the hospital for 2 days after the surgery.
Hopefully everything will go smoothly and you will be able to go home after 2 days.
P: What will be the size of the scar?
D: Incision will be up to 8.5 cm long and the scar will be very thin and will be covered by the
bikini so it won't be visible when you wear the bikini.
P: Is it cancerous?
D: Most of these cysts are benign however we will send the samples to the laboratory to
confirm.
P: Will I be able to become pregnant?
D: You have the cyst in only one of the ovary for which we are doing the operation. The
other ovary is fine and so you will be able to become pregnant.
P: When can I resume my sexual activity?
D: After the surgery, you can start after 4-6 weeks.
P: When can I go to work?
D: If everything is fine you can go back to work after 4 weeks.
P: When can I drive?
D: It is usually advisable to avoid driving until you are able to perform an emergency brake
without feeling any pain or discomfort. It will usually take one or two weeks before you
reach this point after having a keyhole surgery, however, in your case it may take longer
since you have an open surgery.
P: Are there any complications of the surgery?
D: Like any other operations, this may have some complications
You may have some pain after the operation, however, we will give you adequate painkiller
to relieve your pain. Infection can occur after the operation. Fortunately, this is uncommon
949
but if this happens, we can prescribe you antibiotics. Sometimes we give a single dose of an
appropriate antibiotic to minimize any chance of infection. Bleeding and damage to
surrounding structures is also possible. Don't worry this is also rare and if it happens we will
manage it accordingly.
Keyhole operation (Laparoscopic):

It is done under general anaesthesia. In this operation, we will put you to sleep. The surgeon
will make a small cut. One cut is usually near your belly button. Gas is injected through the
cut to inflate the tummy wall to make it easier to see internal organs.
A laparascope which is a thin telescope with a source of light, is pushed through the tummy
through another cut. This camera is connected to a TV and through the other cut
instruments are pushed in the tummy cavity so the surgeon can see the instruments on the
monitor and perform the surgery.
950
PAIN MANAGEMENT BREAST CANCER
You are F2 in Acute Medicine Unit.

Jasmine aged 60 has been referred from Oncology Department to Acute Medicine Unit for
pain management. She has been diagnosed with Breast Cancer 5years ago and now she has
presented with back pain.
Please talk to the patient, outline a treatment plan and address her concerns.

P: Doctor. I’m having this pain, (patient shows lower back).
SOCRATES
D: Can you tell me more about?
D: Where is the pain?
P: It’s in my lower back.
P: It started gradually.
D: Is it continuous or does it come an
P: It is increasing.
D: Could you describe the pain for me?
P: It is dull pain.
P: No
P: I took Paracetamol, but it didn’t help.
D: May I know how much you did you take?
P: I take 2 tablets 3 times a day.
D: How long have you been taking it?
P: Been taking it for three months now.
D: Does anything make the pain worse?
P: It’s getting worse on its own.
the
P: 8-9.
D: How about when the pain started?
P: Doctor, it wasn't that bad.
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P: No doctor
P: No
P: I was diagnosed with breast cancer 5 years ago.
D: I’m so sorry to hear that. What was done for you after that?
P: I had lumpectomy. I received Radiotherapy. Chemotherapy and Hormone Replacement
Therapy for a while for that.
D: Has your disease been well controlled?
P: Doctor 2 years ago I was having back pain so 1 went to them. They did a bone scan and told
me the that now I have cancer in my bones.
D: What has been done for that?
P: They’ve already tried Radiotherapy on my back 3 months ago. It didn't work. Oncologist
decided not do any active treatment.
D: Do you take any other medications apart from the Paracetamol?
P: No
D: Any allergies?
P: No
D: Have you ever been hospitalised?
P: No
P: No
D: Do you smoke?
P: No
D: Can you tell me about your physical activity?
P: I go for brisk walk every day.
P: I have a good diet.
D: What do you for a living?
P: I have an office job.
D: With whom do you live with?
P: I live alone.
D: How has this condition affected your life?
P: Doctor, it’s getting a bit harder. It’s affecting my day-to-day life. I have trouble walking. I
would like to do some Examination. I would like to examine your Vitals and your back.
Ex: Doctor every thing is normal. (+/-She has a mastectomy scar as described by the patient)
P: Doctor what can you do for my pain?

D: From what you told me, in order to control your pain we need to consider moving to an
weak opioid called Codeine. We will continue giving simple painkiller like Paracetamol or
952
Ibuprofen along with it. It comes as cocodamol so we can give you that. Hopefully your pain
will be under control, if not then we have got many options.
P: Like what?
D: If your pain didn't subside with Cocodamol then we can give you strong opoid like
morphine. Again we will continue giving you paracetamol with it.
P: I don't want to take it.
D: Why you don't to take it?
P: I haven't heard good things about it. I heard it makes you drowsy.
D: I do understand your concern. However, morphine is the best medication to treat your
pain. One of the side effects of Morphine is drowsiness, but don't worry, it will subside
after a couple of days.
Morphine has got some other side effects that include constipation, feeling sick, feeling
sleepy
Which one would you like me to discuss?”
Side effects of Morphine:

1. Constipation: Try to eat food rich in fibres, such as fresh fruit and vegetables and cereals.
Try to drink several glasses of water or other non-alcoholic liquid each day. If you can, it
may also help to do some gentle exercise. Speak to your doctor about medicine to help
prevent or treat constipation caused by morphine if your symptoms do not go away.
2. Feeling sick or vomiting: You should take morphine with or just after a meal or snack to
ease feelings of sickness. This side effect should normally wear off after a few days. Talk
to your doctor about taking anti-sickness medicine if it carries on for longer.
3. Feeling sleepy, tired or dizzy: These side effects should wear off within a week or two as
your body gets used to morphine. Talk to your doctor if they carry on for longer.
4. There are some serious side effects of the morphine like seizure, breathing difficulty or
short shallow breathing and muscle stiffness if happens please contact your GP or go to
the A&E.
P: Is morphine addictive?
D: This is unlikely to happen. People who become addicted to drug, usually initially choose
to take them and keep taking them because they have a psychological need to take these
medications. This is very different from someone who is in physical pain and needs the drug
to control the pain
P: There is a wedding going on in the family in a couple of months and I want to attend it.
D: May I know what your concern is?
P: Doctor will I still be in pain by then? Will I be able to attend the wedding?
D: Don’t worry, hopefully we are able to control your pain with Morphine. It is very
important to take your medication as prescribed. Taking regular medication prevents the
pain and prevention is always easier than cure.
If you feel pain, we can increase the dose of your medication. If Morphine doesn’t work, we
have some other options to treat your pain.
953
We may prescribe you some other medication, which are not painkiller but help painkillers
to minimize the pain. One of these medications is Bisphosphonate, which strengthens the
bones.
P: Is there anything else besides tablets that you can give me? / What if I don't want to take
tablets?
D: There is another type of painkiller, which comes in the form of patch. It is not the first
choice.
We usually start with morphine since it’s the best choice for you. If there is any problem
taking Morphine (Morphine tolerance/renal impairment/ poor compliance to oral
morphine), we can prescribe this.
P: Is there any other route for the medication? Can any device be used?
D: We always have another option to consider which is a device called Syringe Driver. Would
you like me to talk about it?
P: Yes
D: This is a small pump that gives you continuous dose of medication under the skin as an
injection. We usually offer this to those who have been on oral morphine for long-term and
have developed some side effects, especially nausea, vomiting and difficulty in swallowing.
As you have pain in your back, it might affect your nerves and you can experience difficulty
in walking, sensation of numbness or pins and needles in your legs or difficulty controlling
urine or bowel movements. If you experienced any of these symptoms, please come back to
us urgently.
If you have any shallow breathing, please contact your GP or come to the hospital.
P: No doctor.
954
PAIN MANAGEMENT (PROSTATE CA)
You are F2 in Medical Unit.

Michael aged 60 has been referred from Oncology Department to Acute Medicine Unit for
pain management.
He has been diagnosed with Prostate Cancer 5 years ago and now she has presented with
back pain.
Please talk to the patient, outline a treatment plan and address her concerns.
955
TWO PEOPLE POLICY

Patient aged, 92 admitted in the hospital due to respiratory failure. She is unconscious and
terminally ill. All family members are coming here praying and making loud noises.
Talk to the grandson and tell him only 2 relatives can visit the patient at a time.
According to the hospital policy 2-5 pm is silent time and no visitor is allowed.

P: All the family members are here and we are praying for our grandmother. She is in the
hospital.
D: I can understand you are going through this tough time. Let me ask you some question
about your grandmother condition.
Do you know why she was in the hospital?
P: She was having some problem with the breathing and she was admitted in the hospital.
Here she was diagnosed with respiratory failure and she is unconscious now. Doctors have
decided that she is in her end stage.
D: I can imagine what you have been through. It is very toughtime for you and for your
family. I am here to talk about some other thing as well. Do you have any idea what I am
here to talk about?
P: No
D: Do you have idea about 2-person policy the hospital?
P: I know about this policy. We are family and a lot of people come to see her and pray for her
from far distance.
D: I understand this conccan do you know why we have this 2 person policy in the hospital?
P: No
D: There are others patients as well in the ward and they get disturbed because of the noise.
They might start making complaint against us. You will agree w ith me that noise might
affect other patients sleep also.
P: This is our religion, these are the norms that we have to follow in our religion.
D: I respect your religion, but according to the hospital policy Only 2 relatives can meet at a
time and no one is allowed from 2pm to 5pm. It will also be unfair with the other patients.
P: Doctors do not respect their religion and they don’t understand the importance of these
rituals.
D: We respect all the religions, but we have to think about other patients as well. They are ill
that is why they are in the hospital and we have to look after each and every1 patient.
P: This is the only way we can perform the last rituals by praying together in front of her.
D: There is a praying area where you can go and pray for your grandmother without causing
any inconvenience to other patients.
P: No doctor, we have to be there beside her. our priest is also coming and all the members
of our family should be there. We will be keeping the Bible beside her.
956
D: As I have already mentioned that we respect all the religion, what we can do here is I will
talk to my seniors, ward manager and head nurse and we may be able to shift your
grandmother to a private room where you can perform the last rites and rituals.
957
COLORECTAL POLYP
You are the F2 in the Gastroenterology.

A 52 year old female presents with complain of per rectal bleeding for the last 6 weeks.
Sigmoidoscopy was done which revealed bowel polyp. Colonoscopy has been planned.
Talk to her & address her concerns.
D: Hello! How can I help you today?

P: Doctor I had a camera test 2 weeks back & now they tell me that I have to get the test
again. I want to know why.
D: Right! I can see that it’s worrying you. Can I please ask exactly what has happened?
P: Well, I got this camera test done 2 weeks ago. then they took so long to give my results.
Then when finally, I got them. I’ve been asked to come back to the hospital for another camera
test. See this note:
Sigmoidoscopy shows bowel polyp.
Biopsy confirms it as adenoma (benign).
You are requested to come back for
colonoscopy.
Signed:
Consultant Gastroenterologist
D: I’m so sorry' that you had to wait that long for the results, it was a special type of test. &
it can sometimes take a little more time to get the results.
P: Ok
D: Have you read this note though?
P: Yes
D: Do you know what is written in this letter?
P: Yes, I have a polyp & I need another test
D: Do you know what that test is?
P: I just know that it’s a camera test.
D: Yes, you are right, it is a camera test, but it is not the same test that was done before
P: Is it not?
D: No
P: Okay
D: Can I ask if you know why was the first camera test done?
P: Well I had this problem of bleeding from my back passage. I went to the GP. he sent me for
this test.
D: Can you please tell me more about the bleeding problem that you had?
P: Well I noticed it 6 months ago for the first time
P: No
958
D: What exactly did you notice?
P: 1 noticed blood in my stool
D: How many times did it happen?
P: I’ve noticed it some 2 3 times since then
P: Like what?
D: Any pain while passing stool?
P: No
P: No
D: Any change in the bowel habits recently?
P: Regular
D: Constipation/diarrhea?
P: No
D: Any nausea/vomiting?
P: No
P: Fine
P: No
P: No
D: Have you ever had piles?
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: Balanced
P: No Dr.
D: A polyp is actually a non-canccrous/benign growth in the lining of the gut. That is what
caused the bleeding that you saw with the stool. It is usually diagnosed with help of a
959
camera test like the one that was done for you, called sigmoidoscopy. Now with this test,
only a specific part of the large gut can be viewed & not the whole of it. The polyps can be in
other parts of the large gut too. To be able to see the whole of the large gut. another test is
done which is called colonoscopy. With that we can see if there are any more polyps and can
also remove them with the same tube right there right then. Then the symptoms that you
were having of bleeding from your back passage, that will go away.
P: But doctor, it only happened a few times, do you really need to do the test again? Is there no
other treatment for it?
D: Well, as I told you. these are non-cancerous growths. But if we do not remove them, over
time they can become cancerous. The only way to treat them is to remove them.
P: Right
960
CHILD TELEPHONE CONVERSATION – FEVER, SUSPECTED CHEST INFECTION
You are an F2 in Paediatrics

10 months old baby has been sick for 2 days and is on triage care call. His mother, Mrs.
Maria is concerned.
Talk to the mother, discuss the initial plan and address her concerns.
(Mother is very worried and concerned)
D: Hello. (Introduce yourself). Confirm the mother’s name, child’ name and age.
M: Dr., can you please come and see my baby immediately, he is ill.
D: I am so sorry to hear that. We are here to help your baby. Could you please tell me what
exactly happened?
M: My baby has fever for 2 days and he is not feeling well.
D: Have you measured the temperature?
M: Yes doctor. I have measured it with my home thermometer, and it was 39 C.
D: Have you done anything for it?
M: I gave him paracetamol, but it has not improved.
D: Have you noticed any other symptoms?
M: Like what doctor?
D: Any cough?
M: Yes, since yesterday.
D: Any phlegm along with cough?
M: No doctor.
D: Any difficulty in breathing?
M: Yes. He has difficulty in breathing since yesterday.
D: Any rashes over the body?
M: No
D: Any difficulty in moving his neck?
M: No
D: Does he shy away from light?
M: No
D: Any headache?
M: No
D: Any ear pain or discharge?
M: No
D: Any vomiting?
M: No
D: Any diarrhoea or loose stools?
M: No
D: Is he passing urine normally?
M: No, I haven’t changed his diaper since yesterday.
D: Any tummy pain?
961
M: No
D: Is your baby active?
M: No doctor, he is lethargic and tired.
D: Has your baby been diagnosed with any medical conditions in the past?
M: No
D: Is he on any regular medications?
M: No
D: Any family member with any medical problems?
M: No
D: Any family member with any similar complaint?
M: No
M: Yes
M: Yes
D: Is he up-to-date with all his jabs?
M: No
D: Did he receive any recent jab?
M: It was a normal delivery
M: No doctor he hasn’t been feeding well since yesterday.
D: Have you travelled anywhere with your child recently?
M: No
D: Who looks after your baby?
M: I do.
D: Thank you for answering all my questions. I suspect your baby might be having chest
infection. He needs immediate admission.
M: What should I do now doctor?
D: Don’t worry, I am going to send an ambulance to get your baby to the hospital. We will
have to examine him, do some blood test and a chest x-ray. If we find it is an infection, we
will give him antibiotics.
M: Ok Dr. When will the ambulance arrive?
D: We will send the ambulance immediately. Hopefully, it should reach you soon.
M: Ok Dr.
M: No
D: Thank you.
962
POST-OP BLEEDING
You are F2 in Vascular Surgery.

Mrs. Janet aged, 65 has undergone an aortobifemoral bypass graft in her lower limb due to
vascular insufficiency that caused calf pain. She was shifted to the recovery room, after the
operation. Your nurse colleague noticed that she was bleeding heavily into the drain, a few
hours after the operation. She was given six units of blood products. Your colleagues all
scrubbed in to the theatre. She was taken to the theatre for re-exploration.
Her husband has come to the hospital to see his wife. Please talk to him about his wife’s
condition and address his concerns.
There was no error in surgery. This is a known complication of the surgery.
Consent from Mrs. Brown has been taken to talk to her husband.
D: Hello! Are you the husband of Mrs. Janet?

P: Yes Dr.
D: How may I help you today?
P: I came to see my wife. Where is she? How is she Dr.?
D: I understand that your wife had a surgery this morning and you have come to see your
wife. I am here to talk to you about your wife's condition.
P: Ok Dr.
D: Do you have any idea about what's happening?
P: No. I don't know what’s happening.
D: Did anyone tell you about your wife's condition?
P: She had her operation this morning. I came to see her but she was not in the recovery room.
D: Yes you are right she has an operation this morning because of problem in her leg.
Operation went well and she was doing fine after that but unfortunately she started to
bleed a few hours after the operation.
P: Bleeding? Is it serious Dr.'.’
D: I understand how worried you are! We have given her six units of blood to make up for
the loss.
P: What? 6 units. Isn’t it too much?
D: It is quite a lot of blood but we need to compensate for the loss of blood and now we
have taken her to the operation theatre immediately to stop the bleeding.
P: Will she be okay doctor?
D: She is in good hands. A team of experienced doctors is w ith her now to look after her.
She is in a critical condition I am afraid, but we are trying our best to help her.
P: Have you guys done a mistake during the surgery?
D: This is one of the complications of this surgery but. may I know why do you think in that
way?
P: How can she lose so much of blood. I am sure something might have gone wrong during the
surgery.
963
D: I can assure that the surgery' went really well and the operation was a success. This is one
of the complications of this surgery which I am sure my colleagues would have explained to
your wife before the operation.
P: I wasn't aware of this. No one told me this.
D: Usually before the operation, we explain the procedure and all the possible complications
to the patient and then take their consent. And I am sure that your wife was aware of all of
the possible complications before going for the procedure.
P: I have lost faith in you guys. Are you sure that it wasn't an error?
D: I can imagine what you are going through and how worried you are. As I said earlier, I can
confidently reassure you that no error has happened in her operation and it was just a
complication.
P: What's the difference between an error and a complication?
D: A complication is as an adverse event caused by some factors such as patient’s general
health, immunity or healing power, that are out of doctor's control.
However, an error is a mistake done by the surgeon or his team during the operation.
P: How can you convince me that what happened to my wife was a complication and not an
error?
D: Let me explain about the nature of this operation to you. In this operation we insert an
artificial vessel between the main artery in the tummy (aorta) and two main arteries in both
groins(femoral arteries) that supply blood to the legs. This involves major blood vessels and
is a major surgery and that's why there is always a risk of complication. Now you can
imagine why there is a chance of bleeding after this operation.
P: What is the success rate of this operation?
D: It differs from patient to patient. It depends on their age. general fitness and whether
they have any medical problems.
Unfortunately, your wife has developed one of the important complications of this
operation, which makes it difficult to say what will happen exactly, however, since bleeding
is a known complication, we were prepared for it and acted immediately, hopefully that
improves the outcome.
P: I didn't know about any of this. If it was that risky, why would she go for it?
D: I do understand your concern because she had a blockage or narrowing of the arteries
supplying her legs, the blood supply to her legs was reduced and this caused pain in her legs
specially during walking, because her muscles required more blood. There was also the risk
of ulcers developing. The aim of this operation was to improve the blood supply to her legs
and to relieve her symptoms. In her case the advantages outweigh the disadvantages and
that's why she went for it.
P: Doctor, what can I do now? Doctor, shall I go home or shall I wait in the waiting area?
D: That’s up to you. The operation may take a few hours. So if you want you can wait in the
hospital until her operation ends.
P: Doctor, shall I call my children to come and say goodbye to their mother?
D: You need emotional support at this time and of course you can call your children. May I
know where your children are?
964
P: Doctor, my son lives in Australia and my daughter lives in London. I’m sure they would want
to see their mom for the last time.
D: Of course you can call to inform them. You may ask your daughter to come, be with you
and support you. I’m sure you need your daughter by your side more than anytime at this
moment.
You told me that your son lives far away, so it’s really up to you if you want him to come.
You can wait until the operation ends so we can update you as soon as possible.
P: l am the only one who looks after her. How long will she be here for?
D: We usually keep our patients in the hospital for one week after the operation but
complication may extend staying in the hospital so she may need to stay a bit longer. Do not
worry, we will have a close eye on her and we won’t discharge her until the surgeon and
nurses decide that she is absolutely fit to go home.
P: Doctor, are there any other complications?
D: Infection at the site of operation or
Infection of the artificial artery, this is rare (about one in 500) but is a very serious
complication, usually requiring removal of the graft if you are fit enough. To try to prevent
this happening you are given antibiotics during your operation and long-term antibiotics can
be used as the treatment option.
 Blockage of the bypass graft, this is a specific complication of this operation where the
blood clots within the bypass graft causing it to block. If this occurs it may be possible to
perform another operation to clear the bypass.
 Limb loss (amputation) happens sometimes when the bypass blocks and the circulation
cannot be restored. The circulation to the foot may be so badly affected that amputation
is then required.
 Chest infections can occur following this type of surgery, particularly in smokers, and may
require treatment with antibiotics and physiotherapy.
 Occasionally the bowel is slow to start working again, this requires patience and fluids
will be provided in a drip until your bowels get back to normal.
P: How will her situation be afterwards?
D: Two to three weeks after discharge from the hospital she needs to have rest more than
usual.
For example sleeping in the afternoon.
After this period she can gradually return to her normal activities.
She should not put too much strain on her operative wound
She can gradually increase the amount of exercise and increasing the distance that she
walks.
She should keep the wound area clean by daily bath or shower and dry the area gently with
a
clean towel.
If she has redness or discharge from her wound please seek advice from her GP.
If she develops sudden pain or numbness in her leg, which doesn’t get better within a few
hours, please contact the hospital immediately.
965
If she experiences any pain or swelling in her calves or any shortness of breath and chest
pain, please immediately come to the A&E.
966
NIPPLE DISCHARGE

Yara White, aged 29, has come to you because of Nipple Discharge.
D: How can I help?

P: I have some discharge coming from my nipples. (Single or Both)
D: Elaborate: When? How long? Colour? Consistency? Blood stained?
P: No
D: Any change in shape and size of the breast?
P: No
D: Any change in the skin of the breast?
P: No
D: Any swelling or mass?
P: No
D: Any lumps and bumps in the body?
P: No
D: Any weight loss?
P: No
P: No
P: No
P: No
D: Tell me about your periods, when was tour last menstrual period?
P: 2 weeks ago
D: Is it regular?
P: Yes
D: Any heavy periods or bleeding in between the periods?
P: No
D: Any pregnancy? If yes how many kids?
D: Are you sexually active now?
P: Yes
P: Yes/No
P: No
P: No
967
D: Any breast problem in the past?
P: No
P: No
D: Any hormonal therapy?
P: No
P: Yes/No
D: Do you smoke?
P: No
P: No
P: Healthy
P: I try to be.
I would like to do a GPE, check the vitals and examine your breasts.
We may refer you to a hospital or breast clinic for further tests. At the hospital or breast
clinic, you may have a:
• breast examination
• scan – usually a breast X-ray (mammogram) or ultrasound
• biopsy – where a needle is inserted into your breast to remove some cells for testing
The tests are often done during the same visit.
You'll usually be told the results on the same day, although biopsy results can take longer –
you should get them in a week or two.
See a GP if you have nipple discharge and any of these:

• it happens regularly and isn't just a one-off
• it only comes from 1 breast
• it's bloodstained or smelly
• you're not breastfeeding, and it leaks out without any pressure on your breast
• you're over 50
• you have other symptoms – such as a lump, pain, redness or swelling in your breast
• you're a man
Causes:
• breastfeeding or pregnancy – see leaking nipples in pregnancy
• a blocked or enlarged milk duct
• a small, non-cancerous lump in the breast
• a breast infection (mastitis)
• a side effect of a medicine – including the contraceptive pill
968
Nipple Discharge
 Nipple discharge isn't usually a sign of anything serious, but sometimes it's a good idea to
get it checked just in case.
 Nipple discharge is often normal
 Lots of women have nipple discharge from time to time. It may just be normal for you.
 It's also not unusual for babies (boys and girls) to have milky nipple discharge soon after
they're born. This should stop in a few weeks.
 Nipple discharge in men isn't normal.
 The colour of your discharge isn't a good way of telling if it's anything serious. Normal
discharge can be lots of colours.
969
HIV TEST RESULTS
You are F2 in GP.

John Bernard aged 40 presented to the clinic because of generalized lymphadenopathy 2
weeks ago. Blood test was done 2 weeks ago. FBC, LFT, U&Es, Urine chlamydia screen was
normal. HIV antibody andp24 antigen test are positive.
Talk to the patient, take history, disclose the blood result and discuss the plan of
management and address his concerns. You can find the blood tests in the cubicle.
D: What brought you to the hospital? P:

D: Could you please tell me why you had these blood tests?
P: I noticed lumps and bumps in my neck, armpits, and in my groin that is why my GP ordered
these blood tests.
D: When did you notice these lumps?
P: From last few months
D: Has it changed?
P: No
D: Is it painful?
P: No
P: No
P: No
D: Any sore throat or cough?
P: No
P: No
D: Any rash?
P: No
D: Any joint or muscle pain?
P: No
D: Any Diarrhoea or nausea vomiting?
P: No
D: Any headache or fatigue?
P: No
D: Any weight loss?
P: No
D: Any loss of appetite'?
P: No
P: No
970
P: No
P: No
P: No
P: No
D: Any previous hospital slays or surgeries?
P: No
P: No
P: Yes/No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: No
P: It is ok
P: Yes/No
P: I am an accountant
D: D: Have you travelled recently?
P: Yes/No
P: Yes
D: Since when?
P: From last 2 years.
P: No
D: Do you have stable partner?
P: Yes, I am married.
D: Any other partner?
P: I went to Thailand 2 months back and I had sex with one woman there.
D: Did you use condoms?
I would like to do GPE, Vitals, and want to examine your lumps and bumps.
971
We did some routine blood investigations like liver and kidney function which came back
positive. We did screen you for Chlamydia which is Sexual transmitted infection which is
also negative. We did another 2 blood test to check for HIV and unfortunately they came
back positive.
HIV (Human Immunodeficiency Virus) is a virus that damages the cells in your immune
system and weakens your ability to fight everyday infections and disease.
How it spreads:
 Sexual Contact: The most common spread is through unprotected vaginal or anal sex. It
 may also be possible to catch HIV through unprotected oral sex, but the risk is much
lower.
 sharing needles: Sharing needles, syringes and sex toys with someone infected with HIV.
 blood transfusion: It is very rare in the UK, but still a problem in developing countries
Regular blood test:

You'll have regular blood tests to monitor the progress of the HIV infection before starting
treatment.
Two important blood tests are:
1. HIV viral load test: Blood test that monitors the amount of HIV virus in your blood
2. CD4 lymphocyte cell count: It measures how the HIV has affected your immune system
Antiretroviral drugs:
HIV is treated with antiretroviral medications, which work by stopping the virus replicating
in the body. This allows the immune system to repair itself and prevent further damage. A
combination of HIV drugs is used because HIV can quickly adapt and become resistant.
Recently some HIV treatments have been combined into a single pill, known as a fixed dose
combination.
The amount of HIV virus in your blood (viral load) is measured to see how well treatment is
working. Once it can no longer be measured it's known as undetectable. Most people taking
daily HIV treatment reach an undetectable viral load within 6 months of starting treatment.
Treatment as prevention:
When patient with HIV takes effective treatment it reduces their viral load to undetectable
levels.
This means the level of HIV virus in the blood is so low that it can't be detected by a lest.
Having an undetectable viral load for 6 months or more means it isn't possible to pass the
virus on during sex. This is called undetectable = untransmittable (U=U), which can also be
referred to as "treatment as prevention".
Condoms:
Both male condoms and female condoms are available. They come in a variety of colours,
textures, materials and flavours. A condom is the most effective form of protection against
972
HIV and other STIs. It can be used for vaginal and anal sex, and for oral sex performed on
men. HIV can be passed on before ejaculation through pre-come and vaginal secretions, and
from the anus.
It's very important condoms are put on before any sexual contact occurs between the penis,
vagina, mouth or anus.
Lubricant:
Lubricant, or lube, is often used to enhance sexual pleasure and safety by adding moisture
to either the vagina or anus during sex. Lubricant can make sex safer by reducing the risk of
vaginal or anal tears caused by dryness or friction, and can also prevent a condom tearing.
Only water-based lubricant (such as K-Y Jelly) rather than an oil-based lubricant (such as
Vaseline or massage and baby oil) should be used with condoms. Oil-based lubricants
weaken the latex in condoms and can cause them to break or tear.
Sharing needles and injecting equipment:

Many local authorities and pharmacies offer needle exchange programmes, where used
needles can be exchanged for clean ones.
Telling your partner and former partners:
It is important to inform your current sexual partner and any sexual partners you've had
since becoming infected are tested and treated.
We may be able to offer pre-exposure prophylaxis (PrEP) medication to reduce your risk of
getting the virus to your partner.
Telling your employer:

There's no legal obligation to tell your employer you have HIV, unless you have a frontline
job in the armed forces or work in a healthcare role where you perform invasive procedures.
Screening for HIV in pregnancy:

All pregnant women are offered a blood test to check if they have HIV as part of routine
antenatal screening. If untreated, HIV can be passed from a pregnant woman to her baby
during pregnancy, birth or breastfeeding
Many of the medicines used to treat HIV can interact with other medications prescribed by
your GP or bought over-the-counter. These include some nasal sprays and inhalers, herbal
remedies like St John's wort, as well as some recreational drugs. Always check with your HIV
clinic staff or your GP before taking any other medicines. Also we can give you leaflets
regarding this.
973
MEASLES COLLEGE BOY

Mr. George Smith, aged 18, came to you with rash.
Please talk to him, take history, discuss your plan of management and address the concerns.

P: I have got rash all over my body
P: It started from the face and now it has appeared on my neck, chest and legs
D: Since when?
P: Yesterday
P: It started on its own.
D: Does the rash come and go?
P: No
P: No
P: No
D: Any itchiness?
P: Yes, it is itchy.
D: Any bleeding?
P: No
D: Any ulceration?
P: No
P: Any other symptoms?
P: I have fever from last 3 days and it was 38.5 C.
D: Did you take anything for it?
P: Paracetamol and it helped.
D: Anything else?
P: I have runny nose with the fever.
D: Anything else?
P: Like what?
D: Any redness or soreness in your eyes?
P: No
D: Any ulcers in the mouth?
P: Yes/No
P: Yes/No
P: Yes/No
P: No
974
P: No
P: No
D: Do you have any allergies from food or medications?
P:
P:
P:
D: Do you smoke?
P: Yes/No
P: Yes/No
P: No
D: Did you take MMR vaccine?
P: No
I would like to check your vitals and examine your lesion.

From my assessment, we are suspecting you may have a condition which we call measles. It
is a viral illness and can be very unpleasant due to its symptoms such as fever, runny nose,
and cough, etc.
Anyone can get measles if they are not vaccinated or have not had it before. The infection
usually takes 7 to 10 days to clear out.
The measles rash appears around after 2 to 4 days after the initial symptoms and normally
fades away in a week’s time. You will usually feel most ill on the first day or second day after
the rash develops.
Treatment
-Paracetamol/ibuprofen
-Drink plenty of water
-Symptomatic
Stay away from work for at least 4 days from when the measles rash first appeared. Avoid
contact with people who are vulnerable such as young children and pregnant women.
975
If you develop any chest pain, shortness of breath, coughing up blood, drowsiness,
confusion or fits, please come back to us.
Notifiable disease
Contact tracing
After recovery, MMR vaccine.
976
FAINTING

Mr. John Normandy, aged 55, has come to the hospital with per-rectal bleeding. Blood reports have
been done and you can find them in the cubicle.
Consultant has decided to do a colonoscopy.
Talk to him, explain to him the lab reports and address his concerns.

P: I just fainted.
P: I don’t know exactly what happened to me. My wife witnessed the episode.
D: How were you feeling before you fainted?
P: Fine
D: Did you have jerky movements?
P: Yes/No
D: Did you hurt yourself when you fainted?
P: No
D: How long did this episode last for?
P: 2-3 minutes
D: Were you drowsy when you woke up?
P: Yes
D: Can you please tell me more about the bleeding problem that you had?
P: I noticed it 6 months ago for the first time.
P: No
D: What exactly did you notice?
P: I noticed blood in my stool
D: Is it bright red or brown?
P: It’s red like fresh blood.
D: How many times did it happen?
P: I’ve noticed it some 2-3 times since then.
P: Like what?
D: Any pain while passing stool?
P: No
P: No
D: Any change in bowel habits recently?
P: No
D: Constipation/diarrhoea?
P: No
977
P: No
P: Fine
P: No
P: No
P: No
D: Do you have any allergies from food or medications?
P:
P:
P:
D: Do you smoke?
P: Yes/No
P: Yes/No
P: No
I would like to examine you. I would like to do GPE, vitals, and an examination of the back
passage.
Lab reports:
Hb-100 (low)
LFT, KFT, TLC (normal)
The results of your blood tests show that while all your other tests are normal, your
haemoglobin levels (red blood cells) are on the lower side. This means that you have a form
of anaemia. As all other tests are normal, the consultant wants to discuss having a
colonoscopy planned for you, to find out the cause.
P: I have already so many tests and I don’t want to do them any more.
A colonoscopy is often done to check what’s causing your bowel symptoms, such as:
 bleeding from your bottom or blood in your poo
 diarrhoea or constipation that does not go away
 losing weight or feeling really tired for no reason
978
Most of the time, it will not find anything to worry abot
But sometimes it might find something that needs a closer look or further testing.
Growths in your bowels (polyps)

Lots of people have growths in their bowels, and most of the time they are harmless. But
they can sometimes become cancerous, so if they’re found they need to be checked. They
can be removed during the colonoscopy and tested.
979
PRESCRIPTION RELATED STATIONS
DRUG PRESCRIPTION EXPLANATION

Marina aged 64 was admitted in the ward with a pelvic fracture & was diagnosed with
osteoporosis. She developed urosepsis while she was under treatment, which was managed
with antibiotics. She is now being discharged & wants to know about the medications that
have been prescribed to her. Lisinopril 5 mg previously it was 10 mg due to dizziness.
Talk to her, explain the prescribed medications & address her concerns.
Medications prescribed:
1. Amoxiclav 500 mg TDS 5 days
2. Codeine 1 tab PRN
3. Alendronate 70mgmane
4. Calcitriol BD
5. Lisinopril 5mg OD
6. PCM 2 tabs BD
7. Atorvastatin 10 mg OD
8. Laxido sachet PRN
D: Hello! How are you doing today?

P: I’m good. I’m happy that I’m getting discharged today.
D: That’s great. I'm glad that you're happy. Can I help you with anything?
P: Yes doctor. They’ve given me these medicines to take at home, can you explain to me how to
take them?
D: Yes sure. Can I ask you a few questions first then I will explain you the medicine?
P: Ok.
D: So how are you doing now?
P: I am good now.
D: Do you have any pain?
P: If I get pain, I take the medicine, it helps me. (Codeine)
D: How about your urine infection?
P: It is fine.
D: Do you feel dizzy or tired?
P: No
P: No
P: Yes, I have osteoporosis, (elaborate)
D: Are you taking the medications regularly that we prescribed?
P: Yes
980
D: Are you taking any medications other than these including OTC or herbal medications?
P: No
D: Are you allergic to any medications?
P: No
D: I will explain about all the medicines one by one, if at any time you do not understand
anything please do let me know.
P: Ok.
1. Amoxiclav:
 It is an antibiotic that was started for the urine infection you had. You will have to
take this medicine 3 times a day for 5 days.
 It has a few side effects; it can cause nausea, vomiting, loose stools. The side effects
usually go away on their own. If you get loose stools, please drink plenty of water. It
can also cause an allergic reaction but that’s very rare. You might get an itchy rash,
swelling of lips and tongue and breathing problems if you get an allergic reaction. If
such a thing happens, stop taking the medicine, call the ambulance & come to the
hospital.
2. Codeine:
 This is for severe pain. As you are not in pain now that is why it’s not been prescribed
regularly.
 You can take it when you have pain.
 There are certain side effects which may occur occasionally, like constipation, feeling
sick, vomiting, feeling sleepy, dizziness or dry mouth. If you experience any of these
please stop taking the medication & come back to us.
3. Alendronate:
 You know, the old bone tissue in our bones is constantly replaced by new bone tissue.
After the age of 30-35 years old bone tissue is lost faster. Alendronate contains
alendronic acid, which belongs to a group of medicines (bisphosphonates) which
reduces the rate of bone loss which in turn decreases the risk of fracture.
 This has been prescribed in tablet form. 70mg, which you have to take once weekly.
 You can take it every Sunday. But remember that you have to take it in the morning,
30 minutes before breakfast. Also make sure that you take it while standing or sitting
upright & that you remain in that position up to half hour after having taken the
medicine.
 If you don’t do that you might feel sick, indigestion, abdominal pain. You might also
experience constipation or diarrhea. Please stop taking it if you experience pain or
difficulty while swallow.
4. Calcitriol:
 It is actually a type of vitamin D that will help your body to absorb the minerals it
needs & will thus help strengthening your bones. This has been prescribed twice daily,
you take it in morning & evening daily.
5. Lisinopril:
981
 This medication is being given to treat your high blood pressure and to prevent heart
related conditions.
 You were feeling a bit dizzy after taking it so the dosage has been reduced from 10 mg
to 5mg. Do remember to take it the same time daily.
 It can some time make you feel lightheaded or dizzy, especially when standing up.
Getting up more slowly should help. If you begin to feel dizzy, lie down so that you do
not faint, then sit for a few moments before standing.
 If this continues beyond the first few days, come back to us. Do not drive or use tools
or machines while you feel dizzy.
6. Paracetamol:
 This one is for pain. If you feel pain you can take it twice daily.
7. Laxido Sachet:
 This is for constipation. I understand that you do not have constipation right now. But
if you develop constipation, do take it once daily.
Were you able to understand about all medicines?

P: Yes doctor
If you would have any more concerns about any of the medications, please do come back to
us. If anytime you develop any unwanted symptoms kindly do come back to us immediately.
INFECTIVE EXACERBATION OF COPD (PRESCRIPTION WRITING)
You are in Acute Medical Unit.

Jonathan, aged 50, is a diagnosed case of COPD, presented with pneumonia. He was
admitted to the A&E last night and the consultant has decided to treat community acquired
pneumonia.
Clarithromycin 500 mg BD for 7 days (CAP)

Tiotropium Bromide: 2 puffs
Serene: 1 puff
Atorvastatin OD
Levothyroxine OD
Penicillin Allergy – Information on the table in the cubicle
PRESCRIPTION WRITING APIXABAN DVT
Amelia May, aged 50, was admitted to the hospital with DVT.
This is her third admission with DVT. She is prescribed with Apixaban.
Please talk to the patient, explain her about the medication, prescribe Apixaban and address
her concerns.
982
D: Hello, how are you feeling today?
P: I am feeling fine. Could you please tell me about my medication?
D: Yes, I am going to talk to you about your medication and address all your concerns. But
before that let me ask you few questions.
P: Okay
D: May I know why were you admitted to the hospital?
P: I had leg swelling
P: For 2 days.
D: Do you know about your diagnosis?
P: Yes. Clot in my legs. This is the third time I am having this condition.
P: I am okay now.
D: Any pain or swelling?
P: No
P: No
D: Any other medical conditions DM, Heart/Kidney disease or high cholesterol?
P: No
D: Are you taking any regular medications including OTC or supplements?
P: No
P: Penicillin
P: No
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: Good/Bad
P: Yes/No
P:
P:
D: Thank you for answering all my questions.
983
We are going to prescribe you a medication called Apixaban, which is a blood thinner.
This will prevent from future clot formation in the legs.
Prescribe APIXABAN on the drug chart in the section for anticoagulation.

Apixaban – Treatment dose 10 mg BD for Days 1-7
Apixaban – Maintenance 5 mg BD for long term from day 8 (for recurrent DVT).
(Also write about Penicillin allergy on the drug chart on the front in allergy column)
You have to take this medication twice a day preferably at the same time, regularly and as
prescribed without missing any dose. As you had this condition for three times, you have to
take this medication for a long time (possibly lifelong).
Tips to prevent DVT:

Do
- stay a healthy weight
- stay active – taking regular walks can help
- drink plenty of fluids to avoid dehydration – DVT is more likely if you're dehydrated
Don'ts
- do not sit still for long periods of time – get up and move around every hour or so
- do not cross your legs while you're sitting, it can restrict blood flow
- do not smoke – get support to stop smoking
- do not drink lots of alcohol
PRES WRIT. (TERMINALLY ILL)
You are an FY2 in Medicine. Leanne, aged 95, is suffering from pancreatic cancer and is
terminally ill. She is not eating and drinking, and we have decided to put her on palliative
care with these medications.
People write this medicine in the prescription paper

As required:
Morphine
Cyclizine
Midazolam (agitation)
Hyoscine bromide (Secretion)
Paracetamol
Regular:
Atorvastatin
984
PATIENT ON APIXABAN NOSEBLEED
You are FY2 in General practice. James Carter, aged 25, has had a nosebleed. He is on
Apixaban. Talk to him and address his concerns.
Dr: Hello, my name is Dr. XYZ, I am one of the junior doctors in GP clinic. How can I help
you?
Pt: Doc, I had bleeding through my nose 2 hours ago.
Dr: I am sorry about that. How are you now?
Pt: I am fine now.
Dr: How much did you bleed?
Pt: Around 1/4th of a glass.
Dr: For how long did you bleed?
Pt: Around 10 minutes
Dr: What were you doing when it started?
Pt: I pricked my nose then bleeding started
Dr: What did you do to stop it?
Pt: Nothing ,I just put a towel on my nose
Dr: Is it the first time it happened?
Pt: Yes
Dr: Bleeding from anywhere else in the body?
Pt: No
Dr: Any bleeding disorders?
Pt: No
Dr: Any fever/ infections?(Blood malignancies)
Pt: No
Dr: Any weight loss or lumps or bumps in body?
Pt: No
Dr: Any tiredness?(ITP)
Pt: No
Dr: Any headaches?
Pt: No
Pt: I have clot in my leg from last 3 years.
Dr: Sorry for that. What are you taking for it?
Pt: I am taking Apixaban
Dr: From how long?
Pt: Last 3 years
Dr: Are you taking it as prescribed?
Pt: Yes
Dr: Are you going for your regular blood check up?
Pt: Yes
985
Dr: Are you taking any other medicine(blood thinner)?
Pt: No
Pt: I am a student.
Examination
I would like to check your vitals now, i.e., your blood pressure, temperature ,pulse and
respiratory rate.
I would also check your nose ,mouth and glands in your body.
Diagnosis
Dr: From what we have discussed we suspect that you had this nosebleed because you
pricked your nose unfortunately.
So, we would advise you not to prick your nose when you are on Apixaban. Is that ok?
Pt: Ok doc
Pt: What do I do when I get bleeding?
Dr: You should:
- sit or stand upright (don't lie down)
- pinch your nose just above your nostrils for 10 to 15 minutes
- lean forward and breathe through your mouth
- place an icepack (or a bag of frozen peas wrapped in a tea towel) at the top of your
nose. When a nosebleed stops:
After a nosebleed, for 24 hours try not to:
- blow your nose
- pick your nose
- drink hot drinks or alcohol
- do any heavy lifting or strenuous exercise
- pick any scabs
Go to the A&E:
- your nosebleed lasts longer than 10 to 15 minutes
- the bleeding seems excessive
- you’re swallowing a large amount of blood that makes you vomit
- the bleeding started after a blow to your head
- you’re feeling weak or dizzy
- you’re having difficulty breathing.
Hospital Treatment
If doctors can see where the blood is coming from, they may seal it by pressing a stick with a
chemical on it to stop the bleeding. If this isn't possible, doctors might pack your nose with
sponges to stop the bleeding. You may need to stay in hospital for a day or two.
Dr: We will also do some blood tests to check you are not anaemic and everything is fine
with your liver and kidneys. Also we will check your INR levels as well.
Pt: Ok doc
Pt: No
986
Dr: We will arrange your follow up in a month. In the meantime, if you have excessive
bleeding or headache, please let us know. Thank you.
987
COVID 19 VISITING POLICY GUIDELINES
You are FY2 in Medicine.

90-year-old Mr. Robert Jones has called to discuss certain hospital visiting policies as his wife
is admitted in the hospital.
Address his concerns.
D- Hello, I am Dr. Jane one of the junior doctors in the department.

D- Is it Mr. Robert Jones I am speaking with.
H: Yes, yes doctor (a very old voice)
D- Well, how may I call you?
H: Robert is fine.
D- Thank you Robert. From what I understand you have called to discuss certain visiting
policies in the hospital, is that right?
H: Yes doctor that is right.
D- Whom do you want to visit Robert?
H: You see doctor my beloved wife was diagnosed with a serious ailment, and the doctors have
now decided that there is no point in giving her any active treatment. They have decided to
keep her on end of life care plan.
D- I am really sorry to hear that Robert. It must be such a hard time for you.
D- Can you confirm her full name and age for me please?
H: Yes it’s Sarah Jones and she is 90 years old.
D- And what exactly would you like me to do for you today?
H: So doctor, the problem is my son is visiting my wife and his name is on the visitors register.
However, as now the doctors have told that she is not going to recover-I want my son’s name
to be taken off the register and put my name instead so that I can be with her.
D- Well Robert, I do understand where you are coming from. And I can see how much you
care about your wife, and be with her in these moments. But Robert, at the moment I am
not very sure of if we are allowed to change the name of visiting person on the register. As
you know the COVID situation still prevails there are a number of things that we need to
take into consideration like your general health, your wife’s condition, social bubble with
your son as well. So I have to ask you certain questions, so that I will be able to help you in a
better way. Will that be okay?
D- Do you and your son live together?
H: Yes doctor (Same social bubble)
D- How old are you Robert?
H: I am 92.
D- Okay. And how is your general health?
H: It’s fine doctor. Just the elderly problems. Pains and aches.
D- Okay. Hope you are taking good care of yourself Robert, if you need any assistance do let
us know.
D- Have you had any recent fever or flu like illness?
988
H: No doctor.
D- Have you been diagnosed with any medical conditions (lung problems, heart problems,
blood disorders, cancer)?
H: No doctor (if he says yes there is one more point to try convince him that it is not safe for
him as he has a health condition)
D- Are you any kind of medications Robert (Steroids, radio or chemotherapy)?
H: No doctor (if yes , medications like this make him immunocompromised and hence it is
advisable to not visit the hospital).
D- Have you come in contact with a person who has been identified with COVID 19?
H: No doctor
D: I am really sorry about your wife’ condition, but Robert can you tell me what exactly
happened to her?
H: Either heart failure/massive stroke.
D- Oh, this must be so distressing for you Robert. We are here to help in this matter as much
as we can. As you said you want to visit your wife, and remove your son’s name from the
register, I will have to definitely check with the authorised people in the hospital if we can
do so. I think we should be able to do it as your wife is on end of life care plans.
H: Ok doctor.
D- Well Robert, as a doctor I am also concerned about your health. As you said you are 92, I
am very concerned that a hospital visit is very dangerous at this age. At this age, you are
very vulnerable to COVID 19 and other infections. Do you follow me Robert?
H: Yes but I have lived happy enough doctor. I want to be with my wife.
D- Alright Robert. Just give me a moment. I do have a visiting policy that I would just like to
go through if it’s alright with you, and then see if we can do something to help you in this
matter.
D- Robert can you tell me the area you live in does come in a high alert zone for COVID 19
infections?
H: I don’t know doctor.
D- No worries Robert, what I can do later is note down your address and I will look into it
myself it comes under a high alert zone (tier 4).
D- I would like you to know Robert, in case it does we will not be able to allow you to visit
the hospital as it puts your health as well as your wife and other patients health to risk.
H: Ok doctor.
D- Also Robert, we have an option that says you can be with your wife through virtual
contact, do you know what that is?
H: No doctor.
D- You can be with her through a video call, this will ensure your safety as well as you can
see her through a video call. Is that something you would like to consider.
H: Doctor, she is dying. What use will I be of if I can’t hold her hands in the end of her days!
D- Well Robert. I understand how you must be feeling. And you are right nothing can take
the place of being with your loved one and hold their hands when they are sick Robert.
989
D- Robert I afraid at this moment if I can permit your visitor the hospital, but as I have your
details, I would like to discuss this further with the head nurse, supervisor and my senior.
Once I have discussed with them and confirmed the zone where you live, I will be able to
help you Robert. Will that be okay.
H: Yes I think so doctor.
D- Also Robert in case we can change the name on the register and we do allow you come
and visit your wife, we want you know you should in the best of your health and not have
had any exposure with a COVID 19 identified patient. Also you must not have any fever or
flu like symptoms. Do you agree?
H: Yes doctor.
D- Can you travel to the hospital on your own?
H: Yes doctor I can. (If no- it is not possible to provide transport for this reason, but you can
come up with ideas such as a social worker or a care person or his son can bring them in to
Visit)
D- Also if you are allowed you have to abide with the social distancing, sanitize your hands
every time you come in and leave the hospital. Also you have to wear a face covering that
covers your nose and face appropriately. Would you consider this?
H: Yes doctor.
D- Well thank you Robert. You can reach out to the NHS websites for more information on
visiting policies of the hospital, COVID symptoms and restrictions. I will get back to you as
soon as I have discussed with my seniors, my supervisor and the head nurse.
H: Thank you doctor
D- Thank you Robert, is there anything else I can help you with?
H: No doctor
A COVID policy A4 size paper will be kept inside the cubicle it will not be given in the
question paper.
After starting the conversation with Robert, either ask for a minute to read the policy and
then ask him questions accordingly or if some students can read and talk simultaneously can
do that as well.
(Read the policy quickly and frame the questions according to the policy)
The policy will state more age of a person is vulnerable to COVID, if the person lives in a high
alert zone he may not be allowed to visit as it puts him, his wife and other patients at risk as
well. Only one visitor is allowed to meet the patient. Also will state if he has any COVID like
symptoms he cannot visit. If a person has any debilitating illness makes him more
vulnerable to infections on a hospital visit. It will also state an option for virtual meeting
through video calls. It will also state 2m distance social distancing, hand hygiene and face
covering etiquette’s. it will state that children below certain age are prohibited from visiting
the hospital. It may also state the visitor may not be able to see the patient every day, and
the guidelines can be changed any day according to the given circumstances due to COVID
19 and visiting restrictions can get more strict.
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Discussion with head nurse, supervisor and seniors is mandatory if relative does not agree
to the terms and condition or is vulnerable but still wants to visit.
SCENARIO #2

Mrs. Elizabeth Windsor, aged 85, admitted to the hospital due to respiratory failure. She is
terminally ill and was put on palliative care. Grandson has removed his name from the
visitor list. Her husband who is 94 years old wants to be added in the visitor list to see her.
Hospital Policy:
- Named visitors can visit the patient if they are < 70 years old due to COVID-19
- All the hospitals are encouraging virtual meetings.
Talk to the husband and address his concerns.
D: How can I help?

P: I want to add my name to the visitor list to see my wife in the ICU so my grandson has
removed himself.
D: I can understand you are going through this tough time. Let me ask you some questions
about your wife’s condition. Do you know why she was in the hospital?
P: She was having some problem with breathing and she was admitted in the hospital. Here
she was diagnosed with respiratory failure and she is unconscious now. Doctors have decided
that she is in her end stage.
D: I can’t imagine what you have been through. It is very tough time for you and for your
family. I am here to talk about something with you. Do you have any idea what I am here to
talk about?
P: No
D: Do you have any idea about the hospital policy for visitation?
P: No
D: We have implemented a policy that discourages visits from family members who are
older than 75 years of age.
P: But I need to visit my wife, she needs me there.
D: Do you know why we have this visitation policy in this hospital?
P: No
D: Due to COVID-19 pandemic, we need to be careful about the spread of the virus. The
elderly population is at higher risk of developing a complication of COVID-19, so we
discourage the elderly from visiting the hospital, to prevent the transmission between
patients and their family members.
P: She is my wife and she is already at the end stage. She needs me there to accompany her.
You don’t understand how important this is.
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D: I can see that this is a difficult policy to accept, however, there are ways where you can
still give her company. If you want, we can set up virtual meetings so that you can talk to
her and see her without being physically present.
P: You doctors do not care about my wife and I. She is alone and I don’t know when I will see
her next.
D: I can see that you are worried about her, but we need to be careful about the spread of
this virus. We do not want you to be at risk of catching it, and we do not want her to get
infected either. This is only for the safety of you and your wife.
P: What if I have been vaccinated for COVID-19?
D: Even if you have received both doses of COVID-19 vaccines, you are still at risk of passing
it on to other elderly people, and those in the ICU such as your wife are at high risk of
catching it.
P: Can my grandson be added back to the visitor list?
D: Yes, I will ask my colleagues to add his name to the list.
P: Thank you.
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CERVICAL SCREENING (DYSKARYOSIS)

Miss Diane Jackson, aged 26, has come to you with some concerns. She has had regular
cervical screening. The results showed mild dyskaryosis and HPV was found negative. She
was advised to have regular follow up after 3 years.
Talk to her, assess her and address her concerns.

P: I am worried about having cancer.
D: May I know why?
P: I had my routine cervical screening, and I was told I have mild dyskaryosis. My grandmother
died of cervical cancer.
D: Let me ask you a few questions.
P: Ok
P: No
D: When was your last LMP?
P: 2 weeks ago.
P: Yes
D: Any discharge from your vagina?
P: No
D: Any bleeding between your periods?
P: No
D: Any problem with the urine or bowel?
P: No
P: It's alright
P: No
P: No
D: Any pain in your lower back or pelvis?
P: No
D: Any lumps and bumps in any part of the body?
P: No
P: Yes
P: Yes, my partner uses condoms.
D: Any bleeding during or after sex?
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P: No
P: No
D: Have you had a vaccine for HPV?
P: Yes/No
P: No
P: No
P: No
D: Any surgeries or hospitalizations apart from your heart condition admission?
P: No
D: Has anyone else in the family been diagnosed with any medical conditions?
P: No
P: Yes/No
D: Do you smoke?
P: Yes/No
P: Yes/No
I would like to check your vitals and GPE

From my assessment, your report says you have mild dyskaryosis, which means mild
changes in your cervical cells. These are not cancerous. During your cervical screening, a
small sample of cells is taken from the cervix and tested for HPV. Fortunately, HPV testing
came back negative. It is advisable to come for next cervical screening after 3 years as
advised. If you develop any weight loss, lumps and bumps, pain during sex or any other
unusual symptoms, please come to the hospital.
Condoms can help you protect from HPV. Please practice safe sex.
The HPV vaccine protects you against the types of HPV that causes the most cases of genital
warts and cervical cancer.
PATIENT'S CONCERNS:
Is it cancer?
What are you going to do?
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CERVICAL SCREEN (LESBIAN)

Sarah, 26-year-old female presented to you with a new concern.
She has recently been sent a letter to undergo cervical screening tests.

P: I have been sent a letter to come for the cervical screening test. I was wandering why?
D: Cervical screening (a smear test) checks the health of your cervix. The cervix is the
opening to your womb from your vagina. It's not a test for cancer, it's a test to help prevent
cancer. We recommend having the test done as long as they are within 25-64 years old.
P: But doctor I don't think I need to go for the test.
D: May 1 ask why do you think so?
P: Dr I am a lesbian
D: Ok let me explain you further. But before that may 1 ask you few questions to assess your
overall health
P: Ok
P: No
D: When was your last Menstrual period?
P: 2 weeks ago
P: No
P: No
D: Any problem with your urine or bowel?
P: No
P: No
P: No
D: Have you had any cervical screening test in the past?
P: No
P: No
D: Has anyone told you that you are losing weight?
P: No
P: Its good
P: No
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P: No
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes
D: What and how much do you smoke?
P: 10 cigarettes per day for the last 3 years
P: No
P: Balanced
P: Yes
D: For how long?
P: 2 years
D: Any previous partners?
P: No
D: Which route of sex do you prefer?
P: All
D: Thanks for answering all my questions. Let me tell you women should be offered
screening and consider attending regardless of their sexual orientation.
P: Why is that? I don't have a male partner.
D: Research suggest that although the virus responsible for cervical cancer (HPV) is more
easily transmitted through heterosexual intercourse. It can also be transmitted through
lesbian intercourse. As with other sexually transmitted infections HPV is passed on through
body fluids. This means that oral sex transferring vaginal fluids on hands and fingers can be
all ways of being exposed to HPV. As well as sexual behaviour, smoking is also a risk factor
for cervical cancer
P: How long does it take to have the test done?
D: During cervical screening a small sample of cells is taken from your cervix for testing. The
test itself should take less than 5 minutes. The whole appointment should take about 10
minutes. It's usually done by a female nurse or doctor. You should get your results within 14
days.
P: Thank you
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Lifestyle counselling regarding smoking
997
MENINGITIS
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.
D: Hello. My name is Dr. ……… I am one of the junior doctors here in the A&E. Is it Mr.
William Carson?
F: Yes.
D: How are doing today, Mr. Carson?
F: I am fine.
D: Could you please confirm your relationship with Mr Max Carson?
F: He is my son.
D: Could you confirm Max’s age for me please?
F: He is 20 years old.
D: Could you tell me what made you bring Max to the hospital today?
P: 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?
F: About an hour ago now.
D: How long did it last?
F: Around 2 minutes.
D: Has he ever had a fit before?
F: No
D: Did he have jerky movements of his arms and legs?
F: He was shaking all over.
D: Did he lose consciousness?
F: No
D: Did he happen to wet himself?
F: No
D: Did he bite his tongue?
F: No
D: What was he like after the fit?
F: He seemed confused as if he didn’t know where he was.
D: Was he drowsy?
F: Yes.
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D: Before he had the fit, you mentioned he was behaving strangely- has he ever been that
way before?
F: No.
D: Did he mention feeling unwell before the incident?
F: Not really. But he did have a bit of the flu for the last couple of days.
D: Did he have a fever?
F: He was a bit feverish.
D: Did he have any other symptoms along with the fever?
F: Like what?
D: Like a headache?
F: He did have a mild headache.
D: Did he mention anything about a pain in the neck or difficulty moving the neck?
F: No.
D: Did he have a rash anywhere on his body?
F: I didn’t notice.
D: Was he feeling sick or did he throw up?
F: No
D: Did he any ear pain?
F: No
D: Did he have runny nose?
F: No
D: Did he have sore throat?
F: No
D: Any cough?
F: No
D: Any pain while passing wee?
F: I don’t know.
D: Any discharge from the penis?
F: I wouldn’t know.
D: Was he more tired than usual?
F: I think so, yeah.
D: Was he losing weight?
F: No
D: Did he have any lumps or bumps in his body? Perhaps in the neck?
F: No.
D: By any chance had he hurt his head recently?
F: No.
D: Has Max been in contact with someone with similar symptoms? Anyone with TB?
F: I don’t know.
D: Has he been diagnosed with any medical conditions before?
F: No
D: Diabetes, for instance? Any mental health conditions?
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F: No.
D: Any past hospital admissions or surgery?
F: No
D: Does he take any medications? Including over the counter medicines and supplements?
F: No
D: Are there any medical conditions that run in the family?
F: No
D: Has any body in the family been diagnosed with epilepsy?
F: No
D: Do you know if he is allergic to any food or medication?
F: No
D: Has he travelled outside of the UK recently?
F: No
D: Is he working or is he a student?
F: He is a student at University
D: Did he take a vaccine for meningitis any time in the past?
F: I am not sure.
D: Other than Max and yourself, who else is at home?
F: Just him and me.
D: Does Max drink alcohol?
F: Yes, occasionally with his friends.
D: Are you aware if he as ever used any recreational drugs?
F: I don’t think so.
D: Is he sexually active?
F: I think so, yeah.
D: Is there anything else you think is important that we may need to know?
F: 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.
1000
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:
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.
D: Do you have any questions so far?
F: What does he have Doctor?
D: I suspect that Max has a condition called meningitis. Have you heard of it?
F: 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:
F: 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.
F: 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?
F: Yes.
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D: 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?
F: Yes.
D: Do you have any questions for me?
F: Will Max be okay doctor?
D: 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.
F: What type of complications can he have, Doctor?
D: 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.
F: How long does he have to stay in the hospital?
D: It depends on how he responds to the treatment but it is generally 7-14 days.
D: Any other questions?
F: No.
D? I hope Max makes a quick and full recovery.
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MENINGITIS PROPHYLAXIS
You are an FY2 in GP/A&E.

Mrs. Olivia Parker, aged 50, has some concerns.

P: I am worried I might get meningitis.
D: May I know why?
P: My sister’s daughter was diagnosed with meningitis one week ago.
D: Have you been in contact with your niece?
P: No
D: When was the last time you were in contact with her?
P: 1 month ago, I saw her.
D: How is she now?
P: She is fine.
P: Like what?
D: Have you got any fever?
P: No
D: Any pain while moving your neck?
P: No
D: Any discomfort towards light?
P: No
D: Have you been having a headache?
P: No
D: Any fits?
P: No
D: Any rash over your body?
P: No
D: Have you been diagnosed with any other medical condition?
P: No
D: Do you take any other regular medication?
P: No
P: No
P: No
P: No
D: Do you smoke?
P: No
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P: No
P: I am not quite active.
D: How about your diet?
P: With my husband.
D: Is he doing well?
P: Yes
P: Manager in ASDA
D: Is it stressful?
P: Yes/No
I would like to check your vitals including temperature. I would also like to do some GPE
examination, examine your body for a rash, and examine your neck.

P: I got meningitis vaccination 3 years ago so do I need to take it again or I will still be
protected?
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.
As you mentioned earlier that you have not been in contact with your niece since the last 1
month, and she developed her symptoms fairly recently, it is safe to say that you have not
been infected. Furthermore, your history and examination show no sign of meningitis.
Meningococcal Infection Chemoprophylaxis

 The decision to initiate contact tracing in respect of meningococcal infection will be made
by the Consultant in Public Health Medicine (CPHM) in conjunction with relevant
clinicians.
 Responsibility for contact tracing and organising the administration of chemoprophylaxis
also lies with the CPHM. Chemoprophylaxis must ONLY be prescribed on the instruction
of the CPHM. It should be given as soon as possible (ideally within 24 hours) after
diagnosis of the index case.
CPHM will establish a list of close contacts; who may include:

 Those who have had prolonged close contact with the case in a household type setting
during the seven days before onset of illness. Examples of such contacts would be those
1004
living and / or sleeping in the same household (including extended household), pupils in
the same dormitory, boy/girlfriends, or university students sharing a kitchen in a hall of
residence.
 Those who have had transient close contact with a case only if they have been directly
exposed to large particle droplets / secretions from the respiratory tract of a case around
the time of admission to hospital.
The use of single dose ciprofloxacin is recommended by a Cochrane Review and included in
the Public Health England’s Guidance for public health management of meningococcal
disease in the UK’. Ciprofloxacin is licensed in adults for the prophylaxis of invasive
infections due to Neisseria meningitides; however, its use in children and adolescents
remains ‘off label’.
If further cases occur within a group of close contacts in the four weeks after receiving
prophylaxis, an alternative agent should be used for repeat prophylaxis. Rifampicin may be
used as outlined in Table 2 below (except in pregnancy). Azithromycin as a single dose of
500 mg may be used as an alternative in pregnancy.
Vaccination for Meningitis:

Meningitis B: 8 weeks, 16 weeks, and booster at 1 year.
Hib vaccination: 8 weeks, 12 weeks, 16 weeks
MMR: 12-13 months and 40-60 months
Pneumococcal vaccine: 2 injections at 12 and booster at 1
Teenagers and University students: Meningitis ACWY (till 25 years)
Concerns:
Is it preventable?
What do you mean by Septicaemia?
1005
CF PRENATAL COUNSELLING

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,
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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
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
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Pt: No doc ,thank you.
SCENARIO #2
You are an FY2 in GP. Mrs. Alisha Mansfield, 30-year-old, has come to you for pre-natal
counselling. Talk to her and address her concerns.

P: I am thinking of becoming pregnant and I am concerned about it?
D: May I know why?
P: My half-brother is suffering from cystic fibrosis.
D: What kind of symptoms is he experiencing?
P: I’m not sure because we don’t live together
D: Are you related to your half-brother by blood?
P: No, he is my stepfather’s son.
D: How is your general health?
P: I’m fine.
D: Any symptoms?
P: No
D: Do you have any cough?
P: No
D: Any recurrent fevers?
P: No
D: Tummy pain?
P: No
D: Recurrent diarrhoea?
P: No
D: Recurrent chest infections?
P: No
D: Anyone else in your family with similar symptoms?
P: No
D: How is your partner?
P: My partner is fine.
D: Does he have any symptoms of cystic fibrosis?
P: No
D: Anyone in his family have similar symptoms?
P: No
P: No
P: No
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P: No
P: No
P: 2/3 weeks ago
P: Yes
P: No
P: No
P: No
P: Yes
D: Do you smoke?
P: No
P: No
P: Good/bad
P: Yes/No
P:
I would like to do GPE, vitals and examine your chest, and your tummy.
From what you have told me, it appears that the chances of your child having cystic fibrosis
are very low. You mentioned that your half-brother is not related to you by blood, which
reduces your chances considerably, and that you and your partner along with your extended
families have no symptoms. This means there is no chance of cystic fibrosis being inherited
or passed down to your child.
Cystic fibrosis is an inherited condition that causes sticky mucus to build up on the lungs and
digestive system. This causes lung infections and problems with digesting food.
Symptoms of cystic fibrosis include:

 Recurring chest infections
 Wheezing, coughing, shortness of breath and damage to the airways (bronchiectasis)
 Difficulty putting on weight and growing
1009
 Jaundice
 Diarrhoea, constipation, or large, smelly poo
 A bowel obstruction in new-born babies (meconium ileus) – surgery may be needed
Cause of cystic fibrosis

Cystic fibrosis is a genetic condition. It’s caused by a faulty gene that affects the movement of
salt and water in and out of cells.
This, along with recurrent infections, can result in build-up of thick, sticky mucus in the body’s
tubes and passageways – particularly the lungs and digestive system.
A person with cystic fibrosis is born with the condition. It’s not possible to “catch” cystic
fibrosis from someone else who has it.
How cystic fibrosis is inherited

To be born with cystic fibrosis, a child has to inherit a copy of the faulty gene from both of
their parents. This can happen if the parents are “carriers” of the faulty gene, which means
they don’t have cystic fibrosis themselves.
Diagnosing cystic fibrosis

In the UK, all newborn babies are screened for cystic fibrosis as part of the newborn blood
spot test (heel prick test) carried out shortly after they are born.
If the screening test suggests a child may have cystic fibrosis, they’ll need some additional
tests to confirm they have the condition.
 A sweat test – to measure the amount of salt in sweat, which will be abnormally high in
someone with cystic fibrosis.
 A genetic test – where a sample of blood or saliva is checked for the faulty gene that causes
cystic fibrosis.
These tests can also be used to diagnose cystic fibrosis in older children and adults who didn’t
have the newborn test.
Antenatal: Amniocentesis/chorionic villus sampling (CVS)
Amniocentesis: Done at 15-20 weeks, there is risk of miscarriage, more at 11-14 weeks
CVS: Sample tissue from placenta, done at 15-22 weeks, risk of miscarriage at 11-14 weeks.
TREATMENTS FOR CYSTIC FIBROSIS:
Medicines for lung problems

Medicines for lung problems include: Antibiotics, steroids, bronchodilators, medicine to
reduce the level of mucus and to make the mucus in the lungs thinner.
Exercise
Any kind of physical activity, like running, swimming or football, can help clear mucus from the
lugs and improve physical strength and overall health.
1010
A physiotherapist can advise on the right exercise and activities for each individual.
Dietary and Nutritional Advice

Eat high-calorie diet, vitamin and mineral supplements, and taking digestive enzyme capsules
with food to help with digestion.
Lung transplants.
Complications of cystic fibrosis:

People with cystic fibrosis also have a higher risk of developing other conditions.
These include: Osteoporosis, DM, nasal polyps, sinus infections, liver problems, fertility
problems.
Prognosis
Cystic fibrosis tends to get worse over time and can be fatal if it leads to a serious infection or
the lungs stop working properly.
Choices for having children:

There are options available to couples who are both CF carriers when planning a family. One
option involves prenatal testing to check if CF has been passed on in a pregnancy. If both
members of a couple are CF carriers and planning children, a referral can be made to the local
genetics service. An appointment will then be arranged to discuss reproductive options.
50% carrier
25% normal
25% affected.
1011
HOMOSEXUAL COUNSELLING
You are FY2 in GP.

Mr. Nathan Wright, aged 16, has got some concerns and is embarrassed to talk about it.

P: These days I am feeling something different. I am embarrassed to say.
D: Would you like to share what you feel?
P: I am attracted to Jamie. He is my school friend.
D: Can you tell me more about this?
P: Like what?
D: Is this the first time you have felt this way?
P: No
D: Since when you have been feeling this way?
P: Since I was young.
D: What’s bothering you about how you feel?
P: I feel wrong about it.
D: Have you spoken to anyone about this previously?
P: I thought I will speak to you before speaking to anyone else.
P: No
P: No
P: No
P: No
P: No
D: Are you in a relationship?
P: I broke up with a girl 2 weeks ago, I wasn’t interested.
P: No
D: Do you know about safe sex?
P: No/Yes
D: Do you smoke?
P: No
P: No
P: No
1012
P: Yes
D: What do you do?
P: Student
P: My parents and sister
D: Do you get along well with your family?
P: Somewhat
D: Have you thought about discussing your feelings with your family?
P: I am afraid to talk to my parents.
D: Why is that?
P: I live with a conservative family; they won’t accept my feelings.
P: It’s okay
D: Score your mood?
P: It is average
D: How are things at school?
P: They are all right.
D: Have you faced any discrimination/bullying at school?
P: Yes/No
D: Have you ever thought of harming yourself?
P: No
I’m really glad you confided in me and trust me with this. I’m proud that you found the
courage to speak up about how you feel. This can be a confusing time for you, but rest
assured it is natural for you to feel attracted to someone of the same sex.
As you are having a tough time with your feelings, I will refer you to my colleagues, who
may recommend CBT.
Cognitive behavioural therapy (CBT)

If you offered CBT, it will usually involve weekly sessions for up to 40 weeks (9 to 10
months), and 2 sessions a week in the first 2-3 weeks.
CBT involves talking to a therapist who will work with you to create a personalised
treatment plan.
They will ask you to practice self help techniques on your own, measure your progress, and
show you ways to manage difficult feelings and situations.
I will also help you with finding LGBTQ support groups and communities recommended by
the NHS so that you find support in your peers and have help available at all times.
1013
I would also like to discuss safe sex options for you in the future.
I understand this may be difficult, but I would also recommend you to speak to your family
and friends about how you feel so that you may find support there as well.
1014
METHODS OF CONCEPTIONS FOR HOMOSEXUALS
You are FY2 in GP.

Miss Jennifer Molly, aged 30, and her partner, Daniella, would like to talk to you about
conceiving a child.
Talk to Jennifer and explain to her about different methods of conception.

P: I am planning to conceive a child.
D: Can you tell me more about that?
D: Since when have you been planning?
P: For the past 6 months
D: Have you decided who will carry the pregnancy?
P: I will
D: Will this be your first pregnancy?
P: Yes
P: No
D: DM? HTN? Kidney problem? Thyroid problem? PCOS? Fibroids? STD/HIV?
P: No
P: No
P: No
D: Any surgical procedures around your private parts or womb?
P: No
P: No
D: How are your periods? Regular?
P: Yes/No
D: Are they painful?
P: Yes/No
D: How long does the bleeding last?
P: 3 to 5 days
D: Any usage of contraception?
P: No
D: Do you smoke?
P: No
P: No
1015
P: Good
P: Yes/No
P: I’m quite active.
P: Office job.
P: With my wife
The number of LGBT people becoming parents is increasing.

If you are thinking about having children, here’s an overview of the various routes to
parenthood available to you.
Donor Insemination
This is where donated sperm is put inside the person who is going to carry the baby. This
person can be single or in a relationship.
How it is performed:
 Donor insemination can be performed at home using sperm from a friend or an
anonymous donor, or at a fertility clinic using an anonymous donor.
 If you decide to look for donor insemination, it is better to go to a licensed clinic
where the sperm is screened. This ensures that the sperm is free from sexually
transmitted infections (STIs) and certain genetic disorders. Fertility clinics also have
support and legal advice on hand.
 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 – are both treated as their child’s legal parents.
 Couples who are not civil partners at the time of conception but who conceive
through donor insemination at a licensed clinic will also be treated as their child’s
legal parents.
 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.
 The NICE guidance therefore expects female same-sex couples to have tried to
conceive six times using artificial insemination (funded themselves, not by the NHS)
before they would be considered for NHS-funded fertility treatment.
1016
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 coparent, you will not 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.
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 do not 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.
Surrogacy
 Surrogacy is when someone has a baby for a couple who cannot have a child themselves.
For the intended father, 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. No financial
benefit other than reasonable expenses can be paid to the surrogate.
 The baby is not legally yours until a parental order has been issued after the child’s birth.
Until this order is issued, the surrogate has the right to keep the baby.
Trans and non-binary parents

When it comes to adoption and fostering, trans people have the same rights as anyone else
who wants to be a parent.
1017
Who are the Legal Parents?
I’ve conceived at home I’ve conceived in a licensed fertility clinic
Did you conceive after 6 No The birth mother Did you conceive after No The birth mother
April 2009? The non-birth mother will 6 April 2009? The non-birth mother will
Yes have to apply to adopt Yes have to apply to adopt the
the child child
Are you in a civil No Your partner cannot be Are you in a civil No This doesn’t matter if you
partnership the automatic legal partnership are conceiving via a
parent of the child. licensed fertility clinic
Yes The non-birth mother will Yes
have to apply to adopt
the child
Does the non-birth No Legally your partner is Does the non-birth No Your partner should sign a
mother want to be responsible for any mother want to be form indicating that she
second parent of the children you have second parent of the does not want to be the
child? because you are in a civil child? legal parent.
Yes partnership. You should Yes
get legal advice
Your partner is Complete the form
automatically the second given to you by the
parent of the child. When clinic. This will show
you register the birth that your partner
make sure you indicate agrees to be the
that you are in a civil second parent of the
partnership and both child.
names will be added to
the birth certificate
1018
CHICKENPOX PREGNANCY

Sophia Jenkins, 30-year-old female came to you with some concerns.
Talk to her and discuss the plan of management.
D: How can I help?

P: I have a son who has chickenpox and I’m worried my unborn child can be infected.
P: He got it 2 days ago
P: Like what?
D: Any fever?
P: No
D: Any body aches?
P: No
D: Any red bumps or blisters?
P: No
D: Do you feel itchy?
P: No
D: Is this your second pregnancy?
P: Yes
D: How many weeks along are you?
P: 32 weeks
P: Pregnancy test at home
P: No
P:
D: Could you feel the movements of your baby?
P: Yes
P: Normal
P: No
D: Any medications during pregnancy?
P: No
D: Have you attended all your antenatal checkups?
P: Yes
D: Have you gotten any scans done?
P: Yes
1019
D: Do you have twins in your pregnancy?
P: No
P: Fine
P: No
P: No
P: No
D: Have you had chickenpox when you were a child?
P: No
D: Have you had chicken pox when you were a child?
P: Yes
D: Are you currently taking any regular medications, OTC drugs or supplements?
P: Folic acid
P: No
P: No
P: No
D: Do you smoke?
P: No
P: No
P: No
P: Office job.
P: My partner and my father
D: Hoe are they doing?
P: My father is having chemotherapy
I would like to check your vitals, GPE, and antenatal examination.
As you have mentioned you had chickenpox as a child, you will be immune and there is
nothing to worry about. You do not need to do anything.
1020
During the last 3 months of pregnancy, antibodies from the mother are passed to her
unborn baby through the placenta. This type of immunity is called passive immunity
because the baby has been given antibodies rather than making them itself.
Antibodies are special proteins the immune system produces to help protect the body
against bacteria and viruses. The amount and type of antibodies passed to the baby
depends on the mother’s immunity.
You also mentioned your father is undergoing chemotherapy, so he has low immunity for
now. It would be best to take some precautions for his safety.
A person with chickenpox is infectious from two days after the spots first appear until they
have all crusted over (commonly about five days after onset of the rash). A child with
chickenpox should stay off school or nursery for fiver days from the onset of the rash and
until all the lesions have crusted. Also, whilst infectious, they should keep away from at-risk
people who may develop a severe illness if they get chickenpox.
Wherever possible, the person who has chickenpox should avoid contact with anyone who
has never had it. That also means not spending much time in a room with other people
because chickenpox can also be spread through the air.
Try to avoid scratching blisters because they may break and the fluid inside is contagious. It
may help to keep children’s fingernails trimmed and put cotton mittens on babies’ and
toddlers’ hands.
If the mother is not immune to chickenpox

Complications for the unborn baby:
Complications that can affect the unborn baby vary, depending on how many weeks
pregnant you are. If you catch chickenpox:
 Before 28 weeks pregnant: there's no evidence you are at increased risk of suffering a
miscarriage. However, there's a small risk your baby could develop foetal varicella
syndrome (FVS). FVS can damage the baby's skin, eyes, legs, arms, brain, bladder or
bowel.
 Between weeks 28 and 36 of pregnancy, the virus stays in the baby's body but doesn't
cause any symptoms. However, it may become active again in the first few years of the
baby's life, causing shingles.
 After 36 weeks of pregnancy, your baby may be infected and could be born with
chickenpox.
Antiviral Medicine:
You may be offered acyclovir, an antiviral medicine, which should be given within 24 hours
of the chickenpox rash appearing. Acyclovir doesn't cure chickenpox, but it can make the
1021
symptoms, such as fever, less severe and help prevent complications. Acyclovir is usually
only recommended if you're more than 20 weeks pregnant, but in some cases your doctor
may suggest it if you're less than 20 weeks pregnant. Discuss the risks and benefits with
your doctor.
Self help
To help relieve your symptoms, you can try the following:
 Drink plenty of fluids
 Take paracetamol to lower a temperature or help with pain
 Use cooling creams or gels from your pharmacy
Will my baby need to be treated?

Once you have chickenpox, there's no treatment that can prevent your baby getting
chickenpox in the uterus.
After the birth, your GP may consider treating your baby with chickenpox antibiotic called
varicella zoster immune globulin (VZIG) if:
 Your baby is born within 7 days of you developing a chickenpox rash
 You develop a chickenpox rash within 7 days of giving birth
 Your baby is exposed to chickenpox or shingles within 7 days of birth and they aren't
immune to the chickenpox virus
If your newborn baby develops chickenpox, your GP may treat them with acyclovir.
Complications for pregnant women:

You have a higher risk of complications from chickenpox if you are pregnant and smoke,
have a lung condition, such as bronchitis or emphysema, are taking or have taken steroids
during the last three months and are more than 20 weeks pregnant.
There is a small risk of complications in pregnant women with chickenpox. These are rare
and include: pneumonia, encephalitis, and hepatitis. Complications that arise from catching
chickenpox during pregnancy can be fatal. However, with antiviral therapy and improved
intensive care, this is very rare.
Complications for the newborn baby:

Your baby may develop severe chickenpox and will need treatment if you catch it:
 Around the time of birth and the baby is born within seven days of your rash developing
 Up to seven days after giving birth
If you are pregnant, have chickenpox and develop chest and breathing problems, headache,
drowsiness, vomiting or feeling sick, vaginal bleeding, a rash that's bleeding, a severe rash
you should be admitted to hospital.
1022
These symptoms are a sign that you may be developing complications of chickenpox and
need specialist care.
1023
KNEE REPLACEMENT FOLLOW-UP
You are FY2 in Medicine. Elizabeth, aged 55, for knee replacement surgery. She came to the
hospital 2 years ago with knee pain and was advised with knee replacement. She refused to
have this surgery.
Guidelines for Knee Replacement:
 2 years ago: if BMI less than 35.
 2 months ago, guidelines changed. Now only below 30 BMI can go for surgery.
D: How can I help?

P: I have pain in my knee joint.
P: Like what?
D: Which knee joint?
P:
P: 2-3 years ago.
P: It was gradual
P: It comes and goes and now its worse.
P: It is a dull ache.
P: It is a dull ache.
P: No
P: Resting
P: Pain killers
P: It is 5
D: Anything else with pain?
P: No
P: No
D: Any weight changes?
P: No
D: Any hot or tender joints?
1024
P: No
D: Did you fall prior to your joint pain starting?
P: No
P: No
P: No
D: Are you currently taking any regular medications, OTC drugs or supplements?
P: Folic acid
P: No
P: I was advised surgery for my knee 2 years ago, but I refused
D: May I ask why?
P: I didn’t feel ready
D: What has changed now?
P: The pain is worse
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: No
P: With my partner.
I would like to do GPE, vitals, knee examination, your height and weight for BMI.
Examination
BMI: 33
From our assessment, it appears that your BMI is on the higher side. The new guidelines for
knee replacement state that now, only below 30 BMI can go for surgery. Fortunately, there
are some lifestyle changes I can recommend that it will help with reducing weight so that
your BMI falls under 30.
It’s very important to take steps to tackle a high BMI, as your knee pain is worsening.
1025
D: Lifestyle changes
DIET:
The best way to reduce weight is to eat a healthy, well balanced, reduced-calorie diet and
exercise regularly. Your diet should consist of plenty of fruits and vegetables with some milk
and dairy foods, some meat. fish, eggs, beans and other non-dairy sources of protein. Try to
avoid foods containing high levels of salt because they can raise your blood pressure, which
can be dangerous for obese people. Eat slowly and avoid situations where you know you
could be tempted to overeat. We can refer you to dietitian who can advise you on that.
EXERCISE:
Because of your knee pain, you may think exercise will make your symptoms worse.
However, regular exercise that keeps you active, builds up muscle and strengthens the joint
usually helps to improve symptoms.
Normally It is advisable to have at least thirty minutes of physical activity every day five
times a week. You don’t necessarily have to go to the gy m. It shouldn't be in one session, it
could be split into two sessions of fifteen minutes or three sessions of ten minutes. You may
need to exercise for longer each day. To avoid regaining weight after being obese, you may
need to do 60-90 minutes of activity each day. You can also try doing moderate intensity
activity brisk walking, cycling, recreational swimming, dancing. Alternatively, you can try 75
minutes (one hour, fifteen minutes) of vigorous-intensity activity a week, or a combination
of moderate and vigorous activity, running, most competitive sports, circuit training. You
should also do strength exercises and balance training two days a week. This could be in the
form of a gym workout. It's also critical that you break up sitting (sedentary) time by getting
up and moving around. Join a local weight loss group. There are other useful services, such
as local weight loss groups and these could be provided by your local authority', the NHS. or
commercial services. We can refer you to a local active health team for a number of sessions
under the supervision of a qualified trainer. You can try' activities such as fast walking,
jogging, swimming or tennis.
It's also important to find activities you enjoy and want to keep doing. Activities with a
social element or exercising with friends or family can help keep you motivated. Make a
start today
- it's never too late. Your GP. weight loss adviser or staff at your local sports center can help
you create a plan suited to your own personal needs and circumstances, with achievable
and motivating goals.
Physiotherapy: Physiotherapy may be recommended if your symptoms continue for several

weeks.
1026
A physiotherapist may use a range of physical techniques to help improve your symptoms,
such as knee exercises, massage and gentle manipulation of your knee joint.
Medications:
As your knee pain is increasing, we can advise some painkillers such as paracetamol or
ibuprofen to help you in the meanwhile. Applying hot or cold packs to the joints can relieve
the pain and symptoms of osteoarthritis in some people. A hot-water bottle filled with
either hot or cold water and applied to the affected area can be very effective in reducing
pain.
Patient concern:
I want to talk to consultant.
1027
HEART FAILURE MEDICATIONS

James Anderson aged, 65 has come the clinic for his heart failure medications follow up . He
had a heart attack 2 weeks ago and diagnosed with heart failure. He was discharged on
these medications.
Clopidogrel
Ramipril
Atorvastatin
Bisoprolol
He was advised follow up every 3 weeks with cardiologist and every week with the GP .
P: Hello dr
D: my name is Dr Jane I am one the junior doctors in the gp surgery. Can you confirm me
your name and age for me please?
P: my name is James Anderson I am 65 years old
P: James Is fine dr
D: ok James, I can see you are here for your follow up
P: yes dr I am here for my follow up
D: Can you please give me a brief recap of what happened and how are you coping up?
P: I had a heart attack 3 weeks ago and I was planned to see the gp every week .
D: I am sorry to hear that James. How are doing now?
P: I am much better now
D: that’s good is there any specific problem that you are concerned about James?
P: yes dr I want to know about the medications side effects .
D: sure we will discuss all the medications but before is it okay if I ask you a few questions
just to understand your condition better?
P: ok dr
(Chief complaints of MI)
D: have you faced any chest pain since the discharge ?
D: any shortness of breath ? On exertion or at rest?
D: any nausea ?
D: any vomiting?
D: Have you noticed heart racing?
D- Any sweating?
D- Any tremors?
D- lightheadedness?
(Complications of MI)
Any breathing difficulty when you lie down?
Any swelling in your ankles?
1028
Any problems with your urination? (Change in quantity or frequency?)
Any dry cough perhaps? (Major Side effect of Ramipril)
Any bleeding that you have noticed recently? (Anti platelets-clopidogrel)
MAFTOSA
D: any similar problem in the past?
P: No
D have you been diagnosed with any medical condition in the past?
P: No
D: Are you currently on any medication beside the one you are taking for the recent illness?
D- Are you taking your medications regularly as advised?
P: No
D-Do you have any doubts regarding how to take your medications?
P: No (Compliance)
D-Have you noticed any new symptom after starting your medications?
P: No (Side effects)
P: No
D: Any family history of any significant health issues or any heart problems ?
P: yes dr my father died of heart attack last year.
D: I am sorry to hear about your loss James. Must have been hard time for you and your
family.
D- D: any past medical and surgical condition?
P: NO
D: what do you do for a living or are you retired James?
P: Yes I am
A few words about your lifestyle:
D: Do you smoke?
P: Yes
D: how much do you smoke? And since when?(if patient gives a long history and excessive
smoking please include smoking cessation in management as it is major risk factor for MI)
P: No
P: Balanced
EXAMINATION
I would like to do a GPE, check the BP, PULSE , RR , TEMP and Examine your chest including
heart examination .
I would like to order initial investigation like routine blood test. Renal function test, liver
function test and Urine dip.
We would also like to perform ECG and CHEST X RAY.
Examiner: BP 130/85
1029
CONCERNS
P: dr I want to know about the side effects of these medications that I am taking?
D: lets discuss them one by one
Well James, most of the medications that we prescribed are absolutely necessary for your
condition at the moment. As you know you had a heart attack, so we have given you certain
medications to protect your heart and prevent you from having further heart attacks.
As every other medications even these medications have side effects: most common side
effects of these medications include nausea, vomiting, headache, tummy pain, changes in
bowel habits. But these side effects seem to settle after some time. In case you face these
effects of the medications after a 3-4 days, we advise you to come back to us immediately.
Do you follow me James?
Now let’s go through some very important side effects of the medications one by one which
need to be kept in mind. Alright?
P: Yes doctor.
D: Well we started you on CLOPIDOGREL. Do you know what is this medication given for.
P: No doctor.
This is a medication to thin out your blood so as to prevent thickening and formation of clots
in your blood James. So you have to keep in mind in case you notice any kind of bleeding
(nose, in your poo, dark stools, wee) or a bruise that bleeds more than 10-15 minutes or you
face any headache or dizziness call 999 immediately. Make sure you avoid falls and if you
are involved in a heavy trauma/accident- you will need medical attention immediately. As
we discussed this medication does cause N/V/tummy pain and upsets but they do settle
after a while.
Coming to the second one RAMIPRIL. This is prescribed to control your blood pressure as
well as prevent further damage to your heart(remodeling of the heart). Now as discussed
above it causes N/V tummy aches. But in addition to that you have to keep in mind as this is
to control your blood pressure, due to major decrease in blood pressure or if your heart is
not able to pump blood efficiently this can cause side effects like feeling dizzy, lightheaded,
blurred vision, headaches. In case they don’t subside do come back to us and we can review
you medications. Also in case you develop persistent dry cough that does not settle with any
OTC cough medication, you have to seek medical attention. Do you any specific concerns
regarding these medications James?
P: No doctor.
ATORVASTATIN- this medication is taken to control your cholesterol levels in your blood as
cholesterol plays a major role in risk factors for Heart attacks. Along with this you have to
keep in mind that you have to take a healthy balanced diet as you already are and try to cut
down on smoking as well. Is that something you’d like to consider?
P: Yes doctor.
ATORVASTATIN can cause side effects like n/v/d but also joint and muscle aches, sleeping
problems, runny or stuffy nose and burning in your urine. In case you of persistent such kind
of symptoms, do come back and we will try to help you as much as we can.
1030
BISOPROLOL- is given to control your heart rate and certain amount of blood pressure as
well.it can cause sleeping problems, joint pain, cough nausea/diarrhea. It can cause irregular
slow heart rate- in case you feel dizzy, unwell call 999 immediately.
I understand all these side effects might sound too overwhelming James, but they don’t
happen to every individual every individual is different and may or many not Harbor these
side effects of these medications, but also it is very important for you to take these
medications as they will prevent you from further complications. But in case you feel
anything unusual, do come back and we will review your medications.
RED FLAGS- already discussed in side effects. But if you have any chest pain, Breathing
difficulty or heart racing do come back to us immediately.
FOLLOW-UP WITH YOUR GP every week
FOLLOW UP with cardiologist every 3 weeks
Leaflets
Specific expectations from this consultation
1031
EPISTAXIS AND HEADACHE (TESTOSTERONE)
John Williams has come with a headache and nose bleeding. He is 30

Speak to him, assess, do further management.
GRIPS
How can I help you
HEADACHE: SOCRATES, anything could have triggered it?
Anything else – nose bleeding – do FODPARA
DD – HTN – vision, dizziness, stroke – FAST, GCA, Meningitis, SOL/cancer
MAFT (Bleeding disorders, blood thinners, OTC, HRT) DESA
He will be taking testosterone off prescription in a very high dose for transitioning. Ask
about PE and DVT (as testosterone causes clotting problems)
Dig in dose, since when, prescribed or not?
Kudos you have come out and you are so brave. I am really happy. But can you tell me why
you are taking it in a high dose or without prescription?
P: I want to transition fast doctor.
D: Is there a specific reason you want a fast transition? Does your family know? Friends
know?
D: I understand your concern, John, however, I want you to understand that there is a
certain process to approach if you have decided about your identity. Again I am really happy
for you, but taking medications without prescription/monitoring the dosage can cause
harmful effects. Are you following me?
P: Yes
Examine vitals, head, nose, chest, legs

Investigations: CBC, LFT, KFT, ECT, clotting profile.
D: Do you have any idea what could be causing your symptoms?

D: I suppose the medications have caused a side effect and are leading to your symptoms.
P: Oh, I had no idea doctor. Now what will happen?
D: Testosterone should be taken under a practitioner's supervision, as it can cause deadly
side effects and be very harmful for your health. Explain clotting problems caused by
testosterone not only in nose but anywhere in the body.
We will be stopping your medication, keeping you under observation for now, and my
seniors will also reassess you. Once you are better and your reports are clear, then we can
think about sending you home.
Will that be okay with you John?
P: Yes doctor.
D: Are you aware of the process of transitioning through gender identity clinic?
P: Yes doctor.
1032
It is a safer way to transition. It does take time but it is very safe as everything is monitored
and done in your best interest.
P: Doctor the time frame is too much, can you speed up my appointment at GIC?
D: Well I see you are very concerned about this, but unfortunately John we cannot speed up
the appointment.
If he throws a concern saying am I doing the right thing – ask why do you think so, and
assure him there is no pressure or force, he has all the time in the world to think about it if
he is not sure. And it is absolutely okay to take his own time and decide as it is a very big
decision. Also GIC gives one year of social transitioning period in which you can live in the
community with the identity you want to for a year and then decide if you want to further
go on for a permanent surgery or not.
Involve support groups – LGBT, STONEWALL, CBT if he thinks he needs to talk about it if he
cannot share this at home.

Melisa, aged 32, has come to you with complaint of headache and bleeding from the nose.
She is waiting for an appointment for gender clinic.
D: How can I help?

P: I am having a headache and bleeding from nose.
D: Tell me more about the bleeding.
P: It started 1 month ago and was bleeding 3 to 4 times a day.
(Has come for the 1st time, been picking nose, held the nose couple of times)
D: Tell me more about the headache.
P: It is dull headache, had 4 to 5 times in a month. No photophobia.
PMH: Insignificant
Medication: Testosterone (injection every morning couple of months)
Personal: Insignificant
Lives alone
Mood is fine.
Tests: Routine Blood Tests

Examination: HTN -160/100
Counsel:
Lifestyle
BP Regular checkup
Testosterone counselling
Book an urgent appointment
1033
LAP CHOLE (JEHOVAH'S WITNESS)
You are FY2 in the surgical department.

A 30-year-old lady, Ms. Emma Swan, has been planned for laparoscopic cholecystectomy by
the consultant.
Speak to her and address her concerns.
GRIPS
Assess knowledge of cholecystitis
In this case, she will know she has gallbladder inflammation and has been planned for
surgery.
D: I am here to address all your concerns about the upcoming surgery.
She will directly say, "Doctor, I am a Jehovah's Witness/religious faith belongs in Jehovah's.
In case, she doesn't, ask her if she has specific concerns about the surgery, if she wants to
know about the surgery.
If yes, explain, it's a keyhole surgery, takes 30-45 minutes, it will be done under general
anaesthesia/sedation (she will be put to sleep), 3 holes are made on the tummy, one is used
to inflate the abdomen to visualize her inner organs better, one is used to insert a camera
and a third for the instruments to remove the gallbladder, 3 small scars will be present on
tummy after the operation, she will be guided on postoperative care of wound and regular
follow-up.
Before the operation, we will take a blood test to see how the blood levels are and if there
are any clotting problems in the blood that will tell us if she certainly requires blood
transfusion or not.
D: To understand your health condition, I would like to ask you a few questions. Will that be
okay?
P: Yes
Do MAFTOSA relevant.
D: As you are a Jehovah's Witness, would you consider blood transfusion if at all required
after the surgery?
P: Doctor that is the problem. I don't want any blood transfusion.
D: We absolutely respect your faith and wishes, but is it alright if I explain about surgery and
its complications in brief?
P: Yes doctor.
D: As you know that the consultant has decided to do a keyhole surgery. This surgery is a
minor surgery and usually does not end up in bleeding problems. It is a very common
procedure that is performed by the experts in the hospital. They ensure best care and
prevent infections, bleeding and other complications after the surgery. Also, we will be
1034
looking into your blood tests to make sure that you are not at a high bleeding risk (if she
wants to know, explain about anaemia and bleeding disorders).
Are you following me?
P: Yes doctor.
D: However, sometimes it may happen that during the keyhole surgery if the surgeon is not
able to visualize the organs properly, it may be converted into an open surgery. This is one
of the risks with any keyhole surgery and when the surgeon performs an open surgery, there
is a higher risk of bleeding as the scar is bigger than the keyhole. Are you with me so far?
P: Yes doctor.
D: If this happens, would you consider blood transfusion in that case Emma?
P: Doctor I am a true believer and I don't think I can take any blood transfusion.
D: I do understand and respect your beliefs about your religion, it was necessary for you to
know about the complications involved and the requirement for any blood transfusion,
hence I had to ask again.
However, in case of bleeding, there are other options such as other blood products (which
do not have the main RBC component, these are plasma, cryoprecipitate, albumin,
coagulation factors, immunoglobulins). What are your thoughts on receiving those
products?
Also there are options like epidural patches, haemodialysis – we can discuss these at length
if you would like. We also have an injection called Epogen that can be used. Epogen is a
man-made form of the protein human erythropoietin that is given to patients to lessen the
need for red blood cell transfusions. Epogen stimulates your bone marrow to make more
red blood cells.
P: I am not sure doctor if I would like these.
D: That's alright Emma, you have some time on hand, how about you discuss this with your
family members and let us know as soon as you have a decision today – as we do not want
to delay your surgery too far. Will that be alright? (iPhone can tell her complications of
delaying surgery as well, infection can increase and spread to blood).
P: Yes doctor, that would be fine.
If you require any help from us in understanding the surgery better, or any questions on
religious matters we can provide help on both of these from the authorities in the hospital.
Do you have any other specific concerns that you would like me to address today.
P: No doctor that's all, thank you.
D: Thank you Emma
Hospital Liaison Center for Jehovah’s Witness
1035
LOW MOOD (LESBIAN MISCARRIAGE)

Joanna Mary, aged 30, has come to you with a low mood.

P: I'm not feeling myself lately.
D: What do you mean by ‘not feeling myself’?
P: I feel low.
D: Since when have you been feeling like this way?
P: For the past 2 weeks.
D: Did something happen 2 weeks ago?
P: I had a miscarriage 2 weeks ago (sometimes says partner had miscarriage)
D: I’m sorry to hear that.
D: Can you score your mood?
P: 3 or 4
P: Yes
P: Yes
P: I don’t know
D: Do you have a disturbed sleep pattern?
P: Yes
D: DO you have recurrent thoughts about dying?
P: Yes/No
D: Do you feel suicidal/like hurting yourself?
P: Yes/No
D: Are these feelings constant?
P: Yes
D: Anything else?
P: No
D: Do you have episodes of feeling very happy, elated or overjoyed?
P: No
D: Do you sometimes feel full of great new ideas and important plans?
P: No
D: Do you make decisions or say things that are out of character and others see as being
risky or harmful? (bipolar mania)
P: No
1036
D: Do you feel cold even in a warm environment? (hypothyroidism)
P: No
D: Do you have similar symptoms of feeling low near your periods? (PMS)
P: No
D: Have you ever heard voices speaking when there is non one around?
P: No (psychosis)
P: No
D: Any history of depression and comorbid mental health or chronic physical disorder?
P: No
P: No
P: No
P: No
P: No
D: Any family history of mental illness?
P: No
D: Do you smoke?
P: No
P: No
P: No
P: Good/bad
P: Yes/No
P: With my partner
D: How is your relationship with your partner?
P: It is good
P: 2 years
D: Is she supportive?
P: Yes
D: Do you have any other family members around?
P: Yes
D: Are they supportive?
P: Yes
1037
D: How about friends?
P: I have many supportive friends.
D: Do you work?
P: I’m on leave
P: Yes
Concern:
1. Will I ever feel better again?
2. Is it depression?
I would like to do GPE and vitals
From the history you have given me, it appears you may be suffering from depression.
Depression is more than simply feeling unhappy or fed up for a few days.
Most people go through periods of feeling down, but when you’re depressed you feel
persistently sad for weeks or months, rather than just a few days.
Depression
Core symptoms:
1. Persistent sadness or low mood. This may be with, or without, a tendency to cry.
2. Marked loss of interest or pleasure in activities, even for activities that you normally
enjoy.
Other common symptoms:
1. Disturbed sleep.
2. Change in appetite.
3. Tiredness
4. Agitation or slowing of movements
5. Poor concentration
6. Feelings of worthlessness or inappropriate guilt
7. Recurrent thoughts of death
You have at least five out of the above nine symptoms, with at least one of these a core
symptom and:
1. Symptoms cause you distress or impair your normal functioning.
2. Symptoms occur most of the time on most days and have lasted at least two weeks;
or to a physical condition such as an underactive thyroid or pituitary gland.
Doctors describe depression by how serious it is:

 Mid depression – has some impact on your daily life
 Moderate depression – has a significant impact on your daily life
1038
 Severe depression – makes it almost impossible to get through daily life; a few people
with severe depression may have psychotic symptoms.
Risk assessment and psychological history:
Most people with depression will get better without treatment. However, this may take
several months or even longer. Relationships, employment, etc., may be seriously affected.
There is also a danger that some people turn to alcohol or illegal drugs. Some people think
of suicide. Therefore, may people with depression opt for treatment.

Cognitive therapy is based on the idea that certain ways of thinking can trigger, or fuel,
certain mental health problems such as depression.
Antidepressant medicines:
Antidepressant medicines are commonly used to treat moderate to severe depression.
Antidepressant medication is not usually recommended for the initial treatment of mild
depression. However, an antidepressant may be advised with mild depression that persists
after other treatments have not helped, associate with a physical illness and patient had an
episode of moderate or severe depression in the past.
Interpersonal therapy (IPT):

This is sometimes offered instead of CBT. IPT is based on the idea that your personal
relationships may play a large role in affecting your mood and mental state. For example,
IPT may focus on issues such as bereavement or disputes with others that may be
contributing to the depression.
Electroconvulsive therapy (ECT): may sometimes be recommended if the person has severe
depression and other treatments, including antidepressants, have not worked.
For people starting an antidepressant:

 Consider suicide risk and toxicity in overdose
 Explain that symptoms of anxiety may initially worsen
 Explain that antidepressants take time to work
 Explain that antidepressants should be continued for at least 6 months following
remission of symptoms, as this greatly reduces the risk of relapse.
SSRIs and SNRIs side effects:

Agitation, sickness, indigestion
Loss of appetite
Dizziness
1039
A sedating effect
Headaches
Low sex drive (difficulties achieving orgasm during sex or masturbation)
(erectile dysfunction)
These side effects should improve within a few weeks, although some can occasionally
persist.
Tricyclic antidepressants (TCAs) side effects:

Dry mouth
Slight blurring of vision
Constipation
Problems passing urine
Drowsiness
Dizziness
Weight gain
Excessive sweating (especially at night)
Heart rhythm problems, such as noticeable palpitations or a fast heartbeat (tachycardia)
The side effects should ease after a couple of weeks as your body begins to get used to
medicine.
Don'ts
5. Don't bottle things up and 'go it alone'. Try to tell people who are close to you how
you feel. It is not weak to cry or admit that you are struggling.
6. Don't despair – most people with depression recover. It is important to remember
this.
7. Don't drink too much alcohol. Drinking alcohol is tempting to some people with
depression, as the immediate effect may seem to relieve the symptoms. However,
drinking heavily is likely to make your situation worse in the long run. Also, it is very
difficult either to assess or treat depression if you are drinking a lot of alcohol.
8. Don't make any major decisions whilst you are depressed. It may be tempting to give
up a job or move away to solve the problem. If at all possible, you should delay any
major decisions about relationships, jobs, or money until you are well again.
Do's
4. Do try to distract yourself by doing other things. Try doing things that do not need
much concentration but can be distracting, such as watching TV. Radio or TV is useful
late at night if sleeping is a problem.
5. Do eat regularly, even if you do not feel like eating. Try to eat a healthy diet.
1040
6. Do tell your doctor if you feel that you are getting worse, particularly if suicidal
thoughts are troubling you. See the separate leaflet called Dealing with Suicidal
Thoughts.
Sometimes a spell off work is needed. However, too long off work might not be so good, as
dwelling on problems and brooding at home may make things worse. Getting back into
hurly-burly of normal life may help the healing process when things are improving. Each
person is different and the ability to work will vary.
Sometimes a specific psychological problem can cause depression but some people are
reluctant to mention it. One example is sexual abuse as a child, leading to depression or
psychological difficulties as an adult. Tell your doctor if you feel something like this is the
root cause of your depression. Counselling may be available for such patients.
1041
LEFT VENTRICULAR DYSFUNCTION WITH ED POST MI

Mr. Jayden Nadal, aged 56, had an MI 3 months ago. A follow-up was arranged 6 weeks
ago. During his follow up, he was diagnosed with LVD and was prescribed Aspirin,
Ticagrelor, Bisoprolol, Ramipril and Statin.
Please talk to the patient, assess him and address his concerns.

P: I feel tired.
P: I am tired all the time since my follow up 6 weeks ago.
P: No
D: Has it changed?
P: I feel more tired.
P: No
P: My hands feel cold.
P: It started after my follow-up.
D: Anything else?
P: I am embarrassed to talk about it.
D: We are here to help and support you.
P: I am not able to maintain erection.
P: It all started after my follow up.
D: Do you have difficulty obtaining an erection?
P: No
D: Is the erection suitable for penetration?
P: Yes
D: How long does the erection last?
P: Not long
D: Do you have problems with sexual libido?
P: No
D: Do you have problems completing the sexual activity, i.e., achieve orgasm?
P: No
D: Do you ejaculate too soon?
P: Yes
D: Does pain or discomfort occur with ejaculation?
P: No
1042
D: Is penile curvature a problem? (Peyronie disease)
P: No
D: Anything else?
P: No
P: Fine
D: Could you score the mood from 1-10, 1 being the lowest and 10 being the highest
P: 7
D: Hot flushes?
P: No
D: Do you have any lumps or bumps anywhere in your body?
P: No (Cancer)
P: No
D: Do you have any loss of appetite?
P: No
D: Do you have shortness of breath or heart racing?
P: No
P: No
P: No
D: Any constipation, diarrhoea? (Thyroid, IBD)
P: No
D: Any tummy pain?
P: No
P: No
D: Do you have any sore throat?
P: No
D: Any headache?
P: No
D: Lack of concentration?
P: No
D: Sleep disturbance?
P: No
D: Have you had a similar problem in the past?
P: No
P: I had MI 3 months ago and I attended follow up 6 weeks ago.
D: What was done for you in follow up?
P: I was started on Aspirin, Ticagrelor, Bisoprolol, Ramipril and Statin.
1043
D: Are you taking them regularly as prescribed?
P: Yes
D: Any side effects?
P: I asked for any side effects during my follow up but the cardiologist dismissed my concern
completely.
P: No
P: No
P: No
D: Any surgeries or hospitalisations apart from your heart condition admission?
P: No
D: Any family history with similar conditions?
P: No
P: Yes/No
D: Do you smoke?
P: Yes/No
P: My diet is very good.
P: I have my own business
D: Is it stressful?
P: Yes/No
I would like to check your vitals and examine your chest, tummy, musculoskeletal and your
private area.
From our assessment, all the symptoms including tiredness, cold hands and erectile
dysfunction might be due to the medications (beta blocker) that have been prescribed to
you for your heart condition.
Every medication has side effects, and we don't expect that every patient will get these side
effects. Now as you are experiencing the side effects, we will have to make changes in your
medications and for that we will have to refer you to the specialist who will be able to help
you.
1044
Once we make the changes in your medicine, the symptoms you are experiencing will get
better over time. Please do not stop the medications until advised by the specialist.
PATIENT'S CONCERNS
 Will my erectile problem resolve?
 Will I get back to my normal self without feeling tired?
 Will there be lifelong effects?
 Will the new medications have the same side effects?
Side Effects of Beta Blockers

 Feeling tired, dizzy or lightheaded (bradycardia)
 Cold fingers or toes
 Inability to achieve a proper erection (impotence), vivid dreams, difficulties sleeping or
nightmares.
 Feeling sick
 Hypoglycaemia
We will do some blood tests to check anaemia, liver and kidney function, vitamin levels and
thyroid hormone. We will also check blood sugar. We will also do some urine tests.
Have a well-balanced diet, we may also prescribe you some vitamin supplements.
Please manage your rest. You can have rest during the day. Please try to have frequent rest.
Please manage your sleep. Please try to have a regular pattern of sleep.
1045
SIMMAN STATIONS
PRIMARY SURVEY CONSCIOUS
You are F2 in A&E

Mr. Andy Charles aged, 45 years fell from 2 meters height on concrete slab. Patient is on
resus trauma.
Assess patient and talk about initial management to examiner.
After 6 minutes tell the examiner your findings and initial management.
I assume I have taken my universal precautions and trauma team is with me.
Universal + trauma team
D: How are you?
P: l am in pain (patient points)
D: What happened?
P: I fell down from the ladder
P: It happened 2 hours ago
D: Now I will examine you quickly.
P: Ok
Airway:
1. Conscious
2. Airway patent
3. Oxygen
4. Triple immobilization
5. Monitor
6. Primary Series of X-Rays (Cervical, Chest and Pelvis)
Breathing:
1. Shortness of Breath
Open Neck Collar (Instruct the patient not to move their head and neck)
2. Engorged neck veins.
3. Trachea
Exposure
Chaperone
4. Chest: Inspection, Palpation, Percussion & Auscultation
Circulation:
1. Blood on Floor / External Haemorrhage
2. Conjunctival Pallor
1046
3. Cold Peripheries
4. Capillary Refill Time
5. Peripheral Cyanosis
6. NEWS Chart -> vitals Management:
1 would like to put 2 Large Bore Cannulas’. I would like to take blood for routine
investigation:
grouping and cross matching for 4 units of blood. I would like to give warn crystalloid
solution 2 litres in 1 hour.
Abdomen : Inspection. Palpation. Percussion & Auscultation

Pelvis:
Inspection :
(Looking for deformity. Scrotal Haematoma and Bleeding from External Urethral Meatus)
Compression Distraction Manoeuvre: Positive
Legs:
Inspection: Looking for Redness, Swelling. Deformity, Scar. Sinuses & Bleeding.
Wriggle the Toes
Check Distal Pulses
Management:
C.D.M I Spring Test (old name) - Grab Pelvis, Thumb on ASIS and jus
just got for it. Compression (Close) then Distraction (Open).
When you do in exam, patient will shoot as soon as you grab, consider this positive.
CDM is positive, so I am suspecting pelvic fracture.
I have already resuscitated my patient. I am going to admit my patient.

I am going to give my patient pain killer:
Morphine in titration
Metoclopramide - (lOmg I/V)
Naloxone 100 - 200ug PRN
I would like to put Pelvic binder I girdle (for pelvic fracture)
I would transfer the patient to trauma centre for definite management.
I would like to order some investigation. (USG of Abdomen and CT Chest. Abdomen & Pelvis)
I would like to cover my patient to protect from hypothermia.
I would arrange for Suprapubic Catheter and NG tube for my patient.
Ideally, I would do secondary survey and full neurological examination.
1047
PRIMARY SURVEY UNCONSCIOUS
You are F2 in A&E

Mr. Andy Charles aged, 45 years fell from 2 meters height on concrete slab. Patient is on
resus trauma.
Assess patient and talk about initial management to examiner.
After 6 minutes tell the examiner your findings and initial management.
I assume I have taken my universal precautions and trauma team is with me.
Universal + trauma team
D: How are you?
P: lam in pain (patient points
D: What happened?
P: I fell down from the ladder
P: It happened 2 hours ago
D: Now I will examine you quickly.
P: OK
Airway:
1. Conscious
2. Airway patent
3. Oxygen
4. Triple immobilization
5. Monitor
6. Primary Series of X-Rays (Cervical, Chest and Pelvis)
Breathing:
1. Shortness of Breath
Open Neck Collar (Instruct the patient not to move their head and neck)
2. Engorged neck veins.
3. Trachea
Exposure
Chaperone
4. Chest: Inspection, Palpation, Percussion & Auscultation
Circulation:
1. Blood on Floor / External Haemorrhage
2. Conjunctival Pallor
3. Cold Peripheries
4. Capillary Refill Time
5. Peripheral Cyanosis
6. NEWS Chart -> vitals Management:
1 would like to put 2 Large Bore Cannulas’. I would like to take blood for routine
investigation:
1048
grouping and cross matching for 4 units of blood. I would like to give warn crystalloid
solution 2 litres in 1 hour.
1049
SIMMAN (ASTHMA)
You are F2 in A&E.

James aged, 40 came with acute shortness of breath.
Please talk to the patient, assess his condition, examine him and discuss about initial plan of
management with the examiner.

P: I can't breathe, my asthma is killing me.
P: It started 2 hours ago.
P: I was sitting at home, started suddenly
P: No
D: Do you have any cough?
P: No
D: Do you have any chest tightness?
P: No
D: Do you have any wheeze?
P: I don't know
D: Have you experienced any heavy pain in your chest?
P: No (ACS)
D: Do you have any pain, redness, hotness or swelling in your legs?
P: No (PE)
D: Do you have any fever, flu like symptoms?
P: No (Pneumonia)
P: No/Yes
D: When were you diagnosed with asthma?
P: No/Yes
P: Since childhood
D: Did you use your inhaler
P: Once/twice a day recently.
D: Do you have any other medical conditions?
P: No
D: Any high blood pressure, diabetes or any heart conditions?
P: No
D: Are you taking any other medications other than blue and brown inhalers?
1050
P: No
D: Have you been using any over the counter painkillers such as ibuprofen?
P: No
P: No
D: Have you been hospitalized before?
P: No
D: Have you had any surgeries in the past?
P: No
D: Has any member of your family ever been diagnosed with any medical conditions?
P: No
D: Do you smoke?
P: No
P: I am not quite active.
P: I am a state agent.
P: No
D: How is your living status?
P: It's fine.
D: Do you have any pets or carpets at home?
Inspection:
Chest: symmetry of chest wall movements.
Palpation:
Chest: chest expansion
Percussion:
Hyper-resonance or Dullness
Auscultation:
Wheeze is present all over the chest.
PEFR:
D: I would like to do PEFR.
MANAGEMENT:
Severe Asthma if any of:
1. PEFR 33% - 50%.

2. Respiratory' rate >25
3. PR>110
4. Unable to complete sentence in one breath.
1051
5. Using accessory muscles.
Management:
1. High flow oxygen:
40% - 60% (6 L/min) up to 100% (15 L/min) to maintain saturation of 94% - 98%.
2. Nebulized salbutamol 2.5 - 5mg every 5-15 minutes,
3. Ipratropium bromide (Atrovent) 500 microgram.
4. Corticosteroids:
Prednisolone 40 mg PO or Hydrocortisone 200 mg iv.
Involve Senior:
1. Magnesium 2 gm iv over 20 minutes
2. Salbutamol 250 microgram iv bolus
3. Salbutamol infusion 5 - 20 minutes
Alternative
1. Aminophylline 5mg/kg iv over 20 minutes loading (unless on oral therapy)
2. Aminophylline 0.5 - 0.7 mg/kg/hour
If patient on oral aminophylline or theophylline, check blood levels on admission and daily if
infusion
1052
SIMMAN (ANAPHYLAXIS)

Patient aged 55, had undergone surgery on the abdomen for burst appendix. Surgery team
decided to give two units of blood. He was given one unit of blood already. While he was
receiving second unit of blood he experienced shortness of breath.
Your nurse colleague was concerned about the patient and asked you to talk to the patient.
Please talk to the patient, assess him and do relevant management.
Inside the cubicle simman is lying down on a couch wearing gown you can see blood
attached to it. There are 2 masks one with a bag attached one with a tubing. Simman is
catheterized as well. There is a bag of blood that is connected and transfusion is taking place
at the moment. There is also a bag of IV fluid, adrenaline, colloid on the table nearby.
Sometimes you may find a wrist band showing penicillin allergy
Monitor findings:
ECG-normal
Oxygen- 85-88%
Pulse-92
BP- 90/50
RR->25

P: Dr. Help me I can’t breath. (Breathing heavily)
D: Please look at the monitor.
D: Examiner I would like to stop blood because I suspect my patient has some reaction to it.
EX: Ok stop it.
D: I would like to give my patient high flow oxygen.

Pick the oxygen mask with a reservoir bag attached. (Saturation will improve)
D: Are you feeling better now?
P: A bit (still breathing heavily) On the monitor Spo2 <90.
D:
1. I would like to give my patient adrenaline 0.5ml IM (500 micrograms) 1:1000 titration.
2. IV fluid (Normal saline - fluid challenge)
(Adults - 500 mL of warmed crystalloid solution (0.9% saline) in 5-10 minutes if the patient is
normotensive or 1 L if the patient is hypotensive).
3. Chlorphenamine-10 mg IM or IV slowly.
4. Hydrocortisone-200 mg IM or IV slowly.
EX: Ok.
D: Are you feeling better

1053
P: Yes. Dr much better.
(If patient is not feeling better then we need to auscultate the chest and further treatment
with a bronchodilator, such as salbutamol (inhaled or IV), ipratropium (inhaled),
aminophylline (IV) or magnesium sulfate (IV - unlicensed indication). Magnesium is a
vasodilator and can compound hypotension and shock)
D: Tell me what exactly happened?

P: I had a surgery for my appendix and I was receiving blood after that. After that my lips and
tongue have swollen up. My hands are itchy.
D: Since when you are having this problem?
P: From last 20 minutes
D: Has it changed ever since it started?
P: It was getting worse.
P: Yes, I feel my tummy is bloated.
Let me examine you quickly. For the purpose of the examination, I would like to undress you
above your waist and I will keep a chaperone with me to ensure your privacy.
Examination: Abdomen shows three bandages as patient had laparotomy.
There was nothing found on palpation.
Chest was also undressed showing rash which was basically red
P: No
P: No
P: Yes in the hospital. I was given many medications.
P: Yes. I am allergic to penicillin.
D: Did u receive any penicillin in last hour
P: I don't know.
D: Did u receive any medication recently
P: Yes, nurse gave some a couple of minutes ago.
P: No
P: No
D: Any other thing that you would like me to know?
P: No
D: We are suspecting that you had a condition called anaphylaxis reaction. It is an allergic
reaction that happens when a foreign object enters the body and our body’s defense system
release a substance to fight against it.
1054
We will send Blood to the lab for further investigation, for Blood grouping and
incompatibility, FBC. LFT, U&Es. Creatinine. ABG. bleeding and Clotting screen. We will do an
ECG and keep an eye on the vitals.
We will also check for blood in the urine.
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 apologise for all you have been going through.
We have a system in our hospital in such situations, I will document about this incident in
your notes. I will inform my consultant and I will fill an adverse report form (Incident form)
to let the hospital authorities know about the incident. In this way. the hospital authorities
in the NHS. These incidents are reported nationally as well in order prevent them happening
1055
SIMMAN (DEATH CONFIRMATION WITH DNAR)
You are F2 medicine

Mr. Albert Corrigon aged 93 has been admitted in the hospital with lung cancer. He has been
receiving treatment for it. Nurse wants to talk to you about Mr. Albert Corrigan.
Talk to the nurse, assess the patient and write medical notes.

Nurse: Mr. Corrigon is admitted in the hospital for past few weeks. He is receiving
chemotherapy for lung cancer. He is not well for last one week and now his condition is
deteriorating.
D: Hello, Hello. Tap on his shoulder
Assess airway, breathing and circulation, (patient had no pulse and was not breathing.)
D: He is in cardiac arrest. Please help me connect monitor to confirm.
Nurse: Sorry doctor, there are no monitors here.
D: Ok then we must start CPR or he has DNAR.
Nurse: Yes doctor, Mr. Corrigon had signed DNAR form. Here I have the form if you want to
have a look at it. (She will show you the form)
D: Mr. Corrigon had wished for no resuscitation so we have to respect that.
Confirm patient death and write in notes
Patient is lying in bed with eyes closed
Note: You will get Neuro-pin, Pen Torch & Stethoscope
Death Confirmation:
1. Confirm the identity of the patient - check the wrist band
2. General inspection - skin colour / any obvious signs of life
3. Look for signs of respiratory effort
4. Does the patient respond to verbal stimuli? - Hello Mr. Corrigon, can you hear me?
5. Does the patient respond to pain? - press on fingernail / trapezius squeeze / supraorbital
pressure.
6. Assess pupils using pen torch - after death they become fixed and dilated.
7. Feel for a central pulse - carotid artery.
8. Auscultation:
Listen for heart sounds for at least 2 minutes.
Listen for respiratory sounds for at least 3 minutes.
(It might differ according to the hospital policies)
Patient declared as deceased at (Date and time)
Inform nursing staff that you have confirmed the death:

a. They will then inform next of kin, if not already present
b. They will also contact the porters to arrange transfer of the body to the morgue.
1056
c. Discuss with the senior regarding cause of death before signing the form.
Consider if this death needs a referral to the coroner, as if this is the case a death certificate
cannot be issued — this will require discussion with the consultant responsible for the
patient.
Name:
Age:
Gender:
Date of Birth
NHS Number:
Date:
Death Confirmation Assessment:
Identity confirmed as Albert Corrigon from wrist band

Patient in bed, eyes closed, no signs of life
No respiratory effort noted
No response to verbal stimuli
No response to painful stimuli
No carotid pulse palpable
Pupils fixed and dilated bilaterally
No heart sounds noted during 2 minutes of auscultation.
No breathing sounds noted after 3 minutes of auscultation.
Death Confirmed at / / at 09.30
• There are several other types of death that must always be reported:
• All deaths of children and young people under 18, even if due to natural causes. This is
for safeguarding purposes.
• Deaths within 24 hours of admission to hospital
• Deaths that may be linked to medical treatment, surgery or anaesthetic
• Deaths that may be linked to an accident, however long ago it happened
• Deaths that may be linked to drugs or medications, whether prescribed or illicit
• If there is a possibility that the person took their own life
• If there are any suspicious circumstances or history of violence
• Deaths that may be linked to the person's occupation, for example if they have been
exposed to asbestos
• All deaths of people who are in custody or detained under the Mental Health Act,
1057
SIMMAN (UTI AFTER TURP)
You are F2 in A&E.

Patient aged 75-year-old was brought in the hospital by his wife as he was feeling sick.
Monitor:
ECG - Normal
Pulse - 110/min
Blood Pressure - 100/70 mmHg
SPO2- 97%,
Temperature - 38 C

P: I am not feeling well.
D: Could you please tell me more?
P: I am feeling very tired, I haven't passed urine and it was very uncomfortable.
D: For how long you are having this problem?
P: Since last one day.
P: Yes Dr., I feel feverish from last few days.
D: Did you take anything for that?
P: I tried PCM it helped a bit.
P: I took 2 yesterday.
P: No
D: Did you have tummy pain?
P: Yes
P: around 5 doc
D: Any changes in your urine color or smell?
P: Yes, it is smelly and cloudy these days.
D: Any blood in it?
P: No
1058
P: Yes, from last few days but I didn't vomit.
D: Any cough?
P: No
D: Any problem with the bowel?
P: No
P: No
D: Someone in your friends or family told you are losing weight?
P: No
D: Any tiredness or SOB?
P: No.
D: Do you have to go to the loo more often these days?
P: I was going to the loo more since last few weeks. I had operation TURP 4 days ago for my
prostate.
D: How did the operation go?
P: It went well, I was in the hospital for two days and then I was sent home.
D: Any complications during the surgery?
P: No
D: Did you have increased frequency of urine at night?
P: Yes (Nocturia)
D: How many times did you wake up during the night?
P: 2-3 times.
D: Did you have to rush to the loo?
P: Yes/No (Urgency)
D: Did you have to Strain while urinating?
P: Yes/No
D: Did you have Difficulty in starting urination?
P: Yes/No(Hesitancy)
D: Were you able to hold your urine before going to loo?
P: Yes/No(Incontinence)
D: Did you have Weak urine stream or a stream that stops and starts?
D: Did you feel like that you are not able to completely empty the bladder?
P: Yes/No (Poor emptying)
D: Did you notice any Dribbling at the end of urination? Does a bit of urine drop and stain
P: Yes
1059
P: Yes/No
P: No
D: Any diabetes, high blood pressure, high cholesterol, kidney or heart disease
P: No
P: No
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
D: Do you drink alcohol'
P: Occasionally
D: I would like to check your vitals, examine your tummy. I will be having a chaperone with
me to ensure your privacy.
EX: Do it doctor.
Remove the hospital gown and the shorts. (Don’t forget to cover in the end)
Urine catheter attached to the urine bag showing yellowish turbid urine with pus collection
+- Blood
Abdomen: Tenderness over suprapubic area.
EX: Dr. What do you think is going on with the patient?
D: I am suspecting my patient is having urinary tract infection probably after TURP as it is
one of the most common complication of this surgery.
EX: what would you like to do for the patient?
D: I would like to send for some initial investigations routine blood test including kidney
function test, urine dip. We would like to take urine sample and send for culture and
sensitivity.
We will do ABG as well.

EX: Here is your ABG
ABG shows metabolic acidosis.
1060
PH-low.
HCO3 - low
CO2 -Normal
Management:
(Follow SEPSIS 6 if patient is in septic shock)
We will give him some broad-spectrum antibiotics. We may also change antibiotics
according to the bug that is causing the infection.
We will give you some PCM and painkiller for the temperature and pain.
We will give some anti-sickness medication for nausea.
We will consider giving him IV fluids.
We will inform my seniors and I will arrange for USG of abdomen and prostate.
General advice:
Place a hot water bottle on your tummy, back or between your thighs
Rest and drink plenty of fluids - this helps your body to flush out the bacteria
NOTE:
Sometimes this patient is planned for surgery and is having urine retention. Patient was
catheterized and posted for surgery.
1061
SIMMAN-HYPOGLYCAEMIA

Samuel, aged 40, is in the hospital drowsy.
Assess and manage him.
Please follow ABCDE protocol.
Inside the cubicle: Blood sugar – 1.8
Treating someone who's unconscious or very drowsy.
Follow these steps:

1. Put the person in the recovery position and do not put anything in their mouth – so
they do not choke.
2. Give them an injection of glucagon medicine – if it's available and you know how to
do it. Call 999 for an ambulance if an injection is not available or you do not know
how to do it.
3. Wait about 10 minutes if you have given them an injection – move on to step 4 if the
person wakes up and starts to feel better. Call 999 for an ambulance if they do not
improve within 10 minutes.
4. Give them a sugary drink or snack, followed by a carbohydrate-containing snack – the
drinks and snacks used to treat a low blood sugar yourself should work.
Intravenous administration of 75-80 ml 20% glucose or 150-160 ml of 10% glucose.
1062
SIMMAN (POST UTI SEPSIS SHOCK)
You are an F2 in Medicine Dept.

Mrs. Rachel Thompson aged 78 years was admitted to the hospital with UTI 3 days ago.
Nurse has called you and says that the patient is feeling poorly. She says that you are the
only doctor available to see her.
Talk to the patient, assess her and manage her situation appropriately.
D: Hello, Mrs. Thompson, how are you doing today. (Introduce yourself)
P: I Cannot breathe doctor
D: I am sorry to hear Mrs. Thompson, but don't worry, let me quickly examine you and see
what's going on.
P: Okay Dr.
D: I would like to check my patients' vitals. (Look at the monitor)

RR 24
SpO2 88
Pulse 96
BP 105/65
Temp 39.0
D: Patient is talking
D: SATS - low, RR - high. Chest Ex (Bilateral crackles may be present) and connect high flow
02 (15L via non-rebreather mask)
D: Pulse - 96, BP - 105/65. CVS Ex and connect two large bore IV cannulas and start warm
crystalloids immediately.
D: She is alert and oriented.
D: Temp - 39.0. Give IV Paracetamol. Look for source of infection.
D: I would like to examine your tummy as well.
P: Okay Dr.
P: Better doctor.
D: You were admitted with UTI, is it right?
P: Yes
D: Do you have any burning sensation while passing urine?
P: No
D: Any tummy pain?
P: Yes/No
D: Any previous medical conditions?
P: Yes/No
D: Any regular medications?
P: Yes/No
1063
D: Any allergies to any food or drugs?
P: No
SEPSIS SCREEN: (Find out source of sepsis)

• Bloods for FBC, CRP, Renal and Liver function tests
• Bloods Culture
• Urine Dip and Culture
• CXR
• Sputum culture (If cough + phlegm present)
SEPSIS SIX:
GIVE: TAKE:
Oxygen Blood cultures
IV Fluids Lactate
IV Antibiotics Urine Output
D: From my assessment, I think you have a condition called Septic Shock. This means that
the infection from your urinary tract has spread to all over your body through blood.
D: I have given you 02 as your oxygen levels are low in your blood. I have given you fluids
and paracetamol through your vein as your BP is low and you have high temperature. I will
arrange for some blood and urine tests and a Chest X-Ray.
D: I will have to give you stronger antibiotics through your veins to help for your condition.
Is that okay with you.
P: Yes doctor.
D: I will inform my senior and Intensive Care team to come and review you.
SCENARIO #2
You are an F2 in Accident and Emergency.

David Knowles, 80-year-old, has been brought in by daughter due to confusion.
Talk to the daughter and address her concerns.

P: My father has been confused since morning. He has been mumbling and I can’t understand
anything.
P: He is going to the loo more often since the last few days and he was complaining about
cloudy urine.
D: Are there any other symptoms?
P: Like what?
D: Any fever, chills, or flu-like symptoms?
P: No
1064
D: Any blood in the urine?
P: No
P: No
D: Does he have any pain while passing urine?
P: No
D: Does he have to strain while urinating?
P: Yes/No
D: Does he have difficulty in starting urination?
P: Yes/No
D: Does he have weak urine stream or a stream that stops and starts?
D: Does he feel like he is not able to completely empty the bladder?
P: Yes/No (poor emptying)
D: Have you noticed any weight loss? (cancer)
P: No doctor.
D: Has he had a similar kind of problem in the past?
P: No
P: No
D: Any DM, HTN, heart disease, or high cholesterol?
P: No
P: No
P: No
P: No
P: No
D: Does he smoke?
P: Yes/No
P: Yes/No
P: He tries to eat healthy
D: Does he do physical exercise?
P: He doesn’t have much time.
P: He doesn’t have much time.
P: No
1065
I will check my patient’s vitals, GPE and examine his tummy
Examination/Investigations
Vitals: BP – 150/90, Temp – 38
All others normal
Abdominal Examination: Bulge in suprapubic area.
P: Why is he behaving like this?

D: He is in confusion because it is the complication of urinary tract infection.
P: How can UTI cause this?
D: This is one of the complications of UTI. In fact, any infection at this age can cause
confusion. Our immune system changes as we get older, it responds differently to the
infection. Instead of pain symptoms, sometimes old age people with such kind of infection
like UTI may show increased signs of confusion, agitation or withdrawal.
P: What are you going to do for him now?
D: We are going to admit him and we will do necessary investigations like bloods
(FBC/U&E’s/LFTs/Glucose/ABG/Clotting Screen/Blood Culture), urine test, ECG, imaging
(abdominal USG). We will also measure his urine output.
We will give him oxygen

We will give him fluids through his blood vessels (veins) as a drip
We will give him antibiotics through his blood vessel (vein) to treat the infection.
If in Sepsis -> SEPSIS SIX within one hour

Give high flow O2, IV antibiotics, IV fluids to the patient
Take blood culture, serum lactate and hourly urine output.
We will give painkillers if he has any pain.

Once the infection is controlled, his symptoms should come back to normal.
P: How long are you going to keep him in the hospital?

D: We will keep him in the hospital till he gets better, and his infection is treated. We will
confirm this by doing blood tests.
Patient concerns.
Is it stroke?
1066
SIMMAN (UPPER GI BLEED)

Mr. John aged 68 was brought into the A&E by his wife, as he is feeling dizzy and faint.
Talk to the patient, assess him and discuss the initial plan of management with him.
Both Sim-Man and Nurse are present inside the cubicle.

D: Who do we have in here? (Introduce yourself to the nurse)
Nurse: We have Mr. John here, who was brought in by his wife.
D: Do we know anything about why his wife brought him here today?
Nurse: No doctor.
D: Have you done anything so far?
Nurse: Yes. I have connected him to the monitor. Please have a look at the patient doctor.
D: That's fine, let me talk to patient first and assess him to see what’s going on.
Nurse: Okay doctor.
D: Hello Mr. John, what brought you to the hospital today?
P: I was feeling dizzy and faint doctor.
D: I am sorry to hear that Mr. John, let me quickly have a look at your vitals and then I will
get back to you.
(Look at the monitor for vitals)
Vitals are stable.
If vitals deranged - Stabilise the patient first.
D: Nurse could you please keep an eye on the vitals and let me know if they are unstable.
Nurse: Okay.
D: Your vitals are stable Mr. John. Could you please tell me more about your dizziness and
fainting?
P: What do you want to know doctor?
D: When did your symptoms start?
P: It started 2-3 days ago dr.
D: What do you mean by dizziness?
P: I feel lightheaded and loose balance.
D: Do you have this all the time?
P: No, only when I walk for some time.
D: How many episodes did you have?
P: 4-5
P: Few minutes
P: Yes
P: When 1 do some activity.
1067
P: When 1 rest
D: You told me that you this feeling of fainting? Could you please tell me more about it?
D: What do you mean by feeling faint?
P: I feel like I am about to fall and lose consciousness, but I don’t.
D: Did you actually lose consciousness anytime?
P: No
D: Did you have a fall anytime?
P: No
P: Same time, 2-3 days
P: Yes
D: Do you have any other symptoms along with these?
P: No
D: Any fever/flu like symptoms?
P: No
P: No
D: Any SOB?
P: Yes/No
D: Any chest pain or discomfort?
P: Yes. I feel some discomfort in my chest.
P: It started with my symptoms & it’s all over my chest.
P: Yes/No
D: Any ear pain or hearing problems?
P: No
D: Any ringing sensation in your ear?
P: No
D: Any head ache?
P: No
D: Any weakness in any part of your body?
P: No
D: Any speech or vision problems?
P: No
D: Any problems with your bowel or bladder?
P: No
D: Any loose stools? (dehydration)?
P: No
D: Any tummy pain or discomfort?
1068
P: No
D: Any bleeding from anywhere in your body?
P: No
D: Any change in colour of your stool/any dark coloured stools?
P: Yes/No, I didn’t look at my stools recently.
D: Is this the first time you have these symptoms?
P: Yes
P: Yes, I have Osteoarthritis of my Knee.
P: 1 take pain killers for that.
D: Which pain killer and for how long?
P: Diclofenac. Since few months.
D: Are you on any other medications apart from this? Any PPI’s (Gastric Tablets), steroids or
blood thinners?
P: No
D: Are you diagnosed with any other medical problems? Any heart problems or blood
disorders?
P: No
D: Do you have any allergy to any food or drug?
P: No
D: Any medical conditions in the family?
P: No
P: Sim-Man says, doctor I have soiled myself now.

D: Let me quickly have a look at your stool. DARK STOOL - MALEANA.
P: I feel short of breath doctor.
D: I think you have some bleeding from your gut. Let me quickly look at your vitals and
examine you.
LOOK at the monitor for vitals:
RR 26
SpO2 90
HR 98
BP 90/60
Temp 37.5
D: SATS - low and RR - High. Chest Ex - Normal.
D: I would like to give you high flow 02 (15 Litres/Min with reservoir bag)
D: I need to examine your chest. For that purpose, I need you to be exposed. I will have a
chaperone with me to ensure your privacy. May I proceed?
P: Okay
1069
D: BP - Low and Pulse - High. CVS Ex and look for active bleeding.
(Pt soiled himself, look his under garments. You can see dark stools - Maleana).
D: I can see dark stools, that means you are bleeding from your gut. This explains why you
have these symptoms. This is an emergency.
D: I would like to give you fluids through your vein immediately. I will send your blood for
routine investigations and group and cross match. I will arrange for blood transfusion. I
would also like to get my senior involved.
P: Okay
D: I will ask specialist (gastroenterologist) to review you.
P: Okay doctor.
D: The specialist will do a procedure called endoscopy (explain endoscopy) and try to find
out the source of bleeding and stop it.
D: I will review you regularly until you are seen by the specialist and get the procedure
done.
P: Okay doctor.
1070
DIZZY SPELLS (ATRIAL FIBRILLATION)
You are F2 in A&E.

Julia aged, 52 came with dizziness.
Please talk to the patient, assess his condition, examine him and discuss about initial plan of
management with the examiner. After 6 mins discuss plan of management with the patient.

(ODIPARA)
P: I have been feeling dizzy.
D: What you mean by dizzy?
P: I feel like I am about to fall. But. I don’ t fall.
P. It started few weeks ago.
D. How did it start?
P: I don’t know. I wasn’t doing anything special.
D: Is it there all the time or does it come and go?
P: I have this feeling time to time.
D: How often do you get this feeling?
P: I had 4 episodes so far.
P: It lasts for a few seconds I minutes.
D: Is there anything which triggers your symptom?
P: No. I can't think of anything.
D: is there anything which makes it better?
P: Not really.
P: What do you mean by that?
D: Are you experiencing it more often these days?
D: Does each episode last longer than before?
P: Not really.
D: Apart from what you told me, is there anything else you are experiencing?
P: I feel tired these days.
P: It started about the same time as dizziness.
P: I am getting more tired now.
D: Are you experiencing anything else?
P: No doctor.
1071
P: I am not sure.
D: Are you feeling light headed?
P: No
D. Are you short of breath?
P: Yes Doc. It started with dizziness. Whenever I feel dizzy' I have this shortness of breath.
D: Do you have any chest pain or chest discomfort?
P: No (ACS)
D: Did you faint by any chance?
P: No
D: Is there anything else you are experiencing?
P: No
P: No, it is happening for the first time.
P: No
D: Any pain, swelling, redness or hotness in your legs?
P: No
D: Any headaches recently?
P: No
D: By any chance, do you have any sweating?
P: No
D: Do you feel hot when everyone around you is fine?
P: No
D: Have you been losing weight? (Thyroid)
P: No
P: No
D: How about any heart disease?
P: No
D: How about high blood sugar or blood pressure?
P: No
D: Any high cholesterol or lung diseases?
P: No
D: Are you taking any medications regularly?
P: No
P: No
D: Has anyone in your family been diagnosed with any heart problems?
P: No
D: Do you smoke?
P: No
1072
P: I am an occasional / social drinker.
P: 1 pretty much eat healthy food.
P: Yes, 1 or 2 cups per day.
P: 1 am quite active.
P: No
D: Do you use any recreational drugs?
P: No
P: I work as a clerk with stage agent.
In this station,
1. Look at the monitor carefully.
2. Check the patient’s pulse for irregularly pulse.
3. Auscultate the heart for murmur.
Monitor
BP: 110/70mmHg
HR: 70 - 100 bpm (Fluctuating)
RR: 20
ECG: AF.
MANAGEMENT
Note: At 6 mins bell, examiner will ask you
E: What is wrong with this patient?
D: Based on the history and examination, patient has got AF.
E: please summarize your findings of examination:
D:
1. Patients pulse is irregularly irregular.
2. On monitor - Look at all the vitals.
- ECG shows narrow complex and absent P waves.
- Pulse rate is fluctuating.
- Blood pressure is •••..
- Temperature is ---..
- Respiratory rate is
3. On Auscultation you will hear murmur.
1073
E: what are you going to do for this patient?
D: I will do some investigations
I would like to do some blood tests (FBC, VBGs, U&E. TFT, LFT, Troponin)
I would like to order a chest x-ray to identify any lung problem that may be causing AF.
E: How will you manage this patient?
 D: I will discuss with case with my senior.
 I would like to give my patient a medication to control the rate of heartbeat as the first
line management such as beta blocker (metoprolol) or a calcium channel blocker
(verapamil or digoxin)
 If symptoms continue after heart rate has been controlled or if the rate control strategy
has not been successful, rhythm control should be considered to restore a normal heart
rhythm (A) medication such as flecainide (B) cardio version
 Since my patient has not got any risk of stroke (based on CHADVAS and HAS-BLED scoring
system) there is no need of prescribing anti-coagulant.
 I will discharge the patient after discussing with the senior.
 I will do cardiology OPD referral urgently for further investigations.
E: Which investigation?
D:
1. Holter Monitor ECG (24 - 48 hrs)
2. Echocardiograph.
Risk Factors Score CHADS2-VASc score

and Annual stroke risk
(%)
Congestive heart failure 1 Score 1 = 1.3
Hypertension 1 2=2.2
Age > 75 years 2 3=3.2
Diabetes mellitus 1 4=4
Stroke/TIA/systemic 2 5=6.7
embolism
Vascular disease 1 6=9.8
Age 65 to 74 years 1 7=9.6
Sex (female) 1 8=6.7
9=15.2
1074
SIMWOMAN – ACUTE LIMB ISCHAEMIA

A 60-year-old female presented with a history of severe pain in her right leg since this
morning.
Talk to her, take history, assess the patient, do relevant examination and discuss the
management.

P: I have severe pain in my right leg since this morning.
D: I am sorry to hear that, are you comfortable to talk?
P: Yes Dr.
D: Could you please elaborate this pain for me?
P: What do you want to know doctor.
D: where exactly is the pain?
P: It's all over my leg.
P: It just started suddenly dr.
D: What were you doing when the pain started?
P: I was at home, not doing anything.
D: Is it continuous or intermittent?
P: Yes
D: Could you please describe this pain for me?
P: It is very painful dr.
D: Does the pain go anywhere else?
P: Just my leg.
D: Does the pain start at your back and travel down your legs?
P: No Dr.
D: Does anything make the pain worse?
P: It is getting worse by itself.
P: No.
D: Could you please score the pain for me on a scale of 1-10, 1 being the lowest and 10 being
P: 6/7/8
P: No
D: Is this the first time you are experiencing this pain?
P: Yes.
D: Have you experienced any pain in your legs recently after walking a certain distance?
1075
P: No.
D: Do you have any fever or flu like symptoms?
P: No
D: Any swelling of the legs?
P: No
D: Any redness/swelling/hotness around the calf?
P: No
D: Any weakness in your legs?
P: Yes Dr. I feel my right leg is weak.
P: This morning.
P: Yes
D: Any tingling or numbness or loss of sensation in your legs?
P: No
D: Have you noticed any change in skin colour or ulcers in your legs?
P: No
D: Have you hurt your leg recently?
P: No
D: Do you have any chest pain or heart racing?
P: Dr. I had a chest pain and my heart was racing 2 weeks back, but I am fine now.
D: Did you have any more episodes like that?
P: No
P: No.
D: Any heart problems or diabetes or high blood pressure or high cholesterol?
P: No.
D: Any regular medications or OTC drugs?
P: No Dr.
D: Any allergies to any food or drugs?
P: No.
D: Any hospital admissions or surgeries recently?
P: No.
D: Any family members diagnosed with any medical conditions?
P: No.
D: Do you smoke?
P: Yes.
D: How much and how often?
P: I smoke 30 cigarettes a day from the last 30 years.
P: Yes
D: How much and how often?
1076
P: I drink occasionally.
D: Could you please tell me about your diet?
P: I am not that active.
P: Yes/No
P: I have an office job.
P: No.
P: I live alone.
D: I need to examine you, check your vitals, GPE and examine your legs
Findings:
Right Limb: Bluish discolouration
Cold compared to other leg
No dorsalis pedis pulse felt
Left Limb: Normal
D: I would like to examine your heart.

Tachycardic
SI S2 heard
Murmur: Yes/No
D: From my assessment, I suspect that you have a condition called acute limb ischemia. This
is a condition in which there is disruption in blood supply due to blockage of one of your
arteries.
P: Why do I have this condition?
D: I think this is because of your heart beating very fast. We call this condition atrial
fibrillation. We have done tracing of your heart called ECG and it shows AF.
D: Sometimes when your heart is beating too fast, there might be some blood clot
formation which may dislodge into the circulation. When these clots get stuck in smaller
arteries, they obstruct the blood flow.
P: What are you going to do next Dr.?
D: This is a serious condition, so we need to admit and treat you immediately. I am going to
arrange for some blood tests and a US scan of the arteries in your legs. I am going to refer
you to specialists called vascular surgeons. Depending upon your ultrasound scan result,
they might have to give you some medication to dissolve the clot or do a procedure to
remove the clot. Sometimes, they might have to do a bypass operation to restore the blood
1077
flow to your legs. Is it OK with you?
P: Yes
1078
SIMWOMAN – PPH
You are an F2 in O&G

Mrs. Jefferson aged 35, multigravida, had her 5th Delivery an hour ago. She is bleeding.
Nurse called you.
Assess the patient and do the initial management.
There is a nurse in the cubicle.
Introduce yourself to the nurse.

Nurse: Dr this lady had her 5th delivery and she is bleeding now.
D: May I know at what time did the patient deliver the baby?
Nurse: An hour ago. (Bleeding <24hrs after delivery Primary PPH)
D: When did the bleeding start?
Nurse: Just now.
D: How are you feeling now? (Introduce yourself to the patient)
P: I can’t breathe, (or say hmm)
Look at the vitals on Monitor:

SpO2: 91
RR: 26
BP: 90/60
Pulse: >100
D: SATS - low and RR - High. Chest Ex.
D: Could you please give the patient high flow 02 (15 Litres/Min with reservoir bag)
Nurse: Okay Dr
D: I need to examine your chest. For that purpose, I need you to be exposed. I will have a
chaperone with me to ensure your privacy and safety. May I proceed?
P: Okay
D: BP - Low and Pulse - High. CVS Ex and look for active bleeding.
(Bleeding visible from vagina).
D: I can see bleeding from her vagina, how much blood has she lost until now?
Nurse: Shows you a bucket filled with blood.
D: You seem to be bleeding heavily from your front passage. We will give you blood and
fluids though your veins. I would also like to get my senior involved.
P: Okay
D: Nurse please insert 2 Large Bore IV Cannulas (Grey 16G or Green 18G) and start her on 2L
Hartmann Solution.
We need to transfuse blood immediately. Could you please take some blood for FBC. U&E's,
Clotting profile and for Grouping and Cross matching 4 Units of Blood.
Nurse: Okay Dr
1079
D: How do you feel now?
P: Better
D: How is your breathing?
P: Better
D: Any pain?
P: No Dr
D: How has your pregnancy been?
P: Fine
D: Any problems during your pregnancy?
P: No
D: Any problems with your previous pregnancies or deliveries?
P: No
P: No
D: Any Blood Disorder?
P: No.
P: No
P: No
P: No
P: No
D: Was the placental delivery complete?
Nurse: Yes
D: Nurse, any vaginal tear during delivery ?
Nurse: Yes/No
D: Please insert a Catheter and Monitor the Vitals and Urine Output?
Nurse: Yes
D: We may need to give Oxytocin 10IUIV with the seniors help.
Nurse: Okay-
Talk to the Examiner: or Present case to Registrar:
Ex: What happened?
Ex: What have you done so far?
Ex: Causes of PPH?
Ex: What else can be done to Control bleeding?
Postpartum haemorrhage (PPH) is a rare complication where you bleed heavily from the
vagina after baby’s birth.
There are two types of PPH, depending on when the bleeding takes place:
 primary or immediate - bleeding that happens within 24 hours of birth.
1080
 secondary or delayed - bleeding that happens after the first 24 hours and up to six weeks
after the birth.
Sometimes PPH happens because your womb doesn't contract strongly enough after the
birth. It can also happen because part of the placenta has been left in your womb or you get
an infection in the lining of the womb (endometritis). It can aslo happen in bleeding
disorders or trauma during delivery.
To help prevent PPH, you will be offered an injection of oxytocin (10 1U IM) as your baby is
being born. This stimulates contractions and helps to push the placenta out.
PPH Management:
Give immediate clinical treatment:
• emptying of the bladder and
• uterine massage and
• uterotonic drugs and
• intravenous fluids and
• controlled cord traction if the placenta has not yet been delivered
First-line treatment (can repeat another bolus)

Administer a bolus of one of the following as first-line treatment for postpartum
haemorrhage (uterotonic drugs):
• oxytocin (10 IU intravenous) or
• ergometrine (0.5 mg intramuscular) or
• combined oxytocin and ergometrine (5 IU/0.5 mg intramuscular).
If haemorrhage continues:
Consider oxytocin infusion or tranexamic acid
If the haemorrhage continues:

• perform examination under anaesthetic
• ensure that the uterus is empty and repair any trauma
• consider balloon tamponade before surgical options.
Surgical options: May include uterine artery ligation, ovarian artery ligation, internal iliac
artery ligation, selective arterial embolisation, B-lynch suture, dilatation and curettage and
hysterectomy.
Post resuscitation care:

It isn't a good idea to use tampons until after your 6-week postnatal check because they
could increase your chance of getting an infection.
You may notice the bleeding is red and heavy when you breastfeed. This happens because
breastfeeding makes your womb contract. You may also feel cramps similar to period pains.
1081
The bleeding will carry on for a few weeks. It will gradually turn brownish in colour and
decrease until it finally stops.
If you're losing blood in large clots, tell your midwife. You may need some treatment.
SB AR Approach for referral or hand over or presenting a case:

Situation: Mrs Jefferson on O&G ward has massive vaginal bleeding after giving birth to a
healthy baby.
Background: She is 35 years old and had her 5'» baby delivered an hour ago. She has no
medical problems from before and she is not on any blood thinners. There are no
complications during her previous deliveries.
Assessment: Mrs Jefferson was stable since admission for her delivery but suddenly' her
vitals deteriorated to SpO2: 91, RR: 26, BP: 90/60, Pulse: >100.
I think she has PPH and she is going into circulatory shock.
Recommendation: I have resuscitated her by giving high flow 02, inserted 2 large bore IV
cannulas and started her on 2L warm crystalloids. I have sent her bloods for clotting and for
grouping and cross match 4 units of blood for transfusion. I would like you to review Mrs.
Jefferson and consider Oxytocin 10 IU IV and balloon tamponade or surgical intervention if
needed.
1082
TEACHING STATIONS
TEACHING ECG

Alexa, your nurse colleague has come to you to learn ECG.
Talk to her about ECG.
D: How can 1 help you today?

N: Doctor, I want to learn how to read this ECG. Can you help me with that?
D: Oh yes sure. Do you know anything about it previously?
N: No doctor, I don’t know anything about it.
D: Don’t worry, I’ll explain it to you. Do you know what ECG means?
N: No
D: An ECG is actually a test that records the electrical activity of the heart on a graph. It gives
information about the rate & rhythm of your heart. Thus we can assess if the heart is
working normally or not. Do you understand?
N: Yes
D: Do you know when it is done?
N: Not exactly
D: It is done when people present with symptoms of chest disease which can include
shortness of breath, chest pain, irregular or heavy heartbeats.
The electrical activity is of the heart is actually because of depolarization & repolarization
that takes place in the heart muscles.
The heart is actually composed of 4 chambers; 2 atria & 2 ventricles. Between these
chambers there are valves which control the pumping of blood through them.
The heart can’t pump blood unless an electrical stimulus occurs first. This stimulus originates
within the heart & is measured when we do an ECG. As impulses are transmitted, heart cells
undergo cycles of depolarization and repolarization. Polarized state means that no electrical
activity is taking place, which is when the cardiac cells at rest.
Our heart has pace makers. The SA(sinoatrial) node is located in the right atrium which
generates the electrical impulses which travel through the heart. It can generate impulses
60 to 100 times per minute. When initiated, the impulses follow a specific path through the
heart.
D: Now you see this graph. This is used for recording the ECG. It has a horizontal axis & a
vertical axis. The horizontal axis represents time & the vertical axis represents the voltage.
As you can see the graph has big squares as well as small squares.
ECG machines run at a standard rate of 25 mm/s. the squares on this graph paper are of
standard size. Each large square (5 mm) represents 0.2 second (s). Therefore, there are five
large squares per second, and 300 per minute. One beat occurs in 1 second so in one minute
there are 60 beats,
1083
P-waves:
P-waves represent atrial depolarisation.
• Location—precedes the QRS complex
• Amplitude—2 to 3 mm high
• Duration—0.06 to 0.12 second
• Configuration—usually rounded and upright
• Deflection—positive or upright in leads I, II, aVF, and V2 to V6; usually positive but
variable in leads III and aVL; negative or inverted in lead aVR; biphasic or variable in lead VI.
Peaked, notched, or enlarged P waves may represent atrial hypertrophy or enlargement
associated with chronic obstructive pulmonary disease, pulmonary’ emboli, valvular
disease, or heart failure.
PR interval:
It represents the time taken for electrical activity to move between the atria and ventricles.
• Location—from the beginning of the P wave to the beginning of the QRS complex
• Duration—0.12 to 0.20 second.
> Short PR intervals (less than 0.12 second) indicate that the impulse originated somewhere
other than the SA node. This variation is associated with junctional arrhythmias.
> Prolonged PR intervals (greater than 0.20 second) may represent a conduction delay
through the atria or AV junction due to digoxin toxicity or heart block—slowing related to
ischemia or conduction tissue disease.
QRS complex:
-> The QRS-complex represents depolarisation of the ventricles.
It is seen as three closely related waves on the ECG (Q,R and S wave).
-> Deep, wide Q waves may represent myocardial infarction. Tn this case, the Q-wave
amplitude is
25% of the R-wave amplitude, or the duration of the Q wave is 0.04 second or more.
-> A notched R wave may signify a bundle-branch block. A widened QRS complex (greater
than
0.12 second) may signify a ventricular conduction delay.
-> A missing QRS complex may indicate AV block or ventricular standstill.
ST segment:
-> The ST-segment starts at the end of the S-wave and finishes at the start of the T-wave.
-> The ST segment is an isoelectric line that represents the time between depolarization and
repolarization of the ventricles (i.e. contraction).
-> The point that marks the end of the QRS complex and the beginning of the ST segment is
known as the J point.
-» A change in the ST segment may indicate myocardial damage.
An ST segment may become either elevated or depressed.
T-wave:
The T-wave represents ventricular repolarisation.
It is seen as a small wave after the QRS complex.
• Location—follows the S wave
1084
• Amplitude—0.5 mm in leads 1, II, and III and up to 10 mm in the precordial leads
• Configuration—typically round and smooth
• Deflection—usually upright in leads I
> Tall, peaked, or tented T waves indicate myocardial injury or hyperkalemia.
> Inverted T waves in leads I, II, or V3 through V6 may represent myocardial ischemia.
> Heavily notched or pointed T waves in an adult may mean pericarditis.
1085
BREAST EXAM (LUMP & TEACHING)
You are F2 in GP.

Mrs. Selina Gomez aged, 44 years, presented to the GP. She is concerned because she found
a lump in her breast.
Please talk to the patient, take focused history, do relevant examination, discuss about
management with the patient and address her concerns

P: While, I was taking a shower this morning and I noticed lump in my left breast.
D: Tell me more about it? Where exactly is the lump? Any pain? Any change in shape and
size of the breast? Any discharge from the nipples? Any lumps and bumps in the body?
Any weight loss? Loss of appetite? Any SOB or tiredness?
P: No
P: No
P: No
P: No
D: Tell me about your periods? Is it regular? Any pregnancy? If yes how many kids
Examination
Explain the procedure
Being gentle
Exposure
Chaperone
Consent
I am here to examine your breast, for the purpose of examination I want you to undress
above your waist. I have a chaperone with me to ensure your privacy. I will examine you in
sitting position, in lying down and in standing position. Is that alight? May I proceed?
Inspection: While sitting:

1. Sit upright and put your hands on your thigh: Both the breast are symmetrical, nipples at
the same level. There is no redness, swelling, visible mass, bruises and scars for any
surgery.
There is no discharge, bleeding from the nipples. There is no peau d'orange.
2. Put your hands on your waist and bend forward: There is no visible mass on bending
forward.
1086
3. Put your hands on the back of your head: There is no fullness in supraclavicular and
axillary area.
4. Lift your breast with two fingers: There is no fungal infection in infra-mammary area.
5. Squeeze your nipples with two fingers: There is no discharge or bleeding from the
nipples.
Palpation: While lying down at 45.
Temperature:
Compare All four quadrants of one breast with all the quadrants with the other breast.
(Upper inner, upper outer. Lower inner. Lower outer)
Superficial Palpation:
Go anti-clockwise and check for any tenderness.
Deep palpation:
Again go anti-clockwise and find the mass and comment on the mass.
(Size, shape, surface, regular or irregular, attached to underlying structures and attached to
overlying skin or not).
I can feel the mass in the right upper quadrant of the right breast. It is around 2x2 cm. It is
round, smooth, regular margin and firm in consistency. It is attached to underlying structure
and it is not attached to overlying skin. It is non-tender.
Periaerolar Palpation:
Go anti-clockwise and Use your thumb to find out the mass
Lymph nodes: While standing check for axillary lymph nodes

From the front check for Anterior, Medial and apical
From the back check for Posterior and lateral
Then check for supra clavicular lymph nodes
Management
 From our assessment, you have lump in........area.
 Treatment for a lump depends on the cause. Most are harmless and may go away on
their own without treatment. We will refer you to the specialist for further investigation
to make sure everything is fine in your case.
 They will some tests like mammogram. (If >40, USG if <40)
 If the cause of breast lump cannot be diagnosed on Mammogram or USG. we will do a
procedure to remove a tissue sample from the lump in your breast. (FNAC)
1087
 They can also consider doing a biopsy (where a needle is inserted into the lump to
remove some cells for testing.
 These tests are often done during the same visit. You'll usually be told the results on the
same day. although biopsy results take longer - you should get them within a week.
 Follow up with your GP and if you feel worried or frightened about anything or if you
want to talk things through or have a question about breast health please come back.
1088
VIIITH CN EXAM TEACHING
You are an F2 working in neurology.

David your colleague wants to learn VIIth cranial nerve examination.
Talk to him and teach him
Build rapport with colleague

> Assess his knowledge about the nerve and give him knowledge about the function of VIII th
nerve
> Greetings with the patient (Both mannequin and patient are there)
> Parts of 8th nerve examination:
* Inspection of ear
* Palpation of ear: temperature, tenderness, Tragus test
* Otoscopy on mannequin
* Hearing test: Rinne and Weber's
* Vertical and horizontal nystagmus
* Romberg test
* Marching test
* Gait and tandem gait
1089
1090
KNEE EXAMINATION
You are F2 in Orthopaedics.

Tom came to the hospital with some knee problem. Your colleague David has taken the
history but he doesn’t know how to do knee examination.
Please teach him knee examination. Don’t let him do the examination.
D: Hello David. How are you?

David: I am good Dr.
David: We have a patient Tom. He came with knee injury. I have taken the history' but I don’t
know how to do knee examination.
D: Don’t worry I will tell you how to do knee examination. Could you please tell me history'
of the patient?
David: I just asked his name.
D: Let’s talk to our patient. Hello. Tom. how are you?
P: I am good dr.
D: Today I will be doing knee examination and I will be teaching to my colleague David as
well But don’t worry I will the one who will do examination.
P: Ok.
D: Tell me which knee is bothering you?
P: It is my right knee.
D: Have you had any surgery of the knee in
P: No
D: Are you able to stand independently ?
P: Yes Dr.
Exposure
Chaperone
Being gentle
Consent
D: Could you please stand for me?

P: Ok
Look:
Anatomical position
Symmetry of joints (shoulder / hip / ankles)
Inspection of the knees: (Deformity. Redness. Scar. Swelling. Wasting)
Gait:
D: Are you able to walk?
1091
P: Yes Dr.
Position patient on an examination couch at 45°
Feel:
Temperature
Tenderness
Bent:
Patella (2 Finger Palpation)
Joint Lines
Popliteal Fossa
Straight:
Tibial Tuberosity
Patellar Tendon
Sweep/Swipe test (Small Effusion): On medial border of patella from down to up several
times use your hands to bring effusion to the upper border, hold hand there. Then with one
hand push the effusion down on lateral aspect, you will be able to see the bulge. (Positive)
Patella tap (Large Effusions): Use hands web space between thumb and index finger to
empty the pouch and hold hand there. With one hand two fingers, gently tap over the
patella, if you feel the bounce, its positive.
Grind test (Patello Femoral Arthritis): Use left hand web space between thumb and index
finger and put beneath the upper border of patella, then tell the patient to squeeze the
muscles of thigh.
Positive if painful.
Move:
Active Movements: - flexion and extension
Special Tests -
1. Stress Test: - For Collateral Ligament (Medial and Lateral)
MCL: Make a hook of right hand, pick up ankle, bend knee at 20 - 30. left hand on lateral
aspect and push it while right towards yourself.
2. Mc Murray’s Test: - For Meniscus (Medial and Lateral)
LM: - bend the heel towards yourself and push it towards yourself then back to original
position
3. Drawers Test: - For Cruciate Ligament (Anterior and posterior):
ACL: - Ask patient if he has pain, tell him you will sit on his foot to stabilize knee and press
over it then put your thumbs on TT. Then pull it towards yourself.
Check Peripheral Pulses.
1092
I would like to finish my examination by examining one joint above and below this joint. I
will do full neurological examination.
1093
BLS ADULT
You are F2 in general medical ward

Alex is a FYI doctor who has not attended his BLS workshop. Please demonstrate and teach
him.
Please explain the steps of BLS, assess him and give him feedback.
1094
SEQUENCE Technical description
SAFETY Make sure you, the victim, and any bystanders are safe
RESPONSE Check the victim for a response
- Gently shake his shoulders and ask loudly: “Are you all right?"
- If he responds leave him in the position in which you find him,
provided there is no further danger; try to find out what is
wrong with him and get help if needed; reassess him regularly
AIRWAY Open the airway
- Turn the victim onto his back
- Place your hand on his forehead and gently tilt his head back:
with your fingertips under the point of the victim's chin, lift the
chin to open the airway
BREATHING Look, listen and feel for normal breathing for no more than 10
seconds
In the first few minutes after cardiac arrest, a victim may be barely
breathing, or taking infrequent, slow and noisy gasps. Do not
confuse this with normal breathing. If you have any doubt
whether breathing is normal, act as if it is they are not breathing
normally and prepare to start CPR
DIAL 999 Call an ambulance (999)
- Ask a helper to call if possible otherwise call them yourself
- Stay with the victim when making the call if possible
- Activate the speaker function on the phone to aid
communication
- with the ambulance service
SEND FOR AED Send someone to get an AED if available
If you are on your own, do not leave the victim, start CPR
CIRCULATION Start chest compressions
- Kneel by the side of the victim
- Place the heel of one hand in the center of the victim’ s chest:
(which is the lower half of the victim ’ s breastbone (sternum)
- Place the heel of your other hand on top of the first hand
- Interlock the fingers of your hands and ensure that pressure is
not applied over the victim's ribs
- Keep your arms straight
- Do not apply any pressure over the upper abdomen or the
bottom end of the bony sternum (breastbone)
- Position your shoulders vertically above the victim's chest and
press down on the sternum to a depth of 5-6 cm
- After each compression, release all the pressure on the chest
without losing contact between your hands and the sternum:
1095
- Repeat at a rate of 100 -120 min-
GIVE RESCUE After 30 compressions open the airway again using head tilt and
BREATHS chin lift and give 2 rescue breaths
- Pinch the soft part of the nose closed, using the index finger
and thumb of your hand on the forehead
- Allow the mouth to open, but maintain chin lift
- Take a normal breath and place your lips around his mouth,
making sure that you have a good seal
- Blow steadily into the mouth while watching for the chest to
rise, taking about 1 second as in normal breathing; this is an
effective rescue breath
- Maintaining head tilt and chin lift, take your mouth away from
the victim and watch for the chest to fall as air comes out
- Take another normal breath and blow into the victim’ s mouth
once more to achieve a total of two effective rescue breaths.
Do not interrupt compressions by more than 10 seconds to
deliver two breaths. Then return your hands without delay to
the correct position on the sternum and give a further 30 chest
compressions
- Continue with chest compressions and rescue breaths in a ratio
of 30:2
- If you are untrained or unable to do rescue breaths, give chest
compression only CPR (i.e. continuous compressions at a rate
of at least 100-120 min-1)
1096
BLS PAEDIATRICS
You are an F2 working in Pediatrics.

Alex is a final year medical student. He wants to learn how to do Pediatric basic life support.
Teach Alex how to perform BLS on a 6 year old child.
1. Ensure the area is safe

Check for hazards, such as electrical equipment or traffic.
2. Check your child's responsiveness
Gently stimulate your child and ask loudly: "Are you all right?"
3a. If your child responds by answering or moving
 Leave them in the position they were found in (provided they're not in danger).
 Check their condition and get help if needed.
 Reassess the situation regularly.
3b. If your child doesn't respond
 Shout for help.
 Carefully turn the child on their back.
 Open your child's airway by tilting the head and lifting the chin.
 To do this, place your hand on their forehead and gently tilt their head back.
 At the same time, with your fingertips under the point of your child's chin, lift the
chin. Don't push on the soft tissues under the chin as this may block the airway.
4. Check their breathing
Keeping the airway open, look, listen and feel for normal breathing by putting your face
close to your child's face and looking along their chest.
 Look for chest movements.
 Listen at the child's nose and mouth for breathing sounds.
 Feel for air movement on your cheek.
Look, listen and feel for no more than 10 seconds before deciding that they're not breathing.
Gasping breaths should not be considered to be normal breathing.
5a. If your child is breathing normally
 Turn them on their side.
 Check for continued breathing.
 Send or go for help - do not leave your child unless absolutely necessary.
5b. If your child isn't breathing or is breathing infrequently and irregularly
 Carefully remove any obvious obstruction in the mouth.
 Give 5 initial rescue breaths (mouth-to-mouth resuscitation) - see below.
 While doing this, note any gag or cough response - this is a sign of life.
 Tilt the head and lift the chin.
 Close the soft part of their nose using the index finger and thumb of the hand
that's on their forehead.
 Open their mouth a little, but keep the chin pointing upwards.
1097
 Take a breath, then place your lips around their mouth, making sure it's sealed.
 Blow a breath steadily into their mouth over about 1 second, watching for the
chest to rise.
 Keeping their head tilted and chin lifted, take your mouth away and watch for the
chest to fall as air comes out.
 Take another breath and repeat this sequence 4 more times. Check that your
child's chest rises and falls in the same way as if they were breathing normally.
6. Assess the circulation (signs of life)
Look for signs of life. These include any movement, coughing, or normal breathing -not
abnormal gasps or infrequent, irregular breaths.
Signs of life present
 If there are definite signs of life:
 Continue rescue breathing until your child begins to breathe normally for
themselves.
 Turn the child on their side into the recovery position and send for help.
 Continue to check for normal breathing and provide further rescue breaths if
necessary.
No signs of life present
 If there are no signs of life:
 Start chest compressions immediately.
 Combine chest compressions with rescue breaths, providing 2 breaths after every
30 compressions.
7. Chest compressions: general guidance
 To avoid compressing the stomach, find the point where the lowest ribs join in the
middle, and then 1 finger's width above that. Compress the breastbone.
 Push down 5cm , which is approximately one-third of the chest diameter.
 Release the pressure, then rapidly repeat at a rate of about 100-120 compressions
a minute.
 After 15 compressions, tilt the head, lift the chin, and give 2 effective breaths.
 Continue compressions and breaths in a ratio of 2 breaths for every 15
compressions.
Although the rate of compressions will be 100-120 a minute, the actual number delivered
will be fewer because of the pauses to give breaths.
Technique
 Place the heel of 1 hand over the lower third of the breastbone, as described
above.
 Lift the fingers to ensure pressure is not applied over the ribs.
 Position yourself vertically above the chest and, with your arm straight,
compress the breastbone so you push it down 5cm, which is approximately one
third of the chest diameter. The quality (depth) of chest compressions is very
important.
1098
 If nobody responded to your shout for help at the beginning and you're alone,
continue resuscitation for about 1 minute before trying to get help – for
example, by dialling 999 on a mobile phone.
8. Continue resuscitation until
 Your child shows signs of life - normal breathing, coughing, movement of arms or legs.
 Further qualified help arrives.
 You become exhausted.
1099
CERVICAL SMEAR
You are FY2 in GP.

Mrs. Michelle Aylsbury, aged 40, presented to the clinic for her routine cervical screening
test.
Talk to the patient; perform the pap smear, and assess the patient concern.
D: What brings you to the hospital?

P: I came here for my routine Pap smear test.
P: No
D: When was you LMP?
P: 2 weeks ago.
D: Is your periods regular?
P: Yes
D: Any discharge from your vagina?
P: No
P: No
D: Any problem with the urine or bowel?
P: No
P: No
P: No
P: It's alright.
P: No
P: No
P: No
D: Any lumps and bumps in any part of the body?
P: No
P: Yes, I have one daughter.
D: Have you used any contraception in the past?
P: Yes, my partner is using condom.
D: Have you had pap smear in the past?
P: Yes
1100
P: No
P: No
P: No
P: No
P: No
D: Do you smoke?
P: Yes/No
P: Yes/No
P: Yes/No.
Why we do PS examination, speculum is the instrument most commonly used to inspect the
vagina
- the purpose of the examination is to look at the size and shape of external and internal
reproductive organs.
The external examination will involve:

- Examination of anatomy.
- Looking for any lesions, ulcers, discharge or other signs of disease.
The internal examination will involve:
- Palpation of the vulva and vaginal walls.
- Examination of the cervix.
- Assessing the size and position of the uterus.
- Palpation of any adnexal tenderness.
- Location of the cervix using the speculum.
- Performing any appropriate swabs or smears using the speculum.
Preparation and Introduction:

Introduce yourself to patient (Greet, Introduce. Identify and Explain Procedure)
Explain the purpose of the examination.
Explain that it will involve undressing fully from the lower half and examination may be a bit
uncomfortable but should not be painful.
Gain consent and offer a chaperone.
Explain to the patient the position they should be lying in supine, with knees bent, heels
brought up towards bottom, and then letting legs fall to either side of the bed. Let the
patient undress in privacy.
1101
Tell the patient to empty the bladder”
Prepare trolley and equipment: flexible light source, gloves, lubricating jelly and speculum
Allow the patient to become comfortable before starting.
Contraindication of Pap smear:

• Pregnancy
• Active menstruation
• Use of spermicidal gel
• Recent sexual intercourse
• Active vaginal bleeding
INSPECTION:
1. Inspect the external genitalia for hair distribution, swelling, scarring, signs of infection for
example warts or ulcers.
2. Ask the patient to cough looking for signs of prolapse.
SPECULUM EXAMINATION and Pap smear:

 Think about the size of the speculum needed and use lubrication.
 Explain to the patient what you are going to do before proceeding.
 Spread the labia from below using the thumb and index finger.
 Gently insert the speculum and rotate the speculum to a horizontal position and gently
open the blades until the cervix is in view. Secure the speculum by turning the thumb
nut.
 Visualize the cervix and vaginal walls for any abnormalities, such as ectopy, cysts or
polyps.
 Comment on whether the cervical os is open or closed? (multiparous or nulliparous) and
if it is downward and backward.
 Perform any necessary tests, obtaining samples for culture and cytology (below). A small
soft brush will be used to gently collect some cells from the surface of your cervix.
o Insert the brush through the speculum avoiding touching the sides of the speculum
with the brush.
o Rotate the brush 5 times 360 degrees in clockwise direction
o Remove the brush and avoiding the sides of the speculum.
o Sample collection
 Dip the brush 10 times in a liquid-based cytology container (Thin Prep);
 Deposit the tip of the brush into liquid-based cytology container (Sure Path)
 Withdraw the speculum slightly to clear the cervix and gently loosen the speculum to
close the blades.
 Continue to withdraw whilst rotating the speculum.
 Tell the patient that you have finished, offer wipes to the patient and tell her to dress up.
1102
 The cell sample is then sent off to a laboratory for analysis and you should receive the
result within 2 weeks.
All women who are registered with a GP are invited for cervical screening:
• aged 25 to 49 - every 3 years
• aged 50 to 64 - every 5 years
• over 65 - only women who have recently had abnormal tests
1. Some women find the procedure a bit uncomfortable or embarrassing, but for most
women it isn't painful.
2. If you find the test painful, tell the doctor or nurse as they may be able to reduce your
discomfort.
3. Try to relax as much as possible as being tense makes the exam more difficult to carry
out. Taking slow, deep breaths might help. You can also bring someone along to the
appointment with you if you want support.
1103
EPI PEN TEACHING

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)
D: Hello. My name is Dr. ….I am one of the junior doctors here in the GP Surgery. Is it Becca
Winslow?
P: Yes, I am Becca. Jason’s mother.
D: It’s nice to meet you, Becca. Could you confirm Jason’s age for me please?
P: He’s eight.
D: How can we help you today?
P: 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.
D: 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?
P: Sure.
D: When was he prescribed the EpiPen?
P: When he was four.
D: What happened at that time?
P: He had difficulty breathing and was taken to hospital after I gave him some peanut butter.
D: Have you had to use the EpiPen in the last four years?
P: 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 what he ate, there must have been peanuts in the cake.
D: 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?
P: 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.
D: How is Jason doing now?
P: He is fine. He is at school.
D: 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.
D: Does Jason have any other allergies?
P: No
1104
D: Has he been diagnosed with any medical conditions? Asthma, for instance?
P: No
D: Does he take any medications?
P: No
D: What was his birth like?
P: It was fine
D: Is he up-to-date with his jabs?
P: Yes
D: Who takes care of him usually?
P: Just me.
D: 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 bigger kids and adults.
(0.15 mg epinephrine in children less than 25 kg and 0.3 mg in adults and children more than
25kg)
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 like that?
P: 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
1105
So, if Jason has these symptoms or if you know he has ingested peanuts- use the EpiPen on
him immediately, okay?
D: 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 remain calm.
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.
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. Now take the blue safety cap off and hold it with the orange tip about 10 cm 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 while injecting.
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.
With one swift jab, bring the pen down at a 90-degree angle on his thigh until you hear a
click. Hold it in place and count to three- not too fast- count- One elephant, two elephant,
three elephant.
1106
Then, remove the pen and call 999 immediately and say- ANAPHYLAXIS or SEVERE ALLERGY.
They will bring Jason to the hospital for further treatment.
Could you repeat for me what you will say when you call 999?
P: 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?
P: 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?
P: Do I need the massage the site of injection?

D: There is no need to massage the area. As long as you hear the click it means the medicine
has been injected.
P: Does he need to go to the hospital if he is feeing better?
D: 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?
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 it reacts
• a blood test – a sample of your blood is taken to test its reaction to a suspected
allergen.
Avoid triggers
1107
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 specific triggers.
Food
You can reduce the chances of being exposed to a food allergen by:
• checking food labels and ingredients
• letting staff at a restaurant know what you're allergic to so it's not included in your
meal
• remembering some types of food may contain small traces of potential allergens – for
example, some sauces contain wheat and peanut.
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 at them
• using an insect repellent if you spend time outdoors, particularly in the summer
• 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 antibiotics known as
macrolides
• non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and aspirin – you
can normally safely take paracetamol; read the ingredients of things like colds medicines
carefully to make sure they do not contain NSAIDs
• one type of general anaesthetic – others are available, or it may be possible to
perform surgery using a local anaesthetic or an epidural injection.
1108
SUBCUTANEOUS INJECTION TEACHING
You are FY2 in skills lab.

Lorrie 3rd year medical student is here.
Teach him how to administer subcutaneous injection. Don’t ask him to perform the
procedure.
Teaching:
A subcutaneous injection is given into the subcutaneous fat under the skin. The skin is made
up of different layers. Underneath the epidermis and dermis, which contain sweat glands
and hair follicles, is a layer of fat. This is the area into which subcutaneous injections are
given.
Getting ready to give the subcutaneous injection

You will need
• Yellow/sharps bin
• Cleaning wipe
• Medicine bottle
• Syringe package
• Cotton wool or gauze
• Site rotation chart
What to do
1. Wash your hands
2. Wipe the top of the medicine bottle with the cleaning wipe and leave to dry
3. Choose the injection site for this dose
4. Open the syringe package and put on a clean surface
5. Insert the needle into the top of the bottle at an angle of 90°
6. Pull back the plunger and draw up slightly more than the prescribed dosage
7. Remove the needle from the bottle
Note: If you are using an auto injector or pen device, load it according to the instructions in
the package and how you have been taught.
Giving the subcutaneous injection - What to do
8. Holding the needle upwards, tap the syringe gently to move any air bubbles towards
the needle
9. Push the plunger gently to remove the air bubble and squirt a small amount of the
medicine into the air
10. Lift the skin in the chosen injection area between your thumb and index finger
11. Holding the needle at a 90° or 45° angle ,insert the needle into the skin fold
12. Continue to hold the skin and push the syringe plunger to inject the medicine while
counting to 10 slowly. Do not aspirate or rub the skin afterwards.
13. Remove the needle from the skin and let go of the skin fold
1109
14. Put a piece of cotton wool or gauze over the injection site for a few seconds
15. Throw the syringe away in a ‘sharps’ bin.
16. Mark the injection site on your site rotation chart
17. Please document the details of procedure and medication administered.
Sites of subcutaneous injection
o Abdomen-2 inches away from umbilicus
o Upper outer aspect of arm
o Upper outer aspect of upper thigh
o Upper buttock
o Do not use the site which is inflamed, scarred or bruised.
o If multiple injections needed, use different sites for each injection.
Post injection care
It is normal for the injection site to be sore for one or two days. Advise that if they
experience worsening pain after 48 hours, they should seek medical help.
Some rare complications of subcutaneous injection are hematoma formation, persistent
nodules, local irritation and rarely anaphylaxis
3a. Lift the skin between thumb and two fingers with one hand, pulling the skin and fat
away from the underlying muscle
3b: Incorrect technique
1110
URINE DIPSTICK – TEACHING
A urine dipstick test is a test of urine, using a special strip of paper that is dipped into a
sample of urine. The result is available almost immediately. It is sometimes called a rapid
urine test.
Why is a urine dipstick test done?

A urine dipstick test is done for lots of different reasons, such as:
• A routine check when you're pregnant.
• To screen for diabetes.
• If you think you might have a urine infection.
• If you have tummy (abdominal) pain.
• If you have back pain.
• If you think you've seen blood in your urine (haematuria).
• Some people with diabetes will do their own urine dipstick testing.
How is it done ?
1. Wash your hands and don PPE.
2. Confirm the patient’s details on the sample bottle are correct including their name,
date of birth and hospital number.
3. Inspect the colour of the urine:
• Straw-coloured urine: this is the normal colour of urine in a healthy, hydrated
individual.
• Dark concentrated urine: suggests the individual is dehydrated.
• Red urine: can be caused by the presence of blood in the urine (macroscopic
haematuria), porphyria, drugs such as rifampicin and certain foods (e.g. beetroot).
• Brown urine: can be caused by the presence of bile pigments (e.g. jaundice) or
myoglobin (e.g. rhabdomyolysis) in the urine. Some antimalarial medication, such as
chloroquine, also cause brown discolouration of the urine.
4. Inspect the clarity of the urine:
• Clear urine: this is normal for healthy, well- hydrated individuals.
• Cloudy urine with sediment: may indicate urinary tract infection, renal stones, high
protein content (e.g. nephrotic syndrome).
• Frothy urine: typically associated with significant proteinuria (e.g. nephrotic
syndrome).
5. Consider opening the sample pot’s cap and assessing the urine’s odour:
• Offensive odour: suggestive of urinary tract infection.
• Sweet odour: suggestive of glycosuria (e.g. diabetes mellitus).
• Assessment of urinary odour is rarely performed in practice.
• Wash your hands
Dipstick testing
1111
Procedure
1. Check the expiry date of the urinalysis dipstick.
2. Remove a dipstick from the container whilst avoiding touching the reagent squares.
3. Replace the container lid to prevent oxidisation of the remaining dipsticks.
4. Insert the dipstick into the urine sample, ensuring all reagent squares are fully
immersed.
5. Remove the dipstick immediately and tap off any residual urine using the edge of the
container, making sure to hold the dipstick horizontally to avoid cross- contamination of the
reagent squares.
6. Lay the dipstick flat on a paper towel.
7. Use the urinalysis guide on the side of the testing strip container to interpret the
findings. Different reagent squares on the strip need to be interpreted at different times, so
ensure you interpret the correct test at the appropriate time interval (e.g. 60 seconds for
protein).
8. Once you have interpreted all of the tests, discard the strip into the clinical waste bin
along with your PPE.
9. Wash your hands
Interpretation
The following tests are ordered by the time at which the reagent square should be
interpreted.
Glucose
Glucose is a water-soluble sugar molecule and its presence in the urine is known as
glycosuria:
• Time at which the reagent square should be interpreted: 30 seconds
• The absence of glucose in the urine is normal.
• Causes of glycosuria include diabetes mellitus, renal tubular disease and some
diabetic medications (e.g. SGLT2 inhibitors).
Bilirubin
Conjugated bilirubin is a water-soluble yellow pigment:
• The absence of bilirubin in the urine is normal.
• The presence of bilirubin in the urine suggests increased serum levels of conjugated
bilirubin, which can occur in conditions such as biliary obstruction (e.g. pancreatic cancer).
Ketones
Ketones are a breakdown product of fatty acid metabolism:
• The absence of ketones in the urine is normal.
1112
• The presence of ketones in the urine suggests increased fatty acid metabolism, which
occurs during starvation and in conditions such as diabetic ketoacidosis.
Specific gravity
The specific gravity reagent square indicates the amount of solute dissolved in the urine:
• Normal range: 1.002 – 1.035 mOsm/kg
• Causes of low specific gravity include conditions that result in the production of dilute
urine such as diabetes insipidus and acute tubular necrosis.
• Causes of raised specific gravity include dehydration, glycosuria (e.g. diabetes
mellitus) and proteinuria (e.g. nephrotic syndrome).
pH
The pH reagent square represents the acidity of the urine:
• Normal range: 4.5 – 8
• Causes of low urinary pH include starvation, diabetic ketoacidosis and other
conditions that cause metabolic acidosis (e.g. sepsis).
• Causes of raised urinary pH include urinary tract infection, conditions that cause
metabolic alkalosis (e.g. vomiting) and medications (e.g. diuretics).
Blood
The blood reagent square indicates the amount of red blood cells, haemoglobin and
myoglobin in the urine:
• The absence of red blood cells, haemoglobin and myoglobin in the urine is normal.
• The presence of red blood cells, haemoglobin and myoglobin in the urine may indicate
urinary tract infection, renal stones, injury to the urinary tract, myoglobinuria
(rhabdomyolysis), nephritic syndrome and malignancy of the urinary tract.
Protein
The protein reagent square indicates the level of protein present in the urine (proteinuria):
• The absence of protein in the urine is normal.
• Causes of proteinuria include nephrotic syndrome and chronic kidney disease.
Nitrites
Nitrites are a breakdown product of gram-negative organisms such as E.Coli:
• The absence of nitrites in the urine is normal.
• The presence of nitrites in the urine is suggestive of urinary tract infection.
1113
Urobilinogen
Urobilinogen is a byproduct of bilirubin breakdown in the intestine and it is normally
excreted in the urine:
• Normal range: 0.2 – 1.0 mg/dL
• The presence of increased levels of urobilinogen in the urine can be caused by
haemolysis (e.g. haemolytic anaemia, malaria).
• Low levels of urobilinogen can be caused by biliary obstruction.
Leukocyte esterase
Leukocyte esterase is an enzyme produced by neutrophils and therefore, when positive, it
indicates the presence of white cells in the urine:
• Time at which the reagent square should be interpreted: 2 minutes
• A negative leukocyte esterase test is normal.
• Causes of a positive leukocyte esterase include urinary tract infection and any
condition that could result in haematuria.
To complete the procedure…

I. Summarise your findings.
II. Document the urinalysis results.
III. Suggest further investigations based on urinalysis results.
Further investigations
• The presence of leukocytes and nitrites in the urine indicates a likely urinary tract
infection. Appropriate further investigation would include microscopy and culture to
identify pathogenic organisms.
• The presence of glucose in the urine (glycosuria) is suggestive of diabetes mellitus and
would warrant further investigation with capillary blood glucose and serum HbA1C.
• The presence of glucose and ketones in the urine, in addition to low urinary pH, is
suggestive of diabetic ketoacidosis and would warrant urgent admission to hospital for
further investigations (e.g. serum blood glucose, venous blood gas) and treatment (e.g.
insulin, glucose and potassium infusion).
• Raised specific gravity and proteinuria is suggestive of nephrotic syndrome. Further
investigations would include U&Es to assess renal function as well as microscopy and culture
to rule out urinary tract infection.
• The presence of blood in the urine would warrant further investigation to narrow the
differential diagnosis. Possible further investigations could include microscopy and culture
(UTI), full blood count, U&Es (glomerulonephritis), CT KUB (renal calculi) and cystoscopy
(bladder malignancy).
1114
PROCEDURES
BLOOD SAMPLING (PCM)
You are F2 in A&E.

Mrs. Billie Brown, aged 25, has taken some paracetamol tablets.
Do venepuncture for necessary investigations, talk to patient, take relevant history, discuss
about further management with the patient and address her concerns.

P: I took some paracetamol tablets.
D: How many tablets?
P: 40 tablets doctor.
D: May I know when did you take?
P: 6 hours ago
BLOOD SAMPLING
1. Explain (like you are talking to a patient)
2. Sharp Scratch
3. Gentle I Quick
4. Repeat
5. Consent
6. Arm Preference
7. Arm Soreness
8. Vein Preference
9. Exposure
I am here to take blood sample from one of the vein of your forearm with the help of a
needle. It will feel like a sharp scratch. I will be as gentle and as quick as possible. I may have
to repeat the procedure if I fail in my first attempt. May I proceed? Do you have any arm
preference, vein preference or arm soreness? Please could you roll up your sleeves.
D: Where is my clean area?

Ex: Shows kidney tray
- Pick up things you need in a kidney tray:
1. Vacutainer
2. Vacutainer Needle
3. Vacutainer Needle Holder
4. Tourniquet - Buckle / Tie
5. Gauze
6. Alcohol swab
1115
“I assume I am gloved”
1. Assembling: fix in holder and put it in the kidney tray.

2. Tear Alcohol Swab, put in kidney tray.
3. Apply tourniquet loosely.
4. Palpate the vein.
5. Tighten tourniquet
6. Palpate again
7. Clean with the swab
8. Warn about sharp scratch
9. Attach Vacutaincr
10.Release tourniquet right away
11.Remove it, shake it (Vacutainer)
12.Remove needle, dispose to sharps.
13.Keep it pressed.
D: How are you feeling?

Label sample and Send it to lab.
Colour Lab
Purple - FBC, ESR, HBA1C
Pink - Grouping andX matching
Blue - Coagulation screening, INR, d- dimer
Yellow - U & E, CRP, LFT, TFT, lipid profile, drug level
Grey - glucose, lactate
Red - toxicology, drug level, bacterial / viral sero
Pick yellow or red.
D: After getting the blood. I would like send the sample for investigations including FBC, LFT,
Bleeding and clotting profile and plasma paracetamol level concentration.
D: Did you take them in one go?

D: Did you take anything else with it?
D: Any alcohol or drags?
D: Did you vomit?
D: Any tummy pain?
D: Have you been diagnosed with any medical condition in the past? Any liver disease/
Blood disorders?
1116
MANAGEMENT:
- Explain the graph properly to the patient.
- The level of PCM is 81 in your blood and you told you took the tablets 6 hours ago.
- As you can sec it in the graph horizontal line tells us the time and vertical line shows us
the level of paracetamol in your blood. If you draw an imaginary line it comes above the
treatment line.
- It means you have to stay in the hospital and we have to give you the medications
through your blood vessels.
- If it is left untreated, it can be dangerous for your liver and kidneys.
- We will give you a medication called N-Acetylcysteine (NAC) through your blood vessels.
- We have to give you 3 drips of this medication and usually it takes 21 hours.
- After that we will reassess you and repeat your blood test and if everything is fine we will
refer you to one of my colleagues (Psychiatrist). He will talk to you and will help to
relieve your stress.
S/E of NAC:
This is a safe medication but it can cause nausea, vomiting, diarrhoea or constipation, rash,
fever, headache, drowsiness, low blood pressure, and liver problems. Don’t worry we will
manage accordingly.
1117
IV CANNULATION

Mr. Peter Smith 27, has been diagnosed with ruptured appendix. Patient underwent a
surgery a few hours ago for his burst appendix. Patient IV cannula is blocked now.
Please talk to the patient, change the IV cannula. After 6 min examiner will ask you some
questions

P: Doctor I am in pain. I had an operation for my appendix, give me some pain killer.
SOCRATES (brief)
D: Anything else?
P: Vomiting.
D: As you are vomiting so we can't give you painkiller through your mouth. We have to give
you medication through your blood vessels, but your cannula is blocked. So please let me
change your cannula first so that I can give you medication through blood vessels.
IV CANNULATION
1. explain the procedure
2. sharp scratch
3. gentle I quick
4. repeat
5. consent
6. arm preference
7. arm soreness
8. vein preference
9. exposure
I am here to insert thin plastic tube into one of the veins of your forearm with the help of a
needle. It will feel like a sharp scratch, I will try to be as gentle and as quick as possible. I
may have to repeat the procedure if I fail in my first attempt. May I proceed. Do you have
any arm preference, vein preference or arm soreness? Please roll up your sleeves.
Ex – where is my clean area
1. Cannula: use non-touching technique and open them into the clean area I kidney tray.
2. Tegaderm
3. Torniquet
4. Alcohol swab
5. Gauze
6. N/S
I assumed to be gloved
1118
1. Assembly: Take 2 stickers of tegaderm and stick it to kidney tray. Stick date sticker as well
2. Tear off alcohol swab.
3. Palpate
4. Tighten tourniquet
5. Palpate again
6. Clean with swab
7. Warn sharp scratches
8. Insert cannula
9. Open the Torniquet
10. Put the gauze piece beneath the cannula.
11. Remove the needle and throw in the Sharps bin.
12. Put the white stopper on the cannula.
13. Flush the cannula.
14. Put the Tegaderm on.
D: Any allergies?
Management is with the examiner:

Ask him which pain killers my patient has already received.
Also tell me the vitals of my patient.
Chart: 5 mg IV Morphine every 4 hours.
Last dose received 1 hour ago.
RR: 12-20/min. Temperature: 38, PR: 94, 02 sat: 92% to 94%, BP: 120/80
EX: what are you going to do for the patient?

D: I will give my patient oxygen and will take some investigations like electrolytes.
I will give my patient 1 gm paracetamol and 10 mg metoclopramide.
As my patient is vomiting so I will give IV fluids as well.
If pt. is still in pain I will tell him that I have given you the pain killer and it will take some
time
to show' its effect.
If pt. is still in pain I will check the vitals of my patient and after discussion with the seniors I
will give another dose 5mg of morphine.
If patient hasn’t received anything tell the examiner, I would like to give my patient
morphine in titration,
Paracetamol 1 gm, metoclopramide 10 mg.
1119
CATHETERIZATION
You are F2 in A&E.

George Jefferson aged 45 year comes to you complaining of lower abdominal discomfort. No
one has seen the patient earlier than you.
Please talk to patient, take relevant history, assess the patient, do emergency management
and discuss about further management with the patient. Do relevant procedure if needed.

P: I cannot pass urine.
D: Since when?
P: From last 24 hours.
D: Anything else?
P: I have tummy pain (Point towards supra-pubic area)
SOCRATES (brief)
I would like to check your vitals, GPE and tummy Examination.

EX: Abdomen is distended and bladder is palpable. There is dullness over percussion.
Rule Out Contraindications:
D: Any Recent Instrumentation in your private area?
Any trauma in your private part?
Any blood at the tip of penis?
From your assessment, you have urinary retei Let me do a procedure to relieve your pain
and retention of urine.
1. Explain the procedure:
2. Being gentle
3. Exposure
4. Chaperone
5. Position
6. Consent
I am going to insert a thin flexible tube in your bladder through your penis in order to relieve
your retention. I will be as gentle and as quick as possible. For the purpose of examination, I
want you to undress below your waist and I have a chaperone with me to ensure your
privacy. I want you to lie down on your back with your legs slightly apart.
May I proceed.
Your trolley:
1. Pack of gauze pieces
2. Forceps
1120
3. Distilled water for balloon inflation
4. Anaesthetic gel (also has lubricant)
5. Drape
6. Urine bag
7. 2-3 pots (Antiseptic Solution, Normal Saline. Lubricating Gel)
8. Catheter.
D: where is my sterile area?

Ex: even thing here is sterile
1. Open catheter with non-touching technique.

2. I assume to be double gloved.
3. Assembly: rip of tip of catheter and put it in a tray.
4. Put the drape.
5. Clean the glans by 3 gauze pieces using forceps to hold and hand to fold it and hold shaft
with a gauze in left hand.
6. Numb by inserting syringe in penis and tell patient about cold sensation.
7. Ideally, I would wait for few minutes.
8. Insert catheter (Don’t touch the catheter)
9. Inflate bubble.
10.Insert bag in another opening.
“Ideally I would write the name and date of patient on the bag hung by the side of the
patient’s bed” .
While catheterising the patient, please don't let catheter come out of the kidney tray.
YOU HAVE TO RULE OUT UTI, BPH AND CANCER. If you can manage take history while you
are putting catheter
Do you have anything else with the pain?
Any fever or flu like symptoms? Frequency? Nocturia? Urgency i ribbling? Poor emptying?
Poor stream? Hematuria? Hesitency?
Any weight loss? Loss of appetite? Tiredness or breathlessness?
P: No
P: No
P: No
After catheterisation, I would like to check blood pressure, amount of urine output and
examine your Prostate.
1121
Ex: Prostate is enlarged in both lobes and their surface is smooth.
 From our assessment, we are suspecting you have a condition called benign prostatic
hyperplasia or big prostate.
 Prostate is a walnut-sized gland that is located under your bladder. The tube connecting
your bladder to your penis goes through this gland. When it gets enlarged it can cause
retention of the urine. We will do some blood tests to check anaemia and kidney
function and urine test to see if there is any bug in your urine. We may give you some
antibiotics if we found any bug there. (Allergy)
 We will do some special blood test to check the amount of substance produced from
your prostate gland. (PSA)
 We will give you a medication to relax the neck of bladder and the tube connecting your
bladder to your penis and we may give you some IV fluids if needed.
 We will observe you to the observation unit and If everything goes smoothly, you are
able to go home.
 We will provide you with some extra bag and we will tell you how to change it.
 We will arrange an outpatient clinic appointment in next two weeks and we will give trial
without catheter. We will do USG to check If you need catheter or not.
 If you are unable to pass urine with catheter or you develop some fever, shivering please
dial 999 and come back to us.
ABG (GEEKY MEDICS)
BLOOD CULTURE (GEEKY MEDICS)
1122
MANNEQUINS (ANKUR VIDEOS & GEEKY MEDICS)
FOOT EXAMINATION (DIABETIC, ALCOHOLIC)
CEREBELLAR EXAM
EXAM FOR MENINGITIS
CRANIAL NERVE EXAMINATION
PERIPHERAL FIELD OF VISION
FUNDOSCOPY
THYROID EXAMINATION
ACOUSTIC NEUROMA
CN VIII EXAM
OTOSCOPY (ADULT & CHILD)
ABDOMINAL EXAM
NECK EXAM
UPPER LIMB EXAM
BREAST EXAM
ANTENATAL ASSESSMENT
HIP EXAMINATION
DRE FOR PROSTATE EXAM
1123

Specialty Wise Stations For Plab2

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Specialty Wise Stations For Plab2

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SPECIALTY WISE STATIONS

IPS marks given by simulator (4 marks)

You are an F2 in A&E

D: What brought you to the hospital?

I would like to check your vitals and examine your chest.

You are an FY2 in A&E.

D: How can I help you?

Examination: Vitals. Sats: 90% PR 110 Temp: 37. BP: 120/80

Investigation: FBC, Urine (Pregnancy), ABG, D-Dimer, CXR, ECG, CTPA

Prevention (Compression Stockings, Stop HRT/Pills, Anticoagulation administered to

You are an FY2 in A&E.

D: How can I help you?

Examination: Examiner said it is normal. BP 120/80, Sats 99%

Risk factors: Prolonged immobilisation, pregnancy, pills, previous PE/DVT, malignancy,

Clinical Feature Points

You are an F2 in A&E

D: What brought you to the hospital?

From my assessment, your chest pain is likely to be musculoskeletal pain or we call it

D: How can I help you?

You are an F2 in A&E

D: What brought you to the hospital?

I would like to check your vitals and examine your chest.

 From my assessment, your chest pain seems to be pericarditis.

You are an FY2 in GP practice.

D: What brings you to the hospital today?

Clinical Feature Points

If WELL’S Score 4 -» CTPA/VQ scan

You are FY2 in medicine.

D: What brought you to the hospital?

You are FY2 in GP clinic.

D: What brought you to the hospital?

Mr. James Anderson 55 years presented in GP surgery have some concerns .

You are F2 in cardio.

D: How may I help you?

You are F2 in respiratory department.

D: What brought you to the hospital?

I would like to check your vitals and examine your chest.

P: What's happening doctor?

Differentials for cough for > 3 weeks:

Differential for cough Acute < 3 weeks

You are F2 in medicine.

D: What bought you to the hospital?

I would like to check your vitals and examine your chest.

You are FY2 in Medicine.

D: Mr…Do you have any idea what may be happening to you?

You are F2 in A & E

D: What brought you to the hospital?

I would like to check your vitals and examine your chest.

P: What’s happening doctor?

From my assessment, you seem to have a chest infection.

D: We will keep you in the hospital.

Please take plenty of rest and drink plenty of fluids.

Patients are stratified for risk of death as follows:

You are F2 in A&E

D: What brought you to the hospital?

I would like to check your vitals and examine your chest.

Tuberculosis (TB) is caused by atype of bacterium called Mycobacterium tuberculosis.

D: You'll be prescribed at least a six-month course of a combination of antibiotics if you're

Preventing the spread of infection

You are F2 in GP.

D: What brought you to the hospital?

I would like to check your vitals and examine your chest.