New Volume 1

Table of Contents
Overview of PLAB 2.......................................................................................................... 11

Feedback Statements................................................................................................................14
Consultation ............................................................................................................................................... 14
Issues .......................................................................................................................................................... 14
Time ............................................................................................................................................................ 14
Findings....................................................................................................................................................... 14
Examination ................................................................................................................................................ 14
Diagnosis..................................................................................................................................................... 14
Management .............................................................................................................................................. 14
Rapport ....................................................................................................................................................... 15
Listening...................................................................................................................................................... 15
Language ..................................................................................................................................................... 15
Signposting: ................................................................................................................................................ 16
History Taking: ..........................................................................................................................18
Presenting Complaint (PC): ........................................................................................................................ 18
Past Medical History (PMH): ...................................................................................................................... 20
Lifestyle: ..................................................................................................................................................... 20
Personal: ..................................................................................................................................................... 21
Social:.......................................................................................................................................................... 21
Lifestyle Modification: ............................................................................................................................... 22
Counselling ...............................................................................................................................26
Disease Counselling: ................................................................................................................................... 26
Any scenario related to medication counselling: ...................................................................................... 26
Counselling of a Procedure: ....................................................................................................................... 30
Types of Operation: .................................................................................................................................... 30
Pain Ladder ...............................................................................................................................33
Check Compliance: ..................................................................................................................................... 33
Syringe Driver: ............................................................................................................................................ 34
Patient Controlled Analgesia (PCA): .......................................................................................................... 34
Choose the Right Painkiller: ....................................................................................................................... 34
Imaging Tests ............................................................................................................................36
Chest X-Ray ................................................................................................................................................. 36
CT Scan ........................................................................................................................................................ 36
MRI Scan ..................................................................................................................................................... 36
USG ............................................................................................................................................................. 36
Bronchoscopy ............................................................................................................................................. 36
Endoscopy................................................................................................................................................... 36
Gastroscopy ................................................................................................................................................ 36
Flexible Sigmoidoscopy .............................................................................................................................. 37
Colonoscopy ............................................................................................................................................... 37
IVP or IVU ................................................................................................................................................... 37
PET CT Scan ................................................................................................................................................. 37
CTPA ............................................................................................................................................................ 38
Biopsy/ FNAC .............................................................................................................................................. 38
Paediatrics & Gynaecology/Obstetrics ......................................................................................39
Notifiable Diseases ...................................................................................................................40
Medicine ......................................................................................................................... 42
www.aspire2plab.com 2
No real PLAB2 cases discussed. All discussed scenarios are fictitious and for educational
purposes only.
Cardiovascular ..........................................................................................................................42
Chest Pain (ACS / Angina) ........................................................................................................................... 42
Chest Pain (Pericarditis) .............................................................................................................................. 46
Chest Pain (Musculoskeletal Pain) .............................................................................................................. 49
Shortness of Breath (Pulmonary Embolism) ............................................................................................... 51
Herpes Zoster (Shingles) ............................................................................................................................. 54
Shortness of Breath (Post Myocardial Infarction, Heart Failure) ................................................................ 56
Palpitations (Arrhythmia)............................................................................................................................ 61
Peripheral Arterial Disease ......................................................................................................................... 64
Respiratory ...................................................................................................................... 67
Dry Cough (Differential Diagnosis) .............................................................................................................. 67
Dry Cough (ACEi induced) ........................................................................................................................... 69
Cough and Shortness of Breath (PCP) ......................................................................................................... 70
Cough and Shortness of Breath (Tuberculosis) ........................................................................................... 73
Cough and Shortness of Breath (Pneumonia) ............................................................................................. 76
Elderly Confusion (Telephone Conversation - SEPSIS) ................................................................................ 80
Cough & Haemoptysis (Lung Cancer) .......................................................................................................... 83
Asthma Wheeze (Diagnosis) ....................................................................................................................... 88
Asthma (Discharge) ..................................................................................................................................... 93
Spacer ....................................................................................................................................................... 102
Obstructive Sleep Apnoea......................................................................................................................... 105
Neurology...................................................................................................................... 108
Subarachnoid Haemorrhage ..................................................................................................................... 108
Giant Cell Arteritis ..................................................................................................................................... 111
Tension Headache ..................................................................................................................................... 113
Headache (Hangover) ............................................................................................................................... 115
Migraine .................................................................................................................................................... 117
Sinusitis ..................................................................................................................................................... 119
Trigeminal Neuralgia ................................................................................................................................. 120
Facial Drooping ......................................................................................................................................... 121
Multiple Sclerosis ...................................................................................................................................... 122
Transient Ischemic Attack (TIA) ................................................................................................................ 124
Guillain-Barré Syndrome ........................................................................................................................... 127
Encephalitis ............................................................................................................................................... 130
Head Injury (Adult) .................................................................................................................................... 136
Postural Hypotension................................................................................................................................ 139
Fall & Hip Fracture .................................................................................................................................... 142
Vestibular Neuritis .................................................................................................................................... 145
Benign Paroxysmal Positional Vertigo (BPPV) ........................................................................................... 148
Unilateral Tinnitus ..................................................................................................................................... 150
Meniere’s Disease (Dizzy Spells) ............................................................................................................... 152
Gastroenterology .......................................................................................................... 155

Blood Test Results (Hepatitis) ................................................................................................................... 155
Abnormal LFT (Gilbert Syndrome) ............................................................................................................ 159
Alcoholic Hepatitis .................................................................................................................................... 161
Constipation (Talk to the Patient) ............................................................................................................. 163
Constipation (Talk to the Nurse) ............................................................................................................... 163
Chronic Diarrhoea ..................................................................................................................................... 165
Diverticulitis .............................................................................................................................................. 167
Irritable Bowel Syndrome ......................................................................................................................... 170
Indigestion ................................................................................................................................................ 173
Dysphagia .................................................................................................................................................. 176
Haematemesis .......................................................................................................................................... 178
purposes only.
Acute Gastroenteritis ................................................................................................................................ 181
Bloating ..................................................................................................................................................... 184
Endocrinology ................................................................................................................ 185

Hyperthyroidism ....................................................................................................................................... 185
Hypothyroidism......................................................................................................................................... 188
Hyperparathyroidism ................................................................................................................................ 191
Haematology ................................................................................................................. 194

Vitamin B12 Deficiency ............................................................................................................................. 194
Anaemia .................................................................................................................................................... 196
Multiple Myeloma..................................................................................................................................... 199
Leukaemia ................................................................................................................................................. 203
ITP ............................................................................................................................................................. 204
Neck Lump ................................................................................................................................................ 206
Rheumatology ............................................................................................................... 208
Rheumatoid Arthritis ................................................................................................................................ 208
Gout .......................................................................................................................................................... 210
Pain & Aches (Polymyalgia Rheumatica)................................................................................................... 212
Polymyalgia Rheumatica (PMR) Refusing Steroids ................................................................................... 212
Chronic Fatigue Syndrome ........................................................................................................................ 215
Carpal Tunnel Syndrome ........................................................................................................................... 217
Reactive Arthritis ...................................................................................................................................... 219
De Quervain’s Tenosynovitis ..................................................................................................................... 222
Raynaud Phenomenon .............................................................................................................................. 224
Nephrology .................................................................................................................... 226
Uraemia & Hyponatraemia ....................................................................................................................... 226
Tiredness (Citalopram) .............................................................................................................................. 228
Analgesic Nephropathy ............................................................................................................................. 231
Ophthalmology.............................................................................................................. 233
Acute Angle Closure Glaucoma (Acute Red Eye) ...................................................................................... 233
Subconjunctival Haemorrhage .................................................................................................................. 235
Cataract ..................................................................................................................................................... 237
Steroid Induced Cataract .......................................................................................................................... 238
Age Related Macular Degeneration .......................................................................................................... 239
Open Angle Glaucoma .............................................................................................................................. 241
Infectious Diseases ........................................................................................................ 242

HIV............................................................................................................................................................. 242
Acute Tonsillitis ......................................................................................................................................... 245
Recurrent Tonsillitis .................................................................................................................................. 247
Allergic Rhinitis.......................................................................................................................................... 249
Dermatology ................................................................................................................. 251
Skin Lesion (Mole) ..................................................................................................................................... 251
Skin Lesion (Melanoma) ............................................................................................................................ 254
Skin Lesion (Non-Melanoma – BCC/SCC) .................................................................................................. 256
Fungal Infection ........................................................................................................................................ 257
Acne (Isotretinoin) .................................................................................................................................... 259
Impetigo .................................................................................................................................................... 262
Urticaria .................................................................................................................................................... 264
Herpes Labialis .......................................................................................................................................... 266
Genital Warts ............................................................................................................................................ 268
Syphilis ...................................................................................................................................................... 270
purposes only.
Scabies ...................................................................................................................................................... 272
Eczema ...................................................................................................................................................... 274
Seborrheic Keratosis (Telephonic) ............................................................................................................ 276
Measles ..................................................................................................................................................... 277
Others ........................................................................................................................... 279
Insomnia ................................................................................................................................................... 279
Insomnia (Cannabis Abuser) ..................................................................................................................... 281
Surgery .......................................................................................................................... 283

UTI & BPH.................................................................................................................................................. 283
UTI (Confusion) ......................................................................................................................................... 287
Mannequin Patient (Urosepsis) ................................................................................................................ 290
UTI Female ................................................................................................................................................ 292
UTI in Pregnant Woman ............................................................................................................................ 295
UTI in Female (Transition Female to Male) ............................................................................................... 295
Recurrent UTI ............................................................................................................................................ 296
STI (Male) .................................................................................................................................................. 298
PSA Test- Demanding Patient ................................................................................................................... 300
PSA Rectal Examination ............................................................................................................................ 302
Loin Pain .................................................................................................................................................... 304
Haematuria ............................................................................................................................................... 307
Back Pain ................................................................................................................................................... 309
Back Sprain................................................................................................................................................ 312
Back Pain (IVDP) ........................................................................................................................................ 314
Cauda Equina Syndrome ........................................................................................................................... 316
Aortic Abdominal Aneurysm ..................................................................................................................... 317
Intestinal Obstruction ............................................................................................................................... 319
Acute Cholecystitis .................................................................................................................................... 320
Acute Pancreatitis ..................................................................................................................................... 322
Counselling .................................................................................................................... 323

Medicine................................................................................................................................. 326
Blood Pressure Management.................................................................................................................... 326
Pregnancy (Hypertension on Ramipril) ..................................................................................................... 328
Ramipril (Side Effects) ............................................................................................................................... 329
Post Myocardial Infarction Lifestyle.......................................................................................................... 330
Psoriasis Lifestyle Modification ................................................................................................................. 331
Stroke Assessment .................................................................................................................................... 333
Recurrent TIA ............................................................................................................................................ 334
Obesity Counselling................................................................................................................................... 336
Knee Replacement Follow Up ................................................................................................................... 338
Statin ......................................................................................................................................................... 340
Diabetic Retinopathy ................................................................................................................................ 341
Diabetic Review ........................................................................................................................................ 343
Hypoglycaemia .......................................................................................................................................... 345
Hypoglycaemia Fits ................................................................................................................................... 348
Diabetic Ketoacidosis ................................................................................................................................ 350
Diabetic Keto Acidosis ............................................................................................................................... 353
Smoking Cessation .................................................................................................................................... 354
Chronic Obstructive Pulmonary Disease (Smoking Cessation) ................................................................. 357
Post-partum Smoking Cessation ............................................................................................................... 359
E-Cigarettes ............................................................................................................................................... 360
Needle Stick Injury (Nurse) ....................................................................................................................... 361
Needle Stick Injury (Child) ......................................................................................................................... 364
purposes only.
Clostridium Difficile Associated Diarrhoea................................................................................................ 366
Methicillin-Resistant Staphylococcus Aureus ........................................................................................... 368
Osteoporosis ............................................................................................................................................. 370
Learning Disability (Diabetes Mellitus) ..................................................................................................... 372
Warfarin (Learning Difficulty) ................................................................................................................... 375
Nosebleed (Apixaban) ............................................................................................................................... 384
Clarithromycin & Warfarin ........................................................................................................................ 386
Haematuria – Lab Results ......................................................................................................................... 388
Drug Prescription ...................................................................................................................................... 390
Oxybutynin Urinary Symptoms ................................................................................................................. 393
Epilepsy ..................................................................................................................................................... 395
First Seizure ............................................................................................................................................... 397
Meningitis Prophylaxis .............................................................................................................................. 399
Chicken Pox (Pregnancy) ........................................................................................................................... 401
Concerned mother (Chicken Pox) ............................................................................................................. 404
Discuss Blood Results ................................................................................................................................ 407
Left Ventricular Dysfunction with ED Post MI ........................................................................................... 409
Heart Failure Medication (Follow Up)....................................................................................................... 411
Varicose Veins ........................................................................................................................................... 413
Upper Respiratory Tract Infection ............................................................................................................ 416
Coeliac Disease ......................................................................................................................................... 418
Colorectal Polyp ........................................................................................................................................ 420
Fainting ..................................................................................................................................................... 422
Barrett’s Oesophagus................................................................................................................................ 424
Cerebral Palsy ........................................................................................................................................... 426
Pain Management Breast Cancer.............................................................................................................. 429
Pain Management Prostate Cancer .......................................................................................................... 431
Post Herpetic Neuralgia ............................................................................................................................ 432
Bullying at Workplace (Lesbian) ................................................................................................................ 434
Cervical Screening (Lesbian) ..................................................................................................................... 436
Erectile Dysfunction .................................................................................................................................. 438
Homosexual Counselling ........................................................................................................................... 441
Methods of Conception for Homosexuals ................................................................................................ 444
Gender Dysphoria ..................................................................................................................................... 449
Epistaxis and Headache (Testosterone) .................................................................................................... 453
Chest Pain (Mastectomy) .......................................................................................................................... 456
Chest Pain (Transgender) .......................................................................................................................... 458
Surgery ................................................................................................................................... 461
Pre - Operative Assessment Ankle Pin Removal ....................................................................................... 462
Pre-operative Care .................................................................................................................................... 464
Herniorrhaphy........................................................................................................................................... 467
Dermoid Cyst............................................................................................................................................. 471
Post Op Hemiarthroplasty ........................................................................................................................ 473
Ductal Carcinoma in Situ ........................................................................................................................... 476
Ethical ........................................................................................................................... 478

Breaking Bad News (Cerebral Bleeding) ................................................................................................... 479
Breaking Bad News (Talk to Daughter) ..................................................................................................... 481
Post-Operative Bleeding (Vascular Surgery) ............................................................................................. 483
Breaking Bad News (Space Occupying Lesion) .......................................................................................... 486
Extradural Haemorrhage (Child) ............................................................................................................... 487
Pelvic Fracture (Child) ............................................................................................................................... 490
Post Mortem ............................................................................................................................................. 494
Domestic Violence .................................................................................................................................... 497
Insomnia Domestic Violence ..................................................................................................................... 500
purposes only.
Domestic Violence Burn (Sex Trafficking) ................................................................................................. 502
Cancer Withhold ....................................................................................................................................... 504
Talk to Consultant son about his mother .................................................................................................. 507
Treatment Refusal (DNAR) ........................................................................................................................ 509
Treatment Refusal 2 (DNAR) ..................................................................................................................... 511
Refusal of Breast Cancer Treatment ......................................................................................................... 512
Multiple Sclerosis (DNAR Form) ................................................................................................................ 514
Infective Endocarditis ............................................................................................................................... 517
Patient doesn’t want to take Warfarin ..................................................................................................... 520
Dementia .................................................................................................................................................. 522
Elderly Abuse ............................................................................................................................................ 525
Dementia Mother ..................................................................................................................................... 527
Elderly Wrist Fracture ............................................................................................................................... 529
Concerned Mother (OCP).......................................................................................................................... 533
Emergency Contraception ........................................................................................................................ 535
Emergency Contraception 2...................................................................................................................... 538
Regular Contraception .............................................................................................................................. 538
Confidentiality Consent............................................................................................................................. 538
Ankle Sprain .............................................................................................................................................. 539
Sick Note Request after Accident.............................................................................................................. 543
Mother wants Sick Note (Chicken pox) ..................................................................................................... 545
Angry Patients ........................................................................................................................ 547
Angry Patient (Change IV Cannula) ........................................................................................................... 548
Angry Patient (Talk to Dr Williams) ........................................................................................................... 550
Talk to Colleague (Delayed Discharge) ...................................................................................................... 552
Post-Operative Wound Infection (Infection Rate within National Guidelines) ......................................... 553
Post-Operative Wound Infection .............................................................................................................. 556
Angiogram (Conflict of Opinion) ............................................................................................................... 558
Angry son talking about mother ............................................................................................................... 560
Levothyroxine Dose Adjustment ............................................................................................................... 562
Angry Son (Late Cancer Diagnoses)........................................................................................................... 564
Cerebral Palsy ........................................................................................................................................... 567
Premature Childbirth ................................................................................................................................ 570
Medical Error’s ....................................................................................................................... 572
Missed Myocardial Infarction ................................................................................................................... 573
Misdiagnosed Pneumonia ......................................................................................................................... 575
Hairline Fracture ....................................................................................................................................... 575
Amoxicillin Rash ........................................................................................................................................ 575
Post Streptococcal Glomerulonephritis .................................................................................................... 576
Sample Not Labelled ................................................................................................................................. 576
Foreign Body ............................................................................................................................................. 577
Miscellaneous ......................................................................................................................... 582
Herbal Medication .................................................................................................................................... 582
Changing the counsellor ........................................................................................................................... 584
Gender Selection....................................................................................................................................... 586
Euthanasia................................................................................................................................................. 589
Two People Policy ..................................................................................................................................... 592
Hospital Policy (Telephonic Conversation)................................................................................................ 593
purposes only.
Disclaimer
This book is published and distributed solely by Aspire Education and prepared by various
authors working for Aspire Education. However, the publisher and the authors are providing
this book and its contents on an “as is” basis and make no representations or warranties of
any kind with respect to this book or its contents. The publisher and the authors disclaim all
such representations and warranties, including but not limited to warranties of healthcare for
a particular purpose and PLAB 2 exam preparatory course material. In addition, the publisher
and the author assume no responsibility for errors, inaccuracies, omissions, similarities or any
other inconsistencies herein.
The contents of this book are for informational purposes only, to provide guidance for
preparation of the PLAB 2 exam in the UK. The content is also not intended to diagnose, treat,
cure, or prevent any condition or disease. The publisher and the author make no guarantees
concerning the level of success you may experience by following the advice and strategies
contained in this book, and you accept the risk that results will differ for each individual. The
similarities of any content / scenario (s) will be totally coincidental. Aspire Education or any
organisation working in collaboration with Aspire will not be held responsible for the content
of this book.
The use of this book implies your acceptance of this disclaimer.!
purposes only.
Products
PLAB 2 Live/Online
PLAB2 Recorded Course
PLAB2 Audiobook
Clinical Assessment
purposes only.
purposes only.
Overview of
PLAB 2
!
purposes only.
Before Covid Post Covid
Passing Criteria a. 11/18 a. 10/16
b. Minimum Average Score b. Minimum Average Score
Each Station Division History Data Gathering – 4 History Data Gathering – 4

Management – 4 Management – 4
Interpersonal Skills – 4 Interpersonal Skills – 4
Total = 12 Total = 12
Overall Total Marks 216 192

Total Number of Stations 20 18
Real Stations 18 16
Rest Stations 2 2
Each Station Inside cubicle = 8 mins Inside cubicle = 8 mins
Outside cubicle = 1.5 mins Outside cubicle = 1.5 mins
Bells = 3 1st bell → Enter the Cubicle 1st bell → Enter the Cubicle
2nd bell → 6 Min Bell 2nd bell → 6 Min Bell
3rd bell → Go to Next Station 3rd bell → Go to Next Station
Total duration of exam 3 hours 10 minutes 2 hours 50 minutes
purposes only.
Example of Feedback
purposes only.
Feedback Statements
Consultation
Disorganised / Unstructured Consultation - includes illogical and disordered approach to

questioning.
You did not demonstrate sufficiently the ability to follow a logical structure in your
consultation. For example, your history taking may have appeared disjointed, with your line
of questioning erratic and not following reasoned thinking. You may have undertaken
practical tasks or examination in an illogical order that suggested you did not have a full
grasp of the reason for completing them or a plan for the consultation.
Issues
Does not recognise the issues or priorities in the consultation (for example, the patient’s key
problem or the immediate management of an acutely ill patient).
You did not recognise the key element of importance in the station. For example, giving
health and lifestyle advice to an acutely ill patient.
Time
Shows poor time management.

You showed poor time management, probably taking too long over some elements at the
expense of other, perhaps more important areas.
Findings
Does not identify abnormal findings or results or fails to recognise their implications.
You did not identify or recognise significant findings in the history, examination or data
interpretation.
Examination
Does not undertake physical examination competently or use instruments proficiently.
Diagnosis
Does not make the correct working diagnosis or identify an appropriate range of differential
possibilities.
Management
purposes only.
Does not develop a management plan reflecting current best practice, including follow up
and safety netting.
Rapport
Does not appear to develop rapport or show sensitivity for the patient’s feelings and
concerns, including use of stock phrases.
You did not demonstrate sufficiently the ability to conduct a patient centered consultation.
Perhaps, you did not show appropriate empathy or sympathy or understanding of the
patient’s concerns. You may have used stock phrases that show that you were not sensitive
to the patient as an individual or failed to seek agreement to your management plan.
Listening
Does not make adequate use of verbal & non-verbal cues. Poor active listening skills.
You did not demonstrate sufficiently that you were paying full attention to the patient’s
agenda, beliefs and preferences. For example, you may have asked a series of questions but
not listened to the answers and acted on them.
Language
Does not use language and/or explanations that are relevant and understandable to the
patient, including not checking understanding.
The examiner may have felt, for example, that you used medical jargon, or spoke too quickly
for the patient to take in what you were saying.
purposes only.
Counsel:
Start
- Introduction and explanation why you are there.
- Build a rapport before launching into the explanation.
- Ask if the patient knows why they are here. Ask them to talk about what has
happened up to this point.
- Assess their prior knowledge – it is imperative to ask what they know about the
condition/ treatment already.
- Describe what you are going to talk about (i.e. your structure) and if that would be
helpful and ask if they want to add anything or discuss anything else.
Middle
- Consider diagram.
- Chunk and check!! This is the most important thing – explain small bits at a time and
check that they understand the information and ask if they have any questions.
- Pause after each section.
- Speak slowly and clearly. Be sympathetic and listen to the patient’s concerns.
End
- Summarise what you have talked about and make a plan.
- Check whether they’ve understood everything.
- Always offer something e.g. a leaflet, website, specialist nurse contact, follow up
appointment.
Signposting:
This is done to indicate the questions you will be asking to make sure the patient does not
feel uncomfortable in answering.
It might sound silly but sometimes alcohol and smoking can make this condition worse. May
I know if you drink or smoke?
Let me ask you some questions about your lifestyle as sometimes alcohol and smoking can
make this condition worse. If you don’t mind telling me, do you drink or smoke?
I want to ask you some questions that might sound weird, but they will really help us in
assessment.
purposes only.
Sample Question
Where you are:

You are an F2 in Paediatrics Department.
Who the patient is:

Jenny Julie, aged 2, has been brought to the hospital by her mother because she had a fit.
Other information you have about the patient:

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.
What you must do:

Please talk to her mother, Mrs. Diana Julie, take history, discuss your plan of management
with the mother and address her concerns.
Special Note:
The mother is very concerned.
The child is not in the cubicle.
purposes only.
History Taking:
Presenting
Complaint
SOCRATES ODIPARA
Shortness
Pain Cough
of Breath
Presenting Complaint (PC):
Ø Elaborate (SOCRATES à Pain)
- Site – Where is the pain?
- Onset – When did the pain start? Gradually? Sudden?
- Character – Could you describe the pain for me?
- Radiation – Does the pain go anywhere?
- Associated Symptoms – Any other symptoms?
- Time – Since when have you been having this pain?
- Exacerbating & Relieving Factors – Anything makes it better/worse?
- Severity/Scoring – Could you score the pain for me?
Ø Elaborate (ODIPARA à Other Symptoms à Cough/SOB)
- Onset
- Duration
- Intensity
- Progression
- Aggravating factors
- Relieving Factors
- Associated Symptoms
purposes only.
Presenting Complaint:
- Fit/ Fall/ LOC/ Vertigo/ Dizziness
During After
Fits:
- Duration
Confusion/ Sleepy/ Drowsy
- Generalised/ Localised
- Tongue Biting/Up rolling eyes/ Incontinence
LOC:
Nausea/ Vomiting
- Duration
Trauma/ Injury
Amnesia:
- Retrograde
- Anterograde
purposes only.
Past Medical History (PMH):
- Previous similar episodes
● Has this happened before? Yes/No
- Medical Conditions?
● Have you been diagnosed with any Medical Condition?
- Medications?
● Are you taking any medications including OTC/Herbal?
- Allergies?
● Do you have any allergies? (Medicine/Food/Environment)
- Hospital Stay/Surgeries
● Have you even been hospitalized?
● Have you had any surgeries previously?
- Family History
● Anyone in your family diagnosed with any medical conditions.
Lifestyle:
- Smoking
● Do you smoke? If patient has already quit then appreciate the patient.
● What do you smoke?
● How much do you smoke?
● How often do you smoke?
● Since when have you been smoking?
● If No, then ask ‘have you ever smoked’?
- Alcohol
● Do you drink alcohol? If patient has already quit then appreciate the patient
● What do you drink?
● How much do you drink?
● How often do you drink?
● Since when have you been drinking?
- Diet
● Could you please tell me about your diet?
● Does it include enough fruits and vegetables?
- Physical Exercise
● Tell me about your physical activity
purposes only.
Personal:
- Sexual History
● Are you sexually active?
● Are you in a stable relationship?
● Do you have any other partners? How many partners do you have?
● Do you use condoms? Do you practice safe sex all the time?
● When was the last time you had unprotected sex?
● Which route of sex do you prefer? Oral, Vaginal or Anal?
● Do you use any sex toys?
● Is your sexual partner male or female? What is your sexual orientation?
● Any previous history of STI or PID?
- Recreational Drugs
● Do you use any recreational drugs?
● Which drug?
● How much do you take?
● How often do you take it?
● How do you take it?
● Since when have you been taking it?
● If they are using syringes, ask ‘are you sharing needles’?
Social:
- Travel
● Have you travelled recently anywhere?
● Where did you travel to?
● How long were you there for?
- Occupation
● What do you do for living?
● Have you been exposed to asbestos? (Mesothelioma)
● Have you been exposed to Aniline Dye? (Bladder CA)
- Living Condition
● Where do you live?
(patient maybe homeless/living in hostel)
● Who do you live with?
(please ask this when discharging old patient)
purposes only.
Lifestyle Modification:
For lifestyle modification, it is very important to take relevant history first and then advise
accordingly. Lifestyle advice is relevant in patients suffering from lifestyle diseases like DM,
HTN, High cholesterol and heart diseases.
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 reduce the risk of further
complications. Eating out frequently 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. Please eat 5 portions per day and decrease the size of the portion.
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.
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.
Minimize intake of foods containing refined sugars. We can also refer you to a dietician who
can help you better.
Patients with Osteoporosis should be advised to have enough dairy products, oily fish and
nuts as they are a good source of Vitamin D, Calcium and Omega-3.
Patients with Chronic Kidney Disease should be advised to take less water and protein.
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 cessation clinic, where 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).
Alcohol:
The recommended daily amount of alcohol is 2 units per day.
purposes only.
One large glass (250ml) of wine approximately contains 3 units of alcohol. A bottle of wine
(750ml) contains approximately 9 units of alcohol.
One pint (585ml) of beer or lager contains approximately 2 units of alcohol.
One shot (25ml) of spirits (e.g. Vodka, Whiskey, Bourbon, Gin, Tequila, Cognac) contains
approximately 1 unit. One bottle (750ml) of spirit contains 30 units of alcohol.
It is always advisable to drink alcohol in moderation, if you do. 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 the patient’s condition/symptoms are directly due to alcohol, then tell the patient to stop
instead of drinking in moderation.
Stress:
Stress could worsen your condition. So, it is important to relieve 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 or meditation, if you feel
it may interest you.
Physical Activity:
purposes only.
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 doesn’t need to 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 walk
instead. Maybe walk instead of driving when you are going to buy something from your
local shop if it’s nearby. 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 the next 6-8 weeks.
purposes only.
purposes only.
Counselling
Disease Counselling:
- Examination
- Initial Investigations
- ICE
- Disclose & Explain the Diagnosis
- Explain Examination and Investigations findings
- Further Investigation
- Treatment
- Symptomatic/Specific
- Medical/Non-Medical
- Admission Yes/No
- Follow Up OT/PT Review
- Warning Signs/Red Flags
- Leaflets/Pamphlets
- While discharging a patient, especially an elderly patient, the patient’s living conditions
including the home environment and presence of any help and support (family or carer)
should be elaborated on.
How to Counsel:
- Make a two-way conversation.
- Involve the patient in the conversation.
- Let the patient ask you questions.
- Use short statements and simple language.
- Keep checking the patient's understanding.
- Go slow. Never rush.
- Don’t answer if you are not sure. (I will confirm it with my seniors)
- Do you have any other concern?
Any scenario related to medication counselling:

Ask these questions first:
- Any medical illnesses?
- Any other medications?
- Any allergy to any medication?
Explain the medication:

- Function of medicine.
- Dose of the medicine.
- Route of the medication
- How often, when and for how long to take medication.
- Side effects of the medication.
General Advice:
- Take your medication regularly as prescribed.
purposes only.
- Do not miss any dose.
- Ask your GP before using any other drug, including OTC herbal or supplements.
- See your GP if you have a persistent side effect.
- Follow Up.
- Red Flags
Show that you are a Safe Doctor:
To assess dehydration in patient presenting with diarrhoea or vomiting:

- Do you feel thirsty?
- Do you have a dry mouth?
- Have you noticed a decrease in urine output?
- Do you feel lethargic?
- Do you feel drowsy?
Rule Out Anaemia:

- Do you feel any heart racing?
- Do you feel any lightheaded-ness or dizziness?
- Do you have any SOB?
- Do you feel tired or lethargic?
Rule Out Cancer:

- Weight Loss.
- Loss of appetite.
- Anaemia symptoms
- Lumps and Bumps
purposes only.
Common You are allowed to not know
things.
Challenges
in PLAB 2
Expect somethings that you
wont know.
You are not the only one

feeling nervous.
You have faced similar

situations many times before.
Be honest.
Ask OPEN-ended question to (do not interrupt the patient

get free information whilst talking)
If the patient mentions If the patient mentions his work

something in between, do not but you are taking HPC, tell the
ignore the patient. patient, ‘You mentioned work, I
will come back to that’.
Remember to manage the

situation, not only the
condition.
You are FY2, ask for assistance I will go and double check with
if not sure. Tell that you work my senior and let you know.
as a part of a team. The drug is this but I will double
check with my book.
Reflect ALL emotions by You seem upset.
verbalising then and there:
You seem frustrated.
purposes only.
Maintain 2 Way Conversation
How does that sound?

Are you with me?
Are we still together?
Are you getting me?
Are you keeping up with me?
Are we still on the same page?
Keep patient involved in the conversation
Let the patient ask questions
Pick up verbal and non-verbal cues
Go slow and Don't rush
Don't answer if you are NOT sure
purposes only.
Counselling of a Procedure:
Pre-op Assessment:
Pre-op assessment is done a few weeks before the operation by a doctor or a qualified
nurse.
It is done by taking history, doing physical examination and running different tests.
Also involves advice about certain medications like diabetic medication.
Consent:
It is very important to take consent from the patient.
The mode and type of anaesthesia:
Local Anaesthesia: We will inject some medication to numb the area. We may also give you
some mild sleep medication if needed.
These medications can be used to treat painful conditions, prevent pain during a procedure
or operation, or relieve pain after surgery.
Unlike general anaesthetics, local anaesthetics don't cause you to lose consciousness. This
means they're generally safer, don't normally require any special preparation before they
can be used, and you can recover from them more quickly.
General Anaesthesia: We need to put you to sleep for the procedure. For GA, avoid eating
and drinking 6-8 hours before the surgery.
It is a state of controlled unconsciousness. During a general anaesthetic, medications are

used to put you to sleep, so you're unaware of surgery and don't move or feel pain while it's
carried out.
General anaesthesia is essential for some surgical procedures where it may be safer or more
comfortable for you to be unconscious. It's usually used for long operations or those
that would otherwise be very painful.
Advantages of Local Anaesthesia compared to General Anaesthesia:

a. Less complications, reduced hospital stay and faster recovery.
b. Less fitness is required.
Types of Operation:
a. Open Operation:
It can be done in local or general anaesthesia. E.g.-Hemicolectomy, Open Nephrectomy,
Hysterectomy, Hip Replacement.
b. Keyhole Operation (Laparoscopic):

It is done under general anaesthesia. In this operation, we will put you to sleep.
purposes only.
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 and make it easier to visualise the internal organs.
A laparoscope, 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 into the tummy cavity so the surgeon can see the instruments on
the monitor and perform the surgery. E.g.- Ectopic Pregnancy, Female Sterilization etc.
Advantages of Keyhole Surgery:

a. Less pain, less complications, less hospital stay and faster recovery.
b. Small scar.
Duration of the Surgery:

It may differ from person to person and also depend on a person’s overall health.
Minor surgery – up to 1 hour
Major surgery – 2-3 hours
Abdominal Incisions Keyhole Scars
Complications:
Here are some general complications and their treatments:
a. Pain – Painkillers.
b. Infection – Antibiotics.
c. Bleeding and Damage to surrounding structures – Will be managed accordingly.
Hospital Stay:
It may differ from person to person and his overall health. Patients, especially old people,
should be assessed by OT, PT. Patients should be medically and socially fit before discharge.
For minor surgery – Day care or up to 2-3 days

For major surgery – Up to 4-7 days
purposes only.
Recovery Period:
It may differ from person to person and his overall health.
1 Week – Household chores
2 Weeks:
- Drive (When you can press the emergency brakes without feeling any discomfort)
- Sex (When you can perform without feeling breathless)
4 – 6 Weeks – Office job. (Depending on the type of surgery and patient’s recovery)
6 – 8 Weeks – Labour job. (Depending on the type of surgery and patients recovery)
Follow up:
A few days after surgery, the patient can be reviewed by a GP or the surgeon (depending on
the nature of the procedure).
purposes only.
Pain Ladder
Simple Painkillers (Aspirin, Paracetamol, NSAIDS) +/- Adjuvants)
Weak Opioids (Codeine, Tramadol) +/- Adjuvants
Stronger Opioids (Morphine, Diamorphine, Oxycodone, Pethidine, Fentanyl) +/- Adjuvants
Adjuvants for Bone Mets pain – Radiotherapy, Bisphosphonates.

Adjuvants for Osteoarthritis – Steroids (Injection)/Intra-articular, Bisphosphonates.
Adjuvants for Neuropathic Pain – Gabapentin, Amitriptyline, Carbamazepine.
Opioid for Moderate

to Severe Pain
Pain Persisting or +- Non-Opioid
+- Adjuvant
Increasing
Pain Persisting or Opioid for Mild to
Increasing Moderate Pain
Non-Opioid + Non-Opioid
+ Adjuvant +- Adjuvant
Check Compliance:
Do you take the medicine regularly?
Do you take the medicine as prescribed?
Any missing dose?
Patient is on painkillers and has good compliance, but pain is not well controlled:
- You can increase the dose of medication up to the maximum dose.
- You can move up the pain ladder to a stronger group.
When we prescribe either a weak or strong opioid, we should always also prescribe a weak
painkiller like Paracetamol or NSAID along with it.
a. Did you take any painkillers?

b. What did you take?
c. How much did you take?
d. When did you take it?
Side Effects:
If the patient has some side effects, we try to tackle the side effects and continue with the
same painkiller.
purposes only.
If side effects cannot be tackled, we change the medication to another drug from the same
group or change the route of administration.
e.g. Oral Morphine can be changed to Oxycodone or Subcutaneous Diamorphine.
Fentanyl Patch:
It is a very strong painkiller.
Indications:
- Patient is on a maximum dose of morphine but still in pain.
- Patient is in severe pain but wants to be mobile (when you cannot use a syringe driver).
- Poor compliance to PO medication.
- If there is renal impairment (GFR < 30).
Usually a Fentanyl Patch lasts for 3 days.

When you start Fentanyl, it takes 12-24 hours to start working, so you may need to
prescribe some other painkiller to your patient when you start fentanyl patch.
It takes about 12-24 hours to clear from the body, so if you stop this medication, you should
not give the patient a painkiller within 24 hours unless the patient feels pain.
Syringe Driver:
The medication that is commonly used is Diamorphine and the route is Subcutaneous
(Sub/Cut). It is one of the options in pain management of terminally ill patients. It is a small
pump that gives a continuous dose of medication under the skin as an injection.
Syringe drivers will usually be given to terminally ill patients who have been on long term
oral morphine and have developed side effects, especially nausea, vomiting.
Patient Controlled Analgesia (PCA):

The medication that is commonly used is IV Morphine. It involves a small device by which
you can control the pain by pressing a button. By doing this, medication enters your blood
vessel. This is a programmed device so you cannot take more than a certain amount of
painkiller in one day, so don’t worry about overdose.
Choose the Right Painkiller:

Usually in terminally ill patients, we need to start from weak painkillers and then step up to
strong painkillers if needed.
Usually for post-op pain management, we start from a strong painkiller and then step down
to a weak painkiller.
Patients may need PCA in the hospital after the operation, PO Morphine along with a simple
painkiller after a while. Since the pain will subside after operation, we can shift it to a weak
opioid along with a simple painkiller such as Co-codamol. And then we can shift the patient
to a simple painkiller such as Paracetamol.
For Minor Surgery we can start with Weak opioids or simple painkillers.
purposes only.
District Nurses can visit people in their own homes or in residential care homes for pain
management and support their family members.
Macmillan Palliative Nurses provide help and support to the patient with pain and palliative
care needs to end of life care. They support the person with cancer, their family and the
nurses and doctors who are looking after them.
Side Effects of Morphine:
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 liquids 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.
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.
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.
There are some serious side effects of Morphine like Seizure, Breathing Difficulty or Short
Shallow Breathing and Muscle Stiffness; if any of these happen, please contact your GP or
go to the A&E.
purposes only.
Imaging Tests
Chest X-Ray
An imaging technique that uses high-energy radiation to highlight abnormalities in body

tissue.
CT Scan
A series of X-rays at slightly different angles are taken and a computer is used to put the
images together.
Before having the scan, you may be given a special dye called a contrast to help improve the
quality of the images. This may be swallowed in the form of a drink, passed into your
bottom (enema), or injected into a blood vessel.
MRI Scan
Magnetic resonance imaging (MRI) is a type of scan that uses strong magnetic fields and
radio waves to produce detailed images of the inside of the body.
USG
It uses high-frequency sound waves to create an image of the inside of your body.
Bronchoscopy
A bronchoscopy is a procedure that allows a doctor or nurse to remove a small sample of

cells from inside your lungs.
During a bronchoscopy, a thin tube called a bronchoscope is used to examine your lungs and
take a sample of cells (biopsy). The bronchoscope is passed through your mouth or nose,
down your throat and into the airways of your lungs.
The procedure may be uncomfortable, but you'll be given a mild sedative beforehand to
help you relax and a local anaesthetic to make your throat numb. The procedure is very
quick and only takes a few minutes.
Endoscopy
An endoscopy is a procedure where the inside of your body is examined using an instrument
called an endoscope. An endoscope is a long, thin, flexible tube that has a light source and
camera at one end. Images of the inside of your body are relayed to a television screen.
Gastroscopy
purposes only.
A gastroscopy is a procedure where a thin, flexible tube called an endoscope is used to look
inside the oesophagus (gullet), stomach and first part of the small intestine (duodenum).
Flexible Sigmoidoscopy
A flexible sigmoidoscopy is an examination of your back passage (rectum) and some of your
large bowels using a device called a sigmoidoscope.
A sigmoidoscope is a long, thin, flexible tube attached to a very small camera and
lightsource. It's inserted into your rectum and up into your bowel.
The camera relays images to a monitor and can also be used to take biopsies, where a small
tissue sample is removed for further analysis.
A sigmoidoscopy can feel uncomfortable, but it only takes a few minutes and most people
go home straight after the examination.
Colonoscopy
A colonoscopy is an examination of your entire large bowel using a device called a

colonoscope, which is like a sigmoidoscope but a bit longer.
Your bowel needs to be empty when a colonoscopy is performed, so you'll be advised to eat
a special diet for a few days beforehand and take a medication to help empty your bowel
(laxative) on the morning of the examination.
You'll be given a sedative to help you relax during the test. The doctor will then insert the
colonoscope into your rectum and move it along the length of your large bowel. This isn't
usually painful but can feel uncomfortable.
The camera relays images to a monitor, which allows the doctor to check for any abnormal
areas within the rectum or bowel that could be the result of cancer. A biopsy may also be
performed during the test.
A colonoscopy usually takes about an hour to complete, and most people can go home once
they've recovered from the effects of the sedative.
IVP or IVU
A dye that shows up on X-ray is injected into a vein in your arm; the X-ray image highlights
any blockages as the kidneys filter the dye out of your blood and into your urine.
PET CT Scan
purposes only.
A PET-CT scan (which stands for positron emission tomography-computerised tomography)
may be carried out if the results of the CT scan show you have cancer at an early stage.
The PET-CT scan can show where there are active cancer cells. This can help with diagnosis
and treatment.
Before having a PET-CT scan, you'll be injected with a slightly radioactive material. You'll be
asked to lie down on a table, which slides into the PET scanner. The scan is painless and
takes around 30-60 minutes.
CTPA
Biopsy/ FNAC
A biopsy is a medical procedure that involves taking a small sample of body tissue so it can
be examined under a microscope.
• A needle biopsy – a special hollow needle, guided by X-ray, ultrasound, CT scan or MRI
scan, is used to obtain tissue from an organ or a tissue underneath the skin.
" An excision biopsy – surgery is used to remove a larger section of tissue.
purposes only.
ICE:
Ideas
"Was there anything you thought it might be?"
Concerns
"What about it is worrying you in particular?"
Expectations
"Is there anything in particular you were hoping we would do today?"
Paediatrics & Gynaecology/Obstetrics
Paediatrics Gynaecology/Obstetrics
Birth History Period
Immunisation (Jabs)
Pregnancy
Development (Red Book)
Diet ( Breast Fed, Bottle Fed) Pill
Wee & Poo
Non-Accidental Injury Pap Smear
purposes only.
Notifiable Diseases
1. Meningitis
2. Encephalitis
3. Acute Gastroenteritis
4. Acute Infectious Hepatitis
5. Tuberculosis
6. Measles
7. Mumps
8. Dengue
9. Haemolytic Uremic Syndrome
10. Typhoid Fever
Registered medical practitioners (RMPs) have a statutory duty to notify the ‘proper officer’
at their local council or local health protection team (HPT) of suspected cases of certain
infectious diseases.
Complete a notification form immediately on diagnosis of a suspected notifiable disease.

Don’t wait for laboratory confirmation of a suspected infection or contamination before
notification.
Send the form to the proper officer within 3 days or notify them verbally within 24 hours if
the case is urgent by phone, letter, encrypted email or secure fax machine.
purposes only.
purposes only.
Medicine
Cardiovascular
Chest Pain (ACS / Angina)
You are an FY2 in A&E. Mr John Smith, 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 the center of my 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 sitting on my chest.
D: Does the pain go anywhere? P: It is going to my left arm/ shoulder/ 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 problems? P: No.
D: Any sweating? P: No.

D: Any breathlessness? P: No.
D: Any nausea? P: Yes.
D: Since when? P: Since the pain started.
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 kinds of problems 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.
purposes only.
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 a 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.
I would like to check your vitals and examine your chest.

I would like to send for some initial investigations including routine blood tests, special
blood test for your heart enzymes and an ECG.
Examination:
ECG:
Troponin: Awaited
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 a 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 (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 repeat the special blood test after a 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 Lifestyle such as smoking/ alcohol cessation, diet,
physical activity because these may lead to the severe complications of your condition.
(Give lifestyle advice accordingly.) If you develop any sudden severe chest pain,
breathlessness, dial 999 and come to the hospital.
P: What is going on?

P: What are you going to do for me?
P: Can I go home?
P: When I can go home?
P: Why do you want to keep me in the hospital?
DD:
Myocardial infarction
purposes only.
Angina
Pulmonary embolism
Pericarditis
Pneumonia
Gastroesophageal reflux disease
purposes only.
!
purposes only.
Chest Pain (Pericarditis)
You are an FY2 in A&E. Mr Daniel Smith, aged 30, presented to the hospital with chest pain.
Please talk to the patient, take history, assess the patient and discuss your initial plan of

D: Tell me more about your pain? P: Like what Dr.
D: When did it start? P: 1 day ago.
D: Was it sudden or gradual? P: It was gradual.
D: Is it continuous or comes and goes? P: It is continuous.
D: What type of pain is it? P: It is sharp pain.
D: Does the pain go anywhere? P: No.
D: Is there anything that makes the pain better? P: When I lean forward it gets better.
D: Is there anything that makes the pain worse? P: When I lie down.
D: Has it changed? P: I think it’s getting worse.
the most severe pain you have ever experienced? P: 7
D: Any breathlessness? P: No
D: Any fever or flu like symptoms? P: I have had a fever for the last one week.
D: Anything else with fever? P: Yes, I have a sore throat.
D: Did you take anything for it? P: I took Paracetamol for it.
D: Any cough? P: No
D: Any sweating? (MI) P: No
D: Any nausea? P: No
D: Any lightheadedness? P: No
D: Do you feel tired? P: No

D: Any trauma? (Pneumothorax) P: No
Ask about the PMH, Lifestyle and Psychosocial history.

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 an inflammation of the pericardium (the fibrous sac surrounding the heart).
If all the tests come back normal, we will send you home.
purposes only.
We will give you anti-inflammatory medicines such as Ibuprofen which 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 reduces the chances of the
inflammation coming back.
If the pain is severe and you are not getting better with ibuprofen and
colchicine, steroids may be used to reduce the inflammation. The pain and inflammation
usually settle within a few weeks.
We’ll also do routine Blood Tests, a Special Blood Test for your heart (Troponin) & a CXR.
Please Follow Up with the heart specialist and your GP.

Give Lifestyle advice accordingly.
If you develop any sudden severe chest pain or 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.
Von Willebrand disease

Avoid aspirin and anti-inflammatory drugs like ibuprofen unless your specialist advises you
it's safe to use them, as these can make bleeding worse – use other medicines such as
paracetamol instead.
purposes only.
purposes only.
Chest Pain (Musculoskeletal Pain)
You are an FY2 in A&E. Mr David Smith, aged 27, presented to the hospital with chest pain.
Please talk to the patient, take history, and discuss your initial plan of management with
the patient.

D: Tell me more about your pain? P: Like what.
D: Where exactly do you have the pain? P: It is here (points)
D: When did it start? P: It started a few days ago.
D: Was it continuous or comes and goes? P: It is continuous.
D: What type of pain is it? P: It is dull pain.
D: Is there anything that makes the pain better? P: No.
D: Is there anything that makes the pain worse?
P: Whenever I am cycling, my pain gets worse / when I take a deep breath in, it hurts.
D: Could you please score the pain on a scale of 1 to 10, 1 being no pain and 10 being the
most severe pain you have ever experienced? P: It is around 5.
D: Any sweating? P: No.

D: Any breathlessness? P: No. (MI, Pneumothorax)
D: Any pain during breathing? P: Yes. (Pleurisy, Pericarditis)
D: Any nausea P: No.
D: Any light-headedness? P: No.
D: Do you feel tired? P: No.

D: Any increase in the pain on lying down? P: No. (Pericarditis)
D: Did you hurt yourself anytime recently?
P: Yes, I did. I do a lot of exercise as I’m training for my triathlon. 3 days ago, I fell from the
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 would like to check your vitals and examine your chest. I will also examine the upper chest
area for any tenderness.
purposes only.
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 hyper-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, CXR
(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 medication 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 a heart attack?

D: This is a valid concern. From my assessment, your chest pain looks more like a muscle
pain, but we will keep you in the hospital and conduct investigations to make sure
everything 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 an 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 subsided.
Steroid injection
TENS (Transcutaneous electrical nerve stimulation)
If you develop any sudden severe chest pain or breathlessness, dial 999 and come to the
hospital.
purposes only.
Shortness of Breath (Pulmonary Embolism)
You are an FY2 in GP practice. A Mrs Hayley Smith, aged 34, has presented to you with a
complaint of breathlessness. Talk to the patient, assess and give her the plan of
management.
D: Hello. What brings you to the hospital today?

P: Doctor, I can’t breathe properly.
D: Oh! Are you comfortable for me to ask a few questions to find out what happened?
P: Yes / No (Oxygen?)
D: Can you please tell me what happened?

P: I was alright a few hours back when I suddenly became short of breath.
D: What were you doing when it started? P: Was just sitting

D: Has it been continuous, or did it stop for some time? P: Continuous
D: Has it ever happened before? P: No
D: Anything else with it? P: Yes, I also have pain in my
chest
D: What kind of pain? P: Sharp

D: When did it start? P: With the breathlessness
D: Have you experienced a similar pain before? P: No
D: Does the pain go anywhere? P: No
D: Did you feel 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: 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) 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
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: When was your LMP? P: 3 weeks ago
D: Is there a chance you might be pregnant? P: I don’t think so
D: Do you have kids? P: Yes, 1 son
purposes only.
D: How old? (Recent pregnancy) P: 4 Years
D: Do you smoke? (risk factor) P: Yes
D: Do you take alcohol? P: Occasionally
D: Have you travelled anywhere recently? P: No
D: I would like to check your vitals & examine your chest.
Examiner: Normal
D: From what you’ve told me & from my examination, I suspect that you have a condition
called pulmonary embolism.
P: No
D: In this condition, a blood clot forms in one of 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), ABGs & 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.
P: Is it serious?
D: It can be serious if not treated. But we’ll start treatment immediately to prevent that. Is
that alright?
P: Why did I get it?
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
& send for tests. We’ll start specific treatment as soon as the results 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 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.
purposes only.
If WELL’S Score 4 à CTPA/VQ scan
If WELL’S Score 3 à D-dimers, if d-dimers raised then CTPA/VQ scan
!
D/D
Pulmonary Embolism
TB
Asthma
Pneumonia
Heart Failure
PCP
Lung cancer
! !
purposes only.
Herpes Zoster (Shingles)
You are FY2 in GP. Mr Peter Smith aged 40, has presented to the clinic with chest pain.
Talk to the patient, assess him and discuss the plan of management.
D: How can I help you? P: I am having chest pain.

D: Tell me more about your pain? P: Like what dr.
D: Where exactly do you have the pain?
P: It is on the right side of my chest (Pt. points towards the lower right side of the chest)
D: When did it start? P: I have had this for the last one day.

D: Was it continuous or comes and goes? P: It was continuous.
D: What type of pain is it? P: It’s like a burning pain.
D: Does the pain go anywhere? P: It is going to my back.
D: Is there anything that makes the pain better? P: No
D: Is there anything that makes the pain worse? P: No
most severe pain you have ever experienced? P: It is 5
D: Anything else with pain? P: I have a skin lesion over my chest.

D: Where exactly on 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? P: Yes
D: Did you come into contact with anyone who had any type of skin lesions? P: No
D: Do you have skin lesions anywhere else? P: No
D: Any skin lesions on the face near the eyes or ears? P: No
D: Have you ever had chickenpox? P: Yes / No
D: Anything else? P: No
D: Any headache? P: No
D: Any breathlessness or sweating? P: No
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 a skin ailment called shingles.
purposes only.
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.
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.
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) a few
times a day.
Don't
● let dressings or plasters stick to the rash.
● use antibiotic cream – this slows healing.
General Advice:
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.
!
purposes only.
Shortness of Breath (Post Myocardial Infarction, Heart Failure)
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 7 years ago. Patient
is not regular with the GP. Please take history, assess his condition, discuss management
and address his concerns.
D: What brought you to the hospital? 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 anything?
P: Whenever I walk a 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 the night due to this.
D: Do you have any other problems? P: Like what.
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.
D: Do you feel tired? 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? P: Yes, my socks are getting tighter.
D: Do you have heart racing? P: Yes/ No.

D: When did it start? 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.
D: Does anything make it better? 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 a similar problem before? P: No.
D: Have you been diagnosed with any medical condition in the past?
P: Yes, I had a heart attack a few years ago.
D: How was it managed?
P: They gave me medications for my heart, blood thinners, and statin.
D: May I know how 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.
purposes only.
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: Have you ever been diagnosed with any other medical condition? P: No.
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? P: No.
D: Any allergy to any food or any drug? P: No.
D: Any previous hospital stays other than for your heart attack? P: No.
D: Have you had 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.
Anyone with diabetes, high blood pressure, high cholesterol in the family? P: No.
D: Do you smoke? P: Yes/ No

D: Do you drink alcohol? P: Yes, occasionally
D: Tell me about your diet? 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, abdomen, heart and lungs.
I would like to send for some initial investigations like routine blood tests including Cardiac
Enzymes, CXR and an ECG.
Examiner:
News Chart:
Temperature: 37
Pulse Rate: 87/min
O2 Sat: 92 - 93
BP: 130/90 mmHg
RR: 12 - 20
Decreased air entry bilaterally.
CXR: Cardiomegaly.
ECG: Normal/ Might find Q waves.
Abdomen – Ascites
purposes only.
P: What’s happening doctor?
P: What is heart failure?
P: Why has my heart 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 the swelling in your
legs and shortness of breath. This is one of the complications of heart attack.
D: We did a CXR 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 strain more to pump blood. This strain has caused the enlargement
of your heart. We call this remodelling of the heart.
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 medications, this could be one of the causes for your heart enlargement.
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 improves.
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
medications. If not, you may have to have a procedure done for your heart or for your
heartbeat.
We might refer you to a Cardiac Rehabilitation service led by healthcare professionals for
people with heart conditions, if needed.
The programme covers the following:
purposes only.
• exercise
• education
• relaxation and emotional support
We will discharge you once your symptoms improve.

You need to take all your medications regularly and as prescribed to prevent further re-
modelling of your heart.
Address lifestyle accordingly.
Smoking
Alcohol
Diet - Cut the amount of salt & fluid intake.
Physical activity.
You need to come for follow ups regularly. You should also see your 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.
purposes only.
purposes only.
Palpitations (Arrhythmia)
You are FY2 in a GP clinic. Mr. Alexander Dukov, aged 57, presented to the hospital
complaining of chest discomfort. This is the patient's first visit. Please talk to the patient,
take a focused history, and discuss your initial plan of management with the patient.
D: What brought you to the hospital? P: I have chest discomfort.
D: I’m so sorry, could you tell me more about it? P: What do you want to know?
D: What do you mean by chest discomfort? P: Like a fluttering sensation in my chest.

D: When did it start? 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., from time to time.
D: How often do you get this feeling? P: 5-6 times in last 6 months
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 symptoms? P: No

D: How about the first episode? P: All the episodes are the same.
D: Do you have any other problems? 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? 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.
D: 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 problems? P: No
D: Do you take any other medications, over-the-counter drugs or supplements? P: No
purposes only.
D: Any allergies from any food or medications? P: No
D: Any previous hospital stay or surgeries? P: No
P: My father died of a 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 drink alcohol? P: Social
D: What about tea or coffee? P: I have a lot of them
D: May I know how many cups per day? P: Around 5
D: Tell me about your diet? P: I try to have a healthy diet
D: Do you do physical exercise? P: I’m quite active
D: Do you have any kind of stress? 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 else that you think is important for us to know? P: No
D: I would like to check your vitals and examine your heart and lungs. I would like to send for
some initial investigations including routine blood tests, a special blood test for your heart
enzymes and ECG.
From my assessment, you seem to have a problem in your heart called Arrhythmia, which is
an irregular beating of your heart.
The heart rhythm is controlled by electrical signals and arrhythmia is an abnormality of the
heart rhythm and sometimes rate. It may beat too slowly, too quickly or irregularly.
I 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
understand what is exactly going on.
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.
purposes only.
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
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
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
can also lead to this condition.
If you experience any heart racing, especially if it is fast and irregular accompanied by
shortness of breath, dizziness or fainting, please come 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.
P: What’s going on doctor?

P: What is arrhythmia?
P: I’m really concerned about this because of what happened to my dad and brother.
P: Is it serious, doctor?
P: Why am I having this problem?
P: Doctor, how are you going to treat me?
Differentials
1. Arrhythmia
2. ACS
3. Angina
4. Pheochromocytoma
5. Hyperthyroidism
purposes only.
Peripheral Arterial Disease
You are an FY2 in A&E. Mrs. Dianna Pattinson, aged 60, presented to the hospital with
pain in her leg. Please talk to the patient, take history, assess her and discuss your initial
plan of management with the patient.
D: What brought you to the hospital? P: I have pain in my leg.

D: Tell me more about your pain? P: It is in my right leg below the knee.
D: When did it start? P: It started a few days ago.
D: Was it sudden or gradual? P: It was gradual
D: Was it continuous or comes and goes? P: It comes and goes.
D: What type of pain is it? P: It is just painful.
D: Is there anything that makes the pain better? P: Resting.
D: Is there anything that makes the pain worse? P: Whenever I am cycling
most severe pain you have ever experienced? P: It is around 6.
D: How is your other leg? P: Other leg is fine

D: Any chest discomfort? P: Yes/ No. (Fluttering sensation sometimes- AF)
D: Any change in the colour of skin? P: Yes/No (Pallor)
D: Any numbness or tingling sensation in the legs? P: Yes/No (Paresthesia)
D: Any loss of sensation? P: Yes/No
D: Any hair loss or ulcer in the legs? P: No
D: Any calf pain, redness or swelling? P: No. (DVT, PE)

Risk factors: DM, HTN, Heart disease, high cholesterol and smoking.
D: I would like to do GPE, vitals including distal pulses and examination of the leg. I would
like to do some blood tests (FBC, VBG, U&E, TFT, LFT, Troponin). I would like to order a chest
x-ray and ECG.
Examination: Vitals à B.P- 120/70, PR- 80, Spo2- 96%, RR- 18, ECG- AF
From my assessment, you have a condition called Peripheral arterial disease (PAD) which is
a common condition, in which a build-up of fatty deposits in the arteries restricts blood
supply to leg muscles. It's also known as Peripheral Vascular Disease (PVD).
purposes only.
The ankle brachial pressure index (ABPI) test is widely used to diagnose PAD, as well as
assess how well you're responding to treatment.
I will discuss the case with my senior. I will give painkiller (Morphine) to my patient. We may
have to give oxygen to our patient.
I would like to give my patient a medication to control the rate of heartbeat as the first line
management, such as a 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 may be considered to restore a normal heart rhythm
using
(A) medication such as flecainide
(B) cardioversion.
We may consider giving clopidogrel which prevents the formation of blood clots in your
arteries.
We may consider anticoagulation based on CHADVAS and HAS-BLED scoring system

We may consider further investigations like ECHO, Holter monitoring (24-48hrs) and
Ultrasound scan where sound waves can identify exactly where in your arteries there are
blockages or narrowed areas.
We may consider doing an Angiogram For detailed image of your arteries.
Give lifestyle advice to the patient.

If you develop any sudden severe chest pain, breathlessness dial 999 and come to the
hospital.
ABPI:
While you rest on your back, your GP or practice nurse will measure the blood pressure in
your upper arms and your ankles. These measurements are taken with a Doppler probe,
which uses sound waves to determine the blood flow in your arteries.
They then divide the second result (from your ankle) by the first result (from your arm).
If your circulation is healthy, the blood pressure in both parts of your body should be exactly
or almost the same, and the result of your ABPI would be one.
However, if you have PAD, the blood pressure in your ankle will be lower because of a
reduction in blood supply, so the results of the ABPI would be less than one.
DD:
Peripheral Arterial Disease
Acute Limb Ischaemia
Cellulitis
DVT
purposes only.
purposes only.
Respiratory
Dry Cough (Differential Diagnosis)
You are FY2 in the respiratory department. Mr Peter Smith, aged 70, has come to you with
a cough for the past few months. Please talk to the patient, take history, and assess the
patient's condition. After 6minutes, discuss differential diagnosis with the examiner.
D: What brought you to the hospital? P: I have had a cough for the past few months.
D: Tell me more about your cough? P: What do you want to know?
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’m 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.

D: When did it start? P: Few months now.
D: Does it get worse by doing anything?
P: When I walk/climb stairs/ lying down flat (Cardiac Asthma).
D: Do you have any other problems? P: Like what.
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/ I 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.
D: Do you have any fever/ flu like symptoms? P: No

D: Any chest infection? 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)
D: Any allergy to a food or drug? P: No.
D: Any hay fever or eczema in the past? (Asthma) P: No.
purposes only.
D: Has anyone in the family been diagnosed with any medical condition? P: No.
D: Anyone with asthma or breathing problems in the family? P: No.
D: Did you notice similar symptoms in any of your family members? (TB)
P: My son was coughing a lot while I was talking to him on skype.
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
D: Do you drink alcohol? P: Yes, 2-3 bottles of red wine in a week
D: Tell me about your diet? P: I eat everything- red meat, pork, bacon
D: Tell me about your physical activity? P: I try to walk but I get tired soon.
D: What do you do for a living? 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? P: Yes, a 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 a routine blood test, CXR.
Examination: All the examinations are normal/ Reduced breath sounds on the right side.
D/D:
TB - (Night sweats, weight loss, fatigue, fever, loss of appetite, contact with son)
Lung cancer - (Weight Loss, Fatigue, Occupational, Loss of Appetite)
Asthma - (Gardening)
Pneumonia - (Fever)
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 definitive diagnosis about what’s wrong with you because all the symptoms you
presented with can have many 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 CXR (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 a sample by introducing a
needle and analyse it in the lab.
purposes only.
We need to examine your phlegm, but as you said you don’t have any phlegm/ sputum along
with cough, we may have to do a procedure to get some sputum/ phlegm out (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 to
check 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 even take a sample of your lung. The sample will then be sent to the lab to have a
closer look.
!
Dry Cough (ACEi induced)
You are an FY2 in GP Surgery. Mr Liam Jackson, aged 52, has come to you with cough. Talk
to him and address his concerns.
One of the most important causes of dry cough is ACEi.

!
purposes only.
Cough and Shortness of Breath (PCP)
You are FY2 in medicine. Mr Michael Smith , aged 24, presented to the hospital with cough
and shortness of breath for the past few weeks. Patient is homeless and losing weight.
Please talk to the patient, assess the patient and discuss initial management with the
patient.
D: What brought you to the hospital? P: I have a cough and breathing difficulty.
D: Tell me more about the cough? P: What do you want to know?
D: May I know since when do you have the cough? P: From the past few weeks (5 weeks).
P: It was on and off when it started, but now it is becoming continuous and worse.
D: Is it becoming worse by anything? 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's worse now.
D: Does anything make it worse?
P: Walking or climbing stairs, I even have it at rest sometimes.
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 a runny nose too.
D: Any chest pain? P: Yes
D: Where is it exactly? P: It is here all over my chest (Patient points to his chest)
D: Since when? P: Since few weeks (5 weeks).
D: Is it continuous or comes and goes? P: It is always there.
D: Is there any difference from the time it started? P: It is worse now.
D: Does anything make the pain better?
P: I took PCM, but it doesn’t help/ rest helps sometimes.
D: Anything makes it worse? P: Coughing/ Breathing.
most severe pain you have ever experienced? P: 5.
D: Do you feel sick? P: Yes/ No.

D: Any vomiting? P: Yes/ No.
D: Do you feel lethargic?
P: Yes, in the past few days I always feel tired and it is getting worse.
D: Have you lost any weight? P: Yes/No.

D: How much have you lost? P: Few Kgs.
D: Have any of your friends or family told you that you are losing weight?
D: Are your clothes getting loose?
purposes only.
P: My friends/ wife told me that I lost some weight. My clothes are a bit looser than before.
D: Is it intentional? P: No.
D: Do you have Night Sweats? P: Yes/No.

D: Any Diarrhoea? P: No.
D: Any skin changes or mouth infection? (Oral thrush) P: No
Ask PMH, Lifestyle and Psychosocial history.
D: Do you smoke? P: Yes, 10 cigarettes per day since 17.

D: Do you drink alcohol? P: No.
D: Tell me about your diet? P: I eat everything.
D: Do you do physical exercise? P: I try to be active.
D: Have you been taking any recreational drugs? P: Yes, Heroine for the 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? P: What do you want to know?
D: Are you in a 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? P: I am gay/ bi-sexual.
D: What is your preferred route of sex? P: Oral, vaginal and anal.
D: What do you do for a living? P: I am unemployed.

D: Could you please tell me about your home condition?
P: I don’t have a home; I have been living on the streets for the past 2 years.
D: Have you travelled overseas recently? P: No.

I would like to send for some initial investigations including routine blood tests, ABG and
CXR.
Findings:
NEWS Chart: Temperature - 38*C, O2 Sats - 90%
Auscultation: Bilateral reduced air entry/ Bi-basal crepitations.
CXR finding: CXR shows pneumonia/ Not done yet.
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 to examine your phlegm, as you said you don’t have any phlegm/ sputum along with
purposes only.
cough, we may have to do a procedure to get some sputum/ phlegm out (saline nebulisation
and chest physiotherapy).
(BAL) to get a sample. We may have to do a biopsy of your lung to get the sample. The sample
will then be 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 by HIV. HIV spreads by 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
vessels. We will give you steroids as well to prevent damage to your lungs. We will then
taper down the dose of steroids in the 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 a needle exchange
programme if you want to enroll in it.
We will talk to social services and try to arrange accommodation for you.
DD:
PCP
Lung cancer
TB
Asthma
Pneumonia
purposes only.
Cough and Shortness of Breath (Tuberculosis)
You are FY2 in A&E. Mr Thomas Johnson, aged 29, presented with a cough and SOB. Talk to
the patient, take history, assess the patient and outline the plan of management with him.
D: What brought you to the hospital? P: I have had a cough from the last 2 months.
D: Is it becoming worse by anything? P: It got worse on its own.
D: Is there any phlegm with it? P: No/ Yes (Colour? Quantity?)
D: Did you notice any blood? P: No/ Yes (Colour? Quantity?)
D: Anything else that's bothering you? P: I have shortness of breath.

D: Tell me more about it please? P: Started at same time & getting worse.
D: Does it get worse by doing anything? P: When I walk/climb stairs.
D: Do you have any other problems? P: Like what Dr.
D: Any chest pain? P: Yes/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.
D: Have you lost any weight? P: Yes, 1 stone in the last few months.
D: How is your appetite these days? P: I don't enjoy my food.
D: Do you have any dizziness or heart racing? P: No.
D: Do you feel tired? P: Yes, just by doing simple activities.

D: Any chest infection before? P: No.

Risk Factors: History of contacts with similar symptoms, smoking and travel.

Examiner:
All the examinations are Normal/ Reduced breath sounds on the right side.
NEWS CHART:
Temperature 37.5 (38)
Pulse Rate 100
O2 Sat 94- 95
BP 110/80
purposes only.
RR >25/min
AVPU Alert
NEWS Score 5-6
X-Ray:
Increased bronchoalveolar marking in the hilar region in both the lungs predominantly on
the right side.
Tuberculosis (TB) is caused by a type of bacterium called Mycobacterium Tuberculosis.

It spreads when a person with active TB in the lungs coughs or sneezes and someone else
inhales the expelled droplets, which contain TB bacteria.

P: What is bronchoscopy?
P: Is bronchoscopy painful?
P: How are you going to treat me?
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 a sample by introducing a
needle and analyse it in the lab.
We need to examine your phlegm with a special dye to look for TB bacteria (If patient says
there is no phlegm - as you said you don’t have any phlegm/ sputum along with cough, we
may have to do a procedure to get some sputum/ phlegm out(saline 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
purposes only.
- 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.
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, 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 from spreading to your family and friends.
You should:
• Stay away from work, school or college until your TB treatment team advises you it's
safe to return.
• Always cover your mouth – preferably with a disposable tissue – when coughing,
sneezing or laughing.
• Carefully dispose of any used tissues in a sealed plastic bag.
• Open windows, when possible, to ensure a good supply of fresh air in the areas
where you spend time.
• Not sleep in the same room as other people – you could cough or sneeze in your
sleep without realising it.
!
purposes only.
Cough and Shortness of Breath (Pneumonia)
You are FY2 in A & E. Mr Daniel McCormick, aged 72, presented with cough and shortness
of breath. Talk to the patient, take relevant history, assess the patient, and discuss the initial
management plan with the patient.
D: What brought you to the hospital?

P: I have had a cough and shortness of breath from the last two weeks.
D: Does anything make it better? P: No
D: Is there any phlegm with it? 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
D: Tell me about your shortness of breath? P: Started with the cough and is getting worse.
D: Does it get worse by doing anything? P: When I walk/climb stairs
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? P: What do you want to know?
D: When did it start? P: Started with the cough.
D: Is there anything that makes the pain better? P: Nothing makes it better.
D: Is there anything that makes the pain worse? P: When I cough or take deep breath.
D: Has it changed? P: I think it’s getting worse.

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 them for 5 days.
purposes only.
D: When did it start? P: A week ago.
D: Is it getting worse? P: It is the same.
D: Do you feel sick? Vomiting? P: No.

D: Any excessive sweating? Night sweats? P: No.
D: Have you lost any weight? P: No.
D: Anyone in the family or friends told you that you are losing weight? P: No.
D: How is your appetite these days? P: It is fine.
D: Do you have any dizziness or heart racing? P: No.
D: Do you feel tired? P: Yes/ 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. 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.
D: Have you got any complications of High BP or Diabetes? P: No.
D: Heart disease, COPD (smokers cough) asthma or TB? P: No.
D: Are you currently taking any medications, over-the-counter drugs or supplements? P: No.
D: Are you taking any other medication? P: No.
D: Any long term steroids, antibiotics or chemotherapy? P: No.
D: Any allergy to any food or any drug? P: Yes, Metronidazole.
D: Any hay fever or eczema in the past? P: No.
D: Anyone with asthma or breathing problems in the family? P: No.
D: Did you notice similar symptoms in any of your family members? P: No.

D: Do you drink alcohol? P: Yes, occasionally
D: Tell me about your diet? P: I eat everything
D: Tell me about your physical activity? P: I try to walk but I get breathless.
D: What do you do for a living? P: Office job

D: Have you been exposed to asbestos? P: No
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.

purposes only.
Examiner:
All the examination is normal/ Reduced breath sounds on the right side.
News chart:
Temperature: 38-39
Pulse Rate: 110/min
O2 Sat: ≤91 % or 90%
BP: 110/80 mmHg
RR: ≥25/min
Blood Sugar: 8
CXR:
Prominent hilar markings in the central area. Round opacity in the right upper lobe.

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

We will do further blood tests to check if you have anaemia 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 to 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 are any.
We need to examine your urine and check your urine output as well.
D: We need to keep you in the hospital.

We will give you oxygen as 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.
If vitals are okay and you are sending the patient home- Please take 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 time)
● 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.
purposes only.
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).
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.
purposes only.
Elderly Confusion (Telephone Conversation - SEPSIS)
You are FY2 in Acute Medical Unit. 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 have been recorded and are as follows.
BP: 90/60 mmHg, Pulse: 120/min, RR: 24/min, Temp: 38.5, O2 Stat: 88%
Call the care home and talk to a member of care home and take history about the patient.
After 6 mins, talk to the examiner regarding the provisional diagnosis and discuss the
management in the best interest of the patient.
D: Hello
P: 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.
P: 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 was she referred to us?

P: She was confused and agitated. She was not able to breathe properly.
D: How long had she been confused? P: Since this morning.

D: Did it change? P: Yes, that’s why we sent her to the hospital.
D: Okay, when did the breathing problem start?
P: From last night and it was also getting worse.
D: Any other symptoms? P: Like what.

D: Any cough? P: Yes
D: Tell me more about her cough? P: What do you want to know?
D: Does she have this cough all the time or is it on and off?
D: Is there any phlegm with it? 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
D: Any fever flu like symptoms? P: Yes (38OC)

D: Any nausea/ vomiting? P: No
D: Any loss of appetite? P: No
purposes only.
D: Any body ache? P: No
D: Any joint/muscle pain? P: No
D: Any urine problem? P: No
D: Any diarrhoea or constipation? P: No
D: Did she have a similar kind of problem in the past? P: No
D: Has she been diagnosed with any medical condition in the past?
P: She had a stroke 3 years ago.
D: Is she taking medications for it? P: Aspirin, Enalapril and Simvastatin.
D: Does she take the medications regularly? P: Yes, we give all residents their prescribed
medication.
D: How is she managing? P: She moves around with the help of a frame.
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? P: No
D: Is she taking any other medications including OTC or supplements? P: No
D: Any previous hospital stay or surgeries? P: Yes, last year due to her chest infection.
D: How was she treated? P: She was treated with some medications.
D: Is there anyone else in the care home with a similar problem? (CAP) P: No.
D: Does she eat properly?

P: We give healthy food and she eats OK.
D: Does she drink enough water? P: Yes/No
D: Does any family member come to see her in the care home?
P: No, she is a widow. No one comes to visit her.
D: Does she have any documents in her name regarding her end of life care? P: Yes/No
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 O2 Sats are low. She
also has shortness of breath. I would like to do necessary investigations like Bloods
(FBC/U&E/LFT/Glucose/ABG/Clotting Screen/Blood Culture), Urine test, ECG, Imaging
(CXR/Abdominal USG)
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.
I will discuss with my senior and use a broad-spectrum antibiotic based on the hospital
protocol. We may consider Co-Amoxiclav 1-2g TDS IV & Clarithromycin 500mg BD IV.
purposes only.
Please talk about power of attorney, advanced directive and DNAR. !
purposes only.
Cough & Haemoptysis (Lung Cancer)
You are FY2 in the respiratory department. Mr Jacob Murphy, aged 55, has come to the
clinic because of cough and haemoptysis. Please talk to the patient, take relevant history,
assess the patient, discuss the initial management plan with the patient and address his
concern.
D: What brought you to the hospital? P: Dr. I am coughing blood again.

D: Could you tell me more about it? P: What do you want to know?
D: When did you notice blood this time? P: Yesterday
D: When did you notice it the first time? P: 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 along with the
phlegm.
D: Can you tell me more about your phlegm?

P: Clear but becomes yellow whenever I get an infection. My GP gives me antibiotics and it
becomes 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?
D: Any shortness of breath? P: Yes

D: Since when? P: 3-4 months
D: Is there anything that makes it worse? P: When I go out for a walk/on climbing stair
D: Any chest pain? P: No.
D: Any calf pain? P: No
D: Did you notice any swelling in your neck or armpit? P: No
D: Do you have any difficulty in swallowing? P: No
D: Did you notice any weight loss? P: Yes, 1 stone in the last few weeks/ No (if says no, ask
closed questions).
D: How is your appetite these days? 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.
D: Any lung problem? P: No
D: Any smoker’s cough? P: No
D: Any blood disorder? P: No
purposes only.
D: Are you currently taking any medications, otc drugs or supplements? P: No
D: Any blood thinner? P: No
D: Do you have any allergies? P: No
D: Any procedure or instrumentation through your gullet? P: No.
D: Any previous hospital stays? P: No
D: Has anyone in 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? (if no to previous question)
P: I smoked 20-40 cigarettes per day for the last 30 years. I stopped 3 months ago when I
started coughing blood.
D: Tell me about your diet? P: I try to have a good diet.
D: Tell me about your physical activity? P: I try to walk but get tired soon.
D: Did you travel overseas recently? P: No

D: What do you do for a living? P: I am a plumber
D: Have you ever been exposed to asbestos? P: Yes/No

I would like to send for some initial investigations including Routine Blood Test, Sputum and
CXR.
Examiner:
On Inspection of Hands-: 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 shaped opacity on the upper lobe
of the left 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?

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.

purposes only.
We have examined you, conducted blood tests and chest X-ray and from that, we suspect
your condition could be a serious one.
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.
(i) But can you see the round opacity here, this could be because of many causes like TB,
infections or lung cancer.
(ii) 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 it 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 CT 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 a 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.
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 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 (if exposed to Asbestos)
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 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
purposes only.
Blood thinners
Instrumentation
!
purposes only.
Cancer
Pathway
GP Specialist
2 Weeks
Admit &
Urgent Referral
Investigate
to Specialist
!
purposes only.
Asthma Wheeze (Diagnosis)
You are FY2 in GP. Mr Adam Jakes, aged 22, presented to the hospital with wheeze and
chest tightness. Take history, assess the patient, discuss diagnosis and the management
plan.
D: What brought you to the hospital? P: I have chest tightness

D: Tell me more about it? P: Started a few months ago. I get it when I play football
D: What about the other times? P: I am fine
D: Is it the same since it started? P: It is getting worse
D: Is there anything that makes it worse or better? P: Gets better when I rest
D: Do you have any other problems? P: I have wheeze

D: When did it start? P: Few months ago
D: Do you have it all the time? P: No, only when I get chest tightness
D: Do you have any other problems? P: I feel short of breath

D: When did it start? P: Few months
D: Do you have it all the time? P: When I get chest tightness
D: Do you have any other problems? P: No

D: Any cough? P: No/ Yes (Elaborate)
D: Any fever/ flu like symptoms? P: No
D: Did you have similar kinds of symptoms before? P: No

D: Have you been diagnosed with any medical condition in the past? P: Yes, Eczema
D: Any lung problem, asthma or TB? P: No
D: Any allergy to any food or any drug? P: No
P: Yes, my dad has asthma.
D: Do you smoke? P: No/ Yes

D: Tell me about your 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
D: Tell me about your home condition? P: I live in a house
D: Is your home carpeted? P: No/Yes
D: Any pets at home? P: No/Yes
purposes only.
D: Do you know about this device? P: No

D: This is peak flow meter, it is used to take Peak flow readings.
(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 makes any mistake).
The Patient's score is ____.
D: Normal Peak flow readings depend on your gender, and height.

D: May I know your height? P: ___ cm
D: Could you please confirm your age for me? P: I am 22 Dr.
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 ____.
The 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. When 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:

Headache - Simple Paracetamol
Muscle Cramps
Heart Racing
Hand Shaking
These symptoms usually pass within a few minutes or a few hours at the most and are not
dangerous.
If any of these become troublesome, please speak to your GP.
You can also try these practical tips:

purposes only.
" 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 exercises - 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 a few important things today:

" Your medication and Inhaler
" Peak flow meter and reading
" Asthma diary
" Triggers
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 to 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 in 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 if you are standing.
P: What should I record in the diary?

D:
- Your morning and evening PEFR readings.
- 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
purposes only.
- 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).
Example: You were stressed, you were doing exercise.
If we can identify your triggers and try to avoid 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 whether 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) 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. This 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.
4. Bending forward.
Technique for inhaler:

" Check the expiry date.
" Remove the cap.
" Shake the inhaler well.
" Put the mouthpiece in your mouth as you begin to breathe in which should be slow and
deep, press the canister down and continue to inhale steadily and deeply.
purposes only.
Remove the inhaler from your mouth and continue to hold your breath for 10 seconds or as
long as it is comfortable.
!
purposes only.
Asthma (Discharge)
You are FY2 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 thereafter. He recovered quickly and is stable now.
He is getting discharged today and has been prescribed 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. Lewis, 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 feel better and are getting discharged. I am here to talk
to you and 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, wheezing 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: Has 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? P: I was given a blue inhaler
D: Did you use it till now? P: Yes, 2-3 times per week
D: Did you see your GP after you were diagnosed? P: No
D: Apart from asthma, have you 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 asthma? P: No
D: Any allergy to a food or drug? P: No
D: Any previous hospital stays or surgeries? P: No
D: Has anyone in the family been diagnosed with any medical condition? P: No

D: Tell me about diet? P: I eat healthy food
D: Any change in your diet recently? P: No
D: Do you do physical exercise? P: No

D: Tell me about your home condition? P: I live in a house
D: Is your home carpeted? P: No
purposes only.
D: Any pets at home? P: No
Thank you Mr Lewis, now 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 it is used for? P: Yes, to check the function of my lungs
(If says no, 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
Patient’s PEFR is near normal. Check the reading from the chart after asking the patient’s
height and age (192 cms and 22 yrs 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. You don’t have any symptoms now, your chest examination is normal and your
peak flow reading is around 90% of the predicted value. So, you are fit to be discharged. I
will make the necessary arrangements for your discharge.
P: Thank you Dr.
D: But before you get discharged, I would like to talk to you about
" Your medications and inhaler
" Peak flow meter and readings
" Asthma diary
" Triggers for asthma
D: If at any point you have any concern, please stop me and ask me. P: Ok Dr.
D: Has anyone told you about your medications? P: No

D: No problem, I will explain them 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 a 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:
purposes only.
Headache - take simple paracetamol
Muscle cramps
Heart racing
Hand shaking
These symptoms usually pass within a few minutes or a few hours at 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 to 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 get here (show it in 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 the same
way all the time. Same if you do it while 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
purposes only.
(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.
D: If we can identify your triggers and try to avoid them, your asthma can be better
controlled. We can work on this together for you to get the 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 infections, 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 within 48 hours. Your GP will tell you whether to continue the
tablets or not.
D: You also need to see your GP regularly so that he can 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 your 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 wheezing 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:

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.
purposes only.
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 blue.
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 every 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
4. Bending forward.
Technique for inhaler:

" Check the expiry date
" Remove the cap
" Shake the inhaler well
" Put the mouthpiece in your mouth as you begin to breathe in which should be slow and
deep, press the canister down and continue to inhale steadily and deeply.
" Remove the inhaler from your mouth and continue to hold your breath for 10 seconds or
as long as it is comfortable.
purposes only.
purposes only.
PEFR Normal Values
purposes only.
!
purposes only.
Summary
Diagnose Discharge Acute
● SOB ● Signs & ● High Flow O2

● Cough Symptoms ● Nebuliser
● Chest Tight ● Chest à Salbutamol
● Wheeze Examination à Ipratropium
● PEFR ● IV Hydrocortisone
o Vitals
o Chest # Medication: Ask Senior:
o PEFR à Inhaler à IV MgSO4
àSteroids à IV Aminophylline
- Routine à IV Salbutamol
# Asthma Diary
Bloods
- CXR # Trigger
Factors
# Inhaler: # Follow Up
àBlue
à Brown
# Asthma Diary
# Spacer
purposes only.
Spacer
You are FY2 in Paediatrics. Mr Rhodes Island, 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. Please talk to her and
address her concern.
D: How can I help you?

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 the last few months.
D: 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.

D: Any cough? P: No
D: Tell me more about his asthma. P: What do you want to know?
D: How is it managed? P: He is taking an 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 them.
D: Could you please show me how are you giving these inhalers to your child?
P: Ok doctor.( she may make some mistakes so explain to 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 him 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.
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
use, 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.
purposes only.
7. Place the mask over your child’s nose and mouth. Ensure an effective seal around the
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 a 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 is 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 stick together and to the sides of the spacer, so the child
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 to 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 lukewarm 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 rub 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 recommended dose.
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.
purposes only.
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.
purposes only.
Obstructive Sleep Apnoea
You are an FY2 in GP clinic. Mr. Sloan Lewis, aged 46, has come with complaints 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: What do you want to know?
D: When did it start? P: Around 2 months ago
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, diarrhoea? (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: My sleep is ok but I feel tired when I wake up
D: How long do you sleep for? P: I sleep at 11pm & wake up at 7 am.
D: How is your sleeping environment? Is your bed comfortable? 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
D: Has anyone in your family been diagnosed with any medical condition? P: No
purposes only.
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.
D: What do you do for a living? 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
I would like to check your vitals, GPE, BMI, Neck, Chest, tummy and heart.
We will do some initial blood investigation including FBC.
From our discussion, it seems that you are feeling tired all the time because of a condition we
call as Obstructive sleep apnoea. OSA is a clinical condition in which there is intermittent and
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 overnight
with the help of special instruments. We would also like to run some blood tests to exclude
other conditions like hypothyroidism, anaemia 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 the 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
purposes only.
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 apnoea’s
and hypopneas 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 overweight), reducing the amount of alcohol you
drink and avoiding sedatives at night. These have 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:

-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
your work is disrupted as little as possible.
!
purposes only.
Neurology
Subarachnoid Haemorrhage
You are FY2 in A&E. Mrs Michelle Jenkins, aged 45, presented to the hospital with a
headache. Talk to the patient; take history, do relevant examinations and plan
management with the patient. After 6 minutes, give your management plan to the
examiner.
D: What brought you to the hospital? P: I have a headache.
NOTE: Sometimes in this station, the 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.
D: Tell me more about your pain? P: What do you want to know?

D: Where exactly do you have the pain? P: At the back/all over
D: When did it start? P: 2 hours ago
D: What were you doing when you had this pain?
P: I was watching TV and suddenly it started.
D: Was it sudden or gradual? P: It was sudden.
D: Does the pain go anywhere? P: No (Sometimes to my neck)
D: Is there anything that makes the pain better? P: I took PCM, didn’t work.
D: How much did you take? P: I took 2 tablets, didn’t help.
D: Is there anything that makes the pain worse? P: I don’t know.
the most severe pain you have ever experienced? P: 9 or 10.
D: Anything else? P: I feel sick.

D: Since when? P: Since this pain started.
D: Did you vomit? P: Yes, once.
D: Anything else? P: Like what.
D: Any problem with the light? P: Yes (Ask examiner to dim 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
D: Any fever or flu like symptoms? P: No. (Meningitis)

D: Any red eye or watery eye? P: No (Cluster headache)
D: Any band like headache? P: No (Tension headache)
purposes only.
D: Have you had a similar kind of problem in the past? P: No
P: Yes, I have had a migraine for the last 5 years but this is different Dr.
D: Are you taking any medications for that? P: Yes, I am taking that medicine which ends
with trip...
D: Are you taking it regularly as prescribed? P: Yes
D: Any other medical conditions like HTN, Polycystic kidney disease SLE? 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, Kernig sign or Brudzinski sign (Meningitis)
Examiner:
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 tests and ECG.
From our assessment, we are suspecting that you have a condition called subarachnoid
haemorrhage. It is an 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, we will do a

lumbar puncture. After confirming the diagnosis, we will shift you to a specialist
neuroscience unit (In severe cases we will shift the pt. to ICU)We will do further tests 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 a 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
purposes only.
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
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.
Patients Concern
1. 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
Sinusitis
Refractory error
Hangover headache
Trigeminal neuralgia
Uncontrolled High BP
Trauma
purposes only.
Giant Cell Arteritis
You are F2 in General Medicine. Ms Maria Davidson, aged 55, came to the hospital with a
headache. Take history, assess the patient and discuss further management with the
patient.
D: What brought you to the hospital? P: I have got a headache

D: Tell me more about your pain? P: Like what?
D: Where exactly do you have the pain? P: Points towards Left Temporal Area
D: When did it start? P: 10 days ago
D: What were you doing when you had this pain? P: I was sitting.
D: Was it continuous or comes and goes? P: continuous
D: Was it sudden or gradual? P: Gradual
D: What type of pain is it? P: Dull
D: Is there anything that makes the pain better or worse?
P: Pain increases on combing my hair and chewing.
most severe pain you have ever experienced? P: It was 5
D: What about now? P: Now it is 7.
D: Any jaw pain? Any visual problems? Any blurry vision? Any weight loss? Any decreased
appetite? Are you feeling tired these days?
D: Any pain in shoulder and pelvic area? (Polymyalgia Rheumatica) P: No

D: Any fever or flu like symptoms? P: No
D: Do you have any neck stiffness? (Meningitis) P: No
D: Do you have a Rash? P: No
D: Do you have the worst ever headache in the back of your head? (SAH) P: No
D: Do you have an 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 a red/watery eye? (Glaucoma, cluster headache) P: No
D: Do you see any line around the light? (Glaucoma) P: No

Risk factor: Smoking
I would like to check your vitals and examine your nervous system. I would like to send for
some initial investigations including routine blood tests.
From our assessment, we are suspecting you have a condition called Giant Cell Arteritis.
This is an autoimmune condition in which medium and large blood vessels, mainly in the head
and neck area become inflamed. It is sometimes called temporal arteritis as it mainly affects
vessels around the temples.
purposes only.
We will do some blood investigations to check the inflammation in your body (ESR, CRP). We
will also consider doing temporal ultrasound. We will do further tests to take some samples
from your artery to check for damage and inflammation of the lining of the vessels (Temporal
biopsy).
Before we do the investigations, we will start you on the treatment. We will give you
painkillers for your pain. We will start you on 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 lifelong.
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 are 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: Side Effects of Methotrexate:
High blood pressure Nausea

High blood sugar Vomiting
Thinning of bones (Osteoporosis) Diarrhoea
Mood changes Skin rashes
Weight gain
Indigestion and Heartburn
You have to maintain a healthy lifestyle like a good diet including calcium rich foods and
physical activity, and also smoking cessation and drinking alcohol in moderation (advice
lifestyle 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.
Patient’s Concerns:
2. What is GCA?
3. Why do I have this condition?
purposes only.
5. What are the side effects of steroids?
Tension Headache
You are FY2 in GP. Mrs Michelle Daniels, aged 45, presented with a 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 a headache.

D: Where exactly do you have the pain? P: He shows forehead (points)
D: When did it start? P: I have had it for the last 2 months.
D: What were you doing when you first had this pain?
P: I was not doing anything. Usually I have this headache after I come back from work.
D: Was it continuous or comes and goes? P: It is continuous during the evening.
D: What type of pain is it? P: It is just pain.
D: Is there anything that makes the pain better? P: After taking a glass of wine, I am fine.
D: Is there anything that makes the pain worse? P: I don’t know.
most severe pain you have ever experienced? P: 5
D: Anything else? P: Like what dr.
D: Any problem with light? P: No (Meningitis, SAH)

D: Any problem with your vision or blurry vision? P: No (SOL)
D: Any facial weakness? P: No
D: Any neck stiffness? P: No/yes.
D: Do you feel sick? P: No
D: Any history of trauma to your head? P: No
D: Any fever or flu like symptoms? P: No. (Meningitis)

D: Do you see color halos around the light? P: No (Glaucoma)

Risk factor: Stress
I would like to check your vitals, GPE and examine your nervous system.
From our assessment, we are suspecting that 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
purposes only.
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 meals, bright sunlight, noise, lack of physical exercise.
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.
From our assessment, it doesn’t seem to be a serious condition. In CT scan we have to use
radiation, 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 triggers.
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.
Patient Concerns
2. What is a tension headache?
4. I want to have a scan for my head.
Note: If a patient is demanding a CT scan try and find out the reason behind it. Do not
commit to doing a CT scan in the beginning, otherwise you may struggle to refuse the CT
scan in the end if the patient does not require it.
purposes only.
Headache (Hangover)
You are FY2 in GP Surgery. Mr Jack Daniels aged 22 presented with headache. Talk to the
patient; take history, assess her and discuss the plan of management with the patient.
D: How can I help you? P: I have a headache.
D: Tell me more about it? 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
D: Where exactly do you have the pain? P: All over my head

D: Did you vomit? P: No
D: Any problem with the light? P: No

D: Any problem with your vision or blurry vision? (SAH) P: No
D: Any facial weakness? (Stroke/TIA) P: No
D: Any fever or flu like symptoms? P: No (Meningitis)

From my 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.
purposes only.
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 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're 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.
purposes only.
Migraine
You are FY2 in GP. Miss Sam Holmes, aged 26, presented with headache. Talk to the
patient; take history, assess and discuss the plan of management with the patient.
D: How can I help you? P: I have a headache.
D: Tell me more about it?

P: I was in a concert and then this pain started on my right side.

D: For how long? P: Last few days.
D: Is there anything that makes the pain worse? P: Bright light.


D: Did you have aura before the headache? P: Yes/No
D: Any problem with your vision? P: No
D: Any tummy pain? P: No
D: Do you feel tired? P: Yes/No
D: How is your mood? P: Good/Bad


D: Have you had a similar kind of problem in the past? P: Yes/No

Triggers: Dieting too fast/Irregular meals/Cheese/Chocolates/Red Wine/ Citrus fruits/
Dehydration
D: When was your last menstrual period? P: 1 week back

purposes only.
D: Are they regular? P: Yes
D: How many days do you get bleeding? P: 3/4 days
D: Any bleeding in between the periods? P: No
D: Any headache during your menses? P: No
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.
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.
purposes only.
Sinusitis
You are an FY2 in GP Surgery. Miss Claire Jones, aged 30, has come to you with complaint
of headache. Talk to her and address her concerns.
Signs and Symptoms:
Headache, pain, swelling around cheeks, eyes and forehead, blocked nose, anosmia, fever.
Risk Factor:
Deviated nasal septum, nasal polyp, allergic rhinitis, seasonal, smoking
Examination & Investigation:
GPE, Vitals, ENT examination.
Management:
Plenty of rest
Drink plenty of fluids
Pain Killers
Cleaning your nose with saltwater solution
Decongestant nasal drops or sprays.
Steroid nasal spray or drops

Antihistaminic
Antibiotics (if bacterial infection is causing the symptoms)
Complications
Suspect acute bacterial sinusitis if:

-Symptomatic >10days
-Severe local pain, discoloured purulent discharge (with unilateral predominance)
-Fever >38OC
purposes only.
Trigeminal Neuralgia
You are an FY2 in GP. Mr Damian Oldfield, aged 60, has come to you with a facial pain.
Please talk to him, assess 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: Tell me more about it? P: What would you like to know?
D: When did it happen? P: 1 week ago.
D: What were you doing? P: I was playing golf in the cold weather.
D: Was it sudden or gradual? P: Sudden
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
the most severe pain you have ever experienced? P: It was 7 but now it is better.
D: Anything else? 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.
Treatment:
- Pain Killers (Ibuprofen/Paracetamol)
- Carbamazepine
- Gabapentin/Pregabalin
- Surgery
DD’s
Trigeminal Neuralgia
Migraine
GCA
Stroke
MS
purposes only.
Facial Drooping
You are an FY2 in A&E. Mrs Kayleigh Robbins, aged 30, has booked an emergency
appointment. She is 6 weeks post-partum. Talk to her and address her concerns.
D: How can I help you? P: I noticed drooping on my left side of the face.
D: Tell me more? P: What would you like to know?
D: What about the other side? P: Its fine
D: When did it happen?
P: It happened 2 weeks ago and since last 2 days it’s been getting bad.
D: What were you doing? P: Nothing.
D: Is there anything that makes it better? P: No
D: Is there anything that makes it worse? P: It’s getting worse on its own.
D: Any pain? P: No
D: Any hearing problem? P: No
D: Any balance problem? P: No
D: Any rash? P: No
D: Any weakness? (Stroke) P: No
D: Any fever or flu like symptoms? (Infections) P: No
D: Any trauma? P: No
D: Did you notice any weight loss? (Malignancies) P: No
D: How is your appetite these days? P: Good
D: From the notes, you have given birth 6 weeks ago. How is your baby doing? P: Good
D: Any problems during the pregnancy? P: No
D: Any high blood pressure during pregnancy? P: No
I would like to check your vitals, GPE and examine head and neck.
Treatment
- 10 days of steroid treatment (prednisolone should being within 3 days of symptoms
starting)
- Eye Drops and Eye ointments to stop the effected eye drying up.
purposes only.
Most people make a full recovery within 9 months, but it can take longer as well.
Warning Signs:
If your symptoms do not improve then please see your GP.
Concerns
Should I go for brain scan?
Will my face be symmetrical again?
Multiple Sclerosis
You are an FY2 GP. 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.
D: How can I help you? P: I have trouble seeing things.

D: Can you tell me more about that? 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
D: Is it getting worse? P: Yes
D: Is it in both the 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
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 ago with my eye problem. I feel weak and stiff all over my body.
D: Do you have any fever or flu like symptoms? P: No

D: Do you have any problem with your 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? 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: How is your sleep? P: Ok
D: Any headache? (GCA) P: No

D: Any cough? (Sarcoidosis) P: No
D: Any shortness of breath? (GBS) P: No
D: Any backpain? (Myelopathy) P: No
purposes only.
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
P: My mother has MS. She was diagnosed in her late 20’s.
I would like to do GPE, vitals and examine your eyes and hands. I would also like to run some
routine blood test like LFT, TFT, KFT, Calcium and Vit 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 and LP to confirm the diagnosis.
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 effected like it is in your case for which high dose
steroids need to be given.
Steroids:
Treatment for a relapse either:
- Oral à 5-day course of tablets taken at home
- Injection à 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:
• Physiotherapy
purposes only.
• Occupational therapy
• Speech therapy
• Specialist nurse advice 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.
Transient Ischemic Attack (TIA)
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 her body, slurred speech, drooping of the angle of
her mouth and difficulty in swallowing. Patient’s symptoms improved after 2 hours. Patient
is completely fine now. Patient cannot remember what happened 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 tests have been done and results are awaited. Please
talk to her husband, take history and discuss your further management with him. Consent
has been taken from the wife to talk to the husband.
D: Hello Mr. Jones. I am here to talk to you about your wife’s condition.
But before I do 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 face drooped on her right side and she
couldn’t move her right arm. I got scared and called the ambulance.
D: You did the right thing; it’s very good that you called an ambulance and brought her here.
D: Could you please tell me when this happened? 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 a 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 a blurry vision? P: I don’t think so
D: Did she have any problem with the balance and coordination?
P: No/ I don’t think so as we were sitting.
D: Did she understand what you were saying to her? P: Not properly.
D: Has she had a 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 has she had this problem? P: More than 10 years now.
D: How is it managed? P: It is controlled on diet.
D: Is she taking any medications for that? P: No
purposes only.
D: Is it well controlled? P: She is seeing her GP regularly
D: Does she have any diabetes related complications such as foot problems or eye
problems? 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 have any abnormal heart beats? P: No
D: Does she take any medications including OTC or supplements? P: No
D: Any history of heart disease or stroke in the family? P: No
D: Does she smoke? P: Yes/no
D: Does she drink alcohol? P: Yes/no
D: Tell me about her diet? P: Good diet, including 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 examinations and neurological
examinations were normal, only her blood pressure was on the higher side.
We are suspecting a condition called TIA (Transient Ischemic Attack). Transient Ischaemic
attacks occur when there is a temporary disruption in the blood supply to a part of the 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 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.
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
may consider doing an MRI scan.
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 find significant
narrowing, then we may have to do surgery (Carotid endarterectomy).
We may consider a CT scan.
purposes only.
Give general advice about lifestyle accordingly.
If your wife has any facial problem, arm weakness, slurred speech please dial 999 and 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 forms elsewhere in your body, mainly in the heart and travels 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.
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?
Symbol Clinical feature Criterion Point

A Age >= 60 1
B Blood pressure >= 140/90 mmHg 1
C Clinical features of the TIA unilateral weakness 2
speech disturbance without weakness 1
D1 Duration of symptoms >= 60 min 2
10-59 min 1
<10 min 0
D2 Diabetes diagnosed with diabetes? 1
ABCD2 Score:
4 and above- admit and TIA Clinic appointment within 24 hours.
Less than 4: To be seen in TIA clinic within a week.
Now every patient should be seen by the specialist within 24 hours regardless of ABCD2
score.
purposes only.
Guillain-Barré Syndrome
You are FY2 in GP. Miss Andrea Downing, aged 33, presents with difficulty in walking since
the last few days. Please talk to the patient, take focussed history, assess the patient and
discuss further management.
D: What brought you to the hospital? 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
D: When did it start? P: Few days ago.
D: Was it sudden or gradual?
P: It started with my feet and hands and now I feel numb everywhere.
D: Was it continuous or comes and goes? P: It is continuous. (MS – comes and goes).
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)
D: Do you have any other problems? P: like what?
D: Do you have pain anywhere? P: I have pain in my back.

D: Where is the pain exactly? P:(Points)
D: Since when have you had this pain? P: Since the last few days.
D: Do you have fever? (Vasculitis) P: No

D: Have you had a fever recently? P: Yes, I had the 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: Is there anything that makes the pain worse? P: Walking
most severe pain you have ever experienced?
P: It was 6 but now it is better.
D: Any vision problem? (MS, Myasthenia) P: No

D: Any heart racing? P: No
D: Any problems with speaking? P: No
D: Any problem in swallowing? P: No
D: Any problem with the bowels? P: No
D: Any problems with urination? P: No
D: Any problem with balance? P: No
D: Have you had any similar problems in the past? P: No
Ask about PMH, Lifestyle and Psychosocial.
D: Have you recently eaten out or had any canned food? (Botulism) P: Yes/No
purposes only.
D: Any chance you are pregnant? P: Yes/No
I would like to check your vitals and do a neurological examination.

I would like to send for some initial investigations including routine blood tests, electrolytes
and ECG.
Examiner: 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
your back and send it off to the lab. (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). We will need to do Nerve Conduction
Studies. (They 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). We will see how well your lungs are doing (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-Barré 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-Barré syndrome affects people of all ages,
but your chances of getting it increase as you get older.
D: Guillain-Barré syndrome is thought to be caused by a problem with the immune system,

the body's natural defence against illness and infection.
Normally the immune system attacks any germs that get into the body. But in people with
Guillain-Barré syndrome, something goes wrong and it mistakenly attacks and damages the
nerves.
It's not clear why this happens, but it can be triggered by:
● an infection, such as food poisoning, flu or cytomegalovirus
● vaccination, such as the flu vaccine (but this is extremely rare and the benefits of
vaccination outweigh any risk)
● surgery, a medical procedure or an injury
Dr: Most people with Guillain-Barré syndrome are treated in hospital. We need to admit you
to the hospital for treatment. Neurologist will come and see you and talk to you.
The main treatments are:

purposes only.
● Intravenous immunoglobulin (IVIG) – a treatment made from donated blood that helps
bring your immune system under control. It is injected through your veins.
● 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.
● 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-Barré 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:
● being unable to walk without assistance
● weakness in your arms, legs or face
● numbness, pain or a tingling or burning sensation
● balance and coordination problems
● extreme tiredness
Therapies such as physiotherapy, occupational therapy and speech and language therapy can
help you recover and cope with any lasting difficulties.
Very occasionally, Guillain-Barré syndrome can cause life-threatening problems such as

severe breathing difficulties or blood clots. Overall, around 1 in 20 cases is fatal.
D: If you develop any sudden breathing difficulty, swallowing, speaking or severe pain in legs
please dial 999 and come to hospital.
P: What is going on?

P: Can I go home?
P: Will I get better?
P: Will I die because of this problem?
Differentials:
GBS
Myasthenia Gravis
Multiple Sclerosis
Botulism
Polymyositis
purposes only.
Encephalitis
You are F2 in A&E. Mr. Peter Andre, 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 behaviour and saying
strange things. He is now confused, drowsy and agitated. He is not unconscious. Patient has
had a 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.
D: How may I help you? P: 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. I
need to ask you a few questions if you don’t mind. P: Ok Dr.
D: Could you please tell me exactly what happened?
P: 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 more about it? P: He just started having jerky movements all over his body.
D: How long did it last? P: 1-2 mins
Before:
D: How was he feeling before the fit?
P: He was a bit unwell & feeling hot since the past 2 days.
D: Did he do anything for his fever? P: He took paracetamol.
D: Did you do anything for it? P: No, I thought it will go away on its own
D: Was he experiencing anything else before the fit? P: No.
D: Any headache? P: Yes / No
D: Any sickness or vomiting? P: No
D: Any difficulty or pain moving his head and neck? P: No.
D: Any rash anywhere on his body? P: No.
D: Was he shying away from the light? P: No.
D: Did he have any sore throat or runny nose? P: No
D: Did he hurt his head in the past few days? P: No
During:
D: Did he lose his consciousness? P: No.
D: Was there any strange feeling before the fit started? P: No.
D: Did he have up-rolling of the eyes during the fit? P: No.
D: Did he bite his tongue? P: No.
D: Did he wet himself? P: No.
D: Did he hurt himself? Were there any injuries on any part of his body? P: No.
After:
D: Could you tell me what happened after the fit?
purposes only.
P: 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?

P: Yes, he was confused. He was hallucinating and acting strange.
D: Was he drowsy? P: Oh yes, he was drowsy.
D: What did you do after that?
P: I panicked, called the ambulance and brought him to the hospital.
D: You did the right thing.
D: Did he have a similar kind of problem in the past? P: No, first time
D: Has he been diagnosed with any medical condition in the past? P: No
D: Any epilepsy, diabetes or neurological problems? P: No
D: Is he currently taking any medications, OTC drugs or supplements? P: No
D: Any allergies from food or medications? P: No
D: Any family member with a similar problem? P: No
D: Any member of the family diagnosed with epilepsy? P: No
D: Does he smoke? P: No
D: Does he drink alcohol? P: No
D: Any recreational drugs? P: No
D: Tell me about his diet? P: He eats healthy food
D: Tell me about physical exercise? P: He is quite active
D: Does he have any kind of stress? P: No
D: By any chance are you aware if he is sexually active? P: No
D: Did he travel abroad recently? P: No.
D: Has he had contact with any ill patient? P: No.
I would like to check his vitals and do a neurological examination.

I would like to send for some initial investigations including a routine blood test to check for
any infection.
Examination Report:
Vitals:
BP: 100/80
HR: 90
O2 Sat: 95%
Temperature: 38
RR: 12-20
Blood sugar: Normal
Physical Examination:
Patient is confused and drowsy.
Neurological Examination:
purposes only.
GCS is 14.
There is no photophobia.
There are no rashes.
There is no neck stiffness.
Brudzinski’s sign is negative.
Kernig’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:
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 let me assure you that he is in good hands. Let me tell you what
we have done for him.
We did a scan of his brain (CT) and fortunately it's normal.
We did another investigation called lumbar puncture in which we removed some fluid from
around his spine and then examined the sample under a 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, 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 the 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.
purposes only.
We need to find the underlying cause, relieve his symptoms, 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 find any blistering rash, then we can also take a swab
sample. We may also consider doing a tracing of the brain called EEG to look for any
abnormal brain activity. We may consider doing an 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 is 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 it 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).
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.
purposes only.
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, specialised
services are available to aid recovery and help him adapt to any persistent problems, this is
known as rehabilitation.
He can get support from:

" A neuropsychologist who is a specialist in brain injuries and rehabilitation.
" An occupational therapist who can identify problem areas in your son’s everyday life and
work out practical solutions.
" A physiotherapist who can help with movement problems.
" A speech and language therapist who can help with communication.
Before leaving the 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.
However, this depends on how well the treatment works and if any complications of
encephalitis occur.

P: Is it a serious condition, doctor?
P: Why has he got this problem, doctor?
D: 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
purposes only.
SOL
Meningitis
purposes only.
Head Injury (Adult)
You are FY2 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 management with the patient.
D: What brought you to the hospital? 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 & suddenly I fell down & became
unconscious.
D: When did it happen? 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 and opened my eyes when I was in
the ambulance.
D: Did you drink alcohol in the restaurant? P: Yes, we drank 2-3 glasses of wine together.
Before
D: How were you feeling before the fall? P: I was fine.
D: Any fever or flu like symptoms? (Meningitis) P: No
D: Any neck stiffness? 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
During
D: For how long you were unconscious? P: I am not sure.
D: Any jerky movements during the fall? P: No
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
After
D: What happened after the fall?
P: Doctor, I regained 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
D: Have you had a similar kind of fall in the past? P: No
D: Any DM, HTN or heart disease? P: No
purposes only.
D: Any epilepsy or stroke? P: No
D: Any blood thinners? P: No
D: Any allergies from food or medications? P: No
D: Any member of the family with any DM, HTN, heart disease, stroke, epilepsy or blood
disorder? P: No

D: Do you drink alcohol? P: Social drinker
D: Do you do physical exercise? P: Yes/No
D: Tell me about your diet? P: Good/Bad
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 tests and ECG.
Examiner:
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 do a CT scan of your head to check for any bleeding.
We will shift you to the observation unit for a closer look. If we find any bleeding, then we
may need to do an operation on your head to remove the blood clot.
If all the tests including CT scan come back normal, we will discharge you but advise 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.
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, please call 999
and ask for an ambulance.
Criteria for performing a CT scan for adults
CT scan head should be performed within 1 hour if:

1. GCS less than 13 on initial assessment in A&E.
2. GCS less than 15 at 2 hours after head injury on assessment in A&E.
3. Suspected open or depressed skull fracture.
purposes only.
4. Any sign of basal skull fracture (haemotympanum, panda eyes, cerebrospinal fluid
leak from ears or nose, battle sign.)
5. Post-traumatic seizure.
6. Focal neurological deficit
7. 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”.
!
purposes only.
Postural Hypotension
You are F2 in A&E. Mrs. Elizabeth Marley, aged 72, has been brought to the hospital with
fall. Please talk to the patient, take history, do relevant examinations and discuss
management with the patient. Patient doesn’t have her medications on her. You will find
extra information in the cubicle.

P: I am falling frequently these days. It has been happening for the 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: What do you mean by dizziness? P: What do you mean?
D: Is it a spinning sensation (true vertigo) or light headedness (Postural Hypotension)?
P: Light headedness
D: How many episodes of fall till now? P: 3 episodes in the last few days.
D: Was there any difference in all the falls? P: No
Before
D: Any other symptoms before the fall? P: No
D: Any visual problem like blurry vision? P: No.
D: Any heart racing? P: No.
D: Any feeling of fullness in the ears? P: No
D: Any balance problem while walking? P: No
D: Any fever/flu like symptoms? (Confusion, Pneumonia, UTI) P: No
During
D: Any loss of consciousness? P: No.
D: Did you hurt yourself? P: No.
D: Any jerky movements? P: No
After
D: Any vomiting? P: No.
D: Were you feeling sleepy or drowsy in the ambulance? P: No
P: Yes, I have had high blood pressure for the 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 change in mediation? P: Yes, my GP changed it 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
D: Are you taking any other medications including OTC or supplements? P: No
purposes only.
D: Any allergies to any food or medications? P: No
Ask about lifestyle and psychosocial.
I would like to check your vitals, BP while standing and lying down, and examine your chest
and nervous system. I would like to send for some initial investigations including routine
blood tests, blood sugar and ECG.
Examination:
BP standing- 110/70, BP lying- 150/90, PR- 80, T- 37, RR- 12-20, O2 Sat- 96
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 found a significant difference in lying and standing BP.
We also did ECG and fortunately it came back normal.
This can be because of the new blood pressure medication that your GP changed 3 weeks
ago, so we need to confirm it with your GP and change your blood pressure medication
accordingly. (You can’t let her go home if she is living alone). Please avoid sudden changes in
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 meals. Avoid excess alcohol (If she drinks). Follow up with your GP
regularly.
If you develop any weakness on 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.
Orthostatic hypotension is defined as a fall in systolic blood pressure of at least 20 mmHg

(at least 30 mmHg in patients with hypertension) and/or a fall in diastolic blood pressure
of at least 10 mmHg within 3 minutes of standing. When orthostatic hypotension has an
underlying neurogenic cause (e.g., peripheral neuropathy) it is associated with a blunted
increase in heart rate.
Differentials:
Anaemia
DM, Hypertension
Visual impairment
Transient ischemic attack
Tachyarrhythmias or bradycardia,
Confusion (UTI, Pneumonia, Constipation)
purposes only.
Medications: especially benzodiazepines, antidepressants, and antipsychotics, alpha-
blockers, antipsychotics, antihypertensives, diuretics, beta-blockers.!
purposes only.
Fall & Hip Fracture
You are F2 in Surgery. Mrs. Sharon Osborne, 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 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 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 I fell.
D: Let me ask you some questions to find out the cause and to see how we can prevent this
from happening again. P: Ok.
D: Could you please tell me when you had the fall? P: It happened 3-4 days ago.
D: Could you please tell me how it happens?
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.
Before
D: Any other symptoms before the fall? P: No
D: Did you feel spinning sensation (true vertigo) or light headedness (Postural Hypotension)
P: No
D: Any visual problem like blurry vision? P: No.
D: Any feeling of fullness in the ears? P: No
D: Any balance problem while walking? P: No
D: Any fever/flu like symptoms? (Confusion, Pneumonia, UTI) P: No
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: 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 Haemorrhage) P: No.
D: Have you recently been constipated? P: No
During
D: Do you remember what exactly happened during the fall? P: I don’t remember.
D: Any loss of consciousness? P: No.
After
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 after the fall? P: No.
D: Did you feel sick? P: No.
D: Did you vomit? P: No doctor.
D: Has this happened before? P: No/Yes (If yes then elaborate)

purposes only.
D: Have you ever been diagnosed with any medical conditions?
P: I have high blood pressure and arthritis.
D: May I know since when have you been diagnosed with high blood pressure?
P: I was 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? 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: Do you wear 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: Is there a chance you might have loose carpets? P: No.
D: Does the house have enough light? P: Yes
D: Are you physically active? 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 a Routine blood test, Urine dip test and ECG.
From my assessment, we need to do some examinations and run some investigations.

1. The reason for fall is a change in blood pressure in different positions. So, we need to
check your blood pressure lying down and standing. (Postural Hypotension)
2. Sometimes anaemia or infections can cause a fall. So, we need to check your blood and
urine. (Anaemia, 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 for 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 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.
purposes only.
Our colleague’s occupational therapist can come and visit your place to do the necessary
changes to prevent falls in the future.
!
purposes only.
Vestibular Neuritis
You are FY2 in A&E. Victoria Snape, 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 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 still feel dizzy (ODIPARA)

D: What do you mean by dizziness? P: It is like the room is spinning.
D: When did this start? P: 1-2 hours ago
D: Is it continuous or does it come and go? P: It is continuous.
D: Anything that makes it better? P: No.
D: Anything that makes it worse? P: No.
D: Does it change when you move your head and neck? P: No.
D: Anything else? P: I am feeling sick.
D: When did it start? P: It started with dizziness
Before
D: Any other symptom before having the fall? P: No.
D: Any fever or flu like symptoms? (Vestibular neuritis)
P: Doctor, 10 days ago I had a sore throat and took Paracetamol for it.
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
During
D: Did you go unconscious during the fall? P: No.
D: Did you have any jerky movements? P: No.
After
D: What happened after the fall? P: I was fine.
D: Did you feel confused, drowsy or sleepy after the fall? P: No.
D: Did you injure yourself? P: No
D: Did you bang your head on the floor? P: No
Ask about PMH, Lifestyle and Psychosocial History.
purposes only.
D: I would like to check your vitals and examine your heart, conduct an ENT examination,
hearing test and central nervous system examination.
Examiner:
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 sends 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 but 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:
Avoid alcohol, avoid bright lights and try to cut out noise and anything else 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 starts to settle, you should gradually increase 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.
purposes only.
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 Neuritis:

Your GP may prescribe medication for severe symptoms, such as:
1. 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
2. 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.
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?
Differentials:
Vestibular neuritis
Labyrinthitis
Meniere’s Disease
Meningitis
Migraine)
Acoustic Neuroma
SOL
TIA
Ototoxicity
Gentamicin/anticonvulsants
Anaemia
Postural hypotension
Hypoglycaemia
purposes only.
Benign Paroxysmal Positional Vertigo (BPPV)
You are an FY2 in GP. Mr Liam Jackson, aged 45, has come to you with dizziness. Please
talk to him, assess him and address his concerns.
D: How can I help you? P: I feel dizzy

D: What do you mean by feeling dizzy? P: I feel everything around me is spinning.
D: Tell me more about it. P: What would you like to know?
D: Since when have you been feeling dizzy? P: Since 4 to 5 days.
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, I feel dizzy.
D: Anything else? P: I felt sick
D: Any vomit? 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) P: No
D: Did you hurt yourself? P: No
D: Any weight loss? P: No
During
After
D: How did you feel after the incident? P: Fine
D: Any confusion? P: No
D: Any drowsiness? P: No
D: Any nausea or vomiting? P: I felt nauseas but didn’t vomit.
D: Were you able to recall the incident? P: Yes
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.
purposes only.
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 a week later 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 and 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.
Concerns:
Is it serious?
Will it go away?
Is there any treatment?
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.
purposes only.
Unilateral Tinnitus
You are an FY2 in GP. Mr Kieran Richards, aged 40, has come to you with complaints of
hearing noises. Talk to him, assess and address his concerns.
D: What brought you to the hospital? P: I have been hearing noises in my ear.
D: Which ear? P: Right ear
D: Tell me more about this? P: What do you want to know?
D: When did it start? P: It started 3 years ago
D: Did it start suddenly or gradually? P: Gradually
D: 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
D: Is it becoming worse by anything? P: It gets worse when I go to sleep.
D: Does anything make it better? P: Yes/No
D: Do you have any other problems? P: Like what?

D: Any hearing loss? P: No
D: Any vertigo/dizziness? P: No
D: Any earache? P: No
D: Any discharge from your ear? P: No
D: Does the ringing sound coincide with your pulse? P: No
D: Any DM and HTN? P: No.
D: Do you smoke? P: No
D: Do you take alcohol P: No
D: Tell me about your diet? P: I eat everything, its fine.
D: Tell me about your physical activity? P: I am active
D: What do you do for a living? P: Office job.
D: Tell me about your home condition? P: I live in a house.
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
instrument called an otoscope to look inside the ear, and I would also like to do hearing
tests and balance tests. We will also do some initial investigations.
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.
purposes only.
Treatment:
Things you can try to help cope with tinnitus
Do’s
● 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:

● 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 is available with people with severe or persistent tinnitus. It's
unclear if tinnitus retraining therapy works for everyone.
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.
purposes only.
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: Tell me more this? P: What do you want to know?
D: Did it start suddenly or gradually? P: Suddenly

D: Does it come and go? P: Yes.
D: Is it becoming worse by anything? P: It gets worse when I stand up suddenly.
D: Does anything make it better? P: It gets better when I lie down.
D: Do you have any other problem? P: Like what.

D: Any nausea? P: Yes
D: Any hearing loss?
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
Ask about PMH and lifestyle history.

D: Do you live alone? P: Yes.
D: Any recent travel? (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.
I will also be sending for FBC, ESR, thyroid function, syphilis screen, fasting glucose, renal
function, lipids as well as an MRI.
Management:
There is no cure for this disease.
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 are:
• prochlorperazine, which helps relieve severe nausea and vomiting
• antihistamines, which help relieve mild nausea, vomiting and vertigo
purposes only.
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.
You may be offered:

• counselling – including cognitive behavioural therapy (CBT)
• Relaxation therapy – including breathing techniques and yoga
At the first sign of an 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.
Things to avoid:
low-salt diet, alcohol, caffeine, 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's 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:
- 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 suit your needs
DD’s:
Migraine
Ear infections
Vestibular Neuronitis and Labyrinthitis
purposes only.
!
purposes only.
Gastroenterology
Blood Test Results (Hepatitis)
You are the FY2 in general medicine. Mrs. Diana Williams, aged 47, came to the hospital to
discuss her blood report. Please talk to the patient, take a focused history, discuss lab
reports and your management plan with the patient. Please address the patient’s concerns.
Patient’s blood result is ready, and the results are as follows:
Test Result Normal

ALT 530 5-35
ALP 83 30-150
AST 110 5-35
Bilirubin 35 3-17
D: What brought you to the hospital? P: I'm here for my blood results.
D: I have your blood results. I will explain them to you shortly but is it alright if I ask you
some questions first? P: Ok.
D: Could you please tell me why you had these blood tests? P: I was retching.
D: I see. May I know since when have you been experiencing retching?
P: I have had this for the last few weeks.
D: Is it the same or getting worse? P: It is getting worse, doctor.
D: Do you have any other problem with it? P: I have a tummy pain, doctor.
D: Tell me more about your pain? P: It is just a discomfort, doctor
D: Where exactly do you have the pain? P: (Points towards RUQ).
D: When did it start? P: The last few weeks.
D: What were you doing when you first had this pain? P: Dr, I was just sitting.
D: Is it continuous or comes and goes? P: It is continuous Dr.
D: Was the onset sudden or gradual? P: It was gradual.
D: What type of pain is it? P: It is a dull kind of pain.
D: Does the pain go anywhere? P: No Doctor.
D: Is there anything that makes the pain better? P: Not Dr.
D: Is there anything that makes the pain worse? P: No Doctor.
most severe pain you have ever experienced? P: It is around 3, doctor.
D: Any other symptoms? P: I have nausea.

D: Since when? P: All these started at the same time.
D: Any other symptoms? P: Like what.

D: Have you noticed any yellow discolouration of your skin? P: No.
purposes only.
D: Have you noticed any change in the colour of urine and stool? P: No.
D: Do you have any itching? P: No.
D: Do you feel tired these days? P: No/Yes.
D: How is your appetite? P: It is Ok.
D: Any Diarrhea? P: No.
D: Do you have any fever? P: No.
D: Any flu-like symptoms? P: Yes/No.
D: Have you had a similar kind of problem in the past? P: No.
D: Any DM, Cholesterol, liver or gallbladder problems? P: No.
D: Have you had any blood transfusion before? P: No.
D: Do you smoke? P: No/Yes

D: Do you drink alcohol? P: Yes, a bottle of wine on the weekend.
D: Do you go out to eat? P: Yes, with my family.
D: Anyone in the family with the same problems? P: No
D: Any needle stick injury? P: No
D: Any tattoo or piercing at all? P: No
D: Are you sexually active? P: Yes

D: Do you have a stable partner? P: Yes, I live with my husband.
D: Any other partner at all? P: No
D: Do you practice safe sex? P: No/Yes
D: I would like to check your vitals and examine your tummy.
Examiner:
Patient has jaundice and mild tenderness on the right upper quadrant.
D: Let me explain the results first.

Show the blood reports to the patient and explain properly.
1. This ALT and AST will increase if the cause of hepatitis is a bug or virus. As you can see in
your case, both are increased.
2. This ALP will increase if the cause of hepatitis is any obstruction. In your case, it is normal.
3. This bilirubin will increase if there is anything wrong with your liver. As you can see in
your report, it is increased.
purposes only.
4. You told me that you drink alcohol occasionally only on weekends, so alcohol is probably
not the cause of your problem.
D: From our assessment, we are suspecting that you have a condition called viral hepatitis
which is swelling and inflammation in your liver.
I would like to order a Serology Test to look for hepatitis A antibodies.

Finding by examiner: Most of the time the examiner keeps quiet, however, sometimes the
examiner says, “Hepatitis A IgM antibody has been found.”
Hepatitis A IgM antibodies can be found as early as two weeks after the first infection.
They disappear 3-12 months after infection.
Hepatitis A IgG antibodies appear 8-12 weeks after you are first infected. They stay in the
blood and protect the body from hepatitis A permanently.
Hepatitis has many causes. It can happen because of a bug or when the liver has been exposed
to harmful substances such as alcohol and medications for a long time. Obstruction due to
gallstones can also cause hepatitis. In your case, it seems that the cause of your hepatitis is a
bug. We call this a viral hepatitis.
We did some blood tests to see how well your liver is functioning. We need to do some more
blood tests to see which bug can cause your condition. In this test, we look for the substance
called antibody, which is produced by our body to fight against bugs, that causes this
condition. We will also do ultrasound to see the structure of your liver.
This condition is usually self-limiting and subsides on its own but we need to treat your
symptoms. You told me you have been feeling sick. So, eat smaller and lighter meals and avoid
rich and spicy food. We may even prescribe you some anti-sickness medications, if needed.
We don’t give painkillers for liver problems. However, we will consider giving you some simple
painkillers like PCM, if needed.
It would be great if you could stop drinking alcohol for a while, as it puts additional strain on
your liver. We will tell you when you may resume your drinking. In the first few days, you may
feel tired, so please get plenty of rest.You can reduce itching by maintaining a cool ventilated
environment. Wearing loose clothes, avoiding hot baths can be helpful in this condition.
Advice safe sex and no blood transfusion.
The incubation period of hepatitis A is usually 14–28 days.

The incubation period of hepatitis B is usually 1.5 to 6 months (average 4 months)
The incubation period of hepatitis C is usually 14–180 days.
DD:
Alcoholic Hepatitis
Hepatitis A
Hepatitis B/C
purposes only.
Non-Alcoholic Fatty Liver Disease (NAFLD)
Drug Induced Hepatitis
Autoimmune Hepatitis
purposes only.
Abnormal LFT (Gilbert Syndrome)
You are an F2 in GP. Adam, aged 25, has come to the clinic to find out his blood test
results. Please talk to the patient, discuss the blood results and address his concerns.
Test Result Normal Range
AST 20 5-40 IU/L
ALT 30 5-40 IU/L
ALP 70 30-150 umol/L
GGT 44 38-50 g/L
Albumin 15 <21 umol/L
Bilirubin 39 1.7 – 20.5 mcmol/L
Direct bilirubin Normal 1.7 – 5.15 mcmol/L
Indirect bilirubin Elevated 3.4 – 20.5 5mcmol/L
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 results with you, may I
ask a few questions? P: Sure
D: May I know why you got these tests done? P: My wife asked me to get them 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
D: Any yellowish discolouration of your skin or eyes? P: No
D: How has your health been recently? P: Good
D: Any flu-like symptoms? P: Yes/No

So, the blood test done to check the function of your liver shows that a substance called
unconjugated bilirubin is elevated in your blood. It 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.
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 a normal healthy life.
Life expectancy is not affected. 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 with an infection, starvation or stress.
Other than inheriting the faulty gene, there are no known risk factors for developing Gilbert's
syndrome. It's not related to lifestyle habits, environmental factors or serious underlying liver
problems, such as cirrhosis or hepatitis C. Gilbert syndrome is a genetic disorder that runs in
the families. People with the syndrome have a faulty gene which causes the liver to have
problems removing bilirubin from the blood.
purposes only.
DD’s: Gilbert Syndrome, Hepatitis, Haemolytic Anaemia, Thalassemia, Drug Induced
purposes only.
Alcoholic Hepatitis
You are an FY2 in Medicine. Mrs Janet Molly, aged 40, came for the blood reports.
Bilirubin – Normal
ALT – Normal
AST – 63 (Raised)
Explain to her the blood results and address her concerns.

P: I am here for my blood results.
D: Why did you have the blood test done?

P: I turned 40 and that’s why I wanted my routine blood check done.
D: Do you any active symptoms? P: Like what?

D: Do you have any tummy ache? P: No
D: Any nausea? P: No.
D: Have you noticed any yellow discolouration of your skin? P: No.
D: Have you noticed any change in your colour of urine and stool? P: No.
D: Do you have any itching? P: No.
D: Do you feel tired these days? P: No/Yes.
D: How is your appetite? P: It is Ok.
D: Any Diarrhea? P: No.
D: Do you have any fever? P: No.
D: Any flu like symptoms? P: Yes/No
D: Have you been feeling drowsy recently? P: No
D: Anyone in the family with the same problems? P: No

D: Any needlestick injury? P: No
D: Any tattoo or piercing at all? P: No
D: Do you have a stable partner? P: Yes, I live with my husband.
D: Any other partner at all? P: No
D: Do you practice safe sex? P: No/Yes
D: Any traveling recently? P: No
D: I would like to check your vitals and examine your tummy.
Show the blood reports to the patient and explain properly.

1. AST levels increase when there's damage to the tissues and cells where the enzyme is
found. As you can see in your case, it is raised
purposes only.
2. This ALP will increase if the cause of hepatitis or any obstruction. As you can see in your
case it is normal.
3. The bilirubin is normal in your case as well.
4. You told me that you drink alcohol every day and more so on weekends so possibly
alcohol can be the cause of your problem.
D: From our assessment, we are suspecting you have a condition called hepatitis which is
swelling and inflammation in your liver. Hepatitis has many causes. It can happen as a result
of bug or when liver has been exposed to harmful substance such as alcohol and
medications for a long time. Obstruction such as gallstone can also cause hepatitis. In your
case, it seems the cause of your hepatitis can be excessive alcohol intake.
We did some blood test to see how well your liver is functioning. We need to do some more
blood test such as serum GGT. We will also do ultrasound to see the structure of your liver.
The liver damage associated with mild alcoholic hepatitis is usually reversible if you stop
drinking permanently. The main treatment is to stop drinking, preferably for the rest of your
life. Hence, it would be great if you could stop drinking alcohol as it put additional strain on
your liver. This reduces the risk of further damage to your liver and gives it the best chance
of recovering.
If you are dependent on alcohol, stopping drinking can be very difficult.
But support, advice and medical treatment may be available through local alcohol support
services.
We may prescribe you some anti-sickness medications if needed.

We don’t give painkillers in liver problem. However, we will consider giving you some simple
painkillers like PCM if needed.
Concerns: Alcohol withdrawal
purposes only.
Constipation (Talk to the Patient)
You are FY2 in Orthopaedics. Mrs Julia Patterson, aged 70, has been admitted to the
hospital. She had a hip replacement 7 days ago because of a fracture of the neck of femur.
She hasn’t passed any stool since she was admitted. Patient has received Co-codamol for
pain. Her pain is controlled now, and she is stable. Please talk to the patient, take history,
assess patient condition, discuss plan of management and address patient concerns.
Constipation (Talk to the Nurse)
You are FY2 in Orthopaedics. Mrs Julia Peterson, aged 85, fell in her house 1 week ago and
sustained a T4 fracture. She was admitted to the hospital. Your nurse colleague, Amy Lopez,
has some concerns about the patient. Talk to the nurse, address her concerns, and discuss
management plans for the patient.
D: What brought you to the hospital? P: I am having constipation.

D: Please tell me more about it? P: What do you want to know?
D: Since when have you had constipation?
P: I have had it since about a week now. I had a surgery on my hip. Since then, I have had it.
D: Are you able to pass wind? P: Yes, but a little bit. (Obstruction)
D: When was the last time you passed wind? P: An hour ago Dr.
D: How was your bowel habit before? P: Fine Dr, I used to go once daily.
D: Do you have any other symptoms? P: I have tummy discomfort since last week
D: Tell me more about it? P: It is around the belly button.
D: Is it continuous or intermittent? P: Continuous
D: Do you have any other symptoms? P: No.

D: Any stomach cramps? P No
D: Do you feel bloated? P: No
D: Do you feel sick? P: No

D: Have you vomited? P: No (Obstruction)
D: Did you notice any bleeding from your back passage? P: No (Cancer, fissure)
D: Do you get the feeling of opening the bowel, but nothing comes out when trying to open?
P: No (Tenesmus for cancer)
D: Do you have diarrhea along with the constipation? P: No (Cancer)
D: Have you noticed weight loss? P: No
D: Has anyone told you that you are losing weight? P: No
D: How is your appetite these days? P: My appetite is good.
D: Do you feel tired or dizzy? P: No
D: Any pain in the back passage while trying to open the bowel? P: No (Fissure)
D: Did you feel any lump in your back passage? P: No (Haemorrhoids)

purposes only.
P: I am taking calcium and bisphosphonates for osteoporosis.
D: Any polyp or IBD? P: No
D: Any DM or thyroid problem? P: No
D: Are you taking any medications including OTC or supplements?
P: Yes, I am taking co-codamol since I came to the hospital for my pain.
D: Is your pain well controlled? P: Yes
D: Any other medications? P: No
D: Any problems with the bowel? (bowel cancer) P: No
Ask about Lifestyle.

D: I would like to check your vitals and examine your tummy and back passage.
Examiner:
Abdomen is distended and bowel sounds are reduced.
On PR: hard stool felt in the rectum
From our assessment, you have this constipation due to the medication co-codamol you are
taking for your pain. We found some hard stool in your back passage on examination. We
will give you some other medications for your pain which will not cause constipation. We
may give you simple paracetamol for your pain as you told me you are not in pain anymore.
You are taking enough water. That is good so please continue doing that.
Please try to have plenty of fruits and vegetables. We will give you laxatives like Lactulose
(Osmotic laxative), senna, bisacodyl, and sodium picosulphate (stimulant) to help you open
your bowel.
Hopefully it will work, if not we will give you a medication that can be inserted into your
back passage as suppository. (bisacodyl suppository) We may need to inject a medication in
fluid form through your back passage. (Enema, Docusate and sodium citrate). If that doesn’t
help, then we can evacuate the stool manually and you will be able to pass the stool easily.
DD:
Diet related
Decreased mobility
Medications like pain killers
Faecal impaction
Anal fissures
Intestinal obstruction
Ca colon
Ca rectum
Diabetic neuropathy
purposes only.
Haemorrhoids
Chronic Diarrhoea
You are FY2 in 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,
assess the patient, and discuss management.
D: What brought you to the hospital? P: I have diarrhoea.

D: Tell me more about it? P: It’s been 3 months.
D: How many times are you going to the loo? P: 2-3 times a day.
D: Has it changed since it started? 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 mucus or blood? P: No doctor.
D: Do you feel thirsty? P: No

D: Do you have dry mouth? P: No
D: Do you have anything else? P: No.
D: Do you have any tummy pain/discomfort? P: Yes.

D: Where do you have it? P: It’s here, doctor (shows his LIF).
D: For how long have you had this problem? P: I have got this in the last few weeks.
D: Has it changed since it started? P: Doctor it’s becoming worse.
D: Could you please describe the pain for me? P: It’s a dull pain.
D: Does it go anywhere? P: No.
D: Is there anything that makes it worse? P: No.
D: Is there anything that makes it better? 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? P: Yes, I have lost 2-3 kg in the past 2-3 months.
D: Tell me about your diet? 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: Any hand shaking? (Hyperthyroidism) P: No
D: Do you feel hot when everyone else is feeling okay? P: No
purposes only.
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: How about any polyp, inflammatory bowel disease, DM, Thyroid? P: No.
D: Any long-term Antibiotics? (Pseudomembranous Colitis) P: No

D: Do you use condoms? P: Yes
I would like to do GPE, check your vitals and tummy examination.
Examination: Left Iliac Fossa pain on both superficial and deep palpation.
From my assessment, you have some problems with your bowel. We need to do further
investigations to find out the exact cause.
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.
We will do a procedure called colonoscopy. We may also take some samples.
Do follow up and safety netting.
Concerns:
Is it cancer?
Differentials:
Bowel Cancer
IBD
Diverticular Disease
GI Infections
Hyperthyroidism
Pseudomembranous Colitis
HIV
IBS
purposes only.
Diverticulitis
You are F2 in A&E. Aleena Romanov, aged 42, female came with lower abdominal pain.
Nurse has taken the vitals and sent the patient to you. Please talk to the patient, assess
the patient, and discuss management.
D: How can I help you? P: I have pain here left iliac fossa.
D: When did it start? P: 2 days ago.

D: What were you doing when you had this pain? P: I was just sitting when it started.
D: Was it continuous or comes and goes? P: Initially on and off but now always there.
D: What type of pain is it? P: It is just painful.
D: Is there anything that makes the pain better? P: I took some PCM, didn’t help that much.
D: Could you please score the pain on a scale of 1 to 10, where 1 being the lowest and 10
being the most severe pain you've ever experienced? P: 7-8.
D: Do you have anything else? P: I feel hot these days.

D: Since when? P: From the last 2 days.
D: Did you measure the temperature? P: No
D: Do you have anything else? P: I feel sick.

D: Since when? P: Since yesterday.
D: Anything else? P: I have constipation.

D: Since when? P: From the 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: 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
purposes only.
D: When was your Last Menstrual Period? (Ectopic) P: 3 weeks back.
D: Are they regular? P: Yes.
D: Any bleeding between the periods? P: No

D: Are you in a stable relationship? P: Yes.
D: Do you practice safe sex? P: Yes, we use condoms.
I would like to check your Vitals and examine your tummy.

Examination: T-38-39 C PR- 110/min BP- 130/80 RR- 12-20 O2 sat – 96%
Left Iliac Fossa pain on both superficial and deep palpation.
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 occurs 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 an 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).
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
purposes only.
PID
IBD
purposes only.
Irritable Bowel Syndrome
You are an FY2 in GP. Mr David Lloyd aged 50 has come in with some abdominal discomfort.
Talk to him, assess and address his concerns.
D: How can I help you today? P: I have some discomfort in my tummy

D: Could you tell me more about it? P: like what?
D: Where exactly is it? P: It’s in all around my tummy
D: When did it start? P: More than a year
D: Is it continuous or comes and goes? P: Comes and goes
D: What type of pain is it? P: Colicky
D: Is there anything that makes it better? P: Yes, after I pass stool
D: Has it changed since started? P: It’s getting worse
D: Could you rate the discomfort on a scale of 1 to 10, where 0 being no pain and 10 being
the worst you have ever experienced? P: 5
D: Do you have any other problems? P: I have a feeling of bloating in my tummy

D: Could you tell me more about it? P: It’s been more than a year and it comes and goes
D: Anything else?
P: I have been having episodes of diarrhoea and constipation every now the then.
D: For how long is that? P: Same, about a year

D: Have you noticed any weight loss recently? P: No
D: Any change your appetite? P: No
D: Any tiredness? P: No
D: Any shortness of breath? P: No
D: Any bleeding from the back passage or blood in stool? P: No
D: Any change in the colour of urine and stool? P: No
D: Any lumps and bumps anywhere in the body? P: No
Ask about PMH, Lifestyle, and Psychosocial History.
D: Do you drink tea or coffee? P: Yes 5-6 cups of coffee a day

D: Do you have any kind of stress? P: I am really stressed about my work
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:
purposes only.
- FBC.
- ESR.
- CRP.
- Coeliac screen.
- CA 125 for women with symptoms which could be ovarian cancer
- Faecal calprotectin for those with symptoms which could be IBD
Examiner: Everything is Normal
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
• ask a pharmacist about medicines that can help, like Buscopan or peppermint oil
purposes only.
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
Bowel Cancer Screening
NHS bowel cancer screening checks if you could have bowel cancer. It's available to
everyone aged 60 or over and 56 year olds.
You use a home test kit, called a faecal immunochemical test (FIT), to collect a small
sample of poo and send it to a lab. This is checked for tiny amounts of blood.
Refer adults using a suspected cancer pathway referral (for an appointment within 2
weeks) for colorectal cancer if:
• they are aged 40 and over with unexplained weight loss and abdominal pain or
• they are aged 50 and over with unexplained rectal bleeding or
• they are aged 60 and over with:
o iron-deficiency anaemia or
o changes in their bowel habit, or
• tests show occult blood in their faeces.
purposes only.
Indigestion
You’re an FY2 in GP. Mr John Doe, aged 55, has come with complaints of indigestion. Please
talk to the patient, assess him, discuss management with him and address his concerns.
D: How can I help you? P: I have a burning sensation in my chest.

D: Could you tell me more about it? P: It is from the last 3 months and is getting worse.
D: Is it continuous or comes and goes? P: It is there when I eat spicy food.
D: Anything else with it?
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 that 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 have any other symptoms? P: No

D: Any tummy bloating? P: No
D: Any fever? P: No
D: Do you feel sick? P: Yes
D: Since when do you feel sick? P: From the last few weeks, 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
D: Any blood in the stool? P: No

D: Anyone in the family or friends told you that you are losing weight? P: No
D: Any SOB or palpitations? P: No
D: Any cough? P: No
D: Has it happened before? 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 Antacids, I keep changing them, but none of them work.
D: Any allergies to any food or medications? P: No
Ask about lifestyle and psychosocial.
I would like to do GPE, Vitals, chest and abdominal examination. We will do some routine
purposes only.
blood investigations including FBC, LFT, U&Es, cholesterol level check.
Examiner:
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 Esophageal pH monitoring which provides direct physiological 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- 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 return 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
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're overweight.
4. Try to find ways to relax.
Don’ts
1. Have food or drink that triggers your symptoms.
2. Eat within 3 or 4 hours before bed.
3. Wear clothes that are tight around your waist.
4. Smoke.
5. Drink too much alcohol.
6. Drink too much coffee & tea.
7. Stop taking any prescribed medicine without speaking to a doctor first.
When Not to Refer for Endoscopy

Aged under 55 years and no alarm signs
Not yet tested for H. pylori and treated, if necessary
Recent normal endoscopy result but persistent symptoms
Long established dyspepsia that has not become worse over a period of time
NB
Most GI ulcers are strongly associated with H. pylori infection
purposes only.
30% of endoscopy results are normal
2% diagnose oesophago/gastric cancer
Endoscopy is expensive
The following symptoms can be a sign of something more serious:

• keep getting indigestion
• are in severe pain
• are 55 or older
• have lost a lot of weight without meaning to
• have difficulty swallowing (dysphagia)
• keep being sick
• have iron deficiency anaemia
• feel like you have a lump in your stomach
• have bloody vomit or poo
DD:
GORD
Cancer
Helicobacter pylori infection
Oesophagitis
Peptic ulcer disease
purposes only.
Dysphagia
You are FY2 Surgery. Mr. Adam Jakes, 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 with him.
D: What brought you to the hospital? 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 now I am not able to even drink properly.
D: Do you have this problem all the time or at any particular time of the day?
P: All the time.
D: Do you have any problems in beginning 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 heartburn? P: Yes/No
D: Do you have persistent vomiting especially soon after 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 month/No
D: How is your appetite? 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 your tummy is bloated after taking food? (Gastric CA). P: No.
D: Have you noticed 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 drinks? (Spasm) P: No
I would like to check your vitals and examine your mouth, food pipe and tummy.
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
purposes only.
for any abnormality, we may have to 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 a 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.
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 mainstay 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, Infection, Bleeding, Damage to lining of the gut
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 food.

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?
Differentials:
Oesophageal Cancer
Gastric Cancer
Oesophageal Stricture
Oesophageal Spasm
GORD
purposes only.
Myasthenia Gravis
Stroke
Haematemesis
You are FY2 in A&E. Miss Maria Ara, aged 27, presented to the hospital with haematemesis.
The vitals have been measured and are as follows: BP: 110/70 mmHg, P.R: 100/min, T: 37,
RR: 17/min, O2 Sat: 97%. Please talk to the patient, take history, assess the patient and
discuss further management with the patient.
D: What brought you to the hospital? P: I am vomiting blood.

D: Tell me about the content of your vomit? P: Doctor, there was no food. It was only blood.
D: When did it start? P: It started this morning.
D: How many episodes have you had since morning? P: 3
D: How much blood was it? P: Each time around a cup.
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 heartburn? P: No
D: Any blood from your back passage or dark stools? P: No
D: Any tiredness or shortness of breath? P: No
D: Any heart racing or dizziness? P: Yes/ No
D: Any fever or flu-like symptoms? P: No (Oesophagitis)

D: Any excessive sudden or forceful vomiting? P: No (Mallory Weiss)

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.
D: Any other medications? P: No.
D: Any blood thinners? P: No.
D: Any instrumentation in your gullet? P: No

purposes only.
D: Do you drink alcohol? P: Yes, I drink wine with my food daily.
D: Any binge drinking recently? P: No
D: Tell me about your diet? P: I try to eat healthy
D: Do you do physical exercise? P: Good
I would like to check your vitals and examine your abdomen and back passage.
I would like to send for some initial investigations including routine blood tests and ECG.
Examiner:
Mild tenderness in epigastric region.
Vitals: BP-110/70, PR- 100, T-37C, RR-17, O2 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 the higher side. You told me that you drink
alcohol daily and have been taking painkillers for your headache for the last six months. Both
of these increases the chances of bleeding from the gut. We will admit you to the hospital
and we will do blood tests 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 vessels. 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 the 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 painkillers that you are taking. So, it is advisable to
refrain from 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 aggravate your ulcer further.
Please follow up regularly with your GP.
P: What could be the reason for that?
P: What is endoscopy?
P: Is endoscopy painful?
Differentials:
Ca Oesophagus
Mallory Weiss Tear
Oesophagitis
Acid Peptic Disease
Gastric Erosion
Liver disease
purposes only.
Bleeding disorders, blood thinners
Instrumentation
purposes only.
Acute Gastroenteritis
You are an FY2 in A&E. Mrs. Alice Parker, aged 40, has presented with complaints of
vomiting & diarrhoea for the last 3 days. Assess the patient & do the relevant management.
You are aware that food poisoning is a notifiable disease.
D: What brought you to the hospital? P: I have diarrhoea.

D: Tell me more about it? P: It’s been 3 days.
D: How many times are you going to the loo? P: 2-3 times a day.
D: Has it changed since it started? 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 mucus or blood? P: No doctor.
D: Do you have anything else? 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, I have had 4
episodes. Have not had vomiting in the last 24 hours.
D: What was the content of vomiting? P: Whatever I ate, I vomited.
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
D: Do you feel thirsty? Dry mouth? P: No (Dehydration)

D: Do you feel dizzy by any chance? P: No (Dehydration)
D: Any fever or flu like symptoms? (IBD, Diverticular Disease, GI Infection) P: No

D: Have you lost any weight? P: No
D: Have you noticed any eye problems, joint problems, skin changes or mouth ulcers? P: No
D: 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

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
D: Has any member of your family ever been diagnosed with any medical condition?
purposes only.
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: How about red meat or processed meat? P: Sometimes doctor.
D: Do you drink alcohol? P: Doctor I am a social drinker.
D: Do you have any stress? P: No

D: Do you practice safe sex? 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.
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).
We need to take a sample of your stool and send it to the lab.
The food that you had outside a 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 will it take to subside diarrhoea?

D: Diarrhoea usually lasts for 5 to 7 days and vomiting usually lasts for 1 to 2 days.
purposes only.
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
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 you:

- 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
DD’s
Acute Gastroenteritis
IBD
Appendicitis
Pseudomembranous Enterocolitis
purposes only.
Bloating
It is where your tummy feels full and uncomfortable. It's very common and there are things
you can do to ease it. But see a GP if you feel bloated a lot or it does not go away.
Causes of bloating
- The most common reason for bloating is having a lot of gas in your gut.
- This can be caused by some food and drinks, such as some vegetables and fizzy
drinks, or by swallowing air when you eat.
It can also be caused by a problem with your digestion, such as:

- constipation
- a food intolerance
- coeliac disease
- irritable bowel syndrome (IBS)
- Some people feel bloated around the time of their period.
Sometimes, bloating that does not go away can be a sign of something more serious such
as ovarian cancer.
How to reduce bloating

Do’s
- exercise regularly to improve your digestion and help prevent bloating – exercise can
also help when you're feeling bloated
- chew with your mouth closed to avoid swallowing air
- drink plenty of water
- eat foods high in fibre if constipated
- eat smaller, more frequent meals instead of large meals
- massage your stomach from right to left to release trapped wind
Don’t
- do not drink lots of fizzy drinks, alcohol or caffeine in coffee and tea
- do not eat lots of foods that are known to cause gas, like cabbage, beans or lentils
- do not eat large meals late at night before bed, or slouch when eating
- do not eat lots of processed, sugary, spicy or fatty foods
- do not eat food you are intolerant to, if you have a food intolerance
See a GP if:
- you've been feeling bloated for 3 weeks or more
- you feel bloated regularly (more than 12 times a month)
- you've tried changing your diet but keep feeling bloated
- you have a swelling or lump in your tummy
- you have bloating along with being sick, diarrhoea, constipation, weight loss or blood
in your poo
- you find it difficult to move or do daily activities because you’re bloated
purposes only.
Endocrinology
Hyperthyroidism
You are the F2 in GP. Miss Susan Smith, aged 22, presents to the Clinic to see you about
her problem. Please talk to the patient, take relevant history, assess the patient and
discuss the plan of management with the patient.
You are the F2 in GP. Miss Susan Smith, aged 40, presents to Clinic with Tremor &
Sweating. Please talk to the patient, take relevant history, assess the patient and discuss
the plan of management with the patient.
D: What brought you to the hospital? 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
D: Is it intentional? P: No, I am actually eating more these days.
D: In how much time period do you think you have lost your weight? P: In the last few
months.
D: Do you have any other symptoms? P: I feel hot when others are feeling fine.
D: Since when did you notice this? P: In the last few months.
D: Any other symptoms? P: I feel that my heart is racing sometimes.

D: Since when? P: In the last few months.
D: Any other symptoms? P: No.

D: Do you feel sweaty? P: Yes/no
D: Do you feel tired? P: Yes/no
D: Do you have any sleep problems? P: Yes/no
D: Any recent change in your mood? P: Yes/no
D: Have you noticed any hand shaking? P: Yes/no
D: Have you noticed any hair loss? P: Yes/ No
D: Did you notice any changes in your bowel movements? P: For the last few weeks, I am
going to the 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 an itchy rash? P: No
D: Could you please tell me about your periods?
P: In the last few months my periods have 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 have any blood in your stools? (IBD) P: No
D: Any fever or flu like symptoms? (GI Infections) P: No
Ask about PMH, lifestyle and psychosocial.
purposes only.
D: Any diabetes or Addison’s disease (endocrine diseases), Heart/Kidney, Autoimmune
conditions like SLE, RA? P: No
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.
Examiner:
Vitals: BP-120/80, PR- 120, T-37, RR-12-20, O2 Sat-96
TSH- 0.3 (0.5-4.5 mU/l)
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, the thyroid gland produces more hormones. We will also give a medication called beta
blocker to quickly relieve your symptoms. We have done some blood tests, which show that
your thyroid gland is producing too much hormone. We will refer you to the Endocrinologist
and you may be prescribed some medications which will stop the production of excess
hormones e.g 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. If you develop high temperature, diarrhoea, vomiting, yellow discolouration of
the eyes and skin, agitation and confusion call 999 for an ambulance immediately.
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:
purposes only.
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
DD:
Tremor Sweating
Hyperthyroidism
Hyperventilation
Hypoglycaemia
Arrhythmias
Ventricular ectopics
Stress
Anxiety / panic attack
Pheochromocytoma
Medications like Salbutamol
Menopause
purposes only.
Hypothyroidism
You are FY2 in Medicine. Mrs. Matilda Bailey, aged 60, presented to the hospital with a
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.
You are an FY2 in GP, Miss Katie Grant, aged 35, came to the hospital for the blood results.
T4 is decreased and TSH is increased. Please explain about the blood results and address
her concerns.
D: What brought you to the hospital? P: I have been feeling tired recently
D: Tell me more about it? 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? P: It is getting worse
D: Do you have it all the time or from 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: Any particular time of the day that you feel more tired? P: Throughout the day

D: Do you feel dizzy or lightheaded? P: No
D: Have you lost any weight? 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 you gained and in how much time?
P: Few kilos in the last few months.
D: Was it intentional? P: No
D: Do you feel cold when others are not? P: Yes, I feel cold when others
are feeling hot. This happens even in summer when it is warm.
D: When did this start? P: Few months ago
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 you have dry hair? P: No
D: Do you have 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.
D: Is it the same since it started? 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
D: How is your mood these days? P: My mood is low all the time. I
have been crying ever since my husband passed away.
D: I am so sorry for your loss. Is it alright if I ask you a few more questions? P: Ok Dr
purposes only.
D: Did you have any fever or flu like symptoms during this period or before the tiredness
started? P: No
(If patient is young, ask menstrual history, look for menorrhagia)
D: Any diabetes or Addison’s disease? (Endocrine diseases) P: No
D: Any thyroid problems? P: No
D: Any heart or kidney disease? P: No
D: Any autoimmune disease like SLE, RA? (Autoimmune diseases) P: No
Ask about PMH, lifestyle and psychosocial. Ask about mood and anhedonia.
(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 windpipe, 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. 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 to restore the hormone, which is low in your
body, so 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.
It takes about 7-10 days for levothyroxine to absorb fully into the body so you may not feel
any improvement initially, 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
regime.
purposes only.
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 behavioural 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, kale almonds, peanuts and
walnuts, sweetcorn, millet, coffee. Consult your doctor before taking any medication.

P: What is hypothyroidism?
P: For how long do I have to take this medication?
P: Are there any side effects of this medication?
DD:
Hypothyroidism
Depression
Carcinoma
DM
Symptoms of an overactive thyroid can Common symptoms of hypothyroidism

include: include:
1. nervousness, anxiety, and irritability tiredness
2. hyperactivity being sensitive to cold
3. mood swings weight gain
4. difficulty sleeping constipation
5. feeling tired all the time depression
6. sensitivity to heat slow movements and thoughts
7. muscle weakness muscle aches and weakness
8. diarrhoea muscle cramps
9. needing to pee more often than usual dry and scaly skin
10. persistent thirst brittle hair and nails
11. itchiness loss of libido (sex drive)
12. loss of interest in sex carpal tunnel syndrome
13. irregular periods or heavy periods
!
purposes only.
Hyperparathyroidism
You are an FY2 in GP. Miss Emma Anderson, aged 55, came to you for her results. Talk to
her and address her concerns. The following are the results:
Test Results Normal Range
CBC Normal
Urea Normal
Electrolytes Normal
HBA1C Normal
ESR Normal
Calcium Corrected 3.05 2.2 to 2.6 mmol/L
Parathyroid Hormone: Increased 10-65 ng/L
D: How may I help you? P: I am here for my blood results.
D: I have got your blood results. I will explain them to you shortly, but I would like to ask
some questions first. P: Ok
D: Why did you have these blood tests. P: I am feeling tired nowadays.
D: Tell me more about your tiredness? P: What do you want to know?
D: Since when? P: Started when I went to Spain (a few months ago).
D: How did it start? P: It was gradual.
D: Is it continuous or comes and goes? P: Continuous.
D: Has it changed since it started? P: It is getting worse.
D: Is there anything that makes the tiredness better? P: Yes/No
D: Is there anything that makes the tiredness worse? P: Yes/No
D: Is there any specific time of the day when the tiredness becomes worse? P: No doctor.
D: Is there anything else? P: I have constipation.
D: Could you please tell me more about it? 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.
D: Is there anything else? P: I am feeling thirsty nowadays.
D: Since when? P: Along with the tiredness
D: Is there anything else? P: Like what?

D: How has your mood been? P: Fine
D: Could you score it for me between 1 – 10, 1 being the least and 10 being best? P: 7
D: Any loss of concentration? P: Yes/No
D: Any bone pain? P: Yes/No
D: Any nausea or vomiting? P: Yes/No
D: Any tummy pain? (epigastric or loin ) P: No
D: Do you go to the loo more often? P: No
D: Any palpitations? P: No
D: Any loss of weight? P: No
Ask about PMH, Lifestyle (Calcium supplements), and Psychosocial history.
purposes only.
I would like to do GPE and vitals. I would like to send for some initial investigations including
Routine Blood Test.
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 a 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 a 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.
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.
purposes only.
Remember: Painful Bones, Renal Stones, Abdominal Groans & Psychic Moans.
purposes only.
Haematology
Vitamin B12 Deficiency
You are FY2 in GP. Mrs Sharon Allen, aged 40, came to the hospital with tiredness. She was
investigated for the symptoms and blood tests were done and Vitamin B12 levels were
found low. Please talk to her and address her concern.
D: How can I help you? P: I am feeling tired.

D: Tell me more about your tiredness? P: It is there all the time
D: May I know since when you are having this problem? P: From last 1 year.
D: Is it there all the time or comes and goes? P: It is always there.
D: Do you have anything else? P: No
D: 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
D: How is your mood? P: It is fine.
D: Are you able to concentrate on your work? P: Yes
D: Do you have any weight loss? P: No
D: Any constipation, diarrhoea? (Thyroid, IBD) P: No
D: Any Nausea, vomiting, swelling in legs? (CKD) P: No
Ask about PMH, Lifestyle (Vegan diet) and Psychosocial history.

D: Any DM, Thyroid, Epilepsy or any skin problem? P: No
D: Are you taking any other medications apart from the Folic Acid Tablets you told me
about, including OTC or supplements? P: No
I would like to do a GPE, Vitals, abdomen and thyroid examination.

I would like to send for some initial investigations including routine blood tests, and a
special blood test for your thyroid gland.
We have done your blood tests and we found that vitamin B12 is low in your blood. We need
to give you B12 injections to correct the deficiency. At first, you'll have these injections every
other day for two weeks, or until your symptoms start improving. Your GP or nurse will give
purposes only.
the injections. You told me that you are on a 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.
People on a vegan diet may need vitamin B12 tablets for life. Good sources of vitamin B12
include meat, salmon and cod, milk and other dairy products and eggs. As you are vegan, you
can include vitamin B12, such as yeast extract (including Marmite), 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 B12 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 B12 deficiency isn't
detected and treated, it could affect your nervous system.
Hydroxycobamin
Non-Diet Related vitamin B12 deficiency: every other day for
At first, you'll have these injections every other day 2 weeks
for two weeks, or until your symptoms start
improving. Your GP or nurse will give the injections.
If your vitamin B12 deficiency isn't caused by a lack Diet Related Non Diet Related
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. Hydroxycobalamin
Cyanocobalamin
Injection (Every 3
Tablet
If you've had neurological symptoms (symptoms that months)
affect your nervous system, such as numbness or
tingling in your hands and feet) caused by a vitamin Hydroxycobalamin
B12 deficiency, you'll be referred to a haematologist, Injection (Every 6
and you may need to have injections every two months)
purposes only.
months. Your haematologist will advise on how long you need to keep taking the injections.
Anaemia
You are FY2 in a GP clinic. Mrs. Mary Hayden, aged 45, has come to the clinic for well women
check-up. She had blood test done three weeks back, now she came to receive his test
results. Discuss these test results with her, take appropriate history and discuss the
management with her.
Test Result Normal Range

Hb 110 g/dl 115 – 165
Total Leucocyte Count 4000 4000 – 11000
Platelets 430,000 150000 – 450000
MCV 58 80 – 100
U&E Normal
LFT’s Normal
Serum Iron Normal
Serum Ferritin Normal
D: How can I help you today? P: I 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 a few questions first.
P: Ok.
D: Do you feel tired or short of breath? 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
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? (Haemorrhoids) P: No.
D: When was your last menstrual period? P: One week ago.

D: Are your periods regular? P: Yes.
purposes only.
D: Has anyone in your family suffered from a similar condition in the past?
P: Yes, my sister has Thalassemia.
D: How was it managed? P: I don’t have much idea about it.
Ask about PMH (Family History of Thalassemia) and lifestyle.
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
the cause of low haemoglobin. There can be many causes for low 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 the low level of iron and
haemoglobin in your blood. We have done most of these tests already. You said that your
sister is having thalassemia so we will do some tests to find out if you have thalassemia or 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). 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.
Consult your GP if you are planning to get pregnant if you are Thalassemia carrier.
Thalassemia Major Treatment:

The treatment of this condition is regular blood transfusions to prevent anaemia with
chelation therapy to remove the excess iron from the body that builds up as a result of
having regular blood transfusions.
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 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 many types of thalassaemia, which can be 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.
purposes only.
DD’s
Iron Deficiency Anaemia
Thalassaemia Minor
Sideroblastic Anaemia
!
purposes only.
Multiple Myeloma
You are an FY2 in GP. Mrs. Jenny Walker, aged 52, came in for her blood results. Talk to
her and address her concerns.
Test Results
Hb 100
MCV Normal
RA factor Normal
IgG Raised
Urine Bence Jones Protein Positive
D: How may I help you? P: I am here for my blood results.

D: I have got your blood results. I will explain to you shortly but before that kindly allow me
to ask some questions first. P: ok
D: Could you please tell me why you had these blood tests?
P: I have backache and fatigue.
D: Could you please tell me more about your pain? P: What do you want to know?
D: Where exactly do you have the pain? P: The lower part of my back.
D: When did it start? P: 4 months ago
D: Was it sudden or gradual? P: It is gradual.
D: Was it continuous or comes and goes? P: comes and goes
D: Has it changed since it started? P: It is getting worse.
D: What type of pain is it? P: It is a dull kind of pain.
D: Does the pain go anywhere? P: No doctor
D: Is there anything that makes the pain better?
P: I have tried some PCM but it did not help.
D: How many PCM? P: 3 tablets daily
D: Is there anything that makes the pain worse? 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
most severe pain you have ever experienced? P: 5-6.
D: How about the fatigue? P: It starts along with the backache and it is getting worse.
D: Is there anything else? P: Like what?
D: Any palpitation? P: No
D: Any dizziness? P: No
D: Lightheadedness? 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: No
D: Any weakness of the legs? P: No
D: Any loss of control of bowel and bladder? P: No
D: Any loss of sensation around the back passage? (Spinal cord compression) P: No
D: How has your mood been? P: Fine
D: Could you score it for me between 1 – 10, 1 being the least and 10 being best? P: 7
purposes only.
D: Any loss of concentration? P: Yes/No
D: Any nausea or vomiting? P: No
D: Any tummy pain? (epigastric or loin) P: No
D: Any constipation? P: No
D: Do you go to the loo more often? P: No
D: Any palpitation? P: No
D: Have you noticed any swelling in your face? P: No
D: Any decrease in the amount of urine? P: No
D: Any leg swelling? P: No
D: Any hiccups or itching? P: No
Ask About PMH, Lifestyle and Psychosocial history.

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.

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)
3. There is a 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 a specific protein called Bence Jones Protein in your urine. Our plasma
cells, which make the antibodies that fight infection, start to multiply uncontrollably
and release the Bence Jones protein.
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 a 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.
purposes only.
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 have any concerns
before meeting the specialist, please come back to us at any time. Please come back to us if
your symptoms worsen. If you experience any problem with the urine or bowel, weakness of
the legs, loss of sensation around the back passage, go to the hospital immediately.
Concerns:
1. Is it rheumatoid arthritis?
2. Is it cancer?
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).
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 indicating the cancer is beginning to
cause problems. If you do need treatment, the most 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
Both non-intensive and intensive treatments involve taking a combination of anti-myeloma

medicines. But intensive treatment involves higher doses and is followed by a stem cell
transplant. The medicines usually include a chemotherapy medicine, a steroid medicine, and
either thalidomide or bortezomib.
Stem cell transplant: People receiving intensive treatment are given a much higher dose of
chemotherapy medication as an inpatient to help destroy a larger number of myeloma cells.
This aims to achieve a longer period of remission (where there is no sign of active disease in
your body) but does not result in a cure.
However, these high doses also affect healthy bone marrow, so a stem cell transplant will be
needed to allow your bone marrow to recover.
In most cases, the stem cells will be collected from you before you are admitted for the high-
dose treatment. In very rare cases, they are collected from a sibling or unrelated donor.
Treating relapses:
Further treatment is needed if myeloma returns. Treatment for relapses is similar to initial
treatment, although non-intensive treatment is often preferred. A small group of people may
purposes only.
benefit from a second course of high-dose treatment, which your haematologist would
discuss with you.
Additional medicines – such as lenalidomide, pomalidomide, carfilzomib and daratumumab

– and other chemotherapy medicines may also be given.
purposes only.
Leukaemia
You are an FY2 in GP. Mr John Bernard, aged 55, came to the clinic with gum bleeding/
wellman check-up. Please talk to the patient, discuss plan of management with the patient
Blood test report: WBC count: >100,000.
D: What brought you to the hospital today? P: I had gum bleeding today morning
D: 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

D: Do you feel tired these days? P: No
D: Any rash or bruise anywhere in the body? 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
D: Any lumps or bumps anywhere in the body? P: No
D: Any weight loss recently you noticed? P: No
D: How’s your appetite? P: Its good
I would like to do a GPE, check the vitals and examine your tummy. I would like to order
initial investigation routine blood test.
Examination: 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. 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.
purposes only.
ITP
You are an FY2 in GP. Mr Mark Anthony, aged 29, has been feeling tired for last 1-2 weeks
and now has come to the clinic. Please talk to the patient, discuss plan of management with
the patient and address his concerns.
D: What brought you to the hospital today? P: I am feeling tired for last couple of weeks
D: Can you tell me more about it? P: I just feel tired.
D: Has it changed since started? P: It’s getting worse
D: Is there any particular time of the day you feel tired? P: It’s throughout the day
D: Anything that makes it better or worse? P: No
D: Is it the first time you had this? P: Yes

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: How’s your mood been recently? P: My mood is fine
D: How did the bleeding start? P: It started on its own
D: Any shortness of breath, dizziness or heart racing? P: No
D: Any fever or flu like illness recently?
P: Yes. I had some cough and fever 3 weeks ago. It got better on its own.
D: Any rash or bruise anywhere in the body? P: Yes. I have lots of bruises in my body
D: By any chance did you hurt yourself? P: I don’t exactly know

D: Any bleeding from anywhere? P: No
D: Any change in weight you recently noticed? P: No
I would like to do a GPE and check your vitals. I would like to order initial investigation
routine blood test.
Examination: 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 platelet. 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.
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.
There are other treatment options like some medicines that act on our body’s defence
mechanism (Immunosuppressive, Immunoglobulin, biological therapies). Another option
purposes only.
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.
purposes only.
Neck Lump
You are an FY2 in GP. Mr William Harding, aged 35, has come to you with a neck swelling.
Please talk to him, assess him and address his concerns.
D: How can I help? P: I have noticed swelling on my neck.

D: When did you notice it? P: This morning.
D: Where exactly is it? 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.
D: Any lumps or swelling in your neck or armpit? P: No
D: Any night sweats? (TB) P: No
D: Did you notice any weight loss? P: No

D: Do you practice safe sex? P: Yes, my partner uses condoms.
D: Has anyone else in the family been diagnosed with any medical condition?
D: Dad died because of cancer.
Ask about Lifestyle.
I would like to check your vitals, do GPE and examine your neck. I would like to send for
Examination:
Swelling is 1x1cm, hard and fixed.
purposes only.
Swollen glands are usually caused by common illnesses like cold, ear or throat infections.
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 (multi-
disciplinary 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 2weeks 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 tumors.
But in some cases, we have to give chemotherapy and radiotherapy to extend the quality
and quantity 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 collar bone (the bone that runs
from your breastbone to each of your shoulders)
DD’s
Infections
Cancers
Autoimmune Conditions
!
purposes only.
Rheumatology
Rheumatoid Arthritis
You are FY2 in GP. Mrs Rachel Smith, aged 50, has presented with the complaint of hand
pain. She is a known smoker for the past 20 years. Take history, assess her and discuss
management with her.
D: How can I help you? P: I have pain in both my hands.

D: Tell me more about your pain? P: I have pain in my fingers and wrist joints.
D: When did it start? P: It has been there for the past 6-7 weeks.
D: Was it continuous or comes and goes? P: It was continuous.
D: What type of pain is it? P: It is a dull pain.
D: Is there anything that makes the pain better? P: I take ibuprofen, it helps a bit.
D: Is there anything that makes the pain worse?
P: It is worse in the morning and decreases as the day progresses.
D: Do you have any other problems? 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, it is more.
D: Any swelling? P: Yes, there is swelling in the finger joints.
D: Any redness, hotness of the joints? P: No
D: Do you feel tired or a 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
Ask about PMH, Lifestyle and Psychosocial history.

D: What do you do for the living? P: I am a Secretory
D: Has it impacted your work? P: Yes, I am having difficulty in typing.
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.
purposes only.
Rheumatoid arthritis is an 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 a 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 an occupational therapist and physiotherapist to help you out at your
workplace.
Methotrexate is usually given once a week in RA. It is given with folic acid. We are not
giving folic acid on the day patient is taking methotrexate.
In case of any infection or UTI, stop methotrexate for 1-2 weeks or until the symptoms
subsides.
Give lifestyle advice for the smoking if 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.
Differentials:
Rheumatoid Arthritis
Psoriatic Arthropathy
Osteoarthritis
Gout Arthritis
Septic Arthritis SLE
purposes only.
Gout
You are an FY2 in GP. Mr Mathew Knight, 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.
D: How can I help you? P: I have pain in my big toe.

D: Tell me more about it. P: I have had it for a few weeks.
D: Does it affect both feet? P: No, only one.
D: Do you have a similar problem in other joints? P: No.
D: Can you describe the pain? P: Sharp.
D: Is the pain always there or comes and goes? P: Always
D: What time of the day do you experience this pain? P: Yes/No
D: Anything making it worse/better? P: Walking
D: Any swelling/redness? P: Yes
D: Can you score the pain on a scale of 1 to 10? P:
D: Any other symptoms? P: Like what doctor?

D: Any fevers/flu-like symptoms? (Septic Arthritis) P: Yes/No
D: Any sweat? P: Yes/No
D: Do you have any ulcer in your foot? (PAD) P: Yes/No
D: Any shooting pain starting from back and going down to your foot? (Sciatica) P: Yes/No
D: Did you have any trauma? P: No
D: Have you ever injured your foot recently? P: No

D: Have you been diagnosed with any medical condition? P: I have high BP
D: How is it managed? P: I am on Amlodipine and Bendroflumethiazide.
D: Are you regular with it? P: Yes
D: Any history of kidney stones? P: No
D: Do you drink alcohol? 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.
D: Tell me about your diet? P: I have a balanced diet.
D: Does it include meat? P: Yes, I’m fond of steak.
D: What do you do for a living? P: Driver
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,
U&Es 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.
purposes only.
It happens due to build-up 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. We will review your blood pressure medications. We need to do lifestyle
modifications such as drinking beer and eating meat. You can drink in moderation something
other than beer.
Attacks of gout are usually treated with anti-inflammatory medicine like ibuprofen. Gout can
come back every few months or years. It can come back more often over time if not treated.
If you have frequent attacks, please come back to us and 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.
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
Don't
● do not knock the joint or put pressure on it
To prevent gout coming back:
Do
● 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)
It's important to take uric-acid-lowering medicine regularly, even when you no longer have
symptoms.
DD’s:
Gout
Septic Arthritis
Sciatica
PAD!
purposes only.
Pain & Aches (Polymyalgia Rheumatica)
You are FY2 in GP. Mrs. Olivia Brown, aged 68, presented to the clinic with pain and aches.
She has been diagnosed with GORD 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.
Polymyalgia Rheumatica (PMR) Refusing Steroids
You are an FY2 in GP. Mrs Janet James, aged 50, has been diagnosed with Polymyalgia
Rheumatica. She is on steroids, aspirin, lansoprazole and bisphosphonates. ESR and CRP
are normal. Talk to her and address her concerns.
D: What brought you to the hospital? P: I am having pain and aches here (Points)
D: Tell me more about your pain? P: What you would like to know.
D: When did it start? P: It started 4 weeks ago.
D: Is it continuous or comes and goes? P: Yes, it is continuous.
D: Is there anything that makes the pain better? 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 anymore.
D: Is there anything that makes the pain worse? P: It is becoming worse with time.
D: Could you please score the pain on a scale of 1 to 10, 1 being the lowest pain and 10
being the most severe pain you have ever experienced? P: Around 7.

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.

D: Any rashes? P: No (Subacute Cutaneous Lupus)
D: Any weight loss? P: No (Cancer, Thyroid)
D: How is your appetite? P: No
D: Do you feel tired or breathless? P: No
D: Any headache? P: No (Some Symptoms match with GCA)
D: Any problem with your vision? P: No

P: I have GORD and I am taking omeprazole for that.
D: For how long have you been diagnosed with that? P: 20 Years.
purposes only.

D: Do you drink alcohol? P: No
D: Tell me about your diet? P: Fine
D: Do you do physical exercise? P: I can’t doctor, I can’t move around with my dog.
D: How is your mood? P: It is fine.
D: Could you please score your mood for me on a scale of 1 to 10? P:
D: How is your sleep? P: It is ok
D: Do you think this pain is affecting your sleep? P: No
D: Whom do you live with?

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.
Examination:
All the examinations are normal
I would like to send for some initial investigations like routine blood tests.
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 tests 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 tests to check your kidney.
We may consider doing some scans like X-ray or USG for your bones and joints. We will give
you painkillers 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 everyone
to two months. We will refer you to the 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 may return after treatment stops, known as a relapse.
purposes only.
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
High blood sugar
Thinning of bones (Osteoporosis)
Mood changes
Weight gain
Indigestion and Heartburn
You have to maintain a healthy lifestyle like a good diet including calcium rich foods and
physical activity, and also smoking cessation and drinking alcohol in moderation (advice
lifestyle 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 are taking steroids regularly and
your dose shouldn’t be stopped suddenly.
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 the patient gives 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.
Differential Diagnosis:
Polymyalgia Rheumatica
Dermatomyositis
Polymyositis
Osteomalacia
Malignancy
Hypomagnesemia (due to PPI)
Thyroid Disorders
DM
purposes only.
Chronic Fatigue Syndrome
You are FY2 in GP. Mr. Steve Barone, aged 45, presented with tiredness. He has been to the
hospital 6 months ago with the same problem after having the flu. The IT system in the clinic
crashed. We don’t have any medical records of the patient. Talk to the patient, take history
and discuss management plans 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.
D: What brought you to the hospital? P: I am always tired, that is why I came back.
D: How long have you been tired? P: Since my last flu.
D: When you had the flu? P: It happened six months ago.
D: How was it managed?
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 am tired all the time in the last six months.
D: Is there any specific time of day you feel more tired? Has it changed? Anything makes it
better or worse?
D: Anything else with tiredness? P: I have body pain
D: Has it changed? Are you taking anything for it? P: Yes/No
D: Anything else?
D: Do you have any sore throat? P: No

D: Lack of concentration? P: No
D: Sleep disturbance? P: No
D: How has your mood been recently? Hot flushes?
D: Do you have any lumps or bumps anywhere in your body? P: No (Cancer)
D: Do you have any weight loss? P: No.
D: Any constipation, diarrhoea? (Thyroid, IBD) P: No.
D: Any tummy pain? P: No.
D: Nausea, vomiting, swelling in legs? (CKD)

D: Any other partner? Safe sex? (HIV)
D: How are things at home? How is your relationship with them?

P: Doctors, it's good but I feel guilty because I can’t give my wife and kids enough time
because of tiredness.
purposes only.
D: Tell me about your physical activity?
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 a walk or to the gym.
I would like to check your vitals and examine your chest, tummy and musculoskeletal
examination. I would like to send for some initial investigations including routine blood tests
and a 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 come back
normal, then it may be Chronic Fatigue Syndrome, which 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 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.
Stress can be a trigger for 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
painkillers 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 instructors can guide you in this.
DD:
Cancer
Hypothyroidism
IBD
CKD
DM
HIV
purposes only.
Carpal Tunnel Syndrome
You are an FY2 in GP. Miss Lucy Smith, aged 34, came to the clinic with pain in both the wrist
and hand. Please talk to the patient, discuss the plan of management with the patient and
address her concerns.
D: What brought you to the hospital today? P: I have pain in my hands and wrists
D: Could you tell me more about it? P: Like what
D: Is it continuous or comes and goes? P: Continuous
D: What type of pain is it? P: Electric shock like pain
D: Does it move to anywhere else? P: It’s moving from my wrists to hands
D: Is there anything that makes it better? P: Changing hand posture or shaking the wrist
D: Is there anything that makes it worse?
P: Gets worse at night/repetitive movements of hand or wrist
D: Has it changed since it started? P: It’s getting worse
D: Could you rate the pain on a scale of 1 to 10, 1 being the lowest and 10 being the worst
pain you have ever experienced? P: 7
D: Any pain in other joints in the body? P: No

D: Any chance that you might have hurt yourself? P: No
D: Any redness or swelling in the joints? P: No
D: Do you have any tingling or numbness in your hands? P: No
D: Do you have any difficulty gripping things by your hand? P: No
D: Any nausea, vomiting or swelling in the ankles? P: No
D: Do you feel cold when others around feel normal? (Hypothyroid) P: No
D: Any change in your bowel habit recently? (Hypothyroid) P: No
D: Do you feel more tired? (Hypothyroid) P: No
Ask about PMH.
D: Do you drink Alcohol? P: No
D: Tell me about your diet? P: Balanced
D: What do you do for a living? P: I worked as a typist in an office.
D: When was your LMP? P: I delivered my baby one month back.
D: Whom do you live with? 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.
purposes only.
● 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.
From our assessment, we suspect you have 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?
D: 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 must 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.
DD’s
Carpal Tunnel Syndrome
Cervical Radiculopathy
De-Quervain Tenosynovitis
Reynaud’s Phenomenon
Stroke
purposes only.
Reactive Arthritis
You are FY2 in Orthopaedics. Mr Peter Randal, aged 27, came to the hospital with the pain
in the joints. Please take history assess the patient and discuss the management with the
patient.
D: How can I help you? 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.
D: How did it start? 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 pain.
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 both your eyes? P: Yes
D: When did it start? P: It started with the joint pain.
D: Have you noticed any redness in your eyes? P: No
D: Do you have pain in your eyes? P: No
D: Have you noticed any discharge from your eyes? P: No
D: Are your eyelids swollen? P: No
D: Is your vision impaired? P: No
D: Is there anything else? P: No
D: Are your knees, feet or ankles swollen? P: No

D: Do you have pain in any other joint? 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
D: Has this happened before? 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: Are you in a stable relationship? P: No
D: Do you practice safe sex? P: Not really, sometimes.
purposes only.
D: When was the last time you had unprotected sex?
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 commonly described as tender,
warm, swollen and sometimes red.
D: I am going to have a look at your eyes.

Examination: redness, oedema, purulent discharge.
B: Joints.
Look:
1. Anatomical position
2. Symmetry of joints
3. Inspection:
There is no redness, swelling, muscle wasting, deformity or any skin patches bilaterally.
Feel:
1. Temp (Ankles, Knees)
2. Tenderness (Knees, Heel, Achilles Tendons)
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 a 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 substances called antibodies to fight against the infection.
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

purposes only.
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 the majority of the
cases. We will check the antibodies to exclude some other causes of joint pain (absence of
rheumatoid factor and antinuclear 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
medications 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 modifying anti-rheumatic
drugs). These act in the same way as steroids. It can take up to a few months before you
notice DMARDs working, so it is important to continue taking medication even if your
symptoms do not improve.
Common side effects of sulfasalazine:

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.
purposes only.
De Quervain’s Tenosynovitis
You are an FY2 in GP. Miss Victoria Smith, aged 42, came to you with pain in the hand.
Please talk to her and address her concerns.
D: How can I help you? P: Doctor I have pain in the thumb.

D: Where exactly do you have the pain? P: In my left hand at the base of thumb
D: When did it start? P: It started few days ago.
D: What were you doing when you had this pain? P: I was vacuuming/gardening.
D: What type of pain is it? P: It is dull.
D: Does the pain go anywhere? P: It goes to my index finger
D: Is there anything that makes the pain better? P: Pain killers.
D: Is there anything that makes the pain worse? P: Using the laptop makes it worse
the most severe pain you have ever experienced?
P: It is around 5.
D: Do you have any other problem?

P: I have a snapping feeling when I move my thumb.
D: Do you have any other problem?

P: I have numbness along the back of your thumb and index finger.
D: Did you hurt yourself anytime recently? P: No.

D: Any bruising on your hand? P: No.
D: Any fever? P: No.
D: Any stiffness in the hand joints? P: No.
D: Have you had similar kind of problem in the past? P: No.

D: Do you do physical exercise? P: Yes, I play tennis.
D: When was your last menstrual period? 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.
purposes only.
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.
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
!
purposes only.
Raynaud Phenomenon
You are an FY2 in GP. Mr Darren James, aged 26, has come to you with complaint of pain
in his fingers. Talk to him, assess him and address his concerns.
D: How can I help? P: I have pain in my fingers.

D: Where exactly do you have the pain? P: In both hands
D: When did it start? P: It started a few hours ago.
D: What were you doing when you had this pain? P: I was out on a walk.
D: What type of pain is it? P: It is dull.
D: Is there anything that makes the pain worse? P: Chilly weather
the most severe pain you have ever experienced?
P: It is around 5.
D: Do you have any other problem? P: Yes, my fingers become pale.

D: Did it start at the same time as the pain? P: Yes
D: Any Fever? P: No
D: Any joint pain? (RA) P: No
D: Any red rash over the nose and cheeks? (SLE) P: No
D: Any pain behind the eye? (MS) P: No
D: Any Patches of hard or thickened skin? (Scleroderma) P: No
D: Any numbness in the hands? P: No
D: any DM, HTN, Heart disease? P: No
D: Any 'connective tissue' diseases? P: No
I would like to do GPE, Vitals, and want to examine your hands. We will also do some
routine blood investigations like liver and kidney function.
From our assessment, we are suspecting you may have a condition called Raynaud's
phenomenon. It is common and does not usually cause severe problems. You can often
treat the symptoms yourself by keeping warm. Sometimes it can be a sign of a more serious
condition.
Things you can do to help Raynaud's

Do
● keep your home warm
purposes only.
● 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’t
● 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
If your symptoms are very bad or getting worse, we 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.
If needed, we may arrange tests if we think Raynaud's could be a sign of a more serious
condition, such as rheumatoid arthritis or lupus.
In secondary Raynaud's, symptoms may first begin in just one or two fingers on one hand.
This is in contrast to primary Raynaud's when all fingers on both hands are typically
affected.
See a GP if:
• 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
DD:
scleroderma
rheumatoid arthritis
multiple sclerosis
systemic lupus erythematosus (SLE).
! !
purposes only.
Nephrology
Uraemia & Hyponatraemia
You are FY2 in A&E. Mr Marcus Baines, aged 82, was admitted to the hospital because of a
new problem. He is confused now. Talk to his daughter, discuss management plans with
her and address her concerns. There are some blood tests inside the cubicle.
D: How can I 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 he does not
even recognise me.
D: Any other symptoms? 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, Anuria, Oliguria) P: No
D: How are his bowel habits? (Constipation) P: It was ok.
D: Any itching, swelling in the legs? (CRF) P: No
D: Any Nausea/Vomiting/SOB? (CRF) P: No
D: Has he been diagnosed with any medical condition in the past?

P: Yes, he has high blood pressure and he had a stroke 5 years back.
D: Is he taking any medications for it?
P: He is taking amlodipine, statin and aspirin. He was recently started on water tablets.
D: Is he taking it regularly? P: Yes

D: How did the stroke affect his life? P: He recovered fully after the stroke.
D: Any other medical condition? P: No
D: Any thyroid or DM? P: No
D: Is he taking any other medications including OTC or supplements? P: No
D: By any chance is he taking opioids or psychiatric medications? P: No
D: Who does he live with? P: He lives alone.

D: Was he able to carry out normal day to day activities? P: Yes, but not from the last 2
weeks.
D: Who has been taking care in the last 2 weeks? P: Carers are coming at home and I
was also visiting him.
purposes only.
I would like to check his vitals, GPE, Abdominal, DRE and neurological examinations.
I would like to do some investigations including routine blood test, U & E, blood sugar and
electrolytes.
Examination: Blood Results
Test Results
Hb 122
WBC Normal
Na 115
Urea Raised
Creatinine Raised
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. They show that urea and creatinine
are raised. 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 the kidneys aren'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 kidney failure. Kidney failure causes raised urea which in turn can cause
confusion.
Also, you mentioned that he was admitted recently in the hospital and he was given water
tablets which actually can lead to a 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, vitamin levels in
his body.
We will give you Iron Supplements. He may require dialysis. It is recommended not to drink
too much water in this condition.
DD’s
Acute Infections
Hypoglycaemia
Dehydration
Medications (Opioids & Psychiatric Medications)
Electrolyte Imbalance
Alcohol/Drugs
Head Injury
purposes only.
Tiredness (Citalopram)
You are FY2 in the GP clinic. Miss Avery May, aged 50, has come to the clinic complaining of
tiredness. She was diagnosed with depression and she is taking Citalopram 10mg. Her eGFR
is >60ml/min. Take history, assess her & discuss the management plan with the patient.
D: What brings you to the hospital today? P: Doctor I feel tired a lot
D: Tell me more about your tiredness.
P: I have been feeling tired for the last 2-3 weeks.
D: By any chance do you feel its worse in the evening? (MG) P: No
D: Anything else with tiredness? P: No

D: Do you have any fever, flu-like symptoms or sore throat? P: No
D: Any constipation or diarrhea? (Thyroid, IBD) 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.
D: How has your mood been 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 in the past? P: Depression
D: Since when? P: Last 3 months
D: Anything happened around 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 have been taking it for the last 3
months.
D: Any DM, HTN, cholesterol, heart, thyroid, kidney and autoimmune problem?
P: I have had high BP and high cholesterol for the last 10 years and I am taking medications
for that.
D: Are you taking regularly as prescribed? P: Yes
purposes only.
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.
Examination:
Test Results Normal Range
Sodium (Na) 128 135 to 145 mEq/L
Potassium (K) 4.8 3.5-5.0 mEq/L
Urea 4.2 2 to 6.6 mm
Cl and HCO3 Normal
eGFR: >60
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 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/1.73 m
Stage 1: The eGFR shows normal kidney function but you are 90 or more
already known to 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 60 to 89
known to have 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 45 to 59 (3A)
known kidney disease. For example, an elderly person with ageing 30 to 44 (3B)
kidneys may have reduced kidney function without a specific
known kidney disease.)
Stage 4: Severely reduced kidney function. (With or without 15 to 29
known kidney disease.)
Stage 5: Very severely reduced kidney function. This is sometimes Less than 15
called end-stage kidney failure or established renal failure.
purposes only.
Mild Symptoms: Moderate Symptoms: Severe Symptoms:
Decreased ability to think Personality Change Drowsiness
Tiredness/Lethargy Muscle cramp Seizure
Headache Weakness Coma
Nausea & Vomiting Confusion
Poor Balance Ataxia
Loss of Appetite
Hyponatraemia
Severity Rate of Onset
Mild 130-135 mmol/L Acute <48 Hours
Moderate 125-129 mmol/L Chronic ≥ 48 Hours
Severe <125mmol/L
purposes only.
Analgesic Nephropathy
You are an FY2 in GP. Mr James Anderson, aged 30, came to the clinic with a new problem.
His eGFR is low and Creatinine is high. Please talk to the patient, discuss the plan of
management with the patient and address his concerns.
D: What brought you to the hospital today? P: I am losing blood in my urine

D: Could you tell me more about it?
P: It’s been happening for the last couple of days when I pass urine.
D: Is the blood in the beginning, at the end or throughout your urination?
P: I’m not sure, its mixed with my 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: 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 a year now.
D: How are you doing in terms of the pain now?
P: It's under control as I am taking the painkillers.

D: Any change in the smell of your urine? P: No
D: Any fever or flu-like illness? P: No
D: Do you have to rush to the loo? P: No
D: Any burning sensation while passing urine? P: No
D: Are you going to the loo more often? P: No
D: Any problem with your bowel? P: No
D: By any chance have you hurt yourself anywhere? P: No
D: Any pain in your pelvic/flank area? P: No
D: Any bony pain? P: No
D: Any rash or bruise anywhere in the body? P: No
D: Any bleeding from anywhere else? P: No
D: Any recent weight loss? P: No
D: Has anyone told you that you seem to be losing weight? P: No
D: How’s your appetite? P: It's good
D: Any swelling in the ankles? P: No
D: Any tingling or numbness in your arms or legs? P: No
purposes only.
D: Did you have similar conditions in the past? P: No
D: Any kidney problems or blood disorders? P: No
D: Are you currently on any medication except the painkillers? P: No
D: By any chance do you use any blood thinners? P: No
D: By any chance have you been eating beetroot recently? P: No

D: Have you travelled anywhere recently? P: Yes/No
D: Have you ever worked in Aniline, Dyes, Textiles, rubber, plastic or paint industries in the
past? P: No
I would like to do a GPE, check the vitals and Examine your back. I would like to order initial
investigations like routine blood tests, Renal function tests and Urine dip.
Examiner: Urine Dip: Protein +; blood+, sediment+, FBC: Anaemia
From our assessment, we suspect you are having a condition called Analgesic 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. We will be referring you to a Kidney specialist for further
investigation and treating existing kidney problems.
We may also consider doing a CT scan to check the size and shape of your kidneys.
The aims of treatment are to prevent further damage and treat any existing kidney failure -
e.g., with dietary changes, fluid restriction, dialysis or kidney transplant.
Some behavioural changes or counselling can help to control chronic pain. We will also be
referring you to the pain management team who will help you tackle the long-term pain that
you are having. Analgesics nephropathy can lead to acute kidney injury, chronic kidney
disease and cause hypertension.
Prognosis: in early cases, renal function stabilises on discontinuation of analgesics. In
advanced cases, it may continue to progress due to secondary changes associated with loss
of nephrons.
DD’s
Analgesic Nephropathy
UTI
ADPKD
Schistosomiasis
Kidney Stones
Bladder Cancer
Blood Disorder
Blood thinners
Instrumentation!
purposes only.
Ophthalmology
Acute Angle Closure Glaucoma (Acute Red Eye)
You are FY2 in A&E. Mrs Janet Johnson, aged 50, came to the hospital with redness in her
eye. Take history, assess the patient and discuss the management with the patient.
D: What brought you to the hospital? P: I have pain in my left eye.

D: When did it start? P: It started a few hours ago.
D: What were you doing when you had this pain? P: I was watching TV.
D: Was it continuous or comes and goes? P: It is continuous and becoming worse.
D: Was it sudden or gradual? P: It was sudden
D: Is there anything that makes the pain better? P: I took PCM but didn’t help.
D: How much did you take? P: I took two tablets.
most severe pain you have ever experienced? P: It is 7
D: What about your other eye? P: It is fine.

D: Any other symptoms? P: I have a headache on the left side of my head and eyebrow.
D: Since when? P: Since my eye pain started
D: Was it continuous or comes and goes? P: it is continuous.
most severe pain you have ever experienced? P: It is 9.

D: Any problem with your vision?
P: I have blurry vision; I can’t see properly with my left eye.
D: Any fever or flu-like symptoms? 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: Any burning sensation, any gritty sensation or any sticky discharge (Conjunctivitis), join
pain, urine problem (Reiter’s) ? P: No
P: Yes, I have depression for 6 months and I am taking Amitriptyline.
purposes only.
D: Any other medical condition such as IBD, AS or RA? P: No
I would like to check your vitals and examine your eye.

Picture of the eye – RED EYE AND DILATED PUPIL.
From our assessment, we are suspecting you have a

condition called Acute Angle Closure Glaucoma. It is a
condition in which the 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 IV medication as a drip
after discussion with my senior (acetazolamide). We may 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 a specialist for further treatment. They will confirm your diagnosis by
measuring the pressure in your eye.
Patient concern: Will I go blind? Why do I have this problem?

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 is advised for the other eye as well to prevent the same condition in your
other eye.
- Sometimes eye drops are needed for a long time to help keep your eye pressure under
control
Carbonic Anhydrase Inhibitor – Acetazolamide
Non-selective Beta Blocker – Timolol
Muscarinic Cholinergic Agonist – Pilocarpine
purposes only.
Subconjunctival Haemorrhage
You are an FY2 in the A&E. Mr Luis Osborne, a 75-year-old, has presented to the hospital
with a complaint of red eye. Take history, discuss the management with the patient and
address his concerns.
D: What brings you to the hospital today? 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: 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 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? (Conjunctivitis) P: No
D: Any joint pain? Wee problem? (Reiter’s) 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
D: Any blood thinners or steroids? P: No

D: Whom do you live with? P: My wife died a 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.
purposes only.
D: From what you’ve told me & from my examination, 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 haemorrhage 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.
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.
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
purposes only.
Cataract
You are an FY2 working in Medicine. Miss Evelyn Addison, 65 years old, has some concerns.
She went to her GP last week who advised her not to drive. Talk to her and address her
concerns.
D: How can I help you today?

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 a few questions to have a better understanding of your vision.
D: Any pain in the eyes? P: No
D: Do you have 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: Yes
D: For how long has it been 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) 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: Any DM, HTN, Glaucoma or visual problems in the past? P: No
I would like to do GPE, check vitals and 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 do I have it?

D: There could be many reasons for it. But in your case, it looks like due to age.
P: What’s the treatment?
purposes only.
D: Cataracts can usually be treated with a day-case operation, where the cloudy lens is
removed and 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, 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 to 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 cataract in only one eye, unless you:
- also have a medical condition in the other eye
- drive for a living
If you drive a bus, coach or lorry, you must inform the DVLA if you have cataracts in one or
both eyes.
DD’s
Cataract
ARMD
Refractory Error
Glaucoma
Steroid Induced Cataract
You are an FY2 in GP Surgery. Miss Amanda Rhodes,

aged 80, has come to you with vision problem. She
was diagnosed with polymyalgia rheumatica 6 months
ago. She is taking steroids, lansoprazole, alendronic
acid. Talk to her, assess her and address her concerns.
!
!
purposes only.
Age Related Macular Degeneration
You are FY2 in Medicine. Mrs Monica Bell, aged 85, came with a vision problem. Talk to her,
assess her and address her concerns.

P: I have got a problem with my vision. I can’t see properly with my spectacles.

P: I have been seeing wavy lines for the last one week and I thought it is serious, that is why
I came to see you.
D: Anything else with this problem? P: No

D: Do you feel the objects looking smaller than the normal? P: No
D: Do you think colours seem less bright than they used to? P: No
D: Any black or grey patch affecting your vision? P: No
D: Any pain in your eyes? P: No
D: Any flashing light? P: No
D: Any blurry vision? (Glaucoma) P: No

D: Any nausea and vomiting? P: No
D: Do you see any rings around lights? P: No
D: Any burning sensation, gritty sensation or sticky discharge? (Conjunctivitis) P: No
D: Have you noticed any weight loss? P: No

P: Yes, I have DM last 20 years and I am taking Insulin for that
D: By any chance any HTN, Heart problem? P: No
I would like to check your vitals, examine your eye and would like to do a fundoscopy.
Examiner: Fundus examination reveals drusen in the macular area.
Drusen = Discrete Yellow Deposits
Age-related macular degeneration is the most common cause of sight impairment in those
aged over 50. It causes a gradual loss of central vision, which we need for detailed work and
for things like reading and driving. Peripheral vision is usually intact.
Ocular coherence tomography is becoming more commonly used. This is a non-invasive test
that uses special light rays to scan the retina. It can give very detailed information about the
macula and can show if it is abnormal. This test is useful when there is doubt about whether
AMD is the wet or dry form, and to monitor treatment.
purposes only.
If wet AMD is diagnosed or suspected, then a further test called fluorescein
angiography may be done. For this test, a dye is injected into a vein in your arm. Then, by
looking into your eyes with a magnifier, the ophthalmologist can see where any dye leaks
into the macula from the abnormal leaky blood vessels. This can give an indication of the
severity of the condition. You'll be seen by a specialist called an optometrist for the scan of
the back of your eyes.
Dry AMD:
There's no treatment, but vision aids can help reduce the effect on your life. Read
about living with AMD.Wet AMD:
Eye Injections (Anti-VEGF medicines – ranibizumab and aflibercept) (Every 1-2 month).
Injections given directly into the eyes, 9 out of 10 people and improves vision in 3 out of 10
people.
Side Effects of Eye Injections
Redness, irritation in the eye, bleeding in the eye, foreign body sensation.
Photodynamic therapy (Every few months alongside eye injection): A light is directed at the
back of the eyes to destroy the abnormal blood vessels that cause wet AMD.
Side Effects of Photodynamic Therapy
Temporary vision problems, and the eyes and skin being sensitive to light for a few days or
weeks.
Intraocular lens is a new approach that may eventually benefit patients with end-stage AMD
of either type. Supplement of vitamin and mineral supplements can slow down the
progression of AMD.
Advice about Smoking, Alcohol, Diet, frequent eye check-up.
You're required by law to tell DVLA about your condition if it affects both eyes and if it only
affects one eye, but your remaining vision is below the minimum standards of vision for
driving.
Dry AMD Wet AMD
Caused by a Build-up of Fatty Substance Caused by the growth of abnormal Blood
called Drusen at the back of the eyes. Vessels at the back of the eyes.
Common Less Common
Gets worse gradually (usually over several Can get worse quickly (sometimes in days or
years) weeks)
No Treatment (Unless it develops into wet Treatment can help stop vision from getting
AMD worse
DD’s
ARMD
Cataract
Glaucoma
Refractory Error
purposes only.
Open Angle Glaucoma
You are an FY2 in GP Surgery. Miss, Rachel Keller, aged 44, has come to you with after
referral from the optometrist. Please talk to the patient, take history, assess, and discuss
the initial plan of management with the patient.
Optometrist Note:
Patient is complaining of blurring vision in both eyes for the past few months.
Tonometry: High IOP
Many people with glaucoma will not notice any symptoms.

They may or may not notice a decrease in peripheral vision, manifested as bumping into
objects that they could not see. The cornea appears clear.
Key risk factors: include intra-ocular pressure >23 mmHg, age >50 years, family history of
glaucoma, and black ethnicity, Myopia, DM, HTN.
Cup-to-disc ratios of >0.5 carry greater risk. However, there can be a lot of anatomical
variants.
Examinations & Investigations:

- Tonometry
- Slit lamp (cornea should be clear, anterior chamber should be deep, and drainage angle
should be open)
- Direct and Indirect Ophthalmoscopy
- Visual Field examination (Loss of peripheral field and scotomas)
- Gonioscopy: (visualisation of anterior chamber and no obstruction of angle)
- Pachymetry (for corneal thickness, thin central corneal thickness can predict progression
from high intra-ocular pressure to glaucoma)
- nerve fibre layer analysis (loss of nerve fibre layer)
Treatment:
Laser trabeculoplasty
Surgical intervention
Eye drops:
- Topical ophthalmic prostaglandin analogues (Latanoprost)
- Topic ophthalmic beta blockers (Timolol)
- Topical ophthalmic carbonic anhydrase inhibitors (Dorzolamide)
- Topical ophthalmic alpha-2 adrenergic agonists (Brimonidine)
- Topical ophthalmic cholinergic agonists (Pilocarpine)
NB:
Early diagnosis and treatment is the primary measure to prevent the disease progression.
Primary relatives of affected patients should have a dilated ophthalmic examination.
!
purposes only.
Infectious Diseases
HIV
You are FY2 in GP. Mr 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 and p24 antigen test are positive.
Talk to the patient, take history, disclose the blood result, discuss the plan of management
and address his concerns. You can find the blood tests in the cubicle.
You are an FY2 in GP. Mr Harry Josh, 21-year-old, presented with lumps in the groin area.
Talk to him, assess him and address his concerns.
D: What brought you to the hospital? P: I am here for my blood results.

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: 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 or nausea vomiting? P: No
D: Any headache or fatigue? P: No
D: Any SOB or tiredness? P: No

D: Any blood transfusion in the past? P: No
D: Has anyone in the family been diagnosed with any medical condition? P: Yes/No
D: Do you take any recreational drug? P: No
D: What do you do for a living? P: I am an accountant.

D: Have you travelled recently? P: Yes/No
D: Since when? P: From the last 2 years.
D: Do you practice safe sex? P: No
D: Do you have a stable partner? P: Yes, I am married.
D: Any other partner? P: I went to Thailand 2 months
purposes only.
back and had sex with a woman there.
D: Did you use condoms? P: No, we enjoy our sex.
I would like to do GPE, Vitals, and want to examine your lumps and bumps.
We did some routine blood investigations like liver and kidney function which came back
normal. We screened you for Chlamydia which is a sexually transmitted infection, and it also
came negative. We did another 2 blood tests 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:
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:

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 replication
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 a 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
purposes only.
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-cum and vaginal secretions, and
from the anus. It's very important that 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 lubricants (such as K-Y Jelly) rather than oil-based lubricants (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 so that they can be 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.
Concerns: If my wife is pregnant, will my child get it?!
purposes only.
Acute Tonsillitis
You are an FY2 in GP. Miss Samaira Adam, aged 34, came to the clinic with a sore throat.
Please talk to the patient, discuss the plan of management with the patient and address
her concerns.
D: What brought you to the hospital today? P: I have sore throat

D: Could you tell me more about it? P: Like what?
D: What type of pain is it? P: Dull pain
D: Is there anything that makes it worse? P: When I swallow
D: Has it changed since it started? P: It’s getting worse
D: Could you rate the pain on a scale of 0 to 10, 0 being no pain and 10 being the worst you
have ever experienced? P: 7
D: Do you have any other symptoms? P: I feel feverish

D: Tell me more about it. P: It’s been 7 days
D: Did you measure the temp? P: No
D: Did you do anything for it? P: I took PCM and it helped
D: How much did you take? P: 1 tab 3 times daily
D: Any other problems? P: I have some lumps and bumps
in my neck.
D: For how long are those? P: 5 days
D: Are those painful? P: Yes, when I touch them
D: Any lumps and bumps elsewhere in the body? P: No
D: Any other symptoms? D: No

D: Any ear pain or hearing problems? D: No
D: Any neck stiffness? D: No
D: Any problem with voice? P: No
D: Any tiredness? D: No
D: Any headache? (Infectious mononucleosis) D: No
D: Any tummy pain? (Infectious mononucleosis) D: No
D: Any diarrhoea? (HIV) D: No
D: Did you have similar conditions in the past?
D: Yes, I had it 6 months back and was given antibiotics.
D: Any allergies from any food or medications? P: Yes, I am allergic to penicillin
purposes only.
D: Are you currently sexually active? P: Yes
D: Are you in a stable relationship? P: Yes
D: Do you use practice safe sex? P: Yes
I would like to do a GPE, check the vitals and Examine your tummy, neck and throat.
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 painkillers and we will start you on antibiotics. As you are
allergic to penicillin, we will be giving you something else
(Erythromycin or Clarithromycin).
Also, you can take Lozenges, throat spray and antiseptic solutions to ease the symptoms.
To help ease the symptoms:
• get plenty of rest
• drink cool drinks to soothe the throat
• gargle with warm salty water
If you get difficulty speaking, difficulty swallowing, difficulty breathing, difficulty opening
your mouth, please come to the hospital. An antibiotic may be advised in certain situations.
For example:
● If the infection is severe (Systemic features)
● If it is not easing after a few days. (3-5 days)
● A history of rheumatic fever
● Unilateral Peri-tonsillitis
● If your immune system is not working properly (for example, if you have had your
spleen removed, if you are taking chemotherapy, etc).
● Acute tonsillitis with three or more Centor criteria present
There are four Centor Criteria that may be used:

a. History of Fever.
b. Tonsillar Exudates
c. No Cough.
d. Tender Anterior Cervical Lymphadenopathy.
The presence of 3 or 4 of these clinical signs suggests that the person may have GABHS
(Group A Beta-haemolytic Streptococcal Infections) and may benefit from antibiotics
treatment.
DD’s
Acute Tonsillitis
Infectious Mononucleosis
Herpes Simplex
HIV
purposes only.
Recurrent Tonsillitis
You are FY2 working in GP. Mrs Anne Tudor, mother of a 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 had 5 episodes of infections over 1 year. 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 for the surgery.
D: Let me ask you a few questions regarding your son.

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. In the 2nd and 3rd episodes, the symptoms were more severe, and
he was given antibiotics. And the last 2 episodes were like the first episode and got better
with steam inhalation as well.
D: How is he doing now? P: He is fine now.
D: Any cough? P: No
D: Any pain or discharge from the ear? P: No
D: Have you noticed any rash on his body? P: No
D: Is he shy to light? P: No
D: Does he cry when moving the neck? P: No
D: Any problem with urine or stool? P: No
D: Is he feeding well? P: Yes/No
D: Is he playful normally? P: Yes
D: Does he go to school?
P: Yes, but he has to take a lot of leaves because of these infections.
Ask about PMH and Psychosocial history.
D: The referral was made upon your request. However, the criteria to have the surgery for
the tonsil removal was not met.
P: What do you mean?
D: There is a criteria which we follow to decide which patients need tonsil removal surgery.
One of the criteria is having at least 7 attacks in a year. Your son has had 5 attacks. This could
be the reason why it was rejected.
purposes only.
P: I can’t see him suffer like that. Please arrange the surgery anyhow.
D: I can see you are worried about your son. The criteria is made to avoid unnecessary surgery
and to ensure better care for the patients. 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.
P: He has already had 5 episodes so please do the surgery.

D: Removing the tonsil would compromise the defence mechanism of the body that fight
against infection. That is why we don’t want to remove them unless it’s necessary.
P: I just think the NHS is doing it for budget cutting.

D: I am really sorry you felt this way. But the NHS has set those criteria for delivering the best
possible care to the patients.
P: What will you do if he gets symptoms again?

D: We will do symptomatic treatment for instance, if he has pain then we will give him
painkillers to relieve the pain. He also needs to take plenty of rest and gargle with warm salty
water.
If your son’s condition gets worse or he develops neck stiffness or can’t swallow, please bring
him back to us.
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.
purposes only.
Allergic Rhinitis
You are an FY2 in GP. Mr Luke Hales, aged 25, has come with complaints of runny nose
from the past 2 days. Take history and address his concerns.
D: How can I help you? P: I have got a runny nose.

P: It has been 2 days since I have had this, and it is getting worse.
D: What is the colour of the fluid? P: Clear watery fluid
D: Anything makes it better or worse? P: It gets worse in the winter season.
D: Any itching? P: No
D: Any swelling or redness? P: No
D: Any pain or discharge from the ear? (Ear Infection) P: No
D: Any redness or watering from the eyes? (Conjuctivitis) P: No
D: Any mouth breathing, cough and bad breath? (Chronic Nasal Congestion) P: No
D: Any fever and flu like symptoms? (Infective rhinitis) P: No

D: Any numbness or tingling on the face? (Cranial Nerve Tumours) P: No
D: Any repeated infections? (Cystic Fibrosis) P: No
D: Does the weather exacerbate your symptoms? (Vasomotor Rhinitis) P: No

P: I have got skin allergy (Atopy)

D: Any DM, history of eczema, thyroid or asthma? P: No.
P: Siblings have Eczema and Asthma
D: What do you do for a living? P: I am a driver.

D: Have you worked in latex, wood dust or chemical industry? (Occupational Rhinitis) P: No
I would like to check your vitals and examine your eyes, ears, nose, throat. The main lines of
treatment are education, allergy avoidance, antihistamines and topical steroids. Please
regularly rinse your nasal passages with a saltwater 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 a driver, we will make sure to prescribe non-drowsy antihistamines.
purposes only.
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.
Symptoms of Allergic Rhinitis can impair the quality of life, having an adverse effect on work
performance, social life, sleep, school attendance and learning.
!
DD’s
Allergic Rhinitis
Infective Rhinitis
Cystic Fibrosis
Non-Allergic Rhinitis:
- Vasomotor Rhinitis
- Occupational Rhinitis
- Hormonal Rhinitis
- Drug induced Rhinitis
o (ACEi, Beta Blocker, Gabapentine, Aspirin, NSAIDS, Cocaine, COCP
!
purposes only.
Dermatology
Skin Lesion (Mole)
You are FY2 in GP. Mrs Maria York, 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 the
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 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.

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: Ok Dr.
D: When did you first notice it? P: I have had it for many years.
D: Can you tell me more about the lesion please? P: Like what?
D: May I know the size of the lesion? P: It’s about 1x1cm.
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 lesions anywhere else? P: No.
D: Any other problems? P: No
D: Any previous skin condition, diabetes? P: No
D: Are you currently taking any medications, otc or supplements? P: No
D: Any long term steroids or antibiotics? P: No
D: Anyone with any skin problems or any skin cancer in the family? P: No
D: Do you drink alcohol? P: Occasionally
D: Tell me about your diet? P: Good diet
purposes only.
D: Any long-term exposure to sun or tanning sessions? P: No
D: Could you please tell me about your home condition? P: I live in a house with my partner.
I would like to check your vitals and examine your lesion.

D: Have you got any idea what the lesion could be? P: No
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 removed, doctor.
D: I will discuss it with my senior, and we may be able to remove the lesion.
D: Do you want me to tell you how we are 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: 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, however there will be a thin scar
left on 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 try and 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
this 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 won’t be a problem if you leave it
without any treatment. It can stay as it is for the rest of your life. However, there is a rare
chance of moles turning cancerous.
purposes only.
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. Your doctor may 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? Complications?
If the patient doesn’t say that it catches her clothes & her only concern is her wedding
dress. Then 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?

D: Explain Shave excision and day case surgery.
purposes only.
Skin Lesion (Melanoma)
You are FY2 in GP. Mrs Maria Roytan, 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
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.
D: When did you first notice it? P: I have had it for many years.
D: May I know the size of the lesion? P: It’s about 2x3cm.
D: What shape is it? P: Round
D: What is the colour of the lesion? P: Brown/ Black
D: Is it painful? P: No/ Yes, it has become sore recently.
D: Is it itchy? P: It was not itchy before but now it is.
D: Any bleeding or discharge from the lesion? P: No/ Yes, little bleeding recently.
D: Have you got any idea how the lesion started? 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
the past few months.
D: Any other problem? P: No

D: Any long term exposure to sun or tanning sessions? P: Yes.
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. D: Ok

D: From our assessment, we are suspecting your lesion to be a melanoma which is a serious
condition. Unfortunately, this is a type of cancer of skin.
purposes only.
We will refer you to a dermatologist and a 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 it and send it for testing to check whether it's cancerous (excisional
Biopsy).
If it is cancer, then the treatment depends upon the type, size, position and stage of cancer
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 like 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.
purposes only.
Skin Lesion (Non-Melanoma – BCC/SCC)
You are FY2 in GP. Mr Donald Virtue, aged 60, has some concerns about his skin
lesion/problem. Please talk to the patient, assess his condition, discuss your management

P: I have a lesion on top of my head. I want it to be checked, my wife is concerned about it.
D: That is fine. We will assess you first and see what can be done. P: Ok Dr.
D: When did you first notice it? P: I have had it for the last 2-3 months.
D: May I know the size of the lesion? P: It’s not that big.
D: What shape is it? P: Irregular
D: What is the colour of the lesion? P: Pink/ Purple.
D: Is it painful? P: No/ Yes, it became sore recently.
D: Is it itchy? P: Yes/ No
Please elaborate as melanoma and treat accordingly.
D: What do you do for a living?
P: I used to work in Australia but now I am doing an office job.
D: Any long term exposure to sun or tanning sessions? P: Yes/ No

D: Does it affect your day-to-day activities?

P: I used to go swimming but now I don’t go because of this.

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.
purposes only.
Fungal Infection
You are an FY2 in GP. Mr John Smith, aged 45, has come to you with some concerns. Talk to
him, assess him & address his concerns.
D: What brings you to the hospital today? P: 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? P: What do you want to know?
D: What colour 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
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
D: Did you notice any insect bite? P: No (Lyme)
D: Any loss of weight? 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

D: Have you ever been diagnosed with any medical conditions? 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: Any steroid intake? (Immunosuppressants) P: No.
D: Are you allergic to any food or medication? P: No
D: What do you do for a living? P: Office. (contact sports)

D: Do you Smoke? P: No.
D: Are you sexually active? P: No
D: Do you by any chance have any pets in your house? P: No (skin infections)
D: Have you travelled anywhere recently? P: No (warm, humid)
D: I would like to do GPE, Vitals and need to examine your rash. P: Sure Doctor.
purposes only.
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 a ringworm. 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, can 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.
P: 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 after the rash has vanished. P: Okay, doctor
!
purposes only.
Acne (Isotretinoin)
You are FY2 in GP. Miss Mariah Preston, 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
NOTE: Instruction’s paper is given in the cubicle. It is given in it as Retinoid – Gel for Mild to
Moderate Acne Treatment and Severe Acne requires Oral Meds. Start as early as possible.
D: What brings you to the hospital today? P: I want Isotretinoin (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: 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: 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 use 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? P: No doctor, I’m taking combined pills
D: Have you noticed any weight gain or more facial hair recently? (PCOS) P: No
D: What do you do for a living? 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: 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
purposes only.
I would like to check your vitals and examine your chest. I will be examining the skin on your
face, chest and back for the different types of spots, such as blackheads or sore, red
nodules.
I would like to send for some initial investigations including routine blood tests, FBC, FSH, LH
and Testosterone.
On Examination: 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.
From my examination, it seems that you have a 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
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.
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 COCPs.
If it's a milder form, we give topical isotretinoin gel and if it's a severe form, we give
tablets. We will refer you to a skin specialist who will decide the management for you.
Side Effects of Isotretinoin:

purposes only.
- Inflammation, dryness and cracking of skin, lips and nostrils.
- Inflammation of Eyes and Eyelids.
- Depression (Psychosis, Mood Swings, Suicidal attempts)
- Pancreatitis (pain in tummy, nausea and vomiting).
- Liver & Kidney problem.
- Muscle ache & pain on strenuous exercise.
- Hair thinning
Misconceptions 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 a 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.
purposes only.
Impetigo
You are an FY2 in GP Surgery. Miss Stacy Blackpool, aged 24, came to you with rashes on
her face. 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: Near the lips.
D: When did you notice the rash?
P: 2 weeks back
D: What is the colour?
P: It is like golden brown colour.
D: What is the size? P: Penny size
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: Yes/No
D: Any other rashes/lesions anywhere in the body? P: No
D: Any change in your weight recently? P: No

D: Any lumps/bumps anywhere in the body? P: No
D: Any fever? P: Yes/No

D: Are you sexually active? P: Yes/No
D: (If No) Were you sexually active before? P: Yes
D: When was the last time you had sexual activity? P: 1 week ago
D: Which routes of sex do you practice? P: Oral and vaginal
D: Have you travelled anywhere recently? P: Yes/No

D: Have you been exposed to the sun lately? P: Yes/No
D: What do you do for a living? P: Retail Assistant
D: Whom do you live with? P: Partner
D: I would like to examine the lesion.
P: What’s going on, doctor?

D: From my assessment, it seems like you have impetigo. It starts with red sores or blisters.
They quickly burst and leave crusty, golden-brown patches. It is very contagious but not
usually serious. It often gets better in 7 to 10 days if you get treatment.
purposes only.
P: How are you going to treat this?
D: If it's impetigo, they can prescribe antibiotic cream to speed up your recovery or
antibiotic tablets if it's very bad. Please do not stop using the antibiotic cream or tablets
early, even if the impetigo starts to clear up.
P: Why did I get Impetigo?

D: Impetigo occurs when the skin becomes infected with bacteria, usually either
Staphylococcus aureus or Streptococcus pyogenes. The bacteria can infect the skin in two
main ways: through a break in otherwise healthy skin – such as a cut, insect bite or other
injury
P: Will I get this again?

D: If your impetigo keeps coming back, the GP can take a swab from around your nose to
check for the bacteria that causes impetigo. They might prescribe an antiseptic nasal cream
to try to clear the bacteria and stop the impetigo coming back.
P: How can I avoid impetigo?

D: Impetigo usually infects skin that's already damaged. Avoid infection by keeping cuts,
scratches and insect bites clean like for example, by washing with warm water and soap.
P: Can it spread?
D: 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 and when the patches dry out and crust over (if you do not get treatment).
Do’s:
● 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’ts
● 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
Impetigo can look similar to other skin conditions:
● Impetigo: Impetigo starts with red sores or blisters. They quickly burst and leave crusty,
golden-brown patches.
● Blisters on lips or around the mouth: Cold Sore.
● Itchy, dry, cracked, sore: Eczema
● Itchy Blisters: Chicken pox, Shingles. !
purposes only.
Urticaria
You are an FY2 in GP. Mrs Daniella Orlando, mother of 5-year-old Daniel Orlando has
some concerns. Talk to her and address her concerns.
D: How can I help you today? P: Daniel has got rash.

D: May I know where exactly is the rash? P: All over the body.
D: When did you notice the rash? P: Last few weeks.
D: What is the colour? P: Reddish
D: What is the size? P: All over his body
D: Is the lesion itchy? P: Yes, it is itchy always.
D: Is it getting worse in any way?
P: Yes, once after shower and another time after playing sports with friends. It disappeared
after few minutes/hours.


D: Any fever? P: No
D: Any insect bites or sting bite? P: No
D: Any recent exposure to cold/hot weather? P: No
D: Have you had a similar kind of rash in the past? P: No

D: Any use of recent antibiotics or NSAIDS? P: No
D: Any family history of asthma or similar conditions? P: No
purposes only.
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.
Investigations
1. FBC
2. Patch testing/prick testing for contact urticarias.
3. IgE tests for specific allergens.
4. Exclusion of suspected medication or food.
5. Tests for infectious diseases
6. Skin biopsy (urticarial vasculitis).
Certain triggers for Urticaria:
- Drinking alcohol or caffeine, emotional stress, warm temperature.

- Food, pollen and plants, insect bites and stings, chemicals, latex, dust mites, heat,
sunlight, exercise or water, Infections, emotional stress, after shower or after playing
sports
- Certain medications – such as non-steroidal anti-inflammatory drugs (NSAIDs)
or antibiotics
P: The school is worried if the rash is contagious and whether my son can go to school or
not.
D: The rash (hives) cannot spread to others and your child can go back to school once they
are feeling better. The hives shouldn't keep him from normal activities. Moreover, hives
from an infection can resolve after the fever is gone. Your child should feel well enough to
join in normal activities
!
!
!
purposes only.
Herpes Labialis
You are an FY2 in GP. Miss Katie Elmhurst, aged 24 year, came with rashes on her lower
lip. She is concerned about it. Please talk to the patient, take history and address her
concerns.
D: How can I help you today? P: I have got a rash on my lip.

D: May I know where exactly is the rash? P: Lower lip.
D: When did you notice the rash? P: 2 weeks back
D: What is the colour? P: Reddish
D: What is the size? P: 1x1
D: Is the lesion itchy? P: Yes, it is itchy sometimes.
D: Is it getting worse in any way? P: Yes/No

D: Any lumps/bumps anywhere in the body? P: No
D: Any fever? P: Yes/No
D: Any problem with your urine? (UTI) P: Yes/No
D: Have you had a similar kind of rash in the past? P: No
D: Any skin condition or STIs? P: No
D: Any allergies from any food or medications? P: Yes, I am allergic to Penicillin.

D: When was the last time you had sexual activity? P: 3 days ago
D: Do you practice safe sex? P: Yes/No
D: Which routes of sex do you practice? P: Oral and vaginal

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."
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.
purposes only.
D: Pain control remains the mainstay 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.
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.
● 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 healed.
● There is a risk of transmission to the eye if contact lenses become 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.
!
purposes only.
Genital Warts
You are an FY2 in GP Surgery. Mr Jack Daniels, aged 25, has made an urgent appointment.
Talk to him and address her concerns.
D: D: What brought you to the hospital? P: I have some skin lesions on the genital area.
D: When did you first notice it? P: I noticed it a few days ago.
D: May I know the size of the lesion? P: 1x1
D: What shape is it? P: Circular
D: What is the colour of the lesion? P: Brownish
D: Any pain? P: No.
D: Any itching? P: Yes
D: Any bleeding or discharge from the lesion? P: No
D: Have you got any idea how the lesion started? P: No.

D: Any other problem? 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
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

D: Any previous skin condition, sexually transmitted infections? P: No
D: Any long-term steroids or antibiotics? P: No

D: When did you last have sexual activity? P: Yesterday
D: Have you had any other partners previously? 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. We use condom
D: How often do you use this protection? P: Sometimes Dr.
D: What is your sexual preference? P: I am bisexual.
D: Were there any issues with the contraception used? P: No
D: Any pain during or after sex? P: No
D: Any similar kind of symptoms in your partner? P: No
I would like to check your vitals, GPE and examine your private area. I would like to send for
purposes only.
Examination: Picture given with several bumps on the
genital area, no scrotal swelling.
It seems that you are suffering from genital warts.
Treatment:
1. Cream or liquid: applied directly to warts a 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 the 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.
It may heal on its own with time as it is viral but this can take many 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, toilet 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 the 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
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?
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:
● HPV vaccine can help protect against genital warts.
● Not having sex while you're having treatment for genital warts.
● 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.
● The HPV vaccine offered to girls in the UK to protect against cervical cancer also protects
against genital warts.
● 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.
purposes only.
Syphilis
You are an FY2 working in GP. Mr Benjamin Stokes, 24 years old, has come with a skin lesion
on his private part. He is concerned about it. Talk to him, discuss management and address
his concerns.
D: How can I help you today? P: Dr I feel so embarrassed

D: I can see you are embarrassed, but I am here to help. Can you tell me what’s going on?
P: I have a small ulcer on my penis.
D: Can you tell me more about it? P: Like what?
D: How long has it been there? P: For the last 1 week
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 colour 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: Any other skin lesions in the body? P: No
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 a week
D: Do those hurt? P: No
D: Any joint pain? P: No
D: Any rash on the palms or soles? P: No
D: Any white patches in the mouth? P: No
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 conditions in the past? P: No

D: Are you currently on any medication? P: No
D: Are you allergic to any foods or medication? P: No
D: Any family history of any significant health issues or skin problems? P: No
D: Are you in a stable relationship? P: No. I have many partners
D: May I ask about your sexual orientation? P: Bisexual
D: Do you use any contraception? P: No
purposes only.
I would like to do a GPE, check the vitals and Examine the ulcer.
From our assessment, we suspect
you are having a condition called
syphilis. It is a kind of sexually
transmitted infection caused by a
bacteria. We will be doing further
investigation like an antibody test
(treponemal 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.
Syphilis is usually treated with either:

● an injection of antibiotics into your buttocks – most people will only need 1 dose,
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 the
partner notification programme. We usually offer HIV test to those who have any kind of
sexually transmitted infections.
D: Do you wish to have one? P: No
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.
purposes only.
Scabies
You are an FY2 in GP. Parents of Lucy aged 2 have come to you with some complaint. Lucy
had gone for a pit walk with her father. Talk to the mother and address her concerns.
D: How can I help you? P: Lucy is scratching all over.

D: Since when? P: 1 week.
D: Is there any rash? P: Yes
D: How did it start? P: It started between her fingers and now it’s all over her body.
D: Any other symptoms? P: Like what?
D: Any Fever? P: No
D: Any Discharge? P: No
D: Has she been diagnosed with any medical condition in the past? P: No
D: Is she taking any medications including OTC or supplements? P: No
D: Is Lucy the only child? P: Yes

D: How was the birth of Lucy? P: It was normal vaginal delivery.
D: Are you happy with the red book? 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? P: No.
D: Is Lucy a playful child? P: Yes
D: Is Lucy playing well? P: Does not go out to play
D: Has Lucy come in contact with anyone with same complaint? P: No

D: I need to have a look at Lucy. P: I have a picture of the rash.
Investigation:
From what you have told me & the rash that you have
shown me, it appears that you have a 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 (Red rashes on knuckles and web spaces)
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.
purposes only.
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: Yes. How long will I have to take the medicine for?

D: The treatment for scabies is by topical application of a 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. Treatment should not be applied after a hot bath (as this increases systemic
absorption and removes the drug from its treatment site). If the hands are washed, the
liquid or cream must be reapplied. This should be repeated a week later.
All members of the household and close contacts need to be treated simultaneously with
your child. It is important that all contacts apply treatment on the same day to reduce the
risk of re-infestation from an untreated contact.
Do:
- wash all bedding and clothing in the house at 50C 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
purposes only.
Eczema
You are an FY2 in GP. Mr 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.
D: How can I help you? P: I have got rash on the back of my legs.
D: Since when? P: 1 week.
D: How did it start? 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.
D: Does anything make it worse? P: No
D: Any Fever? P: No
D: Any itchiness? P: Yes, it is itchy
D: Any bleeding? P: No
D: Any ulceration? P: No
D: Is it itchy. P: Yes/No
D: Have you had similar kind of problem in the past?

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)
P: No
D: How is it controlled?
P: I am on salbutamol inhaler and it is well controlled.
D: Any DM, HTN, Heart disease or high cholesterol? P: No

P: My father and sister have asthma.

D: Tell me about your diet? P: I try to eat healthy.
purposes only.

I would like to send for some initial investigations including Routine Blood Test.
From what you have told me & the rash that you have shown me, it appears that you have a
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),
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 (moisturising 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
Concerns:
P: How many days will it take to go
away?
P: Is it infectious?
P: What happens if it gets worse?
Differentials:
- Psoriasis
- Fungal infection
- Lichen simplex chronicus
purposes only.
Seborrheic Keratosis (Telephonic)
You are an FY2 in GP. Mrs Nancy James, aged 70, emailed you a picture of skin lesion. She
has called you to discuss her skin lesion. Talk to her and address her concerns.
D: How can I help you? P: I have got a lesion on my chest.

D: Since when? P: 2 months.
D: Has it changed in shape, size or colour? P: It has increased in size
D: Has the appeared anywhere else? P: No
D: Any Fever? P: No
D: Any itchiness? P: No
D: Any recent weight loss? P: No
D: Any lumps or bumps? P: No
D: Loss of appetite? P: No

P: My mother had skin cancer.
From what you have told me & the picture you have emailed
me, it appears that you have a skin lesion called Seborrhoea
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:
Seborrhoeic 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: Is it cancer?
purposes only.
Measles
You are an FY2 in GP. 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.
D: How can I help you? 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.

D: Does the rash come and go? P: No
D: Does anything make it worse? P: It’s getting worse.
D: Any itchiness? P: Yes, it is itchy
D: Any ulceration? P: No
D: Any other symptoms? P: I have fever from last 3 days and it was 38.5C.
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
D: Any loss of appetite? P: Yes/No

D: Did you take MMR vaccine? P: No

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.
purposes only.
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.
If you develop any chest pain, shortness of breath, coughing up blood, drowsiness,
confusion or fits, please come back to us.
purposes only.
Others
Insomnia
You are FY2 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
the patient, take history, do examination, discuss management with the patient and
D: What brought you to the hospital? P: I have trouble sleeping.

D: Please tell me more about it? P: What do you want to know?
D: When did this problem start? P: It started 3 months ago.
D: Do you have trouble going to sleep or do you wake up in the middle of the night?
P: I have trouble going to 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 2 am. Sometimes I don’t sleep the whole night.
D: What time do you usually wake up? P: I wake up around 7.
D: Do you wake up in between? P: 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: Can you think of anything which might be the cause of your problem?
P: My husband passed away 6 months back. But I am managing, he used to encourage me
always.
D: How did he die? P: He died because of a heart attack.
D: Tell me what do you do before you go to bed?
P: I drink brandy with milk before going to bed.
D: Is it a new habit or old? P: I have been doing it for long but now it is not helping me.
D: How do you spend your time every day?
P: I have recently found a reading club in our local library. I go there every day.
D: Do you have friends there? P: No
D: Do you interact with people there? P: No
D: Whom do you live with? P: I live alone.
D: Do you have any relatives? P: Yes/No (Elaborate)
D: How about any friends? P: I don’t have any.
D: How is your mood? 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.
D: Any fever, flu or cough? P: No.

D: Any problem with urine or bowel? P: No.
purposes only.
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? P: No
D: Any asthma? P: No
Ask about:
Tea, coffee? How much? When did you take the last cup?
Smoking, Alcohol, Recreational drugs, stress, Watching TV.
Noisy Environment
D: I would like to check your vitals and examine your chest and joints.
D: I would like to send for some routine investigations including routine blood tests, thyroid
function test and U&E’s.
Do’s:
- go to bed and wake up at the same time every day - only go to bed when you feel tired
- 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 covers are comfortable
Don’ts:
- 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
- watch the 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 behaviours 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 won’t have any problems. But if
your sleeping problem persists, I will discuss it with my senior, and we may consider giving
you sleeping pills. !
purposes only.
Insomnia (Cannabis Abuser)
You are an F2 in GP Clinic. Mr Nate Durak, aged 40, came in with sleep disturbance. He is
concerned about it and he is requesting sleeping pills. Please talk to him, assess him and

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: Could you please tell me since when? P: 3 months

D: Is there anything in specific that’s disturbing your sleep? P: No
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 usually go to bed? P: Around 3-4 am.

D: What time do you wake up? P: Noon time.
D: Any naps during the day time? P: No
D: Can you think of anything which might be the cause of your problem? P: No
D: What do you do before you go to bed? P: I play video games.
D: How do you spend your time every day? P: I play video games
D: Where do you live? P: In a house

D: Any airports or train stations nearby? P: No
D: Any kids in the house or any noisy neighbours? P: No
D: Whom do you live with? P: Alone
D: Do you have any relatives? P: Yes/No (Elaborate)
D: How about any friends? P: No
D: How is your mood these days? P: It’s fine

D: Could you please score the mood on a scale of 1 to 10, where 1 is lowest and 10 being the
highest.
P: Average
D: Any fever, flu or cough?

D: Any family history of similar conditions? P: No
purposes only.
D: Any recreational drugs? P: I smoke marijuana(cannabis)
D: Any other drugs? P: No
D: Any tea/coffee? P: No
D: Tell me about your diet? P: I eat everything
D: Do you have any kind of stress or anxiety? P: I feel anxious

D: Can you please tell me what you are anxious about? P: I don’t know
D: What do you do for a living? P: I’m on benefits.
I would like to check your vitals and examine you fully.

I would like to send for some routine investigations including routine blood tests, thyroid
function test and U&E’s.
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?
D: I understand where you are coming from but let’s first discuss what I gathered from your
history and then work out the best way to handle the issue. 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 if 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
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 groups.
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 to
you earlier, we will try 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.
purposes only.
Surgery
UTI & BPH
You are FY2 in GP. Mr Washington Sundar, aged 75, presented to the hospital with dysuria.
Please talk to the patient, take history, do relevant examinations and discuss your initial
plan of management with the patient.

P: While passing urine, I have a burning sensation.
P: It is there from the last few days and is getting worse.
D: Is there any other symptom that is bothering you?
P: I have tummy pain here (points) for the last few days.

D: Was it sudden or gradual? P: It is gradual and becoming worse
D: Is there anything that makes the pain better? P: I tried PCM but it didn’t help.
D: How many did you take? P: I took 2 tabs yesterday.
D: Is there anything that makes the pain worse? P: It is getting worse.
most severe pain you have ever experienced? P: Around 5
P: I am going to the loo more from the last few weeks.
D: Is there any other symptom that is bothering you? P: No
D: Any fever, chills or flu-like symptoms? P: Yes dr. I had some flu-like symptoms.
D: Since when? P: From the 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 an increased frequency of urine at night? P: Yes (Nocturia)
D: How many times do you have to wake up during the night? P: 2-3 times.
D: Do you have to rush to the loo? 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 the 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 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 urinating? P: Yes/No (Dribbling)
purposes only.
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.
D: Tell me about your diet? 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? (epididymo-orchitis) P: No.
D: Any diabetes, high blood pressure, high cholesterol or heart disease P: No.
D: Any big prostate or history of passing a stone in your urinary tract? P: No
D: Any long term antibiotics or steroids? P: No
D: Any allergies from any food or medications? P: Yes, I am allergic to penicillin.
D: Any instrumentation in your urinary tract? P: No

D: Whom do you live with? P: I live with my wife.
D: I would like to check your vitals, examine your tummy and back passage.
D: I would like to send for some initial investigations including routine blood tests, urine dip.
Examiner:
BP- 110/70, HR- 70, T- 38C, O2 sat- 96
Abdomen: Tenderness over suprapubic area.
PR: Both the lobes of the prostate are enlarged, and the prostate is smooth.
Urine dipstick- Nitrates, Leucocytes and Microhematuria.
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.
We will give you some antibiotics. As you told me you are allergic to penicillin, we will give
you some other medications. Hopefully your symptoms will improve within a 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.
purposes only.
We will give you some painkillers for your pain and anti-sickness medication for nausea.
However, sometimes it may cause confusion, or you may develop 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 urine in your bladder. This can create a good
environment for the bugs to grow and can cause urinary infection. We examined your
prostate 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 an 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 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 doesn’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 avoid constipation and ultimately
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 an ambulance.
Treatment of UTI:
Nitrofurantoin (100 mg BD for 3 days)
Trimethoprim (200 mg BD for 3 days)
purposes only.
S/E of Nitrofurantoin and Trimethoprim: Nausea vomiting, diarrhea, 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 you are 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 no symptom that suggests
you have 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
purposes only.
UTI (Confusion)
You are FY2 in A&E. Mr Washington Sundar, aged 75, was 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: (wife): I don’t know why he is 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 he is behaving like this.
P: Ok Dr.
D: How has his health been recently? P: He got a fever 3 days ago.
D: Did you measure the temp? P: No
D: Did he have any symptoms along with fever?
P: He was having a 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: For 3 days.
D: Any other symptoms? P: No Dr.
D: Any blood in his urine? 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
D: Any change in his weight? P: No
D: How about his appetite? P: Good
D: Did you do anything for his fever and urinary symptoms?

D: 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 currently taking any regular medications, over-the-counter drugs or supplements?
P: No
purposes only.
D: Any similar complaints in any member of the family? 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 to check his vitals, GPE (Temp, Pulse Rate, Resp. Rate, BP) and also examine
his chest, tummy and nervous system.
Examination:
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.
P: Why is he behaving like this?

D: He is in confusion because it may be a complication of Urinary Tract Infection.
P: How can UTI cause this Dr.?

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.
D: What are you going to do for him now?

P: We are going to admit him, and we will do necessary investigations like Bloods
(FBC/U&Es/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 and 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 O2, 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.
purposes only.
High Flow O2
Give IV Antbiotics
IV Fluids
Blood Culture
Take Serum Lactate
Hourly Urine Output
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
!
purposes only.
Mannequin Patient (Urosepsis)
You are an FY2 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.
D: Any other symptoms?

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
D: Any blood in the urine? 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 (Hesitancy)
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?
Ask PMH, Lifestyle and Psychosocial history
I will check my patient’s vitals, GPE, and examine his tummy.
Examination/Investigations:
Vitals: BP - 150/90, Temp – 38O
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.
D: What are you going to do for him now?
purposes only.
P: 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.

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.
If in Sepsis à SEPSIS SIX: within one hour.

Give high flow of O2, 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.
Patient concerns.
Is it stroke?
purposes only.
UTI Female
You are FY2 in GP. Miss Janet Kent, aged 27, has presented to the clinic with abdominal
discomfort. Please talk to the patient, take history, assess the patient, discuss management
and address patients concerns.

P: I have tummy pain here (points) for the last few days.
D: Tell me more about your tummy pain? P: What do you want to know?
D: Was it sudden or gradual? P: Gradual and it is becoming worse
D: Is there anything that makes the pain better? P: I tried PCM but it didn’t help.
D: How many did you take? P: I took 2 tab yesterday.
D: Is there anything that makes the pain worse? P: It is getting worse.
the most severe pain you have ever experienced? P: Around 5
P: Dr. While passing urine I have a burning sensation.
D: Tell me more about it? P: It started with my pain and is getting worse
D: Any fever, chills or flu-like symptoms? P: Yes dr. I had some flu like symptoms
D: Since when? P: From the last few days.
D: How are you now? P: It is getting worse.
D: Any changes in the colour/smelly of urine? P: Yes, it is smelly and cloudy these days
D: Any nausea and vomiting? P: Yes/ No
D: Do you have to go to loo more often these days? P: Yes/No
D: How many times do you have to wake up during the night? P: 2-3 times.
D: Do you have to rush to the loo? P: Yes/No (Urgency)
D: Any loin pain? P: No (Pyelonephritis)
D: Have you had a similar kind of problem in the past? P: Yes/ 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.
D: Any other medications? P: No
D: Any long term antibiotics or steroids? P: No
D: Any instrumentation in your urinary tract? P: No
purposes only.
D: Do you smoke? P: Yes/no
D: When was your last menstrual period? P: 2 weeks ago.

D: Any discharge from your front passage? P: No (PID)
D: I would like to check your vitals and your tummy.

D: I would like to send for some initial investigations including routine blood test, urine dip.
Examiner:
Abdomen: Tenderness over suprapubic area.
Urine dipstick- Nitrates, Leucocytes and Microhaematuria.
From our assessment, we are suspecting you have a condition called urinary tract infection.
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.
We will give you antibiotics for now. Write it on the prescription pad (FP10 form).
Drug of choice for UTI:
Nitrofurantoin 100 mg BD for 3 days (7 days in males and pregnant women)
OR
Trimethoprim 200 mg BD for 3 days
Nitrofurantoin may be taken during pregnancy, but it is generally best avoided in the third
trimester because there's a small chance it could cause problems with your baby's red blood
cells.
Hopefully your symptoms will improve within a 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.
We will give you some painkiller for your pain and anti-sickness medication for nausea.
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 the toilet.
- Take shower instead of a bath.
purposes only.
- Try to fully empty your bladder when you go to pee.
- Wear loose and cotton underwear.
If your symptoms don’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
Antibiotics for pregnant women aged 12 years and over:
Amoxicillin (250-1000mg QDS) usually 500mg TDS for 7 Days.
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:

Name, Address, Date of birth and age of the patient.
Name, Dosage, Route, Frequency and Duration of Medication
Put Date, Your Name and Sign.
Differentials:
UTI
Pyelonephritis
Ectopic pregnancy
Appendicitis
PID
Calculi
purposes only.
UTI in Pregnant Woman
You are an FY2 in GP, Miss Samantha Truce, aged 30, has come to you with burning
sensation whilst passing urine. She is 29 weeks pregnant. Talk to her and address her
concerns.
UTI in Female (Transition Female to Male)
You are an FY2 in GP, Miss Natalie Robbins, aged 18, has come to you with burning sensation
whilst passing urine. She is under transition from female to male. Talk to her and address
her concerns.
purposes only.
Recurrent UTI
You are an FY2 in GP Surgery. Miss Sandra Duke, aged 24, has a history of dysuria 2 weeks.
Her urine culture was negative. She was prescribed Trimethoprim, and her symptoms did
not subside. She went to her GP and was prescribed 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 had 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? P: It is continuous.
D: Could you describe this pain for me? P: It is a dull pain.
D: Could you score the pain for me on a scale of 1-10? P: It is around 4-5.
D: Do you have any other symptoms? 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.

D: Do you have any fever? P: No
D: Any back pain? P: No
D: Any blood in your urine? 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
purposes only.
D: Do you have any previous history of DM, renal stones, STIs or UTIs? P: No
D: When was your last menstrual period? P: 3 weeks back.


D: Do you have a stable partner? P: Yes
D: Do you practice safe sex? 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 underwear or tight clothes? P: No

D: When you go to the loo, do you wipe from front to back or back to front? P:
D: What do you do for a living? P: I am a student

D: Who do you live with? 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&Es) and urine tests.
D: Do you have any idea what is going on? P: No

D: Are you concerned about anything? P: No
From my assessment, I suspect you have repeated UTIs. This could be due to multiple reasons
like undertreated 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 using 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.
P: What’s going on?

P: Why do I have recurrent UTIs?
purposes only.
STI (Male)
You are an FY2 in GP. Mr Mark Jones, aged 23, has come to you with burning sensation
whilst passing urine. Talk to him, assess him and address his concerns.

P: I am having burning sensation when I pee.
D: Tell me more about it? P: What do you want to know?
D: May I know since when? P: Since the last few days.
D: Is it continuous or does it come and go? P: Continuous
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
D: Any fever or flu like symptoms? P: Yes, fever.
D: Any sore throat or cough? 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 tummy ache? P: No
D: Any SOB or tiredness? P: No
D: What do you do for a living? P: Office work

D: Have you travelled recently? P: Yes
D: Since when? P: Last 5 years.
D: Do you practice safe sex? P: No
D: Do you have stable partner? P: I have a wife
D: Any other recent partner? P: I have another female partner
D: What is your preferred route of sex? P: Vaginal sex
I would like to do GPE, Vitals, and want to examine your private region.
We will also do some routine blood investigations like liver and kidney function.
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
sexual transmitted infections. If you agree, we will also offer HIV screening.
purposes only.
If the tests show an STI, we will be giving you some antibiotics after the results are back, and
some pain killers to help ease the pain.
If tests show you have an STI, you should tell your sexual partner and any ex-partners 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're 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
purposes only.
PSA Test- Demanding Patient
You are an FY2 in GP. Mr Jason Roy, aged 55, came to the clinic requesting PSA. Please talk
to the patient and address his concerns.
D: What brought you to the hospital today? P: I want to have the PSA test done
D: May I know why? P: Dr one of my friends has 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 a 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.
D: Any fever or flu-like illness recently? P: No
D: Do you have to wake up in the middle of the night to go to 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 a weak urine stream or stream that stops and starts? P: No
D: By any chance is there any blood in your urine? P: No
D: Any weight loss you noticed recently? P: No
D: Did you have similar symptoms in the past? D: 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
D: Are you allergic to any medication? P: No
D: Any family history of any significant health issues or prostate problems? P: No
I would like to do a GPE, check vitals and examine your back passage. I will be having a
chaperone with me.
purposes only.
D: Can you tell me how much you know about the test? P: I know it tests for prostate
cancer
D: PSA is a protein produced by normal and cancerous cells of the prostate. PSA is actually
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).
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 results can further lead to invasive investigations such
as taking a sample from your prostate (biopsy) and there may be adverse events 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 don't have symptoms.
4. We can provide you with some leaflets from the Prostate cancer UK organization before
you decide.
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 the previous 6 weeks.
purposes only.
PSA Rectal Examination
You are an FY2 in GP. Mr Tony Montana, aged 56, has come to you for his results.
PSA: Normal
U & E: Normal.
Talk to him and explain the blood results and disclose the news.
D: How can I help you? P: I am here for my results.

D: Why did you get the PSA test done? P: My friend died of Prostate Cancer
D: I understand, I have your test results. Before I tell you your results, is it alright if I ask you
a few questions? P: Ok
D: Did you have any symptoms that made you get these tests? P: No
D: Any pain while passing urine? P: No
D: Any blood in your urine? 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
D: Do you have to rush to the loo? P: Yes (Urgency)
D: Have you noticed any weight loss? (Cancer) P: No
D: Any of your friends/family told you that you have lost weight? P: No
D: How is your appetite? P: It’s fine doctor.
D: Any pain in your pelvic area? P: No.
I would like to check your vitals and examine your tummy and your back passage.
Please explain the blood results to the patient and manage the patient according to the
findings.
purposes only.
PSA
Pros and cons of the PSA test
Pros:
it may reassure you if the test result is normal

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

it may lead to unnecessary worry and medical tests when there's no cancer
it cannot tell the difference between slow-growing and fast-growing cancers
it may make you worry by finding a slow-growing cancer that may never cause any problems
Should you know your PSA level?
Instead of a national screening programme, there is an informed choice programme, called

prostate cancer risk management, for healthy men aged 50 or over who ask their GP about
PSA testing. It aims to give men good information on the pros and cons of a PSA test.
If you're aged 50 or over and decide to have your PSA levels tested after talking to a GP,
they can arrange for it to be carried out free on the NHS.
If results show you have a raised level of PSA, the GP may suggest further tests.
!
purposes only.
Loin Pain
You are FY2 in A&E. Mr Aaron Patterson, aged 27, presented to hospital with loin pain. The
patient was given Diclofenac by the nurse. Please talk to the patient, take history, assess
the patient and discuss management with the patient.
D: What brought you to the hospital? P: I have got pain here (points at left loin).
D: Tell me more about your pain? P: I was watching TV, suddenly it started
D: When did it start? P: 3 hours ago
D: Was it continuous or comes and goes? P: Continuous
D: What type of pain is it? P: I don’t know
D: Does the pain go anywhere? P: Left groin
P: Your nurse gave me a painkiller and it helped a bit.
the most severe pain you have ever experienced? P: Around 8
D: Do you have any other symptoms? P: I am feeling sick since my pain started
D: Did you vomit? P: Yes, I vomited once.
D: Do you have a dry mouth? P: No
D: Any fever or flu-like symptoms? P: No
D: Do you have any problem with your urine? P: No
D: Did you pass any stone with your urine? P: No
D: Do you have a burning sensation while passing urine? P: Yes/ No
D: Have you noticed any blood in your urine? P: No
D: Are you going to the 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.

D: Any HTN or kidney disease? P: No
D: Gout or hyperparathyroidism? P: No
D: Any calcium or vitamin supplements? P: No
D: Any blood thinner or antacids? P: No
D: Tell me about your diet? P: Good

D: Any high protein containing only meat or low fibre diet? P: No
D: Do you drink enough water? P: Yes
D: Are you physically active? P: Good
purposes only.
I would like to check your vitals and examine your tummy.I would like to send for some
initial investigations including routine blood tests and urine dip.
Examiner:
T-37, HR- 90, BP- 110/70, RR- 12-20, O2 sat- 96%.
Tenderness in the left flank area.
Urine dip: Haematuria++
From our assessment, we are suspecting you have stone in your urinary tract. We have done
a urine test and we found there was some blood in your urine. We will do blood tests and
another 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 a 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 a 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 of urine by relaxing the neck of the bladder
and the tubes (Tamsulosin).
Treatment:
Depends on the size of the stone:
If it is <4mm then it will come out on its own.
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 as it helps 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 a high fiber diet,
reduce salt intake, reduce the amount of meat.
If you have a high temperature of 38C or more, sudden severe pain in your loin, shivering
(pyelonephritis) and you are not able to pass urine, please come to the hospital.
Differentials:
Urinary Stone
UTI
Pyelonephritis
Renal Cell Carcinoma
Pneumonia
purposes only.
Causes of Kidney Stones:
● high-protein, low-fibre diet
● inactivity or bed-bound
● family history of kidney stones
● previous kidney or urinary infections
● history of kidney stone, particularly if it was before you were 25
● only one fully working kidney
● having 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:
1. Aspirin
2. Antacids
3. Diuretics (used to reduce fluid build-up)
4. 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:
1. an inherited condition called hypercalciuria, which leads to large amounts of calcium in
urine
2. Hyper-parathyroidism
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:
1) eating a high-protein diet that includes lots of meat
2) a condition such as gout that prevents the body from 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?
purposes only.
Haematuria
You are FY2 in GP. Mr. David Manzimmer, aged 57, presented to the clinic with
haematuria. Please take history, assess the patient and discuss the management plan with
the patient.
D: What brought you to the hospital? P: I have noticed blood in my urine.

D: Tell me more about it? P: From the 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 haematuria) P: No
D: Is there anything else bothering you? P: No
D: Any changes in your urine colour or smell? P: No
D: Are you going to the loo more often these days? P: Yes/No
D: Do you have an increased frequency of urination at night? P: Yes/No (Nocturia)
D: Do you have to rush to the loo? P: Yes/N (Urgency)
D: Have you noticed any weight loss? (Cancer) P: No
D: Have any of your friends/family told you that you have lost weight? P: No
D: How is your appetite? P: It’s fine, doctor.
D: Any pain in your pelvic area? P: No.

D: Any diabetes, high blood pressure, high cholesterol or heart disease? P: No.
D: Any enlargement of prostate or history of passing stones in your urinary tract? P: No
D: Any chemo/radiotherapy? P: No
D: Any blood thinner? P: No
D: Do you smoke? P: Yes

D: May I know what you do for a living? P: I work in an office.
D: Have you ever worked in aniline, dyes, textiles, rubber, plastic or paint industries in the
past? P: No
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 tests and urine
dip.
purposes only.
Examination:
Prostate is slightly enlarged and is smooth in surface and consistency.
In Urine Dip +++ Haematuria
From our assessment, you seem to have a problem in your bladder and prostate (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 measure the amount of substance produced by your prostate (if prostate
findings positive).
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 within 2weeks time. We will do cystoscopy to
have a closer look inside your bladder to see if there is any abnormality. We may have to
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 ultrasound scan (TRUS) of your prostate may be done to measure the size and
take a sample if needed (if prostate findings positive).
If it is cancer then the treatment depends upon the type, size, position and stage of cancer
and also your overall health. The mainstay 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.
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.

P: What is happening doctor?
P: What can it be doctor?
Differentials:
Bladder cancer
UTI
Kidney stones
Enlarged prostate
Blood thinners
Instrumentation
purposes only.
Back Pain
You are FY2 in GP. Mr Eric Smith, aged 58 years, presents to the clinic complaining of back
pain. Talk to the patient, take history, assess the patient and discuss further management
with the patient and address patient’s concerns.
D: What brought you to the hospital? P: I have pain here (pointing towards lower back)
D: Tell me more about your pain? P: It has been there for the last 3 months.
D: What were you doing when you had this pain? P: Nothing
D: What type of pain is it? P: Dull
D: Is there anything that makes the pain better? P: I tried PCM, but it didn’t help that much
D: How much did you take? P: I took 2 tablets every 6 hourly.
most severe pain you have ever experienced? P: 6
D: Do you have anything else along with pain?

P: Yes, I am going to loo more often these days/No
D: Do you have an increased frequency of urination at night? P: Yes/ No (Nocturia)

D: Do you have to rush to the loo? P: No (Urgency)
D: Do you have Difficulty in starting urination? P: No Hesitancy)
D: Are you able to hold your urine before going to loo? P: No (Incontinence)
D: Do you have a weak urine stream or a stream that stops and starts? P: No
D: Do you feel like you are not able to completely empty the bladder? P: No
D: Have you noticed any dribbling at the end of urination? P: No
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 closed question)
D: How is your appetite? 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 the upper back or pain in your tummy? P: No. (Pancreatic CA)
D: Any heartburn 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 radiating from back to your legs? P: No (Disc prolapse)
D: Any trauma to your back? P: No
purposes only.
D: Any enlarged prostate? P: No
D: Family history of prostate problem? P: No

D: Do you drink alcohol? P: Yes/ No
D: Do you do physical exercise? P: Quite active
D: What you do for a living? P: I’m a builder
I would like to check your vitals and examine your back, back passage and straight leg test.
I would like to send for some initial investigations including routine blood test, urine dip,
CXR and X-Ray of your back.
Examiner:
Normal
From our assessment, we are suspecting you have a condition in your prostate, which is a
small gland which lies beneath the neck of your bladder.
We suspect your condition could be a serious one.
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 prostate.
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 take a
sample if necessary. A bone scan of your back to look for any abnormality. A CT or an MRI
scan.
purposes only.
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 various options with you and will give the suitable
treatment plan for you.
For now, we will prescribe painkillers for your pain. As you are already taking paracetamol
and it doesn’t help, we will prescribe you another medication called Co-codamol.
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.

P: What is happening doctor?

P: What about my pain Dr?
Differentials:
Prostate cancer
Pancreatic cancer
Lung cancer
Renal cell carcinoma
Osteoarthritis
Osteoporosis
Kidney Stones
Pyelonephritis
Disc Prolapse
purposes only.
Back Sprain
You are an F2 in A&E. Mr Victor Chester, aged 30, came to you with acute back pain. Talk
to the patient, assess him and give the further plan of management.
D: How can I help you? P: I have back pain.

D: Are you comfortable to talk? P: Yes, I can manage.
D: Where exactly do you have the pain? P: In my lower back.
D: When did it start? P: Yesterday.
P: I was playing squash and after the game finished, it started.
D: Does the pain go anywhere? (radiation to legs) P: No
D: Did you experience any weakness of the legs? P: No
P: The nurse gave me 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.
D: Could you please score the pain on a scale of 1 to 10, where 1 being the least and 10
being the most severe pain you have ever experienced? P: 3
D: Have you felt any numbness or tingling sensation in your legs? P: No
D: Has it happened before?
P: No, this time I was playing squash for a 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
D: Any loss of weight? P: No

D: What do you do for the living? P: I work in an office.
purposes only.
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 a straight leg test. (SLR test) & neurological
examination of the lower limb.
Examination: There is pain on moving the legs & tenderness in the lumbar area of the back.
There is tenderness in the 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 sports 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 painkillers for your pain. The pain should
subside after a 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 a few
days, please come back.
You can start with some normal activities initially, try doing simple activities that won’t
cause much 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 exercise?

D: It is advisable to avoid strenuous exercise such as running for up to a 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 kinds of sports until your injury heals
and it will take a few weeks.
Please follow up with your GP regularly.

Please do come back to the hospital if you experience:
- 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
purposes only.
Back Pain (IVDP)
You are an FY2 in A&E. Mr Jermaine Jones, 40 years old, has presented to the hospital
complaining of back pain. Talk to him, assess him and discuss the management plan with
the patient.
D: What brings you to the hospital today? P: Doctor, I have this pain in my lower back.
D: Tell me more? P: I have had this pain for the last 2 weeks on
and off, but since yesterday it's been very painful.
P: I was at my job, moving heavy boxes, when the pain started
D: Was it sudden in onset? P: Yes
D: What type of pain is it? P: Sharp
D: Does the pain go anywhere?
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
D: Is there anything that makes the pain better? P: Yes, it gets better when I take
diclofenac.
D: How many tablets did you take? P: 2
D: Is there anything that makes the pain worse? P: Yes, when I try to bend.
D: Could you rate the pain on a scale of 1 to 10, 1 being the least & 10 being the most severe
pain you have ever experienced? P: 7/8
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
D: Any fever, flu like symptoms or cough? P: No
D: How are your urine and bowel habits? P: They are normal.
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: How has your appetite been recently? P: It’s been fine

D: Have you noticed any weight loss 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

D: Are you taking Diclofenac regularly? P: Yes
purposes only.
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

D: Do you do any physical activity? P: Yes
D: What do you do for a living? P: Office work.
D: I would like to check your vitals, GPE, back, lower limb examination and SLR test.
D: I would also like to send for some initial investigations, including routine blood test, FBC,
urine dip, X-ray of your back.
Examiner:
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.
There are nerves in the back, which go to different body parts. 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 diminished, 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 painkiller (NSAID). We’ll add another (paracetamol) to that so that
your pain becomes better. If your pain is not relieved by these painkillers, your GP can
prescribe you stronger painkillers 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 the 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.
purposes only.
An epidural is an injection given into the back. It is usually given into the area in the back
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.
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 area).
Symptoms of Cauda Equina Syndrome:
- Lower Back Pain
- Bowel Problem (constipation)
- Bladder Problem (Urine Retention)
- Sexual Problems may also occur (impotence in men).
- Numbness in the saddle area, which is around the back passage (anus), and weakness in
one or both legs.
Investigations:
- MRI
- Myelography and CT are also sometimes used.
- 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. !
purposes only.
Aortic Abdominal Aneurysm
You are FY2 in A&E. Mr. Robert Pyrone, aged 60, has presented to you with complaints of
back pain for the last 1 day. Patient has been diagnosed with HTN for the last 10 years.
Talk to the patient, take history, assess the patient & discuss the plan of management.
D: What brings you to the hospital today?

P: Doctor I have back pain since yesterday.
D: Tell me more about your pain? P: I have pain in the centre of my back.
D: Is it continuous or comes and goes? P: It was continuous.
D: What were you doing when the pain started? P: I was just sitting.
D: What type of pain is it? P: It is a throbbing pain.
D: Is there anything that makes the pain better? P: I took Ibuprofen, it didn’t help.
being the most severe pain you have ever experienced? P: 7

D: Any pain or numbness in the legs? 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? P: Fine
D: Any burning during urination? 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: I have had HTN for the last 10 years.
D: How are you managing it? P: I am taking medicine for that.
I would like to examine you. I’ll check your vitals, GPE, examine your back, abdomen & back
passage. We will do some initial investigation including FBC, ESR, CRP, LFT, ECG and chest X-
Ray.
Examiner:
Pulsatile and expansile mass in the abdomen
purposes only.
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 & cause pressure to the blood flowing
through it. That’s why you’re feeling the pain in your back. If the pressure becomes too
much, it has a risk of bursting, which can be life-threatening.
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 follow-up
We will be doing a 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
to men aged 65. If negative, this effectively rules out AAA for life.
purposes only.
Intestinal Obstruction
You are an FY2 in Surgery. Miss Irina Wight, aged 32, has come to the hospital with
abdominal pain. Talk to her, assess her and address her concerns.
D: How can I help you? P: I am having tummy pain.

D: Where is it exactly? P: It’s all over
D: Since when? P: Since the morning
D: What were you doing when it started? P: I was just sitting
D: What kind of pain? P: Dull, crampy
D: Anything else with it? P: Yes, I haven’t passed stools
D: Since when? P: Since yesterday
D: Did you pass any wind? P: No
D: When was the last time you did? P: Yesterday
D: Do you have any nausea/vomiting? Any diarrhoea? (Gastroenteritis), Any reflux? (GORD),
Any fever? Any bleeding from your back passage? Any weight loss? (Tumour) P: No

I would like to do GPE, Vitals and abdominal examination. I would like to send for some
baseline investigations FBC, U&Es, creatinine as well as a plain abdominal X-ray. We may
plan an MRI, ultrasound, and CT scan if needed.
Examination: Clinical signs include abdominal distension, 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.
DD:
1. Gastroenteritis.
2. Acute Pancreatitis.
3. Peptic Ulcer Disease.
4. Perforated Diverticular disease.
purposes only.
Acute Cholecystitis
You are an F2 in A&E. Mr 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
D: How can I help you? P: I am having tummy pain.

D: Where is it exactly? P: On the right side, below the ribs.
D: Since when? P: Since yesterday
D: Does the pain go anywhere? P: Yes, it radiates to the shoulder
D: Do you have any nausea/vomiting? P: No

D: Any fever? P: No
D: Any sweating? P: No
D: Any yellow discoloration of the skin? P: No
D: Any abdominal mass? P: No
D: Have you had similar kind of problem in the past? P: No

P: HTN for last 10 years.
D: Any DM, Heart disease or high cholesterol? P: No
P: I am taking amlodipine for the last 10 years

D: Do you drink alcohol? P: Yes

D: Tell me about your home condition? P: I live in a house.
D: Do you live alone? P: I live with my wife
purposes only.
I would like to check your vitals and examine your vitals, GPE and abdominal examination.
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
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
gladder. 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.
Treatment:
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 you IV fluids, painkillers,
and antibiotics.
After the initial treatment, we will be discussing with the senior doctor and may need a
surgery referral.
Causes.
1. Gallstones.
2. Bile duct Block (Kinking or tumour)
3. Infections.
4. Alcohol
purposes only.
Acute Pancreatitis
You are an FY2 in A&E. Mr Robert Keller, aged 30, has come to you with abdominal pain.
Please talk to the patient, take history, assess, and discuss the initial plan of management
with the patient.
Signs and Symptoms

Central abdominal pain radiating to back, N/V, diarrhoea, indigestion, fever, jaundice,
tachycardia, hypotension.
Risk Factors
Gallstones, alcohol, autoimmune pancreatitis, smoking, obesity, family history.
Examination and Investigations
GPE, Vitals, Abdominal (Cullen’s and Grey Turner’s sign)

CBC, Serum amylase, Lipase, U & E, Glucose, CRP, Serum Ca, AST, ALT, CXR, Abdominal X-Ray
USG, CT, MRI
Management
Fluids, O2, PK, ICU care

Symptomatic treatment,
Treat the underlying cause
Complications
Pseudocysts
Pancreatic necrosis
Pancreatic infections
Chronic pancreatitis
Pleural effusion
ARDS
Shock
purposes only.
Counselling
SPECIAL values for a Doctor
• Safety
• Patient centeredness/ Privacy
• Equality
• Confidentiality/ Compassion
• Improving lives
• Autonomy
• Learning
5 Golden principles
• Confidence
• Reassurance
• Diplomacy
• Situation/Management
• Practice
purposes only.
Counselling
DIAGNOSIS Follow up
v Pt’s idea & Understanding Review
v When were you diagnosed? Discharge
v How is it managed? Reports Disclosure
ELABORATE
Non-medical? (Lifestyle)
Medical? – Compliance & Side effects
Surgical?
v Current status – Signs + Symptoms +/ Examinations

v Any complications?
v Do you check your blood sugar/BP regularly?
v Do you go for regular follow ups?
Risk factors
Non-modifiable Modifiable
(Age, Gender, PMHx & Family Hx) (Lifestyle & Social)
Management
COUNSEL
01 02 03 04 05
Doctor: Patient: Trigger factors: Follow up: Warning signs:
- Ex / Ix - Be compliant to - Avoid - Do not miss
Medication
- Come back to the
- Start/ Stop/ hospital
- Healthy Lifestyle
Review/ Change
Medication - Reduce sugars/ Do
not skip meals
- Follow ups
purposes only.
Medication Counselling
• Explain – Purpose and function
• How to take?
• Side effects
• Drug interactions
• Food interactions
• Booklets & Alert cards (Warfarin/ Steroids)
• Follow up
• Warning Signs
Informed DVLA
Therapy type Car or motorcycle Bus, coach or lorry

Diet only No* No*
Sulphonylureas or glinides No* Yes
Other diabetes tablets or incretin mimetics No* Yes
Insulin Yes Yes
purposes only.
Medicine
Blood Pressure Management
You are an FY2 working in a GP clinic. Mr Jamie Landcroft, aged 55, presented to you for his
first follow-up. Patient has diabetes mellitus. Patient had been admitted to the hospital due
to cellulitis four weeks ago and was treated for it with antibiotics. During the admission, the
patient was newly diagnosed with hypertension. On discharge, the patient was prescribed
some medications. Please talk to the patient, take focused history, check his/her blood
pressure and discuss further management with the patient. This is the patient's first review
after being diagnosed with high blood pressure.

P: Four weeks ago, I was diagnosed with cellulitis and 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: I understand 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 cough.
D: Why do you think that way? P: I have been taking these (points towards Aspirin and
Statin) for a long time and I have never had any problems. I 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?
D: Have you been diagnosed with any other medical condition other than high blood
pressure.? P: I have Diabetes.
D: Since how long? P: 10 Years.
D: How do you manage it? P: My diabetes is controlled by my diet.
D: Are you taking any medications for it? P: No doctor.
D: Is it well controlled? P: Yes.
D: Any complications of diabetes? P: No doctor.

D: Do you see your GP regularly? P: Yes, I frequently go to my GP.
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 or heart problem? P: No doctor
purposes only.
D: Since when have you been taking these Aspirin and statin? P: 10 years.
D: Do you take it regularly? P: Yes.
D: Do you take any other medications? P: No

D: Tell me about your diet? P: Not good
D: Do you do physical exercise? P: Not active
D: Now I am going to check your blood pressure now.
Examiner:
BP à170/100
Your blood pressure is high, and it is because you haven’t taken your blood pressure
medication in the 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.
Take your medications regularly as prescribed, otherwise you may face problems in the
future. If you develop any side effects, please feel free to come back to us.
Side Effects of ARBs:

Dizziness, Headache, Drowsiness, Nausea, Vomiting, Diarrhea, Elevated Potassium Levels.
Notes:
Sometimes in this station, the patient is on Amlodipine and complains of Ankle edema
(Common side-effects of CCB’s). Then we can change to another drug and I will confirm
with my book.
If patient is insisting which one, then we can say ACE inhibitors (Ramipril)
!
purposes only.
Pregnancy (Hypertension 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. Talk to her and address her concerns.

P: I am trying to get pregnant.
D: Let me ask you a few questions to make sure everything is fine. P: Ok

D: Have you been pregnant before? P: No
D: How long have you been trying to get pregnant? P: 12 months
D: Have you been using any contraceptives? P: No
D: When was your last menstrual period? P: 2 weeks ago
D: Any bleeding in between? P: No
D: Are you regular with cervical screening? P: Yes
P: Yes, I have been diagnosed with hypertension for the last 5 years.
D: How is it managed? P: I’m on Ramipril
Please ask about PMH, Lifestyle and Psychosocial history.
D: Who do you live with? P: My partner

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 patients must be
started on some other medication. Ramipril should be stopped as she is pregnant. We must
aim for blood pressure lower than 140/90 and always try to keep it around 135/85.
We may consider giving Labetalol, Nifedipine, Methyldopa. ACEi can cause adverse effects
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 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.
purposes only.
Ramipril (Side Effects)
You are an FY2 in GP Surgery. Mr Thomas Radcliff, aged 50, was diagnosed with high
blood pressure 1 month ago when he went for wellman checkup. Patient was started on
ramipril 2.5mg 2 weeks ago. Now patient has come for the follow up. Talk to the patient,
assess him, and address the concerns.
BP – 160/100
eGFR – 90 (2 weeks ago) eGFR – 60 (present)
Electrolytes, ECG – normal
Creatinine – Increased
Renal impairment
For all ACE-i
Hyperkalaemia and other side-effects of ACE inhibitors are more common in those with
impaired renal function.
For Ramipril
Dose adjustments: Start with low dose and adjust according to response.
Max. daily dose 5 mg if creatinine clearance 30–60 mL/minute; max. initial dose 1.25 mg
once daily (do not exceed 5 mg daily) if creatinine clearance less than 30 mL/minute.
The use of drugs in patients with reduced renal function can give rise to problems for
several reasons:
• reduced renal excretion of a drug or its metabolites may cause toxicity;
• sensitivity to some drugs is increased even if elimination is unimpaired;
• many side-effects are tolerated poorly by patients with renal impairment;
• some drugs are not effective when renal function is reduced.
• Many of these problems can be avoided by reducing the dose or by using alternative
drugs.
If even mild renal impairment is considered likely on clinical grounds, renal function should
be checked before prescribing any drug which requires dose modification.
Ramipril Side Effects:
• a dry, tickly cough that does not go away.
• feeling dizzy or lightheaded, especially when you stand up or sit up quickly (this is more
likely to happen when you start taking ramipril or move on to a higher dose)
• headaches.
• diarrhoea and being sick (vomiting)
• a mild skin rash.
• blurred vision.
Patient concerns:
- Kidney damage
- Long term complications
purposes only.
Post Myocardial Infarction Lifestyle
You are an FY2 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, Clopidogrel, and
Ramipril. Please talk to the patient, discuss lifestyle modification and address the patient's
concerns.

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? P: Fine

D: Any chest pains? P: No
D: Any chest tightness? D: No
D: Any SOB? D: No
D: Any heart racing? D: No
D: Any ankle swelling? P: No
Please ask about the PMH, Lifestyle, Psychosocial History.
I would like to do a GPE and check the vitals.
Please advise patient about lifestyle modification.
DVLA recommends that all patients should stop driving for at least 4 weeks after a heart
attack.
DVLA recommends that patients who drive bus, coaches 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).
purposes only.
Psoriasis Lifestyle Modification
You are an FY2 in Medicine. Mrs Kathie Walkers, aged 55, is diagnosed with psoriasis and
is using skin emollients. Her psoriasis is well controlled. Her BMI is 32. Talk to the patient

P: Doctor, can you tell me what dementia is?
D: Yes, but may I know why you want to know about dementia?
P: Because my colleagues and my sister have got vascular dementia that is why I am worried
about it.
D: Could you please tell me how old your sister was 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
D: How is your health in general? P: It is fine
D: Any fever or flu like symptoms? P: No.
D: Have you been diagnosed with any medical condition in the past? P: Yes, I have Psoriasis.
D: How are you managing it? P: I am using emollients for that.
D: Is it under control? P: Yes
I would like to check your vitals and do a 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
mini-stroke in the future.
We have done your examination and your BMI is on the 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
purposes only.
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.
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
!
purposes only.
Stroke Assessment
You are FY2 in GP Surgery. Mr Henry Wordle, 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: I am worried about stroke. My dad also passed away due to a 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
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 we can work on to decrease the risk of developing stroke.
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.
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 a routine blood test to check cholesterol level, sugar level and
kidney and liver function. We will also do a 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.
Act FAST if you develop any:

F: Facial drooping.
A: Arm weakness.
S: Slurred speech.
T: Telephone à Call the ambulance 999.
purposes only.
Recurrent TIA
You are an FY2 working in Medicine. Samuel, aged 50, has had 3 previous episodes of TIA.
Your consultant has asked him to stop driving for 3 months. Talk to him about his driving.
D: Hello. I came to know from your note that you had left sided weakness of the body 3
times in the last couple of weeks.
P: I had 3 previous episodes of mini stroke.
D: How are you feeling today? P: I am feeling fine now.
D: Any weakness or numbness anywhere (Face and arm)? P: No doctor.
D: Any problem with the speech? P: No
D: Any blurry vision? P: No
D: What treatment were you getting in the hospital?
P: I have been given blood thinners.
D: Do you take your medications regularly? P: Yes doctor.
D: Any missing dose? P: No
D: Any similar kind of problem in the past? P: No

D: Any DM, high blood pressure or high cholesterol? P: No
D: Did she have any abnormal heart beats? P: No
D: Do you take any medications including OTC or supplements? P: No
D: Any previous hospital stays or surgeries apart from these mini stroke admissions? P: No
D: Any history of heart disease or stroke in the family? P: No

D: Tell me about your diet? P: Good diet includes fruits and vegetables.
D: Do you do physical exercise? P: Yes, we move around in our house.
D: What do you do for a living? P: I am a taxi driver. (If his job doesn’t involve
driving, then ask do you drive)
D: Have you resumed driving? P: Yes, I did.
D: I am glad you are fine now, and you are recovering, but I am here to talk to you about
something. Do you have any idea what I am going to talk about? P: No doctor.
D: As you told me you had three previous episodes of mini stroke and you have been
treated for that. The consultant who is overseeing your care has advised you not to drive for
3 months. But you mentioned you started driving. May I know why?
P: Because I am fine now that’s why I started driving.
purposes only.
D: Looking at the guidelines, after having these episodes patients are legally banned from
driving for at least 3 months and then there has to be a medical review to determine if
driving can recommence.
P: Doctor I can’t do that; it is my job.

D: I can see you are concerned but according to the guidance you must inform the DVLA and
you cannot drive until you fulfil the DVLA criteria.
P: But who will feed me and my family?

D: I cannot imagine how difficult the situation is but patients who drive for a living are at
greater risk both to themselves and to the public at large. Also, whether you notify the DVLA
or not, your insurance policy is now invalid. What I advise you to do is to see your manager
and ask if there is any opportunity for placement elsewhere within the workplace.
P: If I don’t inform DVLA, are you going to inform them or not?

D: I am afraid to say if you don’t inform the DVLA , I am required by the law to inform them
by myself. Before that ,I am going to inform you about the decision .Once they have been
informed ,I will write to you that disclosure has been made and inform your GP as well .So
please think about our discussion and let me know about your decision.
Also, I am going to document the discussion today in your notes and I am going to talk to
the consultant about the meeting with you.
purposes only.
Obesity Counselling
You are FY2 in GP. Mrs Lucy Jenkins, aged 52, presented to the clinic with complaints of
being overweight. Please talk to her and address her concerns.
D: What brought you to the hospital? P: I am obese I want to lose weight.

D: Since when are you gaining weight?
P: My problem of gaining weight has been 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 recently? P: No
D: Do you feel tired these days? P: Yes
I would like to examine you, check your vitals, do a general physical examination and check
your height and weight. I would like to send for some routine blood tests, to check the
function of your liver and kidneys and to check the level of cholesterol in your blood.
Examiner:
Everything is normal. BMI is 40.
It's very important to take steps to tackle obesity because besides causing obvious physical
changes, it can lead to several 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, and stroke. Obesity can also affect your quality of life and lead to
psychological problems, such as depression and low self-esteem.
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 gym. It doesn’t have to 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, you may need to do 60-90
minutes of activity each day. You can also try doing moderate intensity activity like 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.
purposes only.
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 centre 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 surgeries.
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
full 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.
Differentials:
Hypothyroidism
Long term usage of steroids (Cushing’s Syndrome)
Diet
Physical activity
Family history
purposes only.
Knee Replacement Follow Up
You are in 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.
Talk to her and address her concerns.
D: How can I help? P: I have pain in my knee joint.

D: Can you tell me more? P: Like what?
D: Which knee joint? P:
D: When did it start? P: 2-3 years ago
D: Is it continuous or comes and goes? P: It comes and goes and now its worse
D: What type of pain is it? P: It is a dull ache.
D: Is there anything that makes the pain better? P: Resting
D: Is there anything that makes the pain worse? P: Pain killers
the most severe pain you have ever experienced? P: It is 5
D: Anything else with pain? P: No

D: Any weight changes? P: No
D: Any hot and tender joints? P: No
D: Did you fall prior to your joint pain starting? P: No
D: Any previous hospital stays or surgeries?
P: I was advised surgery for my knee 2 years ago but I refused
D: Why is that? P: I didn’t feel ready
D: What has changed now? P: The pain is worse
Please ask about lifestyle and psychosocial history.

I would like to do GPE, Vitals, knee examination, your height and weight for BMI.
Examination:
BMI= 33.
purposes only.
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 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.
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 a 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 joints
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 gym. 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.
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.
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 centre 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.
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.
purposes only.
Statin
You are FY2 in GP. Mr Emma Blair, aged 55, came to the clinic for health check-up. All the
blood tests including blood sugar, LFTs and U&Es came back normal. Only cholesterol was
found high and her QRISK 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.
D: What brought you to the hospital? P: I want to know about my blood results.
D: Yes, I will discuss your blood tests but let me ask you a few questions first so that I may
explain them better. P: Ok
D: Could you please tell me why you did those blood tests?
P: One of my friends had TIA and I was worried, that is why I had these blood tests.
We have checked your blood tests, 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 are you 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-effect of Statins?

D: One of the side-effects is an increase in blood sugar. Having a well-balanced diet, physical
activity and checking blood sugar regularly can control your blood sugar. If needed, we will
give you some medication as well.
It can lead to problems with the digestive tract like constipation, diarrhoea and flatulence
but these can be managed easily by making some changes in the diet e.g., Sticking to simple
food, avoiding spicy and oily food.
One of the side effects is muscle pain or joint pain. If it happens, please contact your GP.

purposes only.
Diabetic Retinopathy
You are FY2 in GP Surgery. Mr Sammy Roberts, age 48, came to the clinic with a new
problem. He is diagnosed with non-insulin dependent diabetes mellitus, which is controlled
with diet. Please talk to the patient and discuss the plan of management with the patient.

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

P: I just went to check my eyes to see if I need glasses, I’m a painter and I’m having trouble
seeing fine lines while working.
D: When did it start? 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: With 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 have no symptoms.
D: Do you go for your annual check-up? P: No. I missed it.
From the assessment done by the optician, you have a condition called diabetic retinopathy.
It is one of the complications 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.
Let me tell you what we can do for you:

We need to see your blood pressure regularly.
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.
purposes only.
We will also do a urine test. Depending on the results 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 the back of
your eyes.
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 (Fluorescein angiogram)
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 a 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, you should control your blood sugar and be regular with your follow up.
!
purposes only.
Diabetic Review
You are FY2 in GP Surgery. Mr Jack Su, aged 52 years, was diagnosed with type I DM. He is
on insulin. Examination has been done by a nurse. He has loss of fine sensation and pain
below the 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 an 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 a teen.
D: How are you managing it? P: Insulin.
D: Which insulin? P: Glargine once a day.
D: Is it well controlled? P: I think so.
D: Any symptoms of DM? P: No
D: Feeling thirsty? P: No
D: Going to the 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 the foot?
P: I am having sore feet and burning sensation in them.
D: For how long? P: From the last 2 months.
D: Has it changed? P: It is getting worse.
D: Any problem with vision?
P: I am having some blurry vision from the last 2 months that is why I went to my optician
and he sent me here.
D: Do you see your GP regularly? P: No, I don’t get time.

D: Do you go for your annual check-up? P: I missed it last year.
From our assessment, your DM is not well controlled. We examined your leg (perform
examination if not already done) and there is loss of sensation below the ankle in both the
legs. While we were examining your eyes, we found some abnormalities at the back of your
eyes. Your urine shows there might be some problem with your kidneys.
P: Why does diabetes cause these problems?

D: 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.
purposes only.
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.
Let me tell you what we can do for you:

We need to see your blood pressure regularly.
We will also do a 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 the back of
your eyes.
You should always keep your leg clean and dry. Please do not wear too tight or opened
shoes. We can refer you to a foot specialist.
It is very important to come to us regularly and not to miss your annual check up
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.
purposes only.
Hypoglycaemia
You are FY2 in GP. Mr Salman Yusuf, aged 35, had an episode of hypoglycaemia 2 weeks
back. Now he has come for the diabetic review. His HbA1c is 61. Talk to him and address
his concerns.
D: What brings you to the hospital? P: I came for a review of my Diabetes.

D: Great. May I know when you were diagnosed with diabetes? P: 15 years ago
D: May I know how it was managed?
P: I used to take Metformin and Glimepiride initially. 6 months back I started taking insulin.
D: May I know how you take insulin?
P: I take 10 units in the morning and 10 units in the evening.
D: May I know the name? P: Not sure
D: Are you taking your insulin regularly? P: Yes.
D: Do you check your sugar levels regularly? P: I have a glucometer, but I don’t use it.
D: Is it well controlled?
P: Yes but, a few days back I was at a friend’s party at night. I ate a lot at dinner, then I got a
call from my job and I took my car and went. I took an extra dose of insulin. I started
sweating and feeling dizzy. I always carry chocolates with me, so I ate them and called my
sister. She is a nurse. She told me it might be a hypoglycaemia attack.
Please ask about symptoms and complications of diabetes
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 with a special blood test called as HbA1c which tells
us how the sugar level in your blood has been 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 a lot of
sugar.
You mentioned that you ate sweets in the party, these can be harmful in a patient who is
diabetic. It is advisable to make some changes in your lifestyle. (Give lifestyle advice.)
Please take your insulin regularly as prescribed.
purposes only.
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 occur, eat chocolate or drink 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:
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.
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.
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.
Hypoglycaemia and driving:

1. The licensing agencies are trying to ensure you are safe on the road. They will be
concerned if you are unable to recognise or self-treat your hypos.
2. If you are on insulin, check your blood glucose within two hours before getting behind the
wheel and every two hours whilst driving. The DVLA also recommends that this is
appropriate for people treated with Sulphonylureas or Glinides. Find out more about
diabetes treatments.
3. The DVLA advises that if blood glucose is 5mmol/l or less you should take carbohydrate
before driving. If it is less than 4mmol/l do not drive. See advice below on hypo advice for
drivers.
4. If you hold a Group 2 license and take non-insulin medication which may cause a hypo,
you should check your levels at least twice per day at times relevant to driving. The results
should be recorded on the meter memory.
Safe driving tips

1. Avoid delaying or missing meals and snacks.
2. Take breaks on long journeys.
3. Always keep hypo treatments to hand in the car.
4. Do not drink alcohol and drive.
5. Many of the accidents caused by hypoglycaemia are because drivers have continued to
purposes only.
drive, ignoring their hypo warning signs (eg hunger, sweating, feeling faint). If you have a
hypo whilst driving:
6. Stop the vehicle as soon as possible.
7. Switch off the engine, remove the keys from the ignition and move from the driver’s seat.
8. Take some fast-acting carbohydrate, such as glucose tablets or sweets, and some form of
longer-acting carbohydrate.
9. Do not start driving until 45 minutes after blood glucose has returned normal.
10. If you have poor warning signs, or have frequent hypos, you should probably not be
driving because of the risk to yourself and others. Discuss this with your diabetes healthcare
team. If your team advises you to notify the DVLA/DVA you must do so. If you fail to do this,
your doctor has an obligation to do so on your behalf.
purposes only.
Hypoglycaemia Fits
You are an FY2 in A&E. Mr John Davis, aged 22, known case of type 1 DM on insulin, has
been 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.
D: How can I help you? 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: I see. Let me first ask you some questions and assess your condition. If everything is fine,
you can go home.
D: 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

D: Any difficulty or pain moving his head and neck? P: No.
D: Did you have a sore throat or runny nose? P: No
D: Anything you remember during the collapse? P: No
D: Any jerky movements? P: I don’t know.
D: Did you lose consciousness? P: Yes/No.
D: Was anyone around when this happened? P: Yes/No
D: Who brought you to the hospital? 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 is that I was here.
D: Any head injury? P: No
D: How are you feeling now? P: I am fine.

D: Have you been diagnosed with any medical condition? P: Yes, I have DM.
D: Since how long have you been diagnosed with DM? P: Since I was 11.
D: How are you managing it? P: I am taking Insulin.
Elaborate DM with symptoms and side effects.
purposes only.
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
the higher side i.e 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, to treat
it we need to keep you in the hospital. We will do further investigation, including HbA1c.
P: I am already on leave; I am getting married next week.

D: Congratulations! I can imagine you have a lot to do but your health comes first, so it is
advisable to stay in the hospital in this situation. Low blood sugar can be life-threatening if
not treated in time. I will also talk to my seniors 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:
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.
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 4mmol, 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.
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 low blood sugar so
you can treat them quickly.
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 your blood sugar level dropping too low while you sleep.
7. If you keep getting low blood sugar, talk to your diabetes care team about things you
can do to help prevent it.
Give lifestyle advice accordingly.
purposes only.
Diabetic Ketoacidosis
You are FY2 in A&E. Mrs Margret Wilkins, 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, O2 Sat: 95, RR: 17, TEMP: 37
Please talk to the patient and address her concerns.
D: What brought you to the hospital? 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’s already diagnosed:

D: Tell me more about your pain?
P: I have got pain all over my tummy from the last few hours and it is getting worse.
D: Tell me more about your sickness?
P: It started at the same time as my belly discomfort.
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 breath? 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? P: No.
D: Any fever, flu-like symptoms recently? (Viral infection) P: No.

D: Tell me about your diabetes?
P: I have had diabetes for the last 10 years since I was a teenager.
D: How has it been managed? P: Doctor, I take insulin.
D: May I know which Insulin? P: Actrapid and another one.
D: How many times a day are you taking it?
P: I take it once at night and 2-3 times during the day.
D: Do you take it regularly?
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 I 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.
purposes only.
D: I see. 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.
D: Do you check your blood sugar regularly? P: Not really

D: When was the last time you checked it? 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.
D: Do you drink alcohol? P: I’m a social drinker.

D: Tell me about your diet generally? P: I have a good diet.
I would like to check your vitals and examine your tummy.

I would like to send for some initial investigations including a routine blood test.
Investigation’s findings:
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 (+++). Leukocytes 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 and found it to be acidic. There was an increase in the number of
white blood cells which usually rises 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.
purposes only.
The main aim is to remove ketones from your body. We need to give you fluids. We also
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 only be done in the hospital.
This is an emergency and should be treated immediately. This is a fatal condition if not
treated properly. If you don’t receive this treatment, you may end up in a coma.
purposes only.
Diabetic Keto Acidosis
You are an FY2 in A & E. Miss Chloe Putin, aged 17, has come to you with tiredness. Please
talk to the patient, take history, assess, and discuss the initial plan of management with
the patient
!
purposes only.
Smoking Cessation
You are FY2 in General 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: Yes, that’s me.

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. If the vessels that
supply blood to the heart become narrow, the blood flow to the heart is 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 has narrowed. In this procedure, we put a short wire mesh tube in there.
Therefore, the blood can flow through the vessel more freely and your symptoms will be
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 I have this pain even at rest.
D: Any other symptoms? P: Sometimes I have difficulty in breathing.

D: How long have 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.
D: Do you take it regularly? P: Yes, I never miss any medicine.
D: Do you see your GP regularly? P: Yes.
You have high cholesterol, which can be one of the causes of your angina, but you are taking
your medications regularly.
Smoking can be one of the causes of your chest pain. What do you think?
purposes only.
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: It is good that your father is fine but this is not always the case.
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 your 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 relieve your stress, for example
you can go for yoga or meditation.
Many claim that it relaxes them and relieves their stress. The nicotine withdrawal actually
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 the blood vessels 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 from 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.
Non-medical approach:
You can have one to one session from a local smoking cessation clinic and you will be 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 on how to deal with your
cravings.
purposes only.
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 Smoke Free 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
non-smoker.
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 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 an E cigarette. Although they
are not risk free, they are 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.
purposes only.
Chronic Obstructive Pulmonary Disease (Smoking Cessation)
You are FY2 in Medicine. Mr. Luke Neil’s, 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.
D: What brought you to the hospital? P: Nurse said you are going to talk to me.
D: Yes, so 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 been narrowed.
D: When were you diagnosed? P: 10 years ago

D: Do you take any medication? P: I am using Blue and brown inhalers.
D: Do you take it regularly? 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 have you had this symptom? P: Few weeks, doctor.

D: Any other symptoms? P: I also have cough and phlegm
P: When I get an 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
D: Any wheeze? P: No
D: How often do you have chest infection? P: I had it 5 times last year.
D: How has it been managed? P: I go to my GP and he gives me antibiotics.
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.
purposes only.
D: I am sure it’s not easy to stop. You can find many ways to relieve your stress, for example
you can go for yoga or meditation.
Many claim that it relaxes them and relieves 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.
Please explain medical and non-medical ways to help you stop smoking.
purposes only.
Post-partum Smoking Cessation
You are an FY2 in GP. Mrs Katie Robbins, aged 33, has called you as she wants to quit
smoking. She is 6 weeks post-partum. Please talk to her and address her concerns.
About 10.5% of women are still smoking when they give birth. Stopping smoking once your
baby is born will still help protect them against: SIDS, Breathing problems, Ear problem and
deafness, behavioural problems.
As a new mum, not smoking is also the single most important thing you can do to protect your
own health.
However, if you're finding it hard to quit smoking, it's important not to stop breastfeeding.
Breastfeeding will still protect your baby from infections and provide nutrients they can't get
from formula milk.
If you or your partner can't stop smoking, making your home completely smoke free will help
protect your baby's health. You may need to ask friends and family not to smoke near your
baby, too.
If you or your partner smokes, it's important not to share a bed with your baby (co-sleep).
This is known to raise the risk of SIDS, particularly if you smoke, you recently drank alcohol,
or you're taking medication that makes you sleep more heavily.
Licensed NRT products are safe to use while you're breastfeeding. They increase your chances
of quitting smoking, especially if you also have support from your local NHS stop smoking
service.
NRT is available free on prescription while you're pregnant and for 1 year after your baby is
born. It comes in a variety of formats, including patches, gum, lozenges, nasal spray and
inhalators.
The stop smoking medicines Champix and Zyban are not recommended for breastfeeding
women.
purposes only.
E-Cigarettes
E-cigarettes have become a very popular stop smoking aid in the UK. Also known as vapes or
e-cigs, they're far less harmful than cigarettes and can help you quit smoking for good.
An e-cigarette is a device that allows you to inhale nicotine in a vapour rather than smoke.
E-cigarettes do not burn tobacco and do not produce tar or carbon monoxide, two of the
most damaging elements in tobacco smoke.
A major UK clinical trial published in 2019 found that, when combined with expert face-to-
face support, people who used e-cigarettes to quit smoking were twice as likely to succeed
as people who used other nicotine replacement products, such as patches or gum.
You will not get the full benefit from vaping unless you stop smoking cigarettes completely.
They're not completely risk free, but they carry a small fraction of the risk of cigarettes.
The liquid and vapour contain some potentially harmful chemicals also found in cigarette
smoke, but at much lower levels.
Pregnancy:
E- cigs are likely to be much less harmful to a pregnant woman and her baby than cigarettes.
If you're pregnant, licensed NRT products such as patches and gum are the recommended
option to help you stop smoking.
But if you find using an e-cigarette helpful for quitting and staying smoke free, it's much
safer for you and your baby than continuing to smoke.
E-cigarettes are not currently available from the NHS on prescription, so you cannot get one
from your GP.
purposes only.
Needle Stick Injury (Nurse)
You are FY2 in A&E. Your nurse colleague Miss Matilda Drake, aged 25, pricked herself while
taking blood from her patient. Please talk to the patient, take relevant history, discuss 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 the sharps bin.
2. Wash your hand under running water with soap.
3. Inform senior
4. Go to occupational health to seek medical advice, if the time is between 9-5 AM (If out of
hour go to A/E).
5. Fill the incident form.
D: What brought you to the A&E?

P: I was taking blood from a patient. He moved his hand and I pricked my finger accidentally.
D: When did this happen? 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 was it? P: It was just a normal needle we use for taking blood.
D: Any visible blood on the needle? P: I don’t know
D: Did you dispose of 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 prick yourself?
P: I washed it under tap water and then I squeezed 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 a 20 year old suspected case of meningitis.
D: How is he now? P: He is unconscious, doctor.
D: Do you have any concerns? P: I am worried about infections.
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 on. 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, your 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.
purposes only.
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, we may not be able
to take consent 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 purposes. 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.
D: 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
D: Have you received any 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.
purposes only.
If by any chance you notice 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 tests, 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.
purposes only.
Needle Stick Injury (Child)
You are F2 in A&E. 3 years-old Lucy 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.
D: What brought you to the hospital? P: I am worried about Lucy.
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.
D: When did it happen? P: 2 hours ago.
D: What did you do after that? P: Lucy was bleeding, so I washed and
squeezed her hand and then called the ambulance.
D: 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 Lucy’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 Lucy’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? 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 about?
P: Tell me about all of them.
purposes only.
Wound Infection:
We only prescribe antibiotics if the patient develops wound 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 Lucy 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 a lot of side effects.
Hepatitis C is usually diagnosed using two blood tests, 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.
!
purposes only.
Clostridium Difficile Associated Diarrhoea
You are FY2 in General Medicine. Mr James Henry, aged 75 years, 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 has recovered from pneumonia. Patient developed
diarrhoea 2 days ago before getting discharged. Investigation has been done. On stool
sampling, 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 I.V 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 to 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 a 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 him with antibiotics. He was
treated 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 antibiotics.
One of the possible side effects of antibiotics is diarrhoea due to inflammation of the bowel.
P: How is it possible?
D: There are good bugs in the normal flora of the bowel that help to digest food. When this
gets altered, then problems 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 food poisoning?

D: In your dad's condition, the most likely cause of diarrhoea is the antibiotic he was given.
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. It is important to point out that this infection is more common in older
people over 65 years.
purposes only.
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 known side effects of
the medication that your dad needed 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 causes diarrhoea can easily pass from person to
person that’s why when we have any patient with diarrhoea in the main ward we 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 father's 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 samples.
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 a 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 for this loss.
P: Doctor, are you giving him antibiotics again?

D: Yes, we must prescribe an antibiotic. If this condition is left untreated it may cause some
complications such as bowel perforation, which needs surgery. We don’t want this to
happen to your dad.
General advices:
- 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
- Visitors to wear disposable gloves and gown and wash their hands with soap and water
as they enter and leave the room
- Clean contaminated surfaces – such as the toilet, flush handle, light switches and door
handles – with a bleach-based cleaner after each use
- Don't share towels and flannels
- Wash contaminated clothes and sheets separately from other washing at the highest
possible temperature
- 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
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
purposes only.
Methicillin-Resistant Staphylococcus Aureus
You are an FY2 in the Respiratory Department. Mr Aaron Brown, aged 65, was admitted to
the hospital a 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 clothes and masks. I’m not being allowed to go inside.
D: Let me ask you a couple of questions.

P: OK.
D: Why did you bring him to the hospital?

P: He has a smoker's cough and 2 days ago, he suddenly 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: When was he diagnosed with COPD? P: It’s more than 10 years.
D: How has it been managed? P: He is taking blue and brown inhalers.
D: Is his condition well controlled? P: Yes.
D: Has he been diagnosed with any other medical condition? P: No
D: Does he take any other regular medication? P: No
D: Does he have any allergy? P: No
D: Does he smoke? P: Yes (Elaborate)
D: Does he drink alcohol? P: Occasionally.
D: Tell me about his physical activity? P: I am not quite active.
D: How about his diet? P: I try to eat healthy.
P: Doctor, what is going on with him?

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 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 antibiotics BUT we have many
strong antibiotics that can fight against this bug. MRSA stands for Methicillin Resistant
Staphylococcus Aureus.
purposes only.
This bug is not more aggressive or infectious than other subtypes of Staph. Aureus.
However, usual antibiotics don’t work against MRSA. But we do 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 a poor immune system, this bug can be infectious. That’s why when we
admit our patient, we check by taking swabs 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 to apply a
small amount to the whole body including the 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 the 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 the 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, the course of decolonization should
be completed up to two times after the course.
P: I heard MRSA kills many of our people?

D: From what you told me and what we did, it seems your husband hasn’t developed any
MRSA infection. He is the 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 antibiotics that can fight against MRSA and most
patients respond to this Antibiotic. These antibiotics are usually given through a 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 only takes a few seconds. The result is available within a
few days.
purposes only.
Osteoporosis
You are FY2 in GP. Mrs Mary Churchill, aged 62, presented to the clinic. She had a wrist
fracture 3 months ago, which was managed. DEXA Scan was 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.
D: What brought you to the hospital? 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 around the house and there was a loose carpet and
I tripped.
D: What did you do after that? P: I went to the hospital. They did an X-
Ray of my hand and they applied a 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, why do I have osteoporosis?

D: Let me ask you a few questions so I can be in a better position to answer your concerns.
P: Ok.

D: Have you been diagnosed with any medical condition in the past? P: HTN.
D: Since when? P: From last few years.
D: Do you take any medication for it? P: I am taking Amlodipine
D: Is it well controlled? P: Yes
D: Any other medical illness? (Kidney diseases, IBD, Coeliac disease) P: No
D: Are you taking any medications including Steroids, Via D, Calcium. P: No
D: Any previous hospital stays or surgeries? P: When I was 35, I had a surgery to remove
my ovaries and womb.
D: Any bone disease, Osteoporosis or fractures in the family?
P: My mother and grandmother fractured their hips.
D: Whom do you live with? P: I live with my husband.

D: Have you been pregnant before?
P: Yes I have 2 children. I had them when I was 25 and 29.
D: What was the mode of delivery? P: Normal vaginal delivery.
purposes only.
D: May I know when did you have your Last Menstrual Period?
P: When I was 35, before 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

D: Do you drink alcohol? P: Yes/no
D: Do you take enough Dairy products like milk, curd or fish? P: No
D: Do you do physical exercise? P: Quite active
In your case, there are some risk factors about which nothing can be done which include
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 be 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.
Excessive amounts of alcohol intake can weaken the bones. It may be difficult, but it would
be 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 resistance training can help to strengthen the bones. 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 gym 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).
Side Effects of Bisphosphonates: Being sick, Indigestion, Heartburn, Tummy pain,

Diarrhoea and Constipation.
!
purposes only.
Learning Disability (Diabetes Mellitus)
You are an FY2 in GP. 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 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. Talk to him and address his concerns. Note:
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
D: Do you check your blood sugar regularly? P: No.
D: Any complications of DM? P: Like what.
D: Any problem with the foot? P: No
D: Any problem with vision? P: No
D: Do you see your GP regularly? P: Yes
D: Have you been diagnosed with any other medical condition apart from DM? P: No

D: Do you do physical exercise? P: Good/Bad
D: What do you do for a living? P: I work from home.
D: Who do you live with? 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.
purposes only.
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 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
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
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 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 reduce 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.
Please try to have plenty of fruits and vegetables in your diet. Fruits 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.
Physical activity:
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 does not need to be in one session, it could be
split into two sessions of fifteen minutes or three sessions of ten minutes. For example, if
purposes only.
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 go to buy something from your local
shop. If you live in a flat, you can climb the stairs instead of using the lift.
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
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.
purposes only.
Warfarin (Learning Difficulty)
You are FY2 in Medicine. 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
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.

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: Any high blood pressure, liver disease or blood disorders? P: No
D: Are you taking any medications (painkiller/otc)? P: No

D: Do you have any idea why you have calf pain? P: No.
D: You had a blood clot in your leg. P: What is a blood clot?
A blood clot is formed when your blood becomes thick and solid.
You have been prescribed a medicine for your clot and I will discuss this medicine with you.
You have been given this medicine called Warfarin. It 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. 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 every day. Your blood test
will be done daily for the first few days, and then every week.
P: How long should I take it?

D: People with blood clots in their legs 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 you forget something.
purposes only.
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 are unable to stop the
bleeding.
General Advice:
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 green leafy vegetables,
such as broccoli and spinach, vegetable oils, 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 a 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.
purposes only.
purposes only.
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purposes only.
purposes only.
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purposes only.
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purposes only.
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purposes only.
purposes only.
Nosebleed (Apixaban)
You are an FY2 in Medicine. Mr James Carter, aged 25, has had a nosebleed. He had 2 clots
in the span of 3 years and he is on Apixaban. Talk to him and address his concerns.
D: How can I help you? P: I had a nosebleed.

D: Tell me more about it. P: What would you like to know?
D: When did you have the nosebleed? P: Yesterday
D: How long did it last? P: 5 minutes
D: Is this the first time? P: Yes/No
D: How much was the blood? P: My napkin was fully soaked in red.

D: Do you feel dizzy? P: No
D: Any SOB? P: No
D: Have you been diagnosed with any other medical condition in the past?
P: I had 2 clot in last 3 years and I am taking apixaban for it.
D: Are you regular with the medication? P: Yes
I would like to do GPE, examine your nose (ENT) and check your vitals.
I would like to send some routine investigations including routine blood test.
Concern:
What do I do when I get bleeding?
Go to the A&E if:

- 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
How to stop a nosebleed yourself
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
purposes only.
- place an ice pack (or a bag of frozen peas wrapped in a tea towel) at the top of your
nose
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.
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
Please carry your anticoagulant card with you especially during an emergency and dental
procedures.
Less serious bleeding with Apixaban

The kind of bleeding you might have includes:
• periods that are heavier and last longer than normal
• bleeding for a little longer than usual if you cut yourself
• occasional nosebleeds (that last for less than 10 minutes)
• bleeding from your gums when you brush your teeth
• bruises that come up more easily and take longer to fade than usual
• This type of bleeding is not dangerous and should stop by itself.
If it happens, keep taking the apixaban, but tell your doctor if the bleeding bothers you or
does not stop.
Things you can do to help yourself

• Cuts – press on the cut for 10 minutes with a clean cloth.
• Nosebleeds – sit or stand upright (do not lie down), pinch your nose just above your
nostrils for 10 to 15 minutes, lean forward and breathe through your mouth, and place
an icepack (or a bag of frozen peas wrapped in a tea towel) at the top of your nose
• Bleeding gums – if your gums are bleeding, try using a soft toothbrush and waxed dental
floss to clean your teeth.
• Bruises – these are harmless but can be unsightly. It might help to make them fade more
quickly if you put an ice pack wrapped in a towel over the bruise for 10 minutes at a time
several times a day.
purposes only.
Clarithromycin & Warfarin
You are an FY2 in GP. Mr John Smith, aged 35, has Thrombophilia Leiden Factor 5 which
causes Thrombophilia. He has a history of DVT and he is on lifelong Warfarin. His INR is 6,
he had Chest Infection, so he was given Clarithromycin by a locum GP. Talk to him, discuss
the blood results, explain the plan of management and address his concerns.

P: I went to the warfarin clinic for my usual INR and the nurse sent me here.
D: So, you are taking warfarin, may I know the reason? P: I am taking it because of DVT.
D: When you were diagnosed with DVT? P: 3 years ago, and I had 3 attacks.
D: When did it happen last time? P: 1 year ago.
D: How is your DVT now? P: It is fine.
D: Any pain in the legs or calf? P: No
D: Any redness, hotness or swelling? P: No
D: Are you taking your medications regularly? P: Yes.
D: How much warfarin do you take? P: 3 mg per day.
D: Any missing dose? P: No Doc.
D: Are you regular with the warfarin clinic? P: yes
D: What was your INR last time? P: It was Normal.
D: Do you record your INR in the record book? P: Yes
D: Are there any side effects of warfarin? P: No
D: Any bleeding from anywhere or excessive bruising? P: No
D: Have you had a similar kind of problem in the past? P: Few days ago, I was diagnosed
with chest infection.
D: How has it been managed? P: They gave me an antibiotic called Clarithromycin.
D: Are you taking the antibiotic regularly as prescribed? P: Yes
D: How many tablets are you taking and the dose? P:
D: How is your chest now? P: I am improving.
D: Any fever? Any cough? Any blood in phlegm? Any SOB? Any chest pain? P: No.
D: Have you been diagnosed with any other medical condition apart from chest infection?
P: I have factor V Leiden deficiency. when I was admitted to the hospital. They took some
blood tests and the results showed that I have FACTOR V Leiden.
Thank you for answering all my questions. As you know we checked your INR (It measures
how long it takes your blood to clot) and it was higher than the targeted range in your case
which is 2-3 meaning your blood is taking a longer time to clot.
You told me that you are taking warfarin as prescribed and there have been no changes in
your lifestyle, so the most likely cause of increasing INR is the antibiotic that you started for
chest infection. There are some medicines that don't mix well with warfarin. One of them is
clarithromycin. They increase the anticoagulant effect of warfarin.
purposes only.
I am sorry for your situation. We will see why you were prescribed this medication for your
chest infection. Let me tell you what we can do for you. Please stop taking warfarin for the
time being and restart it again when INR <5. It is very important to come to us regularly for
follow up and checking your INR.
Protocol given by the examiner in the exam:
● If INR 6-8 with no bleeding stop warfarin and restart when INR <5.
● If INR >8 with no bleeding stop warfarin until INR <5 and give oral Phytomenadione.
● If INR 5 or >5 with bleeding (Not severe) stop warfarin and give IV Phytomenadione.
● If INR <5 with bleeding (Not severe) Clinical decision must be made. We may
consider modifying warfarin dosage and IV Phytomenadione.
Notes:
● Factor V Leiden is a type of thrombophilia due to specific gene mutation that results
in an increased tendency to form abnormal blood clot.
● Macrolides which works as enzyme inhibitors (inhibit cytochrome p450).
Macrolides are a class of antibiotics that includes erythromycin, roxithromycin,
azithromycin and clarithromycin.
Please keep this booklet/leaflet as it contains all the information that we are discussing. Please
make sure you read it and keep it at home in case you forget something). Please keep your
alert card with you. 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. Please keep your record
book as it indicates your treatment record, dose of your medication and date of your blood
tests.
Please mention about warfarin side effects and general advices.
purposes only.
Haematuria – Lab Results
You are an FY2 in GP. Mrs Maria Newton, aged 62, has come to the clinic for her lab reports.
She was asked by the nurse to see a doctor. She went to a well woman clinic for a regular
check-up 2 weeks 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
D: How can I help you? 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-ups at the well woman 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 woman clinic?
P: No, I regularly go for general health check-ups.
D: Okay, I understand that they tested your urine 2 weeks back and yesterday.
P: Yes.
D: Unfortunately, they found microscopic traces of blood in your urine. We call it

Microscopic Haematuria.
P: What do you mean by that Dr?

D: This means you are passing blood in your urine which cannot be seen with the human
eye.
P: Why did I have this dr?

D: That’s a very valid concern. Let me ask you a few questions to see why this is happening
and to address all your concerns. P: Okay dr
D: You said you didn’t have symptoms. But could you please tell me about your health
recently?
D: Any fever? P: No
D: Any pain anywhere in your body? P: No
D: Any tummy pain or discomfort? P: No
D: Did you have any urinary problems? P: No
P: Like what? P: No
D: Any pain or burning sensation while passing urine? P: No
D: Any change in colour of your urine? P: No
D: How is your appetite these days? P: No
purposes only.
D: Any dizziness or shortness of breath? P: No
P: Yes. I was diagnosed with atrial fibrillation.
D: May I know when you were diagnosed with AF? P: 5 years now
D: May I know how it is managed? P: I take Bisoprolol
and Warfarin
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 we are going to do
some investigations to see why this happened.
D: There can be 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 the 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 within normal range.
D: If this bleeding is not severe and not affecting 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).
purposes only.
Drug Prescription
You are FY2 in Surgery. Mrs Marina Boyle, 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, reduced due to dizziness. Talk to her, explain the prescribed medications &
Medications prescribed:
1. Amoxiclav 625 mg TDS 5 days
2. Codeine 1tab 30mg PRN
3. Alendronate 70mg mane (Sunday)
4. Calcium 1 tab BD
5. Lisinopril 5mg OD
6. PCM 2 tabs BD up to 8-tab prn.
7. Atorvastatin 10mg 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 and then explain the medicines?
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
purposes only.
D: Do you have any other symptoms?
P: No
D: Have you been diagnosed with any other medical condition in the past?
P: Yes I have osteoporosis. (elaborate)
D: Are you taking the medications regularly that we prescribed?

P: Yes
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. It can cause an itchy rash, swelling of lips and
tongue and breathing problems if you develop 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
occasionally may occur, 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.
purposes only.
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 an hour after having taken the medicine. If you don’t do
that, you might feel sickness, indigestion, abdominal pain. You might also experience
constipation or diarrhea. Please stop taking it if you experience pain or difficulty while
swallowing.
4. Calcitriol:
It is actually a type of vitamin D that will help your body to absorb the minerals it needs &
will thus help strengthen your bones. This has been prescribed twice daily, you take it in
morning & evening daily.
5. Lisinopril:
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 10mg to 5mg. Do remember to take it the same time daily. It can sometimes
make you feel light-headed 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 at any time you develop any unwanted symptoms kindly do come back to us
immediately.
purposes only.
Oxybutynin Urinary Symptoms
You are an F2 in GP. 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 it?

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.

D: Any fever, chills or flu-like symptoms? P: No
D: Any changes in your urine colour or smelly? P: No
D: Do you have any pain while passing urine? P: 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.
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 the loo? P: Yes/No (Incontinence)
D: Do you have Weak urine stream or a stream that stops and starts?
D: Do you feel like that you are not able to completely empty the bladder?
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: Someone your friends or family told you are losing weight? P: No
D: Have you had similar kind of problem in the past? P: No

purposes only.

I would like to check your vitals and examine your urinary system and perform a PR.
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 re-evaluate 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?
purposes only.
Epilepsy
You are F2 in medicine. Mr. Sujeet Sharma, 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.
Discharge Summary
Presenting Complaint: Patient presented after having fit. Had aura before fit. Fit lasted
for 3 minutes. Patient has urinary incontinence and confusion. Had 2 episodes of fit in the
last 4 weeks.
Investigations: Blood Test - Normal, EEG - Abnormal
Diagnosis: Tonic Clonic Grand Mal Idiopathic Epilepsy
Treatment: Sodium Valproate 300 mg BD
Please see the GP regularly.

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 been given 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 were to 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 a headache.
purposes only.
D: Please don’t worry this headache will go away after some time or we can give you some
painkillers, but if persists we can review your medication. But you must 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 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 do you do? Do you have to sit in front of the computer for long hours?
D: How about the second time?
P: The same happened the second time.
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 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.

P: I live with my parents, doctor.
People can drive after a year when they are symptom-free. The GP can discuss it in detail.
People who drive and get diagnosed with epilepsy, should stop driving and they must
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, Hyperammonemia (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.
purposes only.
First Seizure
You are an FY2 in Medicine. Mr Mike Taylor, aged 10, has been brought in by his mother
because of having a fit. Talk to her and address her concerns.
D: How can I help? P: My son had a fit.

D: When did this happen? P: 2 hours ago.
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

D: Any neck stiffness? P: No
D: Any headaches? P: No
D: Did he miss any meals? P: No

D: Is he taking any medications including OTC or supplements? P: No
D: Anyone in the family have epilepsy? P: No
D: Tell me about his diet? P: Good

D: Do you 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 and 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.
purposes only.
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
- 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
! !
purposes only.
Meningitis Prophylaxis
You are an FY2 in GP. Mrs Olivia Parker, aged 50, has some concerns. Talk to her and
D: How can I help you? P: I am worried I might get Meningitis.

D: May I know why? P: My niece 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’s fine

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: Do you take any other regular medication? P: No
D: Tell me about your physical activity? P: I am not quite active.
D: How about your diet? P: I try to eat healthy.
D: Whom do you live with? P: With my husband

D: Is he doing well? P: Yes
D: What do you do for a living? P: Manager in ASDA
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.
D: Do you have any concerns?

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.
purposes only.
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 signs 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
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 meningitidis; 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
500mg 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, 16weeks.
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)
purposes only.
Chicken Pox (Pregnancy)
You are an FY2 in GP. Miss Sophia Jenkins, aged 30, 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 chicken pox and I’m worried my unborn child can be infected
D: When did this happen? P: He got it 2 days ago
D: Do you have any symptoms? 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
D: How was the pregnancy confirmed? P: Pregnancy Test at home
D: Were you using contraception? P: No
D: Estimated date of delivery (EDD)? P:
D: Could 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? P: No
D: Have you attended all your antenatal check-ups? P: Yes
D: Have you got any scans done? P: Yes
D: Do you 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: 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
D: May I know whom do you live with? P: My partner and my father
D: How are they doing? P: My father is having chemotherapy
I would like to check your vitals, GPE, and do Antenatal Examination.

purposes only.
As you have mentioned you had chicken pox as a child, you will be immune and there is
nothing to worry about. You do not need to do anything. 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 before 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 five 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 chicken pox:

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
purposes only.
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 antibodies called
varicella zoster immune globulin (VZIG) if:
• your baby's born within 7 days of you developing a chickenpox rash
• you develop a chickenpox rash within 7 days of giving birth
• your baby's 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're 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 new-born 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're 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.
These symptoms are a sign that you may be developing complications of chickenpox and
need specialist care.
purposes only.
Concerned mother (Chicken Pox)
You are an FY2 in GP. Mr Andy Charles, aged 4, was brought into the GP by his mother,
Maggie Charles, because of her son not feeling well. Talk to her and address her concerns.
D: How can I help? P: My child is unwell.

(Fever and rash all over the body for the last one day)
D: Can you please tell me what happened? P: He was fine 3 days ago until he got a fever
D: Did you measure her 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
D: When did you notice it? 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 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? P: No, this is the first time
D: Is he taking any medications including OTC or herbal medications? P: No
D: Is there any other child around him with a similar condition? 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
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 she have any problems with her 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 her? P: It’s me
I would like to examine little Andy to assess him better. I would do a general physical
examination & would examine his rash.
purposes only.
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 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.
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 dehy-dration
● 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 al-low 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
purposes only.
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 in 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 conditions.
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.
!
purposes only.
Discuss Blood Results
You are an FY2 in GP. Mrs Dorothy Perkins, aged 81, has come to you for medication
review. She has been on Amlodipine 10mg for 2 months. Other medications she is on are
Atorvastatin 20 mg and Levothyroxine 125mcg.
Bloods: TSH - <0.02
T4: 24
Lipid Profile, U & E’s, LFT’s - Normal
Talk to her and review the Medications and Blood Results.

P: I am here for review of 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: Ok.
D: Could you please tell me why you had these blood tests. P: I was having headache.
D: When did it start? P: Since last 1 week
D: Does it come and go or is it continuous? P: Comes and goes
D: Does it go anywhere? P: No
D: What kind of pain is it? P: Dull
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
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 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: No
D: How is your mood these days? P: Its ok
P: Hypercholesterolemia and Hypothyroid for many years. Hypertension: For last 2 months.
P: Atorvastatin 20 mg and Levothyroxine 125mcg. Tab. Amlodipine 10mg 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.

purposes only.
D: Do you do physical exercise? P: No
D: What do you do for a living? P: I am retired

D: Whom do you live with? P: I live alone
D: How is your sleep? P: Fine
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 complaint with the medication of HTN, Take it regularly.
Lifestyle advices.
Warning sign and follow up.
purposes only.
Left Ventricular Dysfunction with ED Post MI
You are an FY2 in GP. Mr Jayden Nadal, aged 56, had an MI 3 months ago. A follow was
arranged 6 week 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.
D: How can I help you? P: I feel tired.

D: Tell me more about your tiredness?
P: I am tired all the time since my follow up 6 weeks ago
D: Has it changed? P: I feel more tired
D: Anything else with tiredness? P: My hands feel cold
D: Tell me more about it? 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.
D: Tell me more about it? 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 ie achieve orgasm? P: No
D: Do you ejaculate too soon? P: Yes
D: Does pain or discomfort occur with ejaculation? P: No
D: Is penile curvature a problem? (Peyronie disease) P: No
D: How has your mood been recently? 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 weight loss? P: No.
D: Any constipation, diarrhoea? (Thyroid, IBD) P: No.
D: Any tummy pain? P: No.
D: Do you have any sore throat? P: No
D: Lack of concentration? P: No
D: Sleep disturbance? P: No
purposes only.
P: I had MI 3 months ago and I attended follow up 6 weeks ago.
D: What was done for you in the follow up?

P: I was started on Aspirin, Ticagrelor, Bisoprolol, Ramipril and Statin.
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.
Please ask about PMH, Lifestyle and Psychosocial History.
I would like to check your vitals and examine your chest, tummy, musculoskeletal and your
private area. I would like to send for some initial investigations including routine blood tests.
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. Once we make the changes in your medication, the symptoms you are experiencing will
get better over time. Please do not stop the medications until advised by the specialist.
Patient 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.
purposes only.
Heart Failure Medication (Follow Up)
You are an FY2 in GP. Mrs Angie Cruz , aged 65, has called you for her heart failure follow
up. She had a heart attack 2 weeks ago and was diagnosed with heart failure. She was
discharged with these medications.
Clopidogrel
Ramipril
Atorvastatin
Bisoprolol
She was advised follow up with cardiologist in 3 weeks and every week with the GP.
D: How can I help? P: I am calling in for my follow up.

D: From the notes, you had a heart failure, how are you feeling now? P: Fine
D: Any new symptoms? P: No
D: Are you taking the medications regularly as prescribed? P: Yes
D: Any missing dose? P: No


D: Do you do physical exercise? P: Good/Bad
D: What do you do for a living? P: Retired.
D: Who do you live with? P: Alone. Husband died 2 years ago.
Concerns:
Will I have any side effects from these drugs?
Additional information:
Clopidogrel Side Effects:

• headaches or dizziness.
• nausea.
purposes only.
• diarrhoea or constipation.
• indigestion (dyspepsia)
• stomach ache or abdominal pain.
• nosebleeds.
• increased bleeding (your blood taking longer to clot – for example, when you cut
yourself), or easy bruising.
Ramipril Side Effects:

• a dry, tickly cough that does not go away.
• feeling dizzy or lightheaded, especially when you stand up or sit up quickly (this is more
likely to happen when you start taking ramipril or move on to a higher dose)
• headaches.
• diarrhoea and being sick (vomiting)
• a mild skin rash.
• blurred vision.
Atorvastatin Side Effects:

• Gastrointestinal symptoms such as diarrhea.
• Cold symptoms such as a runny or stuffy nose.
• Joint pain.
• Insomnia.
• Urinary tract infection.
• Nausea.
• Loss of appetite.
• Indigestion symptoms such as stomach discomfort or pain.
Bisoprolol Side Effects:

• Dizziness.
• Insomnia.
• Slow, irregular heartbeats.
• Upper respiratory infection.
• Diarrhea.
• Runny or stuffy nose.
• Joint pain.
• Cough.
purposes only.
Varicose Veins
You are an FY2 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.
D: How can I help you? P: I have painful swelling in both of my legs.

D: Can you tell me more about that? P: Like what?
D: When did you first notice the swelling? 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
D: Is there anything making it worse? 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: Any muscle cramps in your legs? P: No
D: Any burning or throbbing sensation in your legs? P: No
D: Any bluish discolouration? P: Yes/No
D: Do you have any pain in the calf? (DVT) 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: 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 do GPE, vitals and examine your legs. I would also like to run some routine
blood tests like kidney and liver function tests, as well as a duplex ultrasound.
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
purposes only.
• Using compression stockings
• Exercising regularly
• Avoiding standing up for long periods
• Elevating the affected area when resting
• Endothermal Ablation
• Radiofrequency Ablation
• 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 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
!
purposes only.
Demanding Patient
Ø Voice Control
Ø Eye Contact
1. Acknowledge their emo3ons Ø Nodding
(I can see you want this treatment for your child)
2. Pa3ent safety Ø Keep Distance
(Assess pa3ent condi3on if they need it or not)
3. Don’t agree with them in the beginning
(Don’t commit in the beginning or we may struggle when we have to refuse)
4. Find out the reason
(why you want to have this treatment)
5. Pros/Cons
(treatment has got lots of s/e, no point of doing it when not needed)
purposes only.
Upper Respiratory Tract Infection
You are FY2 in GP. Miss Olivia Parker, aged 27, presented to the clinic because of a problem
that she had before. Patient came to the clinic 2 days ago because of a runny nose, sore
throat, sneezing and cough. Patient has been seen by a 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 having the same
problem. Please give me antibiotics
D: Please tell me what brought you to the hospital 2 days ago?

P: I had a 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 was told that I had a cold/flu.
D: What they did for you?

P: I was told it is the flu and they advised me to use 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 the same, I am still having a sore throat and cough.

D: Any runny nose? P: No
D: Any headache or body ache? P: No
D: 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
D: Have you had a similar kind of problem in the past? P: Yes, a few months ago.
D: What was done for that? P: I was given antibiotics.
purposes only.
D: I would like to check your vitals and examine your chest, ear, nose and throat.
Findings:
T - 38C
D: Why do 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 antibiotics. It worked.
From our assessment, you have a condition called URTI or common cold. It is an infection of
the nose, throat and other parts of your upper windpipe. It is caused by viruses and we have
taken swab and no bacterial growth was found.
Antibiotics work against bacteria. Your condition is caused by a virus. If we give antibiotics
now, you may 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 loosen mucus 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 a headache, rash, ear pain or discharge, rusty coloured phlegm, or your
symptoms don't subside in 2 weeks, come back to us.
P: When are you going to give me antibiotics?

P: If it turns into bacterial infection?
Differentials:
Infectious Mononucleosis
Meningitis
Otitis media
Pneumonia
Asthma
!
purposes only.
Coeliac Disease
You are an FY2 in Medicine. Mrs Kelsey Smith, 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 tests 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 her
concerns.

P: I was told I have Iron Deficiency Anaemia and my GP sent me here for Endoscopy.
D: May I know why you went to your GP?

P: I have been feeling tired from the last few weeks and I have tummy discomfort.
D: Tell me more about your tiredness?

P: I feel tired from the last few weeks. I went to my GP, he told me I have Iron Deficiency
Anaemia, and gave me Iron Tablets.
D: Did you take those tablets regularly? P: Yes.

D: Tell me more about your tummy discomfort? P: I have had diarrhoea since last few
weeks.
D: How frequently do you have to go? P: 3 to 4 times a day.
D: How were your bowel habits before? P: I used to go once a day.
D: What is the consistency? P: It is watery.
D: Any blood or mucus? P: No
D: Any alternating bowel habits? P: No
D: Any decrease in urine output? 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
D: Any loss of weight? P: Yes, I lost half a stone in the last few weeks.
D: Is it intentional? P: No
D: Any problem with your balance or speech? (Ataxia) P: No

I would like to do a GPE, Vitals, and abdominal examination.

purposes only.
Iron deficiency anaemia is one of the most common findings of Coeliac disease.
Coeliac disease is an autoimmune condition affecting mainly the small intestines because of
dietary protein gluten. Classic symptoms include gastrointestinal problems such as
chronic diarrhoea, abdominal distention, malabsorption. We have done a blood test for the
antibodies which was found to be positive. However, we need to confirm the diagnosis by
doing endoscopy and taking a biopsy, that is why your GP sent you here.
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 a 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 as a lack of nutrients caused
by poor digestion can make bones weak and brittle.
P: Can it be cancer? D: Why do 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
experiencing explain it. But as I have already mentioned, we have to do an 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.
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.
Differentials:
Coeliac Disease
Colon Cancer
Anaemia
Hypothyroid
HIV
!
purposes only.
Colorectal Polyp
You are the FY2 in Gastroenterology. Mrs Olivia May, aged 52, presents with complaint 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 must get the test
again. I want to know why.
D: Right! I can see that it’s worrying you. May I please ask what exactly happened?
P: Well, I got this camera test done 2 weeks ago, then they took so long to give me my
results. Then when finally, I got them, I was 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:
Dr X
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: May I ask if you know why the first camera test was 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: What do you want to know?
D: When did it start? P: I noticed it 6 months ago for the first time
D: What exactly did you notice? P: I noticed blood in my stool
D: How many times did it happen? P: I’ve noticed it some 2 3 times since then
D: Anything else with it? P: Like what?
purposes only.
D: Any pain while passing stool? P: No
D: Any change in the bowel habits recently? P: Regular
D: Constipation/diarrhea? P: No
D: Any nausea/vomiting? P: No
D: How is your appetite these days? P: Fine
A polyp is actually a non-cancerous/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 the help of a 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, 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: Ok.
purposes only.
Fainting
You are an FY2 in A&E. 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
D: How can I help? P: I just fainted.

D: Can you tell me more about it?
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 he 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: What do you want to know?
D: When did it start? P: I noticed it 6 months ago for the first time
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
D: Anything else with it? P: Like what?
D: Any pain while passing stool? P: No
D: Any change in the bowel habits recently? P: Regular
D: Constipation/diarrhoea? P: No
D: Any nausea/vomiting? P: No
D: How is your appetite these days? P: Fine
D: Have you ever had piles? P: No

D: Do you do physical exercise? P: I don’t have much time
purposes only.
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 had so many tests and I don’t want to do them anymore.
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
Most of the time it will not find anything to worry about.
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're 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.
!
purposes only.
Barrett’s Oesophagus
You are FY2 in Surgery. Mr Louis Daniels, aged 40, had endoscopy and biopsy and is here
for his reports. The diagnosis of Barrett’s oesophagus has been made. He is advised to
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.
D: How can I help you? P: I am here for my report.
Report:
Louis, aged 40, had endoscopy and biopsy. The diagnosis of Barrett’s oesophagus has been
made. It is columnar metaplasia. It is premalignant, non-invasive and non-metastatic.
He has to repeat the 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 heartburn.
D: For how long were you having this heartburn? P: It’s there for the last 6 months.
D: Is it the same or getting worse? P: It is getting worse.
D: Is there anything that makes it worse? P: When I eat spicy food, it gets worse.
D: Is there anything that makes 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.

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? P: No
D: Have you noticed any change in your voice? 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
D: Do you have any weight loss? P: No
I would like to do GPE, Vitals, gullet and abdominal examination.

I would like to send for some initial investigations including a routine blood test.
From our assessment you have a condition called Barrett's oesophagus. In this, the cells that
purposes only.
line the affected area of the 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 as compared to normal cells. In the
majority of cases, the changes in the cells remain constant and do not progress. It is also
known as a Precancerous condition. We have to repeat the 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 follow up. If your symptoms get worse or you develop any weight loss,
breathlessness, dizziness, please come to the hospital.
Monitoring (surveillance):
When you have been diagnosed with Barrett's oesophagus, you may be advised to have a
gastroscopy and biopsy at regular intervals to monitor the condition.
This is called surveillance. The biopsy samples aim to detect whether dysplasia has
developed in the cells, in particular if high-grade dysplasia has developed.
The exact time period between each gastroscopy and biopsy sample can vary from person
to person. It may be every 2-3 years if there are no dysplasia cells detected.
Once dysplasia cells are found, the check may be advised every 3-6 months or so. If high-
grade dysplasia develops, you may be offered treatment to remove the affected cells from
the oesophagus.
purposes only.
Cerebral Palsy
You are an FY2 in Paediatrics. Robert Jones, aged 5, was admitted to the hospital with
Pneumonia. This is the 4th admission with Pneumonia. He has been prescribed a course of
IV Antibiotics for 5 days. This is the 2nd day of treatment. Patient has fever and tachypnoea.
On X-Ray there is consolidation. Talk to the mother Lizzy and address her concerns.
D: How may I help you today?

P: Doctor, I don’t want Robert to have an I/V Cannula.
D: Is there any reason for you to say that?

P: Yes Doctor, He is already in a lot of discomfort. He has very thin and small veins. Doctors
and nurses keep pricking him again and again. He cries a lot, it is really hard for me to see
that.
D: Lizzy your concern is valid, I do understand this process can be a bit painful. Let me ask
you few questions regarding Robert’s condition. P: OK
D: How is feeling now? P: Better

D: Any fever? P: No
D: Is he crying often? P: No
D: Is he playful? P: Yes/No
D: Has he been diagnosed with any medical condition in the past? P: Yes, Cerebral Palsy
D: How are you managing? P: It is difficult to manage.
D: Is he taking any other medications including OTC or supplements? P: No
D: Was your baby delivered at term or post term? P: At term
D: Is he up to date with all the jabs? P: Yes.
D: Who looks after him? P: I do.
D: Is there anyone else? P: Yes, my partner
D: Do you need any support? P: Yes/No
D: Do you have other kids? P: Yes
D: Did any of them have such a condition? P: No
D: I am happy that he is feeling better from the chest infection. However, he must continue
taking the antibiotics through the veins.
P: But it is very painful for him and I cannot allow that. Give him some other medicine, give
him syrup or tablets.
purposes only.
D: Yes, Lizzy you are right, Robert has pneumonia and I really wish we could give him
medicine in the form of syrups or tablets. But these are not as effective as medicines
through veins. As you know this is the fourth time that he is being admitted with pneumonia
and this time it is severe. So, I am afraid, syrups and tablets won’t help Robert much with
this condition.
These medicines are antibiotics, and they are necessary for Robert. It is important that we
complete the course of five days.
P: Yes doctor, I want Robert to get better, but this is too difficult for me to watch. Doctors
and nurses prick him like he is a pin cushion. He doesn’t speak much but pain shows on his
face.
D: I am sorry that you have to see all this. We are only doing all this because we want Robert
to get better as soon as possible. As you are aware that Robert unfortunately has cerebral
palsy. In this condition, muscles of the chest wall are weak and if any chest infection is left
untreated or if the treatment is not adequate, it can be very dangerous. So, we have to act
very fast. This can only be done if we give him medicines through his veins.
If you like I can request the senior most person to put in the I/V cannula. We can also apply
local anaesthetic cream on his arm before the procedure so that he doesn’t feel any pain.
What do you think?
P: Okay, doctor you may pass the cannula. I just don’t want to see him in pain.
Dr: Lizzy, we will be very careful and once the cannula is in place, we will make every effort
that it is maintained, and we don’t have to repeat the procedure.
Is there anything else we can do for you?
P: No doctor, Thank you.
Dr: Thank you very much Lizzy for understanding the need and allowing us to pass the I/V
line. If there is anything else, we will be glad to help you.
Mothers Concerns:
1. Is it painful?
2. Why not Oral?
3. You have to prick him so many times. I can’t see him in pain.
purposes only.
PAIN MANAGEMENT
Neuromuscular
blocking agents
Strong opioids
(Morphine, Oxycodone, PCA pumps
Diamorphine, Fentanyl)
Weak opioids
+/- adjuvants +/- adjuvants
(Tramadol, Codeine,
Dihydrocodeine)
Non opioid +/- adjuvants
analgesics
(PCM, Aspirin, NSAIDS)
+/- adjuvants
+/- NSAIDS Adjuvants

During all steps of Bisphosphonates
Amitriptyline
therapy Gabapentin
Adapted WHO analgesic ladder
purposes only.
Pain Management Breast Cancer
You are FY2 in the Acute Medicine Unit. Mrs Jasmine Jackson, aged 60, has been referred
from the Oncology Department to Acute Medicine Unit for pain management. She was
diagnosed with Breast 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.
!
D: What brought you to the hospital? P: Doctor, I’m having this pain.
D: Can you tell me more about it? P: What do you want to know?
D: Where is the pain? P: It’s in my lower back.
D: When did it start? P: It started 3 months ago.
D: How did the pain start? P: It started gradually.
D: Is it continuous or does it come and go? P: It is continuous.
D: Has it changed since it started? P: It is increasing.
D: Could you describe the pain for me? P: It is a dull pain.
D: Does anything make it better? P: I took Paracetamol, but it didn’t help.
D: May I know how much you took? 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.
being the most severe pain you have ever experienced? P: 8-9.
D: How about when the pain started? P: Doctor, it wasn’t that bad.
D: Is there anything else? P: No doctor
D: Have you been diagnosed with any medical condition?

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 a 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 I went to them. They did a bone scan and
told me 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 to do any active treatment.
Ask PMH, Lifestyle, and Psychosocial history.
D: What do you do 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.
purposes only.
I would like to do some Examination. I would like to examine your Vitals and your back.
Findings:
Doctor everything 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 a
weak opioid called Codeine. We will continue giving simple painkillers like Paracetamol or
Ibuprofen along with it. It comes as co-codamol 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 doesn't subside with Co-codamol, then we can give you a strong opioid like
morphine. Again, we will continue giving you paracetamol with it.
P: I don’t want to take it.

D: Why don't you want 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 also has some other side effects that may 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 morphine like seizure, breathing difficulty or short
shallow breathing and muscle stiffness. If this happens, please contact your GP or go to the
A&E.
P: Is morphine addictive?
D: This is unlikely to happen. People who usually become addicted to drugs, 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.
purposes only.
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 will be able to control your pain with Morphine. It is very
important to take your medication as prescribed. Taking regular medication prevents 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.
We may prescribe you some other medications, which are not painkillers 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 doses 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 shallow breathing, please contact your GP or come to the hospital.
Pain Management Prostate Cancer
You are F2 in the Medical Unit. Michael, aged 60. has been referred from the Oncology
Department to Acute Medicine Unit for pain management. He has been diagnosed with
Prostate Cancer 5 years ago and has now presented with back pain. Please talk to the
patient, outline a treatment plan and address his concerns.
!
purposes only.
Post Herpetic Neuralgia
You are FY2 in GP. Mr 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.
D: How can I help you? P: I am still in pain.

D: Is the pain still in the same place? P: Yes, it’s on the right side.
D: Is it always there? P: Yes
D: Can you score the pain?

P: 3/4 normally, but during night the bed sheets touch the area and I feel unbearable sharp
pain.
D: How has it impacted you?

P: It is hindering my daily life, as I am taking care of my wife who is on a wheelchair and has
RA.
D: How are you feeling? P: I feel tired all the time.

D: Do you have a rash on your body? P: No, they are gone.
D: Did you have a similar condition in the past?

P: Yes, I had it 6 months back and was given antibiotics.
D: Tell me about your diet? P: Healthy
D: Are you physically active? P: I try
D: Do you get any help looking after your wife? P: Yes, Nurse comes Twice a week.
Ask about Sleep, depression, rule out Cancer (As age is 72) and other causes of Tiredness.
Treatment:
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
helpful.
purposes only.
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.
Follow the pain ladder.
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. It can also lead to further
problems, including extreme tiredness, sleeping difficulties and depression.
Concerns:
P: How to get rid of this Pain?
P: How to manage tiredness?
P: Can you give something else other than tablets?

!
purposes only.
Bullying at Workplace (Lesbian)
You are an FY2 in GP. Miss Lucy Kingsley aged 34-year-old presented to you with some new
symptoms. She is a lesbian and her colleagues at workplace are bullying her for that. Please
talk to her and address her concerns.
D: How can I help you today? P: Dr I am feeling anxious for the last 3 weeks
D: I am sorry to hear that. Could you please elaborate what do you mean by anxious?
P: Dr I get shortness of breath and a feeling of being unwell when I go to my office.
D: Could you tell me more about the shortness of breath?

P: Dr it just happens when I am talking with any of my colleagues in the office.
D: So, it comes and goes? P: Yes

D: For how long you are having it? P: 3 weeks and I feel like not going for work.
D: You mentioned you feel unwell. Could you tell me more about it?
P: It’s just that I start having heart racing and start sweating a lot at those times. But when I
am home or anywhere else, I am fine. I feel my stress is causing all these to me.
D: May I know is there anything in particular you are stressed about?

P: Actually, I am a lesbian and one of my colleagues came to know about it. Then he told this
thing to everyone. Since then everyone in my office started bullying me. I feel so
uncomfortable in my office. I started having those kinds of symptoms whenever I talked to
any of my colleagues. I don’t want to go to my workplace anymore. I feel so low.
D: How long do those symptoms last? P: I am not sure, 5-10 minutes may be
D: May I ask you a few more questions regarding your health in general? P: Yes
D: Do you have any nausea or dizziness? P: No
D: How has your mood been recently? P: Average
D: Do you feel any tingling in your fingers? P: No
D: Are you sleeping well these days? P: Yes
D: How’s your appetite? P: Fine
D: By any chance have you ever tried to harm yourself? P: No

D: Do you have any other friends or family members living nearby? P: No
D: Whom do you live with? P: My partner
D: How do you get along with her? P: Really well. She is the one who supports me a lot.
D: For how long have you been in a relationship? P: 3 years
D: Have you ever been diagnosed with any medical condition in the past? P: No
D: Any allergies to anything? P: No
D: Any family history of any significant health issues? P: No
purposes only.
From my assessment, it seems you are having a condition that we call Panic attack. A panic
attack is a rush of intense anxiety and physical symptoms. It can be frightening and can
happen suddenly. It’s happening probably due the stress that you are going through at your
workplace.
Treatment aims to reduce the number of panic attacks you have and ease your symptoms.
Psychological (talking) therapies and medicine are the main treatments for panic disorder.
If you prefer, we can refer you for talking therapy. You might discuss with your therapist how
you react and what you think about when you're experiencing a panic attack. Your therapist
can teach you ways of changing your behaviour, such as breathing techniques to help you
keep calm during an attack.
We may prescribe some medication (Antidepressant) as well to control your symptoms.
D: Did you talk with anyone in your HR department or your supervisor regarding this issue?
P: No
D: You should inform them about what’s happening with you. They would be the best people
to help you in your office.
You should inform them about what’s happening with you. They would be the best person to
help you in your office. Poor levels of mental health among lesbian, gay, bisexual and trans
(LGBT) people have often been linked to experiences of discrimination and bullying.
It might not be easy but getting help with issues you may be struggling to deal with on your
own is one of the most important things you can do.
Talking with a therapist trained to work with LGBT people may help you deal with issues such
as:
• difficulty accepting your sexual orientation
• coping with other people's reactions
purposes only.
Cervical Screening (Lesbian)
You are an FY2 in GP. Miss Sarah Knowles, aged 26, presented to you with a new concern.
She has recently been sent a letter to undergo cervical screening tests. Please talk to her

P: I have been sent a letter to come for the cervical screening test. I was wondering 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 if you are within 25-64 years old.
P: But doctor, I don’t think I need to go for the test.
D: May I ask why do you think so? P: Dr, I am a lesbian

D: Ok let me explain to you further. But before that, may I ask you few questions to assess
your overall health P: Ok
D: Do you have any discharge from your front passage? P: No
D: When was your last Menstrual period? P: 2 weeks ago
D: Are your periods regular? P: No
D: Any bleeding between your periods? P: No
D: Any problem with your urine or bowel? P: No
D: Any bleeding during or after sex? P: No
D: Any pain in your lower back or pelvis? P: No
D: Have you had any cervical screening tests in the past? P: No
D: Any weight loss you recently noticed? P: No
D: Are you allergic to any medication? P: No
D: Any family history of any significant health issues? 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
D: Tell meat about your diet? P: Balanced
D: Are you in a stable relationship? 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
purposes only.
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 suggests 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
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
Smoking:
Smoking can damage the inside of the wall of blood vessels and narrow 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 some tablets
(varenicline and (bupropion).
purposes only.
Erectile Dysfunction
You are an FY2 in GP. Mr Ben Knowles, aged 57, has come to you some problem and wants
to talk to you about his sexual problems. Talk to him, assess him and address his concern.
Dr: How can I help you? P: I have trouble in performing.

D: Tell me more this? P: What do you want to know?
D: When did it start? P: It started 3 months ago.
D: Is it becoming worse by anything? P: No
D: Do you have any other symptoms?
P: I feel like I have difficulty maintaining my erection
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 ie achieve orgasm? P: No
D: Do you ejaculate too soon? P: No
D: Does pain or discomfort occur with ejaculation? P: No
D: Is penile curvature (Peyronie disease) a problem? P: No
D: When did you last have sexual activity? P: Yesterday

D: Do you have any stable partner? P: Yes, my husband
D: What is your sexual orientation? P: Gay
D: What kind of sexual contact do you have? P: Anal/Oral
D: Do you and your partner use any contraception or protection against STIs?
P: We use condom
D: Is adequate foreplay occurring? P: Yes
D: What other concerns or questions regarding your sexual health or sexual practices would
you like to discuss? P: Nothing.
P: I am hypertensive for 10 years
D: Any diabetes, heart or kidney problems? P: No
D: Are you currently taking any regular medications, OTC drugs or supplements?
P: I take a medicine for my hypertension but don’t know the name.
D: Do you take them regularly as prescribed? P: Yes
D: What do you do for a living? P: TV company (Producer)
purposes only.
D: May I know whom do you live with? P: My partner
I would like to check your vitals including blood pressure and do genital examination.
I would like to send for some initial investigations including routine blood test such as FBC,
liver and kidney function, blood sugar and cholesterol, urine test, and an ECG.
From my assessment, I suspect you have a Erectile Dysfunction. Erectile dysfunction (ED)
means that you cannot get and/or maintain an erection. In some cases, the penis becomes
partly erect but not hard enough to have sex properly. In other cases, there is no swelling or
fullness of the penis at all. Both can have a significant effect on your sex life.
This could be due to multiple reasons and it is usually treatable, most commonly by a tablet
taken before sex. You may also receive lifestyle advice and treatments to minimise your risk
of heart disease.Most men have occasional times when they have problems achieving an
erection. For example, you may not get an erection so easily if you are tired, stressed,
distracted, or have drunk too much alcohol. For most men it is only temporary, and an
erection occurs most times when you are sexually aroused.
Common causes of ED:

- Reduced blood flow to the penis: DM, HTN, High cholesterol.
- Nerve damage: Multiple sclerosis, Stroke.
- Hormonal causes. For example, a lack of a hormone called testosterone.
- Injury to the nerves going to the penis. For example: spinal injury.
- Side-effect of certain medicines. The most common are some antidepressants; beta-
blockers such as propranolol, atenolol, etc; some 'water tablets' (diuretics).
- Alcohol and drug abuse.
- Cycling.
- Excessive outflow of blood from the penis through the veins (venous leak). This is rare
but can be caused by various conditions of the penis.
- Mental health (psychological) causes
Various mental health conditions may cause you to develop ED. They include: Stress,
Anxiety, relation difficulties, depression.
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.
Possible cause Treatment

Narrowing of penis blood vessels, high blood Medicine to lower blood pressure, statins
pressure, high cholesterol to lower cholesterol
Hormone problems Hormone replacement (for example,
testosterone)
Side effects of prescribed medicine Change to medicine after discussion with
GP
purposes only.
Medicine such as sildenafil (sold as Viagra) is also often used by doctors to treat erectile
dysfunction. It's also available from pharmacies.
Because of changes in regulations, you no longer need a prescription to get sildenafil.

But you'll have to have a consultation with the pharmacist to make sure it's safe for you to
take it.
Sometimes couple counselling, or sex therapy is useful. These are most useful if certain
mental health (psychological) problems are the cause of, or the result of, ED.
Do’s
● 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
Concerns:
I have heard about Viagra/ Can I take it for performing?
Do I need to see a urologist?
!
purposes only.
Homosexual Counselling
You are an FY2 in GP. Mr Nathan Wright, aged 16, has got some concerns and is
embarrassed to talk about it. Talk to him and address his concern.
Dr: How can I help you?

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 feeling attracted to Jamie. He is my school friend.
D: Can you tell me more about this? P: Like what?
D: Is this the 1st time you have felt this way? P: No
D: Since when have you 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’ll speak to you before speaking to anyone else
D: Is there anything else bothering you? P: No
D: Are you currently taking any medications, OTC drugs or supplements? P: No
D: Any allergy to any food or any drug? P: No
D: Are you in a relationship? P: I broke up with a girl 2 weeks ago, I wasn’t interested
D: Are you sexually active? P: No
D: Have you been sexually active before? P: No
D: Do you know about safe sex? P: No/Yes
D: Do you do any recreational drugs? P: No
D: Tell me about diet? P: I eat healthy food
D: Are you physically active? P: Yes
D: What do you do? P: Student
D: Whom do you live with? 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.
D: How is your mood these days? P: It’s okay

D: Score your mood? P: It is average
D: How are things at school? P: They are alright
D: Have you faced any discrimination/bullying at school? P: Yes/No
D: Have you ever thought of harming yourself? P: No
purposes only.
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 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 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.
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.
Mental health problems such as depression or self-harm are more common among people
who are lesbian, gay, bisexual and trans (LGBT).
This may be linked to LGBT people's experience of discrimination, homophobia or

transphobia, bullying, social isolation, or rejection because of their sexuality.
Talking with a therapist who's trained to work with LGBT people may help with issues such
as:
- difficulty accepting your sexual orientation
- coping with other people's reactions to your sexuality
- feeling your body does not reflect your true gender (gender dysphoria)
- transitioning
- low self-esteem
- self-harm
- suicidal thoughts
- depression
- coping with bullying and discrimination
- anger, isolation or rejection from family, friends, or your community
- fear of violence
Talking therapies such as -
purposes only.
- Cognitive behavioural therapy (CBT)- The aim of CBT is to help you explore and change
how you think about your life, and free yourself from unhelpful patterns of behaviour.
- Guided self-help -The therapist works with you to understand your problems and make
positive changes in your life. It aims to give you helpful tools and techniques that you can
carry on using after the course has finished.
- Counselling- At your appointment, you'll be encouraged to talk about your feelings and
emotions with a trained therapist, who'll listen and support you without judging or
criticising. The therapist can help you gain a better understanding of your feelings and
thought processes and find your own solutions to problems. But they will not usually give
advice or tell you what to do.
Counselling can take place:

face to face
in a group
over the phone
by email
online through live chat services
You may be offered a single session of counselling, a short course of sessions over a few
weeks or months, or a longer course that lasts for several months or years.
It can take a number of sessions before you start to see progress, but you should gradually
start to feel better with the help and support of your therapist.
purposes only.
Methods of Conception for Homosexuals
You are an FY2 in GP. Miss Jennifer Molly aged 30, and her partner Daniella Trudy would
like to talk to you about conceiving a child. Talk to Jennifer and explain to her about
different methods of conception.
D: How can I help you? P: I am planning to conceive a child.

D: Can you tell me more about that? P: Like what doctor?
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 1st pregnancy? P: Yes
D: Have you been diagnosed with any medical condition? 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: Yes/No

D: Are they painful? P: Yes/No
D: How long does the bleeding last? P: Yes/No
D: Any bleeding between the periods? P: Yes/No
D: Any usage of contraception? P: No.
D: How is your diet? P: Good.
D: Do you drink coffee or tea? P: Yes/ No
D: How is your physical activity? P: I’m quite active.
D: Any usage of recreational drugs? P: No.
D: What do you do for living? P: Office job.

D: Whom do you live with? P: With my wife
The number of LGBT people becoming parents is increasing. If you're 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
per-son 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
do-nor, or at a fertility clinic using an anonymous donor.
If you decide to look for donor insemination, it's better to go to a licensed clinic where the
sperm is screened. This ensures that the sperm is free from sexually transmitted infections
purposes only.
(STI) 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.
NICE’s guidance says that couples must attempt to conceive before being considered for
NHS treatment. Opposite-sex couples are expected to try and conceive through sexual
intercourse for two years before being considered. This is obviously not an option for female
same-sex couples.
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.
The guidance does not stipulate whether couples need to try to conceive using a fertility
clinic, or whether attempts to conceive at home with donor sperm makes you eligible for
NHS treatment. This is a decision for your local NHS trust to make. Many NHS trusts will
require same-sex couples to use fertility clinics to conceive before considering funding
treatment, meaning many same-sex couples will need to pay fees before being eligible for
NHS funded treatment.
Co-parenting
This is when 2 or more people team up to conceive and parent children together. Co-
parenting arrangements can be made between 2 single people, a single person and a
couple, or 2 couples.
As a co-parent, you 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.
purposes only.
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.
purposes only.
purposes only.
Conceived in a license
Conceived at HOME
FERTILITY CLINIC
Civil partnership? Civil partnership?
Non-birth mother wants to be Non-birth mother wants to be

second parent? second parent?
Agree on paper (form given in

Your partner is automatically the
clinic) to be the second parent of
second parent of the child.
the child.
The first gay men to be offered IVF treatment on the NHS:

Ross and Chris Muller say they and their families can’t wait to meet their son, who will be
born via a surrogate in early August. The couple, from Edinburgh, are believed to be the first
male same-sex couple to undergo fertility treatment through the national health service
after a blanket ban on using surrogate mothers was lifted by the Scottish government in
2018. It means that all couples, regardless of gender or sexual orientation, are eligible for
free IVF treatment.
purposes only.
Gender Dysphoria
You are an FY2 in GP. Mr Michael Lewis, aged 16, wants to talk to you about some
problem he is facing. Talk to him and address his concerns.
D: How can I help you? 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: Can you tell me more about that? P: Like what Doctor?
D: When did you first notice this?
P: I have always felt this 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.
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 that 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.

D: Who do you live with? P: Parents and sister

D: What do you do for living? P: Student
D: Do you have friends? P: Yes/No
purposes only.
D: Have you spoken to them about this? P: No
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.
D: I would like to do GPE and vitals. I would also like to run some routine blood tests like
kidney and liver 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
gender identity differs from their sex assigned at birth or sex-related physical
characteristics.
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):
§ Below 16: Mandatory Court Permission for Hormonal Therapy
§ Age 16, 17: Optional Court Permission for Hormonal Therapy depending on
their understanding.
§ Young people aged 17 or older may be seen in an adult gender identity clinic
or be referred to one from GIDS. By this age, the teenager and the clinical
team maybe 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).
purposes only.
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
• 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
- A 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.
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 transman
with the cervix or breast tissue.
purposes only.
5. Transfeminine people with breast tissue (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. Gall stones
3. Weight gain
4. Acne
5. Dyslipidaemia
6. Elevated Liver Enzymes
7. High concentration of RBC’s
8. Androgenic alopecia
purposes only.
Epistaxis and Headache (Testosterone)
You are an FY2 in GP. Miss Melisa Mathews, 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’s started 1 month ago and was bleeding 3 to 4 times a day.
D: How did it start?

P: I was feeling itchy and I have been picking my nose.
D: How much did you bleed?

P: It wasn’t that much and I held the nose and then the bleeding stopped.
D: Tell me more about the headache.

P: It is dull headache, had 4 to 5 times in a month.

D: For how long? P: Last few hours.
D: Is there anything that makes the pain worse? P: No.
D: Any problem with light? P: No
D: Any problem with the vision? P: No
D: Did you have aura before the headache? P: Yes/No
D: Do you feel tired? (Anaemia) P: Yes/No
D: Any shortness of breath? (Anaemia) P: No


purposes only.
D: Are you taking any other medications including OTC or supplements?
P: I am taking testosterone injection every morning for last couple of months.
D: Why are you taking it? P: I am undergoing gender transition.
D: Did someone prescribe you these medications?
P: No, but I am waiting to be seen by someone at the gender clinic.

D: Do you do physical exercise? P: I don’t get time.

D: Who do you live with? P: Alone
D: When was your last menstrual period? P: 1 week back

D: How many days do you get bleeding? P: 3/4 days
D: Any bleeding in between the periods? P: No
D: Any headache during your menses? P: No
D: I would like to do GPE and vitals. I would also like to run some routine blood tests like
kidney and liver function tests.
Examiner: Blood Pressure – 160/100
From my assessment, we suspect the reason for the bleeding is due to the usage of the
testosterone that you are taking.
Counsel:
Lifestyle
BP Regular check up
Testosterone counselling
Book an urgent appointment
purposes only.
Common testosterone side effects (in men or women) may include:
• breast swelling;
• headache, increased blood pressure;
• depression, anxiety;
• increased facial or body hair growth, male-pattern baldness;
• increased or decreased interest in sex;
• numbness or tingly feeling; or
• pain or swelling where the medicine was injected.
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
• 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)
purposes only.
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: Anything else with it? P: Yes, I also have shortness of breath

D: When did it start? P: With the chest pain
D: Did you by any chance felt dizzy? P: No
D: Do you have any pain elsewhere in the body? (DVT) P: No

D: Have you been diagnosed with any medical conditions? (MI, Previous VTE)
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 hospitalisations or surgeries? P: Yes
D: Has anyone in your family been diagnosed with any medical conditions? P: No
D: Do you smoke? P: No.

D: When was your LMP? P: 3 weeks ago.

purposes only.
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:
Sat’s: 90%
PR: 110
Temp: 37 C
BP: 120/80
ABG: respiratory alkalosis

CXR normal.
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.

D: Well, the contraceptive pills you’re taking are a risk factor for developing this condition.
People with cancer may also have a higher number of platelets and clotting factors in the
blood which in turn can cause clots to form.
We are going to keep you at the hospital and give you oxygen & do basic management to
ease 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 (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 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.
purposes only.
Chest Pain (Transgender)
You are and FY2 in A & E. Ms Chanella Oliver, 28 Years Old, has come to the hospital with
Chest Pain. He is under transition from Male to Female. She has been prescribed
Oestrogen and spironolactone. Talk to her, asses her and address her concerns.
D: How can I help you? P: I have Chest Pain

D: Where is it exactly? P: Left Side

D: Anything else with it? 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: Do you feel out of breath? P: No

D: Have you been diagnosed with any medical conditions? (MI, Previous VTE) P: No
D: Are you taking any medications?
P: Yes, I’m taking oestrogen and spironolactone.
D: Are you taking your medications as prescribed P: No, I take extra oestrogen tablets
D: Any hospitalisations or surgeries? P: No
D: Has anyone in your family been diagnosed with any medical conditions? P: No
D: Do you smoke? P: No.

D: Do you smoke? (risk factor) P: No

purposes only.
D: Do you take alcohol P: No
D: Are you currently sexually active? P: No
D: Whom do you live with? P: Alone
D: I would like to check your vitals & examine your chest. We will also do some initial
investigations.
Examiner: All examination is normal

BP: 120/80
Sat’s: 99%.
From what you’ve told me & 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 ABG, CXR, and 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.

D: The oestrogen tablets you’re taking for HRT are a risk factor for developing this condition.
As you are taking more than prescribed, we will have to schedule a specialist review to
reassess your medications.
For now, were going to keep you at the hospital & do basic management to ease your pain
and would send for tests. We’ll start specific treatment as soon as they come out.
Treatment:
Morphine & Metoclopramide for pain management
Anticoagulation Heparin 5 Days
Warfarin - 3-6 Months
Prevention: Advise compression Stockings, Stop HRT/Pills
purposes only.
Risks
There's some uncertainty about the possible risks of long-term masculinising and feminising
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
!
purposes only.
Surgery
SURGERY COUNSELLING
Pre - Op Operation Post - Op
Full Hx – Symptoms • Explain – Indication v Recovery - Monitor
PMH • How the Sx is done? - IV Fluids
Lifestyle • Type of Sx – Open/ Lap - Pain Mx
Social • Anesthesia – GA/ LA
• Pain Mx v Ward - Start Feeds
Full Ex – Vitals • Complications – Pain - Mobilize
GPE / BMI Damage - Pain Mx
Chest/ CVS Bleeding
Oral Cavity Infection v Home - Medically Fit
Specific - Socially Fit
Ix – Routine (FBC/ CRP) • CONSENT (OT/PT)
RFTs/ LFTs/ TFTs
Blood Sugars
Clotting Profile
Group & Save
CXR/ ECG
purposes only.
Pre - Operative Assessment Ankle Pin Removal
You are FY2 in Surgery. Mr. Oliver Weather, 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 a 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: I am fine.

D: Any cough, fever or flu like symptoms? P: No
D: Have you been diagnosed with any medical condition in the past? P: DM
D: For how long? P: 20 years
D: How has it been managed? P: I am taking insulin for it.
D: Which insulin do 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 have also taken Novorapid 3 a few times.
D: Do you take your Insulin regularly as prescribed? P: Oh yes.
D: Is your diabetes well controlled? P: Yes
D: Do you have any symptoms such as feeling thirsty? P: No.
D: Do you feel like going to the loo more often these days? P: No.
D: Have you developed any complications of diabetes? P: No.
D: By any chance, any problems in your feet or eyes? P: No.
D: Do you check your blood sugar regularly? P: Yes, I check it regularly.
D: When was the last time you checked it? P: I checked it this morning.
D: What was the reading? P: 6
D: Was it before meal or after meal? P: Before breakfast.
D: Are you going for your annual diabetic check-up? 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
D: Tell me about your experience in the 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.
purposes only.
D: Any complications last time?
P: I vomited a lot of last time. 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 will prescribe you an anti-
sickness medication to prevent it.
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 a 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 examinations and investigations will be normal and you will be able to
have your operation.
Let me tell you what you need to take into 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.
D: Whom do you live with? 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 also
be seen by us in six weeks to check if everything is fine.
If you develop any Severe pain, Bleeding, Shortness of breath and chest pain, pain, hotness,
redness or swelling in your calf, please come back to us.
!
purposes only.
Pre-operative Care
You are an FY2 in Surgery. Ms Sally Armstrong, aged 25, has come to the hospital with a
pre-operative assessment. Talk to her, check her fitness for the surgery and take verbal
consent for the surgery.
D: How can I help?

P: I have been told to come to the hospital for a check-up before my surgery for the gall
bladder 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: I am fine.
D: Any cough, fever or flu like symptoms? P: No
D: Have you been diagnosed with any medical condition in the past? P: Migraine
D: For how long? P:
D: How has it been managed? 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
D: Have you been diagnosed with any other medical conditions? P: Acute cholecystitis
D: Have you been hospitalised? P: Yes, for acute cholecystitis
D: Have you had any blood transfusions? P: No
D: Whom do you live with? 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.
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.
purposes only.
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 gall bladder 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's 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 into 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's 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.
Please confirm that you are willing to undergo the procedure of gall bladder removal?
Patient concern:
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?
purposes only.
Ask:
Is it ok to transfuse your own blood?
Is it ok to transfuse any blood products like platelets & RBCs?
!
purposes only.
Herniorrhaphy
You are FY2 in Surgery. Mr. James Anderson, aged 40, has been planned to have a right
inguinal hernia repair. Anaesthetists 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.
D: How may I help you?

P: I have been planned for a surgery for my hernia and I have some concerns about the
surgery.
D: Okay. I am here to talk to you, explain to you everything and address all your concerns.
But before that let me ask you a 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 anyone 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 is 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.
D: Any high blood pressure, diabetes, bowel problems? P: No.
D: Any heart or kidney problems? 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?
P: No, He used to wear a truss.

D: Do you do physical exercise? P: I am quite active at work
D: May I know what you do for a living? P: I work in a warehouse.
purposes only.
D: Does it involve lifting heavy weights? P: Yes Dr.
D: Whom do you live with? P: I live with my wife
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 a routine blood test 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 with high blood pressure. We need to check it at different
times for us to come to a conclusion. P: Ok Dr.
D: Let me explain to you that we do two types of operations for hernia, keyhole 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. Else we have another option
for you which is, to wait and postpone your surgery for a few days while we control your
blood pressure.
D: 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 to 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 will the surgery last?

D: It usually takes between 30 minutes and 60 minutes, however sometimes it takes longer
varying from person to person.
P: For how long do I have to stay in the hospital?

D: This operation can be done as a day care surgery meaning if everything goes smoothly,
and you are able to take fluids and pass urine, you will be able to go home the day of the
purposes only.
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 are at
risk, you will be given special compression stockings and possibly blood thinning injection to
reduce the risk.
P: Are there any long-term complications?

D: In some patients, the hernia may come back. Patients may experience mesh infection
usually from bugs 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 instructions your nurse gives you about caring for your wound
and its hygiene. A see-through plastic dressing will cover 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 GP
practice nurse.
P: Will I be able to take shower?

D: Yes, you can take shower rather than a 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.
purposes only.
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 is also fairly uncomfortable. It is generally no
longer recommended.
If you have Sudden, severe pain, Vomiting, Calf pain or increasing breathlessness, Excessive
bleeding, Difficulty passing stools or wind (Obstructed 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 a diet after the operation.
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.
!
purposes only.
Dermoid Cyst
You are FY2 in Surgery. Miss Julia Roberts, 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

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 all your concerns. Let me ask
you a few questions so that I can help you better. P: Ok Doctor.
D: Tell me more about your tummy pain? P: I have had this pain for the last few days.
D: Where exactly is it? P: On the right side of my tummy.
D: Have you been diagnosed with any medical conditions in the past? P: No
D: Any HTN/DM/Bowel problem? 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 hospitalisation or surgeries in the past? P: No
D: Has anyone been diagnosed with any medical conditions in the family? P: No

D: Do you drink Alcohol? P: Yes/No
D: Are you physically active? P: Yes, I’m quite active.
D: What do you do for a 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 a US scan of your tummy and we found a fluid-filled sac in your ovary which we
call Ovarian Cyst. 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 the 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 an emergency operation. To avoid such a 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 a
few cases during the procedure, we have to remove the ovary as well.
purposes only.
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? Will it show when I wear a bikini?
D: The 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 ovaries 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, 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 apply 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 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.
purposes only.
Post Op Hemiarthroplasty
You are FY2 in Orthopaedics. Mrs. Jane 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 post-operative management and complications. Discuss about
management once the patient has got discharged and address her concerns. Anaesthetist
has explained pain management. The consultant has explained the procedure.
D: Hello, how can I help you?

P: I am ok now.
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.
D: How are you feeling now?

P: I am fine.
D: Has anyone told you what has happened to you and what are we 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/colleague 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 need to be addressed before the surgery?
P: Yes Dr.
D: Don’t worry my dear I am here to 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 the 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
purposes only.
- Blood clot in the legs
If any of these things happen we will manage them accordingly.
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 a few questions
to assess your risk of getting this condition.
D: Any blood disorders? P: No
D: Are you currently taking any medications, OTC or supplements? P: No
D: Any blood thinners? P: No
D: Any blood disorders or blood clots in the family? P: No
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 a 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 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
purposes only.
they may fix an electric chair to carry you up and downstairs. They will also change any low
toilet seats to high seats.
P: What about showers?

D: Bathrooms can be slippery and pose a risk of fall but don’t worry about it, an electric
chair can be fixed in the shower and hand railings can also 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 return 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 home?
P: No Dr, that’s one of the reasons why I am worried.
D: 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 the 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 would be happy to discharge you after our occupational
health team and social services have assessed your home condition and done the necessary
arrangements for you to stay safe and comfortable.
You can contact your GP if you notice redness, fluid or an increase in pain in the new joint
post discharge. If you develop any sudden chest pain or redness, hotness, swelling or pain
over the 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).
!
purposes only.
Ductal Carcinoma in Situ
You are an FY2 in surgery. Mrs Sarah Roberts, 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. I’m 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: Ok
D: Can you please tell me what brought you to the hospital earlier?
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
D: How is your appetite these days? P: It’s alright
D: Have you noticed any decrease in weight? P: No
D: Any SOB or heart racing? P: No
D: When was your LMP? P: 7 years ago.

D: When did you have your first period? P: When I was 13 years old.
D: Do you have any children? P: Yes/No
D: Have you used any contraception in the past? P: No
D: Any lumps in the past? P: No
purposes only.
D: Have you ever taken hormone replacement therapy? P: No
D: Has anyone in the family been diagnosed with any medical condition? P: Yes/No

D: Do you do physical exercise? P: Yes/No.
D: I have the results of the biopsy. Is there anything specific that you’re worried about?
P: P: I’m just afraid that it might be cancer.
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
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 types 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 felt initially. It
is mostly found on routine breast screening & is confirmed with a biopsy.
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. Usually,
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 it's cancer, so counselling is important.
If she has a sister who is in 30’s so can offer her a screening as well.
purposes only.
Ethical
Breaking Bad News
“I can see how difficult this is for you.”

“I can’t imagine how hard this must be for you.”
“And how have you been coping with all this?”
“I also wanted to check, do you feel like you have support?”
Avoid – I can understand what you are going through/how you feel.
- Break the News in Layers

- No False Assurance
- ICE
- Respond to the reactions of the patient (Denial, Breakdown etc)
- Be a good listener (Respond by nodding your head)
- Do not interrupt
- Pause is very important
1. Setting
(Comfortable room, sitting, no interruption)
2. Perception (Assess their knowledge) Ø Voice Control
(How much do you know/Tell me what happened)
3. Invitation (Warning shot—Family and friends) Ø Eye Contact
(Would you like someone beside you) Ø Nodding
(I have the result here, would you like me to explain it to you now?) Ø Body Posture
4. Knowledge
(We have done the CT scan, I don’t have a good news for you. PAUSE..I
am sorry to tell you he has got bleeding in his brain PAUSE)
5. Emotions and empathy:
(I can see you are worried/concerned/anxious)
I can see this is a huge shock for you”
“I can see that this is not the news that you expected, I’m so sorry”
6. Strategy and summary
(Agree on a plan, give right information, Offer assistance to tell others,
Summarise)
purposes only.
Breaking Bad News (Cerebral Bleeding)
You are Fy2 in A&E. Mr. Ahmed Ali, aged 78, collapsed and has been 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 intracerebral 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. Mariam Ali, explain 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'm John, one of the doctors 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 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: I am here to help you with all your queries. Let me ask you a few questions to be able to
explain the situation better. Has he been diagnosed with any medical condition in the past?
P: He has high blood pressure, but he is taking medication for that.
D: Any other medical condition he is suffering from? P: No

D: Diabetes or high cholesterol? P: No
D: Thank you for patiently answering my questions. 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 collapsed. We examined him and did a CT scan of his head. I am sorry to say
that I don’t have good news for you. 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.
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, that we call the blood vessels. When the
walls of these tubes become weak they become wider and form a sac that looks like a berry
and when this sac ruptures, it causes bleeding in the brain. There are a number of things
that can increase the risk such as having diseases like high blood pressure, family history,
smoking and age.
purposes only.
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. The
team of expert neurosurgeons believes that at this stage operation is not possible. 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.
- We will provide him nutritional vitamins and supplements by passing a flexible tube into
his gut and gullet through his nose.
- We may need to give him IV fluids and medication.
- 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.
- We will move him regularly so that he doesn’t develop bedsores and we will gently
exercise his joints to stop them from becoming stiff. This will also help prevent
formation of blood clots in his legs. We may also use some compression stockings for
this purpose.
- We will also help him in emptying his bladder by inserting a flexible tube through his
penis into his bladder.
- We will give him some medications to reduce the secretion in his mouth (antisecretory
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 breathe 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.
P: Doctor, how much time does he have?
D: It is very difficult to say how much time he has. I’m afraid to say that he may develop
complications. Some of them like infection, formation of blood clot, or breathing problems
may be prevented. However, there are few complications such as re-bleeding that can be
fatal.
P: Doctor, can I ask my daughter to come and say goodbye to her dad?
D: Of course, you can! You can inform your close relatives and they can visit him too. You
also need some emotional support at this time.
P: Doctor, this is too much for me. I cannot tell my daughter, could you please talk to her
and tell her what happened to her dad?
D: Yes, sure. I will do that for you.
P: Can I see my husband?

D: Of course, you can.
purposes only.
Breaking Bad News (Talk to Daughter)
You are an FY2 in Surgery. Mr. David Lowe, aged 65, had an Ischemic 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
hemispheres. Only Analgesics and IV Fluids can be given to the patient. If the patient
deteriorates, it has been decided to not Resuscitate the patient (DNR). His daughter has
come to you to discuss her father’s condition. Please talk to Miss Jane, 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, 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 already 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 the CT scan result?
P: No, tell me what happened.
D: I’m sorry to say that I don’t have good news for you. 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, your father had another stroke yesterday which has affected his both
sides of the brain and he is unconscious now.
D: Unfortunately, we cannot do any operation as this massive stroke affected both sides of
his brain and a team of experts believe that at this stage the operation is not possible. I’m
really sorry to say that his condition is terminal, and we are not expecting him to get better.
P: 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.
3) We will provide mouth care whilst maintaining good hygiene to avoid any dryness or
infection in the mouth.
purposes only.
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?

D: It is very difficult to say how much time he has. I’m afraid to say that he can develop
complications. Some of these, such as an infection, 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 a 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 we
are not expecting him to get better. 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.
purposes only.
Post-Operative Bleeding (Vascular Surgery)
You are FY2 in Vascular Surgery. Mrs. Janet Smith, 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 into 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 Mr Albert Smith 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. Smith has been taken to talk to her husband.
D: Hello. Are you the husband of Mrs. Smith?

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 her 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 had an operation this morning because of a 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?
D: I can see how worried you are! We have given her six units of blood to make up for the
loss.
D: What? 6 units, Isn’t it too much?

P: 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 with her 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 made a mistake during the surgery?

purposes only.
D: This is one of the known complications of this surgery but, may I know why do you think
that way?
P: How can she lose so much blood. I am sure something must have gone wrong during the
surgery.
D: I can assure that the surgery went really well and the operation was a success. This is one
of the known 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 only imagine what you are going through and how worried you are. As I said earlier,
I can confidently reassure you that no error has occurred in her operation and it is a known
complication.
P: What’s the difference between an error and a complication?

D: A complication is an adverse event caused by some factors, such as a 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 serious 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: 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 especially 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.
purposes only.
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?
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: I 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
complications 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, another operation to
clear the bypass may be done.
• 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: For two to three weeks after discharge from the hospital, she needs to have more rest
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.
purposes only.
She can gradually increase the amount of exercise and increase 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.
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.
!
Breaking Bad News (Space Occupying Lesion)
You are an FY2 in Stroke Unit. Miss Grace Ather, aged 60, has been admitted in the
hospital with left sided space occupying lesion. She was operated yesterday for SOL and
now has developed right sided weakness. CT Scan was done which showed ischaemic
stroke. Stroke assessment team is looking after her. Talk to the son, Mike Atherton, and
address his concerns. Consent has been taken from the mother to talk to the son.
purposes only.
Extradural Haemorrhage (Child)
You are F2 in Paediatric Emergency. Mr Josh May 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 haemorrhage. You have not seen
the patient. A team of doctors are resuscitating the child and planning to take him to the
theatre. Please talk to the parents; Mr. and Mrs. May and address their concerns.
D: Hello, could you please confirm that you are parents of Joshua?
Mom: Doctor will he die?
Dad: How is my son?
D: We are looking after your son and doing the best we can. I am here to talk to you about
him. Can you tell me how much you know about his condition? Has anyone talked to you
about his situation?
Dad: We don’t know; is he going to be ok?

D: I am here to answer all your questions but I need you to help me out a bit. I know it might
be very 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. It was my mistake that I was not holding Joshua’s hand.
D: I can only imagine how difficult this must be for you, but please try not to 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 Joshua was 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: Yes/No
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. We examined him for external injuries
and found an injury to his head.
purposes only.
We then examined his 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
the necessary blood tests. 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 shows 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 the 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 remains 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 as much as I know about this surgery. The
blood that has collected in the 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”, in 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 be able to arrange for you to
see him now.
Mom: Are there any complications for this surgery?
purposes only.
D: Every surgery has its own share of possible 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 as well.
Dad: Are there any long-term complications?

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 can be managed by a speech therapist.
D: Does Josh have any medical conditions?

P: No
D: Does he take any regular medications?

P: No
D: Any allergies?
P: No
D: When did he have his last meal?

P: At the restaurant just before he was brought in.
purposes only.
Pelvic Fracture (Child)
You are FY2 in A&E. Mr Josh May, aged 9, had a road traffic accident. He was brought to
the hospital and an 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 the patient has been
resuscitated. He is being prepared to go for a surgery. Parents are quite anxious. Talk to Mr
and Mrs May, discuss further management and address concerns.
D: Hello, let me confirm you are the 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 your
understanding about your son’s condition is?
Dad: We don’t know; is he going to be ok?
D: I am here to answer your questions but need a bit of your help in doing so. 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 only imagine how difficult this must be for you, but please try not to 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 Joshua was 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: He was drowsy/Conscious
D: Did he have any other problem?

Dad: Doctor, he was having some difficulty in breathing.

purposes only.
D: We are doing our best to help him and he is with a team of expert doctors.

D: Let me tell you what we have done for him so far. We did a full examination to check for
any external injuries. We measured his blood pressure and found it to be low. This type of
injury damages the tubes that supply blood around the hip, and this can lead to bleeding. This
can explain why he had difficulty in breathing and low blood pressure too. 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 a 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 could breathe
properly and gave him oxygen. To compensate for the blood loss, we gave him fluids through
the tube that supplies blood in his arm as a drip. We also took some blood samples 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 type 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 with 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 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 know that all this must sound really scary to you but be assured that whatever
we do will be in the best interest of Joshua.
Mom: Surgery! Which surgery?

D: There are still a few scans that we will do before we proceed to surgery which will tell us
which exact surgery Joshua will need. If you are okay with it, I can explain to you 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 (Laparotomy and
Pelvic Packing).
purposes only.
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 be 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 possible 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 develop persistent pain or difficulty to walk but with the 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.
D: Does Josh have any medical conditions?

P: No
D: Does he take any regular medications?

P: No
D: Any allergies?
P: No
D: When did he have his last meal?

P: At the restaurant just before he was brought in.
!
purposes only.
Post Mortem: Ø Voice Control
Post Mortem Requested by: Ø Eye Contact
Ø Coroner Ø Nodding
Ø Doctor Ø Keep Distance
Ø Relative/Partner
Post Mortem Examina<on:

Ø External
Ø Internal
Rela<ve Involvement
Ø Consent
Ø Bereavement Services/Support
purposes only.
Post Mortem
You are FY2 in the Respiratory Dept. Mr. Davis Creswell, aged 60, was brought to the
hospital because of a 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 Creswell 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 the 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 a cough and 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. I don’t know what we 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 paperwork to be completed. Do you have any 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 you are going to do a 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.
In External examination, we will look at the body more closely. Some imaging such as X-ray,
CT scan or MRI may be done as well.
purposes only.
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 the body will be stitched.
Sometimes, the organs need to be kept in the laboratory for examination. In this case, the
cut is closed so the body can be taken for the funeral. The organs can be given later.
Sometimes additional tests such as genetic testing may also be done.
P: Doctor, will the body be disfigured?

D: The body is cut gently with respect and then closed 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 no one will probably 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 are post-mortems 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.
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.
The autopsy usually takes 2-4 hours.
Once the procedure has been done, it usually takes within 1-2 days for the body to be
released for the funeral.
purposes only.
Domestic Violence Ø
Ø
Voice Control
Eye Contact
Ø Nodding
1. Comfort the patient Ø Keep Distance
(You are our priority)
2. Acknowledge their emotions
(I can see you are not comfortable/worried/anxious)
3. Patient safety
(Assess patient condition)
4. Give them time/confidence
(No need to put up with all these/it is illegal/we can help)
5. Confidentiality if needed
(discussion will remain confidential between you & the team until everyone is safe)
6. Social history/Pregnancy/Children/Partner
(safety of children if any/elaborate partner information)
7. Offer support MARAC
(Education/Finances/Accommodation/Police)
8. Thank you !
(Thank you for opening up)
purposes only.
Domestic Violence
You are FY2 in OBG. 12 weeks pregnant, Mrs 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 good news for you. We did an examination and an 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 questions about your pregnancy. Could you please confirm the age
of pregnancy?
P: I’m 12 weeks pregnant.
D: How has your pregnancy been so far? P: It has been fine.

D: Did you have any complications? P: No.
D: Any previous pregnancy? P: I have a 3 years old daughter.
D: Do you have any medical condition? P: No
D: Any blood disorders? P: No doctor.
D: Are you taking any blood thinners? P: No

D: My nurse colleague who examined you told me 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 between
you and my team.
P: OK
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.
D: When did this happen?

purposes only.
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 and four fingerprints on her
wrist. Sometimes she will not show her hand.
D: This bruise doesn’t look like that you banged your hand in the wall, it looks like someone
has applied force/ as my nurse colleague noticed a fingerprint on your right wrist (if she
doesn’t let you examine).
D: Please feel free to talk to me. I am here to help you.

P: My partner and my three-year old daughter.
D: How long have you been together? 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 have sexual relation with you when you don’t want?
Kick: Have you been physically hurt by your partner?
D: Has it happened before as well? P: Yes

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
D: Does he have any criminal record? P: No
D: Is your partner the biological father of your daughter? P: Yes.
D: Has your partner ever hurt your daughter? P: He loves Jenny.
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 members living nearby? P: My mom lives nearby.
D: How is your relationship with your mom? P: It is OK. We don’t talk much.
D: What do you do for a living? P: I am a housewife.
D: Do you have any friends? 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 safe living with him? There are
some ways that we can help and support you. There is a designated person in the hospital
purposes only.
who deals with these issues. We can arrange a meeting with that person. He will explain
about the service 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, and 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 make decisions for yourself but as you are pregnant, we have got some duties
towards your unborn child. I have to talk to my senior regarding your case.
!
purposes only.
Insomnia Domestic Violence
You are an FY2 in Medicine. Mrs Elena Petrovich, 32, has come to the hospital with
insomnia. Talk to the patient and address her concern.
D: What brought you to the hospital? P: I have trouble sleeping.

D: Please tell me more about it P: What do you want to know?
D: When did this problem start? P: It started a few 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 going to 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 2 am. Sometimes I don’t sleep the whole night.
D: What time do you usually wake up? P: I wake up around 7.

D: Do you wake up in between? P: No
D: How was your sleep before this problem started? P: It was fine.
D: Do you take any naps during the day? P: No
D: Can you think of anything which might be the cause of your problem? P: No
D: Tell me what do you do before you go to 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? Anything bothering you? P: Is this conversation confidential?

D: Yes, it is confidential. P: I am having a problem with my husband.
D: Could you please tell me more about it? P: He got violent with me.
D: When did it happen? P: It happened a few days ago.

D: Has it happened before? P: No, this has happened many times.
D: How long have you been together? P: 2 years
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

D: Is there anyone else in the family? P: No
D: Any relative nearby? P: No
D: How is your mood? P: It is ok.
purposes only.
D: Could you please score the mood on a scale of 1 to 10, where 1 is lowest and 10 is the
happiest?
P: It is average.
D: What do you do for a living? P: I work in landscaping.

D: Do you have any friends? P: I have few friends around.
D: Did you discuss it with them? P: No
Ask about:
- Tea, coffee? How much? When did you take the last cup?
- Smoking, Alcohol, Recreational drugs, 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 services 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.
! !
purposes only.
Domestic Violence Burn (Sex Trafficking)
You are an FY2 in GP. 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 concern.
D: How can I help you today? P: I am burnt.

D: Where have you gotten burnt? P: I don’t know/I burnt my tummy
D: Is there anything you would like to tell me? P: What would you like to know?
D: When did this happen? P: In the morning
D: Were you alone when it happened? 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
D: Who brought you to the hospital? P: My landlord
D: Where do you live? P: I live in a hostel with other girls.


D: Whom do you live with? P: I live with other girls in the apartment
D: Do you work currently? P: Yes, I’m 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.
D: 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
D: Was he under the influence of alcohol or drugs when he hit you? P: I don’t know
D: Has your landlord ever hurt other girls? P: Yes.
D: Has he ever hit you in front of other girls? P: No.
D: Have you ever done anything for this problem? P: No
D: Do you have any other family members living nearby? P: No
D: Do you have any friends? P: Not really.
purposes only.
P: I don’t want to go back 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 to
support you. Don’t worry.
My colleague will refer you to an organisation (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.
purposes only.
Cancer Withhold
You are an FY2 in the Surgery Department. Mrs. Maya Ali, aged 78, presented to the hospital
with confusion due to chest infection. Investigations including CT scan have 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. Ali Ahmed 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. Ali Ahmed and address his
concerns. Consent has been taken from Mrs. Maya 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?

Ali Ahmed: 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. Of course, it is a very
tough time for you and for your family but may I know why you don’t want us to tell her?
Ali Ahmed: It will be very devastating for her if she came to know about her condition.
Doctor: I can see where you are coming from 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 will ask
us why we are doing all these tests then we have to explain it to her.
Ali Ahmed: 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 wants
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.
Ali Ahmed: 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: Is there any particular reason that you don’t want us to tell her about her condition?
Ali Ahmed: 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 suffering 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 condolences are 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, or the treatment plan.
Ali Ahmed: She is very simple lady, tell her that she has infection and treat her for the
cancer.
purposes only.
Dr: Mr Ali, the treatments for cancer and infections are entirely 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.
Ali Ahmed: Ok. Just don’t use the word cancer in front of her as I mentioned she knows
about this word.
D: 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 well use these words. She has full
mental capacity, we have to tell her that she has cancer so that we can discuss further plans
of management with her.
Ali Ahmed: Dr, she doesn’t understand English.

D: Don’t worry, we will arrange an interpreter for your mom, so that is not an issue.
Ali Ahmed: Can I be an interpreter?

D: We have specialists in this field who know how to tell the information to our patients. I
am so sorry you cannot be our interpreter.
Ali Ahmed: Can I be there while you are talking to my mom?

D: Yes of course you can be with us when we talk to your mom, if she wants. If she is happy,
we don’t have any problem having you by her side.
Ali Ahmed: Doctor, Can I interrupt you while you are talking to my mom about her
condition?
Doctor: May I know why you want to interrupt us, as it won’t be appropriate?
Ali Ahmed: 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 it
would be appropriate to interrupt us while we are talking to your mom and discussing her
condition.
Ali Ahmed: Okay doctor, thank you.
purposes only.
Confidentiality
o Find out the reason (why).
o We must maintain our posi6on.
o Can’t change the name of the disease (Cancer)
o Professional Translators if required.
o Can’t be present in the room without the consent from the pa6ent.
Explana6on:
• It is the right of the pa6ent to know about her condi6on.
• We need to treat her according to her wishes.
• We need to tell the pa6ent about the side effects.
• Pa6ent might have to do Power of aHorney.
• We will disclose in layers.
• She may get to know later (Trust)
purposes only.
Talk to Consultant son about his mother
You are FY2 in surgery. Mrs Mary Stuart, aged 80, has been referred from the nursing home
as she was losing weight. She had a CT scan of abdomen that showed suspected malignancy
in the ascending colon. You haven’t spoken to the patient. Talk to her son and address his
concern.
Son: I am a Surgical Consultant. I want to discuss the test results and further plans for my
mom.
D: I can see that you are concerned. Let me ask you some questions about her general
health. How has her health been recently?
Son: I don’t have much idea about her condition. I 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 was she 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 your mother's 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 a 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: I am sorry I cannot discuss anything about the results now. First of all, we need to speak
to her and after she gives her consent, then we can discuss the result with you.
Ex: What you will do now?
D: I will talk to my senior about the test result and ask for further plans for the patient and I
will inform the patient about the test result and discuss further investigations and
management plans with the patient. I will also inform my senior that 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.
! !
purposes only.
Treatment Refusal Ø Voice Control
Ø Eye Contact
Ø Nodding
1. Acknowledge their emotions Ø Keep Distance
(I can see you are not happy with the treatment)
2. Patient safety
3. Find out the reason
(S/E, addictive)
4. Resolve the problem
(Can manage the S/E)
5. Pros and Cons
(Benefits are more than S/E)
6. Understanding/Retention/Implication
(Do you understand/can you repeat/ Do you know implications)
7. Social History
(Would you like to discuss with anyone in the family)
8. Support till the end /seniors
(We are always there to help you)
purposes only.
Treatment Refusal (DNAR)
You are FY2 in General Medicine. Mr. David Snape, 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 for the last 2 years since he developed heart failure 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.

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 some more
medications for my heart and I don’t want to continue with those medications.
D: Which medications are you talking about?

P: They are:
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 these medications?

P: I am taking all of them 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 reduces the strain on your heart).
Atorvastatin (It lowers the bad fat in your body).
Ramipril (It prevents your heart from changing its shape (remodelling).
purposes only.
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 the patient says I will think about it.
D: Why?
P: 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 even go out because I get tired. I have to stay at home all the time.
D: I can tell my colleagues- occupational therapists, they can come and assess you at your
home. Maybe 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 a cripple so she can’t visit me.
I feel tired and sleepy. I have already enjoyed my life, I am old and I am ready to go.
D: I can only imagine what you've been through. Ageing is not an illness, but it is challenging
sometimes. A lot of people 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 up my mind.

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.
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: 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 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 this way.
D: How has your mood been recently?

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.
purposes only.
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
café 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.
Treatment Refusal 2 (DNAR)
You are FY2 in Oncology. Mr. Dana Williams, aged 75, 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.
purposes only.
Refusal of Breast Cancer Treatment
You are an FY2 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. Talk to
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.
D: Whom do you live with? 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 anyway.
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 patients’ 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 this particular manner.
P: OK
D: Do you know the implications of not using the treatment?

P: Yes/No,
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.
D: This is just temporary, after the treatment usually the hair grows back, and it will be like
before.
P: OK.
P: I was told that the doctors will remove my breast. I will feel embarrassed.
purposes only.
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 are going 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, I have made my mind.

P: My mood has been fine. I am making an informed decision.

P: No
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.
purposes only.
Multiple Sclerosis (DNAR Form)
You are FY2 in General Medicine. Mrs. Rosa 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 us 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 the 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 have this disease and now I am having frequent attacks of it.
D: How has it been managed?

P: I am in the 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 the do not resuscitate form.
D: I can’t even imagine what you've 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: May I know who you live with?

P: I live with my husband.
D: Have you discussed this decision with your husband as it is a big decision?
P: Yes, I have discussed with him and he understands my situation.

P: My mood has been fine. I am not suicidal. I am making an informed decision.
D: Is there anything else that we can do for you?

P: I want you to sign the form doctor.
D: OK let me fill the form in for you, but at any point of time if you want to change your
decision, let us know. We can assess you again.
P: OK Doctor.
purposes only.
purposes only.
Does the Patient have the capacity to make and communicate the decision à Yes
Summary of main clinical problems and reasons why CPR is inappropriate, unsuccessful or
not in the patient’s best interest à Advanced stage Multiple sclerosis
Summary of the communication with the patient or (Welfare Attorney) patient à Patient
wishes for DNACPR.
Summary of communication with patient’s relatives and friends à Not discussed
Names of members of multidisciplinary team contributing to this decision à Not discussed
Healthcare professional recording this CPR – sign and write position à FY2 doctor, Date
Review and endorsement by most senior professional à Leave blank (Consultant to sign
later).
purposes only.
Infective Endocarditis
You are FY2 in the General Medical Ward. Mrs. Judith 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 now.
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 stay in 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: How about now? P: I'm fine
D: Are you still feeling feverish? P: Just a little bit
D: Are you experiencing any shivers? P: No
D: Are you taking any medications for anything except this? 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 me the antibiotics,
purposes only.
but I 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 regard 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 to not smoke.
P: I don’t want to stay here any longer because of these nurses.

D: Could you please tell me more about it?
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?
purposes only.
P: My condition may not improve and it may lead to complications. (Retention of
information)
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.
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 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, diarrhoea, 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.
Note: Sometimes the patient is already on Methadone and she doesn’t have these
symptoms. Sometimes the 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.
purposes only.
Patient doesn’t want to take Warfarin
You are FY2 in General Medicine. 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 has been given 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 the patient's mental capacity. Patient has a history of two
strokes in the past. Please talk to the patient and address his concerns.

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 don't you 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 I have irregular heartbeat, what you call AF.
D: How has your condition been managed?
P: They gave me some medication 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.
D: How are you feeling now? 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.
D: Have you been diagnosed with any medical condition?
P: I have high blood pressure and 2 strokes in the past.
D: How has it been managed? P: Doctor, they gave me some medications.
D: May I know which medications? P: They are:
Aspirin
Amlodipine
Atorvastatin
Ramipril
purposes only.
D: How has stroke affected your life?
P: Now I’m fine.
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 you don’t take this medication?
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 also been diagnosed with irregular heartbeat.
Having these conditions 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: 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 to happen to you.
P: But doctor, what if I have a fall?

D: You need to come to the emergency department if you have a fall and a head trauma, or
if you were involved in any major trauma or if you experience an unusual headache. If any
of these happen, we will do a CT scan of your brain in order to give you the best treatment
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.
It is very important to take this medicine regularly everyday. If you do not take it regularly
then your blood can become thick and can cause more strokes. You have to take this
medicine daily at the same time.
If the patient is not convinced, then say I will talk to my senior.

Patient has the right to refuse the medication.
purposes only.
Dementia
You are FY2 working in Neurology. Mrs. Dianna Parker, aged 78, has been admitted to
hospital because of weight loss. She has been suffering from dementia since 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 bit 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. Katie Parker, take relevant history, assess her condition, explain
her mother’s present health status, discuss further plans of management and address her
concerns. Patient is not available to talk. Consent was taken from the patient to talk to the
daughter. The weight loss is only due to dementia.
Dementia is a condition associated with an on-going decline of the brain and its ability. It is
caused by gradual change and damage to the brain.
D: Hello I am …. How are you?

P: I am fine. I want to know how my mother is.
D: I am here to talk to you about your mother's condition. Tell me how much do you
understand about your mother's 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 a blood test, X-ray,
ultrasound and CT scan to see if there is any abnormality inside of her body, and all the test
results came back normal. This means that she does not have any other medical problem
presently causing her weight loss. The only cause of her weight loss is Dementia which we
already know about.
P: But why is she not eating?
D: Dementia can present with various symptoms. Some of them are memory problems,
eating problems 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 has been tolerating that.
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 to infections.
Do you still think that she should stay here?
purposes only.
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 its 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 its symptoms, to help you and your mom.
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. Serve 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: I am the main carer.

D: What do you do for the living? 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 the later stages? P: No
D: We are here to help you and we have 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.
- Provide all necessary care at home, e.g. if patients need any help like carers, we can
provide them and they can help you in looking after your mother. There are some
community services which we can offer dementia specialist nurses that can come home
and help you in taking care of her.
- There is an option of sending patients out of the home to meet all the needs such as day
care centre (where you can send your mum where she can get the necessary care and
you can get her back home in the evening).
- There is another option of sending patients out of the home to meet all the needs such
as a care home.
! !
purposes only.
Non Accidental Injury Ø
Ø
Voice Control
Eye Contact
Ø Nodding
Risk Factors: Ø Keep Distance
History doesn’t match with ExaminaUon.
MulUple bruises of different ages.
Drugs or Alcohol
Disability or long term Illness
1. Acknowledge their emotions

(I can see you are anxious/worried)
2. Patient safety, find other causes of fall
3. Social history.
(Ask regarding family members living together)
4. Confront them/Subtle Disclosure
(Injury is not common in this age/there are multiple injury signs)
5. Management Plan:
X-Ray, Skeletal Survey,
Medical Management
Symptomatic treatment.
Inform Seniors
Social Service.
!
purposes only.
Elderly Abuse
You are FY2 in A&E. Mrs. Hannah 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 Blake
and discuss your further management plans with her. Patient is not available to talk. She
has been sent for an 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 know, how is she?
D: You did the right thing by bringing her to the hospital. We have given her a pain killer and
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 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 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 falls 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 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 of her
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 go to work, I leave some food for her. But mostly she doesn’t eat because
of her dementia.
D: Do you work full time? P: Yes. I work in an office full time after my husband passed away.
D: What about your kids? Do they help? P: Not really.
D: How old are they? P: They are in their 20s.
Find other causes of fall:

D: Any fever, flu or cough? P: No
D: Any problem with urine or bowel? P: No.
D: You told me she has dementia Apart from that, any other medical conditions? P: No
purposes only.
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
D: Does she drink alcohol? P: No
D: Any slippery floors? P: No
D: Does the house have enough light? P: Yes
I would like to check her vitals and examine her chest, heart, tummy.
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 pain killer 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 services and occupational therapists 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 the daughter will say I pushed my mom, so we have to involve the social services.
Also, the presence of multiple bruises on her body points towards elderly abuse.
https://www.nhs.uk/conditions/falls/
https://www.nhs.uk/Conditions/dementia-guide/Pages/dementia-and-social-services.aspx
!
purposes only.
Dementia Mother
You are an FY2 in GP. 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 concern.
D: How may I help you? 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
D: Is this the 1st time it has happened? P: Yes
D: Has she complained of incontinence? P: No
D: Has she had trouble with her wee? P: No
D: Is there anything else? 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
D: Does anything make it worse? P: It’s getting worse.
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
D: Has she been diagnosed with any medical condition in the past?
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
D: Has anyone else in the family been diagnosed with any medical condition? P: No
D: Does she smoke? P: No

D: Does she drink alcohol? 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, I am quite physically active.
D: Is she able to do her daily chores? P: Yes
I would like to check your vitals, do a GPE and perform a neurological examination.
purposes only.
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 be caused by:
● 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 require 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.
!
purposes only.
Elderly Wrist Fracture
You are FY2 in Surgery. Mrs. Maria Lowe, 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 service, 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 Lowe, 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 rugs, 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?
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
purposes only.
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.
! !
purposes only.
Confidentiality
Criteria sugges+ve of Abusive Rela+onship:
- Immature to understand/give consent;
- Age/Maturity/Power difference;
Ø Voice Control
- Posi+on of trust; Ø Eye Contact
- Non consensual/Addic+on engagement in sexual ac+vity;
- Sexual partner known to Police/Children Protec+on agency. Ø Nodding
Gillick Competency
Ø Keep Distance
Under age 16 to determine capacity
Lord Fraser Criteria (Contracep+on)

1. Understanding;
2. Not be able to persuade her to inform parents;
3. Likely to con+nue sexual intercourse without contracep+on;
4. Without contracep+on she would suffer mental/physical trauma;
5. It’s in her best interest to give the contracep+on.
!
Maintaining a young patient's confidentiality is very important, however, where there may
be a risk to health, safety or welfare of a young person or others, doctors should follow child
protection procedures and the young patient’s family should be involved.
If doctors realize that a young patient is in an abusive relationship, he can breach
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 patient's sexual partner has a position of trust.
4. Force, emotional or psychological pressure to engage in sexual activity.
5. Drugs or alcohol to influence young patients to engage in sexual activity.
6. If a young patient's sexual partner is known to the police or children protection agency as
someone with a history of abusive relationships with children or young people.
Confidentiality:
Before prescribing:
Establish a good rapport with the patient and support them as much as possible.
Establish the nature of the sexual relationship. Be alert for indications of an abusive
relationship.
Explain the physical implications of sexual activity, including pregnancy and sexually
transmitted diseases.
Encourage the patient to tell their parents or a trusted adult.
purposes only.
Gillick Competency:
Lord Fraser stated that a doctor could proceed to give advice and treatment:
Provided he is satisfied in the following criteria:
1. that the girl (although under the age of 16 years of age) will understand his advice;
2. that he cannot persuade her to inform her parents or to allow him to inform the parents
that she is seeking contraceptive advice;
3. that she is very likely to continue having sexual intercourse with or without
contraceptive treatment;
4. that unless she receives contraceptive advice or treatment her physical or mental health
or both are likely to suffer;
5. that her best interests require him to give her contraceptive advice, treatment or both
without parental consent.
What are the implications for child protection?

Professionals working with children need to consider how to balance children’s rights and
wishes with their responsibility to keep children safe from harm.
Underage sexual activity should always be seen as a possible indicator of child sexual
exploitation.
Sexual activity with a child under 13 is a criminal offence and should always result in a child
protection referral.
Competence is demonstrated if the young person is able to:

- Understand the treatment, its purpose and nature, and why it is being proposed.
- Understand its benefits, risks and alternatives.
- Understand in broader terms what the consequences of the treatment will be.
- Retain the information long enough to use it and weigh it up in order to arrive at a
decision.
purposes only.
Concerned Mother (OCP)
You are FY2 in GP. Mrs. Jordan West 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. Please talk to her and address her concern.
D: Hello Mrs Jordan, how are you doing?

P: I am fine. I need to talk to you about my daughter.
D: Ok Mrs Jordan, I am here to answer all your concerns. Could you please tell 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 anything 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. West, but unfortunately we cannot discuss this
information with you. This information is confidential.
P: What do you 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 they may start having sex without proper
knowledge about it.
P: She is just 15. Is it legal for her to have sex?

D: The legal age to give consent 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 health and give consent for their treatment.
P: What if she gets an STI?

D: We deal with the young patients who come to us carefully. We do assess the situation by
informing them about the risks of sexual activity like STIs, HIV and getting pregnant.
purposes only.
P: What if she is having sex with an older person?
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. 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: This is confidential information and I cannot give out any information regarding any
patients. 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 and 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 another day, she might open up and tell you everything.
purposes only.
Emergency Contraception
You are FY2 in GP. 14 years old Julia Holding has come 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 the 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 contraception?
P: I had unprotected sex with my boyfriend last night.
D: May I know what’s bothering you?

P: I'm scared of getting pregnant.
D: Don’t worry I will prescribe you contraception after asking a few questions.
P: Ok Dr
Offer confidentiality only when the 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, we always use condoms.
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 a relationship with him? P: Few weeks
D: How is your relationship? P: Fine
D: Any other sexual partners? P: No
D: When was your last menstrual period? P: 2 weeks ago.
D: Are your periods regular? P: Yes
D: Any bleeding or discharge between periods? P: No
D: Any pain or bleeding during or after sex? P: No
D: Do you know the legal age to have sex in UK? (16) P: Yes/ No.
D: Any idea about the implications 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?
purposes only.
P: Magazine/ newspaper/ internet.
D: Whom do you live with? 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. Whatever we discuss here is confidential, but we do
advise you to discuss this with your parents as you can get some support from them.
P: That is ok, I don’t want them to know.
D: Any sexually transmitted infections or pelvic inflammatory disease? P: No
D: Are you currently taking any medications, OTC drugs or supplements? P: No
D: Any recreational drug use? P: No
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.
D: Please make sure you take this pill before 72hrs. P: Ok.
D: There are different types of contraception available for you if are having sex regularly. Do
you want me to discuss them with you? P: No Dr that’s
ok/Yes.
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,
maybe your mom as they can give you support. P: Ok thank you.
D: You might have some side effects with this pill 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.
purposes only.
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 the 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.
purposes only.
Emergency Contraception 2
You are an FY2 in GP. Miss Julia Holding, aged 14, has come to you with some concerns.
She had unprotected sex. Talk to her, assess the situation and address her concerns.
If there is an age/maturity/power difference and position of trust à remember to inform

the children protection agency.
Regular Contraception
You are an FY2 in GP Surgery. Miss Tracy London, aged 14, has come to you asking for
regular COCP. Talk to her and address her concerns.
Confidentiality Consent
You are an FY2 in Medicine. Miss Fiona Willis, aged 28, came to you 6 weeks ago with her
father. She has been diagnosed with depression and was started on SSRI’s. She came to
the clinic again 2 weeks ago because she has not noticed any improvement in her
condition. She has lost her job recently and she has not told anything about her job to her
parents. Talk to the father and address his concerns. Her father is concerned and is calling
you to know about his daughter’s mental health.
purposes only.
Ankle Sprain
You are FY2 in A&E. Mrs. Fionna 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 management and
address her concerns. 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.
Ligaments à 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 have come for my X-ray
results.
D: Yes I have your X-ray results with me. First tell me how are 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 AP 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.
purposes only.
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
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 varies from person to person. It depends on one’s 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 & E Note:
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 weight on her ankle. She was also unable to walk.
However, after giving painkillers, 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 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.
purposes only.
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 don’t work.

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.
National Minimum Wage and Living Wage rates
Age Current rate Rates from April 2018

25 and over £7.50 £7.83
21 to 24 £7.05 £7.38
18 to 20 £5.60 £5.90
Under 18 £4.05 £4.20
purposes only.
!
purposes only.
Sick Note Request after Accident
You are FY2 in A & E. Miss 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. Talk to her and address her concerns.
(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).
D: How can I help you? 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 a few more days off to
recover. That’s why I need a sick note from the hospital.
D: Do you have any symptoms? P: Like what?

D: Do you have pain? P: Yes/No
D: Any breathing problems? P: No
D: Any swellings? P: Yes/No
D: Do you sleep fine? P: Yes/No
D: Can you tell me about your work? P:
D: Any DM, HTN or Heart disease? P: No

D: How often do you drink alcohol? (CAGE) P: Everyday
D: Do you have any kind of stress? 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 I had injuries and
need to rest for a few more days?
purposes only.
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 the Citizens Advice Bureau or the Job Centre to help you.
P: Ok
D: Is there anything else I can help you with?

P: No
purposes only.
Mother wants Sick Note (Chicken pox)
You are an FY2 in GP. Mrs Janet May, aged 26, has come to you with some concerns. Her
daughter has got chicken pox. 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 chicken pox for the past 3 days.
D: How is she doing? P: She is fine
D: Any fever? P: Yes
D: Is she feeding well? P: Yes
D: Is she playful? P: Yes
D: Any rashes? P: No
D: Is your daughter shy to light? P: No
D: Who looks after her?

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 of family nearby who can look after? 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
D: What do you do for living? 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
You have to negotiate with the mother, there is no need to give sick note to her initially.
Explore different options:

1. Partner can take care of the child
2. Grand parents can take care if possible
3. You can hire a childminder if possible
4. Any other relatives or family members who can take care
5. Talk to employer regarding other options like phased return or alternate options etc.
She can take any number of leaves from employers for childcare, but it may not be paid as it
depends on the type of contract they have with employers.
If employer is not giving paid leaves as per the contract, we can help financially if needed
(citizen advice bureau)
purposes only.
Even after trying all things, she is still not convinced ask her what she wants us to write in
the notes:
Patient is stressed due to the illness of child.
From my assessment, you are the sole carer for your daughter at the moment as mentioned
by you. Therefore, I would speak to my senior and confirm and gladly give you the required
sick note.
Concerns:
Will I get chicken pox?
Can the students at the university get it also because of me?
D: Have you had chicken pox in the past? P: Yes
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.
purposes only.
Angry Patients
Angry Pa#ent Ø Voice Control

Loud speech, Verbal abuse, Aggressive Posture. Ø Eye Contact
Ø Nodding
1. Acknowledge their Anger
Ø Keep Distance
(I can see you are Angry/Upset)
You’re looking very upset by all of this’
2. Assess the patients condition
How are you feeling now?
3. Why they are Angry,
(Tell me more, Why are you feeling this way)
Empathy and offer solution if possible
‘Its sounds like you have a lot going on at the moment,
and it’s natural that you’re feeling angry’
4. Apology:
‘I’m so sorry this mistake has occurred and you have to face this implication,
But we take it seriously (Incident form)
If not your fault (Be careful when apologise)
‘I am sorry that you are feeling so angry about what has happened’.
5. Don’t give any excuses
(Lack of staff/ junior doctor)
6. Patient Advisory Liaison Service
(If they want to complain)
purposes only.
Angry Patient (Change IV Cannula)
You are FY2 in A&E. Mrs. Irina Yates, aged 50, presented to the hospital because of an 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 the patient and address her concerns. Dr Williams is the
FY1 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 them because
my cannula is blocked. (She will point 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 you feel now?
P: I am fine now.
P: Any pain at your cannula site?

D: No
P: Do you have pain anywhere else?

D: I don’t have any pain. But I want to know why this happened to me?
D: I know this is upsetting for you and it would be for anyone. But may I know if you talked
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
Williams and Dr Williams 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. that no one
turned up.
D: I am really sorry for what you have been through but 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 the whole situation.
P: Dr. I want to know, is this usual in the hospital. Does every patient have to suffer like this?
D: I am sorry for what has happened/ I am so sorry for your experience. I would be asking
the same questions as you are asking. I am sure it must be there on her list but she must
have got something urgent.
P: But this is not my responsibility if she is a junior?

D:In the hospital, all the junior doctors are well supported and take help from their seniors
in case they are facing any issues. I will talk to Dr Williams to find out what exactly
happened.
purposes only.
P: OK Dr. but what do you think if your mom was in my place, would she have suffered?
D: I 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 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 to 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 regret the inconvenience but 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., a medical certificate will not work. I have to be there at 10.

D: I will discuss this with my senior and we may 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 is it 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 complaints 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 happens in the future.
P: Ok.
purposes only.
Angry Patient (Talk to Dr Williams)
You are F2 A&E. Mrs. Irina Yates, 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. Yates asked Dr. Williams 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 Williams about the incident and discuss further plan. Your colleague, Dr
Williams is the FY1 doctor who has just started her training in your hospital. Cannula has
not
been changed yet.
D: Hello, Dr Williams. I am one of your FY2 colleague in the department. How are you?
Williams: I am fine.
D: How is your shift so far going?

P: 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?
Williams: No.
D: I’m here to talk about one of our patients Mrs. River? Do you remember her?
Williams: 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 on my list. I told her that I will change her cannula. She was fine with it.
D: Did you manage to change her cannula?

Williams: No. Have you changed the cannula?
D: No I have not. I think we should go and change her cannula?

Williams: Yes, I will go and change it.
D: That’s great. May I know why you did not change the cannula?
Williams: 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 Williams that you recognised the emergencies and 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?
Williams: Yes, I could have done that. I will make sure of it next time.
D: Well done. I know you have joined the work recently and this environment is new for
purposes only.
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
patients get the best possible care in the hospital. So please don’t hesitate to ask for a
favour.
Williams: Yes , 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.
Williams: Ok, I will talk to her and I will change her cannula.
D: That would be great Williams, 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)
Williams: Do we have to inform the consultant and fill the adverse report form here as
well? I mentioned I was busy with some other serious patients. Otherwise I would have
changed the cannula. This will be the first complaint against me dr.
D: I understand that you were busy with other patients and you prioritized your tasks. This is
nothing against you Williams. 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 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 the HR manager
and solve this problem by appointing more people.
Williams: Ok, that is fine.
D: Williams, whatever we are doing is to improve the services of our hospital and NHS. If
you have any suggestions, 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 ease their stay in the hospital.
Williams: Yes, I understand what you are saying I will take care of these things in the future.
D: If she wants to complain, do you know how to guide her?

Williams: No.
D: Please get her in touch with the PALS service. They will guide her.
P: Okay
D: If you want any help you can contact me anytime. It was nice talking to you Williams.
Williams: Same here.
purposes only.
Talk to Colleague (Delayed Discharge)
You are the FY2 in acute Medicine. Dr Singh is an F1 working in your department. Mrs.
Stream is about to be discharged & Dr Singh has to write the discharge notes & discharge
the patient. She asked Dr Singh 2-3 times to get the 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 Singh & manage the situation. One F1 is sick & is on
sick leave
purposes only.
Post-Operative Wound Infection (Infection Rate within National Guidelines)
You are FY2 in A&E. Mr. Albert Pink, 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 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
D: Any other symptoms? 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: Was it Smelly? P: No
D: Any Bleeding? P: No
D: Any Redness? P: No
D: Any nausea, vomiting? P: No
D: Any cough? P: Yes dr. sometimes.
D: Any reason for a cough? P: Maybe because of my smoking.
D: How are your bowel habits? Any diarrhea or constipation? P: It is fine.
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 a towel after having a shower.
D: Did you follow what you have been told? P: Oh yes doctor.
D: You mentioned smoking. How much do you smoke? P: 1 packet a day.
D: Tell me about your diet? P: Fine
D: May I know what you do for a 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 the 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.
purposes only.
From my assessment it seems like you have a wound infection, which is a complication of
surgery.
P: Why do 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 would have gotten 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.
purposes only.
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 do some routine blood tests to see the level of
infection in your blood and we will also take a 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 the 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 can see your frustration. As I explained to you, wound infection is one of the possible
complications of surgery and I am sure my colleagues in the 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
the complications of surgery. However, my colleagues in the surgery department can discuss
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 on other surgical
staff. These meetings 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.
purposes only.
Post-Operative Wound Infection
You are FY2 in Surgery. Nicole Storm, aged 29, underwent an operation to remove a cyst on
her leg 2 weeks ago. 3 days after the operation, she developed an infection of the wound at
the site of the operation. She was admitted in the hospital for one week. She received
antibiotics for 2 days as IV and then 5 days per oral. She is fine now. She presented today
for the review and she is angry. Please talk to the patient and address her concerns.

P: I want to know why I had this wound infection after my operation.
D: I do understand you had an operation to remove a cyst from your leg 2 weeks ago. How
did the operation go?
P: It went well doctor.
D: When did you develop the wound infection?

P: 3 days after the operation.
D: Tell me about your infection?

P: I developed swelling and it was very painful so I had to come back to the hospital.
D: Any redness? P: No.

D: Any nausea, vomiting? P: No
D: Any cough? P: No
D: How are your bowel habits? Any diarrhea or constipation? P: No
D: May I ask what was done for you?

P: Doctor, they admitted me to the hospital and gave me IV antibiotics for 2 days and then I
received tablets for the next few days. I was stuck in the hospital for a week.
D: How are you now? P: I’m fine now.

D: Did you stay in the hospital after the operation? P: No it was day care surgery.
D: Have you been told how to look after your wound?

P: Doctor, they gave me a letter and I followed exactly as they said.
D: Tell me about your diet. P: Fine
D: May I know what you do for a living? P: I work in an office.
purposes only.
D: Did you work after the operation?
P: No, I was not able to work. I had to take leave for 2 weeks because of this infection.
I would like to check your vitals and examine your wound.
P: How did I get this infection?

D: Wound infection has a few causes. However, in your case, it is likely to be due to the
operation you had. This is one of the common complications of this surgery
P: Then how did I get it?

D: This is a known complication of this surgery. We took all the necessary precautions to
prevent this from happening. But there is always some bug on our skin and in our homes
and hospital environment. Moreover sometimes our immune system is not as strong as it
should be especially after operations and that’s why despite taking all the necessary
precautions such infections are not avoidable. I think one of my colleagues must have
mentioned the complications of this surgery before taking consent?
P: Yes, But If it is a known complication, why didn’t you give me antibiotics before the
operation?
D: Actually we don’t give antibiotics before such types of surgery because the risk of
infection is very low. Unfortunately you developed this infection. So, we treated you with
antibiotics after the operation. If we will prescribe antibiotics for everything then there are
chances of developing resistance and the antibiotics will not work when you really need it.
P: Okay doctor, but my question is, are such things happening a lot in the hospital?
D: As I mentioned earlier, infection is one of the known complications of surgeries.
However, we can discuss such cases in our monthly Meetings.
P: What is this meeting?

D: This is a monthly meeting, which is attended by our consultant surgeons and other
surgical staff. These meetings 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
complaint if you strongly feel that your care is compromised. They will look into detail of it.
purposes only.
Angiogram (Conflict of Opinion)
You are FY2 in Cardiology. Mrs 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 was 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: Okay, so how are you feeling now? P: I am fine.

D: Any chest pain? P: No, I am fine.
D: Any swellings in the legs? P: No
D: By any chance do you have DM, HTN, high 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 want to rest.
D: 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.
D: When you came to the hospital you had chest pain that is why our nurses 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 advised 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
purposes only.
worse/life-threatening complications. That’s why we advise mobilising 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 walk a few
steps in the ward.
D: Do you have any other concern?

P: No
D: Ok. I am sorry for your experience. I will 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.
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
where you can make formal complaint if you strongly feel that your care is compromised.
They will look into detail of it.
purposes only.
Angry son talking about mother
You are an FY2 in Medicine. Mrs Emma Goody, aged 65, admitted to the hospital with heart
failure and receiving treatment for it. Son has some concerns about his mother’s health.
Please talk to the son and address his concerns. Son is angry.

P: I have got some concerns about my mother’s health.
D: Ok, I am here to address all of your concerns.
P: When I tried to talk to the nurses about my mother’s health, they were very rude to me.
They are not taking care of my mother properly. Even doctors were very rude to me when I
tried to ask them about my mother's condition, they said the round is ongoing and we are
busy. They don’t have time at the moment.
D: I am really sorry to hear about it. I am meeting you for the first time; I don’t know what
exactly happened. Can I ask you some questions about your mother's health?
P: Ok
D: Why did you bring her to the hospital?

P: She was having SOB which was getting worse. That is why I brought her to the hospital.
Here she is getting treated for heart failure.
D: Was she taking any medication for the heart failure?

P: Yes
D: Was she taking her medications regularly?

P: Yes
D: Was she reviewed by a heart failure nurse in the community?

P: Yes
D: Are you the only one taking care of her?

P: Yes.
D: How are you coping up with all these?

P: I can manage.
D: Do you need any help at home for your mother?

P: No
D: How is she now? Is her condition improving?

P: It is the same.
purposes only.
D: Did anyone talk to you about her condition?
P: No.
D: I am really sorry for this inconvenience. Doctors are usually busy in the morning hours on
the rounds.
P: How can I discuss the condition of my mother with the doctors?

D: It is always better to book an appointment in advance with the doctors so that they can
finish their work and can answer all of your queries. So in this case doctors will make sure
they will be available for you during that time. But sometimes there are some critical
patients, then doctors have to look after them first.
D: If she was your mother?

P: I appreciate your concern for others. I will talk to my colleagues and will tell them to
come and speak to you if it helps. 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.
D: Do you have any other concern?

P: I want to complain about it.
D: Ok, You have the right to make complaints and we take all the complaints very seriously.
I can get you in touch with PALS service and it is a service where you can make formal
complaint if you strongly feel that your care is compromised. They will look into detail of it.
purposes only.
Levothyroxine Dose Adjustment
You are an FY2 in GP. 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 got the power of attorney and her mother
doesn’t have the capacity. Thyroid function tests were normal and Thyroid function test will
be done again after 6 weeks to check her mother’s thyroid hormone levels. Please talk to

P: I am Michelle. I am the daughter of your patient Mrs Smith. I am here to talk about her.
D: Can you tell me what exactly happened?

P: 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: 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 had dementia for the last 10 years.
D: Is she on any other medication except the thyroid one?

P: No
D: How’s she coping up with her dementia?

P: 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 a care home. She has been there for 8 years now. They keep me updated about
my mother’s health from 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 is for the betterment of our
purposes only.
patients. I know you are having power of attorney so you have rights to discuss about your
mother 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.
P: I want to speak to your senior?
D: 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 the 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 complain?

D: We have a service in the hospital to deal with patients’ complaints (Patient Advisory
Liaison Service). We can arrange an appointment for you with them.
purposes only.
Angry Son (Late Cancer Diagnoses)
You are an FY2 in GP. Mrs Daniella White, aged 67, had presented to the hospital with
breathlessness and was diagnosed with lung cancer. She visited the GP previously with
cough and was treated for lung infection. Son is angry as he thinks the diagnoses was
made late. Talk to him and manage the situation.

P: 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?
P: Okay.
D: May I know why your mother came to the GP?

P: She came to the clinic with cough with phlegm and was given 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?

P: She was fine before, now she is getting worse. Doctors have said her cancer is at an
advanced stage.
D: Were there any investigations done before?

P: 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?
P: Yes/No
D: Since when she’s been having a cough?

P: Few weeks.
D: Did you notice weight loss?

P: No
D: Did she complain of any lumps or bumps around her body?

P: No
D: Did she mention any blood in her sputum?

P: No
purposes only.
D: Does she have any medical conditions?
P: No doctor.
D: Any family history of any medical conditions?

P: No.
D: May I know who takes care of your mother?

P: I do.
D: Is there anyone else in the family?

P: Yes, I live with my family and my kids.
D: How are you coping up with all this?

P: It is a lot to handle.
D: Do you need any help for your mother?

P: No
D: Is there anyone else to help you with that?

P: 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 were 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.
P: Ok
D: Did you mention to the GP that her cough isn’t getting better despite the medicines?
P: 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.
P: Ok
P: 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?
purposes only.
D: We will look into the whole situation. I will also escalate this matter to our seniors.
You can do a written complaint to the GP practice manager. They will acknowledge your
complaint and then internal enquiry will be done. We will talk to your mom’s GP and find
out exactly what happened. We will call you with the update and discuss it with you. A letter
through the GP practice manager will be sent to you regarding what was done in the
meeting and what was the outcome. If you wish, we can arrange an appointment for you
with the GP to discuss this.
P: I want to make a complaint.

D: No problem at all. If you are not satisfied with the outcome of the meeting, you can make
a formal complaint with the solicitor if you want.
It would be great for your mom if you could bring your kids to meet her or even show
pictures and videos. This would boost her morale. Spending more time with your mother
would make her more comfortable in her later stages of her life.
Please note: the scenario is about the impact of his mother’s illness on the son.
purposes only.
Cerebral Palsy
You are F2 in A&E. Mr. Calumn Taylor, 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. Calumn’s father, Johnny, 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,
D: Hello there. How can I help you?
P: Doctor, I brought my son to the hospital a few days ago and I’m unhappy with his
treatment.
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: How about any swelling?

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.
purposes only.
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 lesser 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?

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 any medical conditions?
P: No doctor.
D: How about any blood disorders?

P: No.
D: Is he taking any regular medications?

P: No.
D: Any blood thinners?

P: No doctor.
D: Any family history of any medical conditions?

P: No.
D: Any blood disorders in the family?

P: No doctor.
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.
purposes only.
D: What do you do for a living?
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.
Examiner:
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?
D: Because in such situations they always do an X-ray. But this doctor didn't even bother to
do one for my child.
P: 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.
purposes only.
Premature Childbirth
You are FY2 in Paediatrics. Miss Jenna March, mother of a Lexi, 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's condition and sometimes 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 reassure you that we always take good
care of our patients. I will address all your concerns, let me ask you a few questions
regarding her health.
D: May I know how is she now? P: She is doing fine.

D: Are you happy with the red book? P: Yes, they corrected the age of my child.
D: Is she up to date with all her jabs? P: Yes.
D: Is she feeding well? P: Yes/No
D: Does she have any problems with her wee and poo? P: Yes/No
D: May I know what is bothering you the most?

P: My main concern is whenever I talk to any nurse about my child's 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 detail about my child.
D: I am sorry about your experience. It should not have happened. I will talk to them and
find out what exactly happened.
P: There are no regular nurses. Nurses are temporary so no one knows properly about the
child.
D: 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.
purposes only.
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
If the patient wants to make a 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
!
purposes only.
Medical Error’s
How to approach:
1. Patient safety- a patient safety incident occurs.
2. Documentation- document the incident in the patient’s record.
3. Being open- inform the patient 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 patient wants to make a complaint.
Angry Patient Ø Voice Control

Loud speech, Verbal abuse, Aggressive Posture. Ø Eye Contact
Ø Nodding
1. Acknowledge their Anger
Ø Keep Distance
(I can see you are Angry/Upset)
You’re looking very upset by all of this’
2. Assess the paDents condiDon
How are you feeling now?
3. Why they are Angry,
(Tell me more, Why are you feeling this way)
Empathy and offer soluDon if possible
‘Its sounds like you have a lot going on at the moment,
and it’s natural that you’re feeling angry’
4. Apology:
‘I’m so sorry this mistake has occurred and you have to face this implica<on,
But we take it seriously (Incident form)
If not your fault (Be careful when apologise)
‘I am sorry that you are feeling so angry about what has happened’.
5. Don’t give any excuses
(Lack of staff/ junior doctor)
6. PaDent Advisory Liaison Service
(If they want to complain)
purposes only.
Missed Myocardial Infarction
You are FY2 working in Critical Care Unit. Mr. Andy White, aged, 40 presented to the
hospital 2 days ago with chest pain and has been admitted to the hospital. Patient attended
the A&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
results came back positive while the patient had already been discharged. When he came
the second time, the 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.
D: Hello, 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 a heart attack.
D: Yes, you are right you came to the hospital and were 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: Thank you.
D: Do you have any symptoms? Chest pain? Breathlessness? Heart racing? Swelling in the
legs? Cough? P: No
D: Are you taking any medications? P: No
Examination: D: I would like to check your vitals and examine your chest.
D: Do you have any idea what treatment you got 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 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 to you everything. Unfortunately, the first time when you came to the
purposes only.
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 that went wrong in this case in terms of not waiting for the
blood results and not reading your ECG properly. I am really sorry, this really should not
have happened.
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 you
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 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 to prevent them
happening elsewhere.
P: I can’t accept it Dr. How is it possible?

I will make sure you get the best possible treatment and nothing like this happens in the
future.
P: OK.
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.
We will do some further investigations to make sure everything is fine. We will do:
- 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)
purposes only.
Misdiagnosed Pneumonia
You are FY2 in Medicine. Mr 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 to the Acute Medical Unit and then shifted to the ward.
Patient has been prescribed Amoxicillin. One of the doctors read another patient's 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 the patient's concerns.
Hairline Fracture
You are FY2 in A&E. Mr. Jonathan Williamson had brought his 4-year old son Charlie to the
hospital 2 days ago after having fallen while playing. He had swelling on his right hand.
Doctor on duty saw him. 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 the X-ray and
found a minor hairline fracture of radius. Orthopaedic specialists reviewed the X-ray and
planned to 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 the management which has been decided and address his concerns. Father is
very angry. There is no evidence suggesting NAI and it has already been ruled out.
Amoxicillin Rash
You are FY2 in A&E. Miss Kate Williams, aged 3, was brought to the A&E by her mother,
Miss Katya Williams, yesterday. Your colleague saw the child, and a diagnosis of respiratory
infection was made. Child was prescribed Amoxicillin. The child was given antibiotics 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 the plan of management and address her
concerns. The mother is very worried. The child is not in the cubicle.
purposes only.
Post Streptococcal Glomerulonephritis
You are an FY2 in the Urology Department. Mr. Ashley Trump, aged 27, has been referred
by the GP. The diagnosis of Post-streptococcal 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 has been found for not
getting the sample. Please talk to the patient, disclose the situation and address his
concerns.
Sample Not Labelled
You are FY2 in Trauma. Mr. Peter Keane, aged 40, had a pre-operative assessment
yesterday. As a part of pre-operative assessment, you took some blood yesterday from 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 the phone and explain the error. Tell him that he has to go to the hospital for
the bloods again.
!
!
purposes only.
Foreign Body
You are FY2 in A&E. Miss Amy Blair, aged 3, daughter of Mrs Jane Blair, 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 vomiting? P: No doctor.
D: Is she able to eat or drink? P: Yes
D: Did she pass any stool? P: No.
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
purposes only.
D: It is important that being a doctor we are open in these things if any error happened. We
need to explain to you everything. After we sent you home, we received the report from the
Radiology Department. They realised there is a button in her food pipe and that’s why I’m
calling you now.
P: How can it even be possible?
D: We will look at everything that went wrong. I am really sorry, 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 can only imagine your circumstances but maybe you can talk to your employer and
explain the situation. 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 a single mom. My sister looks after my babies and it's difficult for her to come to the
hospital with two babies.
D: I can see how inconvenient this is but we need to reassess Amy to see if everything is
fine. I can arrange transport for you, if that helps.
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: Has she been diagnosed with any medical condition?

P: No
purposes only.
!
purposes only.
!
purposes only.
P: Doctor, what are you going to do for her?
D: We will examine her and we may do a metal detector test to see if the object is a metal.
We may repeat the X-Ray to see where the button is now. If the button has passed down to
her stomach, it has passed from the narrowest part of the tract, which is the junction
between gullet and stomach, it is most likely that it will pass from her stomach . We can
manage her conservatively and wait for the button to pass in her stool. However, if the
button is still observed to be in her food pipe she will need some intervention.
We may be able to put a flexible tube camera attached into her gullet through her mouth
and try to pull the object out from her gullet or to push it down through his stomach. This
depends on size, location and what exactly the object is. This is done with the help of some
instruments.
The other option is to use some rubber tube to push it down to the stomach. Depending on
what the object is, we may pull it from the stomach or we may manage conservatively as
explained.
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 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 to prevent them happening
elsewhere.
P: I can’t accept it dr. How is it possible?

They will look into detail of it. I will make sure you get the best possible treatment and
nothing like this happens in the future.
P: OK dr.
Hopefully, everything will go fine and you can take your little one home. In this case, you
have to look out for a few things. If your little one cries, if you notice any vomiting, if her
tummy is distended, or if she’s not passing any stool, please bring her to the hospital.
NOTE: If you have time you can give her some general advice to prevent this from happening
again. Sometimes the parent will ask you this question:
Please don’t leave her alone while playing. Try to keep an eye on her while you are doing
your housework, for example when you are cooking, washing, opening the door and
answering the phone.
purposes only.
Miscellaneous
Herbal Medication
You are FY2 in Paediatrics. Miss Jazllyn Smith aged 15 months diagnosed with
neuroblastoma abdomen has been admitted to the hospital with neutropenic sepsis. Few
nurse colleagues noticed that mother Mrs. Devoine Smith 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
D: How was the birth of your baby? P: Normal Vaginal Delivery.

D: Are you happy with Red Book? P: Yes
D: Is she up to date with all her jabs? P: Yes
D: Is she feeding well? 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 medications including OTC or supplements?
P: I’m giving herbal medication
D: May I know why you are giving it 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 medicine to your child?
P: I have been giving her for the last 3 month.
D: How many times are you giving this medication to your child? P: 3 times a day.
D: May I know from where you got that medication? P: My friend gave it to me.
D: Do you know what is 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.
purposes only.
D: I can see that you are very concerned about your child. But this medication can have
interactions with the medication we are giving to your child in the hospital and can have
some bad effects on her body.
P: Like what?
D: It can have bad effects on the organs of her 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 with the
medication we are giving to your child. All the protocols are based on regulated
medications, so we use only those medicines on which our protocols are made.
P: But I have to give her this herbal medication.

D: 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.
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 am sure you meant no harm; 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 tests 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 a rough time, but we are doing our best to do what is right 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.
3. Green tea contains vitamin K and can interact with blood thinners.
4. Kava can interact with buprenorphine.
purposes only.
Changing the counsellor
You are FY2 in GP. Erika Trudeau, aged 30, is going for counselling sessions for depression
and she is taking sertraline for that. She is requesting to change her counsellor. Please talk
to her and address her concerns.

P: I want to change my counsellor.
D: Let me ask you a few questions to get a better understanding of your problem. Could you
please tell me why you 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 you started taking medications for depression?
P: I started taking medication 2 years back.
D: How are you now?

P: I am fine.
D: How is your mood?

P: Fine
D: Do you eat well?

P: Yes
D: Do you have any problems with sleep?

P: No
D: Do you enjoy the activities you used to enjoy before?

P: Yes/No
D: How long have you been taking counselling sessions?

P: I have been taking the counselling sessions for the 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 you want to change your counsellor?
P: I prefer a female counsellor.
D: May I know if there is any particular reason why 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?

purposes only.
P: No, it was Consensual from my side as well. This is not his fault; I used to encourage him
and we went out for a 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 need to inform my seniors because we do not encourage this as it is against our
professional ethics. It is unethical for a doctor to have a 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 can see you are concerned about him. 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 to escalate it to my senior. And also, I will discuss your wish to change the counsellor
with my senior.
If she wants to complain then offer PALS in those cases.
purposes only.
Gender Selection
You are in GP. Mrs Isabelle Truman, 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 a few questions first. Could you please tell me about your previous
pregnancies?
P: My 3 girls are 7, 4 & 1.
D: Are you currently taking any regular medications? 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
D: When was your last menstrual period? P: 1 week ago
D: Any discharge or spotting in between the cycles? P: No
D: Do you use any contraception? 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
confirmed, which means sometimes we cannot be 100% certain about your baby's sex due
to awkward presentation of the baby in the womb.
purposes only.
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.
Make sure the patient is not a victim of abuse.
UK Law
You mentioned that you want a male child. In Britain, sex or gender selection is 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.
The Abortion Act 1967 (as amended by the Human Fertilisation and Embryology Act 1990)
states that an abortion is legal if it is performed by a registered medical practitioner (a
doctor), and that it is authorised by two doctors, acting in good faith, on one (or more) of
the following grounds (with each needing to agree that at least one and the same ground is
met):
(a) that the pregnancy has not exceeded its twenty-fourth week and that the continuance of
the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury
to the physical or mental health of the pregnant woman or any existing children of her
family; or
purposes only.
(b) that the termination is necessary to prevent grave permanent injury to the physical or
mental health of the pregnant woman; or
(c) that the continuance of the pregnancy would involve risk to the life of the pregnant
woman, greater than if the pregnancy were terminated; or
(d) that there is a substantial risk that if the child were born it would suffer from such
physical or mental abnormalities as to be seriously handicapped.
The 1967 Act does not apply to Northern Ireland, where the abortion law remains governed
by the Bourne Decision, discussed below.
Is abortion for reason of fetal sex illegal under the Abortion Act?
No. The law is silent on the matter. Reason of fetal sex is not a specified ground for abortion
within the Abortion Act, but nor is it specifically prohibited. Other reasons for abortion that
are widely accepted as 'good' reasons – for example, if the woman has been raped – are not
specified either.
The Abortion Act gives doctors the power to make decisions about whether a woman can
end a pregnancy on the basis of specific grounds. It does not prevent a doctor approving an
abortion where a woman has mentioned the sex of the fetus, but one of the grounds of the
Act would have to be met. There will be rare circumstances where fetal sex may be a factor
in a woman's decision making - each case will be individual and doctors are asked to decide
in 'good faith' whether that individual woman meets the criteria set out in the Act.
purposes only.
Euthanasia
You are an FY2 in Medicine Ward. A 75-year-old female had a stroke and now she is in the
care home. She has been diagnosed with Colon Cancer which has metastasised. No further
active treatment can be done, only palliative care can be given to the patient. She is
currently on NG Tube and Fluids. She is unconscious. Her son, Mike, lives in Switzerland and
wants to arrange a meeting with the doctor. Talk to her son on the telephone and discuss
the situation of the mother with him.
P: I want to talk to you regarding my mother.

D: Ok
P: I want to end her suffering

D: What do you mean?
P: I would like her to get some injections to relieve the pain so she could die with dignity.
She told me initially that she did not want pain in her later stage of life.
D: Before we continue, let me ask you some questions to better understand your situation.
P: Okay doctor.
D: How much do you know about your mother’s condition?

P: I know that she is terminally ill with colon cancer and is now unconscious.
D: Do you understand what care is being given to her at the hospital for her condition?
P: Yes.
D: Do you have family members who can be here for her?

P: No doctor, I am her only child and I live in Switzerland.
D: We are giving her palliative treatment at the moment, to ease her suffering. Is there
something you want to discuss further with us about her treatment?
P: Yes, I want to know more about euthanasia.
D: How much do you know about euthanasia?

P: Yes/No
D: Euthanasia is the act of deliberately ending a person's life to relieve suffering.

P: Any other way we can do that?
D: I can see you are worried, but euthanasia is illegal here in the UK. Instead, we prefer end
of life care. End of life care is support for people who are in the last months or years of their
life.
purposes only.
Palliative Care
We are providing her nutritional vitamins and supplements by passing a flexible tube into
the gut and gullet through the nose.
We may need to give IV fluids and medication.
We are taking all the necessary measures to prevent infections and we are providing mouth
care, maintaining good hygiene, to avoid any dryness or infections.
We move her regularly so that she doesn’t develop bedsores and we will gently exercise her
joints to stop them from becoming stiff. This will also help prevent formation of blood clots
in the legs. We may also use some compression stockings for this purpose.
We also help her in emptying his bladder by inserting a flexible tube.

We give her some medications to reduce the secretion in his mouth (anti-secretory
medicines) to prevent any breathing problems (aspiration). We may also give her artificial
tears to lubricate her eyes.
End of life care should help our patients live as well as possible until they die and to die with
dignity. The people providing care ask you about your wishes and preferences and take
these into account as they work with the patient to plan their care. They also support the
family, carers or other people who are important to the patient.
Every patient has the right to express their wishes about where they would like to receive
care and where they want to die. Patients can receive end of life care at home, or in care
homes, hospices or hospitals, depending on their needs and preference.
People who are approaching the end of life are entitled to high-quality care, wherever
they're being cared for.
Euthanasia and assisted suicide
Euthanasia is the act of deliberately ending a person's life to relieve suffering.

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
purposes only.
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
purposes only.
Two People Policy
You are an FY2 in Medicine. Mrs Matilda Yates, 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: Let me ask you some questions about your grandmother's condition. Do you know why
she was in the hospital?
P: She was having some problem with the breathing and she was admitted to 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 a very tough time 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 an idea about 2-person policy in the hospital?
P: I know about this policy but we are a big family and a lot of people come to see her and
pray for her from far away.
D: I appreciate your family’s bonding; do you know why we have this 2-person policy in the
hospital? P: No
D: There are other patients as well in the ward and they get disturbed because of the noise.
They might start making complaints against us. You will agree with 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 to the other patients.
P: Doctors do not respect 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 every 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.
D: As I have already mentioned that we respect all the religions, 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 in peace.
purposes only.
Hospital Policy (Telephonic Conversation)
You are an FY2 in Medicine. 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 question
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 the hospital?

P: No
D: Due to the 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
purposes only.
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.
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.
purposes only.

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Table of Contents

Overview of PLAB 2.......................................................................................................... 11

Gastroenterology .......................................................................................................... 155

Endocrinology ................................................................................................................ 185

Haematology ................................................................................................................. 194

Infectious Diseases ........................................................................................................ 242

Surgery .......................................................................................................................... 283

Counselling .................................................................................................................... 323

Ethical ........................................................................................................................... 478

The use of this book implies your acceptance of this disclaimer.!

Each Station Division History Data Gathering – 4 History Data Gathering – 4

Overall Total Marks 216 192

Disorganised / Unstructured Consultation - includes illogical and disordered approach to

Shows poor time management.

Does not undertake physical examination competently or use instruments proficiently.

Where you are:

Who the patient is:

Other information you have about the patient:

What you must do:

Ø Elaborate (ODIPARA à Other Symptoms à Cough/SOB)

One pint (585ml) of beer or lager contains approximately 2 units of alcohol.

Any scenario related to medication counselling:

Explain the medication:

Show that you are a Safe Doctor:

To assess dehydration in patient presenting with diarrhoea or vomiting:

Rule Out Anaemia:

Rule Out Cancer:

You are not the only one

You have faced similar

Ask OPEN-ended question to (do not interrupt the patient

If the patient mentions If the patient mentions his work

Remember to manage the

How does that sound?

Keep patient involved in the conversation

Let the patient ask questions

Pick up verbal and non-verbal cues

Go slow and Don't rush

Don't answer if you are NOT sure

The mode and type of anaesthesia:

It is a state of controlled unconsciousness. During a general anaesthetic, medications are

Advantages of Local Anaesthesia compared to General Anaesthesia:

b. Keyhole Operation (Laparoscopic):

Advantages of Keyhole Surgery:

Duration of the Surgery:

Abdominal Incisions Keyhole Scars

For minor surgery – Day care or up to 2-3 days

Stronger Opioids (Morphine, Diamorphine, Oxycodone, Pethidine, Fentanyl) +/- Adjuvants

Adjuvants for Bone Mets pain – Radiotherapy, Bisphosphonates.

Opioid for Moderate

a. Did you take any painkillers?

e.g. Oral Morphine can be changed to Oxycodone or Subcutaneous Diamorphine.

Usually a Fentanyl Patch lasts for 3 days.

Patient Controlled Analgesia (PCA):

Choose the Right Painkiller:

Side Effects of Morphine:

Feeling sick or vomiting:

An imaging technique that uses high-energy radiation to highlight abnormalities in body

A bronchoscopy is a procedure that allows a doctor or nurse to remove a small sample of

A colonoscopy is an examination of your entire large bowel using a device called a

Paediatrics & Gynaecology/Obstetrics

Complete a notification form immediately on diagnosis of a suspected notifiable disease.

D: What brought you to the hospital? P: I have pain in my chest.

D: Do you have any other problems? P: No.